closed fractures - icrc.aoeducation.org fileclosed fractures scenario closed fracture management pop...

CLOSED FRACTURES

SCENARIOCLOSEDFRACTUREMANAGEMENT

POPIMMOBILIZATIONPOPAFTER-CAREANDFOLLOWUP

REMOVINGCASTSTRACTION

PAEDIATRICCONSIDERATIONSTRANSFERS

MANAGEMENTOFCLOSEDFRACTURESWITHINTERNALFIXATION

SUGGESTEDRESOURCESREFERENCES

7

70 MANAGEMENT OF LIMB INJURIES DURING DISASTERS AND CONFLICTS

CHAPTER 7 I CLOSED FRACTURES

TYPE 1

• Treatnon-displacedclinicalfractureswithimmobilization(backslab,splint-ing)butNOTcircumferentialcasts.

• Provideanalgesiaandmobilityaidssuchascrutchesorwalkingframesfortheelderly.

• Referpatientstohigherlevelsofcarewith:limbdeformities,neurovascularinjury,majortrauma(tibial/femoralfractures)oranyinjurythatcannotbemanagedlocally.

• Ifavailable,radiographymaypreventunnecessarytransfers.

TYPE 2

• Plainradiographyrequired• Treatwithimmobilization(splints/

plaster),tractionwithpinsandexter-nalfixation

• Earlyphysicaltherapytoimprovefunctionaloutcomesandpreventcomplications

TYPE 3

• Noopenreductionandinternalfixation(ORIF)intemporary(tent)structures.• Treatcomplexfracturesthatmaybenefitfrominternalfixation(periarticularor

intraarticular),onlyiftheteamisintegratedintothelocalinfrastructure.• Providehigherlevelsofmedicalandintensivecare.

SCENARIOIt is 5 days post earthquake.

A25-year-oldmanwithaclinicaldiagnosisofaclosedfractureofthemid-shaftoftheleftfemurisbroughttothemedicalfacility.

Anelderlywomanwithaswollen,unstablekneepresents.Shefellduringtheearthquakeandhasbeenunabletobearweightsinceherfall.

A 6-year-old girl presents after a fall fromadamagedbuilding thenight prior.Her leftelbow isgrosslyswollen,deformed,andnoradialpulseispalpable.

The goals of treatment of closed fractures should include:

» Avoid infection – first do no harm (such as through unsafe internal fixation).

» Optimize functional outcomes and minimize pain.

» Promote fracture union with acceptable length, rotation and alignment.

» In the upper limb, mobility is a priority over stability.

» In the lower limb, stability is a priority over mobility.

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MANAGEMENT OF LIMB INJURIES DURING DISASTERS AND CONFLICTS

CLOSED FRACTURE MANAGEMENT

TYPE 1

Iflimbalignmentisnormalbutafractureissuspectedorconfirmedonradiology,asplintorcastshouldbeappliedtomaintainthepositionandreducepain.

NON-DISPLACED FRACTURES» Applicationofcastsandsplintsforfractureswithacceptablepositioninthewrist,forearmand

humerusmaybeappliedwithoutsedation.

» Applicationofcastsfornon-displacedfracturesofthetibiaisdifficultandshouldbeperformedinadesignatedroomwheresedationcanbeprovidedifnecessary.

TYPE 2

Allpatientswhorequireclosedreductionoffracturesandapplicationofsomeformofimmobilizationshouldbemanagedinadesignatedareawheresafeanaesthesiaorsedationcanbeprovided.

DISPLACED FRACTURES REQUIRING REDUCTION » Intheimmediatepostinjuryperiod,backslabsratherthanfullcircumferentialcastsarepreferred.

» Abi-valvedplastercastofthistypeiseasierforfamilytoremoveifnecessary,buthasahigherincidenceoflossoffracturereduction.

» Onmostoccasionsthisbivalveapproachisthesaferoptioniffollowupisofconcern.

» Followupwithallpatientswithlimbsimmobilizedinfullcastsisessential.

» Ifthisisnotpossible,selectthosepatientsmostlikelytohavecomplicationsduringthehealingprocess:

• Patientswithfracturesthatrequiredreduction• Allpatientswithcircularcastsinordertoruleoutissueswithcastpressure• Patientswithfracturesinvolvingtheelbow• Patientswithfracturestreatedveryclosetothetimeofinjury,asthesecanhaveanincreasedriskofproblematicswelling.

• Patientswhounderwentclosedreductionwhileasignificantamountofswellingandoedemawerestillpresent.



