fracture description

1. General aspects of fractures
Berari B(MD)
March,2015

2. classification
• Fractures can be described, categorized, and presented in a number of
ways
• No one system of classification is all-encompassing
• Each fracture should be described and categorized by one of the terms

3. 1. Direction of fracture lines
 Transverse: runs perpendicular to the bone
 Oblique: similar to transverse in that there is no torsional appearance to
the fracture. The fracture line usually runs across the bone at an angle of
45 to 60 degrees
 Spiral: has a torsional component
 Comminuted: more than two fragments noted
 Impacted: one where the fractured ends are compressed together.
-usually very stable fractures

5. 2. Anatomic location
 proximal, middle, or distal thirds of a long bone
 Intraarticular-If the fracture extends into the joint space
 Extraarticular
 head, shaft, and base
 In pediatrics-in relation to the growth plate (physis)

6. 3. Alignment
-relationship of the axes of the fragments of a long bone
- described in degrees of angulation of the distal fragment in relation to the
proximal fragment

7. 4. Displacement
-describe movement of fracture fragments from their usual position in a
direction perpendicular to the long axes of the bone
-is described as a %age of the bone's width
-direction of displacement is described based on the movement of the distal
fragment in relation to the proximal fragment

9. 5. Associated soft-tissue injury
 Closed: A fracture in which the overlying skin remains intact.
 Open: occurs when a break in the skin and soft tissue directly communicates
with a fracture and its hematoma
 Complicated: A fracture that is associated with either neurovascular, visceral,
ligamentous, or muscular damage. Intraarticular fractures are also
complicated.
 Uncomplicated: A fracture that has only a minimal amount of soft-tissue
injury.

10. Open Fractures
• Gustilo and Anderson have classified open fractures
• Grade I -an open wound due to a low-energy injury
-wound is <1 cm in length and shows no evidence of contamination
- #s simple, transverse, or short oblique with minimal comminution.
-wounds are usu caused by a # fragment piercing the skin from the inside
• Grade II wounds -a moderate amount of soft-tissue injury.
- Some comminution of # & a moderate degree of contamination
-wound that is >1 cm
-No soft tissue is stripped from the bone

11. • Grade IIIA -a large wound (usually >10 cm).
- degree of contamination is high and amount of soft-tissue injury is severe
-there is adequate soft-tissue coverage of the bone.
-Comminution of the ass’ed # is usually present.
• Grade IIIB is a large wound (usually >10 cm) with periosteal stripping and exposed
bone
-degree of soft-tissue injury is such that reconstructive surgery is often necessary
to cover the wound
- Massive contamination and a severely comminuted fracture
• Grade IIIC= IIIB injury + arterial injury that requires repair for salvage of the
extremity

12. classn of Salter and Harris
• used to describe the nature of the epiphyseal injury
• Type I – a transverse fracture along the line of the physis;
growing zone is not usu injured
no growth disturbance
This fracture is common
• Type II – similar to type 1 but the fracture line deviates off into the metaphysis at one
end, producing a metaphyseal fragment;
seldom affects growth
This fracture is common
• Type III – passes along the physis and then deviates into the epiphysis (intra articular);
rarely results in significant deformity but can lead to joint incongruity
This fracture is not common

13. • Type IV – crosses the physis passing from the epiphysis into the metaphysis;
-interferes with growing layer of cartilage cells premature focal fusion of the physis ffd
by deformity.
-not common #
• Type V – a crush injury of the physis; ass’ed with growth disturbances at the physis.
-Dx difficult as radiograph may look normal
-premature closure of physis reveals dx
-rare fracture
• Type VI – rare injury ,injury to the perichondral structures by direct trauma,
e.g. heat or chemical

15. • Stability
• Stable fracture: A fracture that does not have a tendency to displace after
reduction.
• Unstable fracture: A fracture that tends to displace after reduction.

16. Mechanism of Injury
• two categories: direct and indirect
• Direct forces cause -transverse, oblique, or comminuted
e.g -nightstick fracture caused by a direct blow to the ulna
- crush injury
- high-velocity bullet
• Indirect forces -induce a fracture by transmitting energy to the fracture
site
e.g. Traction on a ligament attached to a bone »»an avulsion fracture
A rotational force applied along the long axis of a bone »»in a spiral #
A stress fracture- results from repeated indirect stress applied to a bone

17. Clinical Features
• Pain and tenderness - the most common presenting complaints
• Loss of normal function
• abnormal mobility and crepitation-When the fractured ends are in poor
apposition
• gross deformity
• Bleeding
-A patient with multiple fractures can experience shock from blood loss

18. Average Blood Loss with a Closed Fracture

19. Fracture Healing
• three phases—inflammatory, reparative, and remodeling
• inflammatory phase
 hematoma forms »»» clot
 Damage to the blood vessels of the bone»»» death of osteocytes
 With this necrotic tissue, an intense inflammatory response results,
accompanied by vasodilatation, edema formation, and the release of
inflammatory mediators
 PMNs, mфs, and osteoclasts migrate to the area to resorb the necrotic
tissue

20. reparative phase
 begins with the migration of mesenchymal cells from the periosteum
 Osteoblasts from the endosteal surface also form bone
 Granulation tissue invades from surrounding vessels and replaces the hematoma
 Most healing occurs around the capillary buds that invade the fracture site
 Healing with new bone formation -at the subperiosteal region
 Osteoblasts are responsible for collagen formation, followed by mineral deposition of calcium
hydroxyapatite crystals
 A callus forms

21. • remodeling phase
 healing fracture gains strength
 the bone organizes into trabeculae
 Osteoclastic activity is first seen resorbing poorly formed trabeculae
 New bone is then formed corresponding to the lines of force or stress.

