Principles_of_fractures

1. Principles of fractures
BY DR/ KHALED ALSAYANI

2. A fracture is a break in the structural continuity
of bone.
It may be closed if the skin is intact or
compound if the fracture haematoma
connected to the surface of the skin or one of
the body cavities.

3. How fracture happed
 trauma (direct or indirect)
 repetitive stress.
 abnormal weakening of the bone (pathological).
 Green stick fracture.
 Physeal injuries.

4. Types of fractures:
1. Fractures due to
trauma: Types of
fractures in trauma
depend on the force
applied:

7. 2. Fatigue or stress fractures:
• Is the one occurring in the normal bone of a healthy patient due to
repetitive stress rather than single traumatic evidence.
• Most common sites affected pubic rami , femoral neck , tibial shaft
especially in trainee and athletes , distal fibula , metatarsals
especially the second.

9. 3. Pathological fractures:
• When abnormal bone gives way. The causes are numerous but the
diagnosis not made till biopsy taken.

10. Causes:
• General bone disease
1. osteogenesis imperfecta
2. postmenopausal osteoporosis
3. metabolic bone disease
4. multiple myeloma
5. paget disease

11. Local benign conditions
1. chronic infection
2. solitary bone cyst
3. fibrous cortical defect
4. aneurysmal bone cyst
5. chondroma

12. Primary malignant tumours
1. chondrosarcoma
2. osteosarcoma
3. Ewing's tumour
Metastatic tumours
• Carcinoma from breast, lung, thyroid, kidney ….etc

13. 4. Incomplete fractures (Greenstick
fractures)
• In which instead of complete fracture of the bone cortex the bone is
buckled or bent {like snapping a green twig} this usually seen in children.

14. 5. Injuries to the physis:
In children over 10 % of fractures involve the physis.
Classification:
Salter and Harris classification
• Type 1 a transverse fracture across the physis the prognosis is good.
• Type 2 like type 1 but on one end there is a triangular piece of the
metaphysis the prognosis is good .
• Type 3 the fracture split the physis than pass transversely across one
side through the physis.
• Type 4 like type 3 but the splitting cross the physis towards the
metaphysis the prognosis is bad.
• Type 5 a longitudinal compression injury to the physis the fracture is
not seen at the time of injury but detected retrospectively when its
disturbance to the growth is seen.

15. • XR: may need compression to the other side to be detected.
• Treatment: if undisplaced treated by splinting the limb , for 2 – 4 wks.
If displaced gentle manipulation is important than immobilization for
3 – 6 wks. If type 3 or 4 can not reduced accurately open reduction
and internal fixation by smooth k – wire is important .

16. Compound fractures
Is when the fracture hematoma connects to the skin or one of the body
cavities.
It usually classified according to Gustillo classification.

17. Gastillo classification:
G. 1 :penetrating wound from within(by
spike of bone) less than 1 cm.
G.2: Wound >1cm but Less than 10 cm.
G.3 A: adequate soft tissue coverage.
G.3 B: inadequate soft tissue covering.
G.3 C:neurovascular injuries regardless the
soft tissue covering.

19. How fractures are displaced:
• After complete fracture the bones may displaced by the effect of
gravity or the pull of the muscles attached.
• translation (shift)
• alignment (angulation)
• rotation (twist)

21. How fracture heal
• Fractures heal even if not splinted but we splint it for:
1. Alleviate pain
2. To ensure that union takes place in good position
3. To permit early movement and return of function.

22. Five stages of healing:
1. tissue distraction and haematoma formation.
2. inflammation and cellular proliferation {within 8 hours of
fracture} which bridged the fracture and haematoma slowly
absorbed.
3. callus formation {the thick cellular mass with its island of
immature bone and cartilage forms the callus or splint on the
periosteal and endosteal surfaces.
4. consolidation {osteoblastic and osteoclastic activity the
woven bone transformed to lamellar bone. It may take
several months.
5. remodeling thicker lamellae are laid down where stresses
are high unwanted buttresses are carved away, the
medullary cavity is reformed. The bone especially in children
reassume something like its normal shape.

24. the upper limbs in children in general 3Wks
The lower limbs in children Double the time i.e. 6 wks
The upper limbs in adults Double the time needed in children i.e. 6 wks
The lower limbs in adults Double the time needed in children i.e. 12
wks
Fracture healing calendar:

25. Clinical features:
History:
usually history of injury , followed by inability to use the
injured limb.
The fracture may be away form the site of injury: a blow to
the knee may fracture the patella , the femoral condyles ,
the shaft or even the acetabulum.
The patient age and mechanism of injury is important .
If the fracture follow a trivial trauma suspect a pathological
fracture.
Pain , swelling , bruising are common symptoms. Deformity
is more suggestive.
Ask about associated injuries.
General medical and surgical histories are important.

26. Examination:
General signs:
A,B,C . cervical spines injuries should be excluded.
And general survey.
Local signs:
Crepitus or abnormal movement may be noted.
Examine the most obvious injured part.
Test for artery and nerve damage.
Look for associated injuries in the region.
Look for associated injuries in distal parts.

