This document discusses the general principles and methods of fracture management, including classification, diagnosis, and treatment options. There are two main treatment approaches - conservative management involving closed reduction, immobilization and traction, and surgical management using open reduction and internal fixation. The goals of treatment are to restore length, axis, and function by anatomical realignment of fragments through either conservative or operative means.

1. GENERAL PRINCIPLES AND METHODSGENERAL PRINCIPLES AND METHODS
OF MANAGEMENT OF FRACTURES.OF MANAGEMENT OF FRACTURES.
COMPLICATONSCOMPLICATONS

2. Fractures typesFractures types
а –а – TransverseTransverse
б – Segmentalб – Segmental
в – Spiralв – Spiral
г, д – Green stickг, д – Green stick
fracturefracture

3. Displaced and non-displacedDisplaced and non-displaced
fracturesfractures
There are 4 types of displacement
- translation (or
transverse dislocation)
- angulation
- axial rotation
- shift (shortening) Overriding

4. translation (ortranslation (or
transverse dislo- axial rotationtransverse dislo- axial rotation
cation)cation) angulationangulation
Тypes of displacement

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6. ShorteningShortening
Oblique fractureOblique fracture Transverse fractureTransverse fracture
Overriding

7. Infra-articularInfra-articular
fracturesfractures
- partial articular Stable unstable- partial articular Stable unstable
- complete- complete (in loading)(in loading)
articulararticular
1
2 3

8. Miiller's classificationMiiller's classification
Each long bone has three segments -Each long bone has three segments -
proximal, diaphyseal and distal;proximal, diaphyseal and distal;
b, c, d - Diaphysealb, c, d - Diaphyseal
fractures may be simple, wedgefractures may be simple, wedge
or complex,or complex,
e, f, g - Proximal and distal frac-e, f, g - Proximal and distal frac-
tures may be extra-articular,tures may be extra-articular,
partial articular or completepartial articular or complete
articular.articular.

9. Classification of fracturesClassification of fractures
(Miiller(Miiller et al,et al, 1990).1990).
Diagnosis has been formulated likeDiagnosis has been formulated like codecode
32-A2.132-A2.1
- The first digit specifies the bone- The first digit specifies the bone
1 = humerus, 2 = radius/ulna,1 = humerus, 2 = radius/ulna,
3 = femur, 4 = tibia/fibula)3 = femur, 4 = tibia/fibula)
- the second digit the specifies segment- the second digit the specifies segment
1 = proximal, 2 = diaphyseal,1 = proximal, 2 = diaphyseal,
3 = distal, 4 = malleolar).3 = distal, 4 = malleolar).

10. Classification of fracturesClassification of fractures
(Miiller(Miiller et al,et al, 1990).1990). 32-A2.132-A2.1
A letter specifies the type of diaphysisA letter specifies the type of diaphysis
fracture:fracture:
A = simple, B = wedge, C = complex;A = simple, B = wedge, C = complex;
proximal and distal:proximal and distal:
A = extra-articular, B = partial articular,A = extra-articular, B = partial articular,
C = complete articular.C = complete articular.
Two further numbers specify the detailedTwo further numbers specify the detailed
morphology of the fracturemorphology of the fracture

11. As an example of the AO clas-As an example of the AO clas-
sification, a simple obliquesification, a simple oblique
fracture of the proximal part offracture of the proximal part of
the femoral shaft distal to thethe femoral shaft distal to the
trochanters would be coded 32-trochanters would be coded 32-
A2.1, as follows:A2.1, as follows:
3 = the3 = the bone:bone: the femur - thethe femur - the
location of fracturelocation of fracture
2 = the2 = the bonebone segment:segment: thethe
diaphysisdiaphysis
—— = separator between= separator between
location and typelocation and type

12. code 32-A2.1code 32-A2.1
A = the type: A is the least severe typeA = the type: A is the least severe type
of fracture, with two bone fragmentsof fracture, with two bone fragments
onlyonly
2 = the group: group 2 includes all2 = the group: group 2 includes all
oblique fracturesoblique fractures
I = subgroup: subgroup 1 includesI = subgroup: subgroup 1 includes
fractures in the proximal part of thefractures in the proximal part of the
diaphysis where the medullary cavity isdiaphysis where the medullary cavity is
wider than in the more central part ofwider than in the more central part of
the bone.the bone.

