2. classification
• Fractures can be described, categorized, and presented in a number of
ways
• No one system of classification is all-encompassing
• Each fracture should be described and categorized by one of the terms
3. 1. Direction of fracture lines
Transverse: runs perpendicular to the bone
Oblique: similar to transverse in that there is no torsional appearance to
the fracture. The fracture line usually runs across the bone at an angle of
45 to 60 degrees
Spiral: has a torsional component
Comminuted: more than two fragments noted
Impacted: one where the fractured ends are compressed together.
-usually very stable fractures
4.
5. 2. Anatomic location
proximal, middle, or distal thirds of a long bone
Intraarticular-If the fracture extends into the joint space
Extraarticular
head, shaft, and base
In pediatrics-in relation to the growth plate (physis)
6. 3. Alignment
-relationship of the axes of the fragments of a long bone
- described in degrees of angulation of the distal fragment in relation to the
proximal fragment
7. 4. Displacement
-describe movement of fracture fragments from their usual position in a
direction perpendicular to the long axes of the bone
-is described as a %age of the bone's width
-direction of displacement is described based on the movement of the distal
fragment in relation to the proximal fragment
8.
9. 5. Associated soft-tissue injury
Closed: A fracture in which the overlying skin remains intact.
Open: occurs when a break in the skin and soft tissue directly communicates
with a fracture and its hematoma
Complicated: A fracture that is associated with either neurovascular, visceral,
ligamentous, or muscular damage. Intraarticular fractures are also
complicated.
Uncomplicated: A fracture that has only a minimal amount of soft-tissue
injury.
10. Open Fractures
• Gustilo and Anderson have classified open fractures
• Grade I -an open wound due to a low-energy injury
-wound is <1 cm in length and shows no evidence of contamination
- #s simple, transverse, or short oblique with minimal comminution.
-wounds are usu caused by a # fragment piercing the skin from the inside
• Grade II wounds -a moderate amount of soft-tissue injury.
- Some comminution of # & a moderate degree of contamination
-wound that is >1 cm
-No soft tissue is stripped from the bone
11. • Grade IIIA -a large wound (usually >10 cm).
- degree of contamination is high and amount of soft-tissue injury is severe
-there is adequate soft-tissue coverage of the bone.
-Comminution of the ass’ed # is usually present.
• Grade IIIB is a large wound (usually >10 cm) with periosteal stripping and exposed
bone
-degree of soft-tissue injury is such that reconstructive surgery is often necessary
to cover the wound
- Massive contamination and a severely comminuted fracture
• Grade IIIC= IIIB injury + arterial injury that requires repair for salvage of the
extremity
12. classn of Salter and Harris
• used to describe the nature of the epiphyseal injury
• Type I – a transverse fracture along the line of the physis;
growing zone is not usu injured
no growth disturbance
This fracture is common
• Type II – similar to type 1 but the fracture line deviates off into the metaphysis at one
end, producing a metaphyseal fragment;
seldom affects growth
This fracture is common
• Type III – passes along the physis and then deviates into the epiphysis (intra articular);
rarely results in significant deformity but can lead to joint incongruity
This fracture is not common
13. • Type IV – crosses the physis passing from the epiphysis into the metaphysis;
-interferes with growing layer of cartilage cells premature focal fusion of the physis ffd
by deformity.
-not common #
• Type V – a crush injury of the physis; ass’ed with growth disturbances at the physis.
-Dx difficult as radiograph may look normal
-premature closure of physis reveals dx
-rare fracture
• Type VI – rare injury ,injury to the perichondral structures by direct trauma,
e.g. heat or chemical
14.
15. • Stability
• Stable fracture: A fracture that does not have a tendency to displace after
reduction.
• Unstable fracture: A fracture that tends to displace after reduction.
16. Mechanism of Injury
• two categories: direct and indirect
• Direct forces cause -transverse, oblique, or comminuted
e.g -nightstick fracture caused by a direct blow to the ulna
- crush injury
- high-velocity bullet
• Indirect forces -induce a fracture by transmitting energy to the fracture
site
e.g. Traction on a ligament attached to a bone »»an avulsion fracture
A rotational force applied along the long axis of a bone »»in a spiral #
A stress fracture- results from repeated indirect stress applied to a bone
17. Clinical Features
• Pain and tenderness - the most common presenting complaints
• Loss of normal function
• abnormal mobility and crepitation-When the fractured ends are in poor
apposition
• gross deformity
• Bleeding
-A patient with multiple fractures can experience shock from blood loss
19. Fracture Healing
• three phases—inflammatory, reparative, and remodeling
• inflammatory phase
hematoma forms »»» clot
Damage to the blood vessels of the bone»»» death of osteocytes
With this necrotic tissue, an intense inflammatory response results,
accompanied by vasodilatation, edema formation, and the release of
inflammatory mediators
PMNs, mфs, and osteoclasts migrate to the area to resorb the necrotic
tissue
20. reparative phase
begins with the migration of mesenchymal cells from the periosteum
Osteoblasts from the endosteal surface also form bone
Granulation tissue invades from surrounding vessels and replaces the hematoma
Most healing occurs around the capillary buds that invade the fracture site
Healing with new bone formation -at the subperiosteal region
Osteoblasts are responsible for collagen formation, followed by mineral deposition of calcium
hydroxyapatite crystals
A callus forms
21. • remodeling phase
healing fracture gains strength
the bone organizes into trabeculae
Osteoclastic activity is first seen resorbing poorly formed trabeculae
New bone is then formed corresponding to the lines of force or stress.
22.
23. Factors affecting healing
• Age-children experience a higher affinity for rapid bone remodeling
• Cortical bone heals at a slower rate than does the cancellous bone
• amount of contact between the bony ends (apposition and distraction)
• associated soft-tissue injuries
• Inadequate immoblization-significant movement
24. • Fractures through pathologic bone lesions
• presence of infection
• corticosteroids, excessive thyroid hormone, and nicotine from cigarette smoke
• Chronic hypoxia
• * Exercise
• .
• .
• .
25. PRINCIPLES OF FRACTURE MANAGEMENT
• aims of Rx are to restore function safely with minimal complications
• ATLS
• interventional management of # has two components: reduction and stabilisation
• each be achieved by a variety of methods
26. Reduction
• closed or open means
• moving or manipulating the fragments-by a closed technique
• Direct viewing of the fracture ends may be with the naked eye at open operation
or by using imaging or arthroscopy
27. Stabilisation(IMMOBLIZATION)
• when a fracture has been reduced it needs to be held or stabilised while healing progresses
• A fracture is immobilized for three reasons:
to permit healing,
to relieve pain by rest, and
to stabilize an unstable fracture
28. Methods used for stabilising a fracture
Casting and splinting
A cast is composed of plaster of Paris;either as a temporary or a definitive Rx
at least one joint above and one joint below the fracture should be immobilized
the extremity should be placed in the position of function
Padding is provided to prevent pressure sores
When a cast is applied soft-tissue swelling should subside.
29. A plaster slab/Splints
plaster material is not circumferential
the securing bandages circumferential
more frequently used as the initial means of immobilization
permit more motion and provide less stability for a reduced fracture
31. Traction
pulling to change or hold the position of # fragments
works b/c of the integrity of the surrounding soft tissues
can be used both as a temporary and as a definitive Rx
can be applied either using the skin (skin traction) or by direct coupling to
the bone with pins or wires (skeletal traction)
33. Plates and screws
A screw is normally used to join two things together
can be used to compress two bony fragments or a plate to the bone
plate and screws may be used-radial and ulnar shaft #
ORIF
36. Intramedullary nailing
placing the stabilisation device inside the canal
An IMN is usu made of steel or titanium
may be solid, or hollow
normally has transverse holes at either end; this allows locking of the nail to
the bone with further screws to control rotation and length
Because standard nails are introduced at the ends of a bone they are not
suitable for the growing bone where they would transgress a growth plate
allow for early mobilisation and a much earlier discharge from hospital
37.
38.
39. External fixation
a mechanical construction to hold a fracture
Each side of the fracture is coupled to the fixator and the major part of the device is external
to the skin
Immediate environment of the fracture may be left intact with the frame bridging the zone of
injury
commonly used as a temporary measure
For a complex fracture this can provide safe stability while the condition of the soft tissue
improves /further imaging is obtained/patient’s general condition improves before other
definitive fixation
40. Specific indications for external fixators
• emergency stabilisation of a long bone fracture in the polytrauma pt
• stabilisation of a dislocated joint after reduction
• complex periarticular fractures – temporary stabilisation to
allow the soft tissues to settle before definitive fixation, e.g. a distal tibial (pilon) fracture
• fractures associated with infection
• treating fractures with a bone loss
43. Wires
K-wire is a thin, flexible wire made of stainless steel
Transfixing wires can be passed percutaneously to keep fracture fragments reduced
They are cheap and often quick and simple to use
Used extensively around the hand and wrist as definitive fixation
at the patella and olecranon - ‘figure-of-eight’ tension band wire can provide reliable stability
Cplxns -pin track infection, wire breakage,loss of fixation and migration of the wire
44.
45. REHABILITATION
• adjacent joints should be mobilized as soon as possible
• Physical therapy should include active and active-assisted exercises for joint mobilization as
soon as soft-tissue healing permits
• Neurological deficits resulting in loss of active motion should be evaluated, and the
appropriate joints should be splinted in functional positions to avoid contractures
• Weight bearing should be limited, depending on the stability of fixation, the type of fixation
and its inherent fatigue life, and the systemic condition of the patient
46. REHABILITATION
• With intraarticular fractures, weight bearing is not allowed for 3 months, but early motion is
encouraged
• Range-of-motion and strengthening exercises should be monitored and directed by the
physician and physical therapist
• Vocational rehabilitation counseling should be initiated early to enable a productive return to
society
47. Physiotherapy
• Physiotherapists use a variety of techniques to prevent patients developing
complications, to relieve pain and to enhance physical activity
Chest physiotherapy: deep-breathing exercises, coughing, chest percussion.
Muscle exercise and re-education: active and passive exercises, stretching, joint
movements. Electrotherapy may be used to stimulate denervated muscles.
Walking: teaching patients to stand and walk, initially with support
(physiotherapists, parallel bars, walker frames,crutches, stick) and then without
support, progressing to walking up stairs.
48. Pain relief: both heat (superficial and deep) and cold are used to relieve pain.
Transcutaneous electrical nerve stimulation (TENS) is also commonly used in the
management of chronic pain.
-Massage may be combined with heat to reduce oedema and relax muscle tension.
Ultraviolet therapy: some decubitus ulcers (pressure sores) respond favourably to
ultraviolet light.
Hydrotherapy: helps to relieve pain, reduce muscle spasm and induce relaxation
49. Complications
1.Compartment Syndrome
When an injury occurs to the muscles within a compartment, swelling ensues
Because the tight fascial sheaths allow little room for expansion, the pressure within the
compartment begins to increase
Eventually, blood flow is compromised and irreversible muscle injury follows
ensuing muscle and nerve necrosis»»» Volkmann's ischemic contractures
most common locations -forearm and leg
50. • ¾ ths of cases-develop after fracture(tibia, humeral shaft, forearm bones, and supracondylar
fractures in children)
• Other causes -crush injury, constrictive dressings/casts, seizures, intravenous infiltration,
snakebites, infection, prolonged immobilization, burns, acute arterial occlusion or injury, and
exertion
51. Clinical Features
• Dx-clinical
• pain out of proportion to the underlying injury, sensory symptoms, and muscle weakness
• *disproportionate pain is the earliest symptom, while pain with passive stretching of the
involved muscles is the most sensitive sign
• Diminished sensation – 2nd most sensitive examination finding
• Palpation -tenderness and "tenseness" over the ischemic segments
• Paresthesias or hypesthesias in nerves traversing the compartment are also important signs
• distal pulses and capillary filling may be entirely normal -should not be used to r/o
acompartment syndrome
52. Treatment
• immediate fasciotomy
• Delays may result in irreversible damage to muscles and nerves
• muscles can tolerate up to 4 hours of total ischemia. After 8 hours, damage is irreversible
• peripheral nerves survive for up to 4 hours of complete ischemia with only neurapraxic
damage, but after 8 hours axonotmesis and irreversible injury occurs
• Rhabdomyolysis may complicate compartment syndrome and adequate hydration to
maintain UOP is essential
53. Volkmann's Ischemic Contracture
• end result of an ischemic injury to the muscles and nerves of a limb secondary to untreated
compartment syndrome
• occur in 1% to 10% of cases of compartment syndrome
• A contracture is the result of selective ischemia of the muscles and nerves of the distal
segment of the limb (the arm below the elbow, or leg below the knee)
• Most distal tissues, such as the hand and foot, do not become ischemic, however, they are
not immune to injury due to more proximal nerve damage
54. Fat Embolism Syndrome
• Fat embolism occurs in almost all pts who sustain a pelvic or long bone fracture
• majority of pts remain axic
• FES-develops in 0.5% to 3% of pts
• MR-as high as 20% in severe cases
• FES-triads- pulmonary distress, mental status changes, and a petechial rash that develops
from 6 to 72 hours after injury
• incidence increases in young adults with multiple injuries
• rarely occurs in children or patients with upper extremity fractures
55. etiology of FES
• Many theories
• ? Following a fracture, intramedullary fat is released into the venous circulation. These fat
globules subsequently embolize to end organs such as the lungs, brain, and skin
• ? fat emboli cause an inflammatory cascade that damages end-organ tissues
fat emboli are metabolized to free fatty acids that, when present in high concentrations,
induce an inflammatory reaction that damages end organs
56. Clinical Manifestations
• 25% of pts will develop sxs in the first 12 hrs and
• 75% will have sxs by 36 hrs
• Major Criteria
Respiratory insufficiency
Altered mental status
Petechial rash
• Minor Criteria
Fever
Tachycardia
Retinal changes
Jaundice
Renal insufficiency
Anemia
Thrombocytopenia
Elevated ESR
• To make Dx of FES-one major plus three minor criteria or two major and two minor criteria
57. Treatment
• cornerstone of Rx is prevention and early detection
• Early resuscitation, stabilization, and operative treatment -decreased the incidence of FES
• Immobilization with no excessive motion permitted & open reduction with internal fixation
within 24 to 48 hrs of injury will prevent embolism
• respiratory rate and pulse oximetry should be monitored
• Rx with supplemental oxygen
• Respiratory support with oxygen is employed to keep the PaO2 above 70 mm Hg