ORTHOPEDIC TRAUMA

GUIDELINES
For
EMERGENCY HOSPITALS

AUTHORS

Marcello Zavatta, Alberto Landini, Michelle Foltz, Enrico Paganelli

ISSUE

April 2020

REVIEW #

PREFACE
This is a collection of Guidelines in use for management of Orthopedic Trauma and Acute
Orthopedic Surgical cases in EMERGENCY Surgical Centers.

This booklet provides clear clinical guidelines for the optimal management of patients with
war-related and civilian traumatic orthopedic pathologies. They are consistent
with the latest ATLS recommendations and the recent literature. More specifically they are
the result of twenty-five years of experience in the EMERGENCY Surgical Centers and
have shown to be simple and highly effective.

Professionals working with EMERGENCY need to review this booklet before missions.
Questions should be addressed to the Medical Coordinator of the Hospital or the Medical
Division staff.

NOTE:
Some of these Guidelines overlap with Emergency's Surgical Guidelines and are re-posted
here so Orthopedic Surgeons can find all that is needed in one paper.

INDEX
File and doctor orders …………………………………………… Page 3
Abbreviations…………………………….……………………….. Page 4

GENERAL PRINCIPLES FOR FRACTURES

ORTHOPEDIC NON-SURGICAL TREATMEN….……… Page 6
ORTHOPEDIC SURGICAL TREATMENT ……………… Page 9
ANTIBIOTIC and PAIN TREATMENT …………………... Page 10
OPEN FRACTURES ………………….…………..………. Page 13
CLOSED FRACTURES …………………..…………..….. Page 18
PEDIATRIC FRACTURES …………………………..…… Page 20

SPECIFIC FRACTURES
1. HAND ……………………………………………..……… Page 25
2. WRIST ………………………………….………………… Page 28
3. FOREARM ……………………………………………….. Page 29
4. HUMERUS ……………………………………………….. Page 30
5. CLAVICLE ………………………………………………... Page 34
6. SPINE …………………………………………………….. Page 35
7. PELVIS …………………………………………………… Page 38
8. FEMUR …………………………………………………… Page 39
9. LEG ……………………………………………………….. Page 45
10. ANKLE ……………………………………..…………… Page 48
11. FOOT ………………………………….………………… Page 49

SPECIFIC SITUATIONS OF ORTHOPEDIC INTEREST

COMPARTMENT SYNDROME ……………………………….. Page 51
AMPUTATIONS ……………………………………………….… Page 53
ORTHOPLASTY ……………………………………………….... Page 56

REFERENCES & SUGGESTED LECTURES ………………. Page 62

APPENDIX
ESIN ……………………………………………………………… Page 6
FILE AND DOCTOR ORDERS

Patient files are standard in all Emergency Centers.

Standard abbreviations are encouraged and no other abbreviations are allowed.
The use of capital letters makes orders clear for colleagues who may not be familiar with
the Latin alphabet.

SURGEON’S DUTIES
 First page: write the diagnosis and the operation performed on admission
 In the following pages (Doctor Orders) provide detailed information regarding
intraoperative findings and techniques details
 Postoperative notes should include: the Ward in which the patient is to be sent, fluids
and drugs. NPO status, specific nursing care (e.g. circulation checks), physio care,
X-ray, next DRS, date of next OT and operation planned, ROS

REMEMBER

Polytrauma IS NOT a diagnosis and Laparotomy IS NOT an operation

ABBREVIATIONS
in
EMERGENCY SURGICAL CENTERS
AB Antibiotic NWB Non-Weight Bearing
AE Above Elbow OD Once a Day
AEA Above Elbow Amputation O/N On Need
AK Above Knee OPD Outpatient Department
AKA Above Knee Amputation ORIF Open Reduction Int. Fixation
ARDS Adult Respiratory Distress S. OT Operating Theatre
BE Below Elbow PC Primary Closure
BEA Below Elbow Amputation PE Pulmonary Embolism
BI Bullet Injury PO Per Oral
BID Twice daily POP Plaster of Paris
BK Below Knee Pt Patient
BKA Below Knee Amputation PWB Partial Weight Bearing
B/S Back Slab QID Four times daily
CRIF Closed Reduction Internal Fixation RL Ringer Lactate
CT Computerized Tomography ROD Removal of Drain
CS Compartment Syndrome ROS Removal of Sutures
DBR Debridement RTA Road Traffic Accident
D/C Discharge SI Shell Injury
DCS Damage Control Surgery SLR Straight Leg Raise
DNR Do Not Reanimate SSG Split (thickness) Skin Graft
DOA Dead On Arrival STD Standard
DPC Delayed Primary Closure STW Soft Tissue Wound
DRS Dressing SW Stab Wound
DVT Deep Vein Thrombosis T/A Traumatic Amputation
EX FIX External Fixation TBI Traumatic Brain Injury
ESIN Elastic Stable Intramedullary Nail TFT Trans Femoral Traction
FX or # Fracture TID Three times daily
FC Foley Catheter TTT Trans Tibial Traction
F/S Front Slab TCT Trans Calcaneal Traction
FWB Full Weight Bearing US Ultrasound
GCS Glasgow Coma Scale V/S Vital Signs
HPD High Protein Diet WBAT Weight Bearing as Tolerated
ICP Intracranial Pressure
ICU Intensive Care Unit
IM Intramuscular
IV Intravenous
LLD Leg Length Discrepancy
KVO Keep Vein Open
K/W Kirschner Wire
MI Mine Injury
N/D Normal Diet
NGT Nasogastric Tube
NPO Nil Per Oral
NS Normal Saline
 SECTION 1 - GENERAL PRINCIPALS FOR FRACTURES

In treating Fractures, FUNCTION comes first.

Consider social and cultural backgrounds and special patient needs.

In case of late presentation of the fracture, be wary about the possibility of worsening
outcomes by proposed interventions in an already stabilized situation.

ORTHOPEDIC NON-SURGICAL TREATMENT .……… Page 6

ORTHOPEDIC SURGICAL TREATMENT ……………… Page 9
ANTIBIOTIC and PAIN TREATMENT …………………... Page 10
OPEN FRACTURES ………………….…………..………. Page 13
CLOSED FRACTURES …………………..…………..…... Page 18
PEDIATRIC FRACTURES …………………………..…… Page 20
 ORTHOPEDIC NON-SURGICAL TREATMENT

When possible and if the projected outcomes are acceptable, non-surgical options
should be chosen over surgery.

PLASTER of PARIS (POP)

To be used as INITIAL and DEFINITIVE treatment in:

 Closed Non-displaced fractures

 Open Non-War G1 Non-displaced fractures
o In this case consider windowing the POP for wound dressing
 Displaced and potentially stable fractures after Closed Reduction

To be used After EX FIX treatment:

 When soft tissue status allows POP to be performed

EX FIXes should always be removed as soon as possible,

as pin tracts are inevitable source of infection and EX FIXes themselves often

In all cases of POP use:

 Monitor circulation checks in the first 24 hours

 Monitor pain for possible CS, Pressure areas or Complex regional pain syndrome
(CRPS). Fractures stabilized in POP should not be painful

 Check POP for wear and breakage during follow up

  Maintain an individual POP for no longer than 4-6 weeks according to the
fracture type

In case of even minimal risk of displacement in POP: X-ray check in POP as follow:

 after 10 days in Adult

 after 7 days in Pediatric diaphyseal fractures

 after 4-5 days in Pediatric Salter Harris fractures (any type)

If displacement has occurred, treat it.

Do not wait and expect it to correct itself

SLABS

Use Back-slabs or Front-slabs in the following cases:

 Postoperative immobilization

 For max 7-10 days in Pediatric Trauma with pain and tenderness but no fractures
on plain X-ray

 For max 10-15 days in Adult Trauma with pain and tenderness but no fractures
on plain X-ray

Pediatric patients tend to break plaster Slabs:

consider more layers of plaster or apply a POP if there is no Swelling

CHOICE of SLAB or POP:

 If no swelling and no need for DRS: POP

 If swelling present: Slab for 4-5 days, then POP with post-POP X-ray
 When Slab no longer needed for DRS: POP

Monofilament skin suture can be left under POP up to 4 weeks

In warm and humid climate consider DRS every 5 days through a window in the
POP, especially if K/Ws are placed outside the skin
 ORTHOPEDIC SURGICAL TREATMENT

Appropriate timing, preoperative planning, nursing preparation, optimal setup of

instruments, and positioning the patient on the surgical table are the surgeon's
responsibility and must be checked before starting any procedure.

