4. A. By quality of bone in relation
to load( Fractures occur when the load to which
they are subjected exceeds their intrinsic strength)
FRACTURE TYPE BONE STRENGTH LOAD
5. Traumatic fracture of 2nd lumbar vertebra and
vertebral luxation at the site of injury
6.
7. Greenstick fracture :-
It a type of simple
fracture in which only one
side of the bone is broken
while the opposite side bent.
Occurs in children .
It resembles the breaking of
a green tree branch, hence
the name.
8. B. By Direction of force
1) Compression
fracture :-
If the load applied along the
length of a bone exceeds that of
its strength then it may collapse
into itself .
Common in elderly if bones are
osteoporotic and so are less able
to resist a heavy load .
The bone will be shortened and may
also be angulated.
9. 2) Avulsion or
distraction fracture
Here the two fragments of
bone are pulled apart.
It occurs when a tendon is
torn of it attachment to
bone and take a fragment of
bone with it.
Common where strong
muscles insert into small
bones.
e.g patella ( quadriceps ms.) ,
10.
11. 3) Spiral fractures :-
If a long bone is twisted
along its axis a spiral
fracture may result.
the tibia is particularly
susceptible to spiral fracture
when the foot is firmly fixed
to ground and player’s body
continues to twist.
12. 4) Transverse
fracture :-
If a long bone is bent
along its long axis then a
transverse fracture may
result.
13. 5) Butterfly
fracture :-
If a bone is struck a direct blow,
it is common for a more complex
fracture to result where two
break lines spread out obliquely
from point of contact of the
blow, producing a free- floating ‘
Butterfly’ fragment between the
two fracture.
14. 6) Comminuted
fracture :-
Occur when a large amount
of energy is dissipated into a
bone.
bone breaks into fragments
which may impact into each
other or separate and become
displaced.
15.
16. C. By anatomical site :-
Epiphyseal fracture
Articular fracture ( fracture into joint)
17. Salter Harris classification of
epiphyseal fractures :-
Grade 1 :-
In this case there is small crack along the metaphyseal side
of epiphyseal plate.
this side is made up of dying chondrocytes and ossifying
cartilage.
does not affect the blood supply to the epiphyseal plate nor
does it affect the anatomy of the germinal layer
Heals quickly
18.
19. Grade 2
Here the fracture line travels along the metaphyseal side
of the plate but, before reaching the far cortex it breaks
out and tracks down into metaphysis.
most common.
good prognosis.
one of the greatest risk in a grade 2 fracture is causing
growth rest by damaging the growth plate while reducing
the fracture especially if this is attempted after a few days
when the fracture may already be uniting .
20.
21. Grade 3
Fracture line does not run along the epiphyseal plate at
all .
it crosses from the metaphysis to epiphysis.
bony union may occur across the epiphyseal plate and
block further growth
causing most disfiguring progressing deformity of the limb
if it is not promptly released.
the key to management of this type of fracture is
anatomical reduction if it is displaced,
fracture is rare.
22.
23. Grade 4
Fracture line travels along the distal side of the growth
plate.
it affects both the blood supply and the anatomical
integrity of the germinal cells .
the fracture line does not travel the whole length of the
epiphyseal plate but deviates off into the epiphysis itself
and out on the articular surface
Poor prognosis.
The key to successful of this type of fracture is anatomical
reduction.
performed by open surgery
24.
25. Grade 5
This is rare and difficult fracture to diagnose.
The injury is severe crush of the epiphyseal plate.
The x-ray may only look abnormal in retrospect,
and this is indeed how this type of fracture is
usually diagnosed.
The result of complete disruption of the growth
plate is complete growth arrest .
26.
27. Open fractures
At the time of the fracture
soft tissues over the bone
will also b damaged.
If the skin is broken there
is a high probability that at
some time during the
accident the fracturing bone
came in to contact with the
outside world and
contaminated with bacteria.
28.
29. D. By management
1) Stable fractures :- are those which are unlikely to move
further .
2) unstable fracture:- are those which will continue to
displace if the action is not taken to hold the fracture secure.
there is gradation of stability which depends upon the
following factors –
SITE :- Fractures in weight bearing bones are more likely to be
displaced by normal loads than those in bone which can easily be
protected from load such as the long bones of the arm.
30. SHAPE ;- Spiral fractures tend to be unstable, while
impacted fractures tend to be very stable. The more
displaced the fracture, the more unstable it is likely to be.
DISPLACEMENT :- Undisplaced fractures may have
the periosteum intact and are therefore stable. The more
displaced the fracture, the more unstable it is likely to be.
BEHAVIOUR OF THE PATIENT :- patient who are
prepared to be carefull can maintain the position of a
fracture which would become displaced in a young hard-
drinking male, who is not prepared to take any advice.
31. E. international classification
In this classification simple alpha numeric code are given
in which first no. relates to the bone
second no. relates to the position of fracture on the bone.
position no is followed by a letter which defines the severity
of fracture
This letter is followed by a further no. which classifies the
fracture still further
33. Second no.(positon of fracture)
1 = Proximal
2 = Mid-shaft
3 = Distal
4 = Malleolar (ankle only)
34. Third alphabet(Severity of
fracture
A = extra articular
B = partial articular
C = comminuted or complex
Eg. – 42C?????????????????????
Complex fracture mid-shaft of tibia
35.
