conservative treatment of fractures
DESCRIPTION
CONSERVATIVE TREATMENT OF FRACTURES. Dr. Muhammad ASIF Orthopedic Surgeon Department of Orthopaedics College of Medicine King Khalid University Hospital. Fracture management. - PowerPoint PPT PresentationTRANSCRIPT
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CONSERVATIVE CONSERVATIVE TREATMENT OF TREATMENT OF
FRACTURESFRACTURES
Dr. Muhammad ASIFDr. Muhammad ASIF
Orthopedic SurgeonOrthopedic Surgeon
Department of OrthopaedicsDepartment of Orthopaedics
College of MedicineCollege of Medicine
King Khalid University HospitalKing Khalid University Hospital
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Fracture managementFracture management
The ideal goal of fracture management is The ideal goal of fracture management is anatomical reduction and function restoration anatomical reduction and function restoration compatible with the severity of injury, age, compatible with the severity of injury, age, occupation and activity of daily living of injured occupation and activity of daily living of injured patient.patient.
Either Either OperativeOperative Non operative (ConservativeNon operative (Conservative))
TractionTraction Splint (Cast / Slab)Splint (Cast / Slab)
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TractionTraction
TractionTraction is the application of a pulling force to a is the application of a pulling force to a part of the body part of the body
Purpose:Purpose: to reduce, align, and immobilize fractures;to reduce, align, and immobilize fractures;
• Unstable and unfixableUnstable and unfixable When reduction and/or proper length cannot be When reduction and/or proper length cannot be
maintained by static immobilizationmaintained by static immobilization to minimize muscle spasmto minimize muscle spasm to prevent or reduce skeletal deformities or muscle to prevent or reduce skeletal deformities or muscle
contractures.contractures.
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Classification of TractionClassification of Traction
Skin Traction Skin Traction : : is maintained by direct application is maintained by direct application of a pulling force on the patient’s skin . Generally of a pulling force on the patient’s skin . Generally temporary measure. To reduce muscle spasms To reduce muscle spasms To maintain immobilization before surgeryTo maintain immobilization before surgery In childrenIn children
Skeletal Traction Skeletal Traction : : applied to bone by means of a applied to bone by means of a pin or wire surgically inserted into the bone, pin or wire surgically inserted into the bone, providing a strong steady, continuous pull, and providing a strong steady, continuous pull, and can be used for prolonged periods . can be used for prolonged periods .
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Complications of tractionComplications of traction
Neurovascular compromise.Neurovascular compromise. Inadequate fracture alignment..Inadequate fracture alignment.. Skin breakdown .Skin breakdown . Soft tissue injurySoft tissue injury Pin tract infection .Pin tract infection . Osteomyelitis can occur with skeletal traction.Osteomyelitis can occur with skeletal traction.
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Complications of tractionComplications of traction
complications from immobility especially with complications from immobility especially with long term traction and in elder pt.long term traction and in elder pt.
Pressure ulcer Pressure ulcer Pneumonia Pneumonia ConstipationConstipation Anorexia Anorexia Urinary stasis and infection Urinary stasis and infection Venous stasis with DVT Venous stasis with DVT
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General Indications for CASTGeneral Indications for CAST
1. Most fractures in children:1. Most fractures in children:a. Tremendous capacity of remodeling.a. Tremendous capacity of remodeling.b. Non union and stiffness is unlikely.b. Non union and stiffness is unlikely.
2. Undisplaced fracture2. Undisplaced fracture3. 3. Poor bone Quality: Osteoporosis.Poor bone Quality: Osteoporosis.4.4. Unfixable fracture e.g. severe comminuted.Unfixable fracture e.g. severe comminuted.5.5. Systemic contraindication.Systemic contraindication.6.6. Local contraindication.Local contraindication.7.7. Psychosocial problem.Psychosocial problem.
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Splint / CastSplint / Cast
Principle:Principle: To stabilize joint above and joint below the site To stabilize joint above and joint below the site
of injury whenever and wherever is possibleof injury whenever and wherever is possible Objectives:Objectives:
To hold broken bone anatomically to prevent To hold broken bone anatomically to prevent malunion.malunion.
To reduce excessive movements to prevent To reduce excessive movements to prevent non union.non union.
To get early functionTo get early function
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How to Preserve Function?How to Preserve Function?
Immobilize only joint necessary,Immobilize only joint necessary, Range of motion of uninvolved joints.Range of motion of uninvolved joints. Isometric exercise.Isometric exercise. Physiotherapy after cast removal.Physiotherapy after cast removal. Weight bearing whenever possible in case Weight bearing whenever possible in case
of lower limb fracture.of lower limb fracture.
