MANAGEMENT OF LONG BONE FRACTURES

INTRODUCTION

Definition of fracture is a break or disruption in the continuity of a bone or cartilage structure. Fracture of long bone diagnosis should be able to describe closed or open, anatomy location (proximal, shaft, distal and intraarticular, simple or comminuted, complete or based on fracture line direction/extent to articular surface or not) or incomplete, the position of fracture fragments (angulation, displacement), pathologic, avulsion, impaction and stress.

1.      Complete fracture is a fracture involving the entire cross-section of the long bone or an interruption of both cortices of the bone (fig. 1).

Fig. 1 Closed complete fracture of the right humerus

2.      Incomplete fracture; if it involves only one cortex or only a portion of cross section of the long bone.
Example incomplete fracture is a torus fracture (fig. 2 A & B) with characteristic a wrinkling or buckling of the cortex. Other example is a greenstick fracture; it is an incomplete angulation fracture of the long bone.

Fig. 2 A.Torus fracture of the radius distal (Buckel handle),

 B Incomplete fracture of the left tibia

3.      Closed fracture, the skin and the soft tissues overlying the fracture of the long bone site are intact or the fracture site does not communicate with the outside environment (fig. 3). It’s also called simple fracture.

Fig. 3 Closed fracture of the left patella

4.    Comminutives fracture: fracture in which the long bone is broken into more than two fragments (fig. 4)

Fig.4 Segmental Comminutives fracture of the right tibia proximal

5.    Transversal fracture: a fracture line at a right angle to longitudinal axis of the broken bone(fig. 5)

Fig.5 Fracture of the right tibia and fibula with transverse fracture line

6.    Oblique fracture is the fracture line direction is slanted in relation to the long axis of the long bone. The fracture line of the humerus is oblique (fig. 6))

Fig. 6 Isolated of the right tibia diaphysis with oblique fracture line

7.    Spiral fracture: a type of fracture in which a torsional stress produces a winding fracture line relative to the long axis of the broken bone (fig. 7)

Fig. 7 Spiral fracture of the right femur

8.    Segmental fracture is a long bone fracture consisting of more than one fracture line at different levels in the same bone (fig. 8)

Fig. 8 Segmental fracture of the right femur

9.    Open fracture: The long bone fracture site communicates or exposes with the outside environment and the fracture has a potential infection. Open fracture is an emergency of orthopaedic, therefore should be controlled bleeding by a slight compressing sterile dressing covered after removing the gross debris and splinting without reduction except vascular compromised at the site of accident, antibiotic and antitetanus administration and debridement in emergency department management. We classified open fracture based on size of wound, soft tissues, bone and vascular damage, and the degree of wound contamination (Gustilo and Anderson/table1).

Table 1. Open fracture classification (Gustilo and Anderson Classification)

Alignment: the position of one fracture fragment to the next fragment. Deviation from the normal alignment is called angulation.

10.  Valgus angulation means angulation, bending or twisting (apex of the fracture) away from the midline of the body (fig. 9)

Fig. 9 Valgus angulation of the right humerus

11.   Varus angulation is an angulation, bending or twisting (apex of the fracture) toward the midline of the body (opposite of valgus/fig. 10).

Fig. 10 Varus angulation of the right femur

12.  Impacted/impaction fracture is a compression trauma in which the broken bone ends are driven together and fracture become stable. Impaction in vertebral body frequently occurs by a compression force but in tibial plateau fractures occurs by depression forces frequently. The physician should be able to describe the radiographs carefully because frequently extreme subtle.

13.  Avulsion fracture is the separation of a small piece of bone that has been pulled away from the attachment of ligament/tendon caused by forceful muscle contraction or by the resistance of a ligament to a force in the opposite ligament, and usually involving a tuberosity or bony process.

14.  Pathologic fracture is a break the weaken bone by low energy trauma. The weaken bone is the disease of bone tumor (fig. 11) or metabolic disease or bone infection, osteomalacia, osteogenesis imperfecta, scurvy, rickets, and Paget's disease of bone.

Fig. 11 Pathologic of the right proximal femur

Suspected bone cyst

15.  Stress fracture or others name March (military) or Fatigue (jogger, dancers, and athlete) or Insufficiency fracture is repeated or repetitive trauma and the bone become broken.