13. DIAGNOSIS OF FRACTUREDIAGNOSIS OF FRACTURE
Modern diagnostics methodsModern diagnostics methods
- Radiography in two views.- Radiography in two views.
The radiograph will confirm theThe radiograph will confirm the
presence of the fracture and will also showpresence of the fracture and will also show
the dis-placements of fragments.the dis-placements of fragments.
- Functional radiography and radiography- Functional radiography and radiography
in special positionin special position
- CТ (computed tomography),- CТ (computed tomography),
- МRI (magnetic resonance imaging),- МRI (magnetic resonance imaging),
- Ultra sound, - Densitometry- Ultra sound, - Densitometry

14. X-ray:X-ray: is visibleis visible the presence signsthe presence signs
of destruction of L4 body vertebraof destruction of L4 body vertebra
CTCT - significant destruction ob bone- significant destruction ob bone
structure with penetration into softstructure with penetration into soft
tissuestissues
MRIMRI –– confirm soft tissues componentconfirm soft tissues component
and its expansion and interrelationand its expansion and interrelation
with surrounding vessels and Spinalwith surrounding vessels and Spinal
CordCord

15. Aim of TreatmentAim of Treatment
- restoration of length and axis of the limb
- restoration of the function.
Two methods of treatment
- Surgical
- conservative

16. Three types of fracture treatmentThree types of fracture treatment
2. Specialized
3.
Rehabilitation
1. emergency

17. Transport immobilizationTransport immobilization

18. Aim of immobilisationAim of immobilisation
Prevention of complications
Transportation
Prevention of secondary injuries
Decrease of pain
Prevention of
complications

19. Conservative treatmentConservative treatment
ConservativeConservative
treatment oftreatment of
fracturesfractures
reabilitation
Reposition
fixation

20. CONSERVATIVE MANAGEMENTCONSERVATIVE MANAGEMENT
OF FRACTURESOF FRACTURES
The principles of conservativeThe principles of conservative
management are:management are:
1) Closed reduction of the fracture1) Closed reduction of the fracture
by manipulation,by manipulation,
2) Maintenance of reduction.2) Maintenance of reduction.

21. Reduction of FractureReduction of Fracture
Reduction means the restoration ofReduction means the restoration of
the normal anatomical alignment ofthe normal anatomical alignment of
fragments in fractures.fragments in fractures.
This procedure should be painlessThis procedure should be painless
and with relaxed muscles obtained byand with relaxed muscles obtained by
anaesthesia.anaesthesia.

22. Conservative treatmentConservative treatment
- Fixation by Plaster of Paris casts- Fixation by Plaster of Paris casts
- Skeletal traction- Skeletal traction
- without following external fixation- without following external fixation
- with following external fixation- with following external fixation

23. Maintenance of reductionMaintenance of reduction
In the majority of fractures, the maintenanceIn the majority of fractures, the maintenance
of the alignment of fragments has been doneof the alignment of fragments has been done
by immobilisation with Plaster of paris casts.by immobilisation with Plaster of paris casts.
FFractures must be immobilised till the unionractures must be immobilised till the union
is complete.is complete.
The common types of plaster casts are:The common types of plaster casts are:
1. Above Elbow plaster cast1. Above Elbow plaster cast
2. Below Elbow plaster cast2. Below Elbow plaster cast
3. U. Plaster slab for humerus3. U. Plaster slab for humerus
4. Below knee plaster cast4. Below knee plaster cast
5. Above knee plaster cast5. Above knee plaster cast

24. Types of plaster castsTypes of plaster casts

25. TractionTraction
Some fractures of extremities likeSome fractures of extremities like
fracture of the shaft of the femur needfracture of the shaft of the femur need
continuous tractioncontinuous traction to maintain theto maintain the
reduction and to immobilize thereduction and to immobilize the
fragments.fragments.
The methods are:The methods are:
1. Skin traction 2. Skeletal1. Skin traction 2. Skeletal
traction.traction.

