open reduction of fractures

Fracture open reduction is the use of surgical methods to expose the fracture site, the correction and reduction of the fracture end; and according to the different conditions of the fracture, use a variety of internal fixation, to maintain the position after the reduction, called internal fixation. In general, after fracture reduction and reduction, multiple internal fixation is performed at the same time. The purpose of fracture treatment is to enable the wounded to heal quickly and restore limb function under the premise of less pain and high safety. A large number of cases have proved that the vast majority of fractures, including the difficulty of manual reduction and the high degree of alignment, can be reset by hand and fixed by small splints. Therefore, manual reduction is the basic treatment method. Only the small reduction of the result of open reduction can be better than that of manual reduction, or the surgery can not be used to reset the surgery. Children and adolescents have strong shaping ability, and their ability to fight infection is low. Cut and open should be more careful. Once the cut-off is decided, the effective measures should be taken to minimize the extent of periosteal peeling and reduce the damage of blood supply; strict implementation of aseptic technique to avoid wound infection. Eliminate or reduce adverse factors to ensure successful surgery. Treatment of diseases: fractures Indication 1. The fracture involves a significant displacement of the articular surface. It is not suitable for manual reduction, or if the technique fails to reset or the position cannot be maintained after the reduction (such as humeral condyle, femoral condyle, humeral condyle and ankle fracture), it should be opened and reset. The goal is to fight for anatomical reduction of the articular surface to avoid joint instability and damaging arthritis. At the same time, a strong internal fixation, such as the intercondylar fracture of the humerus, is fixed with a bone plug for early joint function exercise. 2. Fracture combined with joint dislocation of the same bone (such as femoral fracture combined with hip dislocation), due to fracture of the distal end of the dislocated joint, it is difficult to perform manual reduction. 3. A fracture of several bones or a fracture of the femur and tibia of the same limb, or multiple fractures, in order to prevent complications and facilitate the patient's movement in the bed, it may be possible to select some methods of difficulty in resetting or external fixation to maintain the fracture of the alignment. Open reduction and internal fixation. 4. There are obvious displacement of avulsion fractures, such as humeral fractures, olecranon olecranon fractures, etc., difficulty in manual reduction, it is difficult to maintain the contralateral alignment after reset. 5. There is soft tissue embedding between the two fracture ends, and the method of loosening the failure. 6. Fracture with major blood vessels or nerve damage, before the repair of blood vessels or nerves, it is necessary to perform an open reduction and restore the support of the skeleton. 7. The wounded failed to seek medical treatment in time. When he came to the hospital, he could not perform manual reduction or traction reduction treatment, and the fracture displacement was obvious, and it would affect the limb function in the future. 8. Some fractures with blood supply disorders, such as femoral neck fractures, external fixation is not conducive to maintaining reduction and healing. Internal fixation such as open reduction or manual reduction of three-wing nails should be used to firmly fix and promote fracture healing. 9. There is a significant displacement of the epiphyseal fracture, poor reduction or close contact between the two fracture ends. Contraindications 1. The general situation of the wounded is not good, or the concomitant shock, must first rescue, until the shock is stable, the general situation can be improved before surgery. 2. If there is a life-threatening head, chest or abdominal cavity and other important organ damage, it must be treated first. The treatment of the fracture should be relegated to the secondary position. Temporary external fixation can be performed first, and the fracture should be treated after the condition is stable, or non-surgical treatment can be used. Try to get a better reset as much as possible. 3. There are more than 8 to 12 hours of open wounds in the fracture. Preoperative preparation 1. The fracture is caused by severe trauma. The patient has severe pain and blood loss. Analgesic and blood matching should be given before surgery. For patients with poor general condition or existing shock, anti-shock treatment such as infusion and blood transfusion should be given, and the operation should be performed after the condition is stable. 2. Preoperative fracture site should be taken with positive lateral x-ray film to determine the location, shape and displacement of the fracture, which is convenient for determining the surgical procedure and internal fixation. For those who need to take x-rays during surgery, they should inform the radiology department and the operating room in advance to prepare. 3. The surgeon should propose the special equipment to be used and check whether the preparation of the equipment is complete, so as to avoid temporary preparation and prolong the operation time. 4. Open fractures should be treated with antibiotics and tetanus antitoxins; or if the original open fractures were delayed for more than 2 weeks, antibiotics and repeated injections of tetanus antitoxin should be used. 5. After the reduction and reduction, the internal fixation or bone graft should be used. The antibiotic should be intravenously administered immediately after anesthesia, and once every 6 hours, share 4 times. 6. The fracture site should have sufficient range of cleaning and disinfection preparations. The surgeon should avoid contact with the suppurative wound on the same day, and strictly follow the hand washing procedure to prevent the wound infection. 7. Patients who need to delay surgery for the first time should be towed first, can be reset, temporarily fixed, and can overcome soft tissue contracture, reducing the difficulty of resetting during surgery. 8. Need to simultaneously bone fractures, such as delayed bone fractures, slow healing fractures, etc., should be prepared for the bone area after surgery. Surgical procedure 1. Position: The position is different due to the location of the fracture. The general requirements are: 1 to facilitate surgical exposure and operation; 2 to prevent surgical reduction of the fracture; 3 patient comfort. For example, the open reduction of the posterior dislocation of the hip joint, when the posterior approach is used, the prone position can be used, but the prone position will hinder the hip traction during the reduction, so it is better to use the lateral or lateral prone position. In addition, when tissue transplantation is performed to repair tissue defects, two groups of people are often required to perform surgery at the same time. At this time, the position and consideration should be considered for the needs and convenience of the donor and recipient surgery. 