Fractures.ppt

Principles of Fracture
Management
J C Munthali, MBChB, MMedSc,
MCS(ECSA), MMed.Orth, FCS.Orth (ECSA)
Lecturer University of Zambia School of Medicine
Senior Registrar, University Teaching Hospital

5th Year Medical Students, September 2008
Learning Outcomes
By the end of this lecture the student should be able to:
1. Define a fracture
2. Discuss the clinical evaluation & investigation of a
patient with a fracture
3. Describe the radiological classification of fractures
4. Discuss the general principles of management of
fractures
5. Discuss the common fractures & their management
6. Outline the differences between fractures in adults &
children
7. Enumerate the early, intermediate and late
complications of fractures

Definition
A fracture is a partial or complete
break in the structural continuity of
bone.

New definition
• Soft tissue injury with bone
involvement.

Introduction
“All fractures unite:
some how, some
when. Be aware of
the difference you
create and make
use of it
rationally.” –P.
Demmer

Introduction
• Bone is the only tissue in the human
body other than liver that heals by
regeneration instead of by scarring.
• For regeneration to occur the bone
must be immobilized to allow
uninterrupted formation of new bone.

How Do Fractures Happen?
Bone is relatively brittle yet it has sufficient
strength and resilience to withstand
considerable stress. Fractures result from:
1. Single traumatic incident ( direct or
indirect force).
2. Repetitive stress (fatigue or stress
fractures).
3. Abnormal weakening of the bone
(pathological fractures).

Clinical Assessment
• History – Injury
- Deformity
- Inability to use limb
- Pain, bruising, swelling
- Symptoms of associated
injuries
- Previous injuries
- General medical history

Clinical Assessment
• General signs (A broken bone is part
of a patient!). Look for evidence of:
1. Shock or haemorrhage.
2. Associated damage to brain, spinal
cord or viscera.
3. Predisposing cause.

Clinical Assessment
Local signs:
1. Look
- Swelling, bruising, deformity.
- Integrity of skin (intact or
broken).

Clinical Assessment
Local signs
2. Feel
- localized tenderness
- warmth
- distal pulses
- sensation

Clinical Assessment
Local signs
3. Move
- motor supply distal to fracture
site
- abnormal movements
- joints distal to injury

Investigations
X-rays
1. Two views (AP & lateral)
2. Two joints (proximal and distal to
#)
3. Two limbs (in children, epiphyses
may confuse)
4. Two injuries (e.g. calcaneum vs
pelvis/spine
5. Two occasions (repeat 10-14 days
later)

Types of Fractures
• Closed (simple)- no communication between
fracture site and skin surface.
• Open (compound)- communication between
fracture site and skin surface (e.g. Gustilo &
Anderson’s classification)

Types of Fractures
• Transverse
• Oblique
• Spiral
• Comminuted
• Impacted
• Greenstick
• Pathological

Types of Displacement
• Sideways shift.
• Overlap.
• Impaction.
• Angulation (tilt).
• Rotation.

Fracture Management -
Priorities
• Life takes priority over
limb!
“Life before Limb”

Fracture Management -
Priorities
Fractures occur with other injuries!
• Save life! (Resuscitate! Primary &
Secondary Survey)
• Save limb
• Save joints
• Restore function

Fracture Management
Non-Operative vs Operative

Non-operative Methods of
Reduction
• Closed Manipulation
• Traction

Closed Manipulation
• Increase deformity
• Traction
• Reduce
• Hold
• Exercise
• Rehabilitate

Goal of Reduction
Key is restoration of anatomy:
• Correct axial alignment
• Correct rotational deformity
• Restore length
• Joint alignment

Closed Reduction not necessary when
1. There is no displacement
2. Displacement does not matter
3. Reduction is unlikely to succeed

Management
Reduce (closed or open)
Hold (immobilise)
- continuous traction (skeletal vs
skin)
- splintage (POP)
- functional bracing
- internal fixation
- external fixation

Management
Exercise
1. Prevention of oedema
2. Prevention of joint stiffness
3. Prevent muscle wasting
4. Prevent DVT & hypostatic
pneumonia.
5. Enhance fracture healing.

Fracture Healing
5 stages:
1. Haematoma formation-
tissue damage and
bleeding.
2. Inflammation-
inflammatory cells appear.
3. Callus formation-
osteoblasts and osteoclasts
appear.
4. Consolidation- woven bone
replaced by lamellar bone
and fracture united.
5. Remodelling- new formed
bone remodelled to
resemble normal structure.

