Fractures can be classified in several ways, including by their relationship to the environment (closed vs open), their displacement (translation, angulation, shortening), fracture pattern (transverse, oblique, etc.), and etiology (traumatic vs pathological). Compound fractures involve a break in the overlying skin. Gustilo-Anderson classification grades open fractures based on soft tissue damage. Fracture healing occurs in stages, from hematoma formation and inflammation to callus formation and remodeling. Management includes first aid, closed or open reduction, and immobilization techniques like internal/external fixation, traction, splinting, and casting to align fragments and promote healing. Complications can be early like fat embolism or

1. FRACTURES
Classification of Fractures
&
Management of Compound Fractures
DR. MEHREEN SATTAR
PGR ORTHO UNIT III

2. DEFINATION:
“ BREAK IN THE CONTINUITY OF BONE”.
BREAK DOWN OF BONE IN TWO OR MORE THEN
TWO PARTS.
RESULTS FROM :1} INJURY
2} REPETITIVE STRESS
3} ABNORMAL WEAKNESS

3. CLASSIFICATION:
Based on Relationship with the
Environment
Based on Displacement
Based on Fracture Pattern
Based on Etiology

4. Classification Based on Relationship
with Environment:
1. CLOSED {SIMPLE}
2. OPEN {COMPOUND}

5. OPEN FRACTURES:
A fracture with break in the
overlying skin and soft tissues
,leading to the fracture
communicating with the ext.
environment

6. Gustilo and Anderson open fracture classification:
 The Gustillo classification is used to classify open fractures.
 Three grades that try to quantify the amount of soft tissue damage associated with
the fracture
I A low energy open fracture with a wound less than 1 cm long and clean
II An open fracture with a laceration more than 1 cm long
without extensive soft tissue damage, flaps or avulsion
III Characterised by high energy injury irrespective of the size
of the wound. Extensive damage to soft tissues, including muscles, skin, and
neurovascular structures, and a high degree of contamination. Multifragmentary and
unstable fractures

7. GRADE 3A
LIMITED STRIPPING OF PERIOSTEUM AND
SOFT TISSUE FROM BONE.
ADEQUATE SOFT TISSUE COVERAGE FOR
BONE, TENDONS AND NEUROVASCULAR
BUNDLE AFTER STABILIZATION.

8. Type 3B
 Extensive stripping of soft tissue
and periosteum from bone.
 Requires a local flap or free tissue
transfer
Type 3C
 A major vascular injury requiring
repair

10. Muller’s Classification:
EACH LONG BONE HAS 3 SEGMENTS
Proximal, Diaphyseal and Distal
DIAPHYSEAL FRACTURES:
Simple
Wedge
Complex
PROXIMAL & DISTAL
Extra-Articular
Partial Articular
Complete Articular

11. AO International classification
It uses an alphanumeric code:
a) First digit specifies the bone
1 = humerus 2= radius/ulna
3 =femur 4 =tibia/fibula
b)Second num relates the
segment:
1= proximal 2=diaphyseal
3= distil 4= malleolar
C) a letter specifies the fracture
pattern:
For diaphysis
A = simple B= wedge
C= complex
For metaphysis
A = extra articular B= partial
articular
C= complete articular

12. Classification: Based on Displacement:
1. UNDISPLACED
2. DISPLACED

13. Displacement - Translation
Translation is sideways motion of the
fracture - usually described as a
percentage of movement when
compared to the diameter of the bone -
- ----------direction of distal fragment
decides

14. Displacement - Angulation
Angulation is the amount of bend at a
fracture described in degrees.
Described with respect to the apex of
the angle .

15. Displacement – Shortening:
Shortening is the amount a fracture
is collapsed/ shifted proximally,
expressed in centimeters.

16. Classification: Based on Pattern
1. Transverse
2. Oblique
3. Spiral
4. Comminuted
5. Segmental
6. Stellate

17. Transverse Fracture
A fracture in
which the line is
perpendicular to
the long axis of the
bone
Oblique Fracture
A fracture in
which the # line is
at oblique angle
to the long axis of
the bone.
Spiral Fracture
A severe form of oblique
fracture in which the #
plane rotates along the long
axis of the bone. These #s
occur secondary to
rotational force.

