Lecture 3&4

Principles of fracture management
Reduction –
may be achieved by local anaesthetic block, sedation and
analgesia or general anaesthetic. Traction,closed, or open reduction
procedures may be used.
Stabilisation - application of plaster cast, percutaneous wires, plate and

screws, external fixator or intra-medullary nails may be required. This decision
is made according to fracture pattern and complexity
Immobilisation - a period of immobilization in a cast may be required even

after fixation with implants.
Rehabilitation - range of motion along with muscle strengthening exercises

must begin as early as is practical but must not compromise fracture healing.
Advanced Trauma Life Support (ATLS)
Primary survey
A - Airway with C-spine control - treatment of any threat to the airway with
manoeuvres such as chin lift and jaw thrust, use of adjuncts (oro- and nasopharyngeal
airways) or securing it with a cuffed endotracheal tube or
tracheostomy. Throughout the resuscitation process, the cervical (C-) spine
must be immobilised in a hard collar and this must be continued until
the spine is cleared clinically and radiologically.
B - Breathing - thorough examination including palpation, percussion,

auscultation and on to chest X-ray to identify and treat life-threatening
conditions such as airways obstruction (treated with removal of obstruction,
bronchoscopy or tracheostomy), tension pneumothorax and massive
haemothorax (both treated with a chest drain)
C - Circulation and haemorrhage control - haemorrhage is a major cause

of preventable death in trauma. Two large-bore intravenous lines are
established and crystalloid solution given followed, if necessary, by blood
products. External bleeding is controlled by direct pressure. Occult bleeding
may be into the chest, abdomen, pelvis or long bone fractures. Severe
abdominal or thoracic haemorrhage may require emergency laparotomy or
thoracotomy to control bleeding. Pelvic fracture causing bleeding may initially
be controlled with a pelvic binder but may require laparotomy with pelvic
packing or interventional radiology and embolisation.
D - Disability - assessment of neurological function using the Glasgow Coma
Score (GCS) and examination of pupil light reflexes. Alteration of conscious
level indicates a need to re-evaluate oxygenation, ventilation and perfusion
status. Alcohol, drugs and hypoglycaemia may influence consciousness level.
If these causes are ruled out, traumatic brain injury must be considered and
searched for.
E - Exposure/Environment - the patient must be fully exposed and examined

thoroughly for major injuries. Then warming blankets must be applied.
Secondary survey
This entails a complete history and head to toe examination performed at a
time when the patient has been stabilised. Every part of the body must be
examined and appropriate X-rays obtained to rule out other injuries. Any
deterioration in the patient’s vital signs means the primary survey should restart
at the Airway stage to identify a cause.
ORTHOPEDIC IMPLANTS:
 Screws
 Plates ( DCP, locking plates, recon plates)
 Nails ( ILN, IMN, PFN, RUSH NAILS)
 DHS, DCS
 K-wires
 Hip prosthesis ( cemented, non cemented)
 Knee prosthesis
 Shoulder prosthesis.
COMMON SPECIFIC FRACTURES:

Intracapsular fractures (neck of femur)
Extracapsular (intertrochanteric, subtrochanteric)
Intracapsular hip fractures
The fracture line is proximal to the insertion of the hip capsule on the femoral
neck. A displaced fracture disrupts the retinacular arteries that run up the
neck, cutting the blood supply to the weight-bearing femoral head. If the head
is subsequently fixed back in place, there is a high risk of it dying and
collapsing due to avascular necrosis (AVN). Therefore, if displaced, the head
is cut out (excised) and replaced with a half (hemi) or total hip replacement
(arthroplasty). If entirely undisplaced, the head may be retained and fixed with
screws (relying on the assumption that the lack of fracture displacement
means the arteries are undamaged).
CRITERIA FOR TYPE OF FIXATION/IMPLANT USE IN NOF fracture:
Undisplaced :
Less than 60 years : AO screws fixation
More than 60 years AO screws fixation
Displaced :
Less than 60: AO screws

More than 60: hemiarthroplasty or total hip replacement (THR)
Hemiarthroplasty:
Non community ambulant

Multiple comorbid
Not fit for prolonged anesthesia
Poor socioeconomic status
THR:
Community ambulant
No or less comorbids
Patients demand
Complications of screw fixation include infection, non-union, loss of position
and femoral head AVN (if painful, requires total hip replacement).
Complications of hip (hemi)arthroplasty : wear through the acetabulum

(requiring total hip arthroplasty)
Complication of THR: infection and dislocation`

Extracapsular hip fractures:
The fracture line is distal to the insertion of the capsule and therefore there is
no risk of AVN.
Intertrochanteric fractures are usually treated by fixation with a special plate

and screw called a dynamic hip screw (DHS). The screw grips into the
femoral head and can slide down through plate barrel (yellow arrow on
diagram), allowing the fracture to compress and heal.
Complex fracture configurations involving more pieces (4-part or if involving
the lesser trochanter) will be more unstable and are often treated with a
proximal femoral nail.
Subtrochanteric fractures are inherently unstable due to the position of the

fracture and require fixation with a proximal femoral nail.
THR POST OP PROTOCOL:
(Precautions and exercises from lecture ).

Lecture 3&4

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Lecture 3&4

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Principles of fracture management

Stabilisation - application of plaster cast, percutaneous wires, plate and

Immobilisation - a period of immobilization in a cast may be required even

Rehabilitation - range of motion along with muscle strengthening exercises

Advanced Trauma Life Support (ATLS)

B - Breathing - thorough examination including palpation, percussion,

C - Circulation and haemorrhage control - haemorrhage is a major cause

E - Exposure/Environment - the patient must be fully exposed and examined

COMMON SPECIFIC FRACTURES:

Intracapsular hip fractures

CRITERIA FOR TYPE OF FIXATION/IMPLANT USE IN NOF fracture:

Less than 60: AO screws

Non community ambulant

Complications of hip (hemi)arthroplasty : wear through the acetabulum

Complication of THR: infection and dislocation`

Intertrochanteric fractures are usually treated by fixation with a special plate

Subtrochanteric fractures are inherently unstable due to the position of the

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