The Surgeon should periodically check with the OT Head Nurse the Surgical
Instruments in terms of efficiency and availability of spare parts and implants.

SURGICAL SITE CLEANING

· Surgical site cleaning should be started at arrival in OPD or in FAP, together with
whole body cleaning. The importance of this part of nursing care should never be
underestimated

· IN CASE OF INTACT SKIN (i.e. ORIF in closed fractures): clean Pt on the

surgical table and with proper sedation, Scrub with a Soft Sponge using Soap &
Betadine. Remove all the gross dirt

· IN CASE OF WOUND or OPEN FRACTURE: clean Pt on the surgical table with

proper sedation, scrub with a Soft Sponge using Soap & Normal Saline.
Remove all the gross dirt. Do not use Betadine

· DO NOT USE Hard Brush (such as the ones generally used by surgeons and
nurses to scrub hands) to avoid superficial skin damage. Exception: callused
soles of non-shoe wearing patients

TRICHOTOMY (shaving the surgical site)

 Only in the selected area of the proposed surgical incision.

 To be done in Ward
 Use machine, if available. Keep hair length around 2 mm
 In case only standard manual razor available: do it gently without exercising
pressure
 ANTIBIOTICS and PAIN TRETAMENT

TIMING FOR ANTIBIOTICS:

· For Open Fractures, start in FAP or in OPD at admission. Continue according to

the type of fracture by Gustilo classification

· For Closed Fractures undergoing surgical treatment (both ORIF or CRIF), start at
induction of anesthesia

STANDARD ANTIBIOTIC PROTOCOL for

ORTHOPEDIC SURGERY
FOR SOFT TISSUE WOUNDS: Ampicillin STD

In Tropical Environment
 If moderate contamination (deep wound, irregular edges, small FB): ADD
Chloramphenicol STD
 If severe contamination (deep wound, soft tissue damage, gross
contamination): USE Ceftriaxone STD plus Gentamycin STD plus
Metronidazole STD

FOR OPEN FRACTURES AND TRAUMATIC AMPUTATIONS: Ampicillin STD plus

Chloramphenicol STD

In Tropical Environment:
 Gustilo G1 & G2: Ampicillin STD plus Chloramphenicol STD
 Gustilo G3: Ceftriaxone STD plus Gentamicin STD plus Metronidazole STD
FOR FIXATION OF CLOSED FRACTURES, at induction of anesthesia:
Ceftrixone 2 g OR Ampicillin 2 g (in children 5-12 y.o.: 1 g) - Single Shot

Consider 1 more dose IF operation lasts more than 3 hrs OR if estimated blood loss
> 1500 cc)

FOR OSTEOMYELITIS: Cloxacillin STD plus Gentamycin ST

 STANDARD ANTIBIOTIC DOSAGE and ROUTE
for ORTHOPEDIC SURGERY
AMPICILLIN STD

 Adult: 1 g IV QID for 24 hrs, then 500 mg PO QID for 4 days

 Pediatric: 50 mg/Kg IV QID for 24 hrs, then 50 mg/Kg PO QID for 4 days
 < 10 Kg: 500 mg IV QID for 24 hrs, then 500 mg PO QID for 4 days
 10-20 Kg: 750 mg IV QID for 24 hrs, then 750 mg PO QID for 4 days
 20-30 Kg :1 g IV QID for 24 hrs, then 500 mg PO QID for 4 days

CHLORAMPHENICOL STD

 Adult: 1 gr IV QID for 24 hrs, then 500 mg PO QID for 4 days

 Pediatric: 25 mg/Kg IV QID for 24 hrs, then 25 mg/Kg PO QID for 4 days
 < 10 Kg: 250 mg IV QID for 24 hrs, then 250 mg PO QID for 4 days
 10-20 Kg: 500 mg IV QID for 24 hrs, then 500 mg PO QID for 4 days
 20-30 Kg: 750 mg IV QID for 24 hrs, then 750 mg PO QID for 4 days

METRONIDAZOLE STD

 Adult: 500 mg IV TID until NPO, then 500 mg PO QID up to 5 days

 Pediatric: 7.5 mg/Kg IV TID until NPO, then 7.5 mg/Kg PO QID up to 5 days
o < 10 Kg: 75 mg IV TID until NPO, then 75 mg PO QID up to 5 days
o 10-20 Kg: 125 mg IV TID until NPO, then 125 mg PO QID up to 5 days
o 20-30 Kg: 250 mg IV TID until NPO, then 250 mg PO QID up to 5 days
GENTAMYCIN STD

 Adult: 160-240 mg IV for 5 days

 Pediatric: 2-7.5 mg/kg IV for 5 days

CLOXACILLIN STD

 Adult: 2 g iIV QID for 14 days, then 1 g PO QID for 4 weeks

 Pediatric: 50 mg/Kg iIV QID for 5 days, then 50 mg/Kg PO QID for 4-6 weeks
o < 10 Kg: 500 mg IV QID for 14 days, then 500 mg PO QID for 4 weeks
o 10-20 Kg: 750 mg IV QID for 14 days, then 750 mg PO QID for 4 weeks
o 20-30 Kg: 1 g IV QID for 14 days, then 500 mg PO QID for 4 weeks

CEFTRIAXONE STD

 Adult: 2g OD for 5 days

 Pediatric: 50 mg/Kg IV OD for 5 days
 STANDARD PAIN TREATMENT in ADULTS

MILD PAIN
 IV: Paracetamol 1 g TID OR Tramadol 100 mg in NS 100 ml
 ORAL: Diclophenac 50 mg TID (BID after 24 hrs.) OR Tramadol 100 mg TID
OR Paracetamol 500 mg TID

MODERATE PAIN
 IV: Tramadol 100 mg in NS 100 ml 15 min before operation followed by:
o IV Paracetamol 3 g PLUS Tramadol 200 mg in NS 250 ml/24 hrs OR
Tramadol 100 mg in NS 100 ml in 30 min
 ORAL: Diclophenac 50 mg TID (BID after 24 hrs.) PLUS Tramadol 100 mg TID
(BID after 24 hrs.) OR Paracetamol 500 mg

SEVERE PAIN
 IV Pentazocin 30 mg 15 min before operation  Then:
o IV Paracetamol 3 g PLUS Pentazocin 3 amp in NS 250 mg/24 hrs
(decrease to 2 amp: after 24 hrs OR if age > 70 y.o. or body weight < 50
Kg)
 ORAL Diclophenac 50 mg BID OR Pentazocin 30 mg SC BID
 OPEN FRACTURES

 Open Fractures are surgical emergencies

o Always keep in mind… fracture treatment starts only after resuscitation,
ABCDs, and treatment of life-threatening injuries

· Early initiation
of IV Antibiotic treatment is mandatory (see antibiotic treatment protocol)

GUSTILO CLASSIFICATION

GRADE 1 Wound < 1 cm Minimal contamination

GRADE 2 Wound from 1 to 10 cm Without extensive soft tissue damage, flaps,

avulsions, degloving
GRADE 3 A Wound > 10 cm Extensive soft tissue damage
Adequate soft tissue coverage
GRADE 3 B Soft tissue loss, periosteal stripping, bone
damage, contaminated. Need for further soft
tissue coverage procedures
GRADE 3 C Arterial injury requiring repair, irrespective of
degree of soft tissue injury

 Classification is done in OT after thorough DBR

 Gustilo Classification is not a complete and reliable tool, especially for war
wounds but it is the most versatile and useful among all the classifications
 Gustilo Classification is used only for long bones and not very accurate for hand
injuries
 WARNING
ALL FRACTURES IN WAR WOUNDS HAVE TO GO IN OT FOR DBR
In War wounds there are no actual G1 Open Fractures or “pin-point” wounds.
What looks like a small wound, often hides massive soft tissue contamination and
destruction involving bone. Take special care in comminuted fractures with any
extensile fracture pattern mistakenly-called G 1 open fractures.

