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03 PRINCIPLES OF FRACTURES
& DISLOCATIONS: GENERAL
DR. GEROCHI, February 02, 2021
Elysian Trans by FJTavera
ORTHOPEDICS
Outline

I. Definition of Terms
II. Fracture 101
 Proper management of fractures
 How to describe/classify fractures
 Types of fractures
 Potential sites
 Fracture displacement
 Fracture patterns
 Diagnosis: Imaging studies
 General treatment DEGREE OF SPRAINS
 Definitive treatment GRADE 1 GRADE 2 GRADE 3
III. Open Fractures Stretching of Tearing of up to 50% Complete tear of ligament
 Gustilo-Anderson Classification ligaments with of ligament fibers; & separation of ends,
minimal small hematoma. hematoma, &
 Treatment
disruption of hemarthrosis
 Complications fibers
*grading is according to the possible tears in joint ligaments
FRACTURES & DISLOCATIONS 5. Strain
Injury to the musculoskeletal system takes many forms  A stretching injury of the musculotendinous unit
depending on:  Muscle and/or Tendons
o the mechanism of injury
o the amount of force FRACTURE 101
o the location at which the force was applied  A fracture is a break in the surface of a bone.
 It can range from a simple crack to complete disruption of the
DEFINITION OF TERMS bony architecture.
1. Dislocation
 A complete & persistent displacement of the Proper management of fractures is based on:
articular surfaces of the bones that make up a o Integrity of overlying skin & soft tissues
joint o Specific location of the fracture within the bone
 With disruption of at least part of the o Degree of displacement of the injured parts
supporting joint capsule and some of its
ligaments. How to describe/classify fractures
o As to whether it’s open or close
2. Subluxation
o As to whether it’s complete or incomplete
 A partial dislocation of a joint
o As to the site of fracture
 The bone ends are partially separated from
each other & the articular surfaces are no o As to fracture displacement
longer congruent o As to fracture configuration
 May also have some ligamentous injury
A fracture can occur…
3. Fracture-Dislocation/Fracture-Subluxation  Either at the  Or through its
 The joint surfaces are no longer congruent & metaphysis or articular surface
segments of the bones are broken as the shaft/diaphysis (Intra-articular)
dislocation occurs (Extra articular)

4. Sprain
 A temporary subluxation of a joint in which the
articulating surfaces subsequently return to
their normal alignment
TYPES OF FRACTURES
 While joint displacement is temporary,
significant damage may occur to the capsule CLOSED FRACTURES
& ligaments  No wounds on or aroung
the fracture area
 The fracture fragments &
its hematoma have no
communication with the
outside environment
 In closed fractures, the
OPEN FRACTURES
 In open fractures, the skin is
breached.
 Fracture communicates with
the external environment thru
an open wound
 There are wounds on or
around the fracture area
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overlying skin remains  Fragments of bone may even ANGULATION

intact protrude from the skin
 Sometimes called
compound fracture

FRACTURE: POTENTIAL SITES

 DIAPHYSIS
o Heals by forming bridging
callus
o Slower rate of healing
 METAPHYSIS
o Heals by apposition of
callus across the
trabeculae
o Heals more rapidly
 INTRA ARTICULAR
o Involve the articular surface
o May cause posttraumatic
arthritis when the joint
congruency is not restored
 EPIPHYSEAL PLATE
o Occur in children FRACTURE PATTERNS
o Some types heal more rapidly; other types may cause  TRANSVERSE FRACTURES
growth arrest o Fracture line is almost
perpendicular to the shaft of the
FRACTURE DISPLACEMENT bone
o Caused by direct blows to the shaft
 NONDISPLACED FRACTURES
o Complete break in bone but with very little or
no deformation
o Usually maintains anatomic position or
alignment
 OBLIQUE FRACTURE
 DISPLACED FRACTURES o Fracture line has an acute angle to
o Not in anatomic alignment the shaft of the bone
o Are described by the type of deformity the displacement o Caused by axial loading along the
produces long axis
TYPES OF DISPLACEMENT
 Angulation
 Rotation
 Shortening
 Translation
 SPIRAL FRACTURES
o Spiral line along the longitudinal
axis, corkscrew, twisting
o Caused by rotatory forces along the
longitudinal axis of the bone

