Fracture Treatment

Local anesthesia

Adequate anesthesia is the first step toward successful bone alignment. The fracture site is treated with iodine, and the skin is infiltrated in an «orange peel» pattern with a 1–2% procaine solution.

Then the needle is advanced deep toward the bone. The key criterion for the correct needle position is obtaining a stream of blood in the syringe when pulling the plunger back. This indicates entry into the interfragmentary hematoma. Only after this is 20 ml of anesthetic administered. If there is no blood, administering the solution will not provide pain relief—the needle must be withdrawn and the puncture repeated more precisely.

Manual reduction of bone fragments

The main principle of any reduction: all manipulations are performed on the distal (peripheral) fragment, since the central fragment is rigidly displaced by muscles and uncontrollable.

• Correction of rotational displacement: the peripheral part of the limb is positioned correctly relative to the longitudinal axis. Rotation is performed in the direction opposite to the displacement. Exception: fractures of the middle and lower thirds of the forearm, where the limb is placed in a neutral position between supination and pronation.
• Elimination of angular displacement: the physician exerts longitudinal traction on the distal part, while the assistant rigidly fixes the central fragment with their hands. This restores the longitudinal axis of the limb.

Immobilization with plaster casts

Slab or circular slab-plaster casts are used for fixation. The length of the slab is measured with a regular piece of bandage. When applying circular turns, bandaging is done loosely, without tension.

The physician is obliged to monitor the condition of the limb to prevent complications:

1. Limb compression: manifests as pain, a feeling of fullness, cyanosis, coldness, and edema of the fingers. Fever and tachycardia may occur. Management: immediately cut the bandage and spread the edges. If the edema has subsided and the color has normalized, the cast is reinforced with new turns of the bandage.
2. Pressure ulcers: manifested by localized pain at a specific point under the cast. Management: bivalve the cast at the site of pain or cut out an inspection "window".

Skeletal traction

For successful conservative treatment by traction, four rules are observed:

1. Mid-physiological position: the limb is placed on functional splints (Böhler, Bogdanov) in a semi-flexed state to balance the antagonistic muscles.
2. Rule of axes: traction is performed strictly along the axis of the proximal fragment.
3. Load dosing: the weight of the load is increased gradually for painless muscle stretching.
4. Creation of counter-traction: the foot of the bed is elevated, using the patient's body weight as a counterweight.

The procedure is performed in the operating room. A Kirschner wire or TsITO wire is drilled through the bone under local anesthesia (anesthetizing the skin, subcutaneous tissue, and periosteum). To prevent the wire from cutting through the bone tissue during traction, it is tightly tensioned with screws in a special caliper. To prevent foot drop (pes equinus), a bandage is glued to the sole, which is fixed via a pulley with a small weight.

Surgical treatment (osteosynthesis)

Surgical intervention has strict selection criteria.

Absolute indications:

• Open fractures.
• Damage by fragments to vital organs, major blood vessels, nerves, spinal cord, or brain.
• Interposition of soft tissues (entrapment of muscles or fascia between fragments, blocking union).
• Pseudarthrosis and purulent-inflammatory complications.
• Malunited fractures with severe functional impairment.

Relative indications include repeated unsuccessful attempts at manual reduction, delayed consolidation, and transverse fractures of long tubular bones that cannot be held conservatively.

Types of fixation:

• Extramedullary osteosynthesis: for example, fixation of the olecranon (Olecranon) with a long screw inserted into the medullary canal of the ulna, tightly pressing the fragment.
• Extra-focal osteosynthesis: application of the Ilizarov apparatus (compression-distraction apparatus). Wires are passed through the bone (Femur, etc.) and attached to external rings connected by rods. The method does not traumatize the fracture zone, preserving the blood supply to the periosteum and bone marrow.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Mechanism of osteogenesis stimulation and phases of callus formation
• Design and rules of application for functional splints (Böhler, Bogdanov)
• Instruments for skeletal traction (TsITO drill, Kirschner stirrups, fixators)
• Pathogenesis of muscle contraction as a cause of secondary fragment displacement
• Principles of operation of the Ilizarov compression-distraction apparatus

Other topics in "CHAPTER 10. GENERAL ISSUES IN TRAUMATOLOGY"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.