The physician should be able to classify the fracture in children (Table: 2) because the cartilaginous portion of an epiphysis is not visualized on radiographs (radiolucent). Therefore, the complexities or difficulties in interpreting radiographs in children should be compared with the normal side of radiographs.

Table 2: Salter Harris fracture classification

(Modified from Kilgore, KP /2006; emergency orthopaedic)

CLINICAL SIGNS

Clinical features are deformity, swelling, tenderness, abnormal mobility, and loss of function. Accurate fracture diagnosis can be confirmed by radiographs examination. Special studies (axial view and others advances examination that include CT scan, MRI, and others) should be performed if there is a clinical suspicious conflict between diagnosis and clinical data.

RADIOGRAPHIC INVESTIGATION

Conventional views (AP and lateral views) of radiographic examination is an essential to confirm or rule out fracture, pathologic condition/quality of bone, and also to detect foreign body, air, position of fragments, angulation, and fracture line. Therefore a systematic evaluation of radiographs should be performed carefully.

MANAGEMENT

Upper and lower extremities of long bones are the most common site of injury. The upper and lower extremity fractures of long bone patients are divided into critical and uncritical conditions.

Critical patient condition is the closed/open of long bone fracture with early complications such as hypovolemic shock cause by bleeding, vascular compression or injury, and compartment syndrome; therefore lifesaving or limb threatening is essential management to this patient.  

Uncritical patient condition is usually closed of long bone fracture or open fracture grade I and II without early complications. Lifesaving and limb threatening are not requirement, but open fracture is an emergency debridement to prevent infection.

Management of long bone fracture has to be started from the scene of accident until at Puskesmas or trauma hospital. Primary care or temporary management can be performed at the scene of accident or Puskesmas but definitive treatment of long bone fractures should be done at Puskesmas (Level I) or trauma hospital (Level II or III) and depend on the site and the type of fractures.

There are three questions should you responds if you are volunteer, team of rescue or physician or resident or the orthopaedic and traumatologic surgeon in management of long bone fracture that includes:

a.      What do you prepare?

b.      What do you call?

c.       What do you do?

A.      THE SCENE OF ACCIDENT

                    I.            UNCRITICAL PATIENT OF CLOSED/OPEN LONG BONE FRACTURE

a.      What does volunteer/community prepare?

Volunteer/community should be able to:

·         Participate in fracture first aid and scene of accident safety

·         Invite others people around the site of accident to assist in preparing of the first aid and safety of the accident area

·         Prepare the splinting material for fracture immobilization management and extrication equipment procedure, if patient body jammed on the collapse of building in disaster or others accident.

·         Prepare sterile dressing for covering the wound

b.        What does volunteer/community call?

Volunteer/community should be able to:

·         Call the nearest ambulance or helicopter rescue team immediately and inform the condition of the patient (uncritical or critical). The rescue team includes: nurse, physician and ambulance driver/helicopter pilot

·         Call the police

·         Call/ask the community around the scene of accident in first aid

c.        What does volunteer/community do?

Volunteer/community should be able to:

·         To check the circulation below injury (pulse and skin temperature) and then inform these data to the ambulance/helicopter rescue team.

·         Cover the fracture wound by sterile dressing and immobilize suspicion fracture. There are types of splinting and depend on the type and the site of fracture. For example splinting of the femur fracture, the volunteer/community should be able to perform immobilization by using triangular bandages and wood or hard cartoon if the ambulance service is going to be on the scene within more an hour (fig. 12 A). Then patient transfers to the safety area

Fig. 12 A & B Left femur fractured

The splinting procedure: Hold and traction the foot of injured lower limb according to longitudinal axis of the lower extremity. Gently pull foot down from hip and then straighten and hold the limb.

ü  Place bandages and then wood cartoon splint or hard-carton splint between legs and pad heavily especially on bone prominent.

ü  Apply bandage:

Ø  Figure 8 bandage around feet

Ø  Bandage above the fracture site and it’s joint

Ø  Bandage below the fracture site and it’s joint

Ø  Tie all knots over padding (fig. 12 B)

Ø  The patient transfers to the safety area

·      Other example is forearm fracture. Hold the hand of injured upper limb, gently traction hand and contra-traction of the elbow joint ipsilateral of the injured extremity and then straighten and hold it by hard carton splint (fig. 13)

(fig. 13) Right forearm fractured

After ambulance/helicopter rescue team arrives at the scene of accident

a.        What does rescue team prepare?

