Treatment of Fractures

Overview

The main objective of treating fractures is to enable the patient to return to normal function as soon and as safely as possible. The 4 principles of managing fractures include resuscitation, reduction, restriction (holding reduction) and rehabilitation. Treating the fracture can be done either operatively or non-operatively, each with their own advantages and disadvantages.

Principles of managing fractures

Component	Description
Resuscitate	Following the ATLS protocol, treat life-threatening and limb threatening injuries
Reduce	Adequate apposition and anatomic/mechanical alignment of the bone fragments
Restrict (Hold)	Appropriate immobilization and fixation of the fracture fragments. Hold the fragments together in place until they unite.
Rehabilitate	Early mobilization of the patient through physiologic loading of the bone via muscle activity or early partial/full weight bearing.

Reduction

Reduction is adequate apposition and anatomic/mechanical alignment of the fracture fragments. The bones are adequately aligned so that they heal in a position that is optimum for function. Extra-articular fractures usually require mechanical alignment, focusing more on alignment, length and rotation. Intra-articular fractures require anatomical alignment in order to restore normal joint movement and avoid post-traumatic osteoarthritis.

Open or closed reduction can be performed. The general principle

• Situations where reduction is unnecessary
  1. Little or no displacement
  2. When displacement does not matter initially (fracture of the clavicle)
  3. When reduction is unlikely to succeed (fracture of the vertebrae)
• Three-fold manoeuvre for closed reduction
  1. Pull the distal part of the limb in the line of the bone
  2. Reposition the fragments as they disengage (by reversing the original direction of force which can be deduced)
  3. Adjust alignment in each plane
• Indications for closed reduction
  • Minimally displaced fractures
  • Fractures with enough soft tissue coverage
  • Most fractures in children
  • Fractures that are not unstable after reduction and can be held by some form of splint or cast

Restriction

Methods of holding reduction

Method	Example
Non-operative	Traction, casting, splinting, functional bracing
Operative	Internal fixation, external fixation

• Reasons for holding reduction
  1. Alleviate pain
  2. Maintain reduction
  3. Avoid further soft tissue damage
  4. Ensure that union takes place in good (anatomical) position
  5. Permit early movement of limb and return of function

Rehabilitation

• Summary of the essence of soft tissue care
  1. Elevate and exercise
  2. Never dangle
  3. Never force
• Objectives of rehabilitation
  1. Prevent oedema
  2. Preserve joint movement
  3. Restore muscle power
  4. Guide the patient back to normal activity