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 COMMINUTED FRACTURES  STRESS FRACTURES

o Fracture that has more than 2 fracture o Fractures caused by repetitive loading of
fragments bone
o Caused by high-energy mechanisms of o Often from overuse in activities i.e.
injury jumping and running
o More common in the lower limbs
 Metatarsals
 Fibula
 SEGMENTAL FRACTURES  Calcaneus
o Is a comminuted fracture with 2 fracture
lines resulting to three large, well-defined (red arrow) 3 weeks - thickened cortex =
fragments in the shaft of the long bone partially healed stress fracture w/o
radiographic evidence at the time of injury

Sometimes stress fracture present w/

just pain and X-ray cannot adequately
 IMPACTED FRACTURES identify the fracture. Request a CT
o The 2 fragments are telescoped to one scan or bone scan, if highly suspected.
another
o Stable fracture pattern

 AVULSED FRACTURES
o A fracture caused by sudden forceful pull
on a bone fragment, usually an area of
attachment for tendon or ligament
 COMPRESSION FRACTURES
o Common in cancellous flat bones,
especially the vertebrae
o Forces directed axially, resulting to
compressed bone
Sample Diagnosis
 Fracture, close, complete, oblique, M/3 femur, L
SIGNS & SYMPTOMS (high probability of a fracture)
 Pain
 Swelling
 Deformity / Angulation
 Shortening
 Attitude/position of the limb
 Pain, tenderness, swelling, & the
presence of hematomas may point to a fracture.
 Looking at the patient with the ff sign and symptoms will
suggest to you which areas to investigate further with
radiographs

DIAGNOSIS: IMAGING STUDIES

 GREENSTICK FRACTURES
o Occurring in the shaft, the cortex on the  Radiographs (x-rays)
o Usually if your impression is a fracture, x-ray can confirm the
convex side is broken but the cortex on
diagnosis
the concave side remains intact
 CT Scan (computed tomography)
o Unique to children (more flexible/elastic)
 MRI (magnetic resonance imaging)
 Bone scan

GENERAL TREATMENT OF FRACTURES

 BUCKLE / TORUS FRACTURES  IMMEDIATE (FIRST AID)
o Occurs in the metaphysis of long bones due to excessive o Splinting/Immobilization
compressive loading o Elevation
o Common in pediatric patients o Cold compress
 DEFINITIVE
 PATHOLOGIC FRACTURES o When the fracture is stabilized
o Occur when the bone is weakened by a o Operative or non operative
tumor or disease
o Even small amounts of force can cause
such fractures

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For initial or emergency treatment of fracture, applying a splint is DEFINITIVE MANAGEMENT OF FRACTURES
important with minimal manipulation esp if there is no X-ray.
“Splint them where they lie”

 Closed reduction
o Does not create a
wound or expose the
bone
o Usually, the fracture is
manipulated with
analgesia or
anesthesia and aided
by imaging

 Immobilzation by casting
o After
manipulation/reduction
of fracture
o Different ways to cast
limbs depending on the
location and the
fracture

 Tractions
o Balanced skeletal
traction for femoral
fracture
o Balanced skeletal
traction for bilateral hip
fractures
 Definitive
management for
bilateral hip
fractures
 However, for quick
SPLINTING IS IMPORTANT BECAUSE… turnover of patients,
 Immobilization reduces pain operative
 Immobilizing the fracture reduces bleeding management is
 Immobilization prevents further damage to surrounding soft sometimes
tissues (vessels, nerve) preferred
 Immobilization facilitates ease of transport/transfer
 Immobilization prevents a closed fracture from becoming an
open fracture

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 Open reduction and 3. TYPE III-A

Internal fixation (ORIF) o Wound >10cm; high contamination
o Operative management o Severe soft tissue injury, w/ crushing
using direct o Comminuted bone, but with soft tissue coverage
visualization of fracture o Soft tissue coverage of the fractured bone is adequate
fragments to fix (minimal periosteal stripping, often occurs with gunshot
fractures with implants injuries and often comminuted)
attached to the bone
and maintain reduction 4. TYPE III-B
until bone healing o Wound >10cm; high contamination
o Severe loss of soft tissue coverage with periosteal
 External Fixation stripping
o Application of fixation o Bone coverage poor; usually requires bone & soft tissue
devices to bone that reconstruction
protrude out of the skin o Severe comminution of the fracture
to maintain fraction o After debridement and irrigation a local or free flap is needed
reductio until bone for coverage. (eg, barnyard injury)
healing
5. TYPE III-C
o Wound >10cm; high contamination
OPEN FRACTURES o Severe soft tissue loss, w/ vascular &/or nerve injury
- fractures with open wound on or around the fracture with the requiring surgical repair
communication to the external environment. This communication o Bone coverage poor; usually requires bone & soft tissue
to the external environment drags the management of open reconstruction
fractures
SUMMARY:
THE GUSTILO-ANDERSON CLASSIFICATION OF OPEN
 Type I, II, III - classified based on wound size, degree of
FRACTURES
contamination, severity of bone and soft tissue injury
- 1st generally accepted and applied classification
 Subtypes of Type III is differentiated with adequacy of bone
- By Dr. Ramon Gustilo
coverage and presence of vascular injuries
 Original classification - Type I, II, III which emphasizes on
wound size, severity of injury and contamination
 Revised version (with Dr. Anderson) - with subdivisions of A, GUNSHOT FRACTURES
B, C based on soft tissue coveraage and presence of vascular  Gunshot fractures are open fractures
injury  The degree of soft tissue injury & fracture comminution
depends on:
o Caliber of the bullet
o Muzzle velocity (pistol vs rifle)

SAMPLE DIAGNOSIS
Fracture, Open type IIIA,
complete, oblique,
M/3 tibio-fibula, L

1. TYPE I
o Wound <1cm; clean Treatment of Open Fractures
o Minimal soft tissue injury  Treat life-threatening conditions
o Simple, minimal comminution of bone  Cover the wound with sterile dressings; splint the fracture
o Clean skin opening < 1 cm  Tetanus prophylaxis
o Most often occurring from inside to out  Antibiotics
o Fx is usually simple, transverse, or short oblique, with little  Debridement of fracture / wound
comminution.  Fracture stabilization

2. TYPE II
o Wound >1cm; moderate contamination
o Moderate soft tissue injury; some muscle damage
o Moderate comminution of bone
o Skin opening > 1 cm
o No extensive soft-tissue damage
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Compartment Syndrome
 Increased pressure within enclosed soft tissue compartments
of the extremities can lead to serious sequelae.
 Elevated compartment pressures commonly follow significant
injuries to the forearm and leg
 Resulting in reduced capillary perfusion below the level
necessary for tissue viability

SIGNS OF COMPARTMENT SYNDROME (5 P’s):

 Pain (esp on passive extension of fingers/toes)
 Pallor
 Parasthesias
 Paralysis
 Pulselessness
Fracture Complications
 EARLY Pulmonary Complications
o Nerve/vascular injury  Fat Emboli Syndrome (FES) - A form of ARDS that follows
major long bone fractures (0.5-2% of patients with multiple
fractures) & pelvic fractures.

o Compartment syndrome
 LATE
o Malunion o Nonunion/delaye
d union

 S/Sx include: petechiae, tachypnea, respiratory distress,

confusion
 Usuallly, fat emboli is seen in the lungs with pulmonary edema
 Sudden onset of respiratory insufficiency and extreme
arterial hypoxia
o Infection (open fractures)  Free fatty acids in the blood stream with pulmonary congestion,
 Long term complications usually atelectasis and interstitial edema
secondary to injury or to operative  Treatment: Supportive Management
management
 e.g. Gas gangrene E•N•D
o Osteonecrosis
 Result of fracture that causes the vascularizationof a
certain part of the bone

Femoral head
Scaphoid
Talus
o Posttraumatic arthritis

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