SPECIALIST SURGICAL TEAMS» If possible, all closed fractures should be initially treated in a closed fashion to minimize

complications, particularly infection, despite the longer treatment times associated with thisapproach.

» Articularandperiarticularfractureswhichcouldbenefitfromdelayedinternalfixationshouldonlybeperformedinfacilitieswiththeexpertise,sterilityandequipmenttodothissafely.

» Surgical techniques must be adapted to the local environment. Exceeding the local technicalcapabilityinfracturemanagementcreatesproblemsforpatientsandstaffalikewhencomplicationsarise.Any patient that has a fracture immobilized must have a follow up plan for review.

» Internal fixation uses up limited resources and carries a high risk of infection in disasters and in conflict.

» ORIF should only be performed at appropriate facilities with a safe water supply, sterile of equipment, specialist surgical teams, appropriate nursing support, and physical therapy following surgery.

» Non-operative fracturemanagement andavoiding internal fixationmethods in the initial threeweekspostdisaster isnota reflectionof the technical capabilityof the surgeonbutof relatedresourcessuchas:

• contaminatedwatersupplies• co-locationof“clean”patientsinwardswithpatientswhohavewoundinfections.

TYPE 1

EMTtype1Facilitiesshouldhavetheequipmentandexpertiseavailabletoapplyandmanagearangeoflowerandupperlimbimmobilizationtechniquesinclud-ingsplintsandPlasterofParisbackslabsorcasts.

APPLYING CASTSCASTING MATERIALS

» Plaster of Paris (POP) is the casting and splinting material of choice.

» Itcanberemovedbysoakingandcuttingthewetplaster.

» Medicalteamswhocarryfiberglassasafracturemanagementsolutionshouldonlyusethismaterialforsplintsandnever for full castsinadisasterorinaconflictzone.

» Powerfailures,plastersawbreakage,andtransferofthepatienttoafacilitywithoutaplastersawallplacethepatientatriskofhavingacastthatcannotberemovedwithoutseriousrisktothecastedlimb.

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PATIENT INFORMATION

» Patientswho have splints or casts appliedmust be providedwith a plain language statement,in theirfirst language, regardingcarewhile in thesplintorcast.Emphasis shouldbeplacedonreturningformedicalcareifpainisnotcontrolledbytheanalgesicsprovided.

» Patientsshouldbeencouragedtomobilizeevenwithoneextremitysplintedorcasted.

» Write the POP calendar on the cast –includingdateofapplicationofthecast,dateofremovalandX-ray.

DIFFERENT EXPECTATIONSWrite on tape secured to the cast the suspected diagnosis, name of provider,place, date, and a line drawnwhere thefracture is. This transcends languagebarriers and helps patient and familyunderstandthediagnosis. Figure 1.PlasterofPariscastwithpatientinforecordedonit.(ICRC)

POP IMMOBILIZATIONFABRICATION PROCEDURE OF POP CASTS AND SLABS PREPARATION OF THE NECESSARY MATERIALS » Prepareagoodnumberofplasterbandagesratherthanjustafewrolls,asthePOPshouldbemade

allatoncetoassurethecontinuityofitsstructure.

POSITION OF THE PATIENT » Adjustpositionwithcushionsandpillowsifrequired.» Morethanonepersonmayberequiredtosupportthefracturedlimb.» Themedicalprofessionalshouldbeinasuitablepositiontoworkwithoutobstructionordifficulty.

PROTECTION OF SENSITIVE AREAS » Cleananddrytheskinaswellaspossibletoavoidodouranddiscomfortinsidethecast. » ApplythestockinetovertheentireareatobecoveredwithPOP,plusanextralengthforfolding

backatbothextremities.

APPLY ADDITIONAL PADDING (COTTON WOOL OR SOFT BAND) OVER SENSITIVE AREAS» Areasthatshouldneverbecompressedandmustbewellpadded:

• Fracture site • Bonyprominences

• Nerves• Vessels

• Wounds



GENERAL PRINCIPLES» Neverputplasterdirectlyonunprotectedskin.» TheedgesofthePOPshouldbecoveredandnotchafeorpuncturetheskin.» Moldingshouldbedonewiththepalmsofthehandsandnotthefingertips.» Applicationshouldbecontinuoustoallowthecasttodryasasingle,solidpiece.» Checkanddocumenttheanatomicalandfunctionalpositionofthelimb.» ForunstablepatientsimmobilizationwithaPOPbackslaborskeletaltractionisfasterandeasier

thanplacinganexternalfixator.

