Fracture is defined as a break in the continuity of a bone

CLASSIFICATION OF FRACTURES:

• It can be classified on the basis of aetiology, the relationship

of the fracture with the external environment, the displacement
of the fracture, and the pattern of the fracture.

ON THE BASIS OF AETIOLOGY:

1. TRAUMATIC FRACTURE

2. PATHOLOGICAL FRACTURES
1. TRAUMATIC FRACTURE:
•A fracture sustained due to trauma is called a trumatic fracture.

•Most fractures seen in day to day practice fall into this category.

•Eg: fractures caused by a fall, road traffic accidents, fight etc...

2. PATHOLOGICAL FRACTURES:
•A fracture through a bone which has been made weak by some
underlying disease is called a pathological fractures.
•No force may be required to cause such a fracture.

•Eg: A fracture through a bone weakened by metastasis.

ON THE BASIS OF DISPLACEMENTS:
1. UNDISPLACED FRACTURE:
•These fractures are easy to identify by the absence of significant
displacement.
2. DISPLACED FRACTURE:
•a fracture may be displaced.
factors for displacement:
1. a fracturing force.
2. the muscle pull on the fracture fragments.
3. the gravity.
•the displacement can be in the form of shift, angulation or
rotation.
• The Displacements are:

a. LATERAL: where the fragments of the fractured bone are

displaced laterally.

b. ANGULAR: where the fragments of the fractured bone may

form an angle with each other.

c. OVERLAPPING: where the fragments of the fractured ends

over lap each other.

d. ROTATIONAL: where the fragments of the fractured bone

may be rotated in relation to each other.
 ON THE BASIS OF RELATIONSHIP WITH EXTERNAL
ENVIRONMENT:

1. SIMPLE OR CLOSED FRACTURE:

•A Fracture not communicating with the external environment, i.e., the
overlying skin and other soft tissue are intact, is called a simple or closed
fracture.

2. COMPOUND OR OPEN FRACTURE:

•A Fracture with break in the overlying skin and soft tissues, leading to
the fracture communicating with the external environment, is called
compound or open fracture.
•a fracture may be compound from within or without, so called internal
or external compounding.
A. Internal Compounding: (compounding from within)
•The sharp fracture end pierces the skin from within, resulting in
an open fracture.

B. External Compounding: (compounding from without)

•The object causing the fracture lacerates the skin and soft tissues
over the bone as it breaks the bone, resulting in an open fracture.

•Exposure of an open fracture to the external environment

makes it prone to infection.
ON THE BASIS OF PATTERN:

1. Transverse fracture: the fracture is transversely placed. it

results from a direct injury to the bone.

2. Oblique fracture: The fracture line is obliquely placed. an

indirect injury causes this type of fracture.

3. Spiral fracture: It result from a twisting (rotational) force to

the bone.

4. Impacted fracture: where the fractured bone ends are driven

into each other maintaing close approximation.
5. Communicated fracture: Where the fractured bone is broken into
more than two pieces.

6. Segmental fracture: (double fracture) a bone is fractured at two

different levels.

7. Incomplete fracture: only one cortex of a bone is fractured without

any change in the alignment of the bone.

8. Greenstick fracture: it is a variety of incomplete fracture seen in

children. in this type one or both cortices of a bone are broken.

9. Compression fracture: result of compressive forces on the bone. the

bony mass gets compressed within it self. common in the cancellous
bones.
• Müller AO Classification?

• Classification of open fractures according to Gustilo et al

• Grade I

• Grade II

• Grade IIIA

• Grade IIIB

• Grade IIIC
• This was originally designed to classify soft tissue injuries associated
with open tibial shaft fractures and was later extended to all open
fractures.
• While description includes size of skin wound, the subcutaneous soft
tissue injury that is directly related to the energy imparted to the
extremity is of more significance.

• Type I:

• Clean skin opening of 1 cm, usually from inside to outside; minimal

muscle contusion; simple transverse or short oblique fractures.
• Type II:

• Laceration 1 cm long, with extensive soft tissue damage;

minimal-to-moderate crushing component; simple transverse or
short oblique fractures with minimal comminution.

• Type III:

• Extensive soft tissue damage, including muscles, skin, and

neurovascular structures; often a high-energy injury with a
severe crushing component
• IIIA:

• Extensive soft tissue laceration, adequate bone coverage;

segmental fractures, gunshot injuries, minimal periosteal
stripping
• IIIB:

• Extensive soft tissue injury with periosteal stripping and bone

exposure requiring soft tissue flap closure; usually associated
with massive contamination
• IIIC:

• Vascular injury requiring repair

DIAGNOSIS OF FRACTURE:
1. HISTORY: the mechanism of injury provides site and type of
fracture.

2. MUSCLE SPASAM: tenderness and loss of movement at the

adjacent joint are the immediate signs.
•In lower extremity fractures the patient is unable to bear body
weight.

3.OEDEMA: soft tissue injury – haematoma, edema over the

fracture site. The process of repair begins with inflammation.
4. WARMTH: Increase in the local temperature due to the rush of
blood to the area of injury.

5. CREPITUS: Passive movements over the fracture site produce

grating between the broken ends.
• It is painful & therefore should be avoided.

6. DEFORMITY: when the fracture is associated with displacement

the deformity is well marked.

7. RADIOGRAPHY: Imp tool in the diagnosis of a fracture. Various

diagnosis tech like computerised axial tomography (CAT),
Cineradiography, radio-nuclide bone scanning & MRI scan.
 HEALING OF FRACTURE:

• The healing of fractured bone occurs in three phases.

1. Inflammatory phase.

2. Cellular proliferation phase &

3. Remodeling phase.
Inflammatory phase:
• Haematoma (a clot) is formed between and around the broken
bone ends.
• It follows vasodilatation, release of protein and blood cells in
this area.
• The histocytes, mast cells and polymorphonuclear leucocytes
invade the toxic bacteria and clear the debris.
• The new granulation tissue is formed due to cell proliferation
between the bone ends.
Cellular proliferation phase:

• The granulation tissue thus formed between the bone ends

bridges the gap between both the fractured bone ends.
• The bone ends become rarified (lower pressure than usual) and
calcium is laid down in the granulation tissue as callus.
• Similar activity goes in the medullary cavity also.

• The external callus and medullary callus may meet and unite the
fracture.
• At this stage the fracture is said to be united clinically, but is not
strong enough to be exposed to stress.
Remodeling phase:

• This is the phase of remodelling of the callus towards normal

ossification.
• The soft callus gets hardened or consolidated by the deposition
of bone salts.
• This is carried out by the osteoblasts.