DEBRIDMENT (DBR)

 Timing and thoroughness of DBR are the keys to reduce wound infections and
osteomyelitis.
 All Open Fractures must go to OT as soon as possible for wound exploration
and DBR

DBR TARGETS
 Systematic evaluation of all structures in and around the zone of injury
 Removal of all contaminated and necrotic tissues, including devitalized bone
fragments

KEEP IN MIND
 Wound and bone healing need a good blood supply
 Damaged or bruised skin has a high potential for recovery; keep as much as
possible
 Remove all free non-vascularized bone fragments
 Need for external fixator pins insertion
  Need for further treatments for soft tissue coverage of bone and noble tissues

SURGERY
 Under anesthesia, NS and Soap scrub the affected limb
 Extend wounds longitudinally to fully assess all tissues in the zone of injury
 Avoid crossing the flexor surface of joints in a straight line longitudinally
 Assess the extremity for stability and the future need for soft tissues coverage
 Apply EX FIX if there is: severe comminution, irreducible bone gap, extensive
soft tissue wounds, vascular injury
o Position pins and bars to avoid interference with further reconstructive
surgery
 At the end of procedure:
o Check hemostasis. Minimize use of cautery
o Irrigate profusely with NS
o Leave wound open to allow free draining
o Dress with fluffy gauze and a loose bandage
o Apply Slab, Splint or Traction if needed
 OT for DPC after 5 days

EARLY POSTOP CARE

 Elevate the involved limb by bed blocks, frames, IV stands or pillow

 Hb check and circulation chart, as needed
 Wound is left untouched until DPC. In case of oozing, overdress
 Start early Physio: exercises for edema reduction and range of motion (ROM)
 Treat pain with scheduled pain killers
 Consider High Protein Diet
 Check X-ray, especially if bone has been removed or manipulated during DBR

DPC

 5 days after DBR

  Evaluate all tissues and Re-DBR if wound suspicious. If there are any doubts,
ask a colleague to see the wound with you
 Remove all unattached (not-vascularized) bone fragments that might have
become free since the DBR
 If no evidence of infection or necrosis, proceed with soft tissue coverage: DPC,
SSG, Flaps
 Evaluate alignment and stability of fracture
 Apply EX FIX in the face of inability to obtain soft tissue coverage or if the
fracture cannot be stabilized by Traction or POP
 Use suction drain only if dead space present
 Avoid any kind of internal fixation at this stage. This includes EX FIX pins
placed in the zone of injury, K/W or screws to stabilize fracture fragments in and
around the zone of injury and devascularized bone graft

POSTOP CARE after DPC

 DRS every 3 - 4 days until ROS

 Nursing care according to type of Traction or Fixation
 Physio care for all patients
o Intensive Physio while in traction
o Out of bed as soon as possible
o Weight bearing as per fracture or other injuries
o Limit crutch walking in wards and ablution areas on newly mobilized
patients
 Replace EX FIX with Circular POP when swelling diminished, and soft tissues
are stable
o Avoid windows in POP if possible
o Check X-ray after POP for alignment

Skin sutures can remain under POP up to 4 - 5 weeks after placement

In humid and hot climate consider earlier DRS

 ORIF in WAR and HIGH ENERGY WOUNDS

If properly stabilized and cared for in the meantime, there are few fractures where
ultimate healing is compromised by waiting

ORIF ONLY IN SELECTED CASES

 Early good and thorough DBR at admission

 Complete clean and dry scar
 No history of wound/soft tissue complications with healing, such as inflammation,
infection, repeated DBRs

 No history of or concurrent systemic infection

 Stable soft tissues over and around the proposed implant

 Perform ORIF not before 4 weeks since DBR

 CLOSED FRACTURES

 Carefully evaluate circulation and rule out possible nerve and vascular injuries
 In case of CS: immediate Fasciotomy
· In case of absent pulse: apply traction or perform closed reduction and carefully
monitor by flow chart hourly

 In case of frank ischemia of distal extremity: immediate surgical exploration

 Loss of nerve function does not require immediate exploration in Closed
Fractures
 After clinical evaluation and temporary immobilization, X-Ray the injured limb
Postero-anterior and Lateral, with oblique and contralateral X-Rays, according to
the type of fracture. If a shaft fracture is suspected, X-Ray should include joints
above and below the fracture

 In Pelvic and Femur fracture or multiple fractures: start fluids

 Look for other injuries
 If good outcomes can be expected with closed treatment, it should be favored

SURGICAL TREATMENT BASIC CONCEPTS

 Choose Internal Fixation if by experience or it is commonly recommended (e.g.
the need for ORIF in closed Galeazzi fracture-dislocation) and the short- and
long-term final results are better than if the same condition is treated non-
operatively

 Surgical treatment should be taken into consideration for fractures needing long
term bed utilization or in case there is pressure on bed availability

 Take in consideration comorbidities (i.e. Malaria, Sickle Cells disease)

 Special care must be given to properly clean the skin and prepare the surgical
site

 Prophylactic antibiotics should be used as a single dose at anesthetic induction

 WARNING
 Most dreadful complication of Internal Fixation is INFECTION
 Internal Fixation should be planned with the aim of giving stability to the fracture,
using appropriate hardware
 K/W and Screws are -generally speaking- more welcome than Plates and
Intramedullary Nailing but they ensure only minimal stability
 For high stabilitybetter Intramedullary Nail (SIGN) than Plates
 Better CRIF than ORIF, whenever possible

POSTOP CARE after INTERNAL FIXATION

 Activity orders according to the fracture, the stability gained with fixation and
proposed long term treatment under supervision of physios and nurses
 X-Ray and doctor review after 4-6 weeks
 Physiotherapy for all lower extremity fracture fixation for: ROM, strengthening,
coordination, balance. The most common reason for long term pain after a
fracture is healed is poor Pt compliance with long-term physio

POP AND SLABS PRODUCTION ARE SURGEON’S RESPONSIBILITY

National Surgeons and International Orthopaedic Surgeons should have deep

knowledge of POP and Slabs technique. They are invited to constantly monitor and
supervise Nurses and Physios job.
POP class are very much welcome. Should be organized by experienced Surgeons/
Physio/ Nurses and should involve all these three medical categories
 PEDIATRIC FRACTURES

Children's fractures differ from those of Adults because of the potential for growth
disturbance, especially when fractures involve an epiphyseal plate. Fractures in
Infants, Children, and Adolescents are also different in type, presentation, and
treatment.

SALTER HARRIS FRACTURES

 Recognize these fractures for possible long-term consequences of axial
deviations and length discrepancies
 For even minimally displaced fractures, especially III and IV, fixation is often
advisable
 Follow up is mandatory
 PEDIATRIC CLOSED FRACTURE TREATMENT

NON-SURGICAL TREATMENT

 First choice, especially when outcomes of various treatments are similar. Other
considerations include: pressure of beds, time to healing, polytrauma
 Traction
o Skin Traction
o Skeletal traction with K/W (only in distal femoral metaphysis, not in
proximal tibia)
 Plaster Slabs or POP
o with or without manipulative reduction

SURGICAL TRETAMENT

 Minimal fixation is often adequate (bone healing is rapid and joint stiffness is not
common)
 Avoid trans-physeal fixation except with small (less than 2 mm) K/W
 Removal of metal (K/W, Plates, Intramedullary Nails) is often necessary

Elastic Stable Intramedullary Nail (ESIN) aka “Nancy Nail”

 Pre-bend and leave nail end under skin
 Remove as soon as fracture fully healed

Kirschner Wires (K/W)

 Mostly in CRIF mode
 Fixation usually with supplemental slabs or POP
 Most suitable when rapid healing with minimal joint stiffness anticipated
 Percutaneous placed K/W is bent and left outside skin with gauze dressing to
prevent skin irritation
 Remove after 3 - 4 weeks
 In ORIF mode: especially in articular fractures, consider leaving the nail edges
under the skin, than to be removed after 3 months

Screws
 Cannulated or Small Fragments

ACCEPTABLE DISPLACEMENT CRITERIAS

for LONG BONES IN CHILDREN
“Acceptable” or “Non-acceptable” displacement, it is not a personal judgment but an
objective one, based on standard criteria related to age and type of # as widely
reported by literature. Here below the most used and trusted criteria as stated by
Rockwood & Wilkins' Fractures in Children (10th Edition). Beaty & Kasser. 2010.