23. Factors affecting healing
• Age-children experience a higher affinity for rapid bone remodeling
• Cortical bone heals at a slower rate than does the cancellous bone
• amount of contact between the bony ends (apposition and distraction)
• associated soft-tissue injuries
• Inadequate immoblization-significant movement

24. • Fractures through pathologic bone lesions
• presence of infection
• corticosteroids, excessive thyroid hormone, and nicotine from cigarette smoke
• Chronic hypoxia
• * Exercise
• .
• .
• .

25. PRINCIPLES OF FRACTURE MANAGEMENT
• aims of Rx are to restore function safely with minimal complications
• ATLS
• interventional management of # has two components: reduction and stabilisation
• each be achieved by a variety of methods

26. Reduction
• closed or open means
• moving or manipulating the fragments-by a closed technique
• Direct viewing of the fracture ends may be with the naked eye at open operation
or by using imaging or arthroscopy

27. Stabilisation(IMMOBLIZATION)
• when a fracture has been reduced it needs to be held or stabilised while healing progresses
• A fracture is immobilized for three reasons:
 to permit healing,
 to relieve pain by rest, and
 to stabilize an unstable fracture

28. Methods used for stabilising a fracture
Casting and splinting
 A cast is composed of plaster of Paris;either as a temporary or a definitive Rx
 at least one joint above and one joint below the fracture should be immobilized
 the extremity should be placed in the position of function
 Padding is provided to prevent pressure sores
 When a cast is applied soft-tissue swelling should subside.

29. A plaster slab/Splints
 plaster material is not circumferential
 the securing bandages circumferential
 more frequently used as the initial means of immobilization
 permit more motion and provide less stability for a reduced fracture

30. Advantages and disadvantages of casting and splinting

31. Traction
 pulling to change or hold the position of # fragments
 works b/c of the integrity of the surrounding soft tissues
 can be used both as a temporary and as a definitive Rx
 can be applied either using the skin (skin traction) or by direct coupling to
the bone with pins or wires (skeletal traction)

32. Advantages and disadvantages of traction

33. Plates and screws
 A screw is normally used to join two things together
 can be used to compress two bony fragments or a plate to the bone
 plate and screws may be used-radial and ulnar shaft #
 ORIF

35. Advantages and disadvantages of plate and screw fixation

36. Intramedullary nailing
 placing the stabilisation device inside the canal
 An IMN is usu made of steel or titanium
 may be solid, or hollow
 normally has transverse holes at either end; this allows locking of the nail to
the bone with further screws to control rotation and length
 Because standard nails are introduced at the ends of a bone they are not
suitable for the growing bone where they would transgress a growth plate
 allow for early mobilisation and a much earlier discharge from hospital

39. External fixation
 a mechanical construction to hold a fracture
 Each side of the fracture is coupled to the fixator and the major part of the device is external
to the skin
 Immediate environment of the fracture may be left intact with the frame bridging the zone of
injury
 commonly used as a temporary measure
 For a complex fracture this can provide safe stability while the condition of the soft tissue
improves /further imaging is obtained/patient’s general condition improves before other
definitive fixation

40. Specific indications for external fixators
• emergency stabilisation of a long bone fracture in the polytrauma pt
• stabilisation of a dislocated joint after reduction
• complex periarticular fractures – temporary stabilisation to
allow the soft tissues to settle before definitive fixation, e.g. a distal tibial (pilon) fracture
• fractures associated with infection
• treating fractures with a bone loss

41. Advantages and disadvantages of external fixation

43. Wires
 K-wire is a thin, flexible wire made of stainless steel
 Transfixing wires can be passed percutaneously to keep fracture fragments reduced
 They are cheap and often quick and simple to use
 Used extensively around the hand and wrist as definitive fixation
 at the patella and olecranon - ‘figure-of-eight’ tension band wire can provide reliable stability
 Cplxns -pin track infection, wire breakage,loss of fixation and migration of the wire

45. REHABILITATION
• adjacent joints should be mobilized as soon as possible
• Physical therapy should include active and active-assisted exercises for joint mobilization as
soon as soft-tissue healing permits
• Neurological deficits resulting in loss of active motion should be evaluated, and the
appropriate joints should be splinted in functional positions to avoid contractures
• Weight bearing should be limited, depending on the stability of fixation, the type of fixation
and its inherent fatigue life, and the systemic condition of the patient

46. REHABILITATION
• With intraarticular fractures, weight bearing is not allowed for 3 months, but early motion is
encouraged
• Range-of-motion and strengthening exercises should be monitored and directed by the
physician and physical therapist
• Vocational rehabilitation counseling should be initiated early to enable a productive return to
society

47. Physiotherapy
• Physiotherapists use a variety of techniques to prevent patients developing
complications, to relieve pain and to enhance physical activity
 Chest physiotherapy: deep-breathing exercises, coughing, chest percussion.
 Muscle exercise and re-education: active and passive exercises, stretching, joint
movements. Electrotherapy may be used to stimulate denervated muscles.
 Walking: teaching patients to stand and walk, initially with support
(physiotherapists, parallel bars, walker frames,crutches, stick) and then without
support, progressing to walking up stairs.