18. Comminuted
Fracture :
The bone is
broken into many
fragments.
Stellate Fracture:
This # occurs in the
flat bones of the skull
and in the patella,
where the fracture
lines run in various
directions from one
point.
Impacted Fracture:
This # where a vertical
force drives the distal
fragment of the
fracture into the
proximal fragment.

19. Depressed Fracture:
This # occurs in the
skull where a
segment of bone
gets depressed into
the cranium.
Avulsion Fracture:
A chip of bone is avulsed by the sudden and
unexpected contraction of a powerful muscle
from its point of insertion,
Examples
1. ASIS Avulsion
2. JONE’S 5th MT base Avulsion

20. Incomplete fracture
The bone is incompletely divided and the periosteum remains in continuity
Greenstick fracture : bone is buckled or bent
 Mainly seen in children, because of their springy bones
 Plastically deformed bones
Compressed fracture: crumpled cancellous bone
 Seen in adults, mainly in vertebral bodies, calcaneum and tibial plateu

21. Classification: Based on Etiology
1. TRAUMATIC
2. PATHOLOGICAL
 Tumors
 Bone cysts
 Osteomyelitis
 Osteoporosis
 Osteogenesis imperfecta
 Rickets

22. Salter-Harris Classification
Only used for pediatric fractures that involve the growth plate (physis)

23. Type I fracture is
when there is a
fracture across the
physis with no
metaphysial or
epiphysial injury
Type III fracture is
when there is a
fracture across the
physis which
extends into the
epiphysis
Type II fracture is
when there is a
fracture across the
physis which extends
into the metaphysis

24. Type IV fracture is
when there is a
fracture through
metaphysis, physis,
and epiphysis
Type V fracture is when
there is a crush injury
to the physis
Type VI fracture is rare
injury consisting of injury
to perichondral structures
by direct trauma e.g. heat
or chemical.

25. BONE HEALING:
PRIMARY FRACTURE HEALING
refers to fractures treated operatively without
callus formation
SECONDARY FRACTURE HEALING
refers to (a) fractures treated non-operatively,
with the formation of callus and no disturbance
of hematoma; (b) fractures operated without
disturbance of hematoma

26. FACTORS AFFECTING BONE HEALING:
(A) Age: Fractures unite faster in children
(B) Type of bone: Faster union in flat and cancellous bone
(C) Pattern of fracture: Spiral # > oblique # > transverse # > comminuted #
(D) Disturbed pathoanatomy: soft tissue interposition and ischaemic # prevent faster healing
(E)Type of reduction: good apposition of
fracture results in faster healing
(F)Immobilisation: depends on the fracture site
eg. Fracture ribs and scapula do not require
immobilisation
(G)Open fractures: often go into delayed union
and non-union
(H)Compression of fracture site: enhances
union(cancellous bone) and primary bone
healing(cortical bone)

27. HEALING BY CALLUS:
STAGE 1: TISSUE DESTRUCTION AND HEMATOMA
FORMATION
- lasts for 7 days
- blood leaks out of torn vessels and forms a
hematoma between and around fracture
- periosteum and local soft tissues are stripped off
- ischaemic necrosis – death of some osteocytes with
sensitization of the remaining precursor cells

28.  STAGE 2: INFLAMMATION AND CELLULAR
PROLIFERATION/GRANULATION TISSUE:
-lasts for 2-3 weeks
- precursor cells form cells that differentiate and
organize to provide vessels, fibroblasts, osteoblasts etc
- soft granulation tissue formed between
fracture fragments, providing anchorage to fracture
- hematoma is slowly absorbed and fine new
capillaries grow into the area

29. STAGE 3: CALLUS FORMATION
- lasts for 4-12 weeks
- granulation tissue differentiates and creates
osteoblasts, laying down intercellular matrix
impregnated with calcium salts
- formation of callus/woven bone
- provides good strength to the fracture,
decreasing the movements at the fracture
site and causes union in about 4 weeks