FEMUR
AGE VARUS/ VALGUS ANTERIOR/ POSTERIOR SHORTENING

Angulation

0-2 30° 30° 1,5 cm

2-5 15° 20° 2 cm

6-10 10° 15° 1,5 cm

11 to maturity 5° 10° 1 cm

LEG (TIBIA)
AGE VALGUS VARUS ANTERIOR POSTERIOR SHORTENING ROTATION

Angulation Angulation

<8 5° 10° 10° 5° 1 cm 5°

8 to maturity 5° 5° 5° 0° 0,5 cm 5°

FOREARM (RADIO & ULNA)

 AGE ANGULATION * MALROTATION DISPLACEMENT RADIAL BOW LOSS

<9 15° 45° complete Yes

9 to maturity 10° 30° complete Partial

* more restrictive for diaphyseal proximal third radius fracture

HUMERUS
AGE ANGULATION APPOSITION SHORTENING

<5 70° Complete Displacement 2 cm

5- 12 40°- 70°

> 12 40° 50% Apposition 1 cm

SECTION 2 - SPECIFIC FRACTURES

1. HAND ……………………………………………..……… Page 25
2. WRIST ………………………………….………………… Page 28
3. FOREARM ……………………………………………….. Page 29
4. HUMERUS ……………………………………………….. Page 30
5. CLAVICLE ………………………………………………... Page 34
6. SPINE …………………………………………………….. Page 35
7. PELVIS …………………………………………………… Page 38
8. FEMUR …………………………………………………… Page 39
9. LEG ……………………………………………………….. Page 45
10. ANKLE ……………………………………..…………… Page 48
11. FOOT ………………………………….………………… Page 49
 1.HAND

The hand is the most important final common way of the brain.

 Maintaining finger’s Length makes sense only if Sensation and Function are
preserved
 Use Flaps to cover bone with healthy soft tissue at amputation level, only in case
you can restore Function

SURGERY
 Use Tourniquet. Always apply, even if not sure it will be used
 Be sure the joint cartilage is not in contact with the coverage skin. (in case
remove the cartilage)
 The most important finger to try to preserve is the Thumb (80% of the hand
efficiency is due to the thumb)

POSTOP CARE

 Elevate the limb

 Check X-ray
 Check circulation for 48 hours
 First DRS on 3rd day after PC/ DPC
 ROS on 10th day
 ACUTE TENDON INJURIES in the HAND region

Tendon injuries are not emergencies and can be performed within 24 hours or later by
an experienced team with proper surgical setup.

GENERAL PRINCIPALS for TENDON SURGERY

 Use Tourniquet
 Perform accurate hemostasis
 Preserve Tendon Sheaths, Pulley and Vinculae
 Direct reconstruction: kesler suture with non-absorbable monofilament 3\0 (Nylon)
reinforced with running paratenon 6-0 nylon
 In OT, after surgery:
o FLEXOR TENDONS INJURIES

Immobilize the hand in B/S from mid forearm to tips of fingers with wrist in
neutral to 10º volar flexion, MPs in 70º flexion with IP joints free in
extension) for at least 2 weeks with further splinting and rehab as per
specific injury

o EXTENSOR TENDON INJURIES

Immobilize the hand with a F/S in extension (wrist in neutral to slight
extension and MPs extended) at least 2 weeks with further splinting as per
specific injury
 First DRS on 3rd day after PC/ DPC. DRS to be done by Surgeon to make sure the
slabs are properly replaced
 ROS on 10th day

POSTOP PHYSIOTHERAPY in FLEXOR TENDONS REPAIR

 With ROS, begin active and passive ROM under a Physio's care based on the
Surgeon's assessment of repair and goals
 Avoid resistive activity till day 60
 SEQUELAE OF RADIAL NERVE INJURY

 Wait 8 month before state a final diagnosis of Radial nerve damage

o Transfer the Pronator Teres (PT) tendon on Extensor Radialis Brevis Carpi
(ERBC)
o Transfer the Flexor Carpi Radialis (FCR) tendon on the Extensor Digitorum
Comunis (EDC) tendon
o Transfer the Palmaris Longus (PL) tendon on the Extensor Pollicis Longus
(EPL) tendon
 Post-operative management is the same as for the extensor tendon injuries

MULTIPLE COMPLEX INJURY of the HAND

 In cases where multiple structures are injured and soft tissue coverage is lacking
priority rests with adequate DBR and antibiotics management
 In Non-War Injuries, a more conservative DBR with a 2nd look at 2 - 3 days may
be useful at which reconstruction plans can be made
 War injuries require a more extensive DBR but often benefit from a second look
2 - 3 days post DBR and plans for reconstruction only if the wounds are clean
 Reconstruction of Bone precedes Tendon repair precedes Skin cover
 Splint with front slab (from proximal to palmar crease to mid forearm) to hold
wrist in 10 - 15º dorsiflexion. And B/S (from tips of fingers to mid forearm) to
maintain MP flexion at 70º
 Elevate above level of heart
 2.WRIST

CARPAL BONES

 Fractures and Fracture-dislocations may need multiple X-Ray views and/or

contralateral views to make a proper diagnosis
 Treatment:
o if stable: POP or Slab
o if unstable: CRIF or ORIF with K/W and plaster

DISTAL RADIUS

 Treatment:
o if non displaced: POP or Slab
o if displaced
1) Closed Reduction
2) Hold reduction with:
 Charnley’s dorsal-radial splint
 AE or BE POP, immediately or after 5 days if swelling
o If unstable after Closed Reduction
 K/W with POP
 EX-FIX with or without K/W or additional F/S or B/S
 In Young and middle-aged adults take care to provide accurate intra-articular
stabilization and proper alignment
 In cases of displaced pediatric metaphyseal or epiphyseal FXs needing to be reduced in
the OT with sedation, it is often wise to hold the reduction with a simple percutaneous
K/W plus Slab or POP
 X Ray control after reduction and in 10 days (7 days for Pediatrics) to confirm
reduction, especially for unstable fractures and non-operative treatments
 Majority of the cases need immobilization for 4-6 weeks
 3.FOREARM

CLOSED FRACTURES
 Treatment:
o if non displaced: AE POP
o if displaced:
1) Closed Reduction
2) Hold reduction with:
 Munster POP with proper molding
 AE POP, immediately or after 5 days if swelling
o If unstable after Closed Reduction:
 CRIF or ORIF with ESIN in Pediatrics
 Only in Adults: ORIF Plating of both bones or plating one
bone and ESIN on the other. Consider higher chance of
non-union for the intramedullary fixed bone
o In Adults Galeazzi and Monteggia fracture-dislocations, commonly need
ORIF with plates
 X-Ray control after reduction and in 10 days (7 days for Pediatrics) to confirm
reduction, especially for unstable fractures and conservative treatments

OPEN FRACTURES
 If requiring SSG or Flap, may need EX FIX until soft tissues are stable
 Followed by choices above for closed fractures

POST OP CARE AND F/U FOR WRIST AND FOREARM INJURIES

 Elevate injured extremity above heart level
o Note: a sling does not elevate the hand or wrist
 ROM of all not immobilized upper extremity joints

OLECRANON FRACTURES
 Treatment:
o If non displaced: AE POP in half-extension
o if displaced: ORIF using Tension Band Wiring
 X-Ray control after reduction and in 10 days to confirm reduction, especially for
conservative treatments
 4.HUMERUS
Conservative Non-surgical treatment is effective in the majority of Shaft and Proximal
Humerus fractures.

PROXIMAL HUMERUS
 Initial treatment with Collar and Cuff, Arm Sling or Desault bandage or B/S
 Depending on how high the fracture and comminution, continue with above or
change to Humeral Brace in 1-2 weeks
 In Displaced Closed Fractures: Consider CRIF with K/W, also for Pediatric Pts

MID SHAFT HUMERUS

CLOSED FRACTURES
 Initially hold in B/S or U-Slab and change to Humeral Brace at 1 - 2 weeks
 In rare cases (i.e. Polytrauma) consider ORIF: SIGN Nail (better) or 4.5 Plate in
Adults and ESIN in Pediatrics

OPEN FRACTURES
 If early DPC possible: continue in B/S or U-Slab (B/S are easier for nursing care)
than changing to Humeral Brace at ROS
 If need SSG or flap: apply EX FIX, changing to U-Slab or humeral brace when
soft tissues are stable
 If the fracture is unlikely to heal, remove EX FIX when soft tissues are stable 
10 - 14 days pin holiday in U-slab, B/S or POP  ORIF with SIGN Nail (in Adults)
or ESIN (in Children)

F/U TREATMENT in Humeral Brace or U-slab

 Change Slab or Brace in Physio every 2 weeks
 early ROM and strengthening exercises in splint
 Review with X-Rays and clinical assessment of FX healing at 4 - 6 weeks
intervals.
 If no progression to healing by 3 - 6 months: ORIF with bone graft
 DISTAL HUMERUS ADULTS
CLOSED FRACTURES
 Olecranon traction
 ORIF with K/W and POP
 ORIF with double plates and early ROM

OPEN FRACTURES
 B/S or Olecranon Traction or EX FIX until wounds healed then AE POP or ORIF
 If fracture is very comminuted and also involves proximal radius/ulna and
surgeon is unable to provide stable ORIF of all fractures that will allow early
ROM: AE POP with forearm neutral until healed, expect a stiff but stable elbow.

