This document discusses different types of fractures including those of the tibia, patella, radius/ulna, femur, and in pediatric patients. It defines fractures, classifies them as complete or incomplete, and describes features of specific fracture types like transverse, oblique, spiral, etc. Treatment principles are also outlined focusing on reduction, retention, and rehabilitation with methods like casting, traction, plating, and more.

1. CME : FRACTURE
PRESENTED BY:
TEOH YEONG HUAN
CHONG YU SWAM
RAMMIYAH
MUHAMMAD HABIB

2. FRACTURE
Break in the structural continuity of bone (crack, crumpling, splinting, complete break)

3. Types of Fracture
A. Skin
- Open Fracture
- Closed Fracture
B. Bone
- Complete Fracture
- Incomplete Fracture

4. Complete fracture
Bone completely broken into 2
or more fragments
1. Transverse
2. Oblique
3. Spiral
4. Segmented
5. Comminuted
6. Impacted
7. Avulsion
bone incompletely broken &
periosteum remains in
continuity
1. Greenstick:
2. Stress
3. Compression
Incomplete fracture

5. ● Transverse Fracture: the broken piece of bone is at a right angle to the bone’s axis.
● Avulsion Fracture: when a fragment of bone is separated from the main mass.
● Comminuted Fracture: the bone breaks into several pieces.
● Compression or Wedge Fracture: usually involves the bones in the back (vertebrae).
● Greenstick Fracture: an incomplete fracture in which the bone is bent; occurs most often in children.
● Linear Fracture: the break is parallel to the bone’s long axis.
● Oblique Fracture: the break has a curved or sloped pattern.
● Pathologic Fracture: caused by a disease that weakens the bones.
● Spiral Fracture: one part of the bone has been twisted at the break point.
● Stress Fracture: a hairline crack.

6. CAUSES OF FRACTURE
1. INJURY/TRAUMA (MVA, fall from height, industrial injury,abuse,etc)
● Sudden, excessive force ie overloading the bone
● Direct force
○ Bone breaks at point of impact
○ Direct blow damages bone/soft tissue
● Indirect force
○ Twisting
○ Compression
○ Bending
○ Tension

7. 2. STRESS FRACTURE
● Overuse injury where a normal or abnormal bone is subjected to repetitive stress, resulting in microfractures
● Often seen in athletes and military recruits
3. PATHOLOGICAL FRACTURE
● Fractures which occur from low energy injuries which occur thru an area of bone weakness with a pre-existing abnormality
● Causes :
○ Tumor
■ Benign - simple bone cyst
■ Malignant - metastatic bone disease
○ Metabolic bone disease - osteoporosis, osteogenesis imperfecta, Paget’s disease
○ Drug induced - long term bisphosphonates
○ Osteomyelitis

8. FRACTURE HEALING
Two types of fracture healing :-
● Primary bone healing (without callus formation)
● Secondary bone healing (with callus formation)
The process depends on :-
● Type of bone involved
● Amount of movement at the fracture site
○ Absolute stability and compression → Primary healing
○ Relative stability → Secondary healing

9. PRIMARY BONE HEALING
Osteoblastic new bone formation occurs directly between the fragments.
1. Contact healing
a. When the fracture surfaces are in close contact with absolute stability, internal bridging may
occasionally occur without any intermediate stages
2. Gap healing
a. Gap between the fracture surfaces are invaded by new capillaries and osteoprogenitor cells
growing in from the edges and the new bone is laid down on the exposed surface
b. At a narrow gap between the fracture surfaces, osteogenesis will produce lamellar bones
c. Wider gaps are filled first with woven bone and then remodelled to lamellar bone when the
fracture is solid enough to allow penetration and bridging of the area by bone remodelling
units. Usually, it takes 3-4 weeks.

10. SECONDARY BONE HEALING
1. Hematoma formation and inflammatory phase.
● Begins immediately after a fracture occurs.
● Bleeding and inflammation begin in the fracture site
● Hematoma formed at the bone edges, providing the framework for bone regrowth to occur
● This phase lasts approximately 1-2 weeks.

11. 2. Bone regrowth phase.
● New fibrous tissue and cartilage form around the fracture site.
● The tissues and cartilage form a “soft callus” around bone ends.
● Eventually, the calluses on the ends of bones meet and join
● Hard bone begins replacing the soft, spongy tissues.
3. Remodeling phase.
● Solid bone continues to grow, and blood circulation improves at the fracture site.
● Typically lasts for several months after the fracture occurs.