• Osteoclasts come into action and properly control the density of

the new bone.
• The medullary cavity is reproduced and the marrow cells
reappear.
• The process of remodelling ends by reconstruction of the new bone
similar to the one before injury.
• The bone tissue always heals by forming a new bone which has all
the characteristics of the normal bone.
• The union of fracture depends upon various factors. The imp factors
are:

1. Type of bone and its thickness

2. The type of fracture

3. Extent of blood supply to the site of fracture

4. Positioning of the boney eands at the site of fracture

5. Age of the patient.

1. The type of bone:
• In a cancellous bone the surface area is wide and the blood
supply is abundant. So healing is quick.
• In a cortical bone, the blood supply may be precarious in some
areas where the healing process may be slow.

2.The type of fracture:

• Spiral & oblique fractures unite faster as compared to the
transverse fractures. (take twice time for union)
• Upper extremity fractures heal faster than the fractures in the
lower extremity.
3. The extent of blood supply to the site of fracture:
• Healing directly depends on the extent of blood supply to the
site of fracture and the bone.

4. Position of the bony ends at the site of fracture:

• Improper alignment results in delayed union, malunion, non
union and their complications.

5. Age of the patient:

• Unite faster in children than in adults and may take longer in
the elderly patients.
 Complications of fractures:
• immediate complications :

• caused by violence producing the # -- shock , injury to vessels ,

injury to the nerve , injury to the viscera.
• delayed complications -- set after a few days or few weeks --
infection, gas gangrene, fat embolism , volkman ischmic
contractures , delayed nerve injury , myositis ossification
• late complications -- occur as late result of injury or
mismanagement, malunion , non union , cross union , stiffness of
jt , post traumatic osteoarthritis , late nerve injury (tardy paralysis)
1. INFECTION:

• Infection of bone may occur generally in a compound fracture

due to micro-organisms like streptococci, E.Coli, Staphylococci,
Pseudomonas and anaerobic species of bacteroids group.
• Infection may occur after a compound fracture or a surgical
operation.
• Rx- antibiotics, rest in a splint or POP cast & drainage of pus
collection if present, movements to adjacent joints will help in
improving local circulation.
• Dead bone will need its removal by sequestrectomy.
2. DELAYED UNION:
• When a fracture does not unite in the usual stipulated period, it
is termed as delayed union.
• The causes of delayed union include generalised diseases like
severe anaemia, malnutrition, syphilis, local bone disease like
osteomyelitis and lack of blood supply to the fractured bony
ends.
• Rx- bone grafting with or with out internal fixation is usually
done.
3. NON – UNION:
• When a fracture fails to unite completely even after the
stipulated time, it is termed as non-union.
• Occasionally there may be a pseudo-joint formation at the
fracture site.
• Delayed union, non-union may occurs as a result of excessive
bone loss due to injury, interposition of soft tissue between the
fractured bone ends and inadequate immobilization.
• The methods of management of non-union are:

a. Cortico cancellous bone grafting with or without internal

fixation.

b. Electro-magnetic stimulation to the fracture site &

c. Ilizarov method of treatment using a ring external fixator.

4. MALUNION:
• Union of a fracture in a malposition is termed as malunion.

• Malunion results in an angular or rotational deformity or limb

length disparity.
• Causes- improper management in the initial stage like faulty
reduction / immobilization are the usual causes.
• Rx- Osteotomy with internal fixation and bone grafting.
5. AVASCULAR NECROSIS:
• In certain situations the blood supply to a segment of the bone
gets jeoparadised due to the injury itself resulting in death of
that segment of the bone.
• Eg: head of femur, proximal half of scaphoid, the body of talus
and lunate.
• As the process of necrosis progress the bone gets dissloved.

• In such cases the fracture may fail to unite and there may be an
early onset of osteoarthrities.
• Rx- surgical procedure – vascularised bone graft & arthroplasty.
 ADHESIONS:

• A fracture close to the joint invariably results in the formation of

adhesions.
• Immobilization for a longer duration also result in adhesion
formation.
• The result is a stiff & painful restriction of the joint.

• The joints more susceptible to develop adhesions are shoulder,

elbow, finger & knee.
• Types --- 1. Periarticular adhesions.

2. Intra articular adhesions.

1. Periarticular adhesions:
• Decreased resilience of the periarticular tissues like
ligaments, muscles & joint capsule.
• Injury to the joint and inactivity gives rise to the collection of
oedema fluid.
• This results in the binding of the connective tissue fibers.
2. Intra articular adhesions:
• Which involve articular surface.

• The adhesions are formed as a result of organisation of the

fibrous strands between the opposing folds of synovial
membrane.
• The formation initiates from haemarthrosis following injury.

• The products of haemarthrosis, as they are absorbed, may

leave some residual strands of fibrin which get into fibrous
adhesions.
 SOFT TISSUE INJURIES ASSOCIATED WITH
FRACTURES:
A. INJURY TO THE SKIN: the skin is usually torn by the
piercing bone fragment in compounding fractures.
• in severe injuries there may be extensive loss of skin.
• In such conditions healing of the skin wound and prevention
of infection assumes priority.

B. INJURIES TO THE BLOOD VESSELS:

• Pulseless, pale ischemic distal segment of the extremity is a
result of vascular damage.
• This need to be detected, carefully watched and treated to
avoid complications following ischemia.
• Total blocking of the artery may lead to gangrene.
• Sometimes the fragment of a fractured bone may compress the
vesel.
• The vein near by fracture site may get compressed resulting in
thrombosis.
• Swelling of the limb, cramps and tenderness over the course of
the vein are the signs of thrombosis.
• Tight bandage, splint or POP may cause vascular symptoms.

• Therefore, repeated checking and immediate measures are to

be taken in such situations.
• Repeated movements to the nearest joints, limb elevation and
stimulation could be used.
C. INJURY TO THE NERVE:
• Muscle paralysis and sensory impairment confirm an injury to the nerve.

• Common site of nerve injury should be regularly checked.