CHOOSE FOR THE LESSER WORST RESULT

A stiff elbow at 90° is better than a non-union or a iatrogenic osteomyelitis

PEDIATRIC SPECIAL FEAUTURES

Pediatric Elbow Fractures and their treatments are very different from Adult Elbow
Fractures and deserve special attention.

PEDIATRIC SUPRACONDYLAR

 Diagnosis by Gartland Classification

 Thorough neurological and vascular exam is mandatory Before and After
Treatment
 o There is no need to stick pins into already traumatized children. Simple
Neurological Exam:
 Anterior Interosseus N. - thumb IP flex (the “OK” sign)
 Ulnar N. - cross index and middle fingers
 Radial N. - thumb IP extension

o A warm Pink but Pulseless Hand needs careful evaluation, consultation

with colleagues, early closed reduction, and monitoring

 These are not surgical emergencies, unless vascular deficit is present (pale
pulseless hand). Even the most displaced fractures can generally wait 8 hours
before going to OT. However, avoid delays that will complicate reduction by
edema

GARTLAND 1 (undisplaced)

 No reduction is needed
 Immobilize in Brachio-Metacarpal POP (in presence of no swollen elbow) or B/S
or Collar and Cuff at 70º elbow flexion, for 3 - 4 weeks

GARTLAND 2 & 3

 CRIF in OT under general anesthesia. Use K/W (1.4 to 1.8 according to Pt. age)
 Use lateral parallel, lateral divergent or medial-lateral pinning

 Check Stability and proper reduction at the end of surgery

 If CRIF is unsuccessful: ORIF (lateral approach recommended)

 Immobilize in Brachio-Metacarpal B/S for 4 weeks at 90º elbow flexion

POSTOP CARE for PEDIATRIC SUPRACONDYLAR

 For all patients: X-Ray and Doctor review with removal of K/W, at 4 weeks
 Check Elbow axis during growth (organize annual review when feasible)
 PEDIATRIC LATERAL CONDYLE
Surgeon must be able to identify and differentiate these fractures from Supracondylar
fractures. In fact, these are articular fractures; they differ in Treatment and Prognosis
 Undisplaced Fractures: POP for 4-5 weeks
o X-Ray check in POP at 5, 10 and 15 days
 Displaced and Minimally Displaced Fractures (2 mm on plain x ray): ORIF with
K/W buried under the skin, to be removed after 3 - 4 months

PEDIATRIC MEDIAL EPICONDYLE

 Undisplaced Fractures: POP for 4 weeks with elbow 90º and forearm in pronation
o X-Ray check in POP at 7 days
 Displaced and Minimally Displaced Fractures (2 mm on plain x ray): ORIF
o K/W buried under the skin in small kids, removed after 3-4 months
o 3.5 cancellous screw in bigger kids
 SHOULDER DISLOCATIONS

Reduce as soon as possible.

Diagnosis is clinical with X-Rays to clearly define one of the three classic dislocations:
Anterior, Posterior and Inferior (Luxatio Erecta)

 X-Ray before reduction: AP and Axillary Lateral

 Closed Manipulation according to the direction of Dislocation

o Try gently in OPD with or without sedation
o If not reduced, bring patient in OT and try again under sedation or general
anesthetic
o In the rare case of irreducible dislocation, perform an Open Reduction
using Anterior Delto-Pectoral approach for Anterior Dislocation

POSTOP CARE
 Immobilization for 3 weeks in Sling or Desault Bandage
 X-Ray and Review at 3 weeks upon removal of bandage

5.CLAVICLE

 Almost always Conservative Treatment is effective

o Sling
o Desault bandage
o Figure of 8 bandage until healed
 6. SPINE

Spine injury is common in patients with multiple blunt trauma or war-related injuries
(55% cervical, 15% thoracic, 15% lumbar and 15% sacral area).
10% of the patients with a C-spine fracture have another vertebral fracture

 When the spine is protected by in-line immobilization and collar, evaluation and
diagnosis of spinal injury may be safely deferred after life-threatening injuries
have been identified and treated.

IN OPD

 Consider Airway protection (intubation) in Pts with cervical trauma not properly
breathing
 Consider NG tube
 Place a Foley catheter

 IDENTIFICATION OF PTs. WITH SUSPECTED SPINE INJURY:

o All Pts. with altered level of consciousness should have spine X-Ray or
CT Scan if available
o Consider Pts with Para or Quadriplegia to have a spinal injury. Do not
keep these Pts. on a long spine board for more than 2 hours (risk of
bedsores). Ask for Spine X-Ray or CT Scan
o Pts is awake and alert, with no neurologic deficits but has pain in neck or
posterior midline: do spine X-Ray or CT Scan. If negative, remove collar
o Pts who are awake and alert with no neurologic deficits and no pain in
neck or posterior midline are unlikely to have a spinal injury. Remove
collar, if voluntary spinal movements produce no pain, X-Ray are not
needed

o In all questionable cases: keep the collar

 NEUROGENIC & SPINAL SHOCK

NEUROGENIC SHOCK
Is the consequence of an disruption in the sympathetic pathway due to
cervical/thoracic spine injury (rare below T5-6) with consequent loss of vasomotor tone
leading to Vasodilatation and Hypotension, resulting in Bradycardia.

SPINAL SHOCK

Is the loss of muscle tones and reflexes after injury to the spinal cord.

 It is important to maintain adequate spinal cord perfusion by avoiding

hypotension. Keep mean arterial pressure (MAP) over 90-95. (MAP = Diastolic P
– 1/3 of differential P between systolic and diastolic).

REMEMBER
If the patient is in Shock, first rule out Hypovolemic Shock

 Moderate fluid replacement, avoiding massive volume replacement (RL, NS 1000

ml @50ml/hr.)
 Positive Inotropic Agents: Dopamine 5-10 mcg/Kg/min, OR Noradrenaline 0.01-
0.1 mcg/Kg/min, OR Adrenaline 0.05-1 mcg/Kg/min
 If severe bradycardia (HR < 45) Atropine 1 mg IV bolus to be repeated if no
response
 No evidence for the use of Steroid

EARLY CARE IN WARD

 Log-roll (four-person technique) turning the patient every 2 hours to prevent

bedsores. Keep cervical spine in-line

 If pt. is neurologically “complete” good nursing care is of paramount importance

 o Change Foley as soon as possible to condom catheter. In case of
Urinary Retention intermittent catheterization should be used if patient
and relatives comply. Avoid Foley clamping as it is associated with
higher rates of urinary infections
o Start Bowel Care using paraffin oil daily and rectal stimulation
o If Pt has no neurological deficits but has a clearly unstable fracture and
stabilization is not possible: bed rest is the only option (at least 6 weeks).
In this case, same nursing care as above and consider C-Spine hard
collar, Minerva POP, thoraco-lumbar orthoses or hyper extension POP
to shorten the bed rest.

PHYSIO & REHABILITATION

 Early Physio for passive ROM paralyzed extremities. Active ROM and
strengthening for others
 Edema reduction in paralyzed extremities
 Mobilization as soon as possible
 7. PELVIS

Pelvic fractures are potentially life-threatening injuries associated with significant blood
loss and multiple system injury.

 Systemic resuscitation
 Do not place urinary catheter until urethral injury has been ruled out
 Temporary pelvic compression with 15 - 20 cm wide circumferential sheeting
centered over the greater trochanters
 X-Ray (Antero-posterior view) in OPD. When Pt is stable do INLET and OUTLET
view if CT scan not available
 Pelvic EX FIX if Pt hemodynamically unstable despite binder or pelvic packing

TREATMENT
 STABLE FRACTURES (rami, diastasis)
o bed rest for 1 week, followed by WBAT with crutches for 3 - 4 weeks

 UNSTABLE FRACTURES (displaced, all involving posterior structures)

o Pelvic EX FIX
o Skin (only in pediatric Pts) or Skeletal Traction applied on distal femur with
20° hip flexion or straight leg for 6 - 8 weeks. Mobilize in traction as FX
healing allows
o Crutches and WB as per progression of healing
o Shortening accommodated by shoe raise

8. FEMUR
 ADULTS CLOSED NON-ARTICULAR FEMUR
FRACTURES
 Place TTT (Trans Tibial Traction) with 5 mm Denham pin regardless of the
further management. Traction Weight ~10% of body weight
 Begin Perkins traction (see “Primary Surgery” discussion on Perkins traction)