DURATION OF IMMOBILIZATION» Ifproperlydiagnosedandtreatedwithimmobilization,fractures

ofdifferentbonesrequirevaryingperiodsofimmobilizationtoachieveunion.

BONEMOST COMMON

IMMOBILIZATION PROTOCOLS WITH

NO COMPLICATIONS

AVERAGE HEALING PERIOD WITH NO COMPLICATIONS

ADULT CHILD < 10 YEARS ADULT CHILD < 10

YEARS

Metacarpal 4-6weeks 2-3weeks 6weeks 4-6weeks

Scaphoid 8-12 weeks

8-10 weeks

15-20 weeks 12weeks

Carpal 4-6weeks 2-3weeks 6weeks 4-6weeks

Ulna 4-6weeks 3-4weeks 6-8weeks 4-6weeks

Radius 4-6weeks 3-4weeks 6-8weeks 4-6weeks

Humerus 4-6weeks 3-4weeks 6-8weeks 4-6weeks

Clavicie 4weeks 2-3weeks 4weeks 2-3weeks

Scapula 4weeks 2-3weeks 4weeks 2-3weeks

Ribs 4-6weeks 2-4weeks 4weeks 2-3weeks

Vertebral bones 6-8weeks 4-6weeks 12weeks 6-8weeks

Pelvic bones 6-8weeks 4-6weeks 6-8weeks 4-6weeks

Femur 6-8weeks 4-6weeks 12weeks 6-8weeks

Tibia 6-8weeks 4-6weeks 12weeks 6-8weeks

Talus 6-8weeks 4-6weeks 12weeks 6-8weeks

Calcaneus 6-8weeks 4-6weeks 12weeks 6-8weeks

Phalanges 4-6weeks 2-3weeks 6weeks 4-6weeks

Figure 2.LengthofImmobilizationtimes.(ICRC)

» When applying POP, the drying time depends on the quantity of water left in the plaster.

» If there is too much water in the plaster, the POP becomes fragile after drying.

» Increasing the water temperature shortens the drying time. For long POP, cold water should be used to allow the different layers to dry as one solid cast.

» The higher the water temperature, the higher the temperature generated inside the cast:

» If the water temperature is 24°C, the POP temperature increases to 38°C. If the water temperature is 38°C, the POP temperature increases to 57°C.

» With a water temperature over 50°C, the heat produced inside the POP could burn the skin.

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APPLYING BACK SLABS» Position thepatient appropriately, obtain

materials,andpreptheskin.» Stockinetisappliedtothelimbtocoverall

jointssurroundingfracture.» Padding is applied over the stockinet to

padhighriskpressurepoints.» The first wetted plaster slab is applied

alongthelengthoftheposterioraspectoftheinjuredlimb.

» A second slab is applied in the samefashionas thefirstusingafigure-of-eightorX-crossingof thetwoslabstogivethelightweightposteriorsplintitsstrength.

» Anyexcessplaster is trimmed forpatientcomfortandtopreventanyskinirritation.

» Gauze or elastic bandage is gently butfirmlyappliedtokeeptheslabsinposition.

» Thebackslabishelduntiltheplasterhassetwith theappropriate jointposition tofacilitatefracturehealing.

APPLYING CIRCULAR CASTS» Theskinshouldbethoroughlywashedand

driedbeforeapplication.» Stockinet is applied and the necessary

amountofpaddingforprotectionofboneyprominencesisapplied.

» The plaster bandages should be appliedby rollingwithout tension. Eachbandagecovers one-half of the previous bandagewithoutwrappingcircumferentially.

» The palm of the hand is used, not thefingers,tomoldthewetbandagestoavoidpressuresoresthroughthecast.

» The limb is held in the appropriate jointpositioninguntilthecastisset.(Figure5)

» When dry, the calendar time, fracturelocation, and other documentation iswrittenonthecast.

Figure 3.Forearmslabwithfingerssplintedinthesafeposition.(ICRC)

Figure 4.Moldingatibialcastbyindentingthumbsintobothsidesofthepatellartendon.(ICRC)

Figure 5.Allowingtheplastertosetonatibialcast.(ICRC)



POP AFTER-CARE AND FOLLOW UPADVICE AND INSTRUCTION FOR PATIENTS

Givethefollowingadvicetothepatientandhisorherfamily.» Respectdryingtimebeforeambulation.» POPshouldnotbecoveredwithcloth,varnish,orablanketuntilitisdry.» ThePOPmustnotcomeincontactwithwateroranyotherliquid.» RaiseorelevatethelegwithPOPonapillowtodecreaseswelling.» PerformisometriccontractionunderthePOPtoprotectagainstmuscleatrophyandphlebitis.» Mobilizefreejoints.» Neverwalkonthecastwithoutarockerortip.

