FRACTURES

DR QUEEN MD
VIHAS
 FRACTURES
• DEFINITION
• CAUSES
• CLINICAL FEATURES AND DIAGNOSIS
• CLASSIFICATION OF #S
• DESCRIBING #S: LANGUAGE OF #S
• MANAGEMENT
• BONE HEALING
• FACTORS INFLUENCING BONE HEALING
• OPEN # MNx
 DEFINITION OF A #
• A fracture is a break of continuity in the substance of bone. with involved
sorrounding tissues

• The term covers ALL BONY DISRUPTIONS ranging from hairline #s at one
end of the scale to multi-fragmentary or comminuted #s at the other.

• In most cases a # produces a complete unstable situation (instability).

EXCEPTONS:
In greenstick #s
 CAUSES OF #S
1.TRAUMA
• Fractures are caused by application of a FORCE OR
IMPACT THAT EXCEEDS the limits of strength of a
bone

• These forces may be:

I. Direct Force/Violence
II. indirect Force/Violence
 Direct Force
• This is a force that acts directly on the bone

• Examples:
• A bone struck by a moving or falling object eg in assault

• A bone striking a resistant or hard object eg in MTA, falls

• In these situations the site of the # is usually at the area

where the force or impact was applied

• These #s are usually transverse or comminuted

 Indirect Force/Violence
• This is due to a twisting, bending or a torsion
force applied to a bone.

• The # site is usually at some distance from the

site of application of the causal force

• The #s are usually spiral or oblique

 2. Stress Fractures
• Stress #s can be divided into 2 categories:

• 1. Fatigue #s: are due to repetitive prolonged stress on

normal bone. Common sites: tibia shaft, midfibula,
metatarsals, patella, calcaneus,pubic ramus, pars
interarticularis

• 2. Insufficiency fractures: #s that result from normal stresses

on abnormal bone eg in osteomalacia, osteoporosis.
• Other major predisposing conditions for insufficiency #s
include: Osteomalacia, osteoporosis, radiation, fibrous
dysplasia, hyperparathyroidism, Paget’s disease.
 3. Pathologic #
• This is a # occurring in an already diseased or weakened bone.

• The force required to cause the # is usually trivial, eg

• In osteoporosis
• In osteomalacia
• In osteomyelitis
• in neoplasm
• In metabolic bone diseases

• Common causes include: benign tumors, osteomyelitis, tb of bone

 Principles of Fracture Diagnosis
• History
• Physical Examination
• Radiographic Imaging
• Fracture Description
 Clinical features (cont’d)
 Tenderness over the # site on palpation
 Swelling at the # site + or – bruising around the # area
• Bruising can take hrs to appear
 Impairment/loss of function of the limb –varies from
minimal to complete.
 Deformity that can be seen or felt at the # site if the
fractured bone ends have been displaced in relation to
each other
Undisplaced #s cause no deformity
 Clinical features (cont’d)
 Abnormal Movements at the # site
• NB: These are absent if the bone ends are impacted

 Crepitus or grating when the bone ends are moved against

each other.

• These last 2 should not be tested deliberately because they

cause unnecessary pain to the patient and may cause further
soft tissue damage and blood loss without giving any
additional advantage to diagnosis
 History
• Acute Injury? .
There is usually a history of trauma or injury
EXCEPTIONS: stress #s, some cases of pathological #s
• When did it happen?
• Mechanism: What happened?
• Where does it hurt?
• History of previous injuries?
• What makes it better?
• What makes it worse?
• Treatment to date?
• Predisposing Factors
• CORMOBIDITIES ? TB,DM,HIV,CANCER
 Physical Examination
• Inspection: – Swollen? Ecchymosed? Deformity?
Open wound?
• Palpation: – Where does it hurt?!!!!
• Range of Motion: – Gentle [active and passive]
–check and note all ranges of movement of the
affected limb,compare with normal limb
• Neurovascular: – check Arterial Pulses distal to the
injury,Capillary refill,Check muscle power,check also
sensation normal?
 DESCRIBING FRACTURES (Fracture
Language)
• The following things are important to describe
when making the diagnosis of a # in order to
enable you select the correct mode of
treatment of the #:
 1.Classification by Bone Exposure

