ORTHROPEDIC SURGERY FRACTURES INTRODUCTION.ppt

Orthopedic Surgery
Fractures
DR MEHWISH IQBAL
DPT,MS-OMPT

By the end of this session you should be
By the end of this session you should be
able to describe:
able to describe:
What is a fracture?
What is a fracture?
 Types of fractures..
Types of fractures..
 Causes..
Causes..
 Clinical Features..
Clinical Features..
 Healing of fractures..
Healing of fractures..
 Complications..
Complications..
Principles of management..
Principles of management..

Definition
“Loss of continuity in the substance of a
bone is called a fracture.”
Spectrum extends from a microscopic
fracture to a hair line fracture and than to
grossly notable fractures.

Types of fractures
 Open
 Closed

Types (cont,d)
 Avulsion fracture:
Muscle or ligament pulls on a bone fracturing it.
 Comminuted fracture:
Bone is shattered into many pieces
 Compression fracture:
Collapse of bone usually vertebra in osteoporosis
 Fracture dislocation:
 Greenstick fracture:
One side of bone fractures, not complete and bone bends
 Hair line fracture:
 Impacted fracture:
Fragments of bone got impacted
 Intraarticular fracture:

Types (cont,d)
 Longitudinal fracture:
Along the length of bone
 Oblique fracture:
Fracture is diagonal to bones long axis
 Pathological fracture:
 Spiral fracture:
Atleast one part of bone has twisted
 Stress fracture:
Bone breaks because of repeated stresses and strains e.g. athletes
 Transverse fracture:
A straight break right across a bone

Anatomic description - Type
Type is the overall
fracture pattern
Examples are:
Simple
Spiral
segmental

Anatomic description of fractures
Type
Comminution
Location
Displacement

Anatomic description - Comminution
Comminution is the measure of the
number of pieces of broken bone that
there are.
Examples are: non-comminuted or mildly
comminuted or severely comminuted

Anatomic description - Location
Location is the anatomic location of the
fracture usually described by giving the
bone involved and location on the bone
Examples are: distal radial shaft, proximal
1/3 humeral shaft, intra-articular distal
tibial

Anatomic description - Displacement
Displacement is the amount the pieces of
a fracture have moved from their normal
location
Can be displaced or non-displaced
Subdivided into 3 sub-categories:
translation, angulation, and shortening

Displacement - Translation
Translation is
sideways motion of
the fracture - usually
described as a
percentage of
movement when
compared to the
diameter of the bone.

Displacement - Angulation
Angulation is the
amount of bend at a
fracture described in
degrees. Described
with respect to the
apex of the angle or
with respect to
direction of distal
fragment.

Displacement - Shortening
Shortening is the
amount a fracture is
collapsed expressed
in centimeters.

Anatomic description
Simple, transverse,
non-communited
midshaft radial and
ulnar fracture with 30
degrees apex radial
angulation.

Why classify fractures?
Classification or description of fractures is
only used when it is useful in providing
treatment or outcomes.

Types of classifications
Anatomic description
AO classification for Long bone fracture
( Humerus, Radius/ Ulna, Femur, Tibia/
Fibula)
Salter-Harris classification for Epiphysial
plate fracture
Gustillo anderson classification for
open fracture

AO Classification
1st
number = long bone
2nd
number = bone segment
Letter = fracture type (A,B,C)
Then 3rd
& 4th
numbers classify fracture group
& subgroup

Oblique fracture Proximal Femoral Shaft :
(32 A2.1)
3 … the bone … femur
(1= Humerus, 2= Radius/ Ulna, 3= Femur, 4= Tibia/
Fibula)
2 … the segment … diaphysis
(1= Epiphysis, 2= Diaphysis, 3= Metaphysis)
A … the type … least severe
(A= least severe, B= Intermediate, C= Most severe)
 2 … the group … Gp. 2 includes oblique fractures
 1 … the subgroup … 1 includes fracture in proximal
part of diaphysis

Salter-Harris Classification
Only used for pediatric fractures that
involve the growth plate (Physis)
Five types (I-V)

Salter-Harris type I fracture
Type I fracture is
when there is a
fracture across the
physis with no
metaphysial or
epiphysial injury

Salter-Harris type II fracture
Type II fracture is
when there is a
fracture across the
physis which extends
into the metaphysis

Salter-Harris type III fracture
Type III fracture is
when there is a
fracture across the
physis which extends
into the epiphysis