Rescue team should be able to

·         Provide the comfort splinting material and extrication equipment procedure if patient body jammed on the collapse of building in disaster or others accident.

·         Prepare sterile dressing materials (sterile dressing and antiseptic solution)

·         Prepare the knowledge of the fracture and the condition of uncritical of closed long bone fracture patient for information to the nearest Puskesmas or trauma hospital Level I or II/III.

b.         What does rescue team call?

Rescue team should be able to

·          Ask the other volunteer to participate in first aid and safety of the accident area

·          Connect the nearest Puskesmas or trauma hospital Level II or III and inform the condition of patient requirement

·          Contact the family of patient according to his/her identity address

c.         What does rescue team do?

Rescue team should be able to

·         Recognize the possibility of long bone fracture based on clinical sign that had been mention above

·         Evaluate the distal pulse of the lesion and the possibility of internal bleeding of the fracture site and perform IV line.

·         Assess the wound of fracture for grading of open long bone fractures and then cover again

·         Collect the information of the accident and physical data in secondary survey for discussion and communication between rescue team and conscious patient

·         Replace the splinting of the injured extremity (femur fracture suspected/fig. 14 A) on a comfort immobilization, for example Thomas splint (fig. 14 B) to achieve transport safety.

(fig. 14 A & B) Thomas traction splinting

The traction immobilization procedure:

ü  Bandage the ankle area and insert the Thomas splint below the lower extremity fracture and then put the abnormality extremity on it

ü  Bandage above the fracture site and it’s joint

ü  Bandage below the fracture site and it’s joint

·           Evaluate the circulation below the fracture site after traction splinting and the tighten of bandage around the wound for suspected compartment syndrome frequently

·           Perform collar neck using (fig. 15 A) and then the patient put spine immobilization of spinal board on for suspected spine fracture. The patient is transferred on spinal board by scoop stretcher. If closed long bone fracture (femur fracture) together with pelvic fracture suspected, the rescue team has to be immobilized by pelvic binder (fig. 15 B) and traction splinting for suspicious of closed femur fracture

Fig. 15 A Collar neck immobilization (left) and pelvic binder patient on spinal board (right/B)

Kendric board immobilization of spine fracture for extrication procedure using is a simple splint

·           Perform discussion of the best management planning based on the condition of closed long bone fracture patient between rescue team and conscious patient

·           Transport the patient to the nearest Puskesmas based on GP competency management or trauma hospital Level II or III for orthopaedic specialist competency care immediately. If the time duration of transportation is more than 12 hours or a long journey to nearest trauma hospital or an irreducible delay before transfer; the rescue team has to perform and indwelling urinary catheter and refer to Puskesmas first for primary care by physician/GP.  

                  II.               CRITICAL PATIENT OF CLOSED/OPEN LONG BONE FRACTURE PATIENT

The volunteer and community first aid preparation, participation and performing are the same with uncritical of closed/open long bone fracture patient at the scene of accident.

After ambulance/helicopter rescue team arrive at the scene of accident

·         What does rescue team prepare?

Rescue team should be able to

·         Prepare fluid resuscitation materials

·         Provide the comfort splinting material, sterile dressing & antiseptic solution and extrication equipment procedure if patient body jammed on the collapse of building in disaster or others accident.

·         Prepare the knowledge of the fracture and the critical of closed/open long bone fracture patient for information to the nearest Puskesmas/trauma hospital

·           What does rescue team call?

Rescue team should be able to

·           Call/ask the other volunteer community to participate in first aid

·           Inform the condition of critical patient requirement  to the nearest Puskesmas or trauma hospital Level II or III

·           Contact the family of patient based on his/her identity address

c.         What does rescue team do?

Rescue team should be able to

·           Perform IVs line for fluid resuscitation, oxygenation, and urinary catheter.

·           Cover the wound of open long bone fracture by sterile dressing with slight compression to stop bleeding

·           Collect the information of the accident and physical data in secondary survey for information to the nearest Puskesmas/trauma hospital Level II or III

·           Replace the splinting of the injured extremity (femur fracture suspected) on a comfort immobilization, for example Thomas splint to achieve transport safety fig. 14 A & B.