• In case of injury to the nerve, measures like splints and positioning

should be taken.
• The status of nerve regeneration should be evaluated clinically and by
electro diagnostic tests to facilitate surgical procedures, if required.
• Gradually progressing symptoms of nerve compression may occur as a
result of pressure on the nerve due to displaced bone or excessive callus
formation.
Site of Fracture/Dislocation Nerve Involvement

Cervical-thoracic spine Spinal cord

Lumbar spine Cauda equina

shoulder Circumflex nerve

Humerus (shaft) Radial nerve

Humerus (Medial epicondyle) Ulner nerve

Hip dislocation with fracture Sciatic nerve

acetabulum

Knee (lateral aspect) Common peroneal nerve

D. INJURY TO THE MUSCLE:
• Muscle fibers may be injured from minor injury.

• Haematoma, tenderness and severe pain on attempted active

movements or loss of active movement may occur.
• Rest with proper positioning or surgical repair may be
necessary in tendon rupture.
• Muscle injury in the periphery of joints like elbow, hip may
lead to the unwanted common complication of myositis
ossification.
E. EDEMA:
• Occurrence of edema over the site of fracture is very common.

• Occurs due to the sudden rush of blood and fluids into the
tissue spaces in the damaged area.
• Through it is necessary for the healing of fracture.

• Its excess delays the treatment of fracture or may result in

joint stiffness.
• Gravitational or recurrent edema is common to the leg and
foot in the lower extremity fractures.
• Limb elevation, pressure bandage, repeated active movements,
electrical stimulation under elastic bandage and avoiding
dependent positioning are the basic measures of treatment.

F. INJURY TO THE JOINT:

• Fractures around shoulder, elbow and hip joints are the
common sites of an associated dislocation.
• Rx: dislocation is reduced first and then the fracture is treated.

• If the fracture involves the jt (intra articular), results in

residual pain and stiffness of the joint.
• Early mobility in the correct pattern of movement and
application of stress are of vital importance following the joint
injury.
• Exercises to strengthen the injured / repaired muscles and
ligaments are imp to restore function early.
 GENERAL COMPLECATIONS:
A. Respiratory distress syndrome:
• Acute respiratory distress syndrome (ARDS) is defined as a
post-traumatic distress syndrome occurring within 72 hours of
skeletal trauma.
• Difficulty in breathing with increased rate of respiration
associated with drowsiness may be found in some pts
following severe injury.
• There is deficiency of gaseous diffusion in the lungs due to an
inflammatory reactions set in due to the micro emboli of fat
released from the fracture.
• The analysis of blood gases shows the deficiency of both
oxygen as well as co2.
• Blood pressure may drop.
• Is an important cause of morbidity and mortality (11%) in
multiple fracture and multisystem injuries.
• Rx: Immediate measures like O2, Tracheostomy, positive
pressure ventilation and chest physiotherapy.
• To avoid fatal consequences, early diagnosis and chest
management is a multiple fractures, or large bone fractures.
B. Venous Thrombosis:
• Deep venous thrombosis in the venous plexus of the calf
muscle is common after a major fractures around the hip.
• A small fragment of this clot (embolus) may get detached and
pass onwards to the femoral, iliac or deep pelvic veins.
• If it passes upwards to the heart or lung, it could be fatal.

• The formation of thrombus is common following vessel injury

and during or following surgery.
• It is always aggravated by bed rest or POP immobilisation.
• Deep venous thrombosis occurs as a result of
1. Damage to the vessel wall.
2. Stasis or interruption of blood flow &
3. Changes in the clotting factor of the blood.

Signs and symptoms:

• Pain
• Tenderness &
• Edema in calf
• Passive DF of foot increases pain (Homan’s sign)
• Rise in temperature

• Classical signs manifest only by 10 – 14 days following injury or

surgery.
• Safest measure to detect thrombosis with accuracy is the
venograpy or a doppler study.

• TREATMENT:

• Drug therapy – heparin, aspirin, dextrans and warfarin are

given to alter the clotting.

• PHYSIOTHERAPY:
• Initiation of early active movements especially to the ankle
and foot – prevents blood stasis & formation of clot.
• If the active movements are not possible repeated passive
movements to the toes and ankle should be given.
• Intermittent pressure devices could be used to enhance venous
drainage.
• Electrical stimulation under pressure bandage is also helpful.

• Light effleurage can be given to enhance venous drainage.

• But there is a danger of detaching the embolus by massage &

it involves a risk.
• The physiotherapist must keep a regular watch to detect the
occurrence of thrombosis during the first 2 days following
injury or surgery to prevent its consequences.
 MANAGEMENT OF FRACTURE:

Basic principles are:

• To achieve anatomical alignment of fractured bone ends.

• To assure correct immobilisation

• To improve circulation at the fracture site.

• To reduce inflammation and pain.

• To provide necessary compressive forces to the embryonic

callus.
Basic methods:

• Reduction

• Immobilisation and

• Protection
 Reduction

• Aim of reduction – to achieve perfect anatomical alignment

and length of the bone.
• Reduction of fracture:

• Could be closed – where alignment is achieved by

manipulation
• Could be open – where alignment is achieved by surgical
operation
 IMMOBILISATION

• The maintenance or holding of the reduced fracture is

important and can be achieved by immobilisation.
• Methods of immobilisation:

1. Traction

2. Plaster of paris cast

3. Functional cast brace

4. Internal fixation &

5. External fixation
 TRACTION:

Definition of traction
• “Application of a pulling force to part of the body”

Aim
• To restore and maintain straight alignment and length of bone
following fractures and dislocations
• Relieve pain due to muscle spasms

• To immobilise limb to treat injured or inflamed joints

• To correct contracture deformities

• To help restore blood flow and nerve function.

• To allow treatment and dressing of soft tissues.

• To rest injured or inflamed joints, and maintain them in a

functional position.
• To allow movement of joints during fracture healing.

• To gradually correct deformities due to contraction of soft

tissues, caused by disease or injury.
• To allow the patient to be moved with ease.
Principles
• Provide Counter traction, using the patient’s body or pull of
weights in the opposite direction.
• Maintain continuous traction in a correct line of pull.

• Prevent friction

• Provide daily traction care

• The grip or hold on the patient’s body must be adequate and
secure.
Traction care:
• Ropes are running freely through pulleys, and are intact and
secure.
• Traction is not hindered by friction, for example bedclothes.
• Weight bags are the correct weight for the child, and are
hanging freely.
• The body weight, and/or appropriate elevation of the foot or
head of the bed, maintains counter traction.
• Bandages are free from wrinkles. Change the outer bandage
daily.
• Type of traction applied, care of traction and any changes
relating to care are documented in the child's notes/care plan.
• Maintain Skin Integrity:

• Pressure area care.

• Foam protection should cover medial and lateral malleoli

(bony prominences on ankle) on all traction involving lower
limbs.
• Skin in contact with Thomas Splint Ring should be checked
when oiling the ring.
• Document the condition of the skin on admission and
throughout care, in the progress notes and care plan, for
example lacerations, rash, pressure areas.
• Nutrition
• A well balanced diet and fluids should be encouraged; no extra
calcium supplements are required.
• If required, consult with a Dietitian.