Fracture Healing

Fracture Healing
Complications
1. Bone- Infection, AVN, delayed
union, non-nion, malunion.
2. Soft tissue- vascular, nerve,
visceral, compartment
syndrome .
3. Joints- instability, stiffness.

Fracture Healing
Delayed union
1. Inadequate blood supply.
2. Infection.
3. Incorrect splintage.
4. Intact fellow bone.
5. Malnutrition

Fracture Healing
• Non-union
1. The injury – soft tissue loss.
- bone loss
- intact fellow bone
- soft tissue
- interposition

Fracture Healing
• Non-union
2. The bone – poor blood supply
- poor haematoma
- infection
- pathological lesion

Fracture Healing
• Non-union
3. The surgeon – Distraction
- Poor splintage
- Poor fixation
- Impatience

Fracture Healing
• Non-union
4. The patient – Immense
- Immoderate
- Immovable
- Impossible

Operative Management
“Primum, non nocere (First do no
Harm!)”-Hippocrates

• Consider it only if it is the best
option.
• Must offer advantages over non-
operative treatment.
• Must be well done!
• Requires adequate planning.

Indications
1. Multiple Fractures
2. Difficult Fractures
3. Pathological Fracture
4. Socioeconomic reasons

Open Reduction & Internal Fixation (ORIF)

Open Fractures
ORTHOPEDIC EMERGENCY!
• Immediate control of hemorrhage.
• Splinting +/- reduction.
• Early administration of sufficient
analgesia, appropriate antibiotics, and
tetanus prophylaxis.
• Copious irrigation & thorough Debridement
• Emergent consultation w/ orthopaedics for
all Type II and Type III open Fx’s (and
some Type I’s).

Principles of management of
Open Fractures
• Prevent infection (staged surgical
debridement!)
• Achieve healing
• Restore anatomy
• Functional recovery

Fracture Disease
• Muscle atrophy
• Joint stiffness
• Osteoporosis
• Chronic oedema

Conclusion
• Life takes priority over limb
• Reason takes priority over
technique

Specific Fractures

Proximal femur
• Generally known as ‘Hip Fractures’
• Include Neck of Femur &
Intertrochanteric fractures
• Common in postmenopausal females
(M:F=1:3)

Risk Factors
• ?Osteoporosis
• Caucasian race
• neurological impairment
• malnutrition
• impaired vision
• malignancy
• decreased physical activity

Clinical Presentation
History
• Trivial fall
• Painful hip
• Failure to walk
Examination
• Elderly patient
• Shortened lower limb
• Externally rotated
• Tender
• Failure/Difficulty to walk

X-rays-Neck of Femur

Classification
Garden’s Classification

Management
• Resuscitation
• Analgesia
• DVT prophylaxis
• Non-operative vs Operative Treatment
• Early Mobilisation
• Follow-up for avascular necrosis (AVN)

Operative Treatment

Intertrochanteric Fractures

Femoral Shaft
• High energy trauma
• Associated injuries
• Blood loss (1000-1500ml)

Complications
• Early
• Neurovascular injury
• Compartment syndrome (rare)
• Intermediate
• Delayed union
• Joint stiffness
• Late
• Malunion
• Non-union

Management
• Resuscitate
• Non-operative
– Skeletal traction (Perkin’s)
– Skin traction (if < 14 years)
– Closed reduction and spica cast immobilization
– Femoral cast bracing
• Operative
– Intramedullary nailing (1st Generation or Interlocking)
– Plates & Screws

Management
• Perkin’s Traction
• Transtibial Steinmann/Denham pin
• Insertion lateral to medial (mind common
peroneal nerve!)
• 1/7 of patient’s body weight
• Elevate foot end of bed by 4cm/Kg of weight
applied.
• Measure leg lengths daily for first 2wks then
weekly thereafter
• Commence exercises 3-4 days after traction
applied
• Pin tract care (teach patient!)

Advantages of Perkins
Traction
• Prevents muscle atrophy
• Prevents joint stiffness
• Increases blood flow to fracture site
• Allows micromovement at fracture site
• Prevents DVT
• Prevents hypostatic pneumonia
• Prevents decubitus ulcers
• Improves patient’s morale!