·           Check circulation below the fracture site after immobilization or traction splinting frequently

·           Perform collar neck using and then the patient put spine immobilization of spinal board on (fig. 15 A) for suspected spine fracture. The patient is transferred on spinal board by scoop stretcher. If closed long bone fracture (femur fracture) together with pelvic fracture suspected, the rescue team has to be immobilized by pelvic binder and traction splinting for suspicious of closed femur fracture (fig. 15 B)

Kendric board immobilization of spine fracture for extrication patient if patient body jammed on the collapse of building in disaster or others accident, because this equipment is a simple splint

·           Perform discussion of the best management planning based on the condition of closed/open long bone fracture patient between rescue team and conscious patient

·           Transport the patient to the nearest trauma hospital Level II or III for orthopaedic specialist competency care immediately or Puskemas for primary care by physician/GP; if the time duration of transportation is more than 12 hours to nearest trauma hospital.    

B.        PUSKESMAS (PHYSICIAN/GP COMPETENCY)

Physician/GP should be able definitive management of closed long bone fracture based on competency or only primary care of closed/open long bone fracture and then the patient transport to the nearest trauma hospital Level II or III for definitive treatment.

                    I.            Uncritical and critical of closed/open long bone fracture

a.      What does physician/GP prepare?

Physician/GP should be able to:

·         Prepare information, physical examination and investigation (x-rays & laboratory) data in secondary survey

·         Prepare the knowledge of the fracture and condition of the uncritical patient for discussion, communication and sharing to patient family or conscious  patient

·         Prepare conservative management materials (definitive therapy):

a)      Plaster of Paris,

b)      Padding and

c)      Stockinet

d)      Simple closed reduction equipment

·           Prepare the knowledge of closed/open long bone fracture

·           Prepare and ask the nurse to participate in preparation of open long fracture debridement surgery (temporary treatment/primary care):

a)      Medical: analgetic/local anesthetic drugs, antibiotic & antitetanus, disposable injection, sterile dressing & antiseptic solution, saline solution and alcohol.

b)      Minor set for wound irrigation and debridement equipment

b.   What does physician/GP call?

Physician/GP should be able to:

·         Call the nurse as assistant

·         Contact the radiographer assistant for x-rays examination (if there is a facility) and laboratory team

·         Inform the family about the uncritical condition of the closed/open long bone fracture patient and discussion and communication of the management for getting of informed consent.

·         Call the nurse for the minor surgery preparation of open long bone fracture

c.    What does physician/GP do?

Physician/GP should be able to:

·         Perform information of the accident history, physical examination and x-rays investigation to collect objective data. The physician/GP analyzes all data to achieve accurate diagnosis and communicate to conscious patient and patient families to get inform consent. If the fracture is not obvious on radiographs, the physician should be able to compare with the x-rays of the normal site. When the results of radiographs are dubious; the physician should be able to consult to orthopaedic or refer to trauma hospital directly after primary care.

·         Re-assess the possibility bleeding problem and vascular compression or compartment syndrome complications of closed/open long bone fracture.

·         Perform definitive management of closed long bone fracture based on physician/GP competency such as closed reduction and casting (for example: incomplete or undisplaced fracture, simple fracture and stable and others). If the fracture is not GP competency or the closed reduction is unsuccessful, the physician has to refer to the nearest trauma hospital Level II or III immediately after primary care.

·         Perform temporary treatment of open long fracture (grade I, II, & III), IVs line, irrigate the wound of fracture by physiologic solution and debridement as soon as possible. Irrigation for Grade I is 3 liters, Grade II is 6 liters, and Grade III is 9 liters of saline solution, debridement/remove  all necrotic tissues and foreign bodies, antibiotic & antitetanus administration, perform urinary catheterization, oxygenation and splinting; and then the patient refer to the nearest trauma hospital Level II or III immediately.             

·         Evaluate input of saline solution and urine output (normal in adult: 0.5 – 1 ml/kg/hr; in child: 1 ml/kg/hr).

·         Monitor pulse at the distal of casting and the complaint of pain. If there is pain out of proportion and pulse problem; the physician has to loosen the splint or univalved/bivalve of casting and then refer to the nearest trauma hospital Level II or III immediately.