48.  Pain relief: both heat (superficial and deep) and cold are used to relieve pain.
Transcutaneous electrical nerve stimulation (TENS) is also commonly used in the
management of chronic pain.
-Massage may be combined with heat to reduce oedema and relax muscle tension.
 Ultraviolet therapy: some decubitus ulcers (pressure sores) respond favourably to
ultraviolet light.
 Hydrotherapy: helps to relieve pain, reduce muscle spasm and induce relaxation

49. Complications
1.Compartment Syndrome
 When an injury occurs to the muscles within a compartment, swelling ensues
 Because the tight fascial sheaths allow little room for expansion, the pressure within the
compartment begins to increase
 Eventually, blood flow is compromised and irreversible muscle injury follows
 ensuing muscle and nerve necrosis»»» Volkmann's ischemic contractures
 most common locations -forearm and leg

50. • ¾ ths of cases-develop after fracture(tibia, humeral shaft, forearm bones, and supracondylar
fractures in children)
• Other causes -crush injury, constrictive dressings/casts, seizures, intravenous infiltration,
snakebites, infection, prolonged immobilization, burns, acute arterial occlusion or injury, and
exertion

51. Clinical Features
• Dx-clinical
• pain out of proportion to the underlying injury, sensory symptoms, and muscle weakness
• *disproportionate pain is the earliest symptom, while pain with passive stretching of the
involved muscles is the most sensitive sign
• Diminished sensation – 2nd most sensitive examination finding
• Palpation -tenderness and "tenseness" over the ischemic segments
• Paresthesias or hypesthesias in nerves traversing the compartment are also important signs
• distal pulses and capillary filling may be entirely normal -should not be used to r/o
acompartment syndrome

52. Treatment
• immediate fasciotomy
• Delays may result in irreversible damage to muscles and nerves
• muscles can tolerate up to 4 hours of total ischemia. After 8 hours, damage is irreversible
• peripheral nerves survive for up to 4 hours of complete ischemia with only neurapraxic
damage, but after 8 hours axonotmesis and irreversible injury occurs
• Rhabdomyolysis may complicate compartment syndrome and adequate hydration to
maintain UOP is essential

53. Volkmann's Ischemic Contracture
• end result of an ischemic injury to the muscles and nerves of a limb secondary to untreated
compartment syndrome
• occur in 1% to 10% of cases of compartment syndrome
• A contracture is the result of selective ischemia of the muscles and nerves of the distal
segment of the limb (the arm below the elbow, or leg below the knee)
• Most distal tissues, such as the hand and foot, do not become ischemic, however, they are
not immune to injury due to more proximal nerve damage

54. Fat Embolism Syndrome
• Fat embolism occurs in almost all pts who sustain a pelvic or long bone fracture
• majority of pts remain axic
• FES-develops in 0.5% to 3% of pts
• MR-as high as 20% in severe cases
• FES-triads- pulmonary distress, mental status changes, and a petechial rash that develops
from 6 to 72 hours after injury
• incidence increases in young adults with multiple injuries
• rarely occurs in children or patients with upper extremity fractures

55. etiology of FES
• Many theories
• ? Following a fracture, intramedullary fat is released into the venous circulation. These fat
globules subsequently embolize to end organs such as the lungs, brain, and skin
• ? fat emboli cause an inflammatory cascade that damages end-organ tissues
fat emboli are metabolized to free fatty acids that, when present in high concentrations,
induce an inflammatory reaction that damages end organs

56. Clinical Manifestations
• 25% of pts will develop sxs in the first 12 hrs and
• 75% will have sxs by 36 hrs
• Major Criteria
Respiratory insufficiency
Altered mental status
Petechial rash
• Minor Criteria
Fever
Tachycardia
Retinal changes
Jaundice
Renal insufficiency
Anemia
Thrombocytopenia
Elevated ESR
• To make Dx of FES-one major plus three minor criteria or two major and two minor criteria

57. Treatment
• cornerstone of Rx is prevention and early detection
• Early resuscitation, stabilization, and operative treatment -decreased the incidence of FES
• Immobilization with no excessive motion permitted & open reduction with internal fixation
within 24 to 48 hrs of injury will prevent embolism
• respiratory rate and pulse oximetry should be monitored
• Rx with supplemental oxygen
• Respiratory support with oxygen is employed to keep the PaO2 above 70 mm Hg

58. Late bone complications
• Delayed union and non-union
• Malunion
• Growth arrest

59. References:

60. THANKS