TBL 1: Orthopedic Trauma
Husna, Izzati, Ili Safia, Aqilah & Safiyyah
TBL Trigger
A 24 year old man was involved in a road
traffic accident.
 He was a pedestrian when a motorcycle
knocked him down when he was crossing
the road.
 Following that incident, he complained of
pain of the left leg and was unable to bear
weight on his left lower limb.


In A&E, physical examination was
performed:
◦ Revealed swollen, tender and deformed
proximal region of the left leg.
◦ No limb threatening injury noted.
◦ No wound overlying the deformed region.

An X-ray of the left leg done reported
transverse fracture proximal of the left
fibula.

He was admitted to the ward:
◦ The left leg was elevated on the Bohler Braun
frame awaiting for the swelling to subside and
to observe for Compartment syndrome.
◦ He was told the fracture is best treated with
internal fixation but he opted for conservative
treatment.
◦ Full leg POP cast was applied after 3 days of
admission.

Follow up visit (6 weeks post-trauma):
◦ X ray was done and it showed no healing
signs.
◦ The earlier cast was removed and changed to
patellar tendon bearing cast for another six
weeks.

Follow up visit (12 weeks post-trauma):
◦ Revealed mobility to the fracture site –
painless.
◦ He was told to have problem with the
fracture healing and needs surgical treatment.
Learning Issues
Anatomy of the Leg.
 Fracture – Definition, Classification and
Patterns.
 Principle of Fracture Management.
 Acute Complications of Fracture.
 Process of Fracture Healing.
 Late Complications of Fracture.
 Non Union Fracture – Definition,
Classification and Management.

Anatomy of the Leg
The Leg
Bones
ii. Muscles
◦
Compartments
iii. Blood Supply
iv. Nerve Supply
i.
i. Bones
ii. Muscles and compartments
Anterior
Tibia
TA
Lateral
EDL
ELH PL & B
FDL Tibialis post.
FHL
Fibula
Deep Posterior
Superficial Posterior
Leg compartments
Anterior compartment
Walls :
i. Interosseous membrane
ii. Tibia
iii. Fibula
Contents :
i.
ii.
iii.
iv.
Extensor muscles of the toes
Anterior tibial artery
Deep peroneal nerve
Most susceptible to compartment syndrome.
Lateral compartment
Walls :
i. Fibula
ii. Intermuscular septums
Contents:
i. Peroneal muscles
ii. Superficial peroneal nerve
Superficial Posterior compartment
Walls:
i. Transverse intermuscular septum
Contents :
i. Gastrocnemius
ii. Soleus muscles
Deep Posterior compartment
Walls :
i. Transverse intermuscular septum
ii. Interosseous membrane
Contents:
i. Flexor muscles of the foot
ii. Tibial artery
iii. Tibial nerve
Summary
Compartments
Anterior
Deep posterior
Superficial
posterior
Lateral
Muscles
Vessels
Sensory
Nerves
Distribution
Deep
Web space
Extensor
Anterior
peroneal of first &
muscles of toes tibial artery
nerve second toes
Deep flexor
muscles
Posterior
tibial artery
Tibial
nerve
Heel
Superficial
flexor muscles
(gastrocnemius
and soleus)
Peroneal
muscles
Superficial Lateral
peroneal dorsum of
nerve
foot
Nerve and
Arteries
Fracture – Definition,
Classification and Patterns
Definition of Fracture
A break in the structural continuity of
bone.
- Apley’s System of Orthopedics & Fractures, 8th Edition
Classification of
Fracture
Open
(Compound)
Fracture
Closed
(Simple)
Fracture
Pathological
Fracture
Stress
Fracture
i. Open (Compound) Fracture
Breakage in the bone that breaches the
skin or one of the body cavities.
 Usually due to high-energy injuries e.g.
MVA, falls, sports injuries.
 Liable to contamination and infection
hence require immediate treatment and
surgery to clean the area.

Open Fracture
Fracture of tibia-fibula
with soft-tissue injury
ii. Closed (Simple) Fracture
Breakage in the bone with the overlying
skin still intact.
 3 types:

◦ Compression fracture
 Occurs when 2 or more bones are compressed
against each other – commonly in the spine bone.
 Due to falling in a standing or sitting position,
advanced osteoporosis.
◦ Avulsion fracture
 Occurs when a piece of bone is broken off by a
sudden forceful contraction of a muscle.
 Common in young athletes.
◦ Impacted fracture
 Occurs when pressure is applied to both ends of
one bone causing it to split into fragments that
collide with each other.
 Similar to compression fracture, only it is within
one bone.
 Common in falls and MVA.
**View video http://video.about.com/orthopedics/Fractures-2.htm for
better understanding.
Closed fracture
Compression fracture of
the spine
Avulsion fracture
of the phalanges
Impacted fracture
of the femur
Impacted fracture
of the tibia
iii. Pathological Fracture

Breakage of bone in an area that is
weakened by another disease process
either by:
◦ Changing the structure i.e. osteoporosis, Paget’s
disease.
◦ Presence of lytic lesion i.e. bone cyst or
metastasis.
◦ Infection.

Usually occur during normal daily activities
 bone unable to withstand even the
normal stresses.
Bone cyst resulting in
pathological fracture in
the neck of femur
Multiple myeloma of
humerus with pathological
fracture
iv. Stress Fracture
Usually fractures are caused by acute, high
force to the bone i.e. MVA, fall.
 In Stress facture, the force applied is much
lower but it happens repetitively for a
long period of time.
 Rarely occur in the upper extremity
because weight bearing is by lower
extremity – common site shin and foot.


Contributing factors:
◦ Athletes
 High demand of activity repetitively.
◦ Diet abnormalities
 Poor nutrition e.g. in aneroxia, bulimia.
◦ Menstrual irregularities
 Irregular cycles/amenorrhea signify lack of estrogen
which results in lower bone density.
 Common in female athletes.
Stress fractures of the tibia-fibula
Patterns of Fracture
Incomplete Fracture
- Bone is incompletely
divided and the periosteum
remains in continuity.
Complete Fracture
- Bone is completely broken
into 2 or more fragments.
Hairline Fracture
Transverse Fracture
Greenstick Fracture
Short Oblique
Fracture
Spiral Fracture
Comminuted
Fracture
Segmental Fracture
i. Incomplete Fracture
Pattern
Hairline fracture
-A crack in the bone
that does not extend
all the way through.
Mechanism of Injury
Minor injury e.g. minor
fall, minor blunt trauma.
Images
Pattern
Greenstick fracture
-Only one side of the
bone break resulting in
the bone buckling or
bending (like snapping
a green twig).
-Common in children
as bone more springy
than adult.
-Similar to this is
Plastic deformity – also
common in children.
Mechanism of Injury
Minor fall, minor blunt
trauma.
Images
i. Complete Fracture
Pattern
Transverse fracture
-Fracture straight
across the bone.
Mechanism of Injury
Tension due to high
energy direct trauma.
Images
Pattern
Short Oblique
fracture
-A fracture which goes
at an angle to the axis.
Mechanism of Injury
Compression.
Images
Pattern
Spiral fracture
-A fracture which runs
around the axis of the
bone.
-S-shaped.
Mechanism of Injury
Twisting.
Images
Pattern
Comminuted
fracture
-A fracture in which
bone is broken,
splintered or crushed
into a number of
pieces.
-A fracture is
considered
comminuted when
there are more than 2
bone fragments.
-Also known as
triangular ‘butterfly’
pattern.
Mechanism of Injury
Bending.
Images
Pattern
Segmental fracture
-A fracture in two
parts of the same
bone.
Mechanism of Injury
Images
Severe direct force.
- Also known as double
fracture.
**View video http://video.about.com/orthopedics/Fractures-1.htm for
better understanding.
Principles of Fracture
Management
FIRST  GENERAL RESUSCITATION
AT THE SCENE
- Protect cervical spine
- Free airway
- Ensure ventilation
- Arrest hemorrhage
- Put up drip
- Control pain
- Splint fractures
- Transport to hospital
AT THE HOSPITAL
- Primary survey
- Detailed Secondary
survey
- Re-evaluation
- Definitive care
At the Hospital



Examine HEAD  TOE
Level of consciousness  GCS
Remember:
Ensure clear airway
irway
A
B
reathing
Examine chest (atelactasis, pneumothorax)
Supplemental O2
ABG if necessary
Circulation
Control bleeding
Asses for signs of shock
FBC and electrolytes
Secondary
Survey
X-rays
Re-evaluation
Monitor vital signs
Fractures – Principles of Treatment


Manipulation – improve position of
fragments.
Splintage – hold.
WHILST:

Preserving the joint movement and
function – exercise and weight
bearing.
Closed
Fractures
1. Closed Fractures – REDUCE
Aim  adequate apposition and normal alignment of the bone
fragments
Methods:
1. Manipulation
- Closed manipulation for minimally displaced fractures
- Under anaesthesia and muscle relaxation:
1. Distal part is pulled in the line of the bone
2. Reposition fragments (reverse original direction of force)
3. Adjust alignment
2. Mechanical
traction
- Hold the fracture until it starts to unite
3. Open
operation
Indications:
1. Closed reduction fails
2. Large articular fragment
3. For avulsion fractures (fragments held apart by muscle pull)
4. Operation needed for associated injuries
5. When fracture anyhow need internal fixation to hold it
2. Closed Fractures – HOLD
Aim  splint fracture
Methods:
1. Sustained traction
- Exert continuous pull in the long axis of the bone
- Counterforce needed
- Used in spiral fractures of long bone shafts
- Types : traction by gravity, balanced traction, fixed traction
2. Cast splintage
- E.g Plaster of Paris
- Movement restricted
- Complications: tight cast(vascular compression, pain),
pressure sores, skin abrasions/lacerations (on removal), loose
cast
3. Functional bracing
- Use POP or lighter materials while permitting fracture
splintage and loading
- Joint movements are less restricted
- Usually applied only when the fracture is beginning to unite
3-6 weeks
Transfixing pin passes to:
1. Proximal tibia – hip, thigh and
knee injuries
2. Distal tibia/calcaneum – tibial
fractures
Balanced skin traction
Braun’s frame
Internal Fixation
Indications:
1. Fractures that cannot be reduced except by operation
2. Fractures that are unstable (prone to re-displacement)
3. Fractures that unite poorly and slowly (e.g femoral neck fracture)
4. Pathological fractures
5. Multiple fractures
6. Patients with nursing difficulties
Types – screws, wires, plates&screws, intramedullary nails
Complications:
(due to poor techniques, poor equipment operating conditions)
– infection, non-union, implant failures, refracture
External fixation
Principle – bone is transfixed above and below the fractures with
screws/pins/wires which are clamped to a frame
Indications:
1. Fractures associated with severe soft tissue damage
2. Severely comminuted and unstable fractures
3. Pelvic fracture
4. Fractures a/w nerve or vessel damages
5. Infected fractures
6. Ununited fractures
Complications:
- Damage to soft-tissue structures
- Over-distraction
- Pin-tract infection
3. Closed Fractures – EXERCISE
Aim  restore function
1.
2.
3.
4.
Prevention of edema
Active movement/exercise – stimulate
circulation, prevents soft tissue adhesion
and promote healing
Assisted movement – restore muscle
power
Functional activity – guide patient in
performing normal daily acitivities
Open
Fractures
Gustilo’s Classification
Type I
• Low energy fracture with small, clean wound and little
soft tissue damage
Type II
• Moderate-energy fracture with a clean wound >1cm
long, but not much soft tissue damage and no more
than moderate comminution of the fracture
Type III
>10%
• High energy fracture with extensive damage to skin,
soft tissue, and neurovascular structures and
contamination of the wound
• IIIA – fractured bone adequately covered by soft
tisssue
• IIIB – periosteal stripping and severe comminution
• IIIC – arterial injury
Principles of Treatment
Prompt wound
debridement
• Under GA – wound is irrigated with warm normal saline
• Extend wound and ragged margins excised, foreign materials
and debris removed
Antibiotic
Prophylaxis
• Combination of benzylpenicillin and flucloxacillin or 2nd gen
cephalosporin – 6hourly for 48 hours
• If wound heavily contaminated – cover G(-) and anaerobes
(Gentamicin/metronidazole) up to 5 days
Stabilization of
fracture
• Crucial in recovery of soft tissues
• Can be treated as for closed injuries (up to IIIA – no major
contamination)
Early definitive
wound cover
• Possible in Types I and II
• Skin grafting is appropriate when wound cannot be closed
without tension
Debridement
Skin graft
Stabilization
Acute Complications of
Fracture
Complications of Fracture
EARLY
i.
Underlying
Visceral injury
ii. Vascular injury
iii. Nerve injury
iv. Compartment
syndrome
v. Haemarthrosis
vi. Infection
vii. Gas gangrene
LATE
i.
ii.
iii.
iv.
v.
Delayed union
Malunion
Non union
Avascular necrosis
Muscle
contracture
vi. Joint instability
vii. Osteoarthritis
i. Underlying Visceral Injury

Often in fractures around the trunk.
◦ Rib fractures  penetration of lung 
life-threatening pneumothorax .
◦ Pelvic fractures  rupture of bladder or
urethra.
 Require emergency treatment, before
treating fracture.
ii. Nerve Injury
Common in fractures of the humerus, injuries
around elbow & knee.
 Look for tell tale signs:
Closed injuries

◦ Nerve seldom severed  wait for spontaneous recovery
(90% in 4 months).
◦ Recovery x occur/nerve studies shows no recovery
explore nerve.
Open fracture
◦ Likely complete nerve lesion.
◦ Explore during debridement/secondary procedure 
repaired.
iii.Vascular Injury
Fracture around knee and elbow, humeral
and femoral shafts  ↑ ass. w. damage to
major artery.
 Cut, torn, compressed, contused by initial
injury/jagged bone fragments.
 N outward appearance  intima may be
detached, vessel blocked by thrombus,
spasm.
 Effects vary : transient diminutive of blood
flow, profound inchaemia, tissue death,
peripheral gangrene.

Clinical features



Paraesthesia /numbness of toes/fingers
Cold, pale, slightly cyanosed weak/absent pulse
X ray shows high risk fractures
Management





Angiogram
Remove bandages/splint
X ray – kinking or compressed  reduction
Reassess circulation
No improvement  explore via operation
◦ Torn  Suture/ replace by vein graft
◦ Thrombosed  endarterectomy to restore blood
flow
iv. Compartment Syndrome
A group of conditions that result from ↑
pressure within a limited anatomic space
(limb compartments), acutely
compromising the microcirculation and
leading to ischaemia of the muscle.
 Causes : high risk fractures, infection,
operation.

Bleeding, oedema or inflammation
↓
↑ Tissue pressures in a compartment
↓
Compromise perfusion
↓
Tissue hypoxia
↓
Damage to the structures coursing through that compartment
(nerves & muscles)
↓
Prolonged muscle hypoxia
↓ 12 hours or less
Necrosis and permanent posttraumatic muscle contracture
(Volkmann's ischemia)
Pathophysiology
VICIOUS CYCLE OF
VOLKMANN’S
ISCHAEMIA
Clinical Features

Ischaemia (5 Ps):
◦
◦
◦
◦
◦

Pain : Earliest symptom  bursting sensation
Paraesthesia
Pallor
Paralysis
Pulselessness
Muscles sensitive to touch  ↑
calf/forearm pain when is hyper-extended.

Pressure of fascial compartment:
◦ Introduce catheter into compartment 
measure P close to compartment.
◦ Diastolic P – compartment P.
◦ Differential less than 30 mmHg.
Treatment

Decompression
◦ Remove bandage, casts, dressings.

Fasciotomy
v. Haemarthrosis
Joint is swollen, tense.
 Pt resists any attempt to move it.

 Aspirate blood first.
vi. Infection
Common in open fractures, unless closed
fracture is opened.
 Chronic osteomyelitis.
 Slow union, w ↑ chance of re-fracturing
Imflamed wound, w seropurulent
discharge.
Send for C&S.
Start antibiotic.

vii. Gas gangrene
Produced by clostridial infection esp
Clostridum welchii in dirty wounds
 Destroy cell walls  necrosis  spread
of disease
 Appear within 24 hours on injury
 Intense pain,swelling,brownish discharge,
↑ HR, characteristic smell, gas formation
 Toxaemic  coma  death

Process of Fracture Healing
TISSUE
DISTRUCTION
AND
HEMATOMA
FORMATION
How Fracture Heal?
INFLAMMATIO
N AND
CELLULAR
FORMATION
CALLUS
FORMATION
REMODELLING
Fracture Healing Process



Stage 1: start few days after
injury and continue for
about a month.
Stage 2: starts within a
week or two and continues
for many months.
Stage 3: continues for many
month to a few years.
Late Complications of Fracture
Local Complication
Deformity
 Osteoarthritis of adjacent / distant joint
 Aseptic necrosis
 Traumatic Chondomalacia
 Reflex sympathetic dystrophy

Local Complication (cont’)
Contractures
 Myositis ossificans
 Avascular necrosis
 Algodystrophy (or Sudeck's atrophy)
 Osteomyelitis

Systemic Complication
Gangrene
 Tetanus
 Septicemia
 Fear of mobilizing
 Osteoarthritis

Non Union Fracture –
Definition, Classification and
Management
What is mobility to the fracture site
but painless?
A sign of non-union (pseudoarthorsis)
Non- Union

The fracture will never unites without
intervention

Clinical features:
 Movement can be elicited at the fracture site
 Pain diminishes

Causes:







Distraction and separation of fragments
Interposition of soft tissues between the
fragments
excessive movements at the fracture site
Poor local blood supply
Severe damage to soft tissues
Infection
Abnormal bone

Classification:
 Hypertrophic (hypervascular)
 Oligotrophic
 Atrophic (avascular)
Hypertrophic Non- Union
Features
Callus formation initially okay
Rich of blood supply at the end of
fragments
But bridging of the fracture gap is failed
Bone ends are enlarged (X-ray)
suggesting osteogenesis
Union is still possible if bone fragments
are apposed and held immobile
Management
Stimulate union:
Pulsed electromagnetic field
Low-frequency pulsed ultrasound
Operative:
Rigid fixation (external/internal)
Oligotrophic Non- Union
Features
Management
Not hypertrophic
Callus is absent
However there’s intact blood supply
Inadequate healing process
Atrophic Non- Union
Features
Osteogenesis is ceased
No sign of attempted bridging
Inert and incapable of biologic rxn
Poor blood supply to the ends of
fragments
Cold bone scan
Bone ends are tapered or rounded (Xray)
Management
Rigid fixation
Excised the sclerotic end of bone ends
and the fibrous tissue that filled the gap
Bone graft around the fracture
Delayed Union
The period in which the fracture is
expected to unite and consolidate is
prolonged
 Causes (as non-union)


Clinical features:
 Tenderness persists
 Mobilization at the fracture site

X-ray:




Fracture line visible
Little callus formation
Bone ends not sclerosed or atrophic
The appearance suggests the fracture has not
united but eventually will

Treatment:
◦ Conservatives
 Eliminate possible causes of delayed union
 Promote healing i.e. immobilization
◦ Operative
 Internal fixator & bone grafting are indicated when
there is delayed > 6 months & no sign of callus
formation
Take Home Message!
Read up the Anatomy!
• Fracture – Types and Patterns
• Reduce! Hold! Exercise!
• Acute and Late Complications
• Process of Fracture healing
• Non Union Fracture – Classification,
Clinical features and Management
•