For undergraduate students

1. PRINCIPLES OF FRACTURES
PARIKEN

2. INTRODUCTION
• A fracture is a break in the structural continuity of bone.
• Closed fracture the overlying skin remains intact.
• open fracture (compound fracture) if the skin or one of the body
cavities is breached, mostly liable to contamination and infection

3. HOW FRACTURES OCCUR
1.Traumatic fractures
• Direct force (direct injury) the bone breaks at the point of impact; the soft
tissues are also damaged – splits the bone transversely or may bend it over a
fulcrum so as to create a break with a ‘butterfly’ fragment.
• Indirect force (indirect injury) the bone breaks at a distance from where the
force is applied- twisting
Dominant mechanism is revealed by X-rays:
• Twisting causes a spiral fracture.
• Compression causes a short oblique fracture.
• Bending results in a fracture with a triangular ‘butterfly’ fragment.
• Tension tends to break the bone transversely; in some cases it may simply
avulse a small fragment of bone at the points of ligament or tendon insertion.

4. CONT..

5. 2.Fatigue/Stress fractures - This occurs if bones are subjected to
chronic repetitive forces, none of which alone would be enough to
break the bone but which mean that the mechanical structure of the
bone is gradually fatigued
• Examples (in order of frequency);
• March fracture of the 2nd & 3rd metatarsal heads
• Mid & Distal Tibia & Fibula fractures in long distance runners & dancers
• Neck of femur
• Fractures of the pubic rami in severely osteoporotic or osteomalacic patients
• Detected early by Scintigraphy or MRI as radiographic changes
appear after 2-4wks.

6. 3.Pathological fractures - Produced when the strength of bone is reduced by disease

7. TYPES OF FRACTURE
1.Complete fractures The bone is split into two or more fragments.
• Transverse fracture the fragments usually remain in place after reduction.
• Oblique or spiral, they tend toshorten and redisplace even if the bone is
splinted
• Impacted fracture the fragments are jammed tightly together and the
fracture line is indistinct.
• Comminuted fracture is one with more than twofragments with interlocking
of the fracture surfaces; it is often unstable.
2.INCOMPLETE FRACTURES
• The bone is incompletely divided and the periosteum remains in continuity.
• Greenstick fracture the bone is buckled or bent (like snapping a green twig);
this is seen in children, whose bones are less brittle than those of adults.

8. CONT..

9. CLASSIFICATION OF FRACTURES
• In this system, the first digit specifies the bone (1 = humerus, 2 =
radius/ulna, 3 = femur, 4 = tibia/fibula, 5 = spine, 6 =
pelvis/acetabulum, 7 = hand, 8 = foot, 9 = craniomaxillofacial bones).
• The second digit specifies the segment (1 = proximal, 2 = diaphyseal,
3 = distal, 4 = malleolar).
• 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).
• Two further numbers specify the detailed morphology of the fracture.

11. Displacement of fractures (TARL)
• Translation (shift) – The fragments may be shifted sideways,
backward or forward in relation to each other, such that the fracture
surfaces lose part or all of their contact.
• Angulation (tilt) – The fragments may be tilted or angulated in
relation to each other. Malalignment, if uncorrected, may lead to
deformity of the limb.
• Rotation (twist) – One of the fragments may be twisted around its
longitudinal axis
• Length – The fragments may be distracted and separated, or they
may overlap, due to muscle spasm, causing shortening of the bone

13. Fracture healing
• Fracture healing is characterized by a process of new bone formation
with fusion of the bone fragments.
• The bone either heals by:
• Primary (without callus formation)
• Secondary (with callus formation)

14. HEALING BY DIRECT UNION
(PRIMARY BONE HEALING)
• Absolutely stable-ie; impacted fracture in cancellous bone, or a fracture
held by a metal plate (no stimulus for callus).
• Osteoblastic new bone formation occurs directly between the
fragments(contact healing)
• 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 very narrow (less than 200 μm), osteogenesis
produces lamellar bone; wider gaps are filled first by woven bone, which is
then remodelled to lamellar bone.
• By 3–4 weeks the fracture is solid enough to allow penetration and
bridging of the area by bone remodeling units, i.e. osteoclastic ‘cutting
cones’ followed by osteoblasts

15. HEALING BY CALLUS (SECONDARY BONE HEALING)
• Healing by callus, most common form of healing in tubular bones..
• 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 postfracture). Osteoclasts are
formed to remove the necrotic ends of bony fragment.
3. Soft callus formation – After 2–3 weeks, the first soft callus is formed.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

16. 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.
5.Remodelling – The woven bone is slowly replaced by lamellar bone.
This process can last from a few months to several years.

