Reduction of Fracture .
Def.: realign into the normal position, or as near to the
normal anatomical position as possible
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Immobilization of Fracture fragments long enough to
allow union.
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Rehabilitation of Soft tissues and Joints.
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Students must be able to identify various
methods of fracture reduction.
Students must be able to differentiate
management strategies in treatment of various
types of fractures ,dislocations and soft tissue
injuries.
Students must be able outline types of traction
procedures.
Students must be able to recognize various
surgical methods of fracture reduction .
Students must be able outline types of
management of musculoskeletal injuries.
 Closed
Reduction
 Open Reduction.
 Mechanical
traction
manipulation
with
or
without
Closed manipulation:
Def.: No surgical intervention is used, the # being
manipulated by hand under local or general anesthesia.
 No need for reduction e.g. # clavicle, may heal with a
bump which may be a problem only in the cosmetic
sense but normal function will be restored without any
intervention.
 imperfect apposition of the fragments can be accepted
much more readily than imperfect alignment..
Open reduction
Def.: the area has been surgically opened and
reduced.
 When an acceptable reduction cannot be obtained
 fractures involving articular surfaces
 when the fracture is complicated by damage to a
nerve or artery.
 When operative reduction is resorted, fragments
fixed internally to ensure that the position is
maintained.
Mechanical traction
 Applied when the contraction of large muscles exerts a
strong displacing force, to draw the fragments out to the
normal length of the bone. e.g. # the shaft of the femur,
cervical spine.
 There are two basic types of traction: skin and skeletal
 Traction may be applied either by weights or by a screw
device, and the aim may be to gain full reduction
(rapidly at one sitting with anaesthesia), or gradual
reduction (by prolonged traction without anaesthesia).
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It is applied by means of Adhesive plaster strapping stuck
directly to skin.
The Weight is applied to bone indirectly via the soft
tissues to bone.
It is suitable for children (gallows traction)&as a
temporary measure in adults.
Gallows (Bryant) Traction
 It is used for a child under the age of three with # femur
of 2-3 weeks.
 Both legs are suspended vertically by strong tapes,
thereby lifting the buttocks off the bed and applying
traction to the femur
Buck's Traction
 It is widely used for femoral fractures, low back pain,
acetabular fractures and hip fractures.
Dunlop traction
 It
is used for a displaced
supracondylar # (more common in
children).
 The child in supine position, the
forearm is held in the vertical
position with the humerus in 90° of
abd. & clear of the bed.
 The pull on the forearm gives a
vertical force on the radius and ulna,
elbow joint and the distal third of the
humerus, which pulls the bone ends
into place.
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Traction is applied to pins passed through bone.
It used to manage # of femoral or tibial shaft, unstable
cervical spine fractures
The common site for insertion of pins are Upper end of
Tibia, Calcaneum, Distal Femur, Olecranon.
Thomas splint
 Femoral shaft #
 Steinmann or Denham pin is
surgically inserted behind the
tibial tubercle so that an
appropriate weight can be
attached to it.
 A longitudinal force is exerted
through the tibia on to the
quadriceps, hamstrings & knee
joint.
 Thus the lower end of the femur
is pulled into correct alignment.
If too much weight is applied the
femoral length will be
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Skeletal traction provided by a Thomas splint. A: The top ring provides one point of traction. The
traction cord is attached to the skeletal pin and to the end of the Thomas splint. B: A 'lively"
system may be preferred, which may be achieved in various ways, e.g. by weights and a system
of pulleys (1). The suspension cord may be arranged in a Y-fashion to straddle both irons of the
Thomas splint (2). Although it is often attempted, support for the proximal end of the splint (3) is
less clearly of benefit as it may cause extra pressure beneath the ring (4).
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Over distraction
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Loss of Position
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Pressure Sores
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Pin Track Infection.
*The objectives of immobilising a fracture are:
• to maintain the reduction
• to provide the optimal healing environment for the
fracture
• to relieve pain.
 Common methods of fracture immobilization:
 conservative, with an external fixation device (plaster
of Paris - POP, splints, etc.)
 External fixators
 Internal fixation.
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Immobilization in slings, collar and cuff (c&c),
Tubigrip, splints, POP, Functional bracing and other
such methods all fall into this category.
Skin or skeletal traction is also included but this
obviously requires hospitalization.
All other forms of conservative immobilization either
need only 1-2 days hospitalization or, as in most cases,
none at all.
These are cheap & easy to apply but the anatomical
area of the fracture indicate this choice.
Slings & collar and cuff
*Used only in UL # & there are 4 types of
immobilization.
A- A simple triangular bandage or broad arm sling
 It used to support the weight of forearm & hand, thus
relieving the weight on the upper arm.
 It can be used for # or injuries around the shoulder,
humerus or elbow.
B- A collar and cuff (c & c).
 It used to support the whole forearm/arm.
 It is support from the wrist only. Thus the c&c takes the
weight of the forearm but the humerus is left
unsupported so that a gravitational traction force is
exerted on it, allowing longitudinal correction of shaft #.
C- A high sling
 It supports the whole arm, keeping the hand/wrist in
elevation so reducing the risk of swelling in the hand.