CAST VITAL SIGNS

» Pain » Strength» Odour » Colour,heat,sensationandmobilityofextremities» Cleanliness » Generalfeverandheartrate

DANGER SIGNS IN CASTED FRACTURES

» Increasing pain » Increasingswelling» Motor or sensory changes » Seepage through or around the cast

FOLLOW UP AND SUPERVISION

» Ideallyhaveonefollowupafter24hours» Providebasicphysicaltherapyexercisesifneeded» Tellthepatient(andfamily)toreturnifthereareanyconcerns» AllPOPnottoleratedbythepatientshouldberemoved» Ensurepatientshaveplansthatallowforclinicalreviewandcastremoval» Ensuremobilityaidsareprovidedifneeded

POSSIBLE COMPLICATIONS

» Skin(pain,burns,soresduetopressure)» Bones(secondarydisplacement,

osteomyelitis)» Joints(stiffness,osteoporosis)» Musclesatrophy(amyotrophy)» Neurovascularcomplications(complex

regionalpainsyndrome,localcompressions, compartment syndrome, thromboembolism). Figure 6.SkinreactiontoPOP.(ICRC)

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REMOVING CASTSIMMEDIATE REMOVAL OF THE POP

» Ifswelling,diffusepainor lackofsensationoccurs,immediatelysplitthePOPalongitslength.

» Should localpainoccur,openawindowandchecktheskin.ClosethewindowwithanelasticbandageorPOPifthereisnowound.Theincidentshouldberecordedinwritingonthecast.

REMOVING CAST TECHNIQUES

» The cast may be removed by an electric cuttingdeviceorplastershears.

» Forchildren,orifelectricityisnotavailable,plastershearsarenecessary.

» Priortoremoval,gatherallmaterialsneeded.Theseincludescissors, removal tools (Figure7),materialstowashthelimbafter,andsupportivematerial.

» Positionanddrapethepatient.Forupperextremitycasts the patient can be in the sitting or supineposition.Forthelowerextremitythepatientshouldbeinthesupineposition.

» Determinecuttinglines,anddonotcutoverboneyprominences.

» When using plaster shears, ensure correct bladealignmentwitheachcut,andafter4-6cutscleartheblades,utilizethebenders,andcontinue.Nevercutaroundcorners,removethebladeandcutfromtheoppositedirection.

» Whenusinganelectriccutter,ensurethepatientiscomfortableandunderstandsthebladewillnotcuttheirskin.

» After the cast is removed, assess the skin for anydamage from removal and assess the form of thelimbfollowingimmobilization.

» Wash and dry the area, and apply oil or lotion toassistinrestorationofnormalskinnutrition.

» The patient needs to be educated about care oftheskinandoftheinjuredlimbasthemuscletonereturns.

» Areferralforrehabilitationisstronglyadvised.

Figure 7.ToolsneededforremovalandmanipulationofPOP.Fromtoptobottom,oscillatingsaw,castspreader,plastershears,castbreaker.(ICRC)

If a window is cut to assess the skin under a cast, or for treatment of a small (type 1) open fracture, the plaster should be reapplied and fixed in place with elastic bandage to prevent the formation of "window edema".



TRACTION

TYPE 2

Surgicalteamsprovidingcareindisasterresponseandinconflictzonesmust be familiar with the principles of managing patients with fractures in traction,whichmaybeusedasatemporarymethodtomanageafractureorasadefinitivetechnique(SeeICRCmanualonPOPandTractionforadditionalinformation).

SKIN TRACTION» Skin traction can be used temporarily in adultswith femur fractures (for nomore than 48–72

hours).

» Itcanserveasamethodtoallowforplacementoftractionfortransfertoahigherlevelofcare.

» Skin traction can serve as a definitivemethod of treatment formany femoral fractures in thepaediatricgroup.

SKELETAL TRACTION» Skeletaltractioncanbeusedasdefinitivemanagementforadultswithopenlongbonefractures,

although external fixation provides better stabilization and optimizesmanagement of the softtissueinjury(seechapteronopenfractures).

» Skeletaltractionforchildrenwithhipfracturesiseffectiveandcommonlyused.