From M King. - Primary Surgery

 X-Rays to check Fracture alignment at 1 week, than and 4 - 6 weeks to check
initial callus formation
  Clinical evaluation weekly for traction adjustment, leg lengths, deformity, early
palpable callus, and quad strength
 Check pin sites weekly at DRS time: look for inflammation, pain
 When fracture is length stable – usually in 4-6 weeks, can decrease weight by 2-
3 kg.
 Traction removed when FX stable clinically and mature callus present – usually
at 8 - 12 weeks
 3 - 4 days before anticipated removal of traction, periodically release traction
weight for bed exercises: quad strength and SLR and ROM knee to 105º

ARTICULATED POPS (Cylinder POP with external knee hinges)

 Used in FX after Perkins when able to do SLR with weights removed, and flexion
to 105º but FX not consolidated enough to allow D/C without some protection.
 WBAT in POP with crutches, progressing to full WB
 Usually keep for 6 weeks, changing at 3 weeks because of loosening

SURGICAL TREATMENT in Adults

Indications:
 Unable to achieve an acceptable reduction
 Polytrauma
 Bed availability problems
 Uncooperative patient
 Associated conditions needing early mobilization

SHAFT AND SUB-TROCHANTERIC FRACTURES

 SIGN nail

SUBCAPITAL FRACTURES
 Close or open reduction with fixation by 6.5 or 7.0 cannulated screws or large
fragments cancellous screws.
 Consider Gilderstone as second step for treating non-union and necrosis

INTERTROCHANTERIC AND HIGH SUBTROCHANTERIC FRACTURES

 DHS or Proximal Femoral Nail
INTRACONDYLAR FRACTURES
 Cannulated screws and SIGN nail
 Condylar plate and screws

PEDIATRIC CLOSED NON-ARTICULAR FEMUR

FRACTURES

TREATMENT OPTION ACCORDING TO AGE

 Birth to 2 Y.O. (max15 kg body weight)

o Gallows Traction for 3-4 weeks
o Immediate Spica

 0 to 4 Y.O.
o Skin Traction for 4 – 6 weeks
o Skin Traction for few days/ weeks, than  Spica
o Immediate Spica (not to be consider as urgent case)

 4 Y.O. to Maturity
o Skin Traction or TTT for 6 weeks
o Skin Traction for few weeks, than  Spica
o CRIF or ORIF with ESIN

 Traction Kgs around 10% of body weight

 Skin Traction maximum weight to apply is 4.5 Kg
 In any of the conservative non-surgical cases listed above:
o X-Ray check at 7 to 10 days to confirm reduction
o Weekly clinical check for leg length equality, angular deformity and
progressive callus
 In Pediatric Pts, Internal Fixation with antegrade SIGN Nail should be avoided
due to high risks of avascular necrosis of the femoral head
 Common complication is hypergrowth of the affected femur with LLD (leg Length
Discrepancy) for which around annual clinical follow up needs to be planned;
consider heel rise for LLD around 2 cm and more

OPEN FEMUR FRACTURES

  Thorough DBR, removing all devascularized tissues
 Tibial traction as with closed fractures and place on frame
 DPC in 5 days (As many of these fractures benefit from SIGN nail, very careful
and accurate soft tissue closure is mandatory to ensure timely ORIF or -even
better- CRIF)
 EX FIX for polytrauma and vascular cases
 If able to DPC begin Perkins traction next day and obtain femur x-ray without
frame
 Check leg lengths and clinical alignment, adjust traction weights and direction
 ROS in 14 days

SURGICAL TREATMENT OF OPEN FEMUR FRACTURES

 Only when all wounds and incisions are closed and dry, ROS, no history of
infection or problems that contraindicate Internal Fixation.

PERKINS TRACTION CAN ADEQUATELY TREAT MOST (OPEN & CLOSED)

FEMUR FXs

Moreover, the necessary prolonged physical exercise during healing, leaves the
patients in a better rehabilitation status than many patients who receive SIGN nail

SPECIFIC CONSIDERATIONS

 High femur FXs or inter trochanteric FXs may benefit from Semi Perkins on a
frame or 90 - 90 traction initially, but usually require Internal Fixation
 Posterior soft tissue wounds may benefit from 90 - 90 traction or EX FIX
 Intra-articular femoral condyle FXs can do well in Perkins using the principles
of ligamentotaxis. X-Ray will confirm inter-fragment alignment
 Distal Metaphyseal femur FXs do well in Perkins, often with rapid rates of
healing
 Highly comminuted femur FXs (>50% of femur length) can do very well in
Perkins traction, often better than with SIGN nail, though may take up to 3
months in traction
 Femur FXs with neurologic injury may not be able to do Perkins, but may be
able to do semi-Perkins on a frame. They often benefit with Internal Fixation
  Linear femoral FXs with minimal translation of fracture fragments do well in
Perkins, sometimes healing by 4-6 weeks with further treatment by articulated
POP
 Middle aged and older women do not do well with Perkins and often need
Internal Fixation

TRACTION PIN PROBLEMS

 Prevent by properly placing pin just distal to tibial tuberosity, avoiding any
involvement in anterior muscles
 Drill with 3.2 drill bit before placing 5.0 Denham pin by hand
 At the first sign of inflammation: stop Perkins, rest, daily pin care
 If problem not resolved in 2 - 3 days: place new pin few cm distally in proper
manner with proper curettage of infected pin site in the OT
 Antibiotics

ALTERNATIVES IF UNABLE TO PLACE TTP

 Calcaneal traction with 4.0 Denham pin or K-wire on frame

 Distal tibial traction pin with 4.0 Denham pin or K-wire on frame
 Skin traction (short time, small weight, check skin carefully)
 Though Perkins exercises not possible in these conditions, depending on the
degree of fracture consolidation, an exercise program can often still be done

INFECTION WITH OPEN FEMUR FRACTURES

 Multiple DRBs, as needed, leave open or close over drain, possible EX FIX
 Antibiotics
 When feasible, close wound and continue with Perkins
 If non-union develops or is likely to develop, the infection has cleared, and the
tissues are soft without inflammation, the Pt may benefit from a cylinder POP,
Spica or mini-Spica, or articulated POP as a holding procedure to let things settle
before re-evaluation

INFECTION AFTER NAIL PLACED

 In early stages: if fixation is stable and FX not yet healed: retain nail, perform
early aggressive DBR, antibiotics, continue rehab with frequent radiological and
clinical F/U
  If Fixation is poor or FX healed or Infection is life/limb threatening: remove
nail and perform extensive DBR

WARNING
Do not underestimate or ignore patients' complaints of pain or discomfort

All patients in traction, in B/S, or POP are susceptible to heel pressure sores and other
pressure sores. These iatrogenic treatment failures are preventable with a sponge or
pad under the Achilles tendon, thick cotton padding under B/S and attention

NOTE
All patients after femur FX, no matter how they are treated need Outpatient Physio for
ROM, gait training, and strengthening. The most common cause of pain, continued use
of crutches, sense of giving way in a well healed femur fracture is atrophy of the
muscles by Pts not following up with Physio and/or Surgeons not paying close attention
to rehab

9. LEG

CLOSED TIBIA OR TIB-FIB FRACTURES

Always (at arrival in OPD and immediately after treatment) rule out Compartment
Syndrome

NON-OPERATIVE TREATMENT

 Stable low energy with or without displacement:

o Apply AK B/S and leg elevation with bed blocks and pillows.
o When swelling subsides apply AK POP
o Post-POP X-Ray for alignment
o D\C when POP dry and Pt safe with crutches. NWB
o In reliable Pts: apply AK B/S, Physio for crutches, D/C with elevation, return 5
day for AK POP

 Extremely Comminuted Fractures:

o TCT: K/W with wire-traction bow or Steinmann pin 5 mm. 3-5 kg according to
body weight, on Braun frame and bed blocks, with sponge or pad under
Achilles Tendon to prevent heel, until swelling subsides and fibrous callus
formed. May take up to 6 wks.
o Check and adjust alignment until satisfactory, confirm with X-Ray
o 3rd day DRS for pin site: check for tenderness/inflammation. Cover pins with
dry gauze
o In case of supposed early infection of the pin tract: switch to Daily DRS
o AK POP when FX stable and post-POP X-Ray

 In All cases
o Post-POP X-Ray to confirm reduction
o Gypsotomy as needed to correct alignment
o NWB

FOLLOW UP for NON-OPERATIVE TREATMENT

 In OPD, at 4-6 weeks:

o Check that Pt is using crutches/frame properly
o R/O POP and X-Ray check out of POP
o Clinical check for healing and skin condition
 o Apply new AK or BK POP if needed, with WB according to specific cases
 In Pediatric Patients: Long-term F/U to rule out possible LLD