 Classifications by Bone exposure:

 Mention whether the fracture is closed (simple) or open (Compound)
i.open fracture
Defined as a broken bone that is in contact with the environment, through
defect on the skin.The amount of contact can vary from a small puncture
wound or laceration in the skin to a large avulsion of soft tissue that
leaves the bone exposed. Open fractures are surgical emergencies
because of their complications (soft tissue damage, infection,
haemorrhage).
ii. Closed fracture
fracture occurs with no contact between fracture fragments and the
environment.
2.Classification by Anatomical Site
• Mention the anatomical site and the level of the #:
 a. Which bone?
 b. Which level? For long bone:
Epiphysis (E)
Epiphyseal plate (EP)
Diaphysis (shaft) (D)
Metaphysis (M)
Intra-articular
 cont’d
 (c) A # may also be described as involving a distinct
anatomical part. Ex:

# of the femoral diaphysis (shaft)

# of the femoral neck

# of the greater/lesser trochanter / intratrochanteric

Supracondylar # of the femur

 Describing #s (cont’d)
 (d) For descriptive purposes a long bone may be arbitrarily
divided into thirds:
proximal third
middle third
distal third
• So you can have:
# of the prox/third of the femur
# of the middle third of the femur (R)
# of the distal third of the femur (S)
# of the femur at the junction of the middle and distal
third (T)
 Describing #s (cont’d)
 (e) Sometimes an eponym name can be used
to describe the level of a #. Ex:

a Colles’ fracture i.e. a # of the radius within

an inch or 2.5 cm of the distal radius (U)
 3.Depending on the nature of the
fracture line
• 3. Fracture Patterns:

• mainly described by the mode of the fracture lines:

• Transverse #
• Spiral #
• oblique # + or – butterfly fragment
• Comminuted # ( more than two # fragments at one fructure site)
• Segmental # : In a single bone, fracture occurs at two different levels
• Avulsion # . This is a fracture occurring due to a pull by a muscle, tendon
or a ligament at its insertion to the bone.
• Intra-articular # ;A fracture that involves (extends into) the articular
surface of a joint.
• Impacted #
• Compression #
• Greenstick #
4.The deformity or disfigurement:
Depending on the displacements
• a. Displaced fracture.
• b. Undisplaced fracture
• May result from the causal force or impact, manipulation during
evacuation of the pt or due to muscle action

• If the bone ends are not displaced relative to one another, then
the # is said to be in anatomical position

• Similarly if after manipulation or reduction of a fracture a perfect

position is achieved, we say that an anatomical reduction has
been achieved i.e. the # fragments are in anatomical position
 Displacement (translation) or
shifting:
• Is said to occur when the bone ends have shifted relative to one another
while the axes of the 2 bone fragments are parallel

Causes of displacement and deformity

• The initial force
• gravity
• muscle action (muscle contraction)
• movement or manipulation of the pt
. During admin of 1st aid
. During transport to hosp
. During initial assessment
 cont’d
• The DIRECTION of displacement is described in terms of
movement of the distal fragment in relation to the proximal
fragment which remains static

• Examples (diagram):
• (1) – no displacement
• (2) _ lateral displacement
• (3) _ posterior displacement
• (4) _ both lat and post displacement

• NOTE: Always have x-rays at least in 2 views at 90 degrees,

i.e. AP and lateral view
 cont’d
• The Degree of Displacement
• Is appreciated by roughly estimating the percentage of the fracture
surfaces in contact. Ex:

• a 50% bony apposition/contact

• a 25% bony apposition/contact

• Good bony contact encourages stability and bone healing/union

• If none of the of # surfaces is in contact, the # is described as having no

bony apposition, no bony contact or being completely off-ended. Such #s
are potentially unstable and liable to shortening. They may be hard to
reduce due to soft tissue interposition btwn the bone ends and delayed or
nonunion can occur.
 Shortening

• Occurs usually due to overlap of the bone

fragments (overriding)

• May also result from impaction of one

fragment into the other
 Angulation

• This is loss of the normal longitudinal axis of the shaft of a

long bone. The axes of # fragments cross at a point.