12. PRINCIPLE OF FRACTURE MANAGEMENT
GOAL
● Is to obtain union of fracture in the most anatomical position compatible with
maximal functional return of the extremity
● 3R:
○ Reduce - Adequate apposition and normal alignment with absolute stability
■ Open vs closed reduction
○ Retain - immobilization of fracture
■ Cast splintage
■ Fixation (internal/external)
■ Traction
○ Rehabilitate

13. 1. REDUCE- CLOSED REDUCTION
● Aim: Reposition the bone fragment and alignment
● Do not delay : swelling make reduction difficult
● Suitable for :
○ Minimally displaced fractures
○ Fractures that likely to be stable (if not, can wear splint/cast)
○ Initial management for unstable fractures

14. OPEN REDUCTION
● Indication
○ Closed reduction fail (difficult to control fragments/soft tissue interposed
between fragments)
○ Large articular fragments that need accurate positioning
○ Avulsion fractures (fragments apart due to tendon or ligament attaches to the
bone)
● Internal fixation (ORIF) **

15. 2. RETAIN – TRACTION METHOD
● Traction by gravity
○ upper limb injuries (wrist sling)
● Skin traction
○ sustain a pull <4-5 kg, holland strapping / one way stretch elastoplast stuck to
shaved skin and held on with bandage, cords / tapes are used for traction
● Skeletal traction
○ stiff wire or pin is inserted; usually behind the tibial tubercle - hip, thigh and
knee injuries; calcaneum - for tibial fracture
○ Cords are tied to them for traction
#skin & skeletal traction is reduced and held in either 3 ways - Fixed,
Balanced or combination

17. CASTS AND SPLINT
1. Aim:
● Immobilize musculoskeletal injuries
● Diminish pain
● Promote healing

18. Ulnar gutter splint with underlying stockinette and
circumferential padding
Padded thumb spica splint.

19. Ulnar gutter cast.

20. INTERNAL FIXATION
1.Fractures that cannot be reduced except by operation.
2. Fractures that are inherently unstable and prone to re-displace after reduction.
Also included are those fractures liable to be pulled apart by muscle action
3. Fractures that unite poorly and slowly, principally fractures of the femoral neck.
4. Pathological fractures in which bone disease may prevent healing.
5. Multiple fractures where early fixation (by either internal or external fixation)
reduces the risk of general complications.

21. EXTERNAL FIXATION
External fixation is indicated for:
1. Unable to perform surgery
2. Patients with severe multiple injuries, especially if there are bilateral femoral
fractures, pelvic fractures with severe bleeding, and those with limb and associated
chest or head injuries.
3. Ununited fractures, which can be excised and compressed; sometimes this is
combined with bone lengthening to replace the excised segment.
4. Infected fractures, for which internal fixation might not be suitable.

22. PAEDIATRIC FRACTURE

23. Key differences: paediatric vs. adult
Bone composition

24. Greenstick Fracture
- Partial thickness long bone fracture
where only one side of cortex and
periosteum are interrupted while the
other side remain uninterrupted.
- Child’s bone is softer & more elastic. It
can break on one side and bend on the
other.
- Occur most commonly after FOOSH or
with NAI where the child is hit with an
object

25. Bowing Fracture
- Due to thinner cortex, child’s bone has
higher degree of plasticity
- This allow the bone to bend without
breaking when angulated longitudinal
force is applied to it.
- There is usually an accompanying
diaphyseal fracture of a paired bone,
e.g. (either greenstick or complete
fracture of radius).

26. Torus Fracture
- Incomplete fractures of the shaft of a
long bone most commonly occur in the
distal metaphysis
- Characterized by bulging of the cortex
due to trabecular compression from an
axial loading force along the long axis of
the bone.

