Treatment of a fracture can be considered in three phases:

• Phase I – Emergency care
• Phase II – Definitive care
• Phase III – Rehabilitation

PHASE I – EMERGENCY CARE

At the site of accident: Emergency care of a fracture
begins at the site of the accident. In principle, it
consists of RICE, which means:

• Rest to the part, by splinting./li>
• Ice therapy, to reduce occurrence of swelling
• Compression, to reduce swelling
• Elevation, to reduce swelling

In the emergency department:

Soon after a patient with a musculo-skeletal trauma is received in an emergency department, one has to act in a coordinated way. It is most important to provide, if required, basic life support (BLS). If in shock, the patient is stabilised before any definitive orthopaedic treatment is carried out.

A quick evaluation of the extent of injury at this stage enables a doctor to understand the seriousness of the problem.

The fractured limb is examined to exclude injury to nerves or vessels. As soon as the general condition of the patient is stablised, the limb is splinted. It is important to check the bandaging done elsewhere, as it may be too tight.

In a case with suspected head injury, narcotic analgesics should be avoided. A broad spectrum antibiotic may be given to those with open fractures.

It is only after the emergency care has been given, and it is ensured that the patient is stable. He should be sent for suitable radiological and other investigations, under supervision.

PHASE II – DEFINITIVE CARE

Fundamental principles of fracture treatment: The three fundamental principles of treatment of a fracture are: (i) reduction; (ii) immobilisation; and (iii) preservation of functions.

• Reduction is the technique of ‘setting’ a displaced
  fracture to proper alignment. This may be done
  non-operatively or operatively, so-called closed and
  open reduction respectively.
• Immobilisation is necessary to maintain the
  bones in reduced position. This may be done by
  external immobilisation such as plaster etc., or by
  internal fixation of the fracture using rods, plates,
  screw etc
• To preserve the functions of the limb, physiotherapy
  all throughout the treatment, even when the limb
  is immobilised, is necessary.

NON-OPERATIVE METHODS

Most fractures can be immobilised by one of the following non-operative methods:

• • Strapping: The fractured part is strapped to an adjacent part of the body e.g., a phalanx fracture,where one finger is strapped to the adjacent norma finger
  • Sling: A fracture of the upper extremity is immobilised in a sling. This is mostly to relieve pain in cases where strict immobilisation is not necessary e.g., triangular sling used for a fracture of the clavicle.
  • Cast immobilisation: This is the most common method of immobilisation. Plaster-of-Paris casts have been in use for a long time

Plaster of Paris (Gypsum salt) is CaSO4
. ½
H2
O in dry form, which becomes CaSO4
.2H2
O
on wetting. This conversion is an exothermic
reaction and is irreversible.

OPERATIVE METHODS

Internal fixation:

In this method, the fracture, once
reduced, is held internally with the help of some
metallic or non-metallic device (implant), such as
steel wire, screw, plate, Kirschner wire (K-wire),
intra-medullary nail etc. These implants are made
of high quality stainless steel to which the body is
inert.

Indications:

Internal fixation of fractures may be indicated under the following circumstances:

• When a fracture is so unstable that it is difficult
  to maintain it in an acceptable position by nonoperative means. This is the most frequent
  indication for internal fixation
• As a treatment of choice in some fractures, in
  order to secure rigid immobilisation and to
  allow early mobility of the patient
• When it has been necessary to perform open
  reduction for any other reason such as an
  associated neurovascular injury

Methods:

• Steel wire: A gauge 18 or 20 steel wire is used
  for internal fixation of small fractures (e.g.,
  fracture of the patella, comminuted fragments
  of large bones etc.).
• Kirschner wire: It is a straight stainless steel
  wire, 1-3 mm in diameter. It is used for the
  fixation of small bones of the hands and feet.
• Intra-medullary nail: It is erroneously
  called ‘nail’, but in fact is a hollow rod made of stainless steel. This can be introduced into the medullary cavity of the long bones such as
  femur and tibia.
• Screws: These can be used for fixing small
  fragments of bone to the main bone (e.g., for
  fixation of medial malleolus).
• Screws: These can be used for fixing small
  fragments of bone to the main bone (e.g., for
  fixation of medial malleolus).
• Plate and screws: This is a device which can
  be fixed on the surface of a bone with the help of
  screws. Different thicknesses, shapes and sizes
  are available
• Special, fracture specific implants: These
  are used for internal fixation of some fractures
• Combination: A combination of the above
  mentioned implants can be used for a given
  fracture

Advantages of internal fixation

It allows early mobility of the patient out of bed and hospital. Joints do not get stiff and the muscle functions remain good. The complications associated with
confinement of a patient to bed are also avoided.

Disadvantages:

The disadvantages of internal
fixation are infection and non-union. It needs a
trained orthopaedic surgeon, free availability of
implants and a good operation theatre; failing
which, the results of internal fixation may not only
be poor but disastrous.

External fixator

This method is useful in the
treatment of open fractures where internal fixation
cannot be carried out due to risk of infection.These are of the following type:

• • Pin fixators: In these, 3–4 mm sized pins are
    passed through the bone. The same are held
    outside the bone with the help of a variety of
    tubular rods and clamps

4

• Ring fixators: In thesethin ‘K’ wires (1–2 mm)
  are passed through the bone. The same are held
  outside the bone with rings

PHASE III – REHABILITATION OF A FRACTURED LIMB

Rehabilitation of a fractured limb begins at the
time of injury, and goes on till maximum possible
functions have been regained. It consists of joint mobilisation, muscle re-education exercises and instructions regarding gait training.</p >

Joint mobilisation:

The joint adjacent to an injured
bone tends to get stiff due to:

(i) immobilisation;

(ii)
inability to move the joints due to pain;

(iii)
associated injury to the joint as well.

To prevent stiffness, the joint should be mobilised as soon as
possible. This is done initially by passive mobilisation

Motorized devices which slowly move the joint through a
predetermined range of motion can be used. These
are called continuous passive motion (CPM) machines.

Muscle re-education exercises:

During immobilisation: Even while a fracture
is immobilised, the joints which are out of the
plaster, should be moved to prevent stiffness
and wasting of muscles.

After removal of immobilisation: After a limb is
immobilised for some period, it gets stiff. As
the plaster is removed, the following care is
required:

• The skin is cleaned, scales removed, and some
  oil applied.
• The joints are moved to regain the range
  of motion.
• The muscles wasted due to prolonged
  immobilisation are exercised.

Functional use of the limb

Once a fracture is on
way to union, at a suitable opportunity, the limb is
put to use in a guarded way. For example, in lower
limb injuries, gradual weight bearing is started –
partial followed by full. One may need to support
the limb in a brace, caliper, cast etc. Walking aids
such as a walker, a pair of crutches, stick etc.

MANAGEMENT OF OPEN FRACTURES

MANAGEMENT OF OPEN FRACTURES
A fracture is called open (compound) when there
is a break in the overlying skin and soft tissues,
establishing communication between the fracture
and the external environment. Three specific
consequences may result from this

• Infection of bone: Contamination of the wound
  with bacteria from the outside environment may
  lead to infection of the bone (osteomyelitis).
• Inability to use traditional methods: A small
  wound can be managed through a window
  in a plaster cast.
• Problems related to union: Non-union and malunion occur commonly in open fractures.