General principles of fracture and dislocation
- 1. General principles of fracture and dislocation Dr. Robel Sirak Orthopedic surgeon
- 2. Outline • Introduction • Mechanisms • Classification • Fractures in Children • Approach to patients • Management of fractures • Management of Dislocations
- 3. Introduction • Definition : fracture is a break in the structural continuity of a bone. • Practically a fracture is a soft tissue injury in the presence of a broken bone • Classification : - Based on cause – traumatic , pathological or stress - Based on pattern - Clinically
- 4. 02/09/2025 4 Mechanism Fractures result from: • Injury (Most common) • Repetitive stress • Abnormal bone weakening (Pathological)
- 5. 02/09/2025 5 Fractures caused by injury Modes of injury • Falls • Direct blows , assault or crush injuries • Sport injuries • MVA • Gun shot injuries
- 6. Majority of the fractures. 1. DIRECT FORCE 2. INDIRECT FORCE 3. Combined
- 7. Fracture patterns : Most fractures are due to a combination of forces , the x-ray pattern reveals the dominant mechanism:
- 8. 02/09/2025 8 Stress fracture Occur in normal bone which is subject to repeated heavy loading (unaccustomed stresses)
- 9. Insufficiency fracture • Occurs with normal stress (load) in a bone with impaired healing • E.g. metatarsal fracture in an elderly who uses a walker
- 10. 02/09/2025 10 Pathological fracture Occur even with normal stresses if the bone has been weakened by • Change in its structure (osteoporosis, OI or Paget’s disease) • Through a lytic lesion (e.g. a bone cyst or a metastasis)
- 11. 02/09/2025 11 Factors Suggesting a Pathologic Fracture Spontaneous fracture Fracture after minor trauma Pain at the site before the fracture Multiple recent fractures Unusual fracture pattern (banana fracture) Patient >45 years of age History of primary malignancy
- 12. 02/09/2025 12 Description of fracture 1. Is it open or closed? 2. Which bone is broken and where? 3. Has it involved a joint surface? 4. What is the type of the break? 5. Is it stable or unstable/ Displacement? 6. Is it a high-energy or a low-energy?
- 13. Describing the Fracture • Why Classify? • As a treatment guide • To assist with prognosis • To speak a common language
- 14. 02/09/2025 14 Classification The OTA devised an elaborate classification system to describe the injury accurately and guide treatment. There are five parts to the code: 1-Bone 2 -Where in the bone 3-Type 4 -Group 5-Subgroup
- 15. Parameters 1. Anatomical site (bone & location in bone) 2. Articular involvement/epiphyseal injuries • fracture involving joint • dislocation • ligamentous avulsion 3. Pattern (Which type and Which group?) 4. Configuration displacement • three planes of angulation • translation • Shortening 5. Soft tissue injury
- 16. Proximal & Distal Segment Fractures • Type A • Extra-articular • Type B • Partial articular • Type C • Complete disruption of the articular surface
- 17. Diaphyseal Fractures • Type A • Simple fractures with two fragments • Type B • Wedge fractures • Type C • Complex fractures with no contact between main fragments
- 18. Simple 1. Spiral 2. Oblique 3. Transverse
- 19. Wedge 1. Spiral wedge 2. Bending wedge 3. Fragmented wedge
- 20. Complex 1. Spiral multi-fragmentary 2. Segmental 3. Irregular
- 21. 02/09/2025 21 Displacement of the fracture fragments The causes of displacement are: • Primary impact(force of injury) • Gravity • Muscle pull
- 22. 02/09/2025 22 Cont’d • The following Displacements are recognized: • Shift (translation) • Angulations (Tilt) • Rotation (twist) • Shortening
- 23. Classification based on soft tissue injury • Closed (simple) fracture • Fracture is not exposed to the environment • Compound (Open) fracture • A break in the skin and underlying soft tissue leading directing into or communicating with the fracture and its hematoma
- 26. 02/09/2025 26 Unique features of Skeletally Immature Bones 1. Epiphysis, physis, metaphysis, diaphysis 2. Cartilaginous growth plate 3. Thick, strong, highly cellular periostum 4. Physeal injuries - “weak link” 5. Rapid healing with complete remodeling 6. Most are treated by closed method
- 27. Injuries of the Physis 02/09/2025 27 • 10% of fractures in children involve injury to the physis
- 28. 02/09/2025 28 Cont’d Factors that increase suspicion of physeal injury 1. Widening of physeal gap. 2. Incongruity of the joint. 3. Tilting of the epiphyseal axis.