Complications of Perkin’s
Traction
• Pin tract infection
• Nonunion (over distraction!)
• Malunion
• Shortening (inadequate weight)

Types of Non-union
• Atrophic
• Hypertrophic
• Oligotrophic
• Fibrous
• Septic

Femoral fractures in Children
• Neonate  Leave
alone or strap to
abdomen.
• < 3 years, <15 kg
 Gallows
traction.
• > 3 years 
Extension skin
traction.

Open Tibial Fractures
• By its location, the tibia is exposed to frequent injury.
• It is the most commonly fractured long bone.
• Because one third of the tibial surface is subcutaneous
throughout most of its length, open fractures are more
common in the tibia than in any other major long bone.
• Blood supply to the tibia is more precarious than that of
bones enclosed by heavy muscles.
• High-energy tibial fractures may be associated with
compartment syndrome or neural or vascular injury.
• Delayed union, nonunion, and infection are relatively
common complications of tibial shaft fractures

Evaluation
• Detailed history and physical examination.
• Inspect limb for open wounds and soft tissue
crush or contusion.
• Thorough neurovascular examination
• Look for signs of compartment syndrome or
vascular injury & treat immediately.
•
• Examine ipsilateral femur, knee, ankle, and
foot.

Initial Treatment
• After examination realign limb gently &
splint it.
• Open wounds are irrigated gently and
dressed under sterile conditions.
• Appropriate tetanus and antibiotic
prophylaxis is administered.
• Plain AP and lateral X-rays that include
the knee & ankle are taken.

Gustilo and Anderson Classification of
Open Fractures
• Type I clean wound < 1 cm long (puncture by bone spike)
• Type II laceration > 1 cm long but is without extensive soft
tissue damage, skin flaps, or avulsions.
• Type III
– IIIA - extensive soft tissue lacerations or flaps but maintain
adequate soft tissue coverage of bone, or they result from high-
energy trauma regardless of the size of the wound. This group
includes segmental or severely comminuted fractures, even those
with 1-cm lacerations.
– IIIB -extensive soft tissue loss with periosteal stripping and bony
exposure. They usually are massively contaminated.
– IIIC -include open fractures with an arterial injury that requires
repair regardless of the size of the soft tissue wound.

Definitive Treatment
• Treat open fractures as emergencies
• Perform a thorough initial evaluation to diagnose life- and limb-
threatening injuries
• Begin appropriate antibiotic therapy in the emergency room or
at the latest in the operating room and continue treatment for
2 to 3 days.
• Immediately debride the wound of contaminated and devitalized
tissue, copiously irrigate (10 litres!), and repeat debridement
within 24 to 72 hours.
•
• Stabilize the fracture with the method determined at initial
evaluation.
• Perform early autogenous cancellous bone grafting.
• Rehabilitate the involved extremity aggressively

Stabilization Methods
• External Fixator
• POP cast
• Calcaneal pin (only
3wks)
• Internal fixation
(only for Type I)

Colles Fracture

Introduction
• Common fracture in elderly patients
(Abraham Colles, 1814), consisting of:
• A transverse fracture of the distal radial
metaphysis proximal to the joint( 2.5cm)
• Dorsal displacement of the distal fragment
• Apex volar angulation
• Radial deviation
• Impaction (with loss of radial length).
• Characteristic ‘dinner fork’ deformity

Mechanism of Injury
• It results from a fall on an
outstretched hand

Deformity

Treatment
• MUA + POP/or back slab- Check position
after 10 days (keep POP for 6wks)
• Closed Reduction & Percutaneous
Pinning (CRPP) + POP
• External Fixator
• ORIF (plate + screws)
• Exercise all free joints

Complications
• Malunion
• Subluxation of radioulnar joint
• Tendon rupture (extensor pollicis longus)
• Stiffness
• Complex Regional Pain Syndrome (CRPS)-
formerly called Sudeck’s Atrophy

Paediatric Fractures

Pathophysiology and
Biomechanics
The immature skeleton is biologically and mechanically
different from the adult skeleton:
• As bone matures it undergoes changes in apparent
porosity, collagen fiber composition and mineral content.
• Elasticity of bone in children allows incomplete fractures
and plastic deformation to occur such as greenstick and
buckle (torus) fractures.
• Immature bone is more resilient- absorbs more energy
before breaking

Pathophysiology and
Biomechanics
• Periosteum is attached loosely to diaphysis
consequently is easily stripped over considerable
length by subperiosteal haematoma.
• Angulation of a child’s bone after fracture can
often be corrected this is termed remodelling.
However rotational malalignment does not
effectively correct itself.
• In the immature skeleton, remodelling occurs
simultaneously with bone growth hence most
childhood fractures can be treated with minimal
surgical intervention.

