PRINCIPLES OF FRACTURES
FRACTURE HEALING
TREATMENT GUIDELINES
Juman Abu Hazeem
Definition
• A Break in the structural continuity of bone.
• Can be divided in to:
1. closed (or simple) If the overlying skin
remains intact
2. open (or compound) fracture; if the skin is
breached
classification
Can also be classified into:
Simple fractures are fractures that only occur
along one line, splitting the bone into two
pieces.
Comminuted (multi-fragmentary) fractures
involve the bone splitting into multiple pieces
Fractures result from:
(1) injury
(2) repetitive stress
(3)abnormal weakening
of the bone
(‘pathological’)
TYPES OF FRACTURE
Complete fractures
Transv
erse
fractur
e
Obliqu
e
spiral
compa
cted
In-complete fractures
commi
nuted
Examples:
greens
tick
fractur
e.
Stress
fractur
e
Compr
ession.
Complete Fractures
• Complete Fracture- A fracture in which bone
fragments separate completely
bone is split into two or more fragments
Complete Fractures types
 Transverse Fracture- A fracture that is at a right
angle to the bone's long axis.
 Oblique Fracture- A fracture that is diagonal to a
bone's long axis.
 Spiral Fracture- A fracture where at least one part
of the bone has been twisted.
 The fracture pattern on x-ray can help predict
behaviour after reduction how?
 answer: in a transverse fracture the fragments
usually remain in place after reduction; if it is
oblique or spiral, they tend to shorten and redisplace even if the bone is splinted
(a) Transverse
(b) segmental
(c) spiral
Complete Fractures types
 Compacted (impacted) Fracture- A fracture caused
when bone fragments are driven into each other or(the
fragmentsare jammed tightly together) and the
fracture line is indistinct
 Comminuted Fracture. Fx, occur at two levels with free segment between
them which there are more than two fragments.
 often unstable because there is poor interlocking of the
fracture surfaces.
• Segmanal fracture : 3 pieces with one piece floating
Oblique fracture
spiral
Impacted fracture
Incomplete fractures
 Fracture where bone is incompletely divided and
the periosteum remains in continuity
o In a greenstick fracture the bone is buckled or
bent .
o seen in children, >>>bones are more springy than
those of adults.
o Children can also sustain injuries where the bone
is plastically deformed (misshapen) without there
being any crack visible on the x-ray.
Incomplete fractures
 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
when the front portion of a vertebra in the spine
collapses due to osteoporosis
 calcaneum
 tibial plateau
Greenstick fracture of radius and ulna
(a) buckle or torus
(b) greenstick
(c)greenstick
More principles
 A stable fracture is one which is likely to stay in a good
(functional) position while it heals.
 An unstable Fx is likely to angulate or rotate before healing
and lead to poor function in the long term
 Fracture of the bony components of the joint is called
fracture-dislocation.
– E.g. shoulder fracture dislocation and elbow fracture
dislocation.
 Burst fracture, occur in vertebra due to severe violence,
acting vertically on a straight spine.
Mechanism of fracture
• Most fractures are caused by sudden and
excessive force
1. direct force
2. indirect force
Forces
 With a 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 so as to create a break with a ‘butterfly’
fragment.
 Damage to the overlying skin is common; if crushing
occurs, the fracture pattern will be comminuted with
extensive soft-tissue damage.
• With an indirect force the bone breaks at a distance
from where the force is applied; soft-tissue damage at
the fracture site is not inevitable.
• Although most fractures are due to a
combination of forces (twisting, bending,
compressing or tension)
The x-ray pattern reveals the dominant
mechanism:
1. • Twisting causes a spiral fracture
2. • Compression causes a short oblique fracture.
3. • Bending results in fracture with transversely or a triangular ‘butterfly’
fragment;
4. • Tension tends to break the bone; in some situations 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.
A cancellous bone, such as a vertebra or the calcaneum, when subjected to
Sufficient force, will split or be crushed into an abnormal shape
Soft tissue damage
• It could be either:
• Low energy fractures like closed spiral fractures, and
it coz moderate soft tissue damage.
• High energy fractures: like comminuted fractures and
it coz severe tissue damage, no matter whether it
open or close.
Mechanism of injury Some fracture patterns suggest the causal mechanism:
(a) spiral pattern (twisting); (b) short oblique pattern (compression); (c) triangular
‘butterfly’ fragment (bending) and (d) transverse pattern (tension)
 Spiral and some (long) oblique patterns are usually due to low-energy
indirect injuries
 Bending and transverse patterns are caused by high-energy direct trauma
FATIGUE OR STRESS FRACTURES



•
Defintion: These fractures occur :
in normal bone
which is subject to repeated heavy loading.
Examples: typically in athletes, dancers or military personnel who
have grueling exercise programmes
• Mechanism:>>>These high loads create minute deformations that
initiate the normal process of remodelling – a combination of bone
resorption and new bone formation in accordance with Wolff’s
law.>>>>
• When exposure to stress and deformation is repeated and
prolonged, resorption occurs faster than replacement and leaves
the area liable to fracture
A similar problem occurs in individuals who are on medication that alters the normal
balance of bone resorption and replacement; stress fractures are increasingly seen in
patients with chronic inflammatory diseases who are on treatment with steroids or
methotrexate.
Fatigue fractures
– fatigue fractures, is caused by the application of abnormal stress
on a bone that has normal elastic resistance, The stress placed
on bone causes resorption and microfractures.
– insufficiency fractures, On the other hand, occurs when normal
muscular activity stresses a bone that is deficient in mineral or
elastic resistance
 Can occur any where but most commonly 2nd metatarsal
followed by Fibula and Tibia.
• Clinically, Pain with gradual onset, examination will show
local tenderness after weeks there will be swelling.
PATHOLOGICAL FRACTURES
Definition: Fractures may occur even with normal
stresses if the bone has been weakened by a
change in its structure
 (e.g. :
 General:
 in osteoporosis
 osteogenesis imperfecta
 Paget’s disease)
or
 through a lytic lesion (e.g. a bone cyst or a
metastasis).
PATHOLOGICAL FRACTURES 2
Local causes
• Bone infection (osteomyelitis).
• Benign tumors (enchondroma, giant cell tumor).
Malignant tumor (osteosarcoma , Ewing sarcoma and metastatic carcinoma).
Generalized causes
• Congenital (osteogenesis imperfecta).
• Diffuse affection of bone (osteoporosis, rickets, uremic osteodystrophy)
• Other causes (Polyostotic fibrous dysplasia, Paget’s disease, Gaucher’s
disease).
CLASSIFICATION OF FRACTURES
• Alphanumeric classification developed by Muller and
colleagues has now been adapted and revised
• In this system, the
1. first digit specifies the bone (1 = humerus, 2=Radius/ulna, 3 =
femur,4 = tibia/fibula)
2. the second the segment (1 = proximal, 2 = diaphyseal, 3 =
distal, 4 = malleolar)
3. A letter specifies the fracture pattern (for the diaphysis: A =
simple, B = wedge, C = complex
4. for the metaphysis: A = extra-articular, B = partial articular,C =
complete articular)
• Two further numbers specify the detailed morphology of the
fracture
•
•
•
•
Each long bone has three segments – proximal, diaphyseal and distal; the proximal
and distal segments are each defined by a square based on the widest part of the
bone. (
(b,c,d) Diaphyseal fractures may be simple, wedge or complex.
(e,f,g) Proximal and distal fractures may be extra-articular, partial articular of
complete articular
FRACTURES DISPLACEDMENT
• After a complete fracture the fragments usually become
displaced, partly by the force of the injury, partly by gravity
and partly by the pull of muscles attached to them.
• The two main fragments of fracture are commonly displaced
• The causes of displacement are:
– Primary impact
– Gravity
– Muscle pull
 The following Displacements are recognized:
• Translation ‘’shift’’
• Length
• Alignment ’’angulation’’
• Rotation ‘’ twist’’
Displacement of the fracture fragments
 Translation (shift) – The fragments may be shifted sideways, backward or
forward in relation to each other, such that the fracture surfaces lose
contact.
 The fracture will usually unite as long as sufficient contact between
surfaces is achieved;
 this may occur even if reduction is imperfect, or even if the fracture ends
are off-ended but the bone segments come to lie side by side.
 Angulation (tilt) – The fragments may be tilted or angulated in relation to
each other.
 Malalignment, if uncorrected, may lead to deformity of the limb.
 • 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.
 Length – The fragments may be distracted and separated, or they may
overlap, due to muscle spasm, causing shortening of the bone
Rotation is NEVER acceptable
Angulation and translation TO A CERTAIN
DEGREE are acceptable
Shortening IN PED.s TO A CERTAIN LIMIT is
acceptabel
FRACTURE HEALING
• The process of fracture repair varies according
to the type of bone involved and the amount
of movement at the fracture site
1. HEALING BY CALLUS
2. HEALING BY DIRECT UNION
HEALING BY CALLUS
• This is the ‘natural’ form of healing in tubular
bones; in the absence of rigid fixation, it proceeds
in five stages:
1. Tissue destruction and haematoma formation
• Vessels are torn and a haematoma forms around
and within the fracture.
• Bone at the fracture surfaces, deprived of a blood
supply, dies back for a millimetre or two.
HEALING BY CALLUS
 2. Inflammation and cellular proliferation –
 Within 8 hours of the fracture there is an acute
inflammatory reaction with
 migration of inflammatory cells
 the initiation of proliferation and differentiation
of mesenchymal stem cells from the
periosteum, the breached medullary canal and
the surrounding muscle.
 The fragment ends are surrounded by cellular
tissue,which creates a scaffold across the
fracture site.vast array of inflammatory
mediators (cytokines and various growth
factors) is involved. The clotted haematoma is
slowly absorbed and fine new capillaries grow
HEALING BY CALLUS
 3. Callus formation – The differentiating stem cells
provide chrondrogenic and osteogenic cell
populations;
• given the right conditions – and this is usually the
local biological and biomechanical environment –
they will start forming bone or, in some cases, also
cartilage.
• The cell population now also includes osteoclasts
(probably derived from the new blood vessels),
which begin to mop up dead bone.
• The thick cellular mass, with its islands of
immature bone and cartilage, forms the callus or
splint on the periosteal and endosteal surfaces.
• As the immature fibre bone (or ‘woven’ bone)
becomes more densely mineralized, movement at
the fracture site decreases progressively and at
about 4 weeks after injury the fracture ‘unites’.
HEALING BY CALLUS
 4. Consolidation – With continuing
osteoclastic and osteoblastic activity the
woven bone is transformed into lamellar
bone.
o The system is now rigid enough to allow
osteoclasts to burrow through the debris at
the fracture line, and close behind them.
o Osteoblasts fill in the remaining gaps
between the fragments with new bone.
o This is a slow process and it may be several
months before the bone is strong enough
to carry normal loads.
HEALING BY CALLUS
 5. Remodelling –
 The fracture has been bridged by a cuff of solid
bone.
 Over a period of months, or even years, this
crude ‘weld’ is reshaped by a continuous
process of alternating bone resorption and
formation.
 Thicker lamellae are laid down where the
stresses are high, unwanted buttresses are
carved away and the medullary cavity is
reformed.
• Eventually, and especially in children, the bone
reassumes something like its normal shape.
HEALING BY DIRECT UNION
• Clinical and experimental studies have shown
that callus is the response to movement at the
fracture site
• It serves to stabilize the fragments as rapidly
as possible – a necessary precondition for
bridging by bone.
• If the fracture site is absolutely immobile – for
example, an impacted fracture in cancellous
bone, or a fracture rigidly immobilized by a
metal plate – there is no stimulus for callus
HEALING BY DIRECT UNION
• Instead, osteoblastic new bone formation occurs directly between
the fragments.
• Gaps between the fracture surfaces are invaded by new capillaries
and osteoprogenitor cells growing in from the edges, and new bone
is laid down on the exposed surface (gap healing).
Where the crevices are very narrow (less than 200 μm), osteogenesis
produces lamellar bone; wider gaps are filled first by woven bone,
which is then remodelled to lamellar bone.
By 3–4 weeks the fracture is solid enough to allow penetration and
bridging of the area by bone remodelling units, i.e. osteoclastic
‘cutting cones’ followed by osteoblasts.
• Where the exposed fracture surfaces are in intimate contact and
held rigidly from the outset, internal bridging may occasionally
occur without any intermediate stages (contact healing).
Comparison
 Healing by callus, though less direct (the term‘indirect’
could be used) has distinct advantages:
• it ensures mechanical strength while the bone ends
heal, and with increasing stress the callus grows
stronger and stronger (an example of Wolff’s law).
 With rigid metal fixation, on the other hand, the
absence of callus means that there is a long period
during which the bone depends entirely upon the
metal implant for its integrity.
• Moreover, the implant diverts stress away from the
bone, which may become osteoporotic and not recover
fully until the metal is removed.
UNION, CONSOLIDATION AND NON-UNION
Union – Union is incomplete repair; the ensheathing
callus is calcified.
Clinically the fracture site is
 still a little tender
 though the bone moves in one piece (and in that
sense is united),
 Attempted angulation is painful.
X-Rays show the fracture line still clearly visible, with
fluffy callus around it.
• Repair is incomplete and it is not safe to subject the
unprotected bone to stress.
 • Consolidation – Consolidation is complete repair ;the
calcified callus is ossified.
 Clinically the fracture:
 site is not tender, no movement can be obtained and
attempted angulation is painless.
 X-rays show:
 the fracture line to be almost obliterated and crossed
by bone trabeculae, with well-defined callus around it.
 Repair is complete and further protection is
unnecessary
• Non-union – Sometimes the normal process of fracture
repair is thwarted and the bone fails to unite
a) Fracture
(
(b) union;
(c) consolidation
(d) bone remodelling
Causes of non-union
• (1) distraction and separation of the fragments,
sometimes the result of interposition of soft
tissues between the fragments;
• (2) excessive movement at the fracture line;
• (3) a severe injury that renders the local tissue s
nonviable or nearly so;
• (4) a poor local blood supply
• (5) infection.
 Of course surgical intervention, if ill-judged, is
another cause!
Non-unions
 Non-unions are septic or aseptic.
 In the latter group, they can be either stiff or mobile as judged by clinical
examination. The mobile ones can be as free and painless as to give the
impression of a false joint (pseudoarthrosis).
On x-ray, non-unions are typified by
• a lucent line still present between the bone
fragments;
• sometimes there is exuberant callus trying but
failing to bridge the gap (hypertrophic non-union)
or at
• times none at all (atrophic non-union) with a
sorry, withered appearance to the fracture ends
What is the cause of…
• Atrophic non-union?
Vascular supply compromise
• Hypertrophic non-union?
Excessive mobility= callus keeps failing
•
•
•
•
Non-unions Aseptic non-unions are generally divided into hypertrophic and
atrophic types.
Hypertrophic non-unions often have florid streams of callus around the fracture
gap – the result of insufficient stability.
They are sometimes given colourful names, such as:
(a) elephant’s foot. In contrast, atrophic non-unions usually arise from an
impaired repair process; they are classified according to the x-ray appearance as
(b) necrotic, (c) gap and (d) atrophic
• Q:Timetable – How long does a fracture take
to unite and to consolidate?
• No precise answer is possible because age,
constitution, blood supply, type of fracture
and other factors all influence the time taken.
Time factor
•
•
•
•
•
•
The rate of the bone healing depends on:
1-type of the bone.
2-type of fracture.
3- blood supply
4-general constitution.
5- pt age.
Average time for Upper limb
healing
Callus visible
Lower limb
union
2-3 weeks
4-6 weeks
2-3 weeks
8-12 weeks
consolidation
6-8 weeks
12-16 weeks
CLINICAL FEATURES
• HISTORY
• There is usually a history of injury, followed by inability to use
the injured limb
• The fracture is not always at the site of the injury: a blow to the
knee may fracture the patella, femoral condyles, shaft of the
femur or even acetabulum.
 The patient’s age
 mechanism of injury
o . If a fracture occurs with trivial trauma, suspect a pathological
lesion.
o Pain,
o bruising
o swelling are common symptoms but they do not distinguish a
fracture from a soft-tissue injury.
o Deformity is much more suggestive.
History 2
 Always enquire about symptoms of associated injuries:
pain and swelling elsewhere (it is a common mistake to
get distracted by the main injury, particularly if it is
severe), numbness or loss of movement, skin pallor or
cyanosis, blood in the urine, abdominal pain, difficulty
with breathing or transient loss of consciousness.
• Once the acute emergency has been dealt with, ask
about previous injuries, or any other musculoskeletal
abnormality that might cause confusion when the x-ray
is seen.
• Finally, a general medical history is important, in
preparation for anaesthesia or operation
GENERAL SIGNS
• Unless it is obvious from the history that the patient has
sustained a localized and fairly modest injury, priority must be
given to dealing with the general effects of trauma
• Follow the ABCs:
• look for, and if necessary attend to, Airway obstruction,
Breathing problems, Circulatory problems and Cervical spine
injury.
• During the secondary survey it will also be necessary to
exclude other previously unsuspected injuries and to be alert
to any possible predisposing cause (such as Paget’s disease or
a metastasis).
LOCAL SIGNS
• Injured tissues must be handled gently.
• To elicit crepitus or abnormal movement is
unnecessarily painful; x-ray diagnosis is more reliable.
• Nevertheless the familiar headings of clinical
examination should always be considered, or damage
to arteries, nerves and ligaments may be overlooked.
• A systematic approach is always helpful:
1. • Examine the most obviously injured part.
2. • Test for artery and nerve damage.
3. • Look for associated injuries in the region.
4. • Look for associated injuries in distant parts.
look
feel
move
Look
• Swelling, bruising and deformity may be
obvious
• the skin is intact>>if the skin is broken and the
wound communicates with the fracture, the
injury is ‘open’ (‘compound’).
• Note also the posture of the distal extremity
and the colour of the skin (signs of nerve or
vessel damage).
Feel
• The injured part is gently palpated for localized tenderness.
• Some fractures would be missed if not specifically looked for
• e.g. the classical sign (indeed the only clinical sign!) of a
fractured scaphoid is tenderness on pressure precisely in the
anatomical snuff-box.
• The common and characteristic associated injuries should also
be felt for, even if the patient does not complain of them.
• For example, an isolated fracture of the proximal fibula should
always alert to the likelihood of an associated fracture or
ligament injury of the ankle
• in high-energy injuries always examine the spine and pelvis.
• Vascular and peripheral nerve abnormalities should be tested
for both before and after treatment
Move
• Crepitus and abnormal movement may be
present,
• Q:but why inflict pain when x-rays are
available?
• It is more important to ask if the patient can
move the joints distal to the injury.
X-RAY
• X-ray examination is mandatory.
Remember the rule of twos:
• • Two views – A fracture or a dislocation may not be seen on a single x-ray
film, and at least two views (anteroposterior 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 malleolus, and also
stress fractures and physeal injuries wherever they occur.
SPECIAL IMAGING
• Sometimes the fracture – or the full extent of the
fracture – is not apparent on the plain x-ray.
• CT may be helpful in lesions of the spine or for complex
joint fractures
• Eg:
• of fractures in ‘difficult’ sites such as the calcaneum or
acetabulum.
• MRI may be the only way of showing whether a
fractured vertebra is threatening to compress the spinal
cord.
• Radioisotope scanning is helpful in diagnosing a
suspected stress fracture or other undisplaced fractures.
DESCRIPTION
• Diagnosing a fracture is not enough; the surgeon
should picture it (and describe it) with its
properties:
• (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 injury? And
last but not least
• (7) who is the person with the injury?
TREATMENT OF CLOSED
FRACTURES
• Treat the patient, not only the fracture.
• Treatment of the fracture consists of
1. manipulation to improve the position of the
fragments
2. followed by splintage to hold them together until
they unite;
• meanwhile joint movement and function must be
preserved.
• Fracture healing is promoted by physiological
loading of the bone>>>>so muscle activity and
early weightbearing are encouraged.
• These objectives are covered by three simple
injunctions:
1. • Reduce.
2. • Hold.
3. • Exercise.
• Two existential problems have to be overcome
• The first is how to hold a fracture adequately and yet
permit the patient to use the limb sufficiently; this is a
conflict (Hold versus Move) that the surgeon seeks to
resolve as rapidly as possible (e.g. by internal fixation).
• However the surgeon also wants to avoid unnecessary
risks – here is a second conflict (Speed versus Safety).
• The most important factor in determining the natural
tendency to heal is the state of the surrounding soft
tissues and the local blood supply.
The Fracture Quartet
• Dual Conflict
– Hold vs Move
– Speed vs Safety
Tscherne (Oestern and Tscherne, 1984) classification of closed
injuries
• • Grade 0 – a simple fracture with little or no soft
tissue injury.
• • Grade 1 – a fracture with superficial abrasion or
bruising of the skin and subcutaneous tissue.
• • Grade 2 – a more severe fracture with deep softtissue
contusion and swelling.
• • Grade 3 – a severe injury with marked soft-tissue
damage and a threatened compartment syndrome.
 The more severe grades of injury are more likely to
require some form of mechanical fixation; good
skeletal stability aids soft-tissue recovery.
REDUCTION
• CLOSED REDUCTION
• OPEN REDUCTION
• Methods of reduction
– Manipulation
– Mechanical traction
1. Manipulation
• 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
1. The distal part of the limb is pulled in the line of the bone
2. The fragments are repositioned as they disengage
3. Alignment is adjusted in each plane
2. Mechanical Traction
• Some fractures are difficult to reduce by
manipulation
• They can often be reduced by sustained
mechanical traction, which then serves also to
hold the fracture until it starts to unite
• In some cases, rapid mechanical traction is
applied prior to internal fixation
3. Open Operation
• Operative reduction under direct vision is
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
Hold
• Restriction of movement
–
–
–
–
Prevention of displacement
Alleviation of pain
Promote soft-tissue healing
Try to allow free movement of the unaffected parts
• Splint the fracture, not the entire limb
• Methods of holding reduction:
–
–
–
–
–
Sustained traction
Cast splintage
Functional bracing
Internal fixation
External fixation
• Closed vs. operative methods
1. Sustained Traction
• Traction is applied to the limb distal to the fracture, so
as to exert a continuous pull in the long axis of the
bone
• In most cases a counterforce will be needed
• Particularly useful for spiral fractures of long-bone
shafts, which are easily displaced by muscle
contraction
• The “hold” is not perfect, but it is “safe” and the
patient can “move” the joints and exercise the muscles.
• The problem is the lack of “speed”complications
• Traction by gravity
– Eg. Fractures of the humerus
• Balanced Traction
– Skin traction: adhesive strapping kept in place by
bandages
– Skeletal traction: stiff wire/pin inserted through
the bone distal to the fracture
Femur fracture managed with skeletal
traction and use of a Steinmann pin in the
distal femur.
2. Cast Splintage
• Plaster of Paris: still used as splint, esp for distal limb
fractures and for most children’s fractures
• “safe” (not applied too tightly or unevenly)
• “speed” of union same as traction, but pt goes home
sooner
• “holding” is not a problem, and patients with tibial
fractures can bear weight on the cast
• Big drawback is that joints encased in plaster cannot
“move” and are liable to stiffen. This complication can
be minimized by:
1. Delayed splintage- using traction until movement has
been regained, and then applying plaster
2. Starting with a cast but after a few weeks replacing it by
a functional brace which permits joint movement
• Most fractures are splinted, not to ensure
union but to: (1) alleviate pain; (2) ensure that
union takes place in good position and (3)
permit early movement of the limb and a
return of function.
• Complications of cast splintage
– Liable to appear once the patient has left the
hospital; added risk of delay before the problem is
attended to
1.
2.
3.
4.
Tight cast
Pressure sores
Skin abrasion or laceration
Loose cast
3. Functional Bracing
• Prevents joint stiffness while still
permitting fracture splintage and loading
• Most commonly for fractures of the femur or
tibia
• Since its not very rigid, it is usually applied
only when the fracture is beginning to unite
– Comes out well on all four of the basic
requirements: “hold” “move” “speed” “safe”
4. Internal Fixation
• “holds” securely with precise reduction
• “movements” can begin at once (no stiffness
and edema)
• “speed”: patient can leave hospital as soon as
wound is healed, but full weight bearing is
unsafe for some time
• “safety”= biggest problem! SEPSIS!!!
– Risk depends on: the patient, the surgeon, the
facilities
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. Fractures in patients who present severe nursing
difficulties
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 screwsresist rotational forces
• Complications of internal fixation
– Most are due to poor technique, equipment, or
operating conditions
– Infection
• Iatrogenic infection is now the most common cause of
chronic osteomyelitis
– 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
5. External Fixation
•
•
•
•
Permits adjustment of length and angulation
Some allow reduction of the fracture in all 3 planes.
Especially applicable to the long bones and the pelvis.
Indications:
1. Fractures associated with severe soft-tissue damage where the wound
can be left open for inspection, dressing, or definitive coverage.
2. Severely comminuted and unstable fractures, which can be held out to
length until healing commences.
3. Fractures of the pelvis, which often cannot be controlled quickly by
any other method.
4. Fractures associated with nerve or vessel damage.
5. Infected fractures, for which internal fixation might not be suitable.
6. Un-united fractures, where dead or sclerotic fragments can be excised
and the remaining ends brought together in the external fixator;
sometimes this is combined with elongation in the normal part of the
shaft
• Complications of external fixation
• High degree of training and skill! Often used for the
most difficult fractures increased likelihood of
complications
– Damage to soft-tissue structures
– Over-distraction
• No contact between the fragments union
delayed/prevented
– Pin-track infection
Exercise
• Restore function to the injured parts and the patient as a
whole
• Active Exercise, Assisted movement (continuous passive
motion by machines), Functional activity
• Objectives:
–
–
–
–
Restore circulation
Prevent soft tissue adhesions
Promote fracture healing
Reduce edema
• Swelling  tissue tension and blistering, joint stiffnes
• Soft Tissue care: elevate and exercise, never dangle, never force
– Preserve joint movement
– Restore muscle power
– Guide patient back to normal activity
OPEN REDUCTION
• Operative reduction of the fracture under direct
vision is indicated:
• (1) when closed reduction fails, either because of
difficulty in controlling the fragments or because
soft tissues are interposed between them;
• (2) when there is a large articular fragment that
needs accurate positioning
• (3) for traction (avulsion) fractures in which the
fragments are held apart.
• As a rule, however, open reduction is merely the
first step to internal fixation.
