NONOPERATIVE FRACTURE TREATMENT
EFFECT OF TREATMENT ON SKELETAL REPAIR PROCESSES
By Dr.D.K DUKE
The skeletal system is very active metabolically with a turnover rate of 3% per year of cortical and 25% per year of cancellous bone.
Marrow stem cells are the seeds not only for hemopoiesis but also for skeletogenesis. Hemopoietic and stromal stem cells have been found escaping continuously into the bloodstream to replace senescent cells throughout the body
The repair of fractures has evolved to accommodate for motion of the fracture fragments.
For many fractures, this motion between fragments appears to stimulate the early repair processes
Rib and clavicle fractures are classic examples of the prompt healing that usually occurs despite,or possibly because of, interfragmentary motion.
Fixation techniques, either operative or nonoperative, which eliminate this stimulus of motion can sacrifice the gift of evolution-tested callus for the possibility of better cosmesis or function.
we must keep in mind that the treatment we select for the fracture is never a neutral factor in the outcome.
mechanisms by which functional motion stimulates callus formation and remodeling are known to be several, including vascular, bioelectric, and biochemical. Some degree of motion at the fracture site stimulates vascular ingrowth from soft tissue as well as from the medullary canal
This vascular ingrowth carries an invasion of cells as well as nutrients to fuel the hypermetabolic response of fracture healing.
Additionally, intermittent loading of the fracture site,either with weight bearing or by muscle activity shifts the piezoelectric balance of the collagen-crystalline matrix.
This appears to be the switch that turns on the bioelectric signals for osteoblasts to form new bone.
Shear and compressive motion between the fracture fragments also break down bone matrix thereby releasing significant amounts of stimulatory factors from their skeletal storehouse promoting bone formation
OPTIONS IN NONOPERATIVE MANAGEMENT OF FRACTURES
reduction by traction and manipulation of the fracture followed by immobilization of the reduced fracture using casts, splints, braces, or other techniques.
a number of common fractures require no reduction and may be effectively treated by symptomatic pain relief, a minimal period of immobilization, and prompt restoration of function.
rest, ice, compression, and elevation (RICE).
The patient should also be prescribed sufficient analgesics to relieve the acute pain of the fracture, which can be quite severe.
Clavicle fracture in the child heals promptly when splinted in a figure-of-8 harness for 2 to 3 weeks.
In the adult, the clavicle fracture is different.
It is the result of a violent injury, which can comminute and displace the fracture fragment significantly.
Nonunion to be about the same as other fractures (3% to 5%).
Splinting of the adult's fractured clavicle with a figure-of-8 harness is often done.
management can often be accomplished best by supporting the weight of the arm in a sling and swath to prevent downward pull on the lateral fragment.
Usually satisfactory clinical alignment can be achieved
The usual treatment of a scapula fracture is bed rest, application of ice, and analgesics.
As the patient becomes ambulatory the limb is supported in a sling and swath (Velpeau bandage ), with the arm held firmly against the chest wall.
The wrap is usually necessary for only 2 to 3 weeks, after which the patient can slowly begin shoulder motion and strengthening exercises.
The shoulder is the most mobile joint in the body and it demands considerable flexibility to maintain its near global range of motion.
Therefore, management of fractures about the shoulder should incorporate a program of early exercises to maintain motion.
Otherwise the shoulder capsule can become progressively stiffer and “frozen”
A fracture of the surgical neck of the humerus in an osteoporotic elderly patient can be consistently and effectively treated by support in a sling, until initial symptoms subside
Early gentle range of shoulder motion at 1 to 2 weeks, followed by progressively more vigorous exercise at 3 to 5 weeks,
Humeral Shaft Fractures
Humeral fracture braces, by allowing elbow motion, can realign the axis of the elbow joint, reduce the fracture, and promote healing.
This technique has significantly improved results to the point that the humeral shaft fracture treated in this way rarely fails to heal.
Fracture brace treatment emphasizes reduction by the force of gravity and functional muscle activity.
A well-vascularized muscle envelope surrounds the humeral shaft
This envelope helps to control the alignment of the fracture in the brace and stimulates callus formation.
Fracture reduction can be accomplished using gravity and the surrounding muscle sleeve.
Isometric muscle contraction in the fracture brace does not deform the fracture; rather, it aligns it.
Muscle function and elbow motion actually serve to align the humeral fracture by restoring the axis of elbow motion to normal relationship with the humeral shaft
HANGING CAST AND HUMERAL BRACE
The undisplaced scaphoid fracture does not require reduction and should be immobilized with a short arm cast extending from below the elbow to the metacarpal heads.
A position of wrist dorsiflexion and radial deviation permits compression of the transverse scaphoid fracture and is the position of choice for immobilization.
The thumb should be in a grasping position with the cast extending across the interphalangeal joint of the thumb
There is no conclusive evidence that prolonged immobilization does in fact prevent nonunion
Bony union can occur without it, and fibrous union can occur in spite of it.