27. Bone structure

28. Anatomy of growth plate

29. Salter-Harris fractures are fractures through a growth plate; therefore, they are unique to pediatric patients. These
fractures are categorized according to the involvement of the physis, metaphysis, and epiphysis. The classification of
the injuries is important, because it affects patient treatment and provides clues to possible long-term complications.
75% 12
%

30. A B C

31. Supracondylar fracture
- most commonly occur in children 5-7 years of age
- fall on an outstretched hand
- Associated nerve injuries
- Anterior interosseous nerve neurapraxia (median nerve branch) - most common
- Radial nerve palsy - second most common
- Ulnar nerve palsy - usually in flexion type injury patterns

32. Gartland classification

33. Lateral Condyle fracture
● Lateral Condyle Fractures are the second most common fracture in the pediatric
● Higher risk of nonunion, malunion, and AVN than other pediatric elbow fractures.
● Most commonly are Salter-Harris IV fracture patterns of the lateral condyle
● Mechanism of injury
a. pull-off theory
i. avulsion fracture of the lateral condyle that results from the pull of the common extensor musculature
b. push-off theory
i. fall onto an outstretched hand causes impaction of the radial head into the lateral condyle causing
fracture
● Brachial artery lies anteriorly in the antecubital fossa
● Lateral ecchymosis implies a tear in the aponeurosis of the brachioradialis (attached to the distal styloid process of
the radius by way of the brachioradialis tendon, and to the lateral supracondylar ridge of the humerus) and signals an
unstable fracture
● internal oblique view most accurately shows fracture displacement because fracture is posterolateral

35. Milch classification

36. FEMUR

38. Stage I: incomplete
Stage II: complete
without displacement
Stage III: complete with
partial displacement
Stage IV: complete
with full displacement

41. THR: 8k
Good family support
No h/o stroke
Pre existing hip pain
High functional demand
Systemic problem: RA …..
Hemi: 4k
Home ambulator
Less demand
Stroke pt
Weakness (higher risk dislocation if thr)

42. RADIUS AND ULNA
FRACTURE

43. Radius / Ulna fracture
Mechanism of injury :
1)Fractures of shafts of both forearm bones occur
quite commonly
2)A twisting force (usually a fall on the
hand)produces a spiral fracture with the bones
broken at different levels
3)An angulating force causes a transverse fracture
of both bones at the same level

44. Special feature : Bleeding ,swelling ,pulse must be felt and
hand examined for circulatory or neural deficit, both bones
are broken ,either transversely and at the same level or
obliquely with he radial fracture usually at a higher level
In children –incomplete
In adults- displacement may occur in any direction

45. Treatment :
-operation for open reduction and internal fixation from the outset
-the fragment are held by plates and screws
-the deep fascia is left open to prevent build up of pressure in the
muscle compartment ,and only the skin and subcutaneous tissues are
sutured
-after operation ,the arm is elevated until swelling subsides
Complication :
Nerve injury ,delay union and non union ,complications of plate
removal ,compartment syndrome (incision o relieve )

46. Monteggia
fracture
Fracture of proximal third of ulna with dislocation of head of radius (olecranon is frequently
involved )
Fracture is obvious , but dislocation maybe missed
Mechanism of injury :
1) Injury usually occurs at fall on hand with pronated forearm
2) The radial head usually dislocates forward and the upper third of the ulna fractures and
bows forward, sometimes hyperextension
Special features : swelling due to dislocation head of radius , pain ,tenderness on the lateral
side of the elbow
Treatment :
1)Restore the length of fractured ulna, only then can the dislocated proximal radioulnar joint
be fully reduced and remain stable
2)ORIF and fix with plate and screws
3) Immobilize in cast with elbow in flexed position (max 6 weeks in most severe case )
Encourage simple exercise after 10 days (flexion , rotation and extension of the arm )

47. The ulna has broken and the radial head has dislocated

49. Treatment
Non operative
• closed reduction
• indications
• more common and successful in children
• must ensure stabilty and anatomic alignment of ulna fracture
Operative
• ORIF of ulna shaft fracture
• indications
• acute fractures which are open or unstable (long oblique)
• comminuted fractures
• most Monteggia fractures in adults are treated surgically
• ORIF of ulna shaft fracture, open reduction of radial head
• indications
• failure to reduce radial head with ORIF of ulnar shaft only
• ensure ulnar reduction is correct
• complex injury pattern
• Monteggia "variants" with associated radial head fracture

50. X-ray showing a Monteggia fracture treated with a combination of plates and
screws

51. Galeazzi fracture
A Galeazzi fracture is a distal 1/3 radial shaft fracture with an associated distal
radioulnar joint (DRUJ) injury.
Patients must be evaluated for ulnar nerve lesion
Normally , reduction of the fracture may be necessary but if radioulnar joint is still
unstable after the reduction , fixation with K wires and additional period of cast
immobilization may needed .

