Introduction to Fractures for medical students. Prepared in collaboration with Dr. Mohammed Alharbi.

1. Introduction to Fractures
Dr. Yasser Alwabli

2. Contents
• Definitions
• Mechanisms
• Classifications
• Fracture description
• Management – conservative or surgical
• Fracture healing
• Complications
• Non-union and delayed union
• Bone grafts

3. Axial skeleton vs Appenicular skeleton
Long bone vs flat bone

4. What is a fracture?
• Discontinuation in the bone cortex
• A broken bone
Normal Fractured

5. • fracture extends 360° of bone
circumference (all around)
Complete fracture

6. • Incomplete: seen almost in children:
• Greensick
Incomplete fracture

7. • Mechanism:
• High energy vs. low energy
• Multiple injuries vs. isolated injury.
• Pathological fracture: normal load in presences of weakened bone (tumor,
osteoporosis, infection)
• Stress fracture: normal bone subjected to repeated load (military recruits).

8. Fracture patterns (descriptive classification)
• Transverse
• Oblique
• Comminuted
• Spiral
• Segmental
• Impacted
• Avulsed

11. • Transverse: loading mode is bending

12. • Oblique: loading mode is compression.

13. • Spiral: loading mode is torsion.

14. • Fracture with Butterfly fragment:
loading mode is bending and
compression

15. • Comminuted fracture: 3 or more fragments
• Segmental fracture

16. Fracture
description
Name of injured bone
Integrity of skin
Skeletal maturity
Location
Fracture pattern
Alignment

17. Integrity of skin
Closed fracture Open fracture

18. Integrity of skin
• Closed fracture
• Skinsoft tissues intact
• Open fracture
• Fracture exposed to the outside environment

19. Skeletal maturity
• Pediatric
• Adult
• ? Geriatric

20. Why pediatric fractures are unique?
• Thicker periosteum
• Presence of growth plate
• Anatomic reduction is not necessary
• Time to heal is shorter
• Think of child abuse

24. Classifications
• Why we use classifications?
• Ease of communication
• Occasionally helps in treatment
• Research uses

25. Classifications
• Every fracture has a unique classification system
• Unified classification system, e.g. AO classification

26. Example:
Garden classification for femoral
neck fractures
Type 1 Type 2
Type 3 Type 4

27. AO
Classification

28. PRINCIPLES OF EVALUATION

29. Diagnosis: History
Patients complain of pain and inability to
use the limb (if they are conscious and
able to communicate)
What information can help you make the
diagnosis?

30. Diagnosis: History
Onset:
When and how did the symptoms begin?
Specific traumatic incident vs. gradual onset?
If there was a specific trauma, the details of the event are essential
information:
Mechanism of injury?
Circumstances of the event? Work-related?
Severity of symptoms at the time of injury and
progression after?

31. Diagnosis: Physical exam
Inspection
Swelling
Ecchymosis
Deformity
If fracture is open:
Bleeding
Protruding bone

32. Diagnosis: Physical exam
Palpation
Bony tenderness

33. Diagnosis: Physical exam
If a fracture is suspected what should we rule
out?
Neurovascular injury (N/V exam)
Compartment syndrome
Associated MSK injuries (examine
joint above and below at
minimum)

34. How to describe a
fracture
Clinical parameters
Radiographic parameters

35. Clinical Parameters
Open vs. closed
ANY break in the skin in proximity to the fracture site is OPEN
until proven otherwise
Neurovascular status
Presence of clinical deformity

36. Location
Which bone?
Which part of the bone?
Epiphysis -intraarticular?
Metaphysis
Diaphysis -divide into 1/3s
Use anatomic landmarks when possible
e.g. medial malleolus, ulnar styloid, etc

37. Location
• Epiphyseal
• Metaphyseal
• Diaphyseal
• Physeal (growth plate)
• Articular

38. Pattern
Simple vs. comminuted
Complete vs. incomplete
Orientation of fracture line
Transverse
Oblique
Spiral

39. Displacement
Displacement is the opposite of apposition
Position of distal fragment relative to proximal
Expressed as a percentage

40. Angulation
Deviation from normal alignment
Direction of angulation defined by apex of
Expressed in degrees

41. Fracture description:
Summary
Clinical parameters
Open vs. Closed
Neurovascular status
Clinical deformity
Radiographic parameters
Location
Pattern
Displacement
Angulation
Shortening

42. Exercises

47. Bone healing

48. Fracture healing

49. • Primary bone healing :
1. Absolute fixation
2. No callus formation
3. Plate
• Secondary bone healing :
1. Relative fixation
2. callus formation
3. Cast + Nail + EX- fix

52. Management
• Reduction (if needed)
• Maintain reduction
• Rehabilitation

53. General scheme for fracture management
• Follow trauma protocols
• Immobilize the limb
• X-Ray the injured bone
• Determine the fracture pattern
• Plan treatment accordingly
• Reduce if needed (closed)
• X-Ray after reduction
• Immobilize and follow
• Rehabilitate early

55. How to maintain the reduction after closed
reduction (CR)?
• Splints
• Cast
• External fixators (Ex. Fix.) [for specific indications]

57. Initial (Immobilization)

58. What if closed reduction failed?
• May need re-reduction
• Other options?
• Open reduction
• aka needs Surgery

59. How to maintain reduction after open reduction
(OR)?
• Internal fixation = ORIF
• The first surgery we learned is ORIF
• Options
• Intramedullary device, e.g. IM rod, wires
• Extramedullary devices, e.g. plates and screws
• Sometimes can be treated by external fixator

61. Summary of fracture treatment
• Immobilization
• Closed reduction and immobilization (stabilizationfixation)
• Open reduction and external or internal fixation

62. Complications

63. Non-union and delayed union
• Non-union when fracture never heals
• Causes are diverse
• Types
• Treatment
• Treatment is to optimize local and systemic factors
• Almost always needs surgery
• Delayed union when the fracture passes the typical time of healing of
such fracture

64. Bone grafts
• Adjuncts used to stimulate bone healing
• Variety of types
• Autografts
• Allograft
• Synthetic