» Althoughdefinitivetreatmentwithtractionisnotaseffectiveinadults,itmaybetheonlylocallyavailabletreatmentforadultswhosustainfracturesoftheproximalfemur,andismoreeffectivethanskintraction.

PLACEMENT OF TRACTION PINS» Traction pins should have a centrally

threaded section, as this will preventslippinginthebone.

» Thiscanbeinsertedunderlocalanesthesiawithahanddrill(forsafepininsertionseethesectiononopenfractures).

» Traction should not be applied across anunstablejoint.

» When placing a Denham pin for skeletal traction in a deployment scenario, place a piece of tape on the pin and write “threaded.” This is important as you cannot guarantee that you will be the one to remove the pin.

» Always check the stability of the knee joint prior to placing a traction pin for a femoral shaft fracture.

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TECHNICAL ASPECTS» Tractionpinsshouldnotpassthroughasynovialjointspaceoranopenphysealplate.

» Bewaretheproximalextentofthekneejointandtheproximaltibialphysisinchildren.

» Checkstabilityofthekneepriortoinsertingatractionpinforafemoralshaftfracture.

» Ifthekneeisunstable,insertthepininthedistalfemoralmetaphysis.

» Duringinsertion,startfromthesafeside—wherethevesselsandnervesatriskcanbelocalizedandavoidedbycarefulselectionoftheinsertionpoint.

» Distal femoral traction pins should beinserted frommedial to lateral to avoidtheadductorcanalandfemoralartery.

» Proximal tibial pins should be insertedfrom lateral to medial to avoid thecommon peroneal nerve as it passesaroundtheneckofthefibula.

» Calcanealpinsshouldbeinsertedmedialto lateral to avoid the posterior tibialneurovascularbundle.

» AThomassplintorvariantcanbeusedfortemporary stabilization, or for definitivecare for a patient with a femoral shaftfracture.

• Thesearecommonlyusedfortemporarytreatment, either until femoral nailingcanbesafelyperformed,ortotransportapatienttoanothersurgicalcentre.

» If using a Thomas splint as a treatmentoption (more common in children), thering must fit the patient, and attentionmust be paid to correctly padding andadjusting the traction equipment topreventpressureareasinthegroin.

Figure 8.Thomassplint.(ICRC)

Figure 9.Tractionpinplacedinthefemoralmetaphysisandanemptyvialusedasapinguard.

(ICRC)

Figure 10.Thelargerforceappliedinskeletaltractionistransmittedalongtheaxisofthelimbviaa

pin,pulleyandaweight.(ICRC)



» AdultswithfemoralshaftfracturesbeingmanagedinskeletaltractionareoftenonaBöhler-Braunframe.

» Thisallowselevationofthelowerlimb,andkneeflexionduringtraction.Theframemustfitthepatientandbesuitablylined.

» IntheabsenceofaBöhler-Braunframe,asplitHamiltonRusselloraThomassplintcanbeusedfortraction.

Figure 12.Alternativemethod to a Böhler-Braunframeforaproximalfemurfracture.(ICRC)

Figure 13.PreparationofaBohler-BraunFrame.(ICRC)

Figure 11.Constructionofatractionframeinthefield.(J. von Schreeb)

» Patients in traction often develop an equinus deformity of the foot.

» This can be prevented with active and passive physiotherapy using bands and/or foot slings.

» Pressure sores of the heel and sacrum should be prevented, and DVT prophylaxis, if available, is indicated.

81



PAEDIATRIC CONSIDERATIONSTRACTION AS DEFINITIVE CARE

» Childrenwhohavefemoralshaftfracturesarecommonlytreatedintractionwithunionoccurringinapproximatelythepatient'sageinyearsplusoneweek.

» Patients less than 8 should be treated with early Spica casting under sedation 1-3 days afterfracture.

» Fixed traction using adhesive skin or skeletal traction in a Thomas splint is possible. HamiltonRussellTractionispossibleaswellanddoesnotrequireaThomassplint.

» SomesurgeonsviewtheThomassplintasprimarilyusefulfortransportasthedevicecanleadtopressuresoresinthegroin.

» Childrenundertheageof2yearswithafemoralshaftfracturecanbemanagedinGallowstraction.» Children under the ageof 6months canbemanaged in a "Soft Spica" builtwith padding and

bandagesorbyusingaPavlikharnessifavailable.» Weightsrequiredareminimal(1-2kg)andshouldbeoverapulleyonanoverheadbar,nottiedoff

tothebar.