17. UNION, DELAYED UNION AND NON-UNION
• Union – Union is incomplete repair; the ensheathing callus is calcified.
Clinically, the fracture site is painless on palpation and weight-
bearing. X-rays show bridging callus.
• Delayed union – Delayed union means that fracture healing is not
taking place at the expected rate and time but healing is still possible.
Clinically, the fractured limb has local swelling and movement or
partial weight-bearing is painful.
• Absence of radiographic progression of healing (3 differenttimes every 4/52
apart
• Or instability of afracture upon clinical examination between 4-6 months post
injury

18. MALUNION
• Healing of a fracture in an abnormal (non-anatomic) position)
• TYPES
1. Rotational deformities -caused due to internal or external rotation of the
broken bone. Caused by intrameduallary nailing. Mx by transverse
osteotomy.
2. Angular deformity. In the frontal or lateral plane, happens as a result of
varus or valgus deformities. Mx by a wedge osteotomy
3. 2 plane deformities –deformity in both frontal & lateral axis
4. Multidirectional deformity – 3 or 4 plane deformities e.G distal femur with
varus, valgus flexion, shortenning. Usually complex aand require multiple
osteotomies for correction.
5. Length malunion

20. Non-union
• Non-union is usually defined as fracture that has not healed 9 months
post operation and there is no visible progress of healing during the
last 3 months
• Fracture characteristics depends on
1. Degree of displacement
2. Segmental loss
3. High energy mechanism
4. Soft tissue injury
• Risk factors
Patients factors;
1. Alcohol/smoking
2. Steroids
3. Nsaids, anticoagulants, anticonvulsant
Systemic factors
1. Infection

21. • TYPES
 SEPTIC -occur with infected osteosynthesis.
ASEPTIC
• Causes of aseptic non-union are:
1. Mechanical instability
2. Impaired vascularity. AVN
• Clinical examination –pseudoarthrosis- free and painless as to give
the impression of a false joint.
• On X-rays, non-unions are typified by a lucent line still present
between the bone fragments;
1. HYPERTROPHIC-
2. ATROPHIC

22. • Hypertrophic non-unions often have florid streams of callus around
the fracture gap – the result of insufficient stability
1. Elephant foot -excess callus associated with poor stability but good blood
supply
2. Horse foot -moderate stability with adequate blood supply
3. Oligotrophic non union -no callus &nno hypertrophy due to fragment
distraction or internal fixation with no aposition
• Atrophic non-unions usually arise from an impaired repair process;

23. X-RAYS
X-ray examination is mandatory. Remember the ‘rule of twos’
1. Two views
2. Two joints
3. Two limbs
4. Two injuries
5. Two occasions

24. Radiographic
1. Name, date
2. Type of view
3. Identify bone & joints demostrate
4. Skeletal maturity (physes,growth plates)
5. Soft tissue swelling
6. Bones & joints ( fracture & dislocation).
7. Direction of the fracture line (transverse, oblique, spiral)
8. Condition of the bone(communicating, segmental)
9. Deformity- displacement, angulation, rotation , shortening

25. TREATMENT OF CLOSED FRACTURES
• The principles of fracture management can be summarized in four R’s:
1. Resuscitate- following the ATLS protocol
2. Reduce- can be closed, open or using traction
3. Restrict/Hold
4. Rehabilitate

27. RESUSCITATION AS PER ATLS PROTOCOL
• 1. Primary survey with simultaneous resuscitation
A. Airway maintenance with C-spine protection
B. Breathing and ventilation
C. Circulation with hemorrhage control
D. Disability
E. Exposure and environment control
2. Adjuncts to the primary survey
3. Secondary survey
4. Adjuncts to the secondary survey
5. Re-evaluation
6. Definitive care