26. Skin tractionSkin traction
weight should be 4 kg.
or less
Age before 1 year

27. Skeletal tractionSkeletal traction
Skeletal traction can
be used with
larger weights. K-wire and types of pin for traction
(a) Steinmann pin, (b) Denham pin

28. Skeletal tractionSkeletal traction
Traction should be sufficient to pull the
bones out to length and overcome local
muscle contraction

29. Skeletal tractionSkeletal traction

30. OPEN (SURGICAL) REDUCTION ANDOPEN (SURGICAL) REDUCTION AND
INTERNAL FIXATIONINTERNAL FIXATION
Some fractures where there is an inherentSome fractures where there is an inherent
instability of the fragments or a tendency forinstability of the fragments or a tendency for
delayed union or non-union are betterdelayed union or non-union are better
treatedtreated
by open reduction of the fracture by surgicalby open reduction of the fracture by surgical
method with internal or external fixation.method with internal or external fixation.
Principles of Open reductionPrinciples of Open reduction
1. Anatomically accurate realignment of1. Anatomically accurate realignment of
fragments.fragments.
2. Rigid fixation with metallic implants.2. Rigid fixation with metallic implants.

31. Operative treatmentOperative treatment
Indications for operative treatment
1. Intraarticular fractures
2. Open fractures
3. Vascular injury. Nerve injury
4. Closed unstable fractures
5. Pathological fractures.
6. Haemorrhage
7. Polytrauma
8. Early mobilization

32. Operative treatmentOperative treatment
 Goals of treatment:Goals of treatment:
- restoration of length and axis of injured- restoration of length and axis of injured
segmentsegment
- anatomical restoration of fractured bone- anatomical restoration of fractured bone
for infra-articular fracturesfor infra-articular fractures
- Restoration of joints function- Restoration of joints function
- early ambulation of patient- early ambulation of patient
- early function and loading- early function and loading
- diminution of treatment period- diminution of treatment period

33. Methods of operative fixation ofMethods of operative fixation of
fracturesfractures
 After open reduction of fractures, theAfter open reduction of fractures, the
fragments are maintained in positionfragments are maintained in position
by fixation by the following methods.by fixation by the following methods.
1. Screws only, 2. Plates and Screws,1. Screws only, 2. Plates and Screws,
3. Wires 4. Intramedullary nails. 5.3. Wires 4. Intramedullary nails. 5.
External fixationExternal fixation

34. ScrewsScrews
Screws alone are used to stabilizeScrews alone are used to stabilize
small fragments like medial malleolussmall fragments like medial malleolus
of the ankle, lateral condyle of hume-of the ankle, lateral condyle of hume-
rus. The types of screws available are:rus. The types of screws available are:
- cortical screws,- cortical screws,
- cancellous screws,- cancellous screws,
- malleolar screws- malleolar screws

35. Type of osteosynthesisType of osteosynthesis
- Intramedullary- Intramedullary
- Subperiostal (external)- Subperiostal (external)
- Perosseous- Perosseous
- external fixation by- external fixation by
apparatusapparatus

36. Plates and ScrewsPlates and Screws
These are widely used in the fixa-These are widely used in the fixa-
tion of diaphyseal fractures liketion of diaphyseal fractures like
fracture both bones forearm, frac-fracture both bones forearm, frac-
ture shaft of humerus and tibia. Theture shaft of humerus and tibia. The
plates used are dynamic compres-plates used are dynamic compres-
sion plates and semitubular platession plates and semitubular plates
Wires: Wires are used in theWires: Wires are used in the
fixation of fractures of the patellafixation of fractures of the patella
and olecranon.and olecranon.

37. Plates for internal fixationPlates for internal fixation
 АО/ASIF (WolrdАО/ASIF (Wolrd
standart)standart)
- compressive- compressive
- buttress- buttress
- dynamic compres-- dynamic compres-
sion plate (DCP)sion plate (DCP)
- low-contact plate- low-contact plate
(LCP)(LCP)

38. Osteosynthesis by platesOsteosynthesis by plates

39. Intramedullary fixationIntramedullary fixation
Intramedullary Nails:Intramedullary Nails:
Diaphyseal fractures in theDiaphyseal fractures in the
lower limbs are stabilised withlower limbs are stabilised with
intra medullary nail fixation.intra medullary nail fixation.
The main advantage ofThe main advantage of
intramedullary fixation is rigidintramedullary fixation is rigid
immobilisation of theimmobilisation of the
fragments which helps in earli-fragments which helps in earli-
er ambulation and quickerer ambulation and quicker
restoration of function.restoration of function.