Even though the fracture line is still faintly visible when the plaster is discarded, it usually becomes obliterated during the ensuing 6 to 12 months. Even if fibrous union develops, it is not usually disabling.
PHALANGEAL AND METACARPAL FRACTURES
Torsional or twisting mechanisms are fairly common causes of phalangeal and metacarpal fractures.
Persistent malrotation with overlapping of the injured finger during grasp can impair function of the hand.
This deformation can be corrected not by manipulative reduction but by maintaining joint alignment through functional motion
Particularly of concern is loss of flexion of the MP joint and secondarily loss of motion in the interphalangeal joints
The key to correcting both of these problems is to place the MP joint in maximum flexion of 70 to 90 degrees.
Doing this utilizes the intact dorsal hood as a tension band.
The majority of fractures of the forefoot including phalangeal and metatarsal fractures can be treated by closed nonoperative methods consisting primarily of a compression dressing with subsequent short leg walking cast or brace
Exceptions to this general rule include multiple fractures or fracture dislocations, and selected fractures in zone III of the fifth metatarsal
The usual mechanism producing a calcaneal fracture is a fall onto the heel from a height, resulting in both extraarticular and intraarticular fractures.
Most extraarticular fractures can be treated symptomatically.
If the patient is minimally symptomatic, the foot is first managed by the RICE technique, followed by early mobilization.
Cast immobilization may be considered, but generally it is best to keep immobilization to a minimum because stiffness of the foot from prolonged immobilization during treatment can be a source of long-term functional impairment.
Fractures of the Lateral Malleolus
The sequence of injury to the supinated–externally rotated ankle, as described by Lauge-Hansen,begins usually with a tear of the anterior tibiofibular ligament followed by a fracture at varying levels of the lateral malleolus or fibula
Often the anterior tibiofibular ligament stretches but remains intact.
The fracture of the lateral malleolus then occurs at the level of the ankle join
This stable fracture without shortening or malrotation of the fibula can be treated much like a sprain without reduction. An air brace support is helpful for early functional recovery
If the lateral malleolus is shortened or malrotated, a more unstable ankle is the result and generally requires operative treatment.
An isolated fracture of the fibula, without a tibial fracture, can occur from a direct impact, such asa kick.
These fractures are comminuted and contrast with the usual fibular fracture occurring from an indirect mechanism, which tends to be oblique or spiral.
The comminuted, isolated fracture of the fibula can be treated symptomatically.
This may require a short leg-walking cast for 4 weeks, after which full weight bearing is usually possible.
Fractures of the Lateral Tibial Plateau
The classic valgus injury to the extended knee produces a lateral plateau fracture
This is usually a stable injury if the fibula has remained intact.
The support of the intact fibula prevents the articular surface of the lateral plateau from depressing further
The overlying large lateral meniscus protects the joint surface itself.
FRACTURE TIBIA AND STRESS FRACTURES
Undisplaced tibial fractures require no reduction and can generally be managed by functional braces or a weight-bearing cast.
Management of tibial stress fractures has been problematic because they most often occur in active young individuals such as military recruits and athletes
pain and swelling localized typically to the middle of the tibia, within 6 to 12 weeks after beginning vigorous running or forced marching.
The patient presents with a slight limp and has tenderness to palpation
An undisplaced intertrochanteric fractures in the young male need not necessarily require internal fixation.
The strong cortical bone of the intertrochanteric region in the younger patient often minimizes comminution of the fracture and thereby prevents shortening or varus angulation.
This allows for treatment by a brief period of bed rest (1 to 2 days), symptomatic pain relief, and partial weight bearing on crutches
Approximately half of pelvic fractures result from severe trauma such as motor vehicle accidents or falls from height
The other half are caused by moderate trauma such as a fall from a standing height.
Most consistently the less severe mechanism occurs in the older age group and fractures one or both rami
Many of these can be treated symptomatically without hospitalization
Operative external or internal fixation should also be considered when the fracture demonstrates clinical instability, as evidenced by shortening and rotational deformity of the limb or palpable motion of the iliac wing
Mechanics of Reduction Based on Reversing the Original Mechanisms of injury
Closed reduction methods rely on two basic techniques.
skeletal and soft tissue traction are required to restore length.
Rotational manipulation then is necessary to correctly realign joint axes of motion.
Ligamentotaxis is the term used to emphasize that, to be effective, traction must be balanced by countertraction provided by the ligaments and soft tissue surrounding the bone.
This pull and counter pull restores length and guides alignment of the fracture fragments.
Traction was usually applied directly to the soft tissues and skin, as with Buck's traction on the lower leg.
A preferable method now in most instances is with some type of skeletal traction.
Skeletal traction elongates and aligns the fracture fragments when it is counterbalanced by the soft tissues still attached to the fragments.
This allows length and alignment of the fracture to be restored close to normal
The basic technique of Buck's skin traction is to apply padding around bony prominences of the malleoli.
Traction tapes are then applied to the skin and an elastic bandage is wrapped from the ankle to the knee.
The end of the tape is then attached to the traction apparatus
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