• The accepted method of describing angulation is in terms of

the direction or position of the angle:

• Ex: # of the femoral shaft with medial angulation

• # of the tibia and fibula with post angulation

 Angulation (cont’d)
• Significant angulation must always be corrected
because:

• a. The limb deformity will be conspicuous

• and regarded by pt as a sign of poor treat

• b. Function may be seriously impaired

• c. May lead to abnormal joint stresses, leading to 2nd

OA
 Axial Rotation (Twisting)

• This results from one fragment rotating on its long axis relative to the
other with or without accompanying displacement or angulation

• The direction of the rotation is determined by the direction of rotation of

the distal fragment: ext or internal

• NB: On an X-ray, rotation can easily be overlooked if the x-rays do not

show both ends of the bone

• Therefore in any # both the joint above and the one below the # should
be included in the x-ray examination
 CONCL……
• “This is a (open/closed) (transverse / oblique /
spiral / comminuted) fracture of the
(location). • It is (displaced / undisplaced) ___
percent (laterally, medially, etc.) • with __
degrees _________ angulation, • ___ cm of
shortening, • and __ degrees of rotation
 INVESTIGATIONS
IMAGING
Radiographic-X RAYS,
.LABORATORY
Haemoglobin level (for major fractures like
pelvic and femoral)
Other investigations are determined by the
possible cause
 X-Rays
• Yes or No?
• Order if: – Dysfunction of limb (ex. Unable to
weight-bear) – Deformity – Marked swelling –
Significant mechanism – Clinical suspicion
• Orthogonal Views: AP and Lateral
Management
 LIFE SAVING
MEASURES

–A Airway and cervical spine immobilisation

–B Breathing

–C Circulation (treatment and diagnosis of

cause)

–D Disability (head injury)

 BASIC METHODS OF TREATMENT
OF FRACTURE
• 1. Immobilization in a cast
• 2.closed reduction
• 3.open reduction and internal fixations
• 4.closed reduction and internal fixations
• 5.external fixation
• 6.tractions.
• Al these methods can be selectively employed to treat
fracture depending on indication. These methods enhance
biological process of healing by maintaining anatomical
alignment and provide necessary stability at fracture site.
 A.CONSERVATIVE TREATMENT
OF FRACTURES
• INDICATIONS
• 1. Pediatrics #s
– except intra-articular, supracondylar humerus, shaft #s in
older children and avulsion #s e.g. medial humeral
epicon
• 2. Undisplaced #s except femoral neck #
• 3. Poor bone quality e.g. osteoporosis
• 4. Unfixable #s e.g. severe comminution
• 5. Systemic C/I e.g. immunodefic, heart dses, etc
• 6. Local C/I e.g. severe skin lesions or wounds
• 7. Others e.g. pt decision, psychological problems,etc
 TYPES OF CONSERVATIVE
Rx
• 1. Cast application
• 2. Splints
• 3. Traction
• 4. Others e.g.
braces
 1. Cast
types

Uses:
•#s of tibia
n fibula

•distal
femoral #s

•Stable
ankle
#s
Short leg Long leg
cast cast
1. Cast types cont…
1
Uses:
ligament injuries of the
knee and stable
fractures about the
knee joint where
rotational control is not
of great concern.

Generally, it is used as
a weight-bearing cast;
therefore, the foot is
left free
1. Cast types cont…
2

Hip spica
1. Cast types cont…
3

Halo
jacket
 1. Cast types cont…
4
Short arm cast Long arm
cast
 1. Cast types cont…
5
Thumb spica, LAT Thumb spica, PA
view view

