touching on all concepts of managing fractures but superficial, mainly open and closed fractures

1. PRINCIPLES OF FRACTURES
AHMAD FADZLI SULONG
Advanced Trauma Unit
Dept of Orthopaedics, Traumatology & Rehabilitation

2. By the end of this lecture,
hopefully…
1.what is fracture
2. Forces that causes fracture
3. Types of fracture – especially
open fracture
4. FRACTURE HEALING

3. DEFINITION
A break in structural
continuity of bone

4. CAUSES
1. Traumatic fracture
• Direct force – bone breaks at point of impact
• Indirect force – bone breaks at a distance from
where force is applied
2. Pathological fracture
• Normal stress in weakened bone
3. Stress fracture
• Repetitive stress in normal bone

5. Mechanism of injury:
• Spiral – torsion
• Short oblique – compression
• Butterfly – bending
• Transverse – tension

6. TYPES

7. 1. Transverse – distraction/bending force
2. Oblique – bending, compression
3. Spiral – twisting
4. Impacted – axial loading
5. Comminuted – high energy
6. Greenstick
7. Torus

8. OPEN
FRACTURES

9. DEFINITION
Fracture with break in skin and underlying
soft tissues with communication between
external environment and fractured bone and
its hematoma

11. GUSTILO CLASSIFICATION
• 4 main components:
 Size of wound
 Degree of soft tissue injury
 Degree of contamination
 Degree of comminution
• Established at time of operative debriment
(intra op classification)

12. TYPE I
• The wound is less than one centimeter
long.
• It is usually a clean puncture, through
which a spike of bone has pierced the skin.
• There is little soft-tissue damage and no
sign of crushing injury.
• The fracture is usually simple, transverse,
or short oblique, with little comminution.
The management of open fractures RB Gustilo, RL Merkow and D Templeman J Bone Joint Surg Am. 1990;72:299-
304

14. TYPE II
• The laceration is more than one centimeter
long (1cm<x<10cm)
• There is no extensive soft-tissue damage,
flap, or avulsion.
• There is a slight or moderate crushing
injury, moderate comminution of the
fracture, and moderate contamination.
The management of open fractures RB Gustilo, RL Merkow and D Templeman J Bone Joint Surg Am. 1990;72:299-
304

16. TYPE III
• Extensive damage to soft tissue, including
muscles, skin, and neurovascular
structures.
• A high degree of contamination. The
fracture is often caused by high-velocity
trauma
• Fracture with high degree of comminution
The management of open fractures RB Gustilo, RL Merkow and D Templeman J Bone Joint Surg Am. 1990;72:299-
304

17. TYPE III A
• Soft-tissue coverage of the fractured bone
is adequate, despite extensive laceration,
flaps, or high-energy trauma.
• This subtype includes segmental or
severely comminuted fractures from high-
energy trauma, regardless of the size of
the wound.
The management of open fractures RB Gustilo, RL Merkow and D Templeman J Bone Joint Surg Am. 1990;72:299-
304

18. TYPE III B
• Periosteal stripping and exposure of bone,
massive contamination, and severe
comminution of the fracture from high-
velocity trauma.
• After debridement and irrigation is
completed, a segment of bone is exposed
and a local or free flap is needed for
coverage.
The management of open fractures RB Gustilo, RL Merkow and D Templeman J Bone Joint Surg Am. 1990;72:299-
304

19. TYPE III C
• Associated with an neurovascular injury
that must be repaired, regardless of the
degree of soft-tissue injury.
The management of open fractures RB Gustilo, RL Merkow and D Templeman J Bone Joint Surg Am. 1990;72:299-
304

20. ALL OPEN FRACTURES, NO
MATTER HOW TRIVIAL THEY
MAY SEEM, MUST BE ASSUMED
TO BE CONTAMINATED

21. SEPSIS
RATE
SEPSIS
RATE
TYPE I 0%
TYPE II 2.5%
TYPE III 13.7% TYPE IIIA 5%
TYPE IIIB 28%
TYPE IIIC 8%
Classification of type III (severe) open fractures relative to treatment and results. Gustilo RB; Gruninger RP;
Davis T Orthopedics. 1987; 10(12):1781-8 (ISSN: 0147-7447)

22. FRACTURE HEALING
1. Primary bone healing
• Rigid fixation
• No callus
• aka contact/gap healing
2. Secondary bone healing
• Non rigid fixation
• Callus formation
• aka endochondral ossification

23. SECONDARY BONE HEALING
1. Tissue destruction & hematoma formation
2. Inflammation & cellular proliferation
3. Callus formation (soft callus)
4. Consolidation (woven bone)
5. Remodelling (lamellar bone)

24. Hematoma
Callus formation
Consolidation
Remodeling
Inflammation

25. PRIMARY BONE HEALING
1. Immobilized fragments (no callus stimulus)
2. Gap healing – osteoblastic activity across
fracture to achieve contact healing
3. Cutting cones – remodeling action by osteoclasts
4. Relies on fixation for strength (no callus) and
may lead to osteoporotic changes of bone

26. Cutting cones (osteoclasts)
Fracture Gap
Fracture ends

29. MANAGEMENT
OF FRACTURE

30. THE ‘4R’
1. RESUSCITATION
2. REDUCE
3. RETAIN / HOLD
4. REHAB / EXERCISE

31. RESUSCITATION
• ABC
• Primary survey

32. REDUCE
• As soon as possible
• Alignment more important than apposition
• Articular surface requires anatomical
reduction
• Closed manipulative reduction
• Open reduction

33. Adequate apposition
Normal alignment
REDUCE FRACTURE

34. REDUCE FRACTURE
Extra articular fracture – relative stability

35. REDUCE FRACTURE
Intra articular fractures – MUST obtain
absolute stability

36. Preferably 3 people
Adequate sedation
essential
Continuous
monitoring
CLOSED REDUCTION

37. CLOSED REDUCTION

38. OPEN REDUCTION

39. RETAIN
1. Cast splintage
2. Functional bracing
3. Internal fixation
4. External fixation
**Traction?

40. RETAIN
Casts

41. RETAIN
Functional bracing

42. RETAIN
Internal fixation

43. RETAIN
External fixation

44. RETAIN
Traction

45. RETAIN (why splint?)
1. Alleviate pain
2. Ensure that union takes place in good
position
3. Permit early movement of the limb and a
return of function

46. REHABILITATION
• Reducing oedema
• Preserve joint movement
• Restore muscle power
• Back to normal activity

48. MANAGEMENT OF OPEN
FRACTURE

49. UNION vs. CONSOLIDATION ?
• UNION
– Incomplete repair
• calcified callus
• # site a little tender, attempted angulation
painful
• Xray – visible # line

50. • CONSOLIDATION
– Completed repair
• ossification of calcified callus
• # site not tender, no movement, attempted
angulation painless
• # line obliterated & crossed by bone
trabeculae

51. PERKIN’S RULES
For spiral fractures in upper limb
• Union in 3/52
• Consolidation x2
• Lower limb x2 again
• Tranverse # x2 again
Why?

52. DELAYED UNION
Fracture that has not healed within expected
time frame
WHY?
WHAT SHOULD WE DO ?

53. NON UNION
Fracture that will not heal without further
intervention
•Mechanical
• Inadequate fracture stabilization
• Uncontrolled repetitive stress
• Distraction & separation of fragments
•Biological
• Insufficient blood supply
• Infection

54. NON UNION
1. Septic (Infected)
2. Aseptic
• Hypertrophic – good blood supply but excessive
motion
• Atrophic – good fixation but poor blood supply

55. COMPLICATIONS
OF FRACTURE

56. GENERAL COMPLICATIONS
1. Shock
2. Coagulopathy
3. Fat embolism
4. Deep venous thrombosis
5. Tetanus
6. Gas gangrene

57. LOCAL COMPLICATIONS
• EARLY
• Bone – infection
• Soft tissues – compartment syndrome
• Joints – ligamentous injury
• LATE
• Bone – delayed union / non union / malunion
• Soft tissues – volkmann ischemic contracture
• Joints – stiffness, instability

58. STRESS FRACTURE

59. • Occur in normal bone of healthy patient
due to repetitive stress below yield strength
• During repetitive strenuous physical activity
causing imbalance in Wolf's Law
• Tibial shaft, calcaneum, MT, NOF
• Pain after – during – without exercise

60. PATHOLOGICAL FRACTURE

61. • Occur from trivial injuries through area of
weakened bone with a preexisting
abnormality
• Osteoporosis
• Paget’s disease
• Osteogenesis imperfecta
• Bone cysts
• Malignant tumors – primary & metastasis

62. THANK YOU

64. STEPS
1. Antibiotic prophylaxis
2. Wound debridement
3. Stabilization of fracture
4. Early wound cover

65. PREVENTION OF INFECTION
1. Antibiotics
• What?
• When?
• How?
2. Wound debridement
• The solution to pollution is dilution
• Removal of nonviable tissue – ‘4C’
• Color
• Consistency
• Contractility
• Capability to bleed
**Bone and fascia

66. STABILIZATION OF FRACTURE
• The importance of skeletal stability
• Promotes soft tissue healing
• Reduces rate of infection
• Wound care
• Options
• External fixation
• Internal fixation

67. WOUND CLOSURE
• 5-7 days is reasonable
• Options
• Primary delayed closure
• Skin grafting
• flaps