• Physiotherapy
• Ensure that the in traction maintains normal range of motion
of unaffected limbs.
• in a Thomas Splint/Hamilton Russell traction, who require
long term traction, quadriceps should be strengthened by
providing an exercise program 2 weeks post fracture.
• If strengthening exercises are required, refer the patient to an
Orthopaedic Physiotherapist.
Potential Complications:
• Skin breakdown/pressure points/allergic reactions to skin
extensions.
• Neurovascular impairment.

• Joint contractures.

• Pin site infections associated with skeletal traction.

• Respiratory problems associated with semi-recumbent

positions.
• Constipation from immobility and analgesics.
 Skin traction:

• Provides generalised pull to the whole limb.

• When using basic skin traction, traction tapes are applied to

the lateral and medial aspects of the skin on the lower limb,
and with the attached.
• weight hung freely over the bed a generating pulling force is
achieved.
• It is used to create a traction force over a large area of skin
which is then transmitted via the soft tissues to the bone.
• remove and check bandages every 24 hours and whenever
necessary
• not remove the extensions unless there are clinical indications

• examine the skin integrity of the patient, and report any signs
of skin damage to a nurse or doctor
• check the extensions for wrinkles and adhesion and change
only if necessary
• check the patient’s limb for any neurovascular change or calf
pain, and report this to the nurse or doctor
 Thomas splint traction:

• The Thomas splint is used in conjunction with skin traction or

skeletal traction to immobilise and position fractures of the
femur.
• Suspended thomas splint
• ensure the skin under the hoop/ring is kept clean and dry to
prevent the formation of pressure sores
• observe for pressure around the back of the hoop/ring.
• Increasing elevation of the foot of the bed may relieve this.
Padding is contraindicated as it increases pressure on the skin
under the hoop/ring
• observe for pressure in the groin region. This can be relieved
by good skin care, repositioning of the patient and, if practical,
abduction of the limb
• observe for increased swelling of the limb. Adjust the hoop
attachment as necessary. If a whole ring, consider changing
the splint to a larger ring size.
• This would require medical confirmation, appropriate
analgesia and a post procedural check X-ray.
• observe for damage to the integrity of the skin. This may be
caused by pressure +/- over tight bandages. Take action to
relieve the symptoms and dress any skin breaks immediately.
It is important to document your findings and take nursing
action
• observe for loss of fracture position. This may occur at any
time during the healing process. Padding applied to the
fracture site may assist in maintaining the fracture in
alignment, but you must report and record any sagging or
deformity
• prevent soiling of the hoop/ring when the patient is using the
bedpan
• provide a monkey pole to enable easier mobility in the bed for
the patient
 Skeletal Traction

• Exerts effective pull on the bone.

• Skeletal Traction attaches directly to the bone, with the use of
pins, wires, halo frame or tongs. This provides a strong steady
continuous pull.
• Skeletal traction is used for unstable fractures, soft tissue
injuries or cervical injuries.
• Skeletal Traction is applied under a General Anaesthetic, a
traction bed and equipment will need to be sent to theatres.
• The Thomas Splint with Pearson's knee piece, counter-
traction is achieved by elevating the foot of the bed. In this
case ensure to sits up only for meal times.
 Gallows/Bryant’s Traction:

• For treatment of fracture shaft femur in infants and reducing

CDH.
• Body weight act as a counter traction.
• Gallows traction is applied to ensure the child achieves the
correct position for a fractured femur.
• Traction reduces muscle spasm and maintains proper
alignment of the affected limb.
• It is also used to lengthen ligaments prior to operative
correction of developmental hip dysplasia, or post operatively
for some forms of anal surgery.
• Is used for children under 15kgs, due to risk of vascular
complications
• Both legs to remain flexed at 90 degrees at the hips.
• The baby's buttocks is to remain slightly off the mattress. i.e. you
should be able to fit the palm of your hand between the mattress
and baby’s buttocks. Adjust the weights to achieve extended legs
and slightly flexed knees.
• Traction abducted 5-cm daily (children with Development
Dysplasia of the Hips as ordered by Orthopaedic Consultant).
• If the child is over 12kg or walking unaided, a Thomas splint or
Buck’s traction is to be applied depending on the child’s
condition.
• A Child should not be picked up at any time, as traction should
remain continuous.
• Bandages protecting skin extensions are applied from the
distal end to the proximal end of the limb as well as from the
lateral to medial points.
• Bandages must be non-restrictive, wrinkle free and changed
daily by the nurse caring for the child.
 Hamilton-Russell traction:

• Hamilton Russell is a balanced traction system using vectors

to effect a pull along the long axis of the femur.
• It is used to maintain the joint space at the hip, manage
fractures of the acetabulum and support fractures of the shaft
of the femur.
• Traction can be applied using below-knee skin traction or a
skeletal pin
 Cervical traction:

• “Cervical traction is a non-invasive method for the reduction

and stabilization of spinal fractures and dislocations as the
method of choice for patients unsuitable for surgery or for
whom surgery is not a priority”
 Halo traction (Halo pelvic traction):
• Halo traction is the application of skeletal traction to the head by
means of a halo device.
• A ‘halo vest’ provides traction and support which allows for proper
healing of the damaged or diseased spinal region.
• A halo vest includes a ‘halo ring’ that is secured to the skull with
skull pins and a rigid, fleece-lined vest.
• The vest is attached to the halo ring with adjustable metal rods or
struts.
• Together the apparatus provides stability to the cervical column
while allowing the patient to be mobile.
Patient selection:
Halo traction is indicated in adults for definitive treatment of
cervical spine trauma including:
• occipital condyle fractures

• occiptio-cervical dislocation

• stable Type II Atlas fracture (stable Jefferson Fracture)

• type II odontoid fractures in young patients

• type II and IIA hangman’s fractures

• adjunctive postoperative stabilisation following cervical spine

surgery.
Halo traction is indicated in children/young people for:
• atlanto-occipital disassociation

• Jefferson fractures (burst fracture of C1)

• atlas fractures

• unstable odontoid fractures

• persistent atlanto-axial rotatory subluxation

• C1-C2 disassociations

• sub axial cervical spine trauma

• preoperative reduction in patients with spinal deformity.