Use:
•Thumb met
#s
1. Cast types
cont…6

Use:
•Distal humerus #s

Hanging arm
cast
 Casts cont
• Complications
• 1. Pressure sores
• 2. Compartment
syndrome
• 3. Nerve injuries
• 4. Malposition
• 5. Stiffness and disuse
• 6. Blisters
• 7. Allergic dermatitis
 2. SPLINTS
• Well-applied plaster splints can be used for
nearly all the smaller tasks performed by
casts, except for the spica casts.
• The primary advantages of splints are that
they are lighter in weight than casts, allow for
swelling of the limb, and are removable.
• They are, however, much weaker, and the
fact that they are removable may pose a
problem in noncompliant patients.
 2. Splint cont…
1
a. Short leg splint/ back slab b. Long leg splint
 3. TRACTIONS
• Indication:
– Generally, Rx #s when reduction of the # or proper
length of the limb cannot be maintained by the
static immobilization provided by casts and splints.
– 1. Rx unstable dislocations, esp hip
– 2. #s of pelvis with vertical displacements
– 3. Unstable acetabular # with minimal displacement
– 4. # shaft and supracondylar femur
– 5. Comminuted Tibia plateau #s
– 6. Tibia #s and tibia plafond #
• NB: 1. Almost never used in Upper extremity #s rare olecranon
 3. TRACTIONS cont…
1
• Disadvantages:
– Need for prolonged bed rest
– Prolonged and expensive
hospitalization
– Return to function is slow
3. TRACTION CONT…1
A. SKIN TRACTION

Indication:
 Pediatrics femoral #
 Old people with
osteoporosis
 etc
 3. TRACTION cont…3

• B. Skeletal traction
• Site:
• 1. Femoral #s: trans-
femoral pin or trans-tibia
[commonest]
• 2. Tibia #s: trans-
calcaneal pin
• 3. Humerus #s: trans-
olecranon [rare]
 3. TRACTION cont…4
a. Perkin’s b. Bohler-Braun
traction frame

Multiple injured pts to Femur #s but rare

easy todate
nursing care.
 3. TRACTION cont…6
a. Fisk’s b. 90 – 90 traction
traction

Knee sling for Prox femoral

exercises #s
 3. TRACTION cont…7

Overhead
Olecranon
pin traction
 3. TRACTION cont…8
Complication of tractions
• Muscle atrophy
•Pressure sores
•Constant attention
•Compartment syndrome due to excessive
traction
•Thrombophlebitis with secondary PE
 B. OPERATIVE FRACTURE
Rx
• TYPES:
• 1. External fixation
• 2. Percutaneous fixation
• 3. Internal fixation
(a). Extra-medullarly fixation
(b). Intra-medullarly fixation
 1. External
fixation
• Indications:
• 1. Open #s or extensive wounds – allows
wound care
• 2. Bone lengthening e.g. illizarov ring
fixator
• 3. Correction of malalignment
• 4. Correcting soft tissue contractures.
• 5. Polytraumatized patient
 1. External fixators cont…
1
TYPES
 1. External fixates cont…
2
Circular Ex-fix e.g. illizarov
 1. External fixates cont…
3
• Complications
• 1. Chronic pain: pin loosening, infection,
etc
• 2. Pin site drainage and infection
• 3. Deformity
• 4. Delayed union and non- union
 2. Percutaneous Pin
fixation
• Use:
– 1. Corrective osteotomy
– 2. Supracondylar #s in peds
– 3. Undisplaced femoral neck fractures
– 4. Comminuted femoral condyle #s
 2. Percutaneous Pin fixation
cont
a. K-wires in intra-articular
Phalangeal # b. Provisional K-wire insertion
 3. Internal
fixation [extra-
medullary]
It involves insertion of
•plates,
•screws and
• wires
a. Cerclage wire b. Screw
fixation
3. Internal fixation [extra-
medullary] cont…1
a. Tension Band Wiring TBW b. Plate insertion

3. Internal fixation [extra-

medullary] cont…2
 4. Internal fixation
[Intra-medullary] cont…
1
Indications:
•1. Closed #s long bones
•2. Open #s (few) e.g. Gustillo I to IIIA
Involves insertion of nails
 4. Internal fixation
[Intra-medullary] cont…
3
a. SIGN Nail b. Rush rod
 4. Internal fixation
[Intra-medullary] cont…
4