OPERATIVE TREATMENT

 If unable to control FX in POP: CRIF or ORIF

 If no evidence of progressive healing by X-Ray or clinical exam by 4 - 5 months:
possible ORIF and bone graft
 Strong contraindication to Operative Treatment is previous history of
infection
 Weight bearing in AK POP only when clinical and X-Ray evidence of progressive
healing present
 In general: BK or Patellar Tendon Bearing (PTB) POPs are placed ONLY when
callus is mature by X-Ray, no pain with full WB in AK POP, and no tenderness
with manual manipulation of fracture.
 Fractures proximal to mid tibia should not be put into BK or Patellar Tendon
Bearing (PTB) POPs

 SHAFT FXS:
o SIGN nail in Adults. ESIN in Pediatrics
o F/U every 4 - 8 weeks until healed
o WBAT to full WB under Physio guidance if construct stable. Strengthening
and ROM

 PROXIMAL TIBIA FXs:

o CRIF or Mini-ORIF fix by K/Ws or cannulated screws, with or without AK
POP

 DISTAL TIB-FIB FXs:

o Retrocalcaneal SIGN nail
o Bone graft any bone loss or atrophic/oligotrophic non-union.

OPEN TIBIA OR TIB-FIB FRACTURES

 Thorough DBR in OT. Leave open

 AK B/S, possible EX FIX
  Devise initial plan for ST coverage and further treatment. State specifically in
chart
 Return to OT in 5 days for DPC, SSG, Flap, EX FIX, or Re-DBR
 Complex injuries with severe soft tissue destruction, bone loss, questionable
viability: should be evaluated by multiple surgeons in OT in 2-3 days
 EX FIXes are used primarily to manage soft tissue injuries and should be
replaced with POP or B/S as soon as possible, as Pin tract infection will limit
treatment options
 For very proximal or distal open fractures, avoid placing EX FIX Pins in zone of
injury and prefer Spanning EX FIX across the joint.

WARNING
BEWARE OF ANY ORIF

When there is a history of infection (anywhere in the body), inflammation, delayed soft
tissue coverage, SSGs directly over fracture, prolonged use of EX-FIX or pin problem

10. ANKLE

CLOSED FRACTURES & FX-DISLOCATIONS

  Closed reduction and Immobilize in POP with elevation bed blocks, pillows, frame
 If severe swelling: immobilize without reduction and elevate. Reduce when
swelling decreased
 If reduction satisfactory in BK POP: continue elevation and recheck X-Ray in
POP in 10 days
 If POP loose: reapply POP, X-Ray in new POP
 6 - 8 weeks in POP  Removal of POP and X-Ray check  WB dependent on
FX configuration

OPERATIVE TREATMENT
 If unable to achieve or maintain reduction in POP
 ORIF with K/W, Screws, Plate, Rush nail
 Additional B/S, U-slab, POP as needed to supplement ORIF
 Elevate postop, X Ray
 NWB
 6 weeks  X-Ray check  Re-assess WB status

OPEN FRACTURES ABOUT THE ANKLE

 Thorough DBR, leave wounds open and apply B/S (BK or AK) or U-Slab. Elevate
 Make a plan for reconstruction and record
o spanning ex fix
o flap
 Avoid any Internal Fixation in zone of injury

REMEMBER
A poor alignment or malunion that is NOT infected can be salvaged

11. FOOT

FX about the foot and ankle are common.

They are often complicated by swelling and require elevation.
The goal is a painless stable platform for ambulation
 SECTION 3 - SPECIFIC SITUATIONS OF ORTHOPEDIC
INTEREST

COMPARTMENT SYNDROME ……………………………….. Page 51

AMPUTATIONS ……………………………………………….… Page 53
ORTHOPLASTY ……………………………………………….... Page 56

COMPARTMENT SYNDROME (CS)

Compartment Syndrome (CS) is a surgical emergency and must be diagnosed and

treated promptly.
Mostly seen in lower leg and forearm, may affect any other closed anatomic space. It
may be present also in Open Fractures

 Diagnosis is primarily made by the Clinical Presentation

o Pain out of proportion to the injury

o Pain with passive stretch of the involved musculotendinous units (most
frequent sign is the painful passive flexion of fingers and toes)
o Firm or tense swelling of the involved compartment

WARNING
Absence of peripheral pulses is not sign of CS but should alert the surgeon to the
possibility of vascular injury

PROCEDURES WHEN SUSPECTED A CS

 When a POP or SLAB or any circumferential bandage is present, release it
immediately

IN CASE OF DOUBT, BETTER TO ACT

i.e. proceed with FASCIOTOMIES than wait and see!

SURGERY

 Apply tourniquet but inflate only if needed

 Perform complete FASCIOTOMY using long incisions
 LEG: perform 2-incision Fasciotomy (Antero-Lateral and Postero-Medial)
 FOREARM: Volar Fasciotomy will often release also the dorsal compartment
 Leave fascia and skin open (do not PC) and follow-up as usual for possible DPC
or SSG. Consider Shoe-lace technique
  Apply B/S or EX FIX, elevate extremity and bed rest (for lower extremity
fasciotomy) until DPC/ SSG time

 Overdress as needed. If bleeding excessive, review in OT

AMPUTATIONS

Amputation is a process, not a procedure:

 Seek confirmation of need for amputation with colleagues

  Discuss early with family the possibility, especially in light of the socio-cultural
background in which you are working

STUMP LENGTH

 Generally speaking, maintain standard length for proper prosthetic fitting but
Check with the local prosthetist if there is a preferred length in case non-
standard prosthesis sockets are used
 Standard bone length is:
o AKA: 10 cm above femoral condyles
o BKA: preserve 10-15 cm of tibia (minimum for proper prosthesis is 8 cm).
Leave the fibula 2 cm shorter than tibia

PEDIATRIC AMPUTATION

If at all possible, do it through joint (Disarticulation)

IN OPD

 Shave (if needed) and wash the patient

 Apply bandage to part to be amputated (cover only the wound, not whole
extremity)

SURGERY

 Apply tourniquet, though may not need to inflate

 In Traumatic cases, widely open every small fascial compartment (look for dirty
cavities in tissues below)
 Spare as much muscles as possible (e.g.: in BKA, spare as much gastrocnemius
as possible). This will allow the use of "flaps of opportunity" to provide soft tissue
coverage of bone and sufficient padding for prosthetic use
 Perform a high dissection of the nerve, then pull it down with a Kocher clamp and
transect sharply with a knife.
 Ligate major vessels (both arteries and veins)
  Periosteum should not be stripped proximally at bone cutting site. This will
decrease the risk of secondary bone spur formation, especially in young patients
 Bone stump should be smooth and not too long compare to soft tissue coverage.
 Anticipate difficult closure leaving enough muscle and skin coverage.
 At the end of procedure:
o Deflate tourniquet. Check hemostasis. Minimize use of cautery
o Irrigate profusely with solution of choice (NS or diluted 3% Hydrogen
Peroxide)
o in all Traumatic cases leave wound open, dress with fluffy gauze and a
loose bandage

EARLY POSTOP CARE

 Consider Hb check
 DPC after 5 days in OT
o Liberal use of suction drains (to be removed after 24 hours or when
collection is below 100 cc/day)
 After DPC, go for DRS on 3rd day
o In case of oozing: do not open the DRS, just overdress
o After first DRS: apply Elastic Bandage (this is crucial for a good shaping of
the stump during scar formation time and a subsequent proper prosthesis
fitting)

PHYSIO & REHABILITATION

Rehabilitation starts at surgery time, by creating a stump that can fit a prosthesis

 Prevent hip and knee flexion contracture when patient is in bed. Care must be
taken especially in the first days postop (consider to use a sand bag to keep AKA
and BKA stumps extended)
 Start early non-involved extremity strengthening
 Elastic Bandage is crucial for early edema reduction and to prepare the stump for
prosthetic use. It should ideally be started as soon as possible, in a dry sutured
surgical wound with no signs of infection
 ROS on day 14
 Doctor Review at 4 - 6 weeks
  Consider Prosthesis when there is no more edema, the soft tissues are stable
and molded (usually it takes around 2-3 months). Prosthesis planning should be
done in conjunction Physios

ORTHOPLASTY

SOFT TISSUE WOUNDS

IN OPD

 Shave (if needed) and wash the patient

  Apply bandage or dressing to affected site (cover only the wound, not the whole
extremity)
 Start Antibiotic IV if needed

