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The main objectives of treating a patient with fractures is to restore the integrity of the bone, the anatomical shape of the joint, the function of damaged limb and the patient’s ability to work. To implement these tasks, the following principles must be followed:

  • reduction of bone fragments;
  • restoration of the length and axis of the limb;
  • reliable fixation of bone fragments;
  • possibility of functional limb load until the end of the consolidation period.

There are two main methods of treating fractures – conservative and surgical.

Conservative treatment

There are only two conservative methods – fixation and extension.

Fixation method

The essence of the fixation method of treatment consists in simultaneous closed manual reduction of bone fragments and their support (Retention) with a fixation bandage, most often plaster. Closed simultaneous manual reposition is widely used for such indications (fracture of the tibia in ankle joint, fracture of arm bones, stable fracture of the spine and the like).

Closed reposition should be performed as soon as possible from the moment of injury, the optimal time is 6-12 hours since it is likely that swelling of soft tissues will increase rapidly, which makes this procedure difficult or impossible.

Extension method

The essence of extensional treatment method is to constantly stretch with the help of a load, it acts gradually and dosed, overcoming muscle refraction, and thereby eliminates fracture of the bone with displacement, and therefore, performs indirect reposition.

Also, with constant traction, it is possible to hold (perform retention of) bone fragments in the desired position. This method is used to treat displaced leg bone fractures.

Skeletal traction method has the following advantages:

  • ease of implementation;
  • technical equipment is not complicated;
  • ability to visually monitor damaged limb;
  • availability to use;
  • minimal traumatism.

Significant disadvantages of constant traction (which makes its implication narrowly limited) are:

  • hypermobility of bone fragments;
  • impossibility of reposition in the presence of soft tissue between the fragments (interposition)
  • non-physiological position of the patient in bed;
  • physical inactivity;
  • hypokinesia;
  • difficult evacuation of the patient;
  • inconvenience of hygienic toilet;
  • the likelihood of developing hypostatic complications (pneumonia, pressure sores, etc.);
  • significant deterioration in the quality of life during the treatment period.

Surgery

Osteosynthesis is an operation for bone fractures, which is based on the connection of bone fragments formed during fractures and their consequences. The purpose of the operation is to eliminate the displacement of bone fragments, their stabilisation for the period of consolidation, restoration of shape and function of the limb.

Indications for osteosynthesis are:

  • inefficiency of conservative treatment;
  • unstable fractures;
  • isolated fractures of radius and ulna, fractures of both bones of the forearm
  • fracture of radial bone (Galeazzi and Monteggia);
  • false joints and neoarthrosis;
  • intraarticular fractures;
  • open or complicated fractures;
  • multiple and combined injuries;
  • fractures in the elderly;
  • fractures in patients with mental disorders.

Contraindications to the implementation of osteosynthesis are:

  • stable fractures (wedging, subperiosteal of green branch type in children);
  • the presence of severe concomitant pathology (cardiovascular failure, decompensated diabetes mellitus, syringomyelia, etc.), when the degree of anaesthesia and surgery risk is very high;
  • terminal state of victims.

There are four methods of osteosynthesis: plate, inside bone marrow (intramedullary), reductive and extrafocal.

Plate osteosynthesis

This is osteosynthesis using plates.

The advantages of plate osteosynthesis are:

  • stability and functionality;
  • implementation of regenerative process in a direct way;
  • preservation of internal bone marrow circulation
  • timely recovery of muscular skeleton;
  • ability to simultaneously heal the fracture and restore movement in adjacent joints.

The disadvantages of bone osteosynthesis are:

  • impossibility to perform without special tools;
  • morbidity of performance, damage to muscles and periosteum;
  • probability of purulent-infectious complications, osteomyelitis
  • traumatic plate removal.

 

Intramedullary osteosynthesis

This is intraosseous fixation using metal and metal-polymer pins (nails). This way of osteosynthesis is used when there are diaphyseal fractures, a fracture of leg bones (proximal and distal parts (intraarticular and periarticular) of the femur), fracture of the proximal tibia, and fracture of the surgical neck of the humerus.

 

Reductive osteosynthesis

This is osteosynthesis with screws. Cortical screws are used for diaphyseal fractures of tibia and humerus, in cases when the fracture line (long and oblique) is 2 times the bone width (Fig. 2.9). With the correct insertion of screws, the latter can withstand a load of more than 40 kg.

Reductive screw osteosynthesis is unstable; the use of a plaster cast is always indicated. Plaster immobilization should continue until the fracture heals.

 

Osteosynthesis with external fixation device

This is an extra focal osteosynthesis with devices on a spoke or pin framework. For example, Ilizarov nail, the main elements of which are spokes inserted into the bone, that intersect, stretch and fasten in rings or arcs; the latter are interconnected using threaded rods. The device allows you to perform closed reposition of bone fragments, to carry out, if necessary, their compression or distraction. Ilizarov nail has unlimited indications for use, especially for open fractures, multiple and combined injuries, and the like.

 

The advantages of spoke-based external fixation devices are:

  • a significantly lower risk of infectious complications;
  • ease of installation;
  • low traumatism and minimal invasiveness;
  • the possibility of improvisation;
  • reduction of bone fragments is possible in the postoperative period.

The disadvantages are:

  • possibility of damage to blood vessels and nerves;
  • infectious-purulent inflammation of soft tissues around the spokes;
  • fractures of spokes;
  • annular burn of bone with excessive reaming;
  • bedsores of soft tissues from the indentation of rings and arches of the nail;
  • limited toilet facilities.

Spinal fracture surgery

Spinal fracture surgery is performed in cases of unstable fractures, or complicated fractures with compression of the spinal cord and development of a neurological deficit. During the operation, open reduction, anterior decompression, and resection of the fractured vertebral body with its plastic reconstruction are performed.