·         Refer the open long bone fracture patient to the nearest trauma hospital (Level II or Level III) immediately after primary care.

·         Analyze x-rays control (if there is a facility). If the position of fragment fractures is an unacceptable, physician has to refer to the nearest trauma hospital Level II or III (orthopaedic surgeon)

·           Perform simple rehabilitation after definitive management

·           Perform post orthopaedic specialist management follow-up based on the specialist instruction

·           Advice the prevention program to patient and family of patient

                  II.          Critical of closed/open long bone fracture

There are three conditions of the critical closed/open long bone fracture patient include: long bone fracture together with hypovolemic shock caused by bleeding, or compression syndrome, or vascular injury.

1.      Hypovolemic shock patient can be caused by:

1)      Blood loss/hemorrhage at the site of closed/open long bone fracture for example femur fracture or multiple long bone fractures  

2)      Multiple trauma (long bone fracture together with trauma abdomen or others organ)

3)      A delay of rescue team arrives at the scene of the elderly fracture patient accident; therefore the elderly patient spent a long time on the floor and also without oral intake.

Prediction of the blood loss/hemorrhage cause by closed/open long bone fracture can be counted based on table 3

Table 3: Expected blood loss of fracture in adult

Fracture site	Expected blood loss
Radius and ulna	150 -250 ml
Humerus	250 ml
Tibia and fibula	500 ml
Femur	1000 – 1500 ml
Pelvis	1500 – 3000 ml

(modified from Kilgore, KP /2006; emergency orthopaedic)

Closed/open long bone fracture itself may result in large amounts of blood loss, shock, and even death from exsanguination. After patient is a stable; the patient should be transported to the nearest trauma hospital immediately.

2.      The compartment syndrome is an elevating pressure within a limit anatomic space compromises the local neurovascular in that space. Severe pain, decreased sensation, increasing pain to passive stretch of fingers or toes, and a tense extremity are all signs of compartment syndrome diagnosis. Distal pulses may remain present long after muscle and nerve ischemia and damage are irreversible. Because of that, fasciotomy for decompression of the increasing pressure is an indication of compartment syndrome immediately. The prognosis depends on the time of fasciotomy; if the time fasciotomy within 6 hours, the outcome are excellent, delayed up to 12 hours only 68% of patients have a normal limb function. The orthopaedic surgeon should also be able to distinguish between compartment syndrome and deep vein thrombosis, cellulitis, peripheral vascular disease, septic arthritis, and rhabdomyolysis

3.      Vascular compression signs are Poikilothermic: Cool is in the extremity; Is it cooler than the unaffected side?, Pallor: Palpation on the skin is pale. Is capillary refill delayed?  Palpation pulse of vascular injury should be evaluated: Is it absent or weak. Ankle Brachial Indes (ABIs) should obtain if signs of vascular compromise exist. The normal ratio ABI is > 0.9. The object examination of vascular injury ia an angiogram with indication include the following:

1)      Cool, pale foot with poor distal capillary refill test

2)      Long bone fracture of the lower extremity with knee dislocation and especially in high energy trauma at the area of trifurcation of popliteal artery

3)      ABI is less than  0.9 associated with a lower extremity trauma

a.        What does physician/GP prepare?

Physician/GP should be able to:

·            Prepare IVs lines, saline solution and oxygen

·            Prepare instrument surgery for irrigation, antibiotic & antitetanus, sterile dressing, antiseptic solution for open fracture and compartment syndrome and splinting equipment for fracture and neurovascular injury.

·            Prepare the knowledge of hypovolemic caused hemorrhage, compartment syndrome, and neurovascular injury for communication to the family of patient and patient (conscious patient)

·            Prepare patient transportation to the nearest trauma hospital for definitive management after primary care

b.         What does physician call?

Physician/GP should be able to:

·      Invite the family patient for discussion/communication

·      Call the nurse for minor surgery preparation

·      Call ambulance driver for transportation after primary management

·      Call radiographer for x-rays investigation

1.         HYPOVOLEMIC SHOCK caused by hemorrhage

c.       What does physician/GP do?