Salter-Harris type IV fracture
Type IV fracture is
when there is a
fracture through
metaphysis, physis,
and epiphysis

Salter-Harris type V fracture
Type V fracture is
when there is a crush
injury to the physis

Gustillo classification
The Gustillo classification is used to
classify open fracture - ones in which the
skin has been disrupted
Three grades that try to quantify the
amount of soft tissue damage associated
with the fracture

Open fractures - grade 1
wound less than 1 cm with minimal soft
tissue injury
wound bed is clean
bone injury is simple with minimal
comminution
With IM nailing, average time to union
is 21-28 weeks

Open fractures - grade 2
wound is greater than 1 cm with
moderate soft tissue injury
wound bed is moderately contaminated
fracture contains moderate
comminution
is 26-28 weeks

Open fractures - grade 3A
wound greater than 10 cm with
crushed tissue and contamination
soft tissue coverage of bone is usually
possible
is 30-35 weeks

Open fractures - grade 3B
wound greater than 10 cm with
crushed tissue and contamination
soft tissue is inadequate and requires
regional or free flap
with IM nailing, average time to union
is 30-35 weeks

Open fractures - grade 3C
is fracture in which there is a major
vascular injury requiring repair for limb
salvage
in some cases it will be necessary to
consider BKA following tibial fracture

Causes of Fractures
Fall (Elderly)
RTA (Younger)
Underlying illnesses that weaken
bones.. Pathological fractures e.g;
Osteoporosis, infection, tumor
Repeated stresses & strains e.g;
athletes .. Stress fractures

Clinical Features
 Depends which bone affected, patients age, general health, severity
of injury.
 Pain
 Swelling
 Bruising
 Discoloured area around affected area
 Angulation
 Inabbility to bear weight
 Inability to move/ painful active or passive movements
 Grating sensation/ crepitus
 Bleeding if open fractures
 If large bone leading to occult bleeding … pallor and dizziness,
feeling of sickness & nausea

Healing of Fractures
Proper alignment & immobility, healing is
straightforward
Osteoclasts absorbs old & damaged bone
Osteoblasts create new bone
Callus is new bone formed around
fracture site

Setting a Break
Bone is constantly in a state of turnover, even
Bone is constantly in a state of turnover, even
when not damaged or injured.
when not damaged or injured.
In order for the fracture to heal without any
In order for the fracture to heal without any
deformity, a good ‘reduction,’ or placement, of
deformity, a good ‘reduction,’ or placement, of
the bones must be attained.
the bones must be attained.
If the reduction cannot be satisfactorily
If the reduction cannot be satisfactorily
achieved then a further procedure may be
achieved then a further procedure may be
necessary, such as an
necessary, such as an operation with fixation
with fixation
of the bone with plates, screws or nails.
of the bone with plates, screws or nails.

Factors affecting healing process
Patient,s age
Bone affected
Type of fracture
Patient general health condition
Smokers

Complications in Fracture Healing
Heals in wrong position
Known as Malunion … either heals in wrong position
or fracture shifts
Disruption of bone growth
If fracture affects growth plate, subsequent deformity
Persistent bone or bone marrow infection
If break in skin … can lead to chronic osteomyelitis
Bone death (Avascular necrosis)
If bone loses its essential blood supply

Principles of General Fracture
Management (REST)
Rest
Elevation
Support & Immobilization:
Bones are aligned in anatomical position &
must stay align during process of healing.
Temperature (warmth)

Methods of Immobilization
Plaster casts or plastic functional braces
Metal plates & screws
Intra medullary nails
External fixators

Definition:
Open Reduction Internal Fixation.
Open reduction internal fixation is a method of surgically repairing a fractured bone.
Generally, this involves either the use of plates and screws or an intramedullary (IM) rod to stabilize the bone.
O.R.I.F.
O.R.I.F.

Definition:
Definition: Intra medullary nails or
Intra medullary nails or
rods are devices used to stabilize
rods are devices used to stabilize
fractures and allow for bone healing.
fractures and allow for bone healing.
IM nails are inserted into the
IM nails are inserted into the
medullary (bone marrow) canal in the
medullary (bone marrow) canal in the
center of the long bones of the
center of the long bones of the
extremities (e.g. femur, tibia, etc.).
extremities (e.g. femur, tibia, etc.).
Intra medullary Rods
Intra medullary Rods

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