General Principles of Fractures

Dr Quazi Shahid-ul Alam

MBBS, MS (Ortho)
Fellow Paediatric Orthopaedics. Seoul, South Korea.
Assistant Professor , Paediatric Orthopaedics

Dhaka Medical College Hospital

 Definition

• A soft tissue trauma where the bone happens

to be broken.

• It is basically Break in the continuity of bone.

 Types of Fractures

• Closed
– Bone can break within its soft tissue envelope and
have no communication to the exterior.

• Open
– When the fracture HAEMATOMA communicates
with the exterior.
• Difference between open and close fracture

• Difference between open and close reduction

 open and close fracture

When the fracture HAEMATOMA communicates

with the exterior or not

• If communicate with exterior – open fracture

• If do not communicate with exterior – close

fracture
Close Fracture
Open fracture
Look at position of soft tissue breach
and site of fracture
 Types of fracture

• Based on extent of fracture line:

– Incomplete Fracture
– Complete Fracture –
• Displaced

• Undisplaced
 Types of fracture

• Based on fracture pattern :

– Linear fractures-
• Transverse
• Oblique
• spiral

– Comminuted Fractures.
– Segmental fractures
 Types of Fracture
Some Atypical Fractures
• Greenstick fractures

• Torus fracture
• Impacted fractures

• Avulsion fractures

• Pathological fractures
• Open fracture
Close fracture
 Approach to Orthopaedic injury

• History

• Age: Birth, early childhood, Late childhood

Adult, Elderly.

• Sex

• Mechanism of injury
 Approach to Orthopaedic injury
Clinical Features
• Symptoms:
– Pain, Swelling, deformity, inability to use the
affected part.
• O/E
– Look – Deformity, swelling, Shortening
– Feel: Tenderness,
– Move : Abnormal mobility, Crepitus
 Investigations in Orth trauma
• Radiography- most important diagnostic tool
for fractures. Minimum two views (AP and
Lateral) are required.
• Sometimes an oblique and other special views
are required.
• CT Scan and MRI – both are noninvasive and
extremely useful in detecting both soft tissue
and bony injury.
 Remember the rules in X-ray
• Law of Two’s :
– Two views

– Two joints

– Two limbs
– Two occasions
– Two physicians
 Remember the rules in X-ray
Rule of 2

• Better no X-ray than one view X-ray

• Read x-ray holding it in anatomical position.

 Management of Fracture

• The goal of fracture management is to restore

the anatomy back to its normal or near to
normal as possible.

• Management of close and open fracture are

different
 Management of #
• Resuscitation :Save life
• Recognition: by xray, ct scan etc.
• Reduction : by traction and counter traction
• Retention : by traction, plaster or brace or
implants
• Rehabilitation: getting functional life back
 Management of closed fracture

• Managed by
– conservative methods
– operative methods.
 Management of closed fracture
• Conservative methods :
• For undisplaced #,incomplete #,Impacted # :
– Collar and cuff sling
– Strapping
– plaster slab/cast,
• For displaced fracture : the aim is to restore
anatomy as near as possible by either closed
or open reduction.
Management of Closed fracture
 Plaster info
• Half circle plaster is slab (either back slab or
anterior slab)
• Full circle plaster is cast
• Initially give slab then after 5 days convert to
cast
• Hold proximal and distal joint within the
plaster . Few exceptions are there
 Plaster info
• Keep plaster as following rules
– For adult upper limb : 6-12 weeks
– For adult lower limb : 12-24 weeks
– For children upper limb : 3-6 weeks
– For children lower limbs : 6-12 weeks
• Be aware of following joints if involved within
your plaster
– IP and MP joint : 2 weeks
– Elbow : 3 weeks
– Rest all joints : 6 weeks
• For displaced closed fracture
– If we can reduce anatomically or near anatomically by
close reduction then plaster will do.

– If we cant reduce in acceptable position by close

reduction then we need to go for open reduction and
internal fixation.

– If close fracture involve intra articular fracture always

go for open reduction from the very beginning.
Choice of implants
• K-wire
• Intramedullary nails
• Plate and screw
• Interlocking nail
• Hip implants, Spine implants, Steel wires
• In combination
• Rehabilitation will ensure final outcome.

• Bone united but joint got stiff or muscle

remain weak/atrophied will lead to functional
failure. .
 Close and open reduction
• Close reduction :
– Fracture was closed and we reduce the fracture by
traction and counter traction without exposing the
fracture hematoma.

• Open reduction :
– Fracture was closed and we failed to achieve close
reduction, so we incise the skin , deep fascia and
muscle to see the fracture end of the bone there by
exposing the fracture hematoma.
 Close reduction and internal fixation

• Fracture was closed and we reduce the

fracture by traction and counter traction
without exposing the fracture hematoma and
implant was inserted without exposing
fracture hematoma.
 Open reduction and internal fixation

• Fracture was open and we reduce the fracture

by traction and counter traction (the fracture
hematoma already exposed) and implant was
inserted through the exposed fracture
hematoma.
• Open fracture
• Open fracture
• Open fracture
 Management of open fracture.
• Antibiotic prophylaxis
• Urgent wound and fracture debridement
– Wound excision
– Wound extension
– Removal of devitalized tissue
– Wound cleansing
• Early definitive wound cover
• Stabilization of the fracture.
Management of soft tissue injury

Preparation
 Management of soft tissue injury

• Note down injury,

• classify
• Assess Neuro-vascular status

Assessment
 Management of soft tissue injury

Washing with
copious saline

Solution of pollution is

Dilution.
 Management of soft tissue injury

Wound excision,
wound extension
Debridement

First debridement
should be extensive
and adequate.
Management of soft tissue injury

Appearance after toileting

 Management of soft tissue injury

Immobilization

For open fracture

For close fracture

 Classification

• Gustilo’s classification of open fractures

• Three type : I, II and III

• Type III is subdivided into A, B and C
Gustilo and Anderson classification (grade I)

• <1 cm clean wound with a simple

fracture pattern.
Gustilo and Anderson classification (grade II)

• >1 cm but <10 cm wound.

Gustilo and Anderson classification (grade
IIIA)
• Grade 3A adequate bone coverage by
local soft tissues.
 Gustilo and Anderson classification (grade
IIIB)

• Grade 3B soft-tissue loss

requires a graft or flap.
Gustilo and Anderson classification (grade
IIIC)

• Grade 3C arterial injury requiring repair

associated with any fracture.
Thank you