53. Homeworkkkkkk
Radial height
Radial inclination
Dorsal and volar tilt
Step
Gap
Rule of 11

54. TIBIA &
KNEE FRACTURE

55. Patella fracture
Patella Fractures are traumatic knee injuries
caused by direct trauma or rapid contracture
of the quadriceps with a flexed knee that
can lead to loss of the extensor mechanism.
Types:
1)Undisplaced crack across patella
2)Comminuted fracture
3)Displaced transverse fracture (present
gap between fragments , passive flexion of
knee)

56. Treatment for type 1 undisplaced crack across patella:
Extensor mechanism is still intact
Hemarthrosis aspirated
Plaster cylinder holding the knee straight (4-6weeks )and quadriceps
exercises
Treatment type 2 comminuted fracture :
Extensor mechanism is still intact
If patella not severely displaced for backslab and daily exercise
Treatment type 3 displaced transverse fracture :
(extensor is not intact ) internal fixation (tension band wiring +
extensors repairs ) + backslab

57. • Tibial plateau fractures are periarticular injuries of the proximal
tibia frequently associated with soft tissue injury.
•Schatzker Classification
•Type I •Lateral split fracture
•Type II
•Lateral Split-
depressed fracture
•Type III
•Lateral Pure
depression fracture
•Type IV
•Medial plateau
fracture
•Type V •Bicondylar fracture
•Type VI
•Metaphyseal-
diaphyseal
disassociation

58. Schatzker classification of tibial plateau fractures

59. PRINCIPAL OF TREATMENT OF ARTICULAR
FRACTURE
1. Absolute stability
2. Stable fixation
3. Early ROM
4. Soft tissue preservation

60. Tibia fractures are classified depending on:
•The location of the fracture (the tibial shaft is
divided into thirds: distal, middle, and proximal)
•The pattern of the fracture (for example, the bone
can break in different directions, such as crosswise,
lengthwise, or in the middle)
•Whether the skin and muscle over the bone is torn
by the injury (open fracture)
Tibia shaft fractures vary greatly, depending on the
force that causes the break. The pieces of bone may
line up correctly (stable fracture) or be out of
alignment (displaced fracture). The skin around the
fracture may be intact (closed fracture) or the bone
may puncture the skin (open fracture)

61. Transverse fracture: In this type of fracture, the
break is a straight horizontal line going across the tibial
shaft.
Oblique fracture: This type of fracture has an
angled line across the shaft.
Spiral fracture: The fracture line encircles the shaft
like the stripes on a candy cane. This type of fracture is
caused by a twisting force.
Comminuted fracture: In this type of fracture, the
bone breaks into three or more pieces.
Open fracture: If a bone breaks in such a way that
bone fragments stick out through the skin or a wound
penetrates down to the broken bone.
Open fractures often involve much more damage to the
surrounding muscles, tendons, and ligaments. They have
a higher risk for complications especially infections and
take a longer time to heal.

62. External fixation. In this type of operation, metal pins or
screws are placed into the bone above and below the
fracture site. The pins and screws are attached to a bar
outside the skin. This device is a stabilizing frame that
holds the bones in the proper position so they can heal.
Complications from Surgery
•Infection
•Injury to nerves and blood vessels
•Blood clots (these may also occur without surgery)
•Malalignment or the inability to correctly position
the broken fragments
•Delayed union or nonunion (when the fracture
heals slower than usual or not at all)
•Angulation (with treatment by external fixation)
X-ray shows a fibula fracture (blue arrow) and a tibial
shaft fracture (red arrows) that extends into the ankle
joint. Both fractures have been treated with plates and
screws.

63. PELVIC FRACTURES
Pelvic Ring injuries
Acetabular fractures

64. Q1. What is Pelvic Ring

66. Pelvic Ring Injuries/fractures
Innominate bone and sacrum form a ring held together by weak symphyseal
joint anteriorly and strong sacroiliac and iliolumbar ligaments posteriorly
Break at one point accompanied by disruption at second point (except for
comminuted fractures due to direct blows or ring fractures in children
whose symphysis and SI joints are springy)