Russell
Taylor
nail
 4. Internal fixation
[Intra-medullary] cont…
5
a. Gamma nail b. Alta
nail
 WHEN IS THE FRACTURE
HEALED?
• 1. Clinically
Upper limb Lower limb
Adult 6-8 weeks 12-16 weeks
Child 3-4 weeks 6-8 weeks

• 2. Radiologically
– Bridging callus
– Remodelling
 REHABILITATIO
N
• Restoring the patient as close to pre-injury functional
level as possible
• May not be possible with:-
– Severe fractures or other injuries
– Elderly patients

– Approach needs to be:-

• Pragmatic with realistic targets
• Multidisciplinary
– Physiotherapist, Occupational therapist, District nurse, GP, Social
worker
 OPEN FRACTURES
 Classification of open fractures by gustilo and Anderson
 Criteria for classification include
a. extent of injury to the skin
b. injury to the soft tissues
c. injury to the bone ,blood vessels, nerve
d. degree of contamination

Type 1: the wound is less than 1 cm in diameter, no skin

crushing , no or little contamination and fracture pattern is
not complex
cnt
 STEPS IN MANAGEMENT OF OPEN
FRACTURE
1. Examination of a patient as a whole for other associated
injuries
2.IV fluids and broad spectrum antibiotics
3.immediate care of the wound-washing with saline and
application of sterile compression
4.immediate immobilization of the injured is done with
appropriate splint
5. if a patient is in shock all resuscitative measures are employed
immediately
6.if necessary a patient should be shifted to a better Centre
7.definitive management is carried out as soon as the patient is
stable for surgical interventions
 COMPLICATIONS OF FRACTURE
• 1. Local complications
• a. associated nerve ,vascular and visceral injuries
• b. non union , delayed union and malunion
• c. infection-osteomyelitis and pyogenic arthritis
d. compatiment syndrome

• 2.systemic complications
• a. hemorrhage and shock
• b. fat embolism
• c. crush syndrome
• d. pulmonary embolism
 Late complications can include:

1.Malunion
2.non union,
3. osteonecrosis,
4 post traumatic arthritis
 DIFFERENTIAL DIAGNOSIS OF
FRACTURE
• 1.Dislocation
• 2.disarticulation
• 3.subluxation
 FRACTURES (cont’d)
• CLASSIFICATION OF FRACTURES

• The AO Classification

• Classification of Open #s -The Gustillo Classif

• Classification of Peri-articular (Epiphyseal)#s in Children –

(The Salter- Harris Classification)

• The Weber Classification of Ankle #s

 HEALING OF A FRACTURE
• Healing takes place in stages over a period of time. There are four stages of
healing of a fracture
• 1st stage: hematoma formation- when blood vessels are torn during fracture blood
accumulates
• forming hematoma which acts as a vehicle delivering the required
material for union.

• 2nd stage: cellular proliferation-within 8hrs of fracture there is inflammation

subsequently leading to subperiosteal and endosteal cellular
proliferation surrounding the broken ends of the bone and new
capillaries start to infiltrate these cellular masses

• 3rd stage: primary woven bone formation-the proliferating cells (osteogenic and
chondrogenic) start to get incorporated into fibrogenic matrix forming woven
bone which is soft as it is not fully mineralized during 2nd and 3rd week
 cnt
• 4th stage: lamellar bone formation-mineralization occur and
primary woven bone is transformed into lamellar
bone this occur btn 3rd and 6th week. Lamellar bone is hard
and is seen as a bridge and indicates early stage of fracture
union.

 The stage of remodeling is better not considered as a stage of

healing as it only takes place after the fracture
unites(heals) and takes months to years
 Healing of fracture in cancelllous bones does not follow these
stages .they heal by direct formation osteoblastic new bone
 FACTORS INFLUENCING HEALING
• 1.Factors not within control of a doctor
• a. nature of trauma
• b. nature of fracture
• c. pattern of fracture; spiral> oblique >transverse
>comminuted
• d. vascularity of the bone
• e. age of the patient
• 2.factors within control of a doctor
• a. proper reduction d. prevention of distraction
• b. adequate fixation e. prevention of infection
• c. adequate immobilization f. adequate nutrition and
Mx of co-morbid illnesses