28. REDUCTION
• Aim IS for adequate apposition and Normal alignment of the bone
fragments.
• CLOSED REDUCTION Under appropriate anaesthesia and muscle
relaxation, the fracture is reduced by a three-fold manoeuvre:
1. the distal part of the limb is pulled in the line of the bone;
2. as the fragments disengage, they are repositioned (by reversing the original
direction of force if this can be deduced); and
3. alignment is adjusted in each plane.
• closed reduction can be used for all minimally displaced fractures, for
most fractures in children and for fractures that are not unstable after
reduction and can be held in some form of splint or cast
• Unstable fractures can also be reduced using closed methods prior to
stabilization with internal or external fixation

29. OPEN REDUCTION
• Operative reduction of the fracture under direct vision is indicated:
1. when closed reduction fails, either because of difficulty in
controlling the fragments or because soft tissues are interposed
between them;
2. when there is a large articular fragment that needs accurate
positioning; or
3. for traction (avulsion) fractures in which the fragments are held
apart.

30. RETAINING (HOLDING) REDUCTION
• METHODS
1. continuous traction
2. cast splintage
3. functional bracing
4. internal fixation
5. external fixation.

31. CONTINUOUS TRACTION

32. CONTINUOUS TRACTION
• Traction is applied to the limb distal to the fracture, so as to exert a
continuous pull in the long axis of the bone, with a counterforce in
the opposite direction
• PURPOSE
1. Reduction of fractures or dislocations
2. Immobilization of fractures or joints after reduction (Restrict/maintain
reduction)
3. Relieve or prevent muscle spasms
4. Relieve pain
5. Relieve pressure on nerves
6. To regain normal length of a bone
7. To prevent or reduce skeletal deformities or muscle contractures
8. Keeping the patient comfortable until definitive treatment

33. CLASSIFICATION
Classification based on method of application
• Skin
• Skeletal
• Gravity- applicable to upper limb fractures (hanging cast)
Classification based on the mechanism
• Fixed – pull is exerted against a fixed point of counter traction i.E. The
appliance obtains purchase on a part of the body (thomas’s splint)
• Balanced –pull is exerted against an opposing force. This opposing force is
provided by the weight of the body and bed adjustments (perkins,gallow).
• Combinied

34. SKIN TRACTION
Traction is applied over a large area and is transmitted to the skeleton
through the soft tissues.
• TYPES
1. Adhesive skin traction: Adhesive material is used for strapping which is applied
antero-medial and postero-lateral on either side of the lower limbs.
2. Non-adhesive skin traction
• Useful in thin and atrophic skin
• Used in patients sensitive to adhesive strap.
• Less secure than adhesive hence may need frequent reapplications
• Adhesive
1. Shave and clean skin
2. Ensure skin is dry
3. Apply adhesive strapping TINCTURE BENZOIN
4. Avoid placing over bony prominences
5. Leave a loop of 5cm to allow dorsi and plantar flexion
6. Duration- 4 to 6 weeks

35. INDICATIONS
• Temporary management of the neck of the femur fracture
• Femoral shaft fracture in children
• Undisplaced fracure of the acetabulum
• Sfter reduction of dislocation of the hip
• To correct minor fixed flexion deformities of the hip
CONTRAINDICATIONS
1. Abrasions
2. Lacerations
3. Impaired circulation; Varicose veins, Impending gangrene
4. Dermatitis
5. Marked shortening (in this case more weight would be needed than can be
applied using skin traction)
6. Allergy to adhesive
7. Any fragile condition of skin

36. COMPLICATION
1. Allergic reaction to adhesive
2. Excoriation of skin (due to slipping of adhesive strapping)
3. Pressure sores around the malleoli and tendoachilles
4. Common peroneal nerve palsy
5. Compartment syndrome tight cast
6. Muscular atropy
7. Paralysis
8. Oedema

37. MOST COMMONLY APPLIED FORMS
• Cervical
1. Head halter
• Lower limb
1. Buck’s traction
2. Gallow’s/ Bryant’s
3. Modified Bryant’s
4. Hamilton Russel’s
5. Agnes Hunt
6. Pelvic traction
• Upper limb
1. Dunlop’s

38. Cervical traction
Dunlop’s traction
Hamilton Russel
(Buck’s with sling)
Gallow’s/Bryant’s
Buck’s traction

40. SKELETAL TRACTION
Application of traction force by a pin or wire transfixing bone
INDICATIONS
1. Cases in which skin traction is contraindicated
2. Patients with lacerated wounds
3. Patients with ex fix in situ
4. Temporary management of musculo-skeletal disorders
5. Definitive management of musculo-skeletal disorder
EQUIPMENT
1. Steinman pin
2. Denham pin
3. Kirschner wires

41. Principles of application
1. Applied under general or local anesthesia
2. Follow strict aseptic measures
3. Pin should be at right angles to the limb and parallel to the ground.
4. Direction of pin insertion is chosen such that neurovascular
structures and other soft tissues are not injured
• Lateral to medial in case of upper tibial traction, to avoid injuring the common
peroneal nerve.
• Medial to lateral in distal femur traction
• Medial to lateral in case of olecranon pin traction to avoid injury to ulnar
nerve
5. Cover the sharp tip on the medial side with a stopper bottle to
prevent damage to the normal limb

42. COMPLICATIONS
At the time of application
1. Anesthetic problems.
2. Vasovagal shock.
During application
1. Injury to the nerves (lateral popliteal nerve).
2. Injury to the vessels.
3. Injury to the muscles, ligaments and tendons.
4. Injury to the epiphysis in children (e.g. upper tibial epiphysis).
5. Pain due to equalization of intraosseus pressure and atmospheric pressure
due to the hole made in the bone

43. CONT..
When pin is in situ
1. Infection—due to improper aseptic measures.
2. Migration—due to loosening.
3. Breakage—thin pin or more weight.
4. Bending—same reasons as above.
5. Loosening—due to osteoporosis, infection, etc.
6. Distraction of fracture fragments and ligament damage—due to excessive
weight/large traction force.
Late effects
1. Pin tract infection.
2. Chronic osteomyelitis with ring sequestra at the site.
3. Genu recurvatum due to damage to the anterior epiphysis of tibia in children.
4. Depressed scar.

44. Most commonly applied forms
1. Perkin’s traction
2. Ninety-ninety
3. Tulloch Brown
4. Olecranon pin traction
5. Crutchfield tongs

46. CAST

47. CAST
INDICATION
• For most children’s fractures.
• Undisplaced fracture
• Poor bone quality osteoporosis
• Unfixable fracture
• Systemic contraindication
• Local contraindication
• Psychosocial problem

48. Principle- to stabilize joint above and below the site of injury
Plaster (pop) white in color hemihydrated calcium sulphate, on adding
water it solidifies by an exothermic reaction into hydrate sulphate
Fiberglass- variety in color pattern & designs
Inside of the cast, cotton & other synthetic materials are used to line
the inside of the cast to make it soft and to provide paddling around
bony areas

49. TYPES
• Short arm below te elbow
• Long arm applied from the upper arm to the hand
• Scaphoid cast/thumb spica below elbow to the hand including the
thumb
• U-slab from shoulder to elbow
• Short leg cas
• Long leg cast
• Hip cast
• Ptb cast

53. FUNCTIONAL BRACING

54. FUNCTIONAL BRACING
• Functional bracing, using either plaster or one of the Lighter
thermoplastic materials, is one way of preventing joint stiffness while
still permitting fracture splintage and loading.
• Functional bracing is commonly used in fracture-dislocations.
• Segments of a cast are applied only over the shafts of the bones,
leaving the joints free; the cast segments are connected by metal or
plastic hinges that allow movement of the joint in one plane.
• The splints are ‘functional’ in that joint movements are much less
restricted than with conventional casts.

56. INTERNAL FIXATION

57. INDICATION
• Absolute
1. Unable to obtain an adequate reduction
2. Displaced intra-articular fractures
3. Certain types of displaced epiphyseal fractures
4. Major avulsion fracture wgere there is loss of function of the joint
5. Non union
6. Re-implantations of the limbs
Relative
1. Delayed union
2. Multiple fracture
3. Unable to maintain reduction
4. Pathological fracture
5. To assist in nursing care
6. To reduce morbidity due to prolonged immobilation

58. TYPES
1. PIN & WIRE FIXAT
2. SCREW FIXAT
3. PLATE & SCREW FIXAT
4. INTRA-MEDULLARY FIXAT

59. PLATES & SCREW
• FUNCTIONAL TYPES
1. COMPRESSION PLATES
2. NEUTRALIZATION PLATE
3. BUTRESS PLATE
4. BRIDGE PLATES
5. LISS PLATE
6. LOCKING PLATES& SCREW
SCREW
1. Cortical (Compact) bone screw-small treads
2. Cancellous screws –large tread to get more thread-to bone contact