 It used in hand, wrist and forearm # treated either with
or without POP or external splint.
 The patient should be encouraged to remove the sling to
exercise the limb through as full range as possible, and
then to return the limb to the elevated position.
D- A body bandage
 It is a sling supports the arm, as with the triangular
bandage, but the arm is then bandaged to the side, so it
can only be worn under the clothes.
 It is used to prevent move. of the upper arm, especially
in the very early stages (1-10 days) after # the neck/head
of humerus or after shoulder surgery.
 It offers extreme support but does loosen in time &
needs to be reapplied regularly.
With any form of sling or c&c,
 the patient must keep the non-painful joints moving
and, when possible contract all muscles isometrically
to maintain minimal tone.
 It is very important that the patient notes any changes
in sensation (numbness or paresthesia), colour
(bluish), severe increase in swelling or loss of motor
function in the hand/wrist (signs of complications).
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Plaster of Paris (POP)
Gypsona-impregnated bandages, used to maintain bone
and joint position.
The bandages, after being soaked in cold water, produce
a semi-liquid POP and are then moulded to the part,
encompassing the joints above & below the #.
After 20-30 minutes the POP starts to dry and hold its
shape, but full drying takes up to 24 hours, so
weightbearing must be delayed at least until after this
time.
Disadvantages
The advantages of POP
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Cheap
easy to apply
Immobilized most # sites
It is easily reinforced or
replaced
It can be placed over small
wounds or scars after they
have been dressed.
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Potential vascular occlusion
pressure sores
Undiagnosed infection
Joint stiffness.
Weight of cast, especially in
LL.
It is quite warm and itchy
If wet it will disintegrate
In children, if they put items
between the skin and the
cast, may cause undetected
pressure
sores
and/or
infection.
When dry, it become rigid
& brittle causing cracking.
A normal Gypsona POP is applied with a synthetic bandage
overcoat. (lighter, durable and integrated when wet BUT
expensive)
 # in young patient or if patient has more than one #, a
synthetic cast (fibreglass, polypropylene) may be applied.
*Trade names include Dynacast Extra (a rigid fibreglass
bandage), Dynacast Optima (a high-performance polypropylene
casting tape.
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A dynamic or Functional bracing (cast)
 It
control movement at a joint while
maintaining the position and stability of the #.
 Patient hospitalization time is reduced and
function and joint mobility can start earlier.
 It used for # shaft of femur, tibia, radius and
ulna and lower humerus.
 It is very expensive.
A dynamic or Functional bracing (cast)
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Pins or wires are driven into the bony fragments and
held by a piece of apparatus on the outside of the body,
either to one side of the bone at both sides with a ring at
the top and bottom of the frame
Used for fractures that are
too unstable for a cast.
Allows correction of deformities
by moving the pins in relation to
the frame.
Advantages:
1. Can be used in Patients with Infection
2. Skin loss
3. Position of Fragments can be adjusted.
4. treatment of Angular deformities and Nonunion or
Malunion.
5. Limb lengthening, correction of deformity.
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'ORIF. This stands for 'open reduction internal
fixation' and describes the act of reducing the fracture
at the time of fixing it internally.
The type of internal fixation depends on the position
and extent of the # & the size, texture and strength of
the bone.
e.g. screws, plates, intramedullary nails, locking
nails, wires or nail-plates (sliding or compression)
Indication:
 Fractures cannot be controlled in any other way, i.e.
other methods of immobilization have failed
 Patients have # of more than one bone
 If the # cause injury to the blood supply of the limb,
to protect vessels.
 Bone ends cannot be reduced without opening the
fracture site to remove muscle and soft tissue debris.
 Displaced & intra articular fractures
Advantages:
 Better chances of obtaining good reduction and union
 Early mobilization both generally and specifically.
Disadvantages:
 Risk of infection
 Skin Necrosis
 Neurovascular Damage
 Additional trauma of surgery to bone and surrounding tissue.
 It can convert a closed fracture into an open fracture.
 The implants may be removed 12-18 months in the future or if
they start to become a problem
This method is applicable to long bones.
 Usually a single six-hole plate suffices & eight-hole
plate for larger bones.
 Screws (Cortical or Cancellous):
A Hole is first drilled at a chosen angle and tapped to
take screw.
 Plates:
Used to hold bones in correct position, compress the
two bone ends together.
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# of the long bones, especially when the
fracture is near the middle of the shaft.
It prevent shortening and rotation
With or without locking screw
It is used for a segmental
Fracture.
Screws are passed through bone
above and below the fracture to
hold bone out to length.
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It is a standard method of fixation for # of the neck of
the femur and for trochanteric #.
The screw component, which grips the femoral head,
slides telescopically in the barrel to allow the bone
fragments to be compressed together across the
fracture.
This compression effect is brought about by
tightening a screw in the base of the barrel.
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Tension band Wiring: Wire is applied as a loop to the
outer side of fracture, so that it comes under tension
when the Joint is flexed. e.g. # Patella, olecranon,
medial malleolus.
It uses the mechanical principle of converting the
tensile stresses of the muscles acting on the bone
fragment, into a compressive force at the fracture site
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Active use
Active exercises
Continuous passive motion