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What are casts made of ?What are casts made of ? The outside, or hard part of the castThe outside, or hard part of the cast, ,
two different kinds of casting materials.two different kinds of casting materials. Plaster (POP)Plaster (POP) - white in color. - white in color.
hemihydrated calcium sulphate.hemihydrated calcium sulphate.
On adding water it solidifies by an exothermic reaction into On adding water it solidifies by an exothermic reaction into hydrated calcium sulphatehydrated calcium sulphate
fiberglassfiberglass - variety of colors, patterns, and designs. - variety of colors, patterns, and designs.
inside of the cast inside of the cast
Cotton and other synthetic materials are used to line Cotton and other synthetic materials are used to line thethe inside of the cast to make it soft and to provide inside of the cast to make it soft and to provide padding around bony areas.padding around bony areas.
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PlasterPlaster is usually used in the early stages of is usually used in the early stages of treatment,treatment, Displaced Fracture that need manipulationDisplaced Fracture that need manipulation can be molded more precisely.can be molded more precisely. heavy heavy must remain dry, water will distort the castmust remain dry, water will distort the cast
FiberglassFiberglass Can be used in Undisplaced Fx if swelling not expectedCan be used in Undisplaced Fx if swelling not expected healing process has already started.healing process has already started. lighter weight, durable, require less maintenancelighter weight, durable, require less maintenance..
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Different types of castsDifferent types of casts
Type of Cast/Slab Location Uses
Short arm Applied below the elbow to the hand.
Distal Forearm or wrist Fx. Also used to hold the forearm or wrist muscles and tendons in place after surgery.
Long arm Applied from the upper arm to the hand.
Distal humerus, elbow, or proximal forearm fractures. Also used to hold the arm or elbow muscles and tendons in place after surgery.
Scaphoid cast/ thumb spica
Below elbow to hand including thumb
Scaphoid Fx, thumb FX
U slab From shoulder to elbow and then to armpit
Humerus shaft fx
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Type of Cast / Slab Location Uses
Short leg cast: Applied to the area below the knee to the foot.
Distal T/F Fx, ankle Fx, severe ankle sprains/strains.
Long leg cast From above knee to foot Proximal T/F Fx,trauma around knee
Hip spica From lower chest to one or both feet
Femur fracture in children
PTB cast From knee to foot For weight bearing in healing Fx T/F
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Closed Reduction MethodClosed Reduction Method
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Closed Reduction MethodClosed Reduction Method Adequate analgesia / anaesthesiaAdequate analgesia / anaesthesia Traction – countertractionTraction – countertraction Increase the deformity if needed, to reduce / Increase the deformity if needed, to reduce /
lock on fragmentslock on fragments Correct rotational deformity as well. Correct rotational deformity as well. Remove any rings from fingers or affected limbsRemove any rings from fingers or affected limbs All acute injuries (<48 hours post injury) All acute injuries (<48 hours post injury)
fully padded well molded plaster, fully padded well molded plaster,
full casts may be splittted.full casts may be splittted.
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After Closed Reduction and After Closed Reduction and CastingCasting
must have circulation checkmust have circulation check Plaster takes 48 hours to become fully dry Plaster takes 48 hours to become fully dry
and harden so take care.and harden so take care. Weekly radiographs for 3 weeks to confirm Weekly radiographs for 3 weeks to confirm
acceptable reduction.acceptable reduction. Can re-manipulate within 3 weeks after Can re-manipulate within 3 weeks after
injury if displaced.injury if displaced.