Contra-indications:
• cranial fractures

• infection

• severe soft-tissue injury especially near proposed pin sites

• polytrauma

• severe chest trauma

• barrel-shaped chest

• obesity
• advanced age
• poor mental capacity.
 Kendrick Traction Device
• A Kendrick Traction Device (KTD) can be applied to all age groups
and is light weight, compact (stored in a pouch), and quick and easy
to apply.
• Variation in the way this modality is applied may exist in clinical
practice; however, it is unlikely to cause additional pressure or pain.
• It can be used to immobilise a suspected fracture of the mid shaft of
the femur plus eliminates the need to roll the patient or raise the leg
during application.
• The KTD will be removed in theatre prior to surgery.
Plaster of Paris cast
 Plaster of Paris cast History:

• Before contemporary casting materials became widely used,

people used a variety of materials to form rigid casts.
• Over the centuries immobilization has evolved from using
simple wooden splints and rags to plaster of Paris, fibre and soft
casts.
• active management of fractures in humans were discovered at
Naga-ed-Der in 1903 during the Hearst Egyptian Expedition of
the University of California lead by Dr. GA Reisne.
•
• In a paper published in the British Medical Journal in 1908,
Mr. G. Elliot-Smith describes two sets of splints that were
found during excavations of tombs from the fifth dynasty
(2494-2345 BC).
• One of the earliest descriptions of casting material was by
Hippocrates in 350 BC. He wrote about wrapping injured
limbs in bandages soaked in wax and resin.
• El Zahrawi (960-1013 AD), a surgeon born near Córdoba in
Spain, described the use of both clay gum mixtures and flour
and egg white as casting materials.
• Starch based casts appear to have been the standard treatment with
only minor changes until the beginning of the 19th century with only
a few minor changes.
• In the 18th century, Henri François Le Dran, who practiced surgery
at Hôpital de la Charité in Paris and was a surgeon in Germany
Army and consulting surgeon to the camps and armies of King Louis
XV, used to soak his bandages with egg white, vinegar and clay
powder or plaster.
• Larrey’s modification was adopted from Don Eugenio de la Penna
who bandaged the fracture with linen that had first been moistened
with Camphor spirit, egg whites and lead-acetate.
• Unfortunately these were not used on a large scale due to
costs.
• Baron Louis Joseph G Seutin (1793-1862) was a belgian
professor and surgeon in chief at the Universite Libre de
Bruxelles became famous for inventing starch bandages
known as “La Bandage Immobile” or “L’Appareil
Amidonnee” that consisted of strips of linen or bandages and
carton splints, soaked in starch and wrapped around the limb.
• Seutin’s method was popular in England by Joseph Samson
Gamgee, the Birmingham surgeon who amongst other things
invented Gamgee tissue.
• In the first half of the 19th century, it was not popular to
reduce fractures until the swelling of the soft tissue decreased.
 ORIGINS OF PLASTER OF PARIS

• Plaster of Paris is produced by removing the impurities from

the mined gypsum and then heating it under controlled
conditions to reduce the amount of water of crystallization.
• Plaster of Paris was well known as a building material for
many centuries before it was introduced as casting material.
• Egyptians as well as Romans used it for plastering walls.

• There are various accounts describing the origin for the name
plaster of Paris.
• One account mentions King Henry III who visited Paris in 1254 and
was so impressed by fine white walls that he introduced similar
plastering in England where it became known as plaster of Paris.
• The first use of plaster of Paris as a cast for injured limbs took place
through a technique known as plâtre coulé that became popular in
Europe at the beginning of 19th century.
• This technique involved pouring plaster of Paris around injured
limbs encased in a wooden construct.
• Due to the weight of the construct, the patient was largely confined
to bed during the period of fracture healing. This disadvantage was
highlighted by Seutin.
• In 1839, Lafargue of St. Emilion used fresh warm starch paste
mixed with plaster of Paris powder applied to layers of linen strips.
• That dressing had the advantage of hardening much quicker,
reducing setting time down to six hours.
• The Dutch military surgeon Anthonius Mathijsen while working at
the military hospital in Haarlem discovered that bandages soaked in
water and plaster of Paris were becoming hard within minutes
providing sufficient casting for injured limbs.
• He published his monograph in 1852 in a medical magazine called
Repertorium.
• His plaster bandage was based on the principles of Seutin, who 10 years
earlier introduced starched bandages known as bandage amidonnee.
• In his paper entitled “New Method for Application of Plaster-of-Paris
Bandage”.
• Mathijsen highlighted many disadvantages of Seutin’s dressings including
lack of self-adjustment to the changing conditions of the limb, long
duration of days needed for the casing to become sufficiently solid, carton
splints shrinking and becoming shorter when they dried off adversely
affecting fractures, and in cases of suppuration or with small children
urinating, dressing becoming soft and loosen.
• Mathijsen’s bandages consisted of strips of coarse cotton cloth
with finely powdered plaster rubbed in.
• This method of preparation was used until 1950.

• Use of plaster of Paris bandages for fracture casts became

widespread after Mathijsen’s death and replaced most other forms
of splintage.
• Early plaster bandages used at hospitals were made by nursing
staff.
• They were usually freshly made from plaster powder kept in air
tight containers that was applied on to the woven bandage or strips
of cloths.
• Care was required while soaking dry bandage in water to
prevent the plaster coming off the bandages and dissolving in
water.
• In the early 1930’s, the first commercially manufactured
bandages were available in Germany.
• They were made by spreading plaster mixed with minute
quantities of volatile liquids on soft cloth.
 APPLICATION OF PLASTER OF PARIS

• Plaster of Paris (2CaSO4.H2O) is calcium sulphate with water.

It is prepared by heating gypsum (CaSO4.2H2O) at 120°C to
allow partial dehydration.
• When mixed with water, it gives out heat and quickly sets to a
hard porous mass within 5 to 15 minutes.
• The first step is called the setting stage with a slight expansion
in volume.
• The second stage is the hardening stage.
• AJ Steele in his article from 1893 on the use of plaster of Paris in
orthopaedics, “The property of rapidly hardening when once wet,
gives to plaster its value.
• Additionally it has merit in its cheapnesss and convenience; it is
ever ready, is easily prepared, and simple in its application”
• In 1906, Meisenbach published a study on plaster of Paris
bandages in the American Journal of Orthopaedic Surgery.
• He outlined the four essential properties of plaster dressings to
include strength, quick set, light weight and ventilation,
summarizing that ideal plaster dressing should be thin and strong.
• Plaster can be used not only for treatment of fractured bones but also
supports sprained ligaments, and inflamed and infected soft tissues.
• It usually sets in few minutes, but needs between 36-72 hours to
completely dry.
• Leg plasters are able to bear weight after 48 hours.

