3. FRACTURES
• Definition: A break in the continuity of a bone with associated damage to the
surrounding soft tissues.
• The majority of fractures are managed non surgically.
• Optimal treatment depends on multiple factors, including the location and type of
fracture.
• In some instances (such as a minimally displaced fracture of the middle phalanx of one
of the lesser toes) no treatment at all other than those for symptoms of pain generally
are necessary
4. • In most other fractures, some form of immobilization is the treatment of choice, this might involve a
simple sling (as for a midshaft clavicle fracture) or a more robust splint or brace.
• When more complete immobilization is desired, immobilization in a circumferential plaster or fiberglass
cast is often ideal.
5.
6.
7. Types of fracture
• 1. Closed (simple) fracture: there is no laceration of the skin overlying the
fracture.
• 2. Open (compound) fracture: An open fracture is a fracture hematoma that
communicates with an epithelial surface, e.g. skin or a pelvic fracture may
communicate with a ruptured rectum or a rib fracture may penetrate a lung.
Open fractures are potentially infected and need urgent treatment.
• 3. Pathological fracture: fracture occurs in a diseased or abnormal bone.
• Stress fracture: due to repeated shearing force in a healthy bone. E.g. athletes.
9. Transverse fracture: This is usually caused by a force applied directly to the site at
which the fracture occurs
Spiral or oblique fracture: This is produced by a twisting force applied distant from
the site of the fracture, usually at each end of a long bone such as the tibia.
Greenstick fracture: This occurs in children whose bones are soft and yielding. The
bone bends without fracturing across completely, the cortex on the concave side usually
remaining intact.
Crush fracture: This occurs in cancellous bone as a result of a compression force
Burst fracture: This usually occurs in a short bone, such as a vertebra from strong
direct pressure; in the vertebrae this usually occurs as a result of impaction of the disc.
11. • Avulsion fracture: This is caused by traction, a bony fragment usually being torn
off by a tendon or ligament.
• Fracture dislocation or subluxation: This is a fracture which involves a joint and
results in malalignment of the joint surfaces
• Complicated fracture: when there is important soft - tissue damage to nerves,
vessels or internal organs.
• Impacted fracture: when the fragments are driven into one another.
• Stable fracture: fracture held in anatomical position firmly by soft tissue
attachment.
• Unstable fracture: Is one which is displaced or has the potential to displace.
• Intra-articular fracture: is one in which the fracture involves the joint surface.
Usually these fractures require operative anatomical reduction if there is
displacement.
15. Signs & Symptoms
• Tenderness is almost invariable with a recent fracture, assuming the patient is
conscious.
• Deformity may or may not be evident. The limb may be bent or shortened, or
there may be a step in the alignment of the bone or joint.
• Swelling is usual when the fracture is fairly superfi cial; gross swelling usually
implies a vascular rupture.
• Local temperature increase is essentially part of the inflammatory response which
rapidly follows the injury and may be evident even if the damage is confined to the
soft tissues.
16. • Abnormal mobility or crepitus , i.e. grating of the fracture ends, may be
noticed. Vigorous attempts to elicit it should be avoided.
• Loss of function is almost always found to some extent. The patient usually
has difficulty in moving the adjacent joints.
• Having diagnosed a fracture or joint injury, the presence and extent of any
wound should be , and the area examined for evidence of ischaemia and nerve
or other important soft – tissue damage.
17. Dislocations
• Sometimes a dislocated joint will spontaneously reduce before your
assessment.
• Confirm the dislocation by taking a patient history.
• A dislocation that does not reduce is a serious problem.
18. Signs and symptoms
• Marked deformity.
• Swelling.
• Pain that is aggravated by any attempt at
movement.
• Tenderness on palpation.
• Virtually complete loss of normal joint motion.
• Numbness or impaired circulation to the limb or
digit.
19. Sprains
• A sprain occurs when a joint is twisted or stretched beyond its normal range
of motion.
• Alignment generally returns to a fairly normal position, although there may
be some displacement.
• Severe deformity does not typically occur.
20. Sprains
• Signs and symptoms
• Point tenderness
• Swelling and ecchymosis
• Pain
• Instability of the joint
21. Strain
• A strain is an injury to a muscle and/or tendon that results from a violent
muscle contraction or from excessive stretching.
• Often no deformity is present and only minor swelling is noted at the site
of the injury.
22. Compartment Syndrome
• Most often occurs with a fractured tibia or forearm of children
• Typically develops within 6 to 12 hours after injury, as a result of:
• Excessive bleeding
• A severely crushed extremity
• The rapid return of blood to an ischemic limb
23. Compartment Syndrome
• This syndrome is characterized by:
• Pain that is out of proportion to the injury
• Pain on passive stretching of muscles within the compartment
• Pallor
• Decreased sensation
• Decreased power
24. Diagnosing fracture
• History: A brief history is essential in order to assess the mechanism of injury and
to raise suspicion of other, less apparent, injuries.
• Pain. This is the commonest symptom, but varies with the site and instability of the
fracture.
• Loss of function. There is almost always some impairment of function in the
injured area, so that patient may be unable to move the limb at all, or may use it with
difficulty.
• Loss of sensation or motor power. This is a particularly important symptom,
suggesting nerve or vascular complications.
25. History Taking
• Investigate the chief complaint.
• Obtain a medical history and be alert for injury-specific signs and symptoms and any
pertinent negatives.
• Obtain a SAMPLE history for all trauma patients.
• OPQRST is too lengthy when matters of ABCs require immediate attention.
26. Secondary Assessment
• More detailed examination of the patient to reveal hidden injuries
• Physical examinations
• If significant trauma has occurred, start with a full-body scan
• Begin with the head and work systematically toward the feet.
• Assess the musculoskeletal system.
27. Secondary Assessment
• Physical examinations (cont’d)
• When lacerations are present in an extremity, consider an open fracture.
• Any injury or deformity of the bone may be associated with vessel or nerve injury.
28. Investigation
• Full Blood Count
• Plain x-ray A-P and lateral views
• Computed tomography (CT) scanning has become a useful aid in diagnosing
the more difficult injuries, particularly fractures of the pelvis, spine and
complex intra - articular fractures. Unfortunately this is not usually done in
our part of the world.
29.
30. Factors that influence the healing of fractures
Unfavorable factors.
• Impairment of blood supply.
• Infection.
• Excessive movement.
• Presence of tumor.
• Interposition of soft tissue.
• Any form of Nicotine.
32. Open fractures
• The treatment of these fractures is an orthopaedic emergency.
• The most important consideration when dealing with an open fracture is to reduce
the risks of infection.
• In order to achieve this, the wound often needs to be extended. Loose fragments of
bone are devitalized and so should be removed, as should bone deep to areas where
the periosteum has been stripped. This process of cleaning and removing
devitalized tissue is termed debridement.
• All communicating wounds should be left open and covered with a sterile dressing,
with a view to later closure when infection has been avoided or overcome.
33. • Primary closure is desirable if it can be achieved safely, if the degree of
contamination and soft - tissue damage is minimal and if the time from the accident
is not too great, usually less than 6 hours.
• To this must be added the that the patient should be kept under observation,
preferably in hospital.
• Antibiotics should always be given after culture swabs have been taken.
• Anti tetanus injection should be given
• Correct shock if any.
35. Indications for open reduction
• Failure of closed reduction
• Failure of maintaining reduction after closed manipulation
• Fracture that cannot be reduced by closed means eg. displaced
epiphyseal fractures
• Associated arterial injury
• Difficulty bringing short fragments together
• Elderly patients with complex #
• Intracapsular # with slow union
• Major avulsion fractures where there is loss of function of a joint or
muscle group
• Non‐unions
• Re‐ implantations of limbs or extremities
36. Relative Indications for OR of fractures
• Delayed unions
• Multiple fractures to assist in care and general management
• Unable to maintain a reduction
• Pathological fractures
• To assist in nursing care
• To reduce morbidity due to prolonged immobilisation
• For fractures in which closed methods are known to be
ineffective
37. Adv and disadv of open reduction
• Adv
• Allows early movement
• Disadv
• Sepsis
• Delay bone repair
38. Closed reduction and fixation
• The fracture segments are manipulated with a force opposite in direction to
the one that produced the fracture to restore nomal anatomy.
• Indicated in simple fractures.
39. Maintaining fracture reduction
• Stability is achieved by one of the following
techniques:
1 Intrinsic stability. Some fractures require no
additional stabilization
2 External splintage.
3 Internal fixation.
40. External splintage
• Many fractures can be adequately immobilized with a simple device, such as a splint made of
wire, metal or polythene, bandaged in place, and a sling or crutches may be used to avoid
load - bearing.
• These devices are often used to relieve pain rather than to secure immobilization.
• Casting: Plaster of Paris is still widely used for making open or closed casts, jointed casts,
splints.
• Cast bracing: Is a hinged or jointed cast. It has been used particularly for fractures of the
femur and tibia.
• Traction: Is pulling bones directly or indirectly in order to reduce and hold fractures.
41. Complications of fractures
• Early ‐ visceral injury
• ‐ vascular injury
• ‐ nerve injury
• ‐ compartment syndrome
• ‐ haemarthrosis
• ‐ infection
• ‐ gas gangrene
• ‐ fracture blisters
• ‐ plaster and pressure sores
• Late ‐ delayed union