Physician should be able to:

·         Perform assessment airways, breathing, circulation, disability, and exposure (ABCDE)

·         Evaluate the immobilization of suspicion fracture. The benefit of immobilization traction include: arrest internal/external hemorrhage, support the injure area, immobilize to the joint above and below the suspected fracture. Physician/GP should be able to predicts blood loss of closed or open long fracture (table4)

Table 4 Expected blood loss of fracture in adult

Fracture site	Expected blood loss
Radius and ulna	150 -250 ml
Humerus	250 ml
Tibia and fibula	500 ml
Femur	1000 – 1500 ml
Pelvis	1500 – 3000 ml

(modified from Kilgore, KP /2006; emergency orthopaedic)

·         Perform discussion and communication of the best management planning based on the condition of closed/open long bone fracture patient between physician and family of patient for getting informed consent

·         Assess and re-asses hypovolemic shock problem. Physician/GP should be able to perform fluid resuscitation (table 5) and oxygenation.

Table 5: Classification of bleeding and management

Bleeding classification	Blood loss	Treatment
I	Less than 15%	Fluid resuscitation
II	15 - 30%	Fluid resuscitation
III	30 – 40%	Fluid resuscitation & blood transfusion
IV	More 40%	Fluid resuscitation & blood transfusion

·      Perform debridement of open long bone fracture, antibiotic &antitetanus administration, urinary catheterization, oxygenation and splinting. Debridement procedure consist:

o   Exploration the wound

o   Removing of foreign bodies, necrotic of soft tissues and bone

o   Irrigation of wound with sterile normal saline. Grade I is 3 liters, grade II is 6 liters, and grade III is 9 liters

·      Perform monitoring of urine output and pulse of the distal splinting frequently and then transport to the nearest trauma hospital immediately

2.         COMPARTMENT SYNDROME

c.       What does physician/GP do?

Physician/GP should be able to:

·      Assess clinical signs such as: pain of fracture is out proportion, palpable swelling and tension in that compartment, paresthesia, poikilothermia, pallor, pulseless, and paralysis (6 Ps).

·      Detect initial suspicion compartment syndrome diagnosis based on the increasing pain caused by specific passive stretch of the compartment muscles of fracture site against resistance.

·      Perform discussion and communication of the best management planning based on the condition of closed/open long bone fracture patient between physician and conscious patient and also family of patient for getting informed consent

·      Perform Removing of any constriction dressing or split them down to the skin or univalved/bivalve of casting, and hold limb at the level of the heart to promote arterial inflow. And then the patient refer to the nearest trauma hospital immediately or if duration time of transportation to nearest trauma hospital is more than 12 hours, perform fasciotomy first, leave it open and cover the wound by sterile dressing, and then transport to the nearest hospital immediately after primary care.

3.         VASCULAR COMPROMISE

c.       What does physician/GP do?

Physician/GP should be able to:

·            Perform ABIs measurement of lower extremity fracture. Normal ratio is  > 90

·            Communicate and discuss the physical and investigation data to patient and family of patient for getting informed consent

·            Perform manipulation of the fracture to achieve the normal alignment by traction-contra traction and then splinting.

·            Monitoring the distal pulse of the lesion and then refer to the nearest trauma hospital immediately together with vascular injury problem information

C.        TRAUMA HOSPITAL (Resident, orthopaedic surgeon and others specialist competency)

All of unstable closed of long bone fractures (oblique, comminutives and fracture complications) and early complications of closed/open long bone fracture patients are the orthopaedic and traumatologic competency.

There are three possibilities of decision making management of closed/open long bone fracture patient in emergency unit of trauma hospital that includes:

1)      Emergency surgery caused by ABC problem should be managed at emergency unit for lifesaving and limb threatening.

2)      Elective surgery to complete investigation data, implants and instrument requirement and also the management planning accurately. Because of that patient should be admitted the orthopaedic ward for optimal management planninh.

3)      Prevention of the second hit phenomena (damage control orthopaedic /DCO) of the long bone fracture patient should be admitted to ICU for maximize management planning.

a.      What does resident/specialist prepare?

Resident/Orthopaedic and traumatologic surgeon should be able to:

·         Prepare instrument and implants of surgery for early operative intervention such as:

o   Closed/open femur fracture, which carry high risk of pulmonary complication

o   Active compartment syndrome

o   Vascular disruption

o   Femoral neck in which fracture has high risk of osteonecrosis

·         Determine management team (consultation the patient condition to anesthetic and others specialist for comorbidities)

·         Prepare the knowledge of long bone fracture for communication and discussion to get informed consent

b.      What does resident/specialist call?