- 29. 02/09/2025 29 Examination for Fracture/Dislocation Look for • Swelling • Bruising • Deformity • If skin is intact or not (open VS simple) • Posture of distal extremities and color of the skin signs of nerve or vessel damage
- 30. 02/09/2025 30 Feel for • Palpate for localized tenderness • In high energy injuries, always examine spine and pelvis • Vascular and peripheral nerve abnormalities should be tested for both before and after treatment Cont’d
- 31. 02/09/2025 31 Cont’d Move • Crepitus and abnormal movement tested - in unconscious patients • Ask if patient can move the joints distal to the injury
- 32. 02/09/2025 32 Imaging X-ray series Rule of two: 1. Two views 2. Two joints 3. Two limbs 4. Two occasions 5. Two injuries .
- 33. 02/09/2025 33 Cont’d CT and MRI display Frx. patterns in difficult sites • Bone scanning is helpful in diagnosing a suspected stress fracture or other undisplaced fractures NB- Secondary injuries should always be assumed to have occurred unless proven other wise
- 34. 02/09/2025 34 Principles of Treatment • Treat the Patient, not only the fracture Principles: STABLIZATION REDUCTION! IMMOBILIZATION! REHABILITATION!
- 35. 02/09/2025 35 Cont’d • Open fractures are assumed to be contaminated Prevent infection! • The essentials: • Antibiotic prophylaxis • Prompt wound debridement • Stabilization of the fracture • Early definitive wound cover
- 36. 02/09/2025 36 Stablization The purposes of emergency splinting are: 1. Prevent further soft-tissue injury by the fracture fragments, 2. Reduce pain 3. Lower the incidence of fat embolism and 4. Decreases ongoing blood loss
- 37. 02/09/2025 37 Reduction • Reduction unnecessary when: • There is little or no displacement • When displacement doesn’t matter initially • Reduction is unlikely to succeed • Aim of reduction • Adequate apposition • Normal alignment of the bone fragments • Methods of reduction • Closed reduction • Mechanical traction • Open reduction
- 38. 02/09/2025 38 1. Closed reduction • Closed manipulation is suitable for 1. All minimally displaced fractures 2. Most fractures in children 3. Fractures that are likely to be stable after reduction • Unstable fractures are sometimes reduced ‘closed’ prior to mechanical fixation • Three fold maneuver: under anesthesia and muscle relaxation
- 39. 02/09/2025 39 2. Mechanical Traction • certain fractures can be reduced by sustained mechanical traction, which then serves also to hold the fracture until it starts to unite
- 40. 02/09/2025 40 3. Open reduction indicated: 1. When closed reduction fails 2. When there is a large articular fragment that needs accurate positioning 3. For avulsion fractures in which the fragments are held apart by muscle pull 4. When an operation is needed for associated injuries 5. When a fracture will anyhow need internal fixation to hold it
- 41. 02/09/2025 41 Immobilization • Restriction of movement • Prevention of displacement • Alleviation of pain • Promote soft-tissue healing • Try to allow free movement of the unaffected parts
- 42. 02/09/2025 42 Cont’d • Methods of holding reduction: • Sustained traction • Cast splintage • Functional bracing • Internal fixation • External fixation
- 43. 02/09/2025 43 1. Sustained Traction The problem is the lack of “speed” • Skin traction • Skeletal traction • Traction by gravity Complication
- 44. 02/09/2025 44 2. Cast Splintage Plaster of Paris: used esp. for distal limb fractures and for most children’s fractures • “move” is the weakest Complications
- 45. 02/09/2025 45 3. Functional Bracing • Prevents joint stiffness while still permitting fracture splintage and loading • Not very rigid, so applied when fracture is beginning to unite
- 46. 02/09/2025 46 4. Internal Fixation • “holds” securely with precise reduction • “movements” can begin at once • “speed”: • “safety”= biggest problem! Infection!!! • Risk depends on: the patient, the surgeon, the facilities
- 47. 02/09/2025 47 Cont’d • Indications for internal fixation 1. Fractures that cannot be reduced except by operation 2. Fractures that are inherently unstable and prone to re- displacement after reduction 3. Fractures that unite poorly and slowly 4. Pathological fractures 5. Multiple fractures 6. patients who present nursing difficulties
