basic principle of fracture well explained by residents

1. Basic principles of fracture &
dislocation management
By Dr Olifan G(OSR-I)
Moderator Dr Bruh k (consultant
orthopaedic surgeon)

2. Learning Objectives
• Define fracture
• diagnose fracture
• classify fracture
• manage a patient with fracture
• Principle of dislocation mgt

3. Introduction
• Definition : it is a break in the structural
continuity of a bone
• Classification :
- Based on cause – traumatic , pathological or stress
- Based on pattern
- Clinically- closed vs open
• When describing a fracture anatomical site ,
configuration of displacement , articular
involvement and pattern of fracture should not
be forgotten

4. • E.g middle third
displaced humeral shaft
fracture

5. Tscherne Classification of closed
fractures(Oestern and Tscherne, 1984)
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Grade 0 – a simple fracture with little or no soft tissue
injury.
Grade 1 – a fracture with superficial abrasion or
bruising of the skin and subcutaneous tissue.
Grade 2 – a more severe fracture with deep soft tissue
contusion and swelling.
Grade 3 – a fracture with marked soft-tissue damage and a
threatened compartment syndrome.

6. Diagnosis
• History – mechanism of trauma
- Pain
- Loss of function
- Associated injuries
• Physical examination –
– ABC of life
– Look , feel , move and measure
• Investigation – x ray is the routine imaging
modality used
-Remember Rule of 2

7. treatment of fracture
• General treatment –
stabilizing the patient
– Airway
– Breathing and
oxygenation
– Circulation and control
of bleeding
– Pain control with
splinting and analgesics

8. Definitive management principles
1. Reduction
2. Maintenance of reduction
3. Rehabilitation

9. Reduction
• Restoration of fracture fragment to acceptable
position
• Its Aim is - to restore length
-to restore alignment and rotation
- to restore perfect joint surface in articular #
• Two methods
Conservative (closed)
 Closed reduction by manipulation
» Under anaesthesia & muscle relaxant
 Continuous traction
» Skin traction
» Skeletal traction
» Gravity
Open reduction (operative)
 Under direct vision

10. Traction– used for fractures
around a strong muscular
counter force
• Can be applied with the
following methods
 A) Traction by gravity –
usually in the upper limb
 B)Skin traction – weight is
attached to the skin to
indirectly put a pulling force
on the bone

11. • Limited force can be applied - generally not to
exceed 4-5 Kg
• Usually indicated for children with femoral
fracture
• Complications include skin sloughing , nuro
vascular compression and compartment
syndrome
• Contra-indications-

12. C)Skeletal traction
 A pin or stiff wire is inserted to a
bone
 More powerful with greater
control than skin traction
 Permits pull up to 20% of body
weight for the lower extremity
 Requires local anesthesia for pin
insertion

13. Complications of skeletal traction
Pressure ulcer
Pin tract infection
Damage growth plate
Neurovascular injury
Distraction
Re displacement
Scar on the skin

14. 2.Maintenance of reduction
- The aim is to keep the fracture
fragment in the acceptable
position
- The Method are
1. Cast splintage
2. Continuous traction
3. Internal fixation
4. External fixation

15. 1. Cast splint
- POP (plaster of Paris) is hemi-hydrated calcium sulphate
widely used around the world
- Can be applied as a slab or full cast
Indication
As a splint for first aid Rx of #
To hold # as definitive Rx
Correct deformity
Prevent pathological #

16. Complication of cast
1. compartment syndrome
2. Joint stiffness
3. Redisplacement
4. Pressure sore
5. osteoporosis

17. 2. Continuous traction
• Traction is able to exert
continuous pull in long axis
of the bone
• It can be
– Fixed
– Balanced
– Combined

18. 3. Internal fixation
• Involves fixing bone fragments with plates ,
screws , intra medullary nails or wires
• It enables early movement
• Indications
1. Fracture that needs operative reduction
2. Unstable fractures prone to re displacement
3. Slowly uniting fractures
4. Pathological fractures
5. Multiple fractures
6. Fractures in patients who present nursing
difficulty

19. Types of internal fixation
• Interfragmentary
screws
• Wires
• Plates and screws
• Intramedullary nails
•

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21. Complications of internal fixation
• Infection
• Non union
• Implant failure
• Re fracture

22. 4. External fixation
• Done by attaching a tensioned
wire or screw above and
below a fracture with a frame
• Indications
1. Fractures associated with
severe soft tissue damage or
contamination
2. Fractures around a joint with
swelling hindering internal
fixation
3. Patients with severe multiple
injuries
4. Un united fractures which may
need excision
5. Infected fractures

23. complications
• Pin site infection
• Over distraction
• Soft tissue damage

24. Rehabilitation
• Aims at restoring normal function
• The methods are
 elevation
 active mov’t
 Assisted mov’t(continuous passive motion by
machines),
 Functional activity

25. Open fracture management
• Definition - A break in the skin
and soft tissues communicating
with a fracture or its hematoma
• Classifying the fracture is
essential to adequately manage
the fracture
• Gustello Anderson classification is
commonly used to guide management

26. • Type 1 – 1 cm or less
laceration , clean with
minimal soft tissue damage
. Low energy trauma

27. • Type 2 – 1-10cm skin
laceration , not much
soft tissue damage and
moderate comminution
. Low to moderate
energy trauma

28. • Type 3a – large
laceration , extensive
soft tissue damage to
underlying tissue . High
energy trauma

29. • Type 3b – fracture cover
not possible with out
flap

30. • Type 3c – associated
arterial injury that
needs repair

31. Treatment
• Treat life threatening cxn
• Antibiotic prophylaxis
• Tetanus prophylaxis
• Urgent wound and fracture debridement with
irrigation
• Stabilization of the fracture
• Early definitive wound cover

32. Complications of fracture
 General/Systemic complication
 Shock, fat embolism, tetanus
 Local complication
Early comp.
• Compartment syndrome
• Neurovascular injury
• Infection
Late comp.
• Delayed union
• Mal-union
• Non-union
• Joint stiffness

33. JOINT DISLOCATIONS
• A dislocation is a separation of two bones where
they meet at a joint.
• Dislocations may be associated with a periarticular
fracture
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34. Causes
• Dislocations are usually caused by a sudden impact
to the joint. This usually occurs following a blow, fall,
or other trauma
Symptoms
• Pain
• Swelling
• Difficulty moving the joint
• Numbness and paresthesia
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35. Signs
• Visibly out-of-place, discolored, or misshapen joint
• Limited joint movement
• Swollen or bruised
• Intensely painful,
• Decreased sensation distal to the joint
• Decreased pulse, cool extremity distal to the joint
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36. Imaging
• Two planes at 90 degrees
to each other
• Good quality
• See the entire joint
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37. • What abnormalities are seen in the radiograph?
• What is your most likely diagnosis?
• What is your next step in therapy?
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38. Treatment Principles
• Reduce the dislocation as soon as possible(under GA)
• Check Neurovascular function distally
• Take post reduction radiograph
• Immobilize the joint
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39. Reference
• Apley`s system of orthopedics and
fractures; 10th Ed
• Handbook of Fractures; 6th Ed
• Rockwood and Green's; Fractures 7th Ed