Resident/Orthopaedic and traumatologic should be able to:

·         Call nurse for preparation of emergency surgery instrument/equipment

·         Call team surgery emergency and ICU team

·         Call anesthetic and other specialist for comorbidity management

·         Call radiologist

·         Call the family of the patient for discussion and sharing

1.      EMERGENCY UNIT

Resident in charge at emergency unit or orthopaedic traumatologic should be able to perform emergency surgery such as debridement and OREF of open long bone fracture grade III, fasciotomy of compartment syndrome, exploration and ORIF & repair of neurovascular injury caused by closed/open long bone fracture and fate emboli (FE) suspected

c.       What does resident/specialist do?

Resident/Orthopaedic and traumatologic should be able to:

Provide Stabilization of closed/open long bone fracture patient. The goals are consists of:

o   Restoration of stable hemodynamic

o   Restoration of adequate oxygenation and organ perfusion

o   Restoration of adequate kidney function

o   Manage the bleeding

·         Perform history documentation of long bone fracture patient in medical record:

o   History & relevant past medical history and physical data

o   Current drug therapy

o   Pre-morbid functional state (mobility) and pre-morbid cognitive function

·         Perform evaluation of the condition of patient in secondary survey (ABCDE):

o   The duration time of splint.

o   Hydration (fluid balance)

o   Pain

o   Body temperature

o   Mental state

o   Previous mobility and previous functional ability

o   Pressure sore risk

·         Evaluate radiographs or ask the advance investigations/laboratory (if necessary)

·         Discuss the condition patient data with the emergency team. Perform discussion, communication, and sharing between surgeon and family of patient and conscious patient for getting informed consent. The discussion contents consists:

o   History accident, surgery indication, and how the long bone fracture will manage

o   How the patient will be mobilized and whether or not a blood transfusion needed

o   How long the patient stay in hospital

o   How the patient may feel, infection problem etc.

o   Discuss about early total care (ETC) that is a concept of definitive stabilization/fixation of long bone fracture at the earliest opportunity.

o   Communicate the stabilization of closed/open long bone fracture goals that consists of:

ü  Restoration of stable hemodynamic

ü  Restoration of adequate oxygenation and organ perfusion

ü  Restoration of adequate kidney function

ü  Manage the bleeding

·         Perform OREF and debridement of open long bone fracture, exploration of the long bone fracture with early vascular compression/injury and ORIF together with primary repair of vascular injury or shunting

·         Perform grafting of fragment fracture gap of closed/open long bone fracture

·         Perform fasciotomy of compartment syndrome and ORIF of closed long bone fracture or OREF of open long bone fracture. Closed/open long bone fracture patient unable to undergo ETC may require damage control surgery as a temporizing and stabilizing measure should be manage in orthopaedic ward.

2.      Orthopaedic ward

Some of closed long bone fracture or open long bone fracture grades I & II patients have to manage in orthopaedic ward for elective surgery. Indication of surgery consists:

1)      Fail of conservative management

2)      Incomplete investigations for elective surgery

3)      Open fracture grades I & II after primary care

4)      Complex closed/open long bone fractures

5)      And others

c.       What does resident/specialist do?

Resident/orthopaedic and traumatologic should be able to:

·         Collect information in history taking, physical examination data completely

·         Perform a complete investigations and advance examination (if necessary)

·         Protect the heel and sacrum from pressure damage, patient administrates pain killer to allow for regular/comfortable change patient position  and keep the patient warm

·         Evaluate and monitor the pain: Is out of proportion that can lead to compartment syndrome, swelling, pale & cool and pulseless at distal part of the lesion

·         Correct any fluid, electrolyte abnormalities and oxygenation supplement

·         Discuss the condition patient data with the internal medicine, anesthetic team

·         Perform communication, discussion and sharing for getting informed consent