27. Look : swelling , bruising and deformity , is the skin intact is it broken and
the wound communicate with fracture the injury is then open or compound.
Feel : the injured part is gently palpated for localized tenderness. Check for
distal pulse and nerve function.
Move : crepitus and abnormal movement is tested.

28. X – Ray
The rule of two:
Two views the fracture may not be seen in single view (anteroposterior
and lateral views are important)
Two joints in the leg or forearm the bone may be fractured and
angulated, angulation may associated with fracture of the other bone or
dislocation so the joint above and below should be taken.
Two limbs as in children where comparism of the shape of the
immature epiphysis on each side is important.
Two injuries sever injury cause injuries in more than one level. So in
fracture of the calcanium or femur it is important to XR the pelvis and
spine.
Two occasions some fractures not seen at the time of injury but only
one or two weeks later as in fracture scaphoid or stress fractures.

29. Special imaging
Some times the fracture not seen in usual XR so do:
Tomography as in spine.
CT
MRI may be the only way to show whether the fractured vertebra
compress the spinal cord.
Radioisotope scan is helpful in stress fractures.

30. Treatment of closed fractures:
Three important rules:
Reduce
Hold
exercise
.

31. Reduce:
•Reduction should aim for adequate apposition and
normal alignment of the bone fragments. The
greater the contact surface area between the
fragments the more likely the healing to occur.
•There are two methods of reduction:

32. closed reduction: under proper anesthesia and
muscle relaxation the fracture reduced by 1. the
distal part of the bone is pulled in line of the
bone 2. as the fragments disengaged ,they are
repositioned
open reduction: by operation
indications:
1. failure of closed reduction
2. displaced articular fractures which need accurate
reduction.
3. for traction fractures where the fragments are
hold apart.

33. closed reduction open reduction

34. Hold
Immobilization is performed by:
1. continuous traction
2. cast splintage
3. functional brace
4. internal fixation
5. external fixation

35. continious traction
the problem with traction that it does not maintain
accurate reduction and the patient remain in bed for
long period. Two types of traction:
1. skin traction: for pull not more than 5 kg using
adhesive straps
2. skeletal traction: by pin inserted in the bone distal to
the fracture , this when high weight is needed.
Complication of traction:
1. circulatory embarrasement. Especially in children.
2. nerve injury . in older people, drop foot may happen
3. pin-site infection.

36. skin traction skeletal traction

37. Cast splintage:
• Plaster of Paris (POP) is a common method of fixation of fractures
after reduction rotation of the fracture shaft can be prevented by
including the joint above and the joint below
• The patient can leave the bed early in LL fractures using of crutches
allow ambulation.

39. Complications:
1. stiffness of the joints
2. tight cast
3. pressure sores
4. skin abrasion or laceration
5. lose cast

40. Functional bracing
Using POP or plastic materials, it prevents joint stiffness, segments of
cast are applied over the shaft of the bones leaving the joints free
Since the brace is not rigid, it applied only when the fracture is
beginning to unite.

41. Functional bracing

42. Internal fixation
Bone fragments can be fixed by screws, transfixing pins , or nails , plate
and screws , intramedullary nail, circumferential bands or
combination.
Advantages:
1. hold fractures securely so allow early movement and prevent
stiffness, and edema.
2. allow early leaving of hospital.
3. accurate reduction as in intraarticular fractures.

43. Internal fixation

44. Indications:
1. failure of closed method.
2. unstable fractures which are likely to displaced, as
in ankle fractures , or those liable to muscle pull as
in transverse patellar fracture or olecranon.
3. fractures that unite poorly or slowly as in fracture
neck femur.
4. pathological fractures.
5. multiple fractures.
6. in patient with nursing difficulties as in paraplegics ,
and multiple injuries.

45. Complications:
1. Infection
2. Non – union
3. Implant failure
4. Refracture

46. External fixation:
The bone is transfixed below and above the fracture by screws
or pins or tensioned wires and these connected to each
other by rigid bars.
Indications:
1. Fractures associated with sever soft tissue damage. So it
makes dressing easier.
2. Fractures associated with sever nerve or vessels damage.
3. Severely comminuted and unstable fractures.
4. Ununited fractures which can be excised and compressed
, and some times combined with bone elongation.
5. Pelvic fractures if cannot controlled by other methods.
6. Infected fractures.
7. Sever multiple injuries.

47. External fixation

48. Complications
1. Damage to soft – tissue structures if the transfixing pins injure
the nerves or vessels. Or may tether ligaments or muscles.
2. Over distraction
3. Pin – tract infection.

49. Exercise
This important after any fracture because:
1. prevention of oedema. This by muscle exercises and elevation.
2. active exercises which pumps the edema away prevents adhesion
of soft tissues, and help fracture healing, and prevent muscle
atrophy.
3. assisted movement this by special machines.