Sites of Fractures
Common sites include
• Distal forearm
• Femoral shaft
• Tibia & fibula
• Supracondylar fractures of the humerus
• Fractures of the epicondyles of the humerus
• Epiphyseal fractures (mostly distal femur)

Healing
• Healing of childhood fractures is nearly
always rapid- the younger the child the
more rapid the healing.
Upper Limb Lower Limb
Adult Child Adult Child
Callus visible 2-3 1-1.5 2-3 1-1.5
Union 4-6 2-3 8-12 4-6
Consolidation 6-8 3-4 12-16 6-8

Effect on Growth
• Growth often accelerated after
fracture of long bone- probably due
to hyperaemia of neighbouring
epiphyseal cartilage but consequent
discrepancy in length is slight.
• Growth may be impaired if there is
damage to epiphyseal cartilage

Physeal Fractures

Physeal Fractures
• Cartilaginous growth plates present at each end
of the major long bones.
• Greater proportion of growth and later closure
occurs:
» Humerus- proximal end.
» Radius & ulna- distal end.
» Femur- distal end.
» Tibia and fibula- proximal end.
• Most growth occurs “away from the elbow and towards the
knee.”
• About 15% of children’s injuries involve the physis.
• Salter-Harris Classification used to classify physeal fractures.

Salter-Harris Classification
of Physeal Fractures
• Type I injury: complete separation at
physis without damage to metaphysis
or epiphysis.
• Type II injury: The most common,
triangular fragment of metaphysis
attached to displaced epiphysis.
• Type III injury: involves articular
surface with separation of an
epiphyseal fragment.
• Type IV injury: fracture of articular
surface with extension into
metaphysis.
• Type V injury: compression fracture
involving part or all of the physis.
• Type VI injury: fracture involves part
of the cortex of both epiphysis and
metaphysis on the edge of the
physeal plate.
These fractures should be reduced well
to prevent impairment of growth.

X-rays of Physeal Fractures

Supracondylar Fractures

Types
Extension Type
• Most common type
Flexion Type
• Rare

• At age of 6.5 yrs, supracondylar
area is remodelling, and is thinner
than at other ages.
• Elbow also tends to hyperextend in
this age group, contributing to the
mechanism of injury.
Anatomy

Mechanism of Injury
• Fall onto outstretched hand.
• The elbow becomes locked in hyperextension.
• The linear applied force then produces tension
forces anteriorly.
• The olecranon is forced into the olecranon
fossa.
• As the anterior bending force continues, the
distal humerus fails in tension at the
supracondylar region.
• Triceps causes posterior and proximal migration
of distal fracture fragment.

Gartland’s Classification of
Supracondylar Fractures (1959)
Type 1 Undisplaced
Type 2 Displaced with intact posterior
cortex
Type 3 Displaced, no cortical contact,
posteromedial, posterolateral

Gartland Types 2 & 3

Definitive Management
1. Undisplaced fractures
• Collar + cuff
• Above elbow backslab
• Mobilise at 3 weeks
2. Displaced fracture with intact posterior cortex
(Type 2)
• MUA
• Collar + cuff /figure of 8 POP
• Mobilize at 3 weeks
3. Totally displaced fractures (Type 3) without
vascular deficit:
• Reduction
• Fixation (percutaneous K-wires)
• Post op care (observe for neurological deficit)
• Rehabilitation

Percutaneous pinning of Type 3
Fractures

Complications of
Supracondylar Fractures
Early
• Vascular damage
• Compartment syndrome
• Nerve damage
Late
• Volkmann’s ischaemic contracture
• Myositis ossificans
• Malunion (cubitus valgus or varus)
• Elbow stiffness

Fractures.ppt

Recommended

Recommended

More Related Content

Similar to Fractures.ppt

Similar to Fractures.ppt (20)

More from Levysikazwe

More from Levysikazwe (16)

Recently uploaded

Recently uploaded (20)

Fractures.ppt