Definitive fracture treatment

To reduce the risk of infection, patients with open fractures must be taken to theatre as early as possible and undergo appropriate and adequate debridement of the soft tissues and the fractured ends of the bones under the cover of appropriate antibiotic prophylaxis (see below) and copious lavage with at least 3 l of saline. This can be combined with appropriate internal or external fixation of the fracture.

If the fracture is closed and there is no associated neu-rovascular deficit, the decision to use either conservative or operative treatment will depend on general and local factors. Both forms of treatment have their disadvantage and advantages. General factors include the patient's:

• general fitness;

• involvement in sporting activities and hobbies;

• social and domestic situation;

• ongoing medical conditions that may be debilitating;

• functional demands;

• psychological makeup, which has a dramatic influence on the patient's ability to cope with a particular fracture treatment and the required postfracture rehabilitation.

Local factors include:

• degree of comminution of the fracture (influences stability of fracture);

• whether the fracture involves an articular surface (also influences stability of fracture);

• quality of the bone stock;

• quality of surrounding tissues, particularly the overlying skin;

• most importantly, the tissue environment for the healing of the fracture.

Conservative treatment

Closed reduction can be achieved by skilful manipulation of the fracture, often under image intensifier control with the patient adequately anaesthetized. The fracture, and possibly the joints above and below it, then need to be immobilized using bandaging, plaster of Paris casts (Fig. 22.3) or specialized splints (e.g. Thomas splint). Check radiographs are usually performed after application of a cast or splint to assess the alignment of the fracture.

The advantage of conservative treatment is that there is no formal operation under anaesthesia and the patient is not left with a scar. As the skin integument is not breached, risk of developing a deep infection at the fracture site should be precluded and as the soft tissue is not disrupted, the local environment for the healing of the fractures should not be adversely influenced. Also, conservative treatment precludes the necessity of a second operation which may be required to remove any metallic hardware.

The disadvantage is the necessity of external immobilization, usually of the joint above and below the fracture site, for a prolonged period of time, which results in stiffness of the joints with bone and soft-tissue atrophy, which is called as 'the fracture disease'. Exact anatomical alignment is often not achieved with closed means of treatment and there may therefore be residual deformity.

Operative treatment

This usually involves internal or external fixation of the fracture. External fixation involves the use of specialized frames to maintain the fracture alignment. Internal fixation can involve the use of percutaneous pins or the formal open reduction of the fracture site and then stabilizing the fracture fragments with a combination of screws, plates and pins which are left in situ (Fig. 22.4). Depending on the bone involved and the site of the fracture, intramedullary nails or special internal fixation devices designed for specific fracture configurations can also be used. When the fracture is deemed unfit for fixation or for instance when an elderly patient sustains an intracapsular femoral fracture, a replacement prosthesis is an excellent option.

The advantage of open surgical treatment is that the exact anatomical alignment is often obtained. With good internal

Figure 22.3. Colles fracture treated in a plaster of Paris cast.

fixation, no external fixation is required to augment stability of the fracture. This allows early active mobilization of the joints above and below the fracture, which prevents the development of postfracture stiffness and tissue atrophy, and aids in the rehabilitation of the affected parts. It also allows the patient to get back to work in a shorter time.

The main disadvantage is that the patient requires an anaesthetic. An open procedure is involved and this predisposes to the development of infections. There is a risk of damage to vital structures such as nerves and vessels, and also the local tissue environment of the healing fracture may be affected if there is disruption of the blood supply to the fracture fragments. The combination of loss of fracture haematoma which has factors essential for fracture healing and devascularization of the bone by surgical handling can lead to delayed union or non-union. The patient is left with a postoperative scar that may be cosmetically important to some individuals. Depending on the site and duration of operation, the patient may also require a blood transfusion.

Figure 22.4. Fractured lateral malleolus with talar shift (a & b) and following open reduction and internal fixation (c).

Thromboembolic phenomena, particularly with lower limb fractures, can occur with either conservative or operative treatment. If the patient remains confined to bed for prolonged periods, particularly in skeletal traction where an affected limb is immobilized, antithromboembolic prophylaxis is required. If surgical fracture fixation is satisfactory, then early mobilization may reduce the risk of deep venous thrombosis (DVT); however, if the patient cannot be mobilized early, operative treatment may actually increase the risk of thromboembolic phenomena. The important risk factors in development of a thromboembolic phenomena are past history of DVT, currently taking an oral contraceptive pill, patients with malignancy, prolonged and major surgery on the lower limb and inherited or acquired hypercoagulability.

Bone grafting

Four types of bone grafts are usually recognized: • Autografts: Donor bone is transferred from one site on the patient to another site. The donor site is typically the iliac crest of the pelvis and grafts are cancellous chips or cortic-ocancellous strips which are laid between and over the exposed fracture ends to encourage union at a fracture site or to achieve fusion across a joint.

• Isografts: Grafts transferred between identical twins.

• Allografts: Grafts transferred between individuals of the same species but with a different genetic makeup. Typically this involves the use of cadaveric bone transferred to a living individual as a structural graft.

• Xenografts: Transfer of a graft from a member of one species to a different species.

Autografts are commonly used in the treatment of delayed unions and non-unions to enhance fracture healing, act as a structural support and, as fresh bone grafts contain cells which can theoretically form new bone, possibly to replace lost bone. By using vascularized bone grafts, most commonly fibular grafts, the blood supply to a fracture area can be enhanced and therefore one of the conditions necessary for fracture healing improved.

0 0

Post a comment