injuries poisoning
Overview of Fractures
Treatment of Fractures
Treatment of associated injuries Reduction as indicated, splinting, and analgesia RICE (rest, ice, compression, and elevation) or PRICE (including protection with a splint or cast) as indicated Usually immobilization Sometimes surgery Serious associated problems, if present, are treated first. Hypovolemic shock is treated immediately. Injuries to arteries are surgically repaired unless they affect only small arteries with good collateral circulation. Severed nerves are surgically repaired; for neuropraxia and axonotmesis, initial treatment is usually observation, supportive measures, and sometimes physical therapy. Suspected open fractures require sterile wound dressings, tetanus prophylaxis, broad-spectrum antibiotics (eg, a 2nd-generation cephalosporin plus an aminoglycoside), and surgery to irrigate and debride them (and thus prevent infection). To minimize the risk of infection in open fractures, IV antibiotics should be given early, for example, within 1 hour of emergency department presentation ( Treatment references ). Most moderate and severe fractures, particularly grossly unstable ones, are immobilized immediately by splinting (immobilization with a nonrigid or noncircumferential device) to decrease pain and to prevent further injury to soft tissues by unstable fractures. In patients with long-bone fractures, splinting may prevent fat embolism. Pain is treated as soon as possible, typically with Opioid Analgesics or regional nerve blocks. If a patient has an isolated extremity fracture and compartment syndrome is not suspected, regional anesthesia may be used; this approach can help minimize the use of opioids and provides greater pain relief than opioids alone ( After initial treatment, fractures are reduced, immobilized, and treated symptomatically as indicated. Rotational malalignment or significant angulation or displacement of fractures is typically treated with reduction (realignment of bones or bone fragments by manipulation), which usually requires analgesia and/or sedation. Exceptions include some fractures in children in whom remodeling over time can correct significant deformities. Closed reduction (by manipulation, without skin incision) is done when possible. If closed reduction is not possible, open reduction (with skin incision) is done; anesthesia is required. Closed reduction of fractures is usually maintained by casting, but some fractures require only a splint or sling. Open reduction of fractures is usually maintained by various surgical hardware, external and/or internal. In open reduction with internal fixation (ORIF), fracture fragments are aligned and held in place using a combination of pins, screws, and plates. ORIF is usually indicated when Intra-articular fractures are displaced (to precisely align the joint surface). ORIF has better results than nonsurgical treatment for a particular type of fracture. Closed reduction was ineffective. Pathologic fractures occur in a bone weakened by cancer; such bone does not heal normally, and ORIF reduces pain more quickly than other treatments and makes early ambulation possible. Prolonged immobility (required for fracture healing) is undesirable (eg, for hip or femoral shaft fractures); ORIF provides early structural stability, minimizes pain, and facilitates mobilization. PRICE (protection, rest, ice, compression, elevation) may be beneficial. Protectionhelps prevent further injury. It may involve limiting the use of an injured part, applying a splint or cast, or using crutches. Restmay prevent further injury and speed healing. Iceandcompressionmay minimize swelling and pain. Ice is enclosed in a plastic bag or towel and applied intermittently during the first 24 to 48 hours (for 15 to 20 minutes, as often as possible). Injuries can be compressed by a splint, an elastic bandage, or, for certain injuries likely to cause severe swelling, a Jones compression dressing. The Jones dressing is 4 layers; layers 1 (the innermost) and 3 are cotton batting, and layers 2 and 4 are elastic bandages. Elevatingthe injured limb above the heart for the first 2 days in a position that provides an uninterrupted downward path; such a position allows gravity to help drain edema fluid and minimize swelling. After 48 hours, periodic application of warmth (eg, a heating pad) for 15 to 20 minutes may relieve pain and speed healing. Immobilization decreases pain and facilitates healing by preventing further injury and keeping the fracture ends in alignment. Joints proximal and distal to the injury should be immobilized. Most fractures are immobilized for weeks in a cast (a rigid, circumferential device). A few rapidly healing, stable fractures (eg, buckle wrist fractures in children) are not casted; early