SURGERY

 Wash the wounded area with Soap and NS poured from above, with patient
sedated
 Extent of DBR depends on extent of injury
o In War Wounds: explore and DBR all missile injuries independently
from their extension
 Perform a sharp excision of all dead, necrotic or non-viable tissue, particularly
dead muscle and loose bone fragments
 Identify vital structures (nerves, vessels, tendon) in attempt to spare them
 Achieve good hemostasis with limited use of cautery
 Spare as much skin as possible, leaving compromised, but possibly viable skin. If
it becomes necrotic, it can be removed at DPC
 At the end of DBR, irrigate profusely with solution of choice (NS and/or 3%
solution of Hydrogen Peroxide)
 Leave wound open
 Apply fluffy gauze and loose bandage dressing with a F/S or B/S as needed
 Consider PC for clean wounds of face and hands
 DPC at 5th day post DBR

WAR WOUNDS
WAR WOUNDS ARE ALWAYS CONTAMINATED

Initial DBR and irrigation is by far the most important surgical operation in war-
wounded patients and requires expertise, patience and surgical discipline
EARLY POSTOP CARE

 Wound is left untouched until DPC (5th postop day)

 In case of oozing, overdress
 Consider HPD and Vitamin/ Calcium supplements
 DPC, SSG or Flap on 5th postop day
o At DPC time, use suction drains only if needed
o Give appropriate Antibiotic treatment
o Avoid DPC under tension
o For skin closure, use non-absorbable monofilament (Nylon)

ROS of DPC After:

 14 days Limbs, Stumps
 5 days Face
 10 days All other wounds

NOTE: Stiches on clean wound under a POP do not need to be removed before POP
removal (4 weeks)

SKIN GRAFTS

Use Skin Grafts to cover wounds that cannot be closed without tension.

TYPES OF SKING GRAFT

 Split Thickness Skin Graft (SSG)
o Used in the majority of cases
 o Advantage: easy to take
o Disadvantage: poor cosmesis results and tendency to scar contracture.
o Donor site: usually thigh

o Take with Humby knife or battery powered Dermatome

o Mesh to expand area and allow fluid regress by “pie crusting” or with
Mesher

 Full Thickness Skin Graft (FTSG)

o Use for face, fingers, joints
o Advantages: better cosmesis and lower tendency to scar contracture
o Disadvantages: higher failure rate, needs a very clean and well
vascularized wound
o Donor site: groin, elbow flexion crease

o Suture primarily and treat as laceration

TIPS

 Proper DBR is the key of SSG success

 Graft only clean non-infected wounds. it is better to wait for good granulation than
risk an SSG failure. Fat has poor blood supply and will not support an SSG

 Avoid blood or serum collection under SSG by meticulous hemostasis

 Over joints or on limbs: immobilize the limb by back slab and encourage bed rest
until 1st DRS

 Use a battery powered Dermatome if available for large wound or in pediatric

patients. Otherwise use the Humby knife

WARNING
SSGs are contraindicated in infected areas
RELATIVE CONTRAINDICATIONS for SSG

 Areas in which normally the skin is not mobile (e.g. the palmar hand). Consider
FTSG
 Places submitted to load or pressure (e.g. the plantar foot or amputation stump)
 The face, for cosmetic reasons
 The extensor or flexor parts of the joints. Consider FTSG
 The mucosae or transitional tissues (e.g.: angle of the mouth)

POST-OPERATIVE DRS for SKIN GRAFTS

 First DRS 5th day post op, than 3rd day DRS
 ROS after 10 days
 First DRS of Donor Site after 21 days. Overdress if needed

FLAPS

Flaps are tissues transferred or rotated with their circulation to cover an area of
deficient skin/soft tissue.

FLAPS for SPECIFIC AREAS

FOREARM, WRIST, HAND

 Groin (fascio-cutaneous), axial pattern

 Abdominal (fascio-cutaneous with random vascular supply)

KNEE, LEG, FOOT

 Gastrocnemius Medial and Lateral (muscular) – Knee, Proximal Tibia

 Soleus and Hemi-Soleus (muscular) – Mid to Distal Tibia
o Direct or Inverted vascularization
· Medial Fascio-cutaneous Leg Flap or Saphenous (fascio-cutaneous) - widely
applicable over most of tibia
o Cross-Leg – avoid in older population
 Inverted Fascia Lata - big Capsular defect, not directly reparable

HEEL, FOOT, ACHILLES TENDON

· Reverse Sural artery - delayed inset more reliable

· Fascio-cutaneous - using medial or lateral perforator arteries

POST OP CARE of DISTANCE FLAPS

 Drain flap: suction, rubber

 If possible, support and splint extremity (EX FIX, Slab, Elastoplast, pillows) to
avoid kinking or pulling on Flap
 Avoid pressure on Flap
 Leave flap and flap edges exposed to check out color and congestion. Monitoring
for 24- 48 hours or longer
 Early congestion: change position, release or replace flap and delay inset
 If unable to leave exposed: DRS at 24 hours, in OT for Pediatric Pts
 ROS in 2 weeks
 Detach Flap at 3 - 3.5 weeks
 Flaps attached to upper extremity: begin ROM of non-involved joints (shoulder,
fingers) under physio to prevent contracture, especially MP extension contracture

SECTION 4 – REFERENCES & SUGGESTED LECTURES

 R McRae - PRACTICAL FRACTURE TREATMENT

 J Charnley - THE CLOSED TREATMENT OF COMMON FRACTURES
 DR Wenger - RANG'S CHILDRENS' FRACTURES
 Rockwood and Wilkins - FRACTURES IN ADULTS VOL 1 AND 2
 Rockwood and Wilkins - FRACTURES IN CHILDREN
  M King - PRIMARY SURGERY VOL. 1 AND 2
 RA Gosselin, M Foltz - GLOBAL ORTHOPEDICS 2nd edt.
 ICRC - WAR SURGERY VOL 1 AND 2
 AO & ICRC - MANAGEMENT OF LIMB INJURIES
 A Lerner - ARMED CONFLICT INJURIES TO EXTREMITIES

 R Tubiana - SURGICAL EXPOSURES OF UPPER EXTREMITY

 A Masquelet, R Tubiana - SURGICAL EXPOSURES OF LOWER EXTREMITY
 S Hoppenfeld - SURGICAL EXPOSURES IN ORTHOPAEDICS

 JC Kelleher - ABDOMINAL PEDICLE FLAPS TO THE HAND AND FOREARM

 B McCraw - ALTAS OF MUSCLE AND MUSCULOCUTANEOUS FLAPS
 A Masquelet - FLAPS OF THE MUSCULOSKELETAL SYSTEM
 A Masquelet - FLAPS IN LIMB RECONSTRUCTION

SECTION 5 – APPENDIX

ESIN in Pediatric Fractures …………………………….…… Page 64

 ELASTIC STABLE INTRAMEDULLARY NAIL (ESIN)
Also Known as “Nancy Nail”
in Pediatric Fractures

FRACTURES NOT SUITABLE FOR ESIN

 Infected wounds or infected skin (considering the whole body, not only the
affected limb)
 Non-Infected wounds with skin coverage problems
  All cases in which non-surgical approach is thought to give comparable results

FRACTURES SUITABLE FOR ESIN

FEMUR FRACTURES

Technique:

 Retrograde (ascending technique): Trochanteric, Sub-trochanteric, Diaphyseal

 Antegrade (descending technique): Distal third diaphyseal, Distal metaphyseal
Age limits:

 From 4 y.o. to 14 y.o.

 Age limit can be extended to older male patients with open growth plate and
younger child in case of multiple injuries
Body weight limit:

 50 Kg

LEG FRACTURES

Only in case of:

• Gross displacement in unstable fractures

• Reduction not held in POP
• Secondary displacement in POP before callus formation
Technique:

 Antegrade Tibia (descending technique): Tibia Diaphyseal and Distal

metaphyseal
Consider to add fibula nailing (Retrograde, ascending technique) in case of distal
unstable fractures
FOREARM FRACTURES

Only in case of:

• Gross displacement
o involving the proximal half of the radius
o with loss of separation between radio and ulna (that means it is lost the
effectiveness of the interosseous membrane)
• Reduction not held with POP or Secondary unacceptable displacement
• Floating Elbow
• Polytrauma

DIAPHYSEAL HUMERUS FRACTURE

Only in case of:

• Gross displacement not reducible conservatively, especially in patients > 10 y.o.

• Secondary unacceptable displacement during conservative treatment before
callus formation
• Floating Elbow
• Polytrauma