30.  STAGE 4: REMODELLING
- takes 1-4 years for the bone to become
strong enough to carry weight
- with continuing osteoclastic and osteoblastic
activities, the woven bone gets transformed into lamellar
bone
- osteoblasts fill in the remaining gap between the new
bone and the fragments to strengthen the bone

31.  STAGE 5: MODELLING
- stage where the bone is gradually
strengthened
- shapening of the cortices occurs at the
endosteal and periosteal surfaces
- all these occur when the person starts
resuming his activities ie bearing weight and muscle
forces
- thicker lamellae are laid down where high
stresses are present, unwanted buttresses are
carved away and medullary cavity is reformed

32. Clinical manifestations
pain
loss of function
deformity
shortening
crepitus
swelling and discoloration

33. MANAGEMENT
FIRST AID TREATMENT

34. MEDICAL /SURGICAL
MANAGEMENT OF FRACTURES:
1. Reduction
Reduction of a fracture (“setting” the bone) refers to restoration of
the fracture fragments to anatomic alignment and rotation.
It’s a surgical approach, the fracture fragments are reduced.
External/Internal fixation devices (metallic pins, wires, screws, plates,
nails, or rods) may be used to hold the bone fragments in
position until solid bone healing occurs.

35. INTERNAL FIXATION :

36. External fixation :
 “External Fixator is a device uses for stabilization and
immobilization of long bone open fractures.
Types
Type -1 Unilateral Uniplanar
Type -2 Uniplanar Bilateral.
Type -3 ◦ Classical Bilateral Biplanar.
◦ Delta Unilateral Biplanar
According to Planes:
◦ Planner: Hoffman’s, orthofix etc.
◦ Circular: Ilizarov

37. External
fixation :

38. Difference between internal or
external fixation

39. Closed reduction :
 closed reduction is accomplished by bringing the bone fragments
into apposition (ie, placing the ends in contact) through
manipulation and manual traction.
 Extremity is held in the desired position while the physician applies a
cast, splint, or other device.
 X - rays are obtained to verify that the bone fragments are correctly
aligned.
 Traction (skin or skeletal) may be used to effect fracture reduction
and immobilization.

40.  Traction
Traction is the use of weights, ropes and pulleys to apply
force to tissues surrounding a broken bone.

41. Traction:
1. Skin traction-
 Bucks traction used for knee,hip bone fracture
 Weight usually 5-7 pounds attach to skin
2. Skeletal traction –
 Needs invasive procedure
 Weight is upto 10 kg attached to bone

42. Splinting:
 Splinting is the most common procedure for immobilizing an injury.
 The splint should go beyond the joints above and below the fractured or
dislocated bone to prevent these from moving

43. Complication of fracture :
Early complications
 Shock
 fat embolism
 compartment syndrome
 deep vein thrombosis
 disseminated intravascular coagulopathy
 Infection
Delayed complications
 delayed union and nonunion
 avascular necrosis of bone
 reaction to internal fixation devices

44. COMPLICATIONS

45. Compartment Syndrome
 Occurs with fracture of elbow, forearm bones, proximal third of
tibia, hands or foot ;
 Crush injuries and circumferential burns
 Increase of pressure within the osseofascial compartment
 Due to bleeding , oedema or inflammation

46.  Confirmation of diagnosis:
 Measuring the intracompartmental pressures
Introduced a split catheter into the compartment
Pressure measured close to level of the fracture
Differential pressure (difference between the diastolic pressure and
compartment pressure ) is <30mmHg – immediate decompression
 Management:
 Remove any casts, bandages and dressings
 Differential pressure < 30mmHg – immediate fasciotomy

47. LATE COMPLICATIONS

DELAYED UNION
When a fracture takes more than usual time to unite, it is said
to have gone in ‘delayed union’.
NON-UNION
 Delayed union gradually turns into non-union – that is it
becomes apparent that the fracture will never unite without
intervention
Movement can be elicited at the fracture site and pain
diminishes; the fracture gap becomes a type of
pseudoarthrosis

48. • Malunion:
• the fragments join in an unsatisfactory position
(unacceptable angulation, rotation or shortening)
• Causes are :
 failure to reduce a fracture adequately
 failure to hold reduction while healing proceeds
 gradual collapse of comminuted or osteoporotic bone.