mobilization has the best results. is usually used for fractures that require weeks of immobilization. Rarely, swelling under a cast is severe enough to contribute to Compartment Syndrome . If clinicians suspect severe swelling under a cast, the cast (and all padding) is cut open from end to end medially and laterally (bivalved). Patients with casts should be given written instructions, including the following: Keep the cast dry. Never put an object inside the cast. Inspect the cast’s edges and skin around the cast every day and report any red or sore areas. Pad any rough edges with soft adhesive tape, cloth, or other soft material to prevent the cast’s edges from injuring the skin. When resting, position the cast carefully, possibly using a small pillow or pad, to prevent the edge from pinching or digging into the skin. Elevate the cast whenever possible to control swelling. Seek medical care immediately if pain persists or the cast feels excessively tight. Seek medical care immediately if an odor emanates from within the cast or if a fever, which may indicate infection, develops. Seek care immediately for progressively worsening pain or any new numbness or weakness, which may indicate compartment syndrome. Good hygiene is important. (see figure Joint immobilization as acute treatment: Some commonly used techniques ) can be used to immobilize some stable injuries, including some suspected but unproven fractures and rapidly healing fractures that require immobilization for several days or less. A splint is noncircumferential; thus, it enables patients to apply ice and to move more than a cast does. Also, it allows for some swelling, so it does not contribute to compartment syndrome. Some injuries that ultimately require casting are immobilized initially with a splint until most of the swelling resolves. © Elsevier Inc. All Rights Reserved. This video is for personal informational use. Users are prohibited from copying, reproducing, licensing, subscribing, selling, leasing or distributing this video. © Elsevier Inc. All Rights Reserved. This video is for personal informational use. Users are prohibited from copying, reproducing, licensing, subscribing, selling, leasing or distributing this video. Aslingprovides some degree of support and comfort and limits mobility; it can be useful for certain fractures (eg, minimally displaced clavicle fractures, certain proximal humerus fractures), particularly if complete immobilization is undesirable (eg, for shoulder injuries, which, if completely immobilized, can rapidly lead to adhesive capsulitis [frozen shoulder]). Aswathe(a piece of cloth or a strap) may be used with a sling to prevent the arm from swinging outward, especially at night. The swathe is wrapped around the back and over the injured part. A swathe is sometimes used with a sling to immobilize one-part proximal humeral fractures. Bed Rest Effects , Prolonged immobilization (>3 to 4 weeks for young adults) of a joint can cause stiffness, contractures, and muscle atrophy and is usually not recommended. These complications may develop rapidly and may be permanent, particularly in older people. Some rapidly healing injuries are best treated with resumption of active motion within the first few days or weeks; such early mobilization may minimize contractures and muscle atrophy, thus accelerating functional recovery. Splints and casts should immobilize joints in positions that optimize the likelihood of return of full function (eg, immobilization of the metacarpophalangeal [MCP] joints should position the MCP joints in flexion to maintain lengthening of the hand tendons). Physical therapists can advise patients about what they can do during immobilization to maintain as much function as possible. After immobilization, physical therapists can provide patients with exercises to improve range of motion and muscle strength, strengthen and stabilize the injured joint, and thus help prevent recurrence and long-term impairment. Joint replacement(arthroplasty) may be needed, usually when fractures severely damage the upper end of the femur or the humerus. Bone graftingmay be done immediately if the gap between fragments of bone is too large. It may be done later if healing is delayed (delayed union) or does not occur (nonunion). 1.Lack WD, Karunakar MA, Angerame MR, et al: Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection.J Orthop Trauma29(1):1–6, 2015. doi: 10.1097/BOT.0000000000000262. Erratum in:J Orthop Trauma29(6):e213, 2015. PMID: 25526095 2.Beaudoin FL, Haran JP, Liebmann O: A comparison of ultrasound-guided three-in-one femoral nerve block versus parenteral opioids alone for analgesia in emergency department patients with hip fractures: A randomized controlled trial.Acad Emerg Med20(6):584–591, 2013. doi: 10.1111/acem.12154 