2. A fracture is a break in the structural
continuity of the bone
It may be closed if the skin is intact or
compound if the fracture haematoma
connected to the surface of the skin or one
of the body cavities.
3. How fracture happed
trauma (direct or indirect)
repetitive stress.
abnormal weakening of the bone (pathological).
Green stick fracture.
Physeal injuries.
4. Types of fractures:
1. Fractures due to
trauma: Types of
fractures in trauma
depend on the force
applied:
7. 2. Fatigue or stress fractures:
Is the one occurring in the normal bone of a healthy patient due to
repetitive stress rather than single traumatic evidence.
Most common sites affected pubic rami , femoral neck , tibial shaft
especially in trainee and athletes , distal fibula , metatarsals
especially the second.
9. 3. Pathological fractures:
• When abnormal bone gives way. The causes are numerous but
the diagnosis not made till biopsy taken.
10. Causes:
• General bone disease
1. osteogenesis imperfecta
2. postmenopausal osteoporosis
3. metabolic bone disease
4. multiple myeloma
5. paget disease
11. Local benign conditions
1. chronic infection
2. solitary bone cyst
3. fibrous cortical defect
4. aneurysmal bone cyst
5. chondroma
13. 4. Incomplete fractures (Greenstick
fractures)
• In which instead of complete fracture of the bone cortex the bone is
buckled or bent {like snapping a green twig} this usually seen in children.
14. 5. Injuries to the physis:
In children over 10 % of fractures involve the physis.
Classification:
Salter and Harris classification
17. How fractures are displaced:
• After complete fracture the bones may displaced by the effect
of gravity or the pull of the muscles attached.
• translation (shift)
• alignment (angulation)
• rotation (twist)
19. How fracture heal
• Fractures heal even if not splinted but we splint it for:
1. Reduce pain
2. To ensure that union takes place in good position
3. To permit early movement and return of function.
20. Five stages of healing:
1. tissue distraction and haematoma formation.
2. inflammation and cellular proliferation
3. callus formation
4. consolidation
5. remodeling
22. the upper limbs in children in general 3Wks
The lower limbs in children Double the time i.e. 6 wks
The upper limbs in adults Double the time needed in children i.e. 6 wks
The lower limbs in adults Double the time needed in children i.e. 12
wks
Fracture healing calendar:
23. Clinical features:
History:
usually history of injury , followed by inability to use the
injured limb.
The fracture may be away form the site of injury
The patient age
mechanism of injury is important
If the fracture follow a trivial trauma suspect a pathological
fracture.
24. Pain ,
swelling ,
bruising.
Deformity is more suggestive.
Ask about associated injuries.
General medical and surgical histories are important.
25. Examination:
General signs:
. cervical spines injuries should be excluded. And
general survey.
Local signs:
Crepitus or abnormal movement may be noted.
Examine the most obvious injured part.
Test for artery and nerve damage.
Look for associated injuries in the region.
Look for associated injuries in distal parts.
26. Look : swelling , bruising and deformity , is the skin intact is it broken and the
wound communicate with fracture the injury is then open or compound.
Feel : the injured part is gently palpated for localized tenderness. Check for
distal pulse and nerve function.
Move : crepitus and abnormal movement is tested.
27. X – Ray
The rule of two:
Two views
Two joints
Two limbs
Two injuries
Two occasions
28. Special imaging
Some times the fracture not seen in usual XR so do:
Tomography as in spine.
CT
MRI may be the only way to show whether the fractured vertebra
compress the spinal cord.
Radioisotope scan is helpful in stress fractures.
29. Treatment of closed fractures:
Three important rules:
Reduce
Hold
exercise
.
30. Reduce:
•Reduction should aim for adequate apposition and
normal alignment of the bone fragments. The
greater the contact surface area between the
fragments the more likely the healing to occur.
•There are two methods of reduction:
31. closed reduction: under proper anesthesia and muscle
relaxation the fracture reduced by
1. the distal part of the bone is pulled in line of the
bone as the fragments disengaged ,they are
repositioned
open reduction: by operation
indications:
1. failure of closed reduction
2. displaced articular fractures which need accurate
reduction.
3. for traction fractures where the fragments are hold
apart.
33. Hold
Immobilization is performed by:
1. continuous traction
2. cast splintage
3. functional brace
4. internal fixation
5. external fixation
34. continious traction
the problem with traction that it does not maintain
accurate reduction and the patient remain in bed
for long period.
Two types of traction:
1. skin traction: for pull not more than 5 kg using
adhesive straps
2. skeletal traction: by pin inserted in the bone
distal to the fracture , this when high weight is
needed.
Complication of traction:
1. circulatory embarrassment. Especially in children.
2. nerve injury . in older people, drop foot may
happen
3. pin-site infection.
36. Cast splintage:
• Plaster of Paris (POP) is a common method of fixation of fractures
after reduction rotation of the fracture shaft can be prevented by
including the joint above and the joint below
• The patient can leave the bed early in LL fractures using of
crutches allow ambulation.
39. Functional bracing
Using POP or plastic materials, it prevents joint stiffness, segments of
cast are applied over the shaft of the bones leaving the joints free
Since the brace is not rigid, it applied only when the fracture is
beginning to unite.
41. Internal fixation
Bone fragments can be fixed by screws, transfixing pins , or nails , plate
and screws , intramedullary nail, circumferential bands or
combination.