36. GENERAL MANAGEMENT.
ABCD
Maintain airway
Breathing
Circulation
Disability
SPECIFIC MANAGEMENT
Reduction
Holding a fracture
Rehabilitation
37. REDUCTION
Reducing a fracture means trying to return the bones
to as near to their original position as possible
Types :- open
Closed
.
Open :- In this case fracture is exposed surgically so that the fragments
can b reduced under direct vision
Closed :- If a fracture is reduced closed, then the accuracy
Of the reduction can only be checked on an X-ray
Advantage - The soft tissue and blood supply should not be
disrupted any further than occur at the time of trauma
38. Principles of closed reduction :-
Relies on the attachments of the bone to soft tissues (
i.e. periosteum and/or ligament) to obtain and to hold
reduction.
PAIN RELIEF :- patient need to be free of pain when
reducing fractures , so a general anaesthetic will be
required if a regional block is not possible .
VALUE OF PERIOSTEUM:-
when the bone fracture periosteum remains largely intact, especially
on the concave side of fracture. This strong membrane is not
visible on X-ray. So its value may not always be fully appreciated .
39. Cont……
Impacted fractures which are also partially displaced will need
disimpacting before the displacement can be corrected .
Disimpaction is carried out by steady distraction to fracture until you feel
the bone ends separate .
force applied should not be more than 4 or 5 kg as otherwise there is
danger of degloving the limb( pulling of the skin and soft tissue)
Traction should be continued for couple of minutes to drive out edema out
of the tissue around the fracture. This will allow the soft tissues to extend
to their normal length and make the reduction easier.
40. ENGAGING THE BONE ENDS:-
This is done by angulating the fracture even further than before
and sliding the fractured end of the distal fragment up the
cortex of the proximal fragment until it slips over the broken
edge of the proximal fragment.
when the fracture come to anatomical alignment, the intact
periosteum on what was the concave side will become tight and
prevent over correction of the fracture.
41. 2) OPEN REDUCTION OF FRACTURE:-
exposure of s fracture should allow a adequate access to see as
much of the fracture as necessary while minimizing damage to
the soft tissue.
It should also minimize the damage to the periosteum, which
will be providing the bulk of blood supply to the broken bone
fragments if that blood supply is lost the fracture cannot be
unite.
if there is skin & soft tissue loss then incision
should be planned with a plastic surgeon to ensure that skin
and soft tissue cover of the bone and fixation can be
obtained at the end of operation.
42.
43. Holding of fracture :-
once the fracture has been reduced it need to be held until it
has united ( the bone ends have joined together)
PRINCIPLES OF HOLDING FRACTURE:-
Two main ways – rigid fixation
non- rigid fixation
44. RIGID FIXATION:- block the normal callus formation of the
bone healing.
in this fixation thee is no movement at fracture site.
remodeling of the bone takes about a year in rigid fixation
NON- RIGID FIXATION:- such as P.O.P(plaster of
paris)
It allows limited movement and the loading of the fracture site
the aim is to allow movement and load to stimulate callus
formation without allowing the fracture to redisplaced .
45. REHABIILITATION :-
once fracture is stabilized , patient may needs help
with rehabilitation so that they return to as full
and as independent a life as possible.
46. FIXATION
The basic goal of fracture fixation is to stabilize the
fractured bone, to enable fast healing of the injured
bone.
2 types – External fixation
Internal fixation
External fixation :- Those where the mechanical
strength of the construct is outside the skin are
defined as external fixation.
47.
48. Internal fixation :-
Implants which are fitted directly on to or put
down the inside of the bone and are then
covered with soft tissues and skin are
classified as internal fixation.
Types :- Screws
Plates
Wires
Nails
51. PATHOPHYSIOLOGY OF FRACTURE
HEALING
BONE BREAKS
Disruption of periosteum, trabaculae bone , blood vessels which run in the
periosteum and medulla
Haemorrhage and immediate release of cytokines
Signals to cell locally that damage has occurred
52. Cytokines attract macrophages
Cleaning up process start
Cytokines than attract undifferentiated stem cells which migrate in from endosteum &
periosteum.
Stem cells start differentating into fibroblast & bone forming cells
Haematoma arround the fracture invaded in small capillaries
Microphages remove the haemotoma itself
53. C.T tissue is laid down & slowly organises
Oraganised C.T appear first as a collar arising from the periosteum close to the end of each broken
bone
Collars grow towards the collar on the other bone
Eventually , spurs of callus meat and bridge the fracture site
They become increasingly thick & strong fibrocartilage stabilises the fracture
Now it is no longer possible to translate the fracture
54. In the fracture cleft itself , osteoclast continue to resorb haematoma
Osteoclast then eat away other dead tissue & broken bone ends
Now callus of fibrous cartilage arround the fracture cleft becomes calcified &
then ossified (so that it visible on X-ray)
Ossification starts at the bone end but in the centre of the fracture cleft,where
O2 levels may be very low , cartilage may be laid down intially rather than bone
This cartilage is then replaced by bone (endochonral ossification)
55.
56. Clinical union:- when the fracture can no longer be
angulated with normal loads , and it is not painful to try , fracture
is said to be clinically united.
Radiological union:- On X-ray, when the strands of
ossified callus can be seen to be stretching continuously from one
bone end to another, fracture is said to be radiologically united
Consolidation :- Finally , the callus forms a fat cuff of a
woven bone from one bone end to the other this callus is as
strong as the bone around it .because biomechanically it has
widened the diameter of the tube and this confers extra strength
.This is called as consolidation.
57. Over the next months the
woven bone is replaced by
haversian cortical bone
which remodels over the
following years .
