Page 21 - 63 craniocerebral-and-spinal-trauma30-35_opt

210 Musculoskeletal Trauma

children with fractures of both bones of the forearm, both sites must be A long leg cast extends from the proximal thigh to the metatarso-
anaesthetised for reduction. phalangeal joints, and is used to treat tibia fractures. Immobilising
Ideally, fractures should be reduced under an image intensifier the femur is particularly difficult because the hips must be stabilised,
(C-arm). When this is not possible, fractures should be reduced which requires a hip spica cast. This cast begins just below the nipples
by palpation only, then postreduction plain films must be obtained and extends to the thigh on the unaffected side and the ankle on the
immediately to verify the result. It is particularly important to correct injured side. This is particularly useful for fractures in infants.
rotation when reducing fractures; otherwise, a permanent deformity will Traction
result. Some degree of fracture overlap may be acceptable and beneficial Traction, which is application of force along the axis of the injured
due to the overgrowth phenomenon in skeletally immature bones. bone, is used to overcome muscle spasm to reduce fractures in long
This closed method of fracture reduction is applicable to even type bones. It is also used to immobilise long bone fractures. In other words,
I open fractures, with a resultant infection rate in some series of 2.5%. 8 patients on traction do not require casts. There are two main types
Operative treatment of traction: skin traction, where up to 5 kg of weight can be applied
Many closed fractures in the adolescent age group are managed by attaching adhesive tapes to the skin; and skeletal traction, which
operatively in the developed countries. Open fractures are generally requires a pin inserted transversely through a bone, taking care not to
considered orthopaedic emergencies. Most orthopaedic surgeons agree go through the growth plates to avoid premature epiphysiodesis and
that type II and III open fractures require urgent operative management. shortening of the bone. Traction can also be applied by gravity acting
The goal of operative management of type II and III open fractures is to on the weight of the upper limb or a combination of traction and a cast.
prevent infection in or around the fracture site, which can lead to osteo- These are seen in distal fractures of the humerus with a hanging cast.
myelitis. Infection prevention is accomplished by: (1) administration In children, skin traction can usually provide enough traction to
of antibiotics, (2) copious irrigation and removal of all foreign mate- overcome muscle tension and reduce most fractures. Russell’s traction
rial, (3) debridement of all devitalised tissue, and (4) coverage of all uses a weighted cord to elevate the knee and distract the lower leg, and
exposed bones when possible. Irrigation is generally accomplished with is useful for fractures of the femoral shaft. In younger children and
several litres of warmed normal saline. Battery-powered pulse irriga- toddlers, Bryant’s traction is used for femoral fractures: both feet and
tion devices are available in the United States. A reasonable substitute is legs are suspended from the bed.
a 60-ml syringe attached to sterile intravenous (IV) tubing with a three- Traction is also useful to reduce an anterior shoulder dislocation,
way stopcock. The IV tubing is attached to a bag of warm, sterile saline which typically occurs from a fall on an abducted arm. More than 90%
off the surgical field. The stopcock is rotated to allow rapid filling, then of these dislocations can be reduced by having the patient lie prone
flushing of 60-ml aliquots of saline for cleansing the wound. The saline on a table with the arm hanging down by the side. The dependent arm
should be ejected with force to dislodge contaminants in the wound. is weighted to increase the traction. Following reduction, the arm is
immobilised to the body with the elbow at 90°.
Immobilisation Other methods
Casts Fractures of the clavicle can be managed with a figure-of-eight splint
Once closed reduction has been effected on fractures, casts could be that draws back and elevates the shoulders. This position applies trac-
used to immobilise it. Casts are bandages that contain chemicals that tion on the distal clavicle and stabilises the fracture. These splints may
harden after water is applied. Plaster cast materials contain anhydrous occasionally cause swelling of the arms and hands.
calcium sulfate, which solidifies when water is added. An injured
After operative reduction of fractures, many hardware options are
extremity must be covered with a layer of gauze or cotton padding
available to internally fix or immobilise the fractures, depending on the
(such as orthoban) before a cast can be applied. Additional padding
fracture configuration and proximity of fractures to the growth plates.
should be applied to bony prominences. The cast material must be
This hardware includes smooth pins and wires, plates and screws, and
molded over bony prominences and joints. As a general rule, the joint
external fixators (Figure 32.1). Intermedullary nails (interlocking or not)
proximal and distal to the fractured bone must be included in the cast
are not commonly used in children for fear of premature epiphysiodesis.
to fully immobilise the fractured bone. However, fingertips or toes must
Implants are available in most orthopaedic units in Africa, but tractions
be left exposed so that peripheral circulation can be evaluated.
and casts are devices that are still handy in remote practice areas. The
The most serious complication of plaster cast application for fracture
advantage of internal fixation is that it leads to earlier mobilisation. Any
immobilisation is vascular insufficiency due to unrelieved swelling.
hardware used in children should be removed as soon as consolidation of
This is the pathophysiology of bonesetter’s gangrene, a serious and
the fracture sites are achieved; otherwise, growing bones could overgrow
potentially life-threatening complication of the folk medicine practice
the implants and even mold onto the contours of the implants. This makes
of tightly splinting fractured extremities. The resulting vascular
delayed removal difficult and sometimes impossible and abandoned. The
insufficiency leads to gangrene that is usually advanced by the time
development of biodegradable implants has solved these challenges.
the patient seeks attention at a hospital. In one review of 35 major
extremity amputations among children at a centre in Nigeria, 26 were
due to trauma, and 24 of these patients had “simple, straightforward
fractures” that were treated by traditional bonesetters. 9
In the case of a cast, if unrelieved pain, sensory loss, or motor
paralysis occurs, the cast must be opened immediately by splitting the
cast down to the skin, allowing expansion and return of circulation. If
the patient complains of localised pain, then a pressure point may be
developing under the cast. The treatment of this condition is to cut a
“window” into the cast, add more padding to the area, then cover the
window with additional plaster.
Casts commonly used in children include the “short arm cast”
for wrist fractures, which extends from just below the elbow to the (A) (B)
metacarpo-phalangeal joints but leaves the thumb free. Forearm
fractures require casting above the elbow (with the elbow at 90°). Figure 32.1: Fracture separation of proximal humeral epiphysis with shoulder
dislocation (A) before treatment; (B) treated with smooth cross pin fixation.