• Completely dry casts when tapped with knuckles will sound crisp and
clear whereas wet casts emit a dull sound.
• Cast should only be dried by natural methods. No artificially
generated heat is recommended.
• Despite its frequent use, allergic reactions to plaster of Paris are
extremely uncommon.
• When plaster of Paris dries off it becomes porous which helps to
maintain patient’s skin free from moisture.
• The strength of the plaster cast is determined by the quality of plaster,
water to gypsum ratio, product age and storage conditions.
• Non-operative management of fractures has been declining in recent
years due to significant advances in operative technology and greater
patient expectations of an early return to activity.
• Younger surgeons are not as familiar with non-operative treatment of
fractures with a plaster cast as their predecessors.
• This is due to a lack of experience in application of plaster casts and the
subsequent management.
• Plaster of Paris is unique and still remains the favoured casting material
in many countries.
• It is cheap, non-toxic, and can easily be moulded to the desired shapes
and contours of the body. Skin irritation and allergy is extremely rare.
• Prior to casting, any skin lesions or soft tissue injuries must be carefully
noted.
• It is important to observe and document neurovascular status of the
extremity, and this needs to be repeated following application of
plaster.
• Patients with neuropathy or neurologic deficits are at greater
risk for skin problems with abnormal sensation under the
plaster.
• Figure of eight turns, creases and ridges have to be avoided.

• Rubbing and massaging plaster bandages during application

helps to bond layers together creating stronger and lighter
casts.
• Plaster bandages should be soaked in tepid or slightly warm
water. Plaster sets quicker with warm water compared with
cold water.
• Temperature elevations could be related to the plaster being dipped
too briefly and the water being squeezed too aggressively out of the
plaster.
• The water helps release heat, and if there is not enough, the plaster
gets hotter.
• A fiberglass cast is a newer synthetic alternative to plaster of Paris.

• Fiberglass cast is a lightweight and extremely strong material.

• Fiberglass, also called glass-reinforced plastic (GRP) or glass fiber

reinforced plastic (GFRP) is a fiber reinforced polymer made of a
plastic matrix reinforced by fine glass.
• It is light in weight and more durable.

• It is three times stronger and but is only one third in weight.

• Fiberglass cast is a lightweight and extremely strong material.

• Fiberglass cast is used for fracture management but is not

applied in the acute settings because it is less accommodating
to swelling and does not allow moulding.
COMPLICATIONS ASSOCIATED WITH
SPLINTING AND CASTING

• There are risks associated with plaster cast immobilization and

patient has to be made aware of these.
• Patients with known diabetes or sensory impairment due to
spinal cord injury are those who need particular attention at
the time of plaster application and later.
• 1. Deep Vein Thrombosis (DVT)

• 2. Compartment Syndrome

• 3. Soft Tissue Swelling

• 4. Pressure Sores

• 5. Venous Congestion
 1. Deep Vein Thrombosis (DVT)

• Prolonged lower limb immobilization in plaster carries the risk of

deep vein thrombosis (DVT) that the patient has to be made aware of.
• Two independent studies found that adults treated with a lower
extremity cast for an average of 3 weeks had an incidence of DVT
between 15% and 36%.
• Low molecular weight heparin did not significantly reduce the risk of
developing DVT.
• Although these are more common in the lower limbs, these have also
been described in upper limb immobilisation.
 2. Compartment Syndrome:

• One of the most serious complications to be considered is

compartment syndrome.
• This is a condition in which increased pressure within a
limited space compromises the circulation and function of the
tissues within that space.
• Compartment syndrome may lead to fatal complications
including major loss of limb function and even death and are
more common in lower leg and forearm fractures.
 3. Soft Tissue Swelling:
• Soft tissue swelling associated with the fractured limb will usually
subside within 48 hours from the injury leaving the cast loose.
• This may lead to displacement of well positioned or reduced fracture,
and the reapplication of a new well-fitted cast may be needed.
• This is more likely to be an issue with unstable fractures.

• This is more noticeable in lower limb injuries where after education

and elevation, swelling can reduce significantly.
• It is vital to ensure sufficient padding with swelling to prevent
complications.
 4. Pressure Sores:

• Plaster pressure sores can occur as a result of poor plastering

technique associated with inadequate skeletal protection or
failure to trim the extremities of the cast correctly.
• Foreign bodies especially with young children can be easily
misplaced in the cast and exert pressure on the skin that can lead
to a break in the skin.
• Every patient should be warned about dangers of scratching
beneath the cast with different sharp implements as this can
cause infection.
• Cutting windows in plasters and leaving them unprotected
may lead to oedema developing within the window area that
will lead to soreness of the skin at the margins.
• Bivalving casts can be considered as an alternative to enable
inspection.
 5. Venous Congestion:

• Swelling or blue discoloration of the extremities suggests

impaired venous return due to tightness of the plaster.
• The blue discoloration of venous congestion must be
differentiated from bruising.
• There are a number of other complications that relate to long
periods of immobilization and include joint stiffness, muscle
atrophy, cartilage degradation, ligament weakening, and
osteoporosis.
• Some risks can be minimized with correct casting technique
What is internal fixation?
• Internal fixation is the surgical implantation of mechanical
devices inside the human body for the purpose of repairing a
bone after fracture.

• The facture once reduced, is fixed internally with the help of

some metallic or non metallic device, such as steel-wire,
screw, plate, kirschner wire (k-wire), intra-medullary nail etc.
 Types of internal fixation

• 1. Open Reduction Internal Fixation (ORIF)

• 2. Closed Reduction Internal Fixation (CRIF)

Open Reduction Internal Fixation (ORIF),
• Open reduction refers to open surgery to set bones, as is
necessary for displaced fractures.
• Internal fixation refers to fixation of screws and / or plates, or
intramedullary bone nails (femur, tibia, and humerus) to
enable or facilitate healing.
• The former type (plates and screws) provides rigid fixation
which prevents micro-motion across the lines of fracture,
enabling direct bone healing (or primary bone union).
• Open Reduction Internal Fixation techniques are often used in
cases where the fractures are at or close to the joints, such as
displaced articular fractures and forearm fractures, cases
where the bone would otherwise not heal correctly with
casting or splinting alone.
Closed Reduction Internal Fixation (CRIF)
• Aims at achieving fracture reduction without opening up the
fracture site, often with the help of X-ray.
• where pins or K-wires are used after closed reduction.
 Risks and Complications of Internal Fixation
• bacterial colonization of the bone,
• infection,
• stiffness and loss of range of motion,
• non-union, mal-union,
• damage to the muscles,
• nerve damage and palsy,
• arthritis, tendonitis,
• chronic pain associated with plates, screws, and pins,
• compartment syndrome,
• deformity,
• audible popping and snapping
 Benefits of Internal Fixation

• restoring stability to the fractured bone,

• allows for a shorter hospital stay,

• enables patients to return to function earlier and reduces the

incidence of non-union or delayed union (failed or slow
healing), and mal-union (healing in an improper position).
 Indications for Internal Fixation:

• Not all fractures require internal fixation. Required in unstable fractu

• Indeed most fractures can heal without it, only that it takes longer and in a
bad position in case of displaced fractures.
• it is only performed in the following fractures with the following
conditions:
• Displaced intra-articular fracture.