- 48. 02/09/2025 48 1. Interfragmentary/Lag Screws: o Fixing small fragments onto the main bone 2. Kirschner Wires o Hold fragments together where fracture healing is predictably quick 3. Plates and screws o Metaphyseal fractures of long bones o Diaphyseal fractures of the radius and ulna 4. Intramedullary nails o Long bones o Locking screwsresist rotational forces
- 49. 02/09/2025 49 Complications Most are due to poor technique, equipment, or operating conditions • Infection • Non-union • Excessive stripping of the soft tissues • unnecessary damage to the blood supply in the course of operative fixation • rigid fixation with a gap between the fragments • Implant failure & Refracture
- 50. 02/09/2025 50 5. External Fixation Indications: 1. Fractures with severe soft-tissue damage 2. Severely comminuted and unstable fractures 3. Fractures of the pelvis, which often cannot be controlled quickly by any other method. 4. Infected fractures 5. Fractures with NV damage Complications pin site infections
- 51. 02/09/2025 51 Rehabilitation • Restore function to the injured parts and the patient as a whole • Active Exercise, • Assisted movement (continuous passive motion by machines),
- 52. 02/09/2025 52 • Restore circulation • Prevent soft tissue adhesions • Promote fracture healing • Reduce edema • Preserve joint movement • Restore muscle power • Guide patient back to normal activity Objectives
- 53. 02/09/2025 53 Complications of Fractures
- 54. 02/09/2025 54 General complications • Shock • Deep vein thrombosis and pulmonary embolism. • Tetanus. • Gas gangrene. • Fat embolism syndrome. • Crush syndrome.
- 55. 02/09/2025 55 Early, local complications 1 . visceral injury 2 . vascular injury 3 . compartment syndrome 4 . nerve injury 5 . infections 6 . hemarthrosis
- 56. 02/09/2025 56 Late complications of fractures • Delayed union • Non union/ Malunion • Avascular necrosis • Osteoarthritis • Heterotopic ossification • Myositis ossificans • Complex regional pain syndrome
- 58. 02/09/2025 58 JOINT DISLOCATIONS • A dislocation is a separation of two bones where they meet at a joint. • Dislocations may be associated with a periarticular fracture
- 59. Definition • Dislocation is a complete displacement of the articular surface of joint. Joints are no longer in contact. • Subluxation is an incomplete displacement. • Recurrent dislocation – repeated dislocation of a joint usually due to damage to the ligaments and joint margin
- 60. Classification • 1. Congenital • Hip dislocation • 2. Traumatic • 3. Pathological • Polio • infection
- 61. Clinical feature • Dislocations are usually caused by a sudden impact to the joint. This usually occurs following a blow, fall, or other trauma • Painful & swollen joint • Abnormally shaped joint and bony landmarks may be displaced • Abnormal position of the limb • Tenderness • Neurovascular injury
- 62. 02/09/2025 62 Signs • Visibly out-of-place, discolored, or misshapen joint • Limited joint movement • Swollen or bruised • Intensely painful, • Decreased sensation distal to the joint • Decreased pulse, cool extremity distal to the joint
- 63. Imaging • Confirm the Dx • Shows associated bony injury • Two planes at 90 degrees to each other • Good quality • See the entire joint 02/09/2025 63
- 64. 02/09/2025 64 Treatment Principles • Reduce the dislocation as soon as possible • Check Neurovascular function distally • Take post reduction radiograph • Immobilize the joint
- 65. Cont’d… • Acute dislocations should be reduced as soon as possible. If they are not reduced promptly, pathological changes occur, especially around the hip. • Open techniques rarely are necessary for acute dislocations. • Closed reduction with intravenous analgesia and sedation or with general anesthesia for uncomplicated dislocations. • If general anesthesia is necessary, OR personnel should prepare for the possibility of an open surgical procedure • Excessive force should not be used in closed reduction these could lead to fractures or additional articular trauma.
