The advantages and disadvantages for each method of fracture immobilization are considered for different wounds; the advice given here emphasizes the efficacy of well-applied basic techniques. Much is controversial but this section represents a consensus of a large practical experience of many ICRC surgeons.
For the management of most wounds of the arm with a humerus fracture, a plaster of Paris splint is effective. The splint can be removed with the arm hanging for the purposes of dressing the wound. When the wound is healed, a plaster of Paris cylinder may be needed for continued stability of the fracture. The fracture is usually solid within 3 or 4 weeks (Fig. 3.5). The advantage is rapid secondary bone healing. There are few advantages to external fixation for humerus fractures; it is only advisable when there is a very large wound. It is especially unsuitable for proximal humerus fractures. Distal humerus fractures tend to produce pain, swelling and stiffness in the elbow joint: an initial 2 weeks in overhead traction, the pin being applied to the olecranon, may help this. (b)
When one forearm bone has a fracture and the other is intact, the wound can easily be managed in a plaster of Paris splint. When both bones are fractured, and the fractures are unstable, an external fixator is very useful as it gives access to the soft tissue for dressing and reconstruction; joint mobilization is facilitated but the disadvantage of slow callus formation remains. However, when missile trauma fractures both radius and ulna, there is usually such a degree of nerve, muscle and tendon involvement that the degree of functional recovery is not determined by accurate alignment of the fracture. Distal radius fractures are considered with wrist injuries.
Wounds of the proximal femur (peritro-chanter) are difficult to excise; their immobilization is also difficult. Traction is favoured, with possible later transfer to a hip spica, although the disadvantages, in relation to confinement in bed, are severe. It is nearly impossible to use external fixation for these wounds effectively. Whatever method is used, patience is required.
Figure 3.5 (a) Photograph of a patient 2 months after a fragment injury of the left arm (grade 2, type F) amongst other limb wounds. After wound excision, the fracture was immobilized for 2 weeks by a plaster of Paris splint after which time the patient had a triangular bandage. At the time of the photograph, he was not aware of any disability in the arm.
Figure 3.5 (b) Radiographs of the left arm at admission, 1 month and 2 months. The extent of rapid callus formation is obvious.
Femoral shaft fractures generate the most controversy. They are the easiest femoral fractures to treat whatever the method used for their immobilization. Good results can be achieved by skeletal traction or external fixation (case 4). Lack of supervision of the traction or lack of expertise in application of the fixator leads to bad results. The advantages of traction are its simplicity and rapid bone healing, whilst its disadvantages are that the patient is confined to bed for up to 6 weeks and dressing of a posterior thigh wound is difficult.
The advantages of external fixation are that the patient is mobilized rapidly whilst the disadvantages are slow secondary bone healing with pain and stiffness in the knee due to the pins being applied through the vastus lateralis muscle and the joint capsule. Surgeons are always reluctant to remove external fixators from the femur when there has been only partial bone healing; these fixators may remain in situ for many months if the pin sites have not become infected beforehand. A bone graft should be considered at an early stage.
When a large wound involves extensive bone and soft tissue loss there may be insufficient muscle bulk to immobilize the fracture in a reasonable position with traction. Such fractures are best managed with external fixation (Fig. 3.3).
Distal femur fractures suffer the same problems as the femoral shaft. In addition, the fracture is more likely to sag in traction, which is difficult to correct and results in malunion (case 2); the disadvantages of external fixation with respect to the knee joint are more serious.
When managing leg fractures from missiles, one should bear in mind that it is common to have a large comminuted tibial fracture with an intact fibula; this is rarely encountered in blunt trauma. The situation lessens the need for external fixation as the fibula will hold the limb to length and prevent angulation of the fracture; it will not prevent rotation but a plaster of Paris splint achieves this. Whichever method of immobilization is employed, early weight bearing in the plaster is safe and should be encouraged.
The most severe leg wounds are often associated with traumatic amputation of the other leg; the importance of limb salvage under these circumstances is magnified (case 3).
The early management of proximal tibia fractures is best in plaster of Paris splints incorporating the knee and ankle or calcaneal traction with transfer to a full plaster cylinder later. Early closure of large wounds can be achieved by gastrocnemius muscle flaps; these are especially useful if the knee joint is involved. External fixation should only be used if the pins can be safely inserted above the fracture without endangering the knee joint. There is rapid callus formation in this part of the bone compared with the middle third of the shaft.
Tibial shaft fractures are a good indication for application of external fixation. Its advantages are maximized in comparison to conservative methods whilst relative ease of pin application minimizes the disadvantages. The leg should be moved into a plaster of Paris cylinder or cast brace (patellar tendon-bearing) as soon as the skin wounds have healed (Fig. 3.6).
A large wound involving the distal tibia is amongst the most difficult of non-vital war wounds to treat. There is little soft tissue cover; there is a high proportion of cortical bone to cancellous bone. External fixation is very useful here if the pins can be inserted into the tibia distal to the fracture. If the limb survives, a bone graft is invariably needed. The difficulties are compounded by there
Figure 3.6 (a) Operative photograph of the medial aspect of the right leg which has a tibial fracture and a large wound. The fracture is immobilized with an external fixator and covered by a soleus muscle flap.
Figure 3.6 (b) The muscle flap and the wound were subsequently covered by a split-skin graft.
Figure 3.6 (c) Radiograph of the tibial fracture (F1).
Figure 3.6 (d) Radiograph after application of the external fixation.
Figure 3.6 (e) Radiograph taken after 5 months. The fracture needed a bone graft to achieve union. being no reliable local soft tissue flap to cover this fracture. Fractures immediately above the ankle joint are considered.