What are the Basic principles of Treatment?
The line of treatment depends on the nature and stability of the fracture. Three general methods of treatment are adopted, which can be described under three separate headings:
- Closed reduction and immobilization.
- Open reduction and internal fixation.
- Closed reduction and immobilization
Discussions can be made under three separate headings:
- Ideal cases.
(ii) Suitable cases.
- Unsuitable cases.
- Ideal cases: Most suitable cases for closed reduction are undisplaced fractures of all varieties, e.g., greenstick, transverse, oblique, spiral and comminuted types. Angulatory deformity may co-exist with undisplaced lesions. This can be corrected easily.
- Suitable for closed reduction: These are the fractures which after reduction remain stable and do not get displaced. Some of the transverse and oblique fractures come under this category.
- Unsuitable for closed reduction: These are the fractures which fail to maintain the reduced position even after reduction. These include the unstable fractures of transverse, oblique and spiral varieties. Displaced segmental and comminuted fractures with butterfly segment are often difficult to reduce by closed technique.
Prediction of stability: It is not always possible to predict about the stability of the fracture simply by looking at the x-ray. Many widely displaced fractures seen in x-rays can be reduced by closed technique when performed with patience and ideal care. The best compromise is to attempt closed reduction in every case. At times, this may have to be repeated and the situation is carefully studied by check x-rays. Surgery performed in tibial fractures can be hazardous when done without proper judgement, skill and suitable conditions. Treatment is usually done by three methods:
- Closed reduction and plaster immobilization.
- Treatment by traction.
- Operative reduction and internal fixation.
Technique of closed reduction and plaster immobilization: This is performed under general anaesthesia and can be done by two techniques.
- Reduction by putting the patient’s legs hanging over the edge of the table and plaster immobilization.
- Lifting the knee up and by applying traction and plaster immobilization.
- Manipulation by keeping the knee bent at the edge of the table.
- Reduction: While under anaesthesia the patient’s legs are allowed to hang from the edge of the table. The operator sits on a low stool to manipulate the fracture. The surgeon reduces the deformity by exerting traction om the distal segment of the fracture towards the floor along with application of pressure with both hands.
- Application of plaster: A well-moulded plaster is then applied. This extends from the metatarsal heads to below the knee-joint.
- Extension of plaster above knee: The assistant then lifts the leg up from/the hanging position and the plaster is extended up to the groin. During application of plaster, care must be taken that the patella and the foot are in aligned position. All rotational and angulatory deformities are corrected.
- Method of application of plaster by elevating the limb:
Elevation of knee: The knee is elevated and supported on a concave support. Cotton or linen is placed under the knee to prevent pressure. The knee and the leg are fixed at an angle of 90⁰.
Traction: Traction can be applied manually by firmly grasping the ankle or by inserting a pin through the calcaneum. The manipulator reduces the fracture.
Application of plaster: Plaster is then applied extending from groin to foot with the knee in a slightly flexed position.
Post immobilization management: After reduction, the leg is kept elevated on a pillow. Circulatory condition of the leg should be carefully watched.
Check x-ray: Immediate post-reduction x-ray is done. Further x-rays are taken to observe the progress of union.
Weight bearing: Early weight bearing may be allowed when the fracture is transverse and of a stable nature. Other fractures tend to get displaced by pressure of weight and this should be deferred till the union is satisfactory. Removal of plaster: Plaster is usually removed after a period of 12 weeks. A crepe bandage is applied for some time after the removal of plaster.
Treatment by traction
Cases suitable for traction: This is indicated in oblique spiral and comminuted fractures. In these cases shortening of the limb is likely to occur due to the pull of the muscles when treated in a plaster cast.
Technique of traction
- Under general anaesthesia the fracture is reduced.
- Traction on a Thomas splint.
- Insertion of orthopedic pin: The pin is inserted either through the calcaneum or through the anterior part of the distal end of tibia.
- Application of Thomas splint and traction: Skeletal traction is applied after fixing the Thomas splint. The foot-end of the bed is raised. In order to prevent any lateral displacement and angulation, a short leg dorsal plaster slab can be applied along with the Thomas splint.
(¢) Check x-ray: This is done at intervals to see if there is any separation of fragments. The weight of the traction may need- adjustment.
Application of plaster: When evidence of early union is present the traction can be removed and a long leg plaster is applied. The condition is then managed as in the case of closed reduction and immobilization.
Open reduction and internal fixation
Operation for reduction converts the closed fracture into a compound lesion. Dangers of surgery must be assessed and due care must be taken.
- Suitable cases: Transverse, oblique or spiral fractures which are likely to get dis- placed after closed reduction should be treated by operative means.
- Less suitable fractures: Segmental fractures and fractures-with butterfly segment which are unlikely to be reduced by closed method come into this category.
Type of fixation: Fixation is done by screw, orthopedic bone plate and by intramedullary nail.
- Fixation by orthopedic bone screw: For long oblique and spiral fractures, fixation by simple insertion of screw or screws after open reduction can be ideal.
(ii) Fixation by plate and screws: Short oblique and transverse fractures are suitable for this procedure.
- Medullary nail: This is indicated in trans. verse, short oblique and segmental fractures. This procedure is not performed in long spiral fracture. Fracture over the middle 1/3rd of the shaft is the ideal site for this method. The medullary canal proximal or distal to this site expands and fractures over these areas are difficult to fix by this method.