Dr. Rami Abo Ali

1. ORTHOPEDIC SURGERY
Dr. Rami Abo Ali
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali
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2. GENERAL PRINCIPLES IN FRACTURES
Orthopedic
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Dr.
Rami
Abo
Ali
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3. BONE FORMATION
 Bone formation (ossifi cation) occurs in 3 different ways:
enchondral, intramembranous, appositional
 Enchondral
 • Bone replaces a cartilage anlage (template). Osteoclasts
remove the cartilage, and osteoblasts make the new bone
matrix, which is then mineralized.
 • Typical in long bones (except clavicle).
 • Primary ossification centers (in shaft) typically develop in
prenatal period.
 • Secondary ossification centers occur at various times after
birth, usually in the epiphysis.
 • Longitudinal growth at the physis also occurs by enchondral
ossification.
 • Also found in fracture callus 3
Orthopedic
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Dr.
Rami
Abo
Ali

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Ali
Enchondral

5. BONE FORMATION
 Intramembranous
 • Bone develops directly from mesenchymal cells
without a cartilage anlage.
 • Mesenchymal cells differentiate into osteoblasts,
which produce bone.
 • Examples: flat bones (e.g., the cranium) and clavicle
 Appositional
 • Osteoblasts make new matrix/bone on top of existing
bone.
 • Example: periosteal-mediated bone diameter (width)
growth in long bones 5
Orthopedic
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Dr.
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Abo
Ali
Intramembranous
Appositional

7. FRACTURES
 Fracture definition: It is a break in the structural continuity of bone .
 How fracture happen?
1. from single traumatic incident.
2. repetitive stress .(stress fracture)
3. abnormal weakening of the bone (pathological fracture).
 Clinical manifestations
 Localized pain and tenderness
Decreased function
Inability to bear weight or use of the affected part
Edema and Swelling
Muscle Spasm
Deformity
Ecchymosis and Contusion
Loss of function
Crepitation
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Dr.
Rami
Abo
Ali

8. CLASSIFICATION OF FRACTURES
 Simple and compound
 Compound fractures, in which
there is soft tissue damage and
an open wound, whereas
simple fractures, has intact skin
 ‘Simple ’and ‘compound’ have
been replaced by ‘closed’ and
‘open’ but ‘compound’ is
sometimes used to describe
how the skin has been
damaged
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Orthopedic
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Dr.
Rami
Abo
Ali

9. SHAPE
 Fractures can also be classified according to the shape of
the fragments and this is helpful in deciding management
 Transverse fractures are the result of a direct blow
or a pure angular force applied to the bone
 Oblique or spiral fractures are caused by a violent
twisting movement about the long axis of the bone
 Comminuted. Applied to a fracture where the bone is
splintered into more than two fragments
 Crush fractures. A fracture in which cancellous bone is
squashed or crushed presents a difficult problem because
there are no fragments left to manipulate back into
position.
 Greenstick fractures. When a green stick breaks, it does
not snap cleanly but bends so that one ‘cortex’ buckles
while the other remains intact
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Orthopedic
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Dr.
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Abo
Ali

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Ali

11. PATHOLOGICAL FRACTURES
 Pathological fractures occur through abnormally
weak bone.
 Tumors, cysts and osteoporotic bone
are common sites of pathological fractures
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Orthopedic
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Dr.
Rami
Abo
Ali

12. FATIGUE FRACTURES
 Repeated small bending stresses will break any
material , including bone.
 The commonest example is a fracture of the second metatarsal in
young adults who walk excessive distances.
 Classically, military recruits suffered this injury after route marches
and the fracture is still known in English as a ‘march fracture’ and in
French as ‘pied du jeune soldat’.
 Fatigue fractures are also seen in the tibiae of long-distance runners
and hurdlers, and in the pars interarticularis of fast bowlers and
javelin throwers.
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13. DISPLACED /NON-DISPLACED FRACTURE
 Non-displaced fractures
The fragments in an
undisplaced fracture are in
almost anatomical position
and manipulative reduction
is not required.
 Displaced Fracture :
Fragment out of normal
position at fracture site.
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Ali

14. STABLE AND UNSTABLE FRACTURES
 A stable fracture is one in which the two bones are lying
in a position from which they are unlikely to move.
 Stable fractures are often undisplaced but some are
stable even though the bone is misshapen.
 Unstable fracture is a fracture with an intrinsic tendency
to displace after reduction.
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Dr.
Rami
Abo
Ali

15. COMPLICATED FRACTURES
 A complicated fracture is one that has a complication,
such as infection or vascular damage.
 The term is seldom used but must be distinguished from
compound and comminuted.
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Ali

16. PROXIMAL & DISTAL SEGMENT FRACTURES
 • Type A
– Extra-articular
• Type B
– Partial articular
• Type C
– Complete disruption
of the articular
surface from the
diaphysis
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Ali

17. DIAPHYSEAL FRACTURES
 • Type A
– Simple fractures with
two fragments
• Type B
– Wedge fractures
– After reduced, length
and alignment restored
• Type C
– Complex fractures with
no contact between
main fragments
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Ali

18. EPIPHYSEAL INJURY
 Injury to the epiphyses of growing bone can cause severe deformity in later
life if a bony bridge forms across the fracture site and prevents growth on
one side of the bone.
 The following five patterns of injury were described by Harris and Salter:
1. A fracture along the epiphyseal line.
2. Separation of the epiphysis with a triangular fragment of shaft attached
to it .
3. Fracture of the epiphysis, part of it remaining attached to the shaft.
4. A fracture line passing through both epiphysis and shaft.
5. A crushing injury . This is difficult to recognize at the time of injury, either
clinically or radiologically. This type of injury is more commonly associated
with later growth arrest or retardation
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Ali

19. HEALING BY DIRECT UNION
(PRIMARY BONE HEALING)
 If the fracture site is absolutely stable – for example, an
impacted fracture in cancellous bone, or a fracture held by a
metal plate with absolute stability – there is no stimulus for
callus.
 Instead, osteoblastic new bone formation occurs directly
between the fragments
 Gaps between the fracture surfaces are invaded by new
capillaries and osteoprogenitor cells growing in from the edges,
and new bone is laid down on the exposed surface (gap healing)
 Where the crevices are narrow (less than 200 µm), osteogensis
produces lamellar bone; wider gaps are filled with woven bone
first, which is then remodeled to lamellar bone
 By 3-4 weeks the fracture is solid enough to allow penetration
and bridging of the area by bone remodelling units, i.e.
osteoclastic ‘cutting cones’ followed by osteoblasts
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Abo
Ali

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Ali

21. HEALING BY CALLUS
(SECONDARY BONE HEALING)
 Secondary bone healing is the most common form of
healing in tubular bones; in the absence of rigid fixation
 It proceeds in five stages
 1) Haematoma formation – At the time of injury,
bleeding occurs from the bone and soft tissues.
 2) Inflammation – The inflammatory process starts
rapidly when the fracture haematoma forms and
cytokines are released, and lasts until fibrous tissue,
cartilage, or bone formation begins (1–7 days post
fracture). Osteoclasts are formed to remove the necrotic
ends of bony fragments.
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Dr.
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Ali

22.  3) Soft callus formation – After 2–3 weeks, the
first soft callus is formed. This is about the time when
the fragments can no longer move freely.
The strain applied to the cells in the fracture gap
modifies their growth factor expression and
progenitor cells are stimulated to become osteoblasts.
The cells form a cuff of woven bone periosteally . The
fracture can now still angulate but is stable in length.
 4 )Hard callus formation – When the fracture ends
are linked together, the hard callus starts and lasts
until the fragments are firmly united (3–4 months).
Bone callus forms at the periphery of the fracture
and progressively moves centrally
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Orthopedic
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Dr.
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Ali

23.  5) Remodelling – The woven bone is slowly replaced
by lamellar bone. This process can last from a few
months to several years
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Dr.
Rami
Abo
Ali
Remodelling
Hard callus
formation
Soft callus
formation
Inflammation
Haematoma
formation

24. FACTORS AFFECTING FRACTURE HEALING
 Blood Supply
 Soft tissue injury
 Radiation
 Chemical or thermal burns
 Infection
 Anaemia & hypoxia
 Denervation
 Excessive compression
 Excessive Movement
 Inadequate immobilization
 Inadequate fixation or compliance
 Gap
 Intact fellow bone (as in fracture of tibia )
 Interposed soft tissue
 Distraction of bones
 Other
 Nutrition (Vit C required for normal collagen)
 Drugs (corticosteriods inhibit osteoblast differentiation)
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Ali

25. PRINCIPLES OF FRACTURE FIXATION
 The four principles of fracture fixation are :
1. Fracture reduction to restore anatomical relationships
2. Fracture fixation providing absolute or relative
stability as the “personality” of fracture, patient and
injury requires.
3. Preservation of blood supply to soft tissues and bone.
4. Early and safe mobilization of the injured part and the
patient as a whole.
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Orthopedic
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Dr.
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Abo
Ali

26.  There are two forms of displacement:
1. Translational displacement:
1. Medial or lateral and posterior or anterior
2. Shortening or lengthening
2. Rotational displacement:
1. Internal or external rotational malaligment
2. Valgus or varus malaligment
3. Flexion or extension malalignment
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Orthopedic
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Dr.
Rami
Abo
Ali

27.  Aim of reduction :
 Anatomical reduction
 To restore the bony anatomy and morphology
 Intra-articular fractures
 Functional reduction
 To restore the relationship between the proximal and distal main
fragments of the fracture
 To restore the length, alignment and rotation
 Mechanical and anatomical axis as reference
 Often in diaphyseal fractures
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Orthopedic
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Dr.
Rami
Abo
Ali

28.  Reduction methods
 The decision, which reduction method should be used, depends on
the location of the fracture:
 1. Meta- and diaphyseal fractures usually need functional reduction.
 2. Joint fractures need anatomical reduction
 Reduction of diaphyseal fractures
 The functional anatomy is restored (length, alignment, and rotational axis).
 The load-bearing axis of the extremity is restored (especially important in
the lower limb).
 An exception is the forearm which functions as a single articular unit.
 Reduction of articular fractures
 The joint surface is restored anatomically. Gaps and steps in the articular
surface must be avoided.
 “Steps” means that there is a difference between the levels of two main
articular fragments.
 “Gaps” means that there is some space between two adjacent main
articular fragments.
 The axial alignment is restored.
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

29.  Goal of fracture fixation
 To maintain the reduction
 To create adequate stability which:
 Allows early and optimal function of the injured limb
 Minimizes pain
 Methods of reduction
 There are two reduction methods:
 Direct reduction where every fragment under direct vision is restored.
 Indirect reduction where the direction is done without direct view on the
fracture.
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Dr.
Rami
Abo
Ali
Direct reduction
Indirect reduction

30. STABILITY
 Absolute stability
 no movement at fracture site, rigid
 Achieved through interfragmentary compression; e.g lag
screws, compression plates
 Often in intra-articular fractures
 No callus forms, fracture heals through direct healing
 Relative stability
 Movement at fracture site
 There is no interfragmentary compression at fracture site . It
is achieved by splinting or bridging, eg. elastic nails
 There is callus formation. Indirect bone healing is achieved.
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Orthopedic
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Dr.
Rami
Abo
Ali

31. REDUCTION:
 IF fracture is displaced.
 Meant to realign fracture fragments.
 To minimize soft tissue injury.
 Can be considered definitive if fragments’ position is
accepted. If reduction is acceptable, we can put a cast
and that would be a definitive treatment. If not, we can
put a temporary splint and later on we can treat the
patient in a definitive way.
 Should be followed by immobilization.
 To maximize healing potential
 To ensure good function after healing 31
Orthopedic
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Dr.
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Abo
Ali

32. Important points to remember:
1. Take consent from patient prior to
2. Patient must receive adequate analgesia prior to
reduction.
3. Most reductions occur under conscious sedation at
emergency.
4. Reduction must be followed by immobilization.
5. Nerve/Vascular status must be documented before and
after reduction and immobilization (before and after
reduction).
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Abo
Ali
Neurovascular assessment: 6Ps
pain, paralysis, paresthesias, pulselessness, pallor, and
pressure

33. EMERGENCY CARE
 • Begins at the site of the accident.
• It consists of ‘splint them where they lie’.
 Closed fracture
 Before splinting remove any ring or bangles worn by the patient.
 Almost any available object( for eg: folded news paper, magazine,
rigid cardboard, stick, umbrella, pillow etc.) can be used for splinting
at the site of the accident.
 Open fracture
 The bleeding from the wound is stopped by applying firm pressure
using a clean piece of cloth.
 Circular bandage can apply proximal to the wound in order to stop
bleeding.
 If the wound is very dirty, it is washed with clean tap water and
covered with a clean cloth.
 The fracture is splinted
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Dr.
Rami
Abo
Ali

34. DEFINITIVE CARE
 The aim of treatment is rehabilitation of the limb
to pre-injury status.
 Anatomic realignment of bone fragments(reduction)
 Immobilization to maintain realignment
 Restoration of normal or near normal function of the
injured part
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Rami
Abo
Ali

35. METHODS OF TREATMENT
 Treatment by functional use of the limb: Some
fractures (eg: fractured ribs, scapula) need no reduction or
immobilization. These fractures unite despite functional use of
the body part. Analgesics are needed for the initial few days.
 Treatment by immobilization : Fractures without significant
displacement or fractures where the displacement is of no
concern are treated this way.
 Treatment by reduction followed by immobilization: It is
required for most displaced fractures. These otherwise result in
deformity, shortening etc.
 Open reduction and internal fixation: Some fractures , such as
intra- articular fractures, are best treated by open reduction and
internal fixation. 35
Orthopedic
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Dr.
Rami
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Ali

36.  Fracture reduction
Reduction of a fracture can be carried out by
following methods
• Closed reduction
• Open reduction
• Continuous traction
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

37. CLOSED REDUCTION
 Nonsurgical, manual realignment of bone fragments
to their previous anatomic position.
 Traction and counter traction are manually applied to
the bone fragments.
 Usually performed under local or general anesthesia.
 After reduction, traction, casting, external fixation,
splints or orthoses immobilize the injured part to
maintain alignment until healing occurs.
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Dr.
Rami
Abo
Ali

38. OPEN REDUCTION
 Open reduction is the correction of bone alignment through a
surgical incision.
 It usually includes internal fixation of the fracture with the use
of wires, screws, pins, plates, intra medullary rods or nails.
 This techniques allows anatomic reduction and the creation of
highly stable constructs.
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Orthopedic
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Dr.
Rami
Abo
Ali

39.  Indication Open reduction
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
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Orthopedic
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Dr.
Rami
Abo
Ali

40. GOALS AND INDICATIONS FOR INTERNAL FIXATION
 Goals:
 Restoration of bony anatomy while respecting soft tissues
 Stable fixation
 Accelerated recovery
 More predictable and potentially faster healing
 Indications:
 Displaced intra-articular fractures
 Open fracture
 Polytrauma
 Associated neurovascular injury
 Failure of closed treatment
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Orthopedic
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Dr.
Rami
Abo
Ali

41. IMMOBILIZATION
 Plaster casts or plastic functional braces – these hold the
bone in position until it has healed.
 Metal plates and screws – current procedures may use
minimally invasive techniques.
 Intra-medullary nails – internal metal rods are placed down
the center of long bones. Flexible wires may be used in
children.
 External fixators – these may be made of metal or carbon
fiber; they have steel pins that go into the bone directly
through the skin. They are a type of scaffolding outside the
body.
 Traction can be used for the treatment of any long bone
fracture or major joint dislocation using ropes, pulleys, and
weights
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Orthopedic
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Dr.
Rami
Abo
Ali

42.  Strapping : The fractured part is strapped to an adjacent
part of the body.
Eg: phalanx fracture, where one finger is strapped to the
adjacent normal finger.
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Orthopedic
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Dr.
Rami
Abo
Ali

43.  Sling : A fracture of the upper extremity is immobilized with
the help of a sling, mostly to relieve pain in cases where
strict immobilization is not necessary.
Eg : Triangular sling used for a fracture of the
clavicle
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Orthopedic
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Dr.
Rami
Abo
Ali

44.  Casts immobilization
A cast is a temporary circumferential immobilization device.
It allows the patient to perform many normal activities of daily
living while providing sufficient immobilization to ensure stability.
Cast materials are natural (plaster of paris ) , synthetic acrylic,
latex free polymer or a hybrid of materials
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Orthopedic
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Dr.
Rami
Abo
Ali

45.  Splints
• Splints are used for immobilizing fractures; either
temporary during transportation or for definitive
treatment.
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

46.  Functional bracing
 Braces are used to provide support ,control movement ,
and prevent additional injury
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

47.  Continuous Traction
 It is the application of a pulling force to an injured or diseased
part of the body or an extremity while counter traction pulls in
the opposite direction.
 Traction-Purposes
1. Prevent or reduce muscle spasm
2. Immobilize a joint or part of the body
3. Reduce a fracture or dislocation
4. Treat a pathologic condition.
 The two most common types of traction are
• Skin traction
• Skeletal traction
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Orthopedic
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Dr.
Rami
Abo
Ali

48.  Skin traction
 It is generally used for short term treatment (48 to 72 hours) until skeletal
traction or surgery is possible.
 An adhesive strap is applied on the skin and traction applied.
 The traction weights are usually limited to 2.3 to 4.5 kg.
 Pelvic or cervical skin traction may require heavier weights applied
intermittently.
 The traction force is transmitted from the skin through the deep fascia and
inter muscular septae to the bone.
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Dr.
Rami
Abo
Ali

49.  Skeletal Traction
 Provides long term pull that keeps the injured bones and joints aligned.
 Applied directly on the bone by inserting K-wire or Steinmann pin through the
bone to align and immobilize the injured body part.
 Used to align injured bones and joints or to treat joint contractures and
congenital hip dysplasia
 Weight for skeletal traction ranges from 2.3 to 20.4 kg. The use of too much
weight can result in delayed union or nonunion.
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Orthopedic
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Dr.
Rami
Abo
Ali

50.  Types of Internal Fixation
 Pin & wire fixation.
 Screw fixation.
 Plate & screws fixation.
 Intra-medullary fixation.
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Orthopedic
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Dr.
Rami
Abo
Ali

51.  Screw
• Interfragmentary screw (lag screw) are used for fixing small fragment onto the
main bone
 Wires
Kirschner wire often inserted percutaneously without exposing the fracture
Used in situation where fracture healing is predictably quick
 Pins and screws
• They are the simplest implants.
• often placed percutaneously.
• Krischner wires may be used temporarily and frequently for the stabilization of
small fragments.
• Screws can be used for inter fragmentary compression.
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Orthopedic
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Dr.
Rami
Abo
Ali

52.  Plate & screws fixation
 Open Reductionand Internal fixation with Plates and screws
 Used for many fractures especially those involving joints
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Orthopedic
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Dr.
Rami
Abo
Ali

53.  Intramedullary nail
 Suitable for long bones
 Nail is inserted onto
medullary canal to splint
the fracture
 Rotational fracture are
resisted by introducing
locking screw which
tranfix the bone cortices
and the nail proximal and
distal to the fracture.
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Orthopedic
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Dr.
Rami
Abo
Ali

54. EXTERNAL FIXATORS
 The bone is transfixed above
and below the fracture with
screw or pins or tension wire
and these are then clamped
to a frame or connected to
each other by rigid bars
outside the skin
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Orthopedic
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Dr.
Rami
Abo
Ali

55. REHABILITATION:
 To ensure return to function.
 Initiating motion (improve range of motion) should be
attempted as early as possible without jeopardizing
maintenance of reduction.
 Weight bearing restriction for short period (6-8 weeks).
Especially if the fracture is not stable. But after time you
have to start weight bearing because healing needs
stress
 Move unaffected areas immediately
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Orthopedic
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Dr.
Rami
Abo
Ali

56. COMPLICATIONS OF FRACTURE HEALING
 • MALUNION
• DELAYED UNION
• NONUNION
 Malunion
A malunited Fracture is one that has healed with
the fragments in a non anatomical position.
Causes:
1) inaccurate reduction
2) ineffective immobilization
 Nonunion
• FDA defined nonunion as “established when a
minimum of 9 months has elapsed since fracture
with no visible progressive signs of
healing for 3 months”
• Every fracture has its own timetable (ie long
bone shaft fracture 6 months, femoral neck
fracture 3 months)
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Dr.
Rami
Abo
Ali

57.  Types of nonunion
 septic nonunion
 caused by infection
 CRP test as the most accurate predictor of infection
 pseudoarthrosis
 hypertrophic nonunion
 caused by inadequate stability with adequate blood supply and
biology
 abundant callous formation without bridging bone
 typically heal once mechanical stability is improved
 atrophic nonunion
 caused by inadequate immobilization and inadequate blood supply
 oligotrophic nonunion
 produced by inadequate reduction with fracture fragment
displacement
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Orthopedic
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Dr.
Rami
Abo
Ali

58.  Delayed union
a delayed union is generally defined as a failure to reach bony union by 6
months post-injury this also includes fractures that are taking longer than
expected to heal (ie. distal radial fractures)
 Systemic factors:
• Metabolic
• Nutritional status
• General health
• Activity level
• Tobacco and alcohol use
 Local factors
• Open
• Infected
• Segmental (impaired blood supply)
• Comminuted
• Insecurely fixed
• Immobilized for an insufficient time
• Treated by ill-advised open reduction
• Distracted by (traction/plate and screws)
• Irradiated bone
• Delayed weight-bearing > 6 weeks
• Soft tissue injury > method of initial treatment 58
Orthopedic
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Dr.
Rami
Abo
Ali

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Abo
Ali