60. PINS
• Used to hold fragments of bone together temporarily or permanently and
to guide large screw insertion.
• Have different tip design
1. Trocar tip – most efficient in cutting- often used for cortical bone
2. Diamond tip
WIRES
Used to reattach large fragments of bone
Useful especially for spiral breaks and reattaching greater trochanter of hip
Wires suffer from twisting and knotting
The deformed region of the wire are more prone to corrosioN
PIN & WIRE FIXAT

61. INTRA-MEDULLARY FIXAT
• Centro-medullary
• Unlocked
• Interlocking (static-dynamic double locked)
• Condylocephalic
• Cephalomedullary

64. EXTERNAL FIXATION

65. Advantages of ex-fix
1. Minimal damage to blood supply
2. Minimal damage to soft tissues (minimal interference with soft
tissue cover)
3. Rigidity of fixation is adjustable without surgery
4. Fixation is away from site of injury
5. Good option when significant infection risk

66. Parts of an external fixator
1. Connecting rods
2. Schanz pins
3. Wires
4. Clumps
Types of external fixators
• Based on location on limb
• Unilateral
• Bilateral
• Circular
• Based on planes
1. Uniplanar
2. Biplanar
3. Multiplanar

75. EXERCISE
• More correctly, restore function – not only to the injured parts but
also to the patient as a whole.
• The objectives are to
1. Reduce oedema,
2. Preserve joint movement,
3. Restore muscle power
4. Guide the patient back to normal activity
Elevation
Active exercise
Functional activity

76. TREATMENT OF OPEN FRACTURES

77. INTRODUCTION
Open fracture definition
• a fracture with direct communication to the external environment

80. Gustillo type one
Gustillo type two

81. Gustillo Type 3 B
Gustillo Type 3 C
Gustillo Type3 A

82. Emergency Room
• Fracture management begins after initial trauma survey and resuscitation is complete
• Antibiotics
• initiate early IV antibiotics and update tetanus prophylaxis as indicated
• Control bleeding
• direct pressure will control active bleeding
• do not blindly clamp or place tourniquets on damaged extremities
• Assessment
• soft-tissue damage
• neurovascular exam
• Dressing
• remove gross debris from wound
• place sterile saline-soaked dressing on the wound
• Stabilize
• o plint fracture for temporary stabilization
• decreases pain, further injury from bone ends, and disruption of clots

83. PRINCIPLES OF TREATMENT
• All open fractures, no matter how trivial they may seem, must be
assumed to be contaminated; it is important to try to prevent them
from becoming infected.
• The four essentials are:
1. antibiotic prophylaxis
2. urgent wound and fracture debridement
3. early definitive wound cover
4. stabilization of the fracture

85. Tetanus Prophylaxis
• Initiate in emergency room or trauma bay
• Two forms of prophylaxis
• toxoid dose 0.5 mL, regardless of age
• immune globulin dosing
• <5-years-old receives 75U
• 5-10-years-old receives 125U
• >10-years-old receives 250U
• toxoid and immunoglobulin should be given intramuscularly with two
different syringes in two different locations
• Guidelines for tetanus prophylaxis depend on 3 factors
• complete or incomplete vaccination history (3 doses)
• date of most recent vaccination
• severity of wound

86. DEBRIDEMENT
• Aggressive debridement and irrigation
• Thorough debridement is critical to prevention of deep infection
• Low and high pressure lavage are equally effective in reducing
bacterial counts
• Saline shown to be most effective irrigating agent
• On average, 3L of saline are used for each successive Gustilo type
• Type I: 3L
• Type II: 6L
• Type III: 9L
• Bony fragments without soft tissue attachment can be removed

87. The following principles must be observed.
• Wound excision
• Wound extension
• Delivery of the fracture
• Removal of devitalized tissue
• Wound cleansing
• Nerves and tendons

88. Wound closure
• A small, uncontaminated wound in a type I or II fracture may be
sutured (after debridement), provided this can be done without
tension.
• In more severe injuries, immediate fracture stabilization and wound
cover using split-skin grafts, local or distant flaps are ideal

89. Stabilizing the fracture
• Stabilizing the fracture is important in reducing the likelihood of
infection and assisting recovery of the soft tissues.
• The method of fixation selected depends on the degree of
contamination, time from injury to operation and amount of soft-
tissue damage
• Fracture stabilization can be with internal or external fixation, as
indicated