- 66. Complications of open or closed reduction • Ectopic ossification, • Posttraumatic arthritis, and • Osteonecrosis
- 67. INDICATIONS FOR OPEN REDUCTION 1. If anatomical, concentric reduction cannot be achieved by gentle, closed techniques. 2. If a stable reduction cannot be maintained. 3. If complete motor and sensory nerve deficit. 4. If circulatory impairment distal to the injury is Present. 5. If ischemia is persistent.
- 68. Thank you
Editor's Notes
- #5: A-Direct blow that causes a transverse fracture with damage to skin. B-Crushing force that causes comminuted fracture with extensive damage to soft tissue. The bone breaks at a distance from where the force is applied. Soft-tissue damage at the fracture site is not inevitable.
- #8: If the patient rests and the stress decreases then repair may continue with resultant relief of pain. However, if the repair process can no longer keep up with the resorptive process, then cortical disruption and a radiographically visible fracture may ensue insufficiency fractures, wherein normal stresses applied to abnormal bone produce fracture. When exposure to stress and deformation is repeated and prolonged, resorption occurs faster than replacement and leaves the area liable to fracture
- #11: * A “banana fracture” is a transverse fracture after minimal trauma through an abnormal area of bone. It is a frequent pattern in pathologic situations and has the appearance of breaking a segment off of a banana.
- #12: who is the person with the injury? In short, the examiner must learn to recognize what has been aptly described as the ‘personality’ of the fracture.
- #13: These bending, torsion, tensile and compressive forces are applied to bones, and if excessive, may lead to fracture.
- #27: The fracture usually runs transversely through the hypertrophic or the calcified layer of the growth plate, However, If a fracture transverses the cellular (reproductive) layer of the plate premature ossification of injured part and cessation of growth or bone deformity.
- #33: Secondary injuries:- thoracic, SCI, pelvic & abdominal, pectoral girdle injuries.
- #41: Not complete immobility; usually it is the prevention of displacement. Nevertheless, some restriction of movement is needed to promote soft-tissue healing and to allow free movement of the unaffected parts.
- #43: Traction is applied to the limb distal to the fracture, so as to exert a continuous pull in the long axis of the bone particularly useful for shaft fractures that are oblique or spiral and easily displaced by muscle contraction. Circulatory embarrassment Nerve injury Pin site infection
- #55: NB-There is no accepted time for a complication to be considered ‘early’, but the term is usually applied to complications that occur during the acute phase of treatment.
- #65: Excessive force should not be used in closed reduction because soft tissue or bone sometimes becomes interposed between the articular surfaces, making closed reduction impossible. Forceful manipulation under these conditions can result in fractures or additional articular trauma.
- #67: If anatomical, concentric reduction cannot be achieved by gentle, closed techniques with the patient under general anesthesia. Interposed soft tissues or osteochondral fragments may contribute to the irreducibility. If a stable reduction cannot be maintained. Articular fractures often are unstable and must be reduced and fixed to ensure stability of the reduction. If careful evaluation before closed reduction reveals normal neurological function, and after reduction a definite, complete motor and sensory nerve deficit becomes evident. If circulatory impairment distal to the injury is well documented before reduction and persists after reduction. Further assessment of the circulation is essential and should include arteriography. If ischemia is persistent. Surgical exploration with appropriate management of the vascular injury is indicated.