2. Incision: Requirements for selection of incision site: 1 Full exposure, easy operation, less damage, less bleeding, scar does not affect function after healing; 2 Do not choose the part under the skin that has bone or bone protrusion to avoid adhesion and adhesion in the future. Pain; 3 incisions are best not to pass through the joints, when the joints must be passed, a sacral incision should be used to avoid scar contracture and affect joint function. 3. Expose the fracture end: According to a certain exposure route, cut the skin, subcutaneous tissue and fascia, separate the muscles along the muscle gap or cut the muscles and reach the periosteum. The periosteum is cut and subperiosteal is separated to reveal the fracture end. The exposure process should be observed as follows: 1 Enter as much as possible from the muscle gap. In this way, the anatomical level is clear, the damage is small, the bleeding is small, the surgical field is clear, and the nerves and blood vessels are not easily injured. 2 Try to keep the soft tissue and periosteum in contact, and maintain the blood supply to the fracture end as much as possible. 3 As long as the range of the exfoliated membrane can meet the reduction and internal fixation, do not peel too much, so as not to damage the blood supply at the fracture end and affect the healing. 4. Treatment of the fracture area: The treatment of the fracture area includes 1 removal of the clot and damaged tissue; 2 the broken bone piece connected with the soft tissue should be retained in principle, the free small bone piece or bone debris should be cleaned, and the completely free large bone The film can not be removed, it should be reset and fixed, so as not to cause bone defect (the large broken bone piece of open fracture is washed with physiological saline, and then immersed in 1:1000 Xinjie and immersion for 5-10 minutes). 3 The soft tissue embedded between the two fracture ends should be loosened and restored; 4 the fracture of the fresh fracture does not need to be trimmed, but for those who have old fractures or fractures, the fracture ends should be trimmed with a bone knife and cut into new wounds. And drill through the marrow cavity. 5. Fracture reduction: generally under direct vision, using instruments and techniques. Slight overlap and lateral displacement, can be inserted between the fracture ends by periosteal stripper, use the lever to open the fracture end, while the assistant gently pulls the distal end of the limb and corrects the rotation into angular displacement, the surgeon uses The finger or another periosteal stripper corrects the lateral displacement. More obvious overlap shift and side shift. After the two assistants' manual traction and reverse traction correction overlap shift and rotational shift, the two fracture ends were clamped with a rongeur after surgery, and the force was reversed to correct the lateral shift. Bit. Old displaced fractures can be adjusted gradually by means of a fracture reduction device. 6. Internal fixation or bone grafting: In addition to severely contaminated and open fractures of more than 12 hours, internal fixation is usually performed at the same time as open reduction (see internal fixation). After 2 weeks of fractures, old fractures, and fresh fractures with poor blood supply and difficulty in healing, bone grafting should be performed at the same time as open reduction to promote fracture healing. 7. Stitching: Completely stop bleeding, and after suspending the wound, suture layer by layer. If the incision is large and the bleeding is more, the negative pressure drainage should be performed. complication 1. Shock: Due to the strong stimulation of local bleeding and pain in the fracture, shock or pre-shock may occur. Open reduction is a surgery with more damage and more blood loss. If you do not prepare well before surgery, you will be aggravated or cause shock. Therefore, the key to preventing shock is to perform the necessary infusion and blood transfusion before and during surgery to supplement the blood volume. During the operation, blood transfusion should be performed according to the amount of blood loss. In addition, rude operations must be contraindicated to reduce damage stimuli. If a shock occurs, the operation should be temporarily suspended and the rescue should be actively carried out. 2. Incision infection: This is a serious complication of open reduction. Incision infection means infection at the fracture end (ie, suppurative osteomyelitis). After infection, localized long-term congestion, the fracture end is soaked by pus, tissue necrosis liberates a large number of decomposition products, which are not conducive to the healing of the fracture, so that the incidence of delayed healing and non-healing is greatly increased, the function of the limb is affected, and even occurs. Disabled. Therefore, the prevention of wound infection is extremely important, which is related to the success or failure of surgery and the recovery of limb function. The key to prevention is to adopt strict aseptic technique before and during surgery. In addition, it is important to pay attention to the light weight during surgery to avoid aggravating the damage. If an infection has occurred, drainage should be performed as soon as possible, and a sufficient amount of antibiotics should be given to control the infection. At the same time, the treatment of the fracture should not be abandoned, and external fixation or traction is still needed to maintain the fracture reduction. After infection, although the internal fixation has become a foreign body, it is not necessary to rush to remove it. After the acute inflammation subsides, the lesion is cleared, tissue metastasis or transplantation is performed to eliminate the wound and promote fracture healing. 3. Delayed healing and non-healing: The clinical healing time is prolonged in almost all fractures with open reduction. Such as intraoperative blood damage, fracture treatment, poor internal and external fixation, improper postoperative treatment or wound infection, it is more likely to cause delayed healing and non-healing. Therefore, we must pay attention to prevent infection, minimize tissue separation and peeling of periosteum, and operate lightly and reduce soft tissue damage to ensure adequate blood supply at the fracture end. For long-term and poorly transmitted fractures, bone grafts and periosteum grafts should be performed to promote healing. Fractures with delayed healing should be carefully analyzed to remove the cause. Non-healing fractures can only be cured by re-operation, trimming the bone ends, performing bone grafting and secure internal fixation.