SKELETAL TRACTION

» Skeletaltractionforchildrenwithhipfracturesiseffectiveandcommonlyused.» Skeletaltractionisthebestchoicefor:

• Initialimmobilizationofmostfemoralandsometibialandhumeralfractures• Definitiveimmobilizationoffracturesofthefemur• Definitiveimmobilizationofparticularlydifficultfracturesofthetibianearthekneeandofthe

humerusneartheelbow• Tractionpinsinchildrenshouldnotbeplacednearthetibialtuberosityastheymaycausean

anterior growtharrestand subsequent recurvatumdeformity. They shouldbeplaced in thedistalfemur1cmproximaltothegrowthplate.

Figure 14.Gallowstractionfromabeam.(ICRC)

Figure 15.Patientinskeletaltraction.(ICRC)

DISADVANTAGES OF SKELETAL TRACTION AND CONSIDERATIONS

» Theprincipaldisadvantageofskeletaltractionisprolongedbedrest,alongwithincreaseddemandsonbothnursingandphysiotherapycare.



TRANSFERS» Aninjuredpatientmayhavetheopportunityforevacuationfromthefirsthospitaltoahigherlevel

ofcare.

» Thepatientneedstobeconsultedaboutatransferandthetransfershouldbediscussedwiththeirfamilyorsupportsystem.

SKIN TRACTION AND TRANSFERS

» Transportofapatientwithalongbonefracturecanbefacilitatedbyusingskintractionforalimitedamountoftimeduringthetransport.Skintractionfortransportshouldbeadhesiveinchildrenandnon-adhesiveintheadult.

» Femoralshaftfracturesinadultscanbemanagedduringashortdistancetransferbycontinuingtractionwithaweightonatractionpin,butthisshouldbeavoidedifpossible.

» AnalternativeistheapplicationofaDonway,HareorThomassplint.These splints cannot be used in the presence of ipsilateral pelvic fracture.

» Anotheroptionisbandagingthefracturedlimbtotheintactlimbwithslingsorstripsoffabric.

AIR TRANSPORT

» Consideraprophylacticfasciotomyofthecalfpriortotransferduetopressurechanges.

TRANSFERS IN CASTS

» Anypatientinafullcastshouldhavethecastsplittoskinfortransfer.

• This isdoneduetoswellingandtominimizetheriskofatightcast/compartmentsyndromeduringthetransfer.

» Elevatethepatient’shandorfootasappropriatetopreventdistallimbswelling.

» Avoidhanginganarminfabriconapolebesidethebed.

• Theedgeof that fabricwill causeanulnarnerveneuropathy if it isallowedtocompress theposterio-medialaspectoftheelbow.

• Simplyelevatethehandontheabdomen,orpropittobewellabovetheelbowatrest.

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MANAGEMENT OF CLOSED FRACTURES WITH INTERNAL FIXATION

TYPE 3BEWARE THE RISKS OF INTERNAL FIXATION

LIMITED INDICATIONS IN DISASTER AND EMERGENCY SITUATIONS

» Onlyindicatedifthesituationhasstabilizedandatype3teamisintegratedintoalocalfacilitywithpriorhistoryofperforminginternalfixation.

» Incidenceof50-80%ofinfectionhasoccurredwheninternalfixationwasusedasaprimarymeansoftreatment.

» Considertransferringthepatienttoamoreadvancedfacilityifinternalfixationisnecessary.

» Evaluationofpatient’snormalenvironment,safety,riskofcomplications,andavailableresourcesmustbeconsideredbeforeclosedfractureinternalfixationisperformed.

» TheprincipalmethodsofPlaster-Of-Paris,skeletaltraction,andexternalfixationareviableoptionsformanyfracturesandshouldbethefirstchoiceindisasterandconflicts.

Figure 16.Puspoursfromawoundtreatedwithinternalfixation.Theplatesandscrewsmustnowberemoved.(ICRC)



SUGGESTED RESOURCES

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4. Herard P, Boillot F. Amputation in emergency situations: indications, techniques and Médecins Sans Frontières France’s experience in Haiti. International Orthopaedics 2012: 1-3.

5. Dufour D, Jensen SK, Owen-Smith M, Salmela J, Stening GF, Zetterström B. Surgery for victims of war. 1998.

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7. Hayward-Karlsson J, Jeffery S, Kerr A, Schmidt H. Hospitals for the War Wounded: a practical guide for setting up and running a surgical hospital in an area of armed conflict. Geneva: International Committee of the Red Cross; 2005.

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EMT Website: https://extranet.who.int/emt/page/homeAO/ICRC/WHO Training Resources: http://www.aofoundation.org/icrc

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