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Excellent Reduction with Well Excellent Reduction with Well Molded CastMolded Cast
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Colles’ FractureColles’ Fracture
Displaced Displaced dorsolaterrallydorsolaterrally
Treatment:Treatment:
Cast +/- surgery, Cast +/- surgery, depending on depending on shortening and shortening and displacementdisplacement
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Scaphoid Bone FXScaphoid Bone FX
Retrograde blood Retrograde blood supplysupply
Total healing time of Total healing time of 10-12 weeks or more10-12 weeks or more
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Boxer’s FractureBoxer’s Fracture
Classically neck of Classically neck of the the fifth metacarpal
bump over the back bump over the back of palm just below the of palm just below the small finger knucklesmall finger knuckle
Treatment: casting or Treatment: casting or surgery (pinssurgery (pins))
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Patellar FracturePatellar Fracture
Fall onto kneecap or Fall onto kneecap or when quadriceps is when quadriceps is contractingcontracting
Attempt “straight leg Attempt “straight leg raise”raise”
If Extensor mechanism If Extensor mechanism intact / undisplaced Fx intact / undisplaced Fx Cast / Slab Cast / Slab
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Fracture of 5Fracture of 5thth Metatarsal Metatarsal
Avulsion FractureAvulsion Fracture base of 5th metatarsal from pull of attached base of 5th metatarsal from pull of attached
tendon;tendon; heal well in castheal well in cast
Jones FractureJones Fracture Transverse fracture through base of 5th Transverse fracture through base of 5th
metatarsal, about 1-2 cm from tip;metatarsal, about 1-2 cm from tip; cast for 6-8 wks if undisplacedcast for 6-8 wks if undisplaced
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Fracture of 5Fracture of 5thth Metatarsal Metatarsal
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Avulsion FxAvulsion Fx
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Jones’ fractureJones’ fracture
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30 year old patient30 year old patient
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Torus FractureTorus Fracture
““Buckle Buckle fracture”fracture”
mostly in mostly in children; children; metaphysismetaphysis
cast for 2-4cast for 2-4
weeksweeks
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Type 1 S/C Fx humerus:Type 1 S/C Fx humerus:non-displacednon-displaced conservative conservative
Note the non- Note the non- displaced fracture displaced fracture (Red Arrow)(Red Arrow)
Note the posterior fat Note the posterior fat pad (Yellow Arrows)pad (Yellow Arrows)
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Type 2: Angulated/displaced fracture with intact Type 2: Angulated/displaced fracture with intact posterior cortex;posterior cortex;
close reduction and K-wires fixation close reduction and K-wires fixation
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Type 3: Complete displacement, with no contact Type 3: Complete displacement, with no contact between fragments;between fragments;
close / open reduction and K-Wire fixation close / open reduction and K-Wire fixation
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UNDISPLACED FRCTURE UNDISPLACED FRCTURE LATERAL CONDYLELATERAL CONDYLE
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Fracture surgical neck humerus,Fracture surgical neck humerus,10 year old10 year old
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Post Cast instructionsPost Cast instructions Keep your limb elevated to prevent swelling. Apply an ice bag to injured area. Keep the cast clean and dry. Check for cracks or breaks in the cast. Rough edges should be padded to protect the skin
from scratches. Do not scratch the skin under the cast by inserting
sticks. Encourage patient to move his/her fingers or toes to
promote circulation
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ContdContd
Prevent small toys or objects from being put inside the cast.
Do not put powders or lotion inside the cast. Cover the cast while your child is eating to prevent
food spills and crumbs from entering the cast. Do not use the abduction bar on the cast to lift or
carry the child. Use a diaper or sanitary napkin around the genital
area to prevent leakage or splashing of urine.
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How To Know if Something Is How To Know if Something Is Wrong With Your CastWrong With Your Cast
Pain Pain that is not adequately controlled with medication that is not adequately controlled with medication prescribed by your doctor.prescribed by your doctor.
IncreasingIncreasing swelling swelling Numbness or tingling Numbness or tingling in the extremity (hand or foot).in the extremity (hand or foot). Inability to move Inability to move your fingers or toes beyond the cast.your fingers or toes beyond the cast. Circulation problems Circulation problems in your hand or foot. in your hand or foot. Loosening, splitting or breaking Loosening, splitting or breaking of the cast.of the cast. Unusual odorsUnusual odors, sensations, or , sensations, or woundswounds beneath the beneath the
cast.cast. If you develop a If you develop a feverfever or generalized illness or generalized illness
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Complications of castComplications of cast
Compartment syndrome, tight cast that restricts Compartment syndrome, tight cast that restricts swelling.swelling.
Impaired distal neurovascular.Impaired distal neurovascular. most serious is deep venous thrombosis leading most serious is deep venous thrombosis leading
to pulmonary embolism----calf pain.to pulmonary embolism----calf pain. Re displacement of fracture.Re displacement of fracture. stiff joints, muscle wasting.stiff joints, muscle wasting. Plaster Sores.Plaster Sores. Malunion, Nonunion, Delayed unionMalunion, Nonunion, Delayed union
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Cast Burns- can Cast Burns- can occur during cast occur during cast removal if blade dull removal if blade dull or improper technique or improper technique used.used.
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Fracture distal Radius & ulnaFracture distal Radius & ulna
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Close reduction and castingClose reduction and casting
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Fracture HealedFracture Healed
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Fx distal Radius ulna in a ChildFx distal Radius ulna in a Child
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After Close reduction and castingAfter Close reduction and casting
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One week follow up; AngulatedOne week follow up; Angulated
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Surgery; Surgery; close reduction and fixationclose reduction and fixation
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HealedHealed
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21 year old patient21 year old patient
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THANKSTHANKS