50. Open
Fractures

51. Definition
• Break in the skin and underlying soft tissue leading directly into or
communicating with the fracture and its hematoma

52. Epidemiology
• 3% of all limb fractures
• 21.3 per 100,000 per year

54. Open fracture classification
• Allows comparison of results
• Provides guidelines on prognosis and treatment
• Fracture healing, infection and amputation rate correlate with the degree of
soft tissue injury
• Gustilo upgraded to Gustilo and Anderson
• AO open fracture classification
• Host classification of open fractures

55. Type 1 Open Fractures
• Wound less than 1 cm,
• Inside-out injury
• Clean wound
• Minimal soft tissue damage
• No significant periosteal
stripping

56. Type 2 Open Fractures
• Moderate soft tissue damage
• Outside-in
• Higher energy
• Some necrotic muscle
• Some periosteal stripping

57. Type 3a Open Fractures
• High energy
• Outside-in
• Extensive muscle devitalization
• Bone coverage with existing soft
tissue

58. Type 3b Open Fractures
• High energy
• Outside in
• Extensive muscle
devitalization
•Requires a flap for
bone coverage and
soft tissue closure
• Periosteal stripping

59. Type 3c Open Fractures
• High energy
• Increased risk of amputation
and infection
• Any grade 3 with
major vascular injury requiring
repair

60. Why use this classification?
•Grades of soft tissue injury correlates with infection and
fracture healing
Grade 1 2 3A 3B 3C
Infection
Rates
0-2% 2-7% 10-25% 10-50% 25-50%
Fracture
Healing
(weeks)
21-28 28-28 30-35 30-35
Amputation
Rate
50%

61. Radiological Examination
• Usually, only AP and lateral radiographs are required
• They should include adjacent joints and any associated injuries.
• There are a number of features that the surgeon should look for
when examining the radiographs
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62. Radiological Examination
• MRI and CT scans are rarely required in the acute situation but may
be helpful in open pelvic, intra-articular, carpal, and tarsal fractures.
• Angiography may be required in Gustilo IIIb or IIIc fractures.
• In the polytraumatized patient, the surgeon must decide if a delay for
further imaging is appropriate.
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63. Goals of treatment
• 1. preserve life
• 2. preserve limb
• 3. preserve function
• Also….
• Prevent infection
• Fracture stabilization
• Soft tissue coverage

64. Stages of care for open fractures

65. Types of fracture stabilization
• Splint
• Good option if operative fixation not
required
• Internal fixation
• Wound is clean and soft tissue coverage
available
• External fixation
• Dirty wounds or extensive soft tissue injury

66. Fracture stabilization
• Gustilo type 1 injury can be treated the same way as a comparable
closed fracture
• Most cases involve surgical fixation
• Outcome is similar to closed counterparts

67. Fracture stabilization
•Gustilo type 2&3 usually displaced and unstable
• dictate surgical fixation
•Restore length, alignment, rotation and provide
stability
• ideal environment for soft tissue healing and reduces
wound infection
• reduces dead space and hematoma volume
• Inflammatory response dampened
• Exudates and edema is reduced
• Tissue revascularization is encouraged

68. When to use plates?
• Open diaphyseal fractures of arm & forearm
• Open diaphyseal fractures lower extremity
• NOT recommended
• Open tibial shaft plating assoc high infection rate*
• Open periarticular fractures
• Treatment of choice in both upper and lower extremities

69. When to use IM nails?
•Treatment of choice for most
diaphyseal fractures of the
lower extremity
•Inserted without disrupting
the already injured soft tissue
envelope
•Preserves the remaining extra
osseous blood supply to
cortical bone
•Malunion is uncommon

70. When to use external fixation?
• Diaphyseal fractures not
amenable to IM nails
• Ring fixators for
periarticular fractures
• Temporary joint spanning
ex fix is popular for knee,
ankle, elbow and wrist
• If temporary, plan for
conversion to IM nail
within 3 weeks

71. Ex-fix: Weigh the pros and cons!
•Historically was definitive treatment
•Now, more commonly as temporary fixation
•Can be applied almost always and everywhere
•Severe soft tissue damage and contamination

72. Advantages
•Easy and quick
•Relatively stable fixation
•No further damage done
•Avoids hardware in the open wound

73. Disadvantages
•Pin track infections
•Malalignment
•Delayed union
•Poor patient compliance

74. Skin cover and soft tissue
reconstruction
• Do these early!
• 1994 Osterman et al.*
• Retrospective 1085 fractures, 115 G2 and 239 G3
• All treated with appropriate IV Abx and I&D
• No infection if wounds closed at 7.6 days
• Yes infection if wounds closed at 17.9 days
Infection risk
increases if wound
open > 7 days

75. Flap coverage for type 3b

76. Type 3c, a bad injury!
• Devastating damage to
bone and soft tissue
• Major arterial injuries that
require repair
• Poor functional outcome
• Consensus btwn ortho,
vascular and plastics
• Salvage is technically
possible in most cases
• However it is not always
the correct choice esp type
3c tibia fractures

77. How to decide, salvage or amputate?
• Important factors in decision making:*
• General condition of the patient (shock)
• Warm ischemia time (>6hours)
• Age (>30 years)
• Cut to crush ratio (blunt injuries has a large zone of crush)