67. Anatomy
Shows proximity of
neurovascular structures to
pelvis
Vascular
common iliac system begins near L4 at bifurcation of
abdominal aorta
-external iliac artery courses anteriorly along pelvic brim
and emerges as the common femoral artery distal to the
inguinal ligament
-internal iliac artery dives posteriorly near SI joint and
divides in the posterior division (giving of superiior gluteal
artery) and anterior division (becoming obturator artery)
-corona mortis is a connection between the obturator and
and external iliac systems
mean distance of 6.2cm from the pubic symphysis
-venous plexus in posterior pelvis accounts for 90% of the
hemorrhage associated with pelvic ring injuries
Neurologic
Lumbosacral trunk crosses anterior sacral ala and SI joint
L5 nerve root exits below L5 TP a courses over sacral ala
2cm medial to SI joint

69. Mechanism of Injury
Anteroposterior compression
>Usually caused by frontal collision
btwn pedestrian and car
‘Open book’ injury: Pubic rami
fractured or innominate bones
sprung apart and externally rotated
w diastasis of symphysis
May have torn SI ligaments or
fracture of posterior part of ilium
Stability:
• Stable: Separation of < 2cm
• Unstable: Greater separation or
when CT scan shows displacement
at SI joint
Lateral compression
Usually due to side on impact or
fall from height
Side to side compression causes
pelvis ring to buckle and break
Anteriorly: Pubic rami on one or
both sides fractures
Posteriorly: Severe SI strain or
fracture of ilium or sacrum
If SI injury much displaced pelvis
is unstable
Vertical sheer
Usually when fall from
height onto one leg
Innominate bone on one
side is displaced vertically
fracturing pubic rami and
disrupting SI region on
same side
Usually severe and
unstable
Associated with gross
tearing of soft tissue and
retroperitoneal
hemorrhage

70. Signs and Symptoms
Stable injuries :Pain on trying to walk, Localised tenderness
Unstable injuries
Severely shocked
Great pain Unable to stand
Widespread tenderness and attempt to move ilium painful
Risk of visceral damage
Other possible signs/symptoms:
• Unable to pass urine
• Blood at external meatus – indicative of urethral damage,
hence cannot catheterize via urethra
• Partially anaesthetic leg due to sciatic nerve injury
Complications
o Urogenital damage (usually due to compression
fractures)
o Nerve injury: Sciatic nerve or lumbosacral plexus
o Persistent SI pain: May necessitate arthrodesis of
SI joint
o Massive bleeding

71. Young-Burgess Classification

72. INTERPRET

74. Tile Classification

75. Fractures of Acetabulum
Judet and Letournel Classification
Elementary
MOST COMMON

76. Associated Fractures

77. Interpret
Posterior wall and
anterior column

78. COMPLICATIONS OF ACETABULAR #

79. 1. Stabilize the pelvis: Exfix
2. Rule out intraabdominal injury
3. AFTER stable- IF (Close the book)

80. SPINE FRACTURES
Jefferson
Hangman
Burst
Chance

81. Jefferson Fractures
Jefferson fracture is the
eponymous name given to a
burst fracture of the atlas. It was
originally described as a four-
part fracture with double
fractures through the anterior
and posterior arches
Atlas Fractures & Transverse
Ligament Injuries are traumatic
injuries usually caused by high-
energy trauma with axial loading
in young patients (Jefferson
Fracture) or low-energy falls in
elderly Landells Atlas Fractures
Classification

82. lateral displacement of the lateral masses of C1 with respect to C2 meaning the bony ring of C1
must be disrupted (normally the lateral bony margins of C1 should not overhang C2). Lateral
views of the cervical spine (with a hard collar applied) demonstrate widening of the atlantodens
interval and a lucency (fracture) can also be seen traversing the posterior arch.

83. Hangman fracture (Traumatic Spondylolisthesis of
Axis)
Traumatic fracture of the bilateral pars
interarticularis of C2
Levine and Edwards
Classification

85. Burst Fractures-
Thoracolumbar Burst Fractures are a
common high-energy traumatic
vertebral fractures caused by flexion of
the spine that leads to a compression
force through the anterior and middle
column of the vertebrae leading to
retropulsion of bone into the spinal
canal and compression of the neural
elements.
burst fractures typically occur between
T10-L2 (thoracolumbar junction)

87. TLICS

88. Chance Fracture
traumatic fractures of the thoracic and lumbar spine that occur by a flexion-distraction injury mechanism (Seatbelt
injury and are associated with high rates of mechanical instability and gastrointestinal injuries.

89. THANK YOU