Advantages:
1. hold fractures securely so allow early movement and prevent
stiffness, and edema.
2. allow early leaving of hospital.
3. accurate reduction as in intraarticular fractures.
43. Indications:
1. failure of closed method.
2. unstable fractures which are likely to displaced, as
in ankle fractures , or those liable to muscle pull as
in transverse patellar fracture or olecranon.
3. fractures that unite poorly or slowly as in fracture
neck femur.
4. pathological fractures.
5. multiple fractures.
6. in patient with nursing difficulties as in paraplegics ,
and multiple injuries.
45. External fixation:
The bone is transfixed below and above the fracture by
screws or pins or tensioned wires and these connected to
each other by rigid bars.
Indications:
1. Fractures associated with sever soft tissue damage.
2. Fractures associated with sever nerve or vessels damage.
3. Severely comminuted and unstable fractures.
4. Ununited fractures.
5. Pelvic fractures if cannot controlled by other methods.
6. Infected fractures.
7. Sever multiple injuries.
48. Exercise
This important after any fracture because:
1. prevention of oedema. This by muscle exercises and elevation.
2. active exercises which pumps the edema away prevents
adhesion of soft tissues, and help fracture healing, and prevent
muscle atrophy.
3. assisted movement this by special machines.
52. Open fracture classification
• Allows comparison of results
• Provides guidelines on prognosis and treatment
• Fracture healing, infection and amputation rate correlate with the
degree of soft tissue injury
• Gustilo upgraded to Gustilo and Anderson
• AO open fracture classification
• Host classification of open fractures
53. Type 1 Open Fractures
• Wound less than 1 cm,
• Inside-out injury
• Clean wound
• Minimal soft tissue damage
• No significant periosteal
stripping
54. Type 2 Open Fractures
• Moderate soft tissue damage
• Outside-in
• Higher energy
• Some necrotic muscle
• Some periosteal stripping
55. Type 3a Open Fractures
• High energy
• Outside-in
• Extensive muscle devitalization
• Bone coverage with existing soft
tissue
56. Type 3b Open Fractures
• High energy
• Outside in
• Extensive muscle
devitalization
•Requires a flap for
bone coverage and
soft tissue closure
• Periosteal stripping
57. Type 3c Open Fractures
• High energy
• Increased risk of amputation
and infection
• Any grade 3 with major
vascular injury requiring repair
58. Why use this classification?
•Grades of soft tissue injury correlates with infection and
fracture healing
Grade 1 2 3A 3B 3C
Infection
Rates
0-2% 2-7% 10-25% 10-50% 25-50%
Fracture
Healing
(weeks)
21-28 28-30 30-35 30-35
Amputation
Rate
50%
59. Goals of treatment
• 1. preserve life
• 2. preserve limb
• 3. preserve function
• Also….
• Prevent infection
• Fracture stabilization
• Soft tissue coverage
61. Types of fracture stabilization
• Splint
• Good option if operative fixation not
required
• Internal fixation
• Wound is clean and soft tissue coverage
available
• External fixation
• Dirty wounds or extensive soft tissue injury
62. Fracture stabilization
• Gustilo type 1 injury can be treated the same way as a comparable
closed fracture
• Most cases involve surgical fixation
• Outcome is similar to closed counterparts
63. Fracture stabilization
Gustilo type 2&3 usually displaced and
unstable
dictate surgical fixation
Restore length, alignment, rotation and
provide stability
ideal environment for soft tissue healing and
reduces wound infection
reduces dead space and hematoma volume
Inflammatory response dampened
Exudates and edema is reduced
Tissue revascularization is encouraged
64. When to use plates?
• Open diaphyseal fractures of arm & forearm
• Open diaphyseal fractures lower extremity
• NOT recommended
• Open tibial shaft plating assoc high infection rate*
• Open periarticular fractures
• Treatment of choice in both upper and lower extremities
65. When to use IM nails?
Treatment of choice for most
diaphyseal fractures of the
lower extremity
Inserted without disrupting
the already injured soft tissue
envelope
Preserves the remaining extra
osseous blood supply to
cortical bone
Malunion is uncommon
66. When to use external fixation?
• Diaphyseal fractures not
amenable to IM nails
• Ring fixators for
periarticular fractures
• Temporary joint
spanning ex fix is popular
for knee, ankle, elbow
and wrist
• If temporary, plan for
conversion to IM nail
within 3 weeks
69. Skin cover and soft tissue
reconstruction
• Do these early!
• 1994 Osterman et al.*
• Retrospective 1085 fractures, 115 G2 and 239 G3
• No infection if wounds closed at 7.6 days
• Yes infection if wounds closed at 17.9 days
Infection risk
increases if wound
open > 7days
71. Type 3c, a bad injury!
Devastating damage to
bone and soft tissue
Major arterial injuries
that require repair
Poor functional outcome
Consensus btwn ortho,
vascular and plastics
Salvage is technically
possible in most cases
However it is not always
the correct choice esp
type 3c tibia fractures
72. How to decide, salvage or amputate?
• Important factors in decision making:*
• General condition of the patient (shock)
• Warm ischemia time (>6hours)
• Age (>30 years)
• Cut to crush ratio (blunt injuries has a large zone of crush)
