How to treat fractures

Here are the examples how fractures are treated

a)Close fracture of tibia shaft

• Close manual reduction under GA(but in reality most doctors do under sedation)
• Then apply full length POP (FLPOP)with attention to the alignment and three point fixation
• Check under Image Intensifier and Xray
• If acceptable(to be explained later) then patient will be sent home with POP advice and on non-weight bearing crutches
• Follow-up in a week or 10 days(to check for the position-whether maintain or displaced as edema has subsided and the POP might become loose.Note:this check Xray is not to check for union)
• Then patient is advice to come in a month time.A check Xray is done on that follow-up and if there is element of bridging callus then his FLPOP will be converted to patellar tendon bearing cast.He is then ask to come again after six weeks with advice to move and mobilise his knee and a partial weight bearing (so on next follow-up the total duration on cast is three months )
• During this visit Check X ray to be done after POP is removed and he is examined for clinical union at the fracture site(no movement no pain)If there is still some tenderness he will be given a tibial brace and he is allow to start walking on single crutch and slowly and gradually putting weight.This is so when there is increasing evidence of callus formation.

general overview of trauma-2

Musculoskeletal healing following acute traumatic injury will results in the following:

• restoration of original tissue
• scar
• Excessive repair
• failure of healing

There are four variables that influnce healing and extend of injury

• The injury itself

1. type
2. intensity
3. duration

• patient factor

1. age
2. metabolic state
3. disease and its modification

• tissue types

1. bone
2. cartilage
3. muscle
4. skin

• Treatment

1. apposition
2. stabilization
3. loading and motion

Where as in nervous tissue the results is not as good.
It can be divided into either injury in peripheral nerve or in central nervous system
in peripheral nerves
it depens either cut or crush injury.There will mild degenerative changes of the neuron and the distal ends will undergoes wallerian degeneration. Within 48 hrs the axon disintegrates and myelin becomes fatty droplets.The Schwann cells survives and engulf the degenerative tissue =autophagosomes.
The Schwann cells proliferate to established continuity with sprouting axons elongates along the tract of degenerated tissue by 20mm/week=1mm/d.
Within 6 months to one year and good apposition good restoration of function is expected.Otherwise there will be formation of traumatic neuroma and the distal nerve remnants dissapear and muscles become severely atrophied.

In CNS
the affected cells undergo chromatolysis and necrosis with proliferating neuroglia cells to become dense glial scar.Oligodendroglia will take the place of schwan cells.
After initial swelling with inflammation which later subsides there will gradual improvement and that depends on the improved utilization of the residual undamaged pathway with some limited new fibres maybe formed and it take places in nine to 12 months

General overview on fractures-1

Fantastic facts about bone.Whenever it fractures it always wants to heals.When it heals the quality of the replacement tissue(which is the bone)is similar to the quality prior to fractures. Failure to unite is due to the extrinsic factors rather than from the bone itself.
There are two factors that affect the bone healing:
a)biological factors(either systemic or regional)
b)mechanical factors which deals with stability factor.
The treating doctor only tries to optimise these two factors.

What is the aim of treating patient with fracture?
The aim is to get back the patient to his original status as soon as possible.Note that the aim is not just to get bone unites.The aspect of rehabilitation is of paramount important.There is a situation where the bone unites but the patient cannot go to his work because of stiff joints or weak atrophied muscles.

We termed this condition as "fracture disease" where the bone union is achieved but during the course of treatment,the joint got stiff,muscle become atrophied and the bone become osteoporotic.
To overcome this the patient need to be able to do rehabilitation program as soon as possible by mobilising the joints and strengthening the muscles.
This required fracture to be stabilised and the joint is free to move.To achieve this situation patient need to do surgery, the fractures are reduced and stabilized with implants and the joints are free to move and to be involved in rehabilitation program.
So the main objective of open reduction and internal fixation is to get patient into early rehabilitation process.
However open reduction and internal fixation is not without problem.Most important is the risk of infection and delayed in union.Putting implants especially using plates jeopardise the blood supply to the bone.
To overcome this, new techniques of using:
a)close reduction and internal fixation usually intramedullary nailing is done
b)MIPO technique.MIPO=Minimal invasive percutaneous osteosynthesis.

Newer implants design also done to minimise vascular disruption such as LCP plates and interlocking nails.
Generally intramedullary nails are preferred implants compared to plates as they are less disruptive to blood supply to bone.

The stages of fracture management are as follows:

a)Treatment at the scene of injury /initial treatment :
Most important is splinting of fractures.The benefits of splinting:

• Reduces pain
• Minimises further injury

b)Reduction either close or open
c)Stabilization either POP or implants

where as for open fractures

a)wound debridement must be done should be within 6-8hours(golden time) otherwise risk of infection increases with delay.The said golden time is because this is a period where the body immune systems are fighting with organisms and without any debridement the organism always win and multiply exponentially after 6-8 hours.

b)stabilised either using POP or external fixator.With POP a window should be created to allow dressing of wound.The external fixator has dual function:

• stabilise the fracture
• allow wound management ie:dressing,redebridement,skin graft or flaps)