40. Intramedullary fixationIntramedullary fixation
Different types of nails:Different types of nails:
KuncherKuncher
BogdanovBogdanov
Russel – Taylor interlocking nailsRussel – Taylor interlocking nails
RichardRichard’s compression hip screw -’s compression hip screw -
(Gamma Nail)(Gamma Nail)
Rublenik interlocking nailRublenik interlocking nail

41. Russel – Taylor interlocking nailRussel – Taylor interlocking nail
standart and reconstruction nailsstandart and reconstruction nails

42. - Russel-Taylor- Russel-Taylor
interlocking nailinterlocking nail
- Richard- Richard’s’s
compressioncompression
hip screw (Gamma Nail)hip screw (Gamma Nail)

43. Open awful fracture afterOpen awful fracture after
debridement and interlockingdebridement and interlocking
intramedullary fixationintramedullary fixation

44. Tibial interlocking nailTibial interlocking nail

45. Segmental (triple) fracture of tibia fixedSegmental (triple) fracture of tibia fixed
by interlocking nailby interlocking nail

46. External fixation by apparatusExternal fixation by apparatus
- needle (K-wire) apparatus (Ilizarov)- needle (K-wire) apparatus (Ilizarov)
- Pin apparatus- Pin apparatus
- combined pin-needle apparatus- combined pin-needle apparatus

47. - it can be used in
patients with skin
loss or infection.
- the position of the
fragments can be
easily adjusted
- early function of
adjacent joints
- early full weight-
bearing
External apparatus
advantages

48. Gunshot wound with extensiveGunshot wound with extensive
injury of soft tissues and commi-injury of soft tissues and commi-
nuted fracture of the legnuted fracture of the leg
- Debridement, open reduc-- Debridement, open reduc-
tion of fragments, externaltion of fragments, external
fixation by Ilizarovfixation by Ilizarov′s apparatus′s apparatus

49. Models ofModels of External apparatusExternal apparatus
 Examples of external fixation devices: AO,Examples of external fixation devices: AO,
Unifix, Orthofix.Unifix, Orthofix.
AO Unifix Orthofix

50. Operative treatment of unstable injuriesOperative treatment of unstable injuries
of the spineof the spine
 Transpedicular fixationTranspedicular fixation
 Endoprostheses of the vertebral body andEndoprostheses of the vertebral body and
intervertebral discintervertebral disc
 Plates for anterior and posteriorPlates for anterior and posterior
spondylodesspondylodes
 vertebroplasty (osteoporosis, tumors ofvertebroplasty (osteoporosis, tumors of
vertebral bodies)vertebral bodies)

51. Correction of deformity,Correction of deformity,
anterior spondylodes by auto-anterior spondylodes by auto-
bone graft and transpedicularbone graft and transpedicular
fixation for burst fracture offixation for burst fracture of
the Spinethe Spine

52. Anterior spondylodesAnterior spondylodes
by vertebral endopro-by vertebral endopro-
thesis and by anteriorthesis and by anterior
plate for Spineplate for Spine
injuriesinjuries

53.  Joints replacement (endoprothesis)Joints replacement (endoprothesis)
- fracture of the neck of femur- fracture of the neck of femur
- comminuted infra-articular fractures- comminuted infra-articular fractures
- Arthritis- Arthritis′′ss
- tumor of the epiphyses- tumor of the epiphyses
- Endoscopic operations- Endoscopic operations
- for joint pathology- for joint pathology
- for Spine surgery- for Spine surgery

54. Austin MoorAustin Moor
endoprothesis forendoprothesis for
subcapital fracturesubcapital fracture
of the neck of femurof the neck of femur
 Total endoptothe-Total endoptothe-
sis for neglectedsis for neglected
(non-union) subca-(non-union) subca-
pital fracture of thepital fracture of the
neck of femurneck of femur

55. Fracture of pelvis.Fracture of pelvis.
Open reduction. Fixation by reconstruc-Open reduction. Fixation by reconstruc-
tive platestive plates

56. Miniinvasive surgeryMiniinvasive surgery
with endoscopicwith endoscopic
instrumentationinstrumentation

57. Manipulation for discManipulation for disc
prolaps excisionprolaps excision

58. FRACTURE COMPLICATIONSFRACTURE COMPLICATIONS
These complications can beThese complications can be
- immediate- immediate
- delayed- delayed
- late.- late.
Many of theseMany of these complicationscomplications areare
preventable and hence great carepreventable and hence great care
should be taken to minimise theirshould be taken to minimise their
incidence.incidence.

