Principles of fractures

5th stage
Dr.Kalid Ali Zayer

A fracture is a break in the structural continuity of bone. It may be no more

than a crack, a crumpling or a splintering of the cortex; more often the break
is complete and the bone fragments are displaced.

HOW FRACTURES HAPPEN

Fractures result from
(1) injury
(2) repetitive stress
(3) abnormal weakening of the bone (a ‘pathological’ fracture).

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Classification of fracture
A- According to the state of soft tissue
1. Closed (or simple) fracture; If the overlying skin remains intact.
2. Open (or compound) fracture if the skin or one of the body cavities
is breached , liable to contamination and infection.

B- According to appearance of fracture.

1- Complete fracture The bone is split into two or more fragments
subdivided into
▪ transverse fracture the fragments usually remain in place after
reduction.
▪ Oblique or spiral, they tend to shorten and re-displace even if
the bone is splinted.
▪ Impacted fracture the fragments are jammed tightly together and the
fracture line is indistinct.
▪ Comminuted fracture is one in which there are more than two
fragments these are often unstable.

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2- Incomplete fracture Here the bone is incompletely divided and the
periosteum remains in continuity, Subdivided into:
▪ A greenstick fracture this is seen in children, whose bones are more
springy than those of adults. (like snapping a greentwig)
▪ Buckle or torus the bone is plastically deformed (misshapen)without
there being any crack visible on the x-ray.
▪ Compression fractures occur when cancellous bone is crumpled. This
happens in adults and typically where this type of bone structure is
present, e.g. in the vertebral bodies, calcaneum and tibial plateau.

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Mechanism of the fracture:
1- Direct force the bone breaks at the point of impact; the soft tissues
also are damaged. A direct blow usually splits the bone transversely or
may bend it over a fulcrum so as to create a break with a ‘butterfly’
fragment.
2- Indirect force the bone breaks at a distance from where the force is
applied; soft-tissue damage at the fracture site is not inevitable

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Classification of fracture according to mechanism of injury;
- Twisting causes a spiral fracture.
- Compression causes a short oblique fracture.
- Bending results in 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.

NOTE: The above description applies mainly to the long bones.

HOW FRACTURES ARE DISPLACED

After a complete fracture the fragments usually become displaced
1. Partly by the force of the injury.
2. Partly by gravity.
3. Partly by the pull of muscles attached to them.

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Types of Displacement;
1. Translation (shift) – The fragments may be shifted sideways, backward
or forward in relation to each other, such that the fracture surfaces lose
contact.
2. Angulation (tilt) – The fragments may be tilted or angulated in relation
to each other. Malalignment, if uncorrected, may lead to deformity of
the limb.
3. Rotation (twist) – One of the fragments may be twisted on its
longitudinal axis; the bone looks straight but the limb ends up with a
rotational deformity.
4. Length – The fragments may be distracted and separated, or they may
overlap, due to muscle spasm,causing shortening of the bone.

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CLINICAL FEATURES
1- pain
2- bruising
3- swelling
4- deformity is much more suggestive
5- associated symptoms
a. pain and swelling elsewhere
b. numbness or loss of movement
c. skin pallor or cyanosis
d. blood in the urine
e. abdominal pain
f. difficulty with breathing or transient loss of consciousness

Diagnosise of fracture :
1. clinical features
2. Imaging study which include

A- X-Ray the rule of two:

▪ Two views – A fracture or a dislocation may not be seen on a
single x-ray film, and at least two views (antero posterior and
lateral) must be taken.
▪ Two joints – In the forearm or leg, one bone may be fractured and
angulated. Angulation, however, is impossible unless the other bone
is also broken, or a joint dislocated. The joints above and below the
fracture must both be included on the x-ray films.
▪ Two limbs – In children, the appearance of immature epiphyses may
confuse the diagnosis of a fracture; x-rays of the uninjured limb are
needed for comparison.
▪ Two injuries – Severe force often causes injuries at more than one
level. Thus, with fractures of the calcaneum or femur it is important
to also x-ray the pelvis and spine.
▪ Two occasions – Some fractures are notoriously difficult to detect
soon after injury, but another x-ray examination a week or two later
may show the lesion. Common examples are undisplaced fractures
of the distal end of the clavicle, scaphoid, femoral neck and lateral

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 malleolus, and also stress fractures and physeal injuries wherever
they occur.

B- Computed tomography (CT Scan) may be helpful in lesions of the

spine or for complex joint fractures indeed, these cross sectional images
are essential for accurate visualization of fractures in ‘difficult’ sites
such as the calcaneum or acetabulum.
C- Magnetic resonance imaging may be the only way of showing whether
a fractured vertebra is threatening to compress the spinal cord.
D- Radioisotope scanning is helpful in diagnosing a suspected stress
fracture or other undisplaced fractures.

What are the points should be the surgeon known after diagnosis the
fracture;
(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 shape of the break?
5- Is it stable or unstable?
6- Is it a high-energy or a low-energy.

Healing of fracture;
A- primary healing by direct union
B- secondary healing by calluse formation

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Stages of fracture healing
1. Tissue destruction and haematoma formation –
Vessels are torn and a haematoma forms around and within the fracture.
2. Inflammation and cellular proliferation – Within 8 hours of the fracture
there is an acute inflammatory reaction with migration of inflammatory
cells and the initiation of proliferation and differentiation of mesenchymal
stem cells from the periosteum.
3. Callus formation the cell population changes to osteoblasts and
osteoclasts; dead bone is mopped up and woven bone appears in the
fracture callus.
4. Consolidation This is woven bone is replaced by lamellar bone and the
fracture is solidly united a slow process and it may be several months
before the bone is strong enough to carry normal loads.
5. Remodelling – The fracture has been bridged by cuff of solid bone. Over
a period of months, or even years, the newly formed bone is remodelled to
resemble the normal structure