·         Prevent fat emboli syndrome (FES) complication of long bone fracture especially young and bilateral femur fractures patient. FES typically manifests 24 to 72 hours after trauma or orthopaedic intervention in orthopaedic ward care. Classic triad of FES: hypoxemia (increasing respiration rate, hypoxia), neurologic abnormalities (confusion, headache, seizures, strokes), and petechial rash at head, neck, anterior chest, subconjunctiva, and axilla (in late finding, 20-50% of patients). Clinical diagnosis of FES is made by snow storm pattern (not sensitive nor specific), ventilator/perfusion scans, focal areas of ground glass opacification with interlobar septal thickening on CT of the chest, high intensity T2 signal on MRI of the brain. Clinical of classic Gurd’s criteria is divided into mayor criteria (Pa O2 < 60 mmHg and FiO2 > 40%, altered mentation and petechial rash) and minor criteria (temp > 38.5 C, HR > 120/min, PLTs < 150 X 19 /L, retinal fat emboli, oligouria/anuria, decreasing HCT, and fat macroglobulemia. Principle treatment are: ATLS protocol, early mobilization and definitive treatment, maintain intravascular volume, mechanical ventilation.

·         Plan conservative management based on indication:

ü  Reduction via manipulation

ü  Casting

ü  Traction

·         Plan elective surgery:

ü  Open reduction and internal fixation (ORIF): interfragmentary compression, splintage and bridging implant

ü  Open reduction and external fixation (OREF). Indication: open fracture grade III (temporary management), periarticular fractures (ligamentotaxis), closed fracture with severe soft tissue injury and fractures or nonunion associated  infection

PREOPERATIVE PREPARATION

·           Determine the operative planning

o   Preoperative assessment

o   Reversal of warfarin anticoagulant

o   Antiplatelet therapy

o   Cardiac and others organ  investigation

o   Effect of delay on patient outcome

·           Discuss preoperative traction

o   The routine traction (skin/skeletal) is not recommended prior surgery for hip fracture

·           Plan to reduce infection by antibiotic administration

·           Reduce the risk of venous thrombosis

·           Assess mobility, mental state and quality of long bone and its joint pathology.

EARLY POSTOPERATIVE MANAGEMENT

·         Pain killer is the important to promote mobilization and discuss about the side effects of this medication

·         Oxygen

·         Fluid and electrolyte balance

·         Delirium: asses oxygen saturation, blood pressure, fluid and electrolyte balance, pain, medication, bowel and bladder function, nutritional intake, early mobilization, and  detection and treatment of intercurrent illness will prevent some episode and minimize the severity of others

·         Early mobilization

·         Constipation: increase mobility, increase fluid intake, increase fibre in diet, and laxative

·         Urinary catherterization if necessary. Antibiotic administration

·         Rehabilitation

o   Early assessment of preliminary rehabilitation, pre-morbid function, mental state, mobility function

o   Early mobilization is a challenge and will be uncomfortable but early mobilization is an important strategy management of the long bone fracture

·         Inform discharge management will be performed by multidisciplinary (community and hospital nurse, hospital doctor and GP, physiotherapist, occupational therapist, social worker and family of the patient). Advice the patient of possible discharge dates and further rehabilitation setting. Provide patient with written information on medication, mobility and useful sources of information

·         Inform prevention of accident strategies/fall prevention for reduction of the long bone fracture rate

3.      ICU

Closed/open long bone fracture is the most common caused by high energy trauma that can lead to other region injury (head or chest or abdominal, urinary tract) frequently. Because of that, patient has to transport to trauma hospital immediately. The high energy patient’s chance of survival diminishes rapidly after 1 hour, with a threefold increase mortality rate for every 30 minutes without care/first aid. Therefore, trauma team is essential to manage the multiple trauma patient with the captain is a trauma general surgeon.

c.       What does resident/specialist do?

Resident/orthopaedic and traumatologic should be able to:

·      Perform communication, discussion and sharing about the condition of patient for getting informed consent

·      Discuss the condition patient data with the emergency team

·      Manage airway, breathing, and circulation problem as soon as possible. Critical patient has to manage at ICU first and if patient is a stable, the orthopaedic and traumatologic can plan the surgery. But some of critical patients need surgery for stops bleeding first then ICU care for management airways and breathing problem and fluid resuscitation. Management shock hemorrhage includes exploration of vascular damage to stop bleeding, fixation of fracture (ORIF/OREF), traction or splinting.

·         Perform the delay in surgery for damage control orthopaedic (DCO) that can lead to prevent second hit phenomena.

SUMMARY: Accident health care in Indonesia

Pre-hospital management of fracture