• Axial or angular instability which cannot be controlled by closed methods.

• Mal-reduction / failure of reduction (e.g. interposed soft tissue).

• Multiple traumas.
 METHODS OF INTERNAL FIXATION

1. Intramedullary Fixation 2. Screws and Plates

• Steinmann Pinning • Compression plate
• Multiple Steinmann Pins • Neutralisation plate
• Rush Pins • Buttress plate
• Kuntscher Nailing • Sp nail plate
• Smith petersen nail • Dynamic hip screw
• Talwalkar’s nail • Condylar blade plate
• V-nail • T plate
• Hartshill rectangle • Spoon plate
• G.k nail • Cobra plate
• Gamma nail
. Orthopaedic Wire Techniques
• Full Cerclage Wiring
• Hemicerclage Wiring
• Tension Band Wiring

4. External Skeletal Fixation

• Applications of Kirschner-Ehmer Apparatus
• External fixation is a surgical treatment used to stabilize bone
and soft tissues at a distance from the operative or injury
focus.
• Initial assessment and also for secondary interventions needed
to restore bony continuity and a functional soft tissue cover.
• It is an alternative to internal fixation, where the components
used to provide stability are positioned entirely within the
patient's body.
 Indications:

• Stabilization of severe open fractures

• Stabilization of infected nonunions

• Correction of extremity malalignments and length

discrepancies
• Initial stabilization of soft tissue and bony disruption in poly
trauma patients
• Closed fracture with associated severe soft tissue injuries

• Severely comminuted diaphyseal and periarticular lesions

• Temporary transarticular stabilization of severe soft tissue and
ligamentous injuries
• Pelvic ring disruptions

• Certain pediatric fractures

• Arthrodesis

• Ligamentotaxis (cont longitudinal force (distraction) in order

to bring fracture fragments more closely together.
• Osteotomies

• Open fractures that have significant soft tissue disruption (e.g.,

type II or III open fractures)
• Soft tissue injury (e.g., burns)

• Acetabular and pelvic fractures

• Severely comminuted and unstable fractures

• Fractures that are associated with bony deficits

• Limb-lengthening procedures

• Fractures associated with infection or nonunion

 Contraindications:

• Patient with compromised immune system

• Non compliant patient who would not be able to ensure proper

wire and pin care
• Pre-existing internal fixation that prohibits proper wire or pin
placement
• Bone pathology precluding pin fixation
 Method:

• In this kind of reduction, holes are drilled into uninjured areas of

bones around the fracture and special bolts or wires are screwed
into the holes.
• Outside the body, a rod or a curved piece of metal with special
ball-and-socket joints joins the bolts to make a rigid support.
• The fracture can be set in the proper anatomical configuration by
adjusting the ball-and-socket joints.
• Since the bolts pierce the skin, proper cleaning to prevent
infection at the site of surgery must be performed.
• Installation of the external fixator is performed in an operating
room, normally under general anesthesia.
• Removal of the external frame and bolts usually requires
special wrenches and can be done with no anesthesia in an
office visit.
• External fixation is usually used when internal fixation is
contraindicated- often to treat open fractures, or as a
temporary solution.
• In most cases it may be necessary for the external fixator to be
in place for many weeks or even months.
• Most fractures heal in between 6 and 12 weeks.

• However, in complicated fractures and where there are

problems with the healing of the fracture this may take longer
still.
• It is known that bearing weight through fracture by walking on
it, for example, with the added support of the external fixator
frame actually helps fractures to heal.
• The parts of an external fixator include:

• Schanz pin

• Connecting rods

• Clamps
Types:

• Ilizarov apparatus

• Taylor Spatial Frame

 Ilizarov apparatus:

• The Ilizarov apparatus is a type of external fixation used

in orthopedic surgery to lengthen or reshape limb bones; as
a limb-sparing technique to treat complex and/or open bone
fractures; and in cases of infected nonunions of bones that are
not amenable with other techniques.
• It is named after the orthopedic surgeon Gavriil Abramovich
Ilizarov from the Soviet Union, who pioneered the technique.
• Ilizarov used external fixation devices on patients to treat non-
unions in the 1950s.
• Ilizarov observed the callus formation and
discovered distraction osteogenesis when one patient
lengthened his frame rather than compressing it.
• The procedure, and the first apparatus he designed for it, was
inspired by a shaft bow harness on a horse carriage.
• Originally bicycle parts were used for the frame.
• The technique gained fame across the Soviet Union when he
successfully treated Soviet world-record holder and gold
medalist high jumper, Valery Brumel in 1968.
• Brumel broke his tibia in a motorcycle accident and had 20
unsuccessful operations over a three-year period to try to
repair his non-union.
• Ilizarov used distraction osteogenesis to heal the non-union
and 3.5 cm (1.4 in) leg length discrepancy.
• The technique was brought to the US in 1987 by Victor
Frankel, president of Hospital for Joint Diseases, and Dr.
Stuart Green who, in 1992, edited the first English translation
of Ilizarov's book.
• The Ilizarov external fixators can be used to correct angular
deformity in the leg, to correct leg-length differences, and treat
non-unions.
• In most developing countries it is a highly specialized
technique used mainly for deformity correction by
experienced surgeons due to its complexity.
• The apparatus is based on the principle which Ilizarov called
"the theory of tensions".
• Through controlled and mechanically applied tension stress,
Ilizarov was able to show that the bone and soft tissue can be
made to regenerate in a reliable and reproducible manner.
Bone lengthening/reshaping:

• the Ilizarov frame is also commonly used to correct deformity

through distraction osteogenesis.
• The procedure consists of an initial surgery, during which the
bone is surgically fractured and the ring apparatus is attached.
• As the patient recovers, the fractured bone begins to grow
together.
• While the bone is growing, the frame is adjusted by means of
turning the nuts, thus increasing the space between two rings.
• As the rings are connected to opposite sides of the fracture,
this adjustment, done four times a day, moves the now-healing
fracture apart by approximately one millimeter per day.
• The patient is able to fully weight bear on the Ilizarov frame,
using crutches initially and pain is lessened.
• Once healing is complete, a second surgery is necessary to
remove the ring apparatus.
• While the Ilizarov apparatus is minimally invasive (no large
incisions are made,) it is not free of complications. Pain is
common and can be severe, but is treatable with analgesics.
• Careful attention to cleaning and hygiene is necessary to
prevent pin site infection.
• Other complications include swelling, muscle transfixion, and
joint contractures.
• Physical therapy is often indicated.
Bone fracture treatment:

• The Ilizarov method is widely used to treat complex and/or

open bone fractures.
• This method is preferred over conventional treatment options
(such as internal fixator or cast) where there is a high risk of
infection or the fracture is of such severity that internal fixators
are unworkable.
• Journalist Ed Vulliamy wrote a detailed description from the
patient's viewpoint of Ilizarov apparatus treatment of a bad
fracture.
 Taylor Spatial Frame:
• The Taylor Spatial Frame (TSF) is an external fixator used
by podiatric and orthopaedic surgeons to treat complex
fractures and bone deformities.
• The medical device shares a number of components and features of
the Ilizarov apparatu.
• The Taylor Spatial Frame is a hexapod device based on a Stewart
platform, and was invented by orthopaedic surgeon Charles Taylor.
• The device consists of two or more aluminum or carbon fibre rings
connected by six struts.
• The TSF is used in both adults and children. It is used for the
treatment of acute fractures, mal-unions, non-unions
and congenital deformities.
• It can be used on both the upper and lower limbs.

• Specialised foot rings are also available for the treatment of

complex foot deformities.
• Each strut can be independently lengthened or shortened to
achieve the desired result, e.g. compression at the fracture site,
lengthening, etc. Connected to a bone by wires or half pins,
the attached bone can be manipulated in six axes
(anterior/posterior, varus/valgus, lengthen/shorten.) Angular,
translational, rotational, and length deformities can all be
corrected simultaneously with the TSF.
Correcting deformities:

• The struts are adjusted daily by the patient until the correct
alignment is achieved.
• Correction of the bone deformity can typically take 3–4 weeks.

• For simpler fractures where no deformity is present the struts may

still be adjusted post-surgery to achieve better bone alignment, but
the correction takes less time.
• Once the deformity has been corrected, the frame is then left on the
limb until the bone fully heals. This often takes 3–6 months,
depending on the nature and degree of deformity.
Dynamisation:

• When the bone has sufficiently healed, the frame is

dynamised.
• This is a process of gradually reducing the supportive role of
the frame by loosening the struts one at a time.
• This causes force that was previously transmitted around the
fracture site and through the struts to be transmitted through
the bone.
Removal of frame:

• After a period of dynamisation, the frame can be removed.

This is a relatively simple procedure often performed
under gas and air analgesic.
 Use for fractures:
• External fixation via TSFs tends to be less invasive than internal
fixation and therefore has lower risks of infection associated with
it.
• This is particularly relevant for open fractures.

• For open comminuted fractures of the tibial plateau the use of

circular frames (like TSF) has markedly reduced infection rates.
• The time taken for bones to heal (time to union) varies depending
on a number of factors. Open fractures take longer to heal, and
infection will delay union.
Infection:

• Infection of the pin sites (points where wires enter the skin) of
the TSF is a common complication (estimates are that it affects
20% percent of patients).
• In extreme cases this can result in osteomylitis which is difficult
to treat.
• However, pin site infections are normally successfully treated
with a combination of oral antibiotics, intravenous antibiotics, or
removal of the affected pin.
• Pin sites are classified as percutaneous wounds
• Common practice involves the regular cleaning of the pin sites
with chlorhexidine gluconate solution, regular showering, and
dressing of sites that exude liquid with non-woven gauze
soaked in chlorhexidine gluconate.
• This dressing can be held in place with bungs or makeshift
clips or by twisting around the wire.
PROTECTION:

• It is necessary to prevent the fracture sitefrom excessive

compressive and rotational stresses till the fracture
consolidates.
• In UL, the fractures are protected by a sling or a splint.

• In LL, plasters, brace, crutch or cane is used.

 Prevention of fracture-related infection: a multidisciplinary
care package

• Fracture-related infection (FRI) not only accounts for a high

morbidity and mortality rate, it has a substantial socioeconomic
impact compared with musculoskeletal trauma patients who do not
develop this complication.
• The incidence of infection after internal fixation of closed fractures is
reported to be 1–2% but can reach 30% in cases of open fractures.
• As the consequences of such infection can be life-changing for the
patient due to permanent functional loss or amputation of the affected
limb, patient quality of life (QoL) and functional status also decrease.
 Risk factors for FRI
• The risk of developing an FRI is multifactorial.

• Patient-related risk factors include, for example, smoking, which

can delay wound healing and increase the risk of infection.
• Other factors, such as obesity, extremes of age, diabetes mellitus,
use of steroid or immunosuppressant drugs, malnutrition and a
prolonged preoperative hospital stay, increase the risk of
colonisation with a resistant hospital-acquired bacterial strain.
• Long procedure time is a risk factor.
• Other risk factors include lack of appropriate antibiotic
prophylaxis.
• Patients who are medically compromised or critically ill will
most likely be unable to fight an infection systemically or
locally.

• Preventive measures divided into preoperative, peri-operative

and post-operative phases.
Pre-operative prevention measures:

• Staphylococcus aureus Screening

• Hand hygiene

Surgical-site preparation
• Hair removal

• Pre-operative washing

• Skin antisepsis (preparation)

• Antibiotic prophylaxis
 Perioperative prevention measures:
• The operation room environment,
• Surgical attire consists of scrub suits (pants and shirt with short sleeves, with cuffs on
arms and ankles), washable shoes, caps, and surgical masks and (sterile) gloves and
gowns.
• ventilation,
• sterilisation of surgical instruments and
• Traffic patterns in and out,
• Adhesive drapes.
• Patient-specific measures:
• Normothermia
• Normoglycaemia
Peri-operative wound management:

• Surgical debridement and irrigation

• Wound closing

• Wound drainage
Post-operative prevention measures:

• staff compliance with hand hygiene and aseptic procedure

protocols are important throughout the entire hospital stay of
the patient.