Easy Orthopedics

Introduction Lecture
Definitions and Classifications
By : Karim Hisham
 Long bone structure

Immature Mature
Definitions

Fracture Dislocation Sublaxation Fracture

• Bones • Joint • Joint dislocation
• Loss of • Complete loss of • Partial loss of
• Bone + Joint
continuity of Continuity of Continuity of
Bone Cortex Articulating Articulating • Dislocation by
surfaces of joint surfaces Fracture of one
or more
Articulating
surfaces
Classification Traumatic
Direct

Indirect
Etiology Pathological

Shape and
Stress
pattern

Extent

Relation to
Translation
Exterior

Classification Displacement Angulations

Impaction Rotation

Stability

Healing

Age
Etiology ( Traumatic )
Healthy Bone + Exposure to High Stress > strength failure
Traumatic ( Direct ) Traumatic ( Indirect )
At site of Fracture More Soft Away from Site of Fracture
tissue injury Less Soft tissue injury

In Both Bone → Not Same Level

(Weakest point of each )
In Both Bone → Same level 1. Forearm: Distal radius + Proximal ulna
2. Leg: Distal tibia + Proximal fibula

E.g. Avulsion – Falling from height or on outstretch

E.g. Crush Fracture hand
 Direct Vs Indirect
Direct → In Both Bone → Same level
Indirect → In Both Bone → Not Same Level (Weakest point of each )
Etiology ( pathological )
• Diseased Bone + Exposure to Physiological Stress
Tumor

Hyper-para Infectio
thyroidism n

Pathology

Renal Osteoprosis

Rickets
 Etiology ( Stress)
Healthy Bone + Exposure to Unusual Repeated Stress < Strength Failure

Imbalance between Bone Synthesis, Turnover

Weak Bones

Bone
synthesis
Microfractures coalesce together

Stress Fracture Turnover

March Fracture in Soldiers (Metatarsals)

Ballet Dancers (Distal Fibula)
Shape ( pattern )
• angle < 30o
Transverse
• Fracture = Diameter

• angle > 30o

Oblique
• Fracture > Diameter

• Rotational or Twisting
Spiral
(> 1 plane)

Comminuted • 2 or more fragments

Segmental • Double level fracture

Extent

Complete
(Both sides ) Adult
Extent
Incomplete =Fissure
(one Side ) Child =
Greenstick
Relation to Exterior

No connection
Closed
with Exterior
(Simple )
environment

Wound Connect
Fracture
Open Hematoma
(Compound) +
Exterior
environment
Displacement
Movement of Fracture Site

Relation of Distal to Proximal Fragment

Trauma Ligament Muscle Weight of

itself injury contraction limb
Displacement ( Translation )
Side – Side Displacement
Perpendicular to Long Axis Parallel to Long Axis
Overriding
1. Medial or Lateral
(Overlapping) →
(AP Film)
Shorter or bayonette

2. Anterior or
Posterior Distraction → Longer
(Lateral Film)
 Displacement ( Angulations )

Angular Connection ()
Proximal and Distal Fragments

Relation of Distal Axis to

Proximal Axis
Displacement ( Rotation )

Different Views of at
same Film

Cross section
Mismatch (Diameter)
Impaction

Fragment is Driven into other

Stability

Stable Unstable

No risk for Risk for Further

Displacement Displacement
Healing

Delayed Non-
Union Malunion
Union union
Age

Children Adult
Diagnosis of Fracture
Clinical Plain X-ray

History :Trauma or Diseased Bone 2 Views (AP / Lat)

2 Joints (Proximal – Distal)

Pain – Hotness – Swelling – Tenderness –
Ecchymosis
2 films (Pre, Post)
Sure signs:
Crepitus sign –Deformity- Loss of motion ±
Length Discrepancy
2 Sides (compare)
Management of Fracture
General Management of Polytrauma → ATLS

Definitive management of Fracture: Open or Closed

Management of Complications

Rehabilitation
 Reduction & Fixation
Reduction Fixation
Re-alignment Maintain Reduction

restore anatomy Rapid union

Prevent deformity
Rapid Union

Prevent deformity
External Internal External
Fixation Fixation Fixator

Skeletal LLizarov Taylor spatial

Cast – Slap Plate, Screw IM nail Wires
Manipulation Traction apparatus frame

Closed
Traction by
Anesthesia
Open
Cast Traction

Plate and Screw Intermedulary Nail

LLizarov apparatus

Taylor spatial frame

Indications of open Reduction
Failure of Conservative

Open Fracture

Intra-articular Fracture

Pathological Fracture

Severe comminuted

Segmental

Nerve/Vessel injury

Malunion or Non-Union
Fracture Healing
Stages

Requirement
Fracture
Healing
Types

Duration
 Stages of Healing
• Soft tissue injury by Fracture
1. Hematoma:

• Capillary regeneration – Chemotaxis

2. Organization: (Inflammatory, Polypotent stem cells)

3. Callus • Cartilage Formation by polypotent

stem cells
Formation:

4. Callus • Bone Formation by ossification

Maturation:
• Restoration of normal shape
5. Remodeling:
N.B : Wolff's law
↑ Stress over Fracture

Rapid proliferation

Rapid healing
Requirement
Reduction
+
Fixation

Good
Healing
Good
vascularity
 Types of Healing
Primary Secondary
Rigid Fixation by Blade and Unrigid fixation by Plaster
Screw or Internal Fixation of Paris or IM nail or Ex – Fx

No Stress Stress + micromotions

Bone healing without Bone healing with cartilage

cartilage stage stage

Good but Slow Less Good but Rapid

 Duration of Healing
Clinical Radiological
UL (6-8 w)
Adult
LL (12-16 w)
Duration
UL ( 3-4 w )
Child
LL ( 6-8 w ) Bridging callus formation → Remodelling
 Remoