Principles of Fracture
Treatment
What is a (bony) fracture?

Disruption of a bone’s normal structure or
“wholeness”

Crack, break, or rupture in a bone

There are many how’s and why’s to bony
fractures
 Terms used to describe each are related
Definition of Fracture

There are 2 types of # in which this is not
so:
1.
Pathological fract.
1.
Stress fract.
Pathological fracture :
It is one in which a bone is
broken through an area
weakened by pre-existing
disease , & by a degree of force
that would have left normal
bone intact e.g osteoporosis ,
O.M. , bone tumours.
Stress fracture :
Bone, like other materials,
reacts to repeated loading. On
occasion, it becomes fatigued
& a crack develops e.g military
installations, ballet dancers &
athletes.
Diagnosis
Clinical
picture
Radiography
Clinical Features of Fracture


History of trauma
Symptoms & signs:
1. Pain & tenderness
3. Deformity
5. Loss of function
move.
7. N.V. injuries
2. Swelling
4. Crepitus
6. Abnormal
Orthopaedic History

A good general orthopaedic history
contains:
 Onset, Duration, and Location of a problem
 Limitations and debilitation attributed to the
problem
 Good surgical history, especially with
regards to orthopaedic surgeries and prior
anesthesia
 Co-morbid conditions that contribute to the
problem or will preclude healing in some
manner
Physical Exam Basics
Inspect and Palpate everything- start
with normal structures and move to
abnormal
 Range of motion in all planes
 Strength
 Sensation
 Reflexes
 Gait
 Stability

Physical Exam Basics

1.
2.
NVI What does this mean?
Neurologic exam- Always document
the neurologic status. Some fractures
are associated with nerve injuries and
knowing the status of the nerve is
critical
Vascular exam- Always check for
pulses distal to the fracture sight.
Missed vascular injuries can be
devastating
Pre-reading Musculoskeletal
Radiographs






1: Name, date, old films for
comparison
2: What type of view(s)
3: Identify bone(s) & joint(s)
demonstrated
4: Skeletal maturity
(physes: growth plates)
5: Soft tissue swelling
6: Bones & joints
(fractures & dislocations)
Physical Exam
NEVER trust someone else’s exam.
ALWAYS put your hands on the patient
and see for yourself
 Always trust your exam- you WILL pick
up something that someone else has
missed at some point

OPEN AND CLOSED FRACTURES
Intro to Reading X-rays
Reading a radiograph is essentially
describing the anatomy of a certain
structure
 In order for it to be universal and
understandable for others, clarity and
precision are essential
 A fracture is described based on the
findings of the physical exam and a
review of radiographs

Reading X-rays
1.
Say what it is- what anatomic structure are
you looking at and how many different
views are there
2.
Regional Location- Diaphysis (rule of 1/3),
Metaphysis, Epiphysis including intra and
extra-articular
3.
Direction of the fracture line- Transverse,
Oblique, Spiral
Reading X-rays
5.
6.
Condition of the bone- comminution (3
or more parts), Segmental (middle
fragment), Butterfly segment,
incomplete, avulsion, stress, impacted
Deformity-Displacemtent (distal with
respect to proximal), angulation (varus,
valgus), rotation, shortening (in cm’s),
distraction
Fracture Pattern
 Transverse
 Produced
by a
distracting or
tensile force
Fracture Pattern
 Spiral
 Produced
by a
torsional force
Fracture Pattern
 Produced
by
pure bending
force
 Butterfly
Fracture Pattern
 Comminuted
 Broken
into
many pieceshigh energy
with combined
forces
Displacement
 Characterized
by % of bone
contact on either view
Angulation
 Distal
fragment relative to proximal
 Varus, Valgus, Anterior, Posterior
 Apex
of angle formed by fragments
 E.g., Apex Anterior, Apex Medial,
Apex Ulnar
Location

Commonly described in thirds of
affected bone
 ie distal third of tibia
 ie junction of proximal and middle
third of femur
 If fractured at two levels describe as
segmental
Location-Diaphysis

Shaft portion of
bone
Location-Metaphysis

The ends of the bone
(if the fracture goes
into a joint it is
described as intraarticular)
Now All Together

Transverse fracture of
the femur at the middle
third- distal third junction
with 100% displacement
and varus (or apex
lateral) angulation
What do you see?
What do you see?
What do you see?
Mnemonic: OLD ACID
O: Open vs. closed
 L: Location
 D: Degree (complete vs. incomplete)

A: Articular extension
 C: Comminution / Pattern
 I: Intrinsic bone quality
 D: Displacement, angulation, rotation

O: Open vs. Closed

Open fracture
 AKA: “Compound fracture”
 A fracture in which bone
penetrates through skin;
 “Open to air”
 Some define this as a
fracture with any open wound
or soft tissue laceration near
the bony fracture

Closed fracture
 Fracture with intact overlying
skin
L: Location


Which bone?
Thirds (long bones)
 Proximal, middle, distal third

Physis
Metaphysis
Anatomic orientation
 E.g. proximal, distal, medial,
lateral, anterior, posterior

Epiphysis
Anatomic landmarks
Diaphysis
(Shaft)
 E.g. head, neck, body /
shaft, base, condyle

Segment (long bones)
 Epiphysis, physis,
metaphysis, diaphysis
Articular
Surface
D: Degree of Fracture

Complete
 Complete cortical
circumference involved
 Fragments are completely
separated

Incomplete
 Not fractured all the way
through
 “Only one cortex” involved
 e.g “Greenstick fracture”
A: Articular Extension / Involvement
Intra-articular
fractures
 “Involves the
articular surface”
 Dislocation

 Loss of joint surface
/ articular congruity

Fracture-dislocation
C: Comminution / Pattern







Transverse (Simple)
Oblique (Simple)
Spiral (Simple)
Linear / longitudinal
Segmental
Comminuted
Compression / impacted
 “Buckle / Torus”

Distraction / avulsion
C: Comminution / Pattern

Transverse (Simple)
C: Comminution / Pattern


Oblique (Simple)
Spiral (Simple)
 Oblique in 2+ views
C: Comminution / Pattern

Linear / longitudinal / split
C: Comminution / Pattern

Segmental
 Bone broken in 2+ separate places;
Fx lines do not connect
C: Comminution / Pattern

Comminuted
 Broken, splintered, or crushed into >3 pieces
C: Comminution / Pattern
Compression
 Impacted

 (e.g. “Buckle / Torus”)
C: Comminution / Pattern

“Buckle / Torus”
C: Comminution / Pattern
Distracted
 Avulsion

I: Intrinsic Bone Quality
Normal
Osteopenia
Decr’d density –
I: Intrinsic Bone Quality
Normal
Osteopetrosis
Incr’d density –
I: Intrinsic Bone Quality
Normal

Osteopoikilosis
 Focal areas of
incr’d density
D: Displacement, Angulation, Rotation
Displacement
Extent to which Fx –
fragments are not axially
aligned
Fragments shifted in –
various directions relative
to each other
Convention: describe –
displacement of distal
fragment relative to
proximal
Oblique tibial shaft Fx b/w
distal & middle thirds; laterally
displaced
D: Displacement, Angulation, Rotation
Angulation
Extent to which Fx –
fragments are not
anatomically aligned
In a angular fashion
Convention: describe –
angulation as the
direction the apex is
pointing relative to
anatomical long axis of
the bone (e.g. apex
medial, apex valgus)
R Tibial shaft Fx b/w prox &
middle thirds, angulated
apex lateral (apex varus)
D: Displacement, Angulation, Rotation
Angulation
Valgus
Apex medial
Parallel
No angulation
Varus
Apex lateral
D: Displacement, Angulation, Rotation
Rotation
Extent to which Fx –
fragments are rotated
relative to each other
Convention: describe which –
direction the distal fragment
is rotated relative to the
proximal portion of the bone
D: Displacement, Angulation, Rotation
Rotation
Normal PA view of hip
Greater trochanter in –
profile
PA view of rotated hip Fx
Greater trochanter –
perpendicular to film
Salter-Harris Fractures
Other signs of fractures

Periosteal reaction
Callus /
Osteosclerosis
Other signs of fractures

Fat pad sign / “Sail sign”
Conclusions

Know how to read X-rays
(Patients expect this & we order a lot of
them)

Communicate and share with your
consultants
(It affects patient outcomes)
 Pre-reading
 Describing fractures
Fracture Classification
 Anat.
Location
 Direction
of
fract. Line
the
fract. Is linear or
comminuted
 Condition
of
overlying S.T.
 Mechnism of
injury
 Wherther
 AO
classification
AO Classification
A
: Simple fract.
B
: Wedge fract.
C
: Complex fract.
AO Classification
A= simple fract.
A1 simple fract.
Spiral
A2 simple fract.
Oblique(≥30)
A3 simple fract.
Transverse(<30)
AO Classification
B=
fract.
B=wedge
Wedge fract.
B1 wedge fract
Spiral wedge
B2 wedge fract
Bending wedge
B3 wedge fract
B3 wedge
fract
fragmented
wedge
fragmented wedge
AO Classification
C= complex fract.
C1 complex fract.
spiral
C2 complex fract.
segmental
C3 complex fract.
irregular
Mechanism of Injury
Classification
 Direct
trauma
 Indirect
Trauma
Direct trauma :

Tapping fractures

Crushing fractures

Penetrating fractures
- High velocity missiles > 2500 f/s
- Low velocity missiles < 2500 f/s
Indirect Trauma :


Traction or tension fract.
angulation fract.

Rotational fract.

Compression fract.
Principles of fractures
Fracture repair
 Fracture
repair is a tissue regeneration
process rather than a healing process the
injured bone is replaced by bone.
 The
process of repair varies according to:
-The type of bone involved.
-The amount of movement at the
fracture.
-The closeness of the fracture surfaces.
Principles of fractures
Rate of union
 Unfavorable
factors
 Impairment of blood supply
 Infection
 Excessive movement
 Presence of tumor
 Synovial fluid in intraarticular Fx.
 Interposition of soft tissue
 Any form of Nicotine
Definitive fracture treatment
The goal of fracture treatment is to obtain union of
the fracture in the most anatomical position
compatible with maximal functional return of the
extremity.
 Conservative
 Operative
Principles of Treatment
 Treat
the Patient, not only the
fracture
 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
Principles of Treatment
 Methods
of holding reduction:
 Sustained traction
 Cast splintage
 Functional bracing
 Internal fixation
 External fixation
Definitive Fracture Fixation Options

Casts and Splints
 Appropriate for many
fractures especially
hand and foot
fractures
 Adults typically will get
plaster splints initially
transitioned to
fiberglass casts as
swelling decreases
 Kids typically will get
fiberglass casts
CLOSED, UNDISPLACED
CLOSED, REDUCIBLE
 CONSERVATIVE TREATMENT
2- CAST
Below Knee
Above Knee

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
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”
Definitive Fracture Fixation Options

Traction
 Useful in patients
who are too sick
for surgery
 Useful to
maintain
alignment until
definitive fixation

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.
Operative

ORIF (open reduction internal fixat.)

External fixation
Indications of ORIF
- absolute
- relative
Indications of ORIF






Absolute Indications for ORIF of fractures
Unable to obtain an adequate reduction
Displaced intra-articular fractures
Certain types of displaced epiphyseal fractures
Major avulsion fractures where there is loss of
function of a joint or muscle group
Non-unions
Re- implantations of limbs or extremities
Indications of ORIF
Relative Indications for ORIF of fractures







Delayed unions
Multiple fractures to assist in care and general
management
Unable to maintain a reduction
Pathological fractures
To assist in nursing care
To reduce morbidity due to prolonged
immobilisation
For fractures in which closed methods are
known to be ineffective
Indications of ORIF
Questionable
 Fractures
accompanying nerve of vessel
injury
 Open fractures
 Cosmetic considerations
 Economic considerations
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
Open Operation
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
Types of Internal Fixation
- Pin & wire fixat.
- Screw fixat.
- Plate & screws fixat.
- Intra-medullary fixat.
Plate & screws fixat.
Functional types:
 Compression plates
 Neutralization plates
 Buttress plates
 Bridge plates
 LC- DCP
 Liss plates
 Locking plates & screws
Definitive Fracture Fixation Options
 Open
Reduction and
Internal fixation with
Plates and screws
 Used for many
fractures especially
those involving joints
Intra-medullary fixat.

Centro-medullary
- Unlocked
-Interlocking(static – dynamic – double
locked)

Condylocephalic

Cephalomedullary
Definitive Fracture Fixation Options
 Intramedullary
Nails
 Treatment of choice for
most tibia and femur
fractures
 Used in selected
humerus and forearm
fractures
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
2.
3.
4.
5.
6.
operation
Fractures that are inherently unstable and prone
to re-displacement after reduction
Fractures that unite poorly and slowly
Pathological fractures
Multiple fractures
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
Definitive Fracture Fixation Options
 Joint
Replacement
 Used in displaced femoral
neck fractures in geriatric
patients
 Allows for early ambulation
 Occasionally used in geriatric
pts with comminuted
shoulder or elbow fractures
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
Definitive Fracture Fixation Options

External Fixation
 Used primarily in the
treatment of open
fractures and pelvis
fractures
 Also useful as temporary
stabilization prior to
definitive fixation
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 of the pelvis, which often cannot be
controlled quickly by any other method.
2. Fractures associated with severe soft-tissue
damage where the wound can be left open for
inspection, dressing, or definitive coverage.
External Fixation
3. Severely comminuted and unstable fractures, which
can be held out to length until healing commences.
4. Fractures of the pelvis, which often cannot be
controlled quickly by any other method.
5. Fractures associated with nerve or vessel damage.
6. Infected fractures, for which internal fixation might not
be suitable.
7. 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
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.
Types of Open Fractures
○ 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
Types of Open Fractures
- 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
CONTRAINDICATIONS TO SURGICAL
REDUCTION AND STABILIZATION
Situations in which there is a high probability
for failure with operative treatment are as
follows:
1. Osteoporotic bone that is too fragile to allow
stabilization by internal or external fixation.
2. Soft tissues overlying the fracture or planned
surgical approach of such poor quality
because of scarring, burns,active infection, or
dermatitis .
3. Active infection or osteomyelitis.
CONTRAINDICATIONS TO SURGICAL
REDUCTION AND STABILIZATION
4.
Fracture comminution to a degree that does
not allow successful reconstruction. This is
most commonly seen in severe intraarticular
fractures.
5. General medical conditions that are
contraindications to anesthesia are generally
contraindications to the surgical treatment of
fractures.
6. Undisplaced or stable impacted fractures in
acceptable position do not require surgical
exposure or reduction.
7. Inadequate equipment, manpower, training,
and experience.
Thank you