59. Immediate complicationsImmediate complications
- usually caused by the violence- usually caused by the violence
producing the fracture and these occurproducing the fracture and these occur
at the time of fracture or immediatelyat the time of fracture or immediately
after.after.
- These can be general complications- These can be general complications
like shock or local complications likelike shock or local complications like
injury to vessels, injury to nerves.injury to vessels, injury to nerves.

60. Delayed complicationsDelayed complications
 These are complications, setting in after aThese are complications, setting in after a
few days up to a few weeks.few days up to a few weeks.
- Infection in open fractures causing non-- Infection in open fractures causing non-
specific wound infections or specific infec-specific wound infections or specific infec-
tions like tetanus and gas gangrene occurtions like tetanus and gas gangrene occur
in the first few days.in the first few days.
- The other complications are Fat embo-- The other complications are Fat embo-
lism, Volkmann's ischemia, delayed nervelism, Volkmann's ischemia, delayed nerve
injuryinjury

61. Volkmann's IschemiaVolkmann's Ischemia
AcuteAcute.. The clinical features thus are:The clinical features thus are:
-- pain, pallor, paresthesia,pain, pallor, paresthesia,
pulselessness and paralysis.pulselessness and paralysis.
Chronic Volkmann's IschemicChronic Volkmann's Ischemic
ContractureContracture
This is the established contracture of theThis is the established contracture of the
forearm muscle in varying grades of seve-forearm muscle in varying grades of seve-
rity. The forearm is wasted, the wrist isrity. The forearm is wasted, the wrist is
flexed, the meta-carpo-phalangeal jointsflexed, the meta-carpo-phalangeal joints
remain extended, inter-phalangeal jointsremain extended, inter-phalangeal joints
are flexed.are flexed.

62. Late ComplicationsLate Complications
These occurs as late results of the injury or ofThese occurs as late results of the injury or of
its mismanagement.its mismanagement.
These include:These include:
(a) Malunion, (b) Nonunion,(a) Malunion, (b) Nonunion,
(c) Cross union, (d) Stiffness and contracture(c) Cross union, (d) Stiffness and contracture
of joints, (e) Post traumatic osteoarthrosis,of joints, (e) Post traumatic osteoarthrosis,
(f) Late nerve palsy (Tardy paralysis),(f) Late nerve palsy (Tardy paralysis),
(g) Avascular necrosis,(g) Avascular necrosis,
(h) Infection in open fracture.(h) Infection in open fracture.

63. Late ComplicationsLate Complications
Delayed UnionDelayed Union of a fracture is one whereinof a fracture is one wherein
healing has not progressed at the averagehealing has not progressed at the average
rate for the site and type of fracture, (usually 3rate for the site and type of fracture, (usually 3
to 6 months).to 6 months).
Non unionNon union is established when the fractureis established when the fracture
shows no visible progressive signs of healingshows no visible progressive signs of healing
for 3 months and a minimum of 9 months hasfor 3 months and a minimum of 9 months has
elapsed since injury.elapsed since injury.

64. MALUNIONMALUNION
This means that the fracture has anato-This means that the fracture has anato-
mically malunited with angulation, rota-mically malunited with angulation, rota-
tion or overriding of the fragmentstion or overriding of the fragments..
-- This is due to failure to reduce theThis is due to failure to reduce the
fragments into proper alignment orfragments into proper alignment or
failure to hold them in position tillfailure to hold them in position till
union.union.

65. Осложнения приОсложнения при
переломахпереломах

66. Cause of developing complicationsCause of developing complications
- local factors:- local factors:
- Degree of local damage- Degree of local damage
a. Compound fracturea. Compound fracture
b. Comminution fracturesb. Comminution fractures
c. Velocity of injuryc. Velocity of injury
d. Extent of disruption of vascular supply tod. Extent of disruption of vascular supply to
bone, its fragments or soft tissues;bone, its fragments or soft tissues;
severity of injuryseverity of injury
- Systemic factor:- Systemic factor:
Age, hormonal factors, diseases – diabetes,Age, hormonal factors, diseases – diabetes,
anemiaanemia

67. THANK YOU FOR YOURTHANK YOU FOR YOUR
ATTENTIONATTENTION