OPEN FRACTURES
• Initial Management
– At the scene of the accident
– In the hospital
Types of Open Fractures
•
Gustilo’s classification of open fractures:
– Type 1: low-energy fracture with a small, clean wound and little soft-tissue
damage
– Type 2: moderate-energy fracture with a clean wound more than 1 cm long,
but not much soft-tissue damage and no more than moderate comminution of
the fracture.
– Type 3: high-energy fracture with extensive damage to skin, soft tissue and
neurovascular structures, and contamination of the wound.
• Type 3 A: the fractured bone can be adequately covered by soft tissue
• Type 3 B: can’t be adequately covered, and there is also periosteal
stripping, and severe comminution of the fracture
• Type 3 C: if there is an arterial injury that needs to be repaired, regardless
of the amount of other soft-tissue damage.
- The incidence of wound infection
- correlates directly with the extent of soft-tissue damage, <2% in type 1
>10% in type 3
- rises with increasing delay in obtaining soft tissue coverage of the
fracture.
Principles of Treatment of Open
Fractures
• All open fractures assumed to be contaminated
Prevent infection!
• The essentials:
–
–
–
–
–
Prompt wound debridement
Antibiotic prophylaxis
Stabilization of the fracture
Early definitive wound cover
Repeated examination of the limb because open
fractures can also be associated with compartment
syndrome
Sterility and Antibiotic cover
• The wound must be kept covered until the
patient reaches the operating theatre
• Antibiotics ASAP
• Most cases: Benzylpenicillin and flucloxacillin
• Even better: 2nd generation cephalosporin, every
6 hrs/48 hrs
• If heavily contaminated, cover for Gram (-)
organisms and anaerobes by adding gentamicin
or metronidazole and continuing treatment for 4
or 5 days
Debridement and Wound Excision
•
•
•
•
•
•
•
•
•
•
•
•
•
In the operating theatre, never in the ER!
Under GA
Maintain traction on injured limb and hold it still
Remove clothing
Replace dressing with sterile pad
Clean and shave surrounding skin
Remove pad and irrigate wound with A LOT of warm normal
saline
Do not use a tourniquet!
Extend wound and excise ragged margins healthy skin edges
Remove foreign materials and tissue debris
Wash out wound again with warm NS (6-12 L)
Remove devitalized tissue
Best to leave cut nerves and tendons alone
Wound Closure
• “to close, or not to close” the skin= difficult
decision
– Uncontaminated types 1 and 2 wounds may be
sutured
– All other wounds: delayed primary closure
– Type 3 wounds may occasionally have to be debrided
more than once and skin closure may call for plastic
surgery.
– Skin grafting= most appropriate if the wound cant be
closed w/o tension and the recipient bed is clear, free
of obvious in fxn, and well vascularized
Stabilization of the Fracture
• Stability of the fracture is imp in
– Reducing the likelihood of in fxn
– Assisting in recovery of the soft tissues
• Method of fixation depends on:
– Degree of contamination
– Length of time from injury to operation
– Amount of soft tissue damage
• Open fractures of all grades up to 3A treated as for
closed injuries
• More severe injuries: combined approach by plastic
and ortho surgeons
– The precise method depends on the type of soft-tissue
cover that will be employed, although external fixation
using a circular frame can accommodate to most problems
Aftercare and Team Work
• Post-op
– Limb is elevated
– Circulation carefully monitored
– Antibiotic cover continued; swab samples will dictate whether a
diff. antibiotic is needed
– If wound has been left open, inspect in 2-3 days. Delayed
primary suture is then often safe or, if there has been much skin
loss, plastic surgery for grafting may be necessary
• Teamwork
– For optimal results, open fractures with skin and soft-T damage
are best managed by a partnership of ortho and plastic
surgeons, ideally from the outset rather than by later referral
– If no plastic surgeon on site, use a digital camera for image
transmission by internet to communicate and consult.
That’s it 