4. CAUSES
Sudden trauma
direct(fracture of the ulna caused by blow on the arm)
indirect(spiral fractures of the tibia and fibula due to
torsion of the leg, vertebral compression fractures,
avulsion fractures)
Stress or fatigue-repetitive stress(athletes,
dancers, army recruits)
Pathological(osteoporosis, Paget’s disease, bone
tumour)
16. FRACTURES DISPLACEMENT
After a complete fracture the fragments usually
displaced:
partly by the force of injury
partly by gravity
partly by the pull of muscles attached to them.
4 types:
Translation/Shift
Alignment/Angulation
Rotation/Twist
Altered length
19. Healing by callus
Callus is the response to movement at the fracture
site to stabilize the fragments as rapidly as
possible.
Steps:
Tissue destruction and haematoma formation.
Inflammation and cellular proliferation.
Callus formation: dead bone is mopped up & woven bone(immature)
appears in fracture callus.
Consolidation: woven bone(immature) is replaced by lamellar
bone(mature).
Remodelling:Newly formed bone is remodelled to resemble the
normal structure.
20.
21. Healing without callus
For fracture that is absolutely immobile:
impacted fracture in cancellous bone.
fracture rigidly immobilized by internal fixation
New bone formation occurs directly between fragments.
Gaps between the fracture surfaces are invaded by new
capillaries & bone forming cells growing in from edges.
For very narrow crevices(<200um), osteogenesis
produces lamellar bone(mature).
For wider gaps, osteogenesis begins with woven bone
(immature) first which is then remodelled to lamellar
bone (mature bone).
22. RATE OF REPAIR DEPENDS
UPON:
Type of
bone
cancello
us bone
heals
faster
than
cortical
bone.
Type of
fracture
spiral
fracture
heals
faster
than
transver
se
fracture.
State of
blood flow
poor
circulati
on will
slow the
healing
process.
Patient’s
general
constitutio
n
healthy
bone
heals
faster.
Patient’s
age
healing
is faster
in
children
than
adults.
25. First aid management
Airway, Breathing and Circulation
Splint the fracture
Look for other associated injuries
Check distal circulation – is distal circulation
satisfactory?
Check neurology – are the nerve intact?
AMPLE history- Allergies, Medications, Past
medical history, Last meal, Events
Radiographs – 2 views, 2sides, 2 joints, 2 times.
29. Reduce
Aim for adequate apposition and normal alignment
of the bone fragments
The greater contact surface area between
fragments, the more likely is healing to occur
30. However, there are some
situations in which reduction is
unnecessary:
When there is little or no displacement
When displacement does not matter (e.g. in some
fractures of the clavicle)
When reduction is unlikely to succeed (e.g. with
compression fracture of the vertebrae)
32. Closed Reduction
Suitable for
Minimally displaced fractures
Most fractures in children
Fractures that are likely to be stable after reduction
33. Most effective when the periosteum and muscles
on one side of fracture remain intact
Under anaesthesia and muscle relaxation, a
threefold manoeuvre applied:
Distal part of the limb is pulled in line of the bone
Disengaged, repositioned
Alignment is adjusted
34.
35. Mechanical Traction
Some fractures (example fracture of femoral shaft)
are difficult to reduce by manipulation because of
powerful muscle pull
However, they can be reduced by sustained
muscle mechanical traction; also serves to hold the
fracture until it starts to unite
36. Open Reduction
Operative reduction under direct vision
Indications:
When closed reduction fails
When there is a large articular fragment that needs
accurate positioning
For avulsion fractures in which the fragments are held
apart by muscle pull
When an operation is needed for associated injuries
When a fracture needs an internal fixation
41. Principle
Bony fragment may
be fixed with:
• screws,
• transfixing pins or nails,
• a metal plate held by
screws,
• a long intramedullary
nails,
• circumferential band,
• or a combination with
these method
42. Indication
1. Fracture that cannot be
reduced except by
operation
2. Fracture that are
inherently unstable and
prone to displacement
after reduction
3.Fracture that unite
poorly and slowly
• Principally fracture of the
femoral neck
4.Pathological fracture
• Bone disease may
prevent healing
5.Multiple fracture
• Where early fixation
reduced the risk of
general complication
6.Fracture in patient who
present severe nursing
difficulty
45. Exercise
Prevention of edema
active exercise and elevation
Active exercise also stimulates the circulation.
Prevents soft-tissue adhesion and promotes fracture
healing.
Preserve the joint movement
Restore muscle power
Functional activity
47. Open Fracture
First Aid & Management of the Whole
Patient
Prompt wound debridement
Antibiotic prophylaxis
Stabilization of the fracture
Definitive wound cover
48. First Aid & Management of the
Whole Patient
Airway
Breathing
Circulation
49. 1. Emergency Management of
Open Fracture
A,B,C
Splint the limb
Sterile cover - prevent contamination
Look for other associate injury
Check distal circulation – is distal circulation satisfactory?
Check neurology – are the nerve intact?
AMPLE history- Allergies, Medications, Past medical history,
Last meal, Events
Radiographs – 2 view, 2sides, 2 joints, 2 times.
Relieve pain
Tetanus prophylaxis
Antibiotics
Washout / Irrigation
Wound debridement
fracture stabilisation
49
50. Preoperative
Assessment
HISTORY
Age
General health & comorbidities
Alcohol & drugs
Ambulatory status
Cause of injury
• High or low energy
• Potential for infection
• Previous injuries
PHYSICAL
EXAMINATION
ATLS
Other injuries
Vascular status of limb
• Limb color, pulse, capillary refill
Neurological status of limb
• Power, sensation
51. Preoperative Assessment
EXAMINATION OF OPEN
WOUND
Location & extent of the wound
Length of wound
Number of skin wounds
Degree of skin contamination
RADIOLOGICAL
EXAMINATION
X-ray: AP, lateral
CT & MRI: open
pelvic, intra-
articular, carpal,
tarsal fractures
53. Aftercare
The limb is
elevated & it's
circulation
carefully
monitored
Antibiotic
cover
If the wound
has been left
open, it is
inspected
after 2-3 days
& covered
appropriately
Physiotherapy
and
rehabilitation
59. General 1: Shock
Why we need to treat
shock?
• Blood redistribution
• Renal shutdown
• Intestinal ischemia
• Tissue hypoxia
• Metabolic acidosis
• Reduced hepatic blood
flow
• Acute Respiratory
Distress Sydrome
• Altered consciousness
How to manage shock?
• Identify: Thirst, rapid
shallow breathing, the
lips and skin are pale and
the extremities feel cold,
impaired renal function
test and decreased
urinary output.
• ABC
• IV lines: fluids and blood
• Oxygenation/Ventilation
• Urinary Catheter
• Central Venous Pressure
• Ionotropic drugs
62. General 4: Crush Syndrome
[traumatic rhabdomyolitis]
Serious medical condition characterized by
major shock & renal failure following a
crushing injury to skeletal muscles or
tourniquet left too long
When
compression
released
Myohaemati
n release
from cells
Nephrotoxic
effects
Block
tubules
Oliguria,
uremia,
metabolic
acidosis
Bywaters’ Syndrome
63. General 4: Crush Syndrome
Clinically
• Shock
• Pulseless limb redness
swelling
• Loss of muscle sensation and
power
• Decrease renal secretion
• Uremia, acidosis
• Prognosis
• If renal secretion return
within 1 week the patient
survive
• But most of them die within
14 days
Management
• PREVENTION
• Strict tourniquet timing
• Amputation
• limb crushed severely
• tourniquet left on > 6 hrs
• above site of compression
& before compression
released
• Monitor intake & output
• Dialysis
• Correct electrolytes &
acidosis
• Antibiotics
64. General 5: Deep vein thrombosis
and pulmonary embolism.
Virchow’s triad factor Clot formation in
large vein thrombus breaks off Emboli
Site: leg, thigh and pelvic vein.
Risk factors:
Knee and hip
replacement
Elderly Immobility Malignancy
Cardiovascular
disease
Trauma
Hypercoagulab
le status
65. General 5: Management Deep vein
thrombosis and pulmonary embolism.
PREVENTION
Correct hypovolemia
Calf muscle exercise
Proper positioning
Well fitting bandages &
cast
Limb elevation
Graduated compression
stockings
Calf muscle stimulation
Anticoagulation
Ambulate patient
Established
thrombosis/embolism
Limb elevation
Heparinization
Thrombolysis
Oxygenation or
ventilation
66. General 6: Fat Embolism
Fat globules from marrow pushed into
circulation by the force of trauma that causing
embolic phenomena
Fractures
that most
often cause
FES
• Long
bones
• Ribs
• Tibia
• Pelvis
Closed/open
Fracture
Fat in bone
marrow
escape
Formation of
fat globules in
vessels
Fat embolus
Stick in
target organ
Triad of
symptoms
67. General 6: Fat Embolism
Triad of Symptoms
• Brain: mental
confusion
• Lung:
breathlessness,
ARDS
• Skin: Petechia
Management
• Prevent hypoxemia
• oxygenation or
ventilation
• Rule out head injury
• CT Scan of brain
• Monitor fluid &
electrolyte balance
• CVP, urinary
catheter
69. General 7: Gas Gangrene
Rapid and extensive necrosis of the muscle
accompanied by gas formation and systemic toxicity
due to clostridium perfringens infection
Clinical Features
• sudden onset of pain localized
to the infected area.
• swelling , edema
• +/- pyrexia
• profuse serous discharge with
sweetish and mousy odor .
• Gas production
Management
• early diagnosis .
• surgical intervention and
debridement are the mainstay
of treatment.
• IV antibiotics
• fluid replacement.
• hyperbaric Oxygen
70. General 7: Gas Gangrene
Prevention: ALL DEAD TISSUE [4C]
SHOULD BE COMPLETELY EXCISED,
71. General 8: Tetanus
A condition after clostridium tetani infection that
passes to anterior horn cells where it fixed and cant
be neutralized later produces hyper-excitability and
reflex muscle spasm
Clinical Features
• Tonic and clonic
contractions of esp. jaw,
face, around the wound
itself ,neck ,trunk, finally
spasm of the diaphragm
and intercostal muscles
leads to asphyxia and
death.
Management
• Prophylaxis
• Treatment
• Antitoxin & antibiotic
• Muscle relaxant
• Tracheal intubation
• Respiration control
73. Early 1: Visceral injury
Fractures around the trunk are
often complicated by visceral
injury.
E.g. Rib fractures
pneumothorax / spleen trauma /
liver injuries.
E.g. Pelvic injuries bladder or
urethral rupture / severe hematoma
in the retro-peritoneum .
Rx: Surgery of visceral injuries
74. Early 2: Vascular injury
Commonly associated with high-energy
open fractures. They are rare but well-
recognized.
Mechanism of injuries:
The artery may be cut or torn.
Compressed by the fragment of bone.
normal appearance, with intimal detachment
that lead to thrombus formation.
segment of artery may be in spasm.
It may cause
Transient diminution of blood flow
Profound ischaemia
Tissue death and gangrene
75. Early 2: Vascular injury
5P’s
of
ischemia
Pain
Pallor
Pulseless
Paralysis
Paraesthesia
X-ray: suggest high-risk fracture.
Angiogram should be performed to confirm diagnosis.
76. Early 2: Vascular injury
muscle ischaemic is
irrevesible after 6 hours.
Remove all bandages and
splint & assess circulation
Skeletal stabilization –
temporary external
fixation.
Definitive vascular repair.
Vessel sutured
endarterectomy
Vessel
Injury
subclavian
1st rib fracture
Axillary
Shoulder dislocation
Brachial
Humeral supracondylar
fracture
Brachial
Elbow dislocation
Presacral
and
internal
iliac
Pelvic fracture
Femoral
Femoral supracondylar
fracture
Popliteal
Knee dislocation
Popliteal
or its
branches
Proximal tibial fracture
77. Early 3: Compartment Syndrome
Leg
• 4 compartments:
anterior, lateral,
superficial and deep
posterior
• NOT interconnected
Forearm
• 3 compartments: dorsal,
superficial and deep
volar
• interconnected, hence
fasciotomy of 1
compartment may
decompress the other 2
A condition in which increase in pressure within a
closed fascial compartment leads to decreased
tissue perfusion.
Untreated, progresses to tissue ischaemia and
eventual necrosis
78. Early 4: Nerve Injury
It’s more common than
arterial injuries.
The most commonly injured
nerve is the radial nerve [in
its groove or in the lower third of
the upper arm especially in
oblique fracture of the humerus]
Common with humerus,
elbow and knee fractures
Most nerve injuries are due
to tension neuropraxia.
nerve
Injury
Axillary
1. Shoulder dislocation
Radial
2. Humeral shaft
fracture
Median
3. Lower end of radius
Radial or
median(ant.interosseo
us)
4. Humeral
supracondylar (esp.
children)
Ulnar
5. Medial condyle
Ulnar
6. Elbow dislocation
Sciatic
7. Hip dislocation
Peroneal
8. Knee dislocation
Peroneal
9. Fracture of fibular
neck
79. Early 4: Nerve Injury
Damaged by laceration, traction, pressure or
prolonged ischaemia
Neurapraxia
• axon remains
intact but
conduction
ceases due to
segmental
demyelination.
Spontaneous
recovery in a few
days or weeks
Axonotmesis
• axonal
separation with
degeneration of
distal portions.
Sheath remains
intact, thus
recovery likely
but delayed
Neurotmesis
• nerve
completely
divided.
Spontaneous
recovery
unlikely.
80. Early 4: Nerve Injury
Clinical features
Numbness and
weakness
Skin smooth and
shiny but feels dry
Muscle wasting and
weakness
Sensation blunted
Tinel’s sign +ve
Investigations
Electromyography
Nerve conduction study
May help to establish
level and severity of
lesion
81. Early 5: Haemarthrosis
Bleeding into a joint spaces.
Occurs if a joint is involved in the
fracture.
Presentation:
swollen tense joint; the patient
resists any attempt to moving it
treatment:
blood aspiration before dealing with
the fracture; to prevent the
development of synovial adhesions.
82. Early 6: INFECTION
Closed fractures – hardly ever
Open fractures – may become infected
Post traumatic wound – may lead to chronic
osteomyelitis
Clinical features
• wound is inflammed
• draining seropurulent
fluid
Treatment
• antibiotic
• excise the devitalised
tissue
• tissues opened &
drained the pus
84. Late 1: DELAYED UNION
Union of the upper limbs - 4-6 weeks
Union of the lower limbs - 8-12
weeks(rough guide)
Any prolong time taken is considered
delayed
85.
86. Late 2 : NON-UNION
In a minority of cases, delayed union--non-union
Factors contributing to non-union:-
inadequate treatment of delayed union
too large gap
interposition of soft tissues between the fragments
The growth has stopped and pain diminished- replaced
by fibrous tissue - pseudoarthrosis
Treatment :-
conservative / operative
atrophic non-union – fixation and grafting
hypertrophic non-union – rigid fixation
87. Late 2: NON UNION
bone ends are rounded off or exuberant
Hypertrophic non union
Bone ends are enlarged, osteogenesis is still active but
not capable of bridging the gap
‘elephant feet’ on X ray
Atrophic non union
Cessation of osteogenesis
No suggestion of new bone formation
90. CAUSES OF DELAYED UNION OR
NON-UNION OF THE FRACTURES
Distraction &
separation of the
fragments
Interposition of
soft tissues
between the
fragments.
Excessive
movement at the
fracture site
Poor local blood
supply
Severe damage to
soft tissues which
makes them
nearly/non-viable.
Infection
Abnormal bone.
91. Late 3: MALUNION
Factors:-
failure to reduce the fracture
failure to hold the reduction while healing proceed
gradual collapse of comminuted / osteoporotic bone
fragments that are joined in
an unsatisfactory position
93. Late 3: Mal-union
X-ray are essential to check the position of the
fracture while uniting. important- the first 3 weeks
so it can be easily corrected
Clinical features:
Deformity usually obvious , but sometimes the true
extent of malunion is apparent only on x-ray
Rotational deformity can be missed in the femur, tibia,
humerus or forearm unless is compared with it’s
opposite fellow
94. Late 4: AVASCULAR
NECROSIS
Certain region-known for their propensity to develop
ischaemia and bone necrosis
Head of femur
Proximal part of scaphoid
Lunate
Body of talus
(Actually this is an early complication however the
clinical and radiological effects are not seen until
weeks or even months)
No clinical feature of avascular necrosis but if there
is a failure to unite or bone collapse-pain
95. A B
The cardinal X-ray feature – increased bone density in the weight-
bearing part of the joint(new bone ingrowth in necrotic segment)
96. Late 5: OSTEOARTHRITIS
A fracture-joint may damage the articular cartilage
and give rise to post traumatic osteoarthritis within
a period of months.
Even if the cartilage heals, irregularity of the joint
surface may cause localized stress and so
predispose to secondary osteoarthritis years later
97.
98. Late 6: JOINT STIFFNESS
Commonly occur at the joints close to malunion or
bone loss eg: knee, elbow, shoulder
Causes of joint stiffness
haemarthrosis → lead to synovial adhesion
oedema and fibrosis
adhesion of the soft tissues
Worsen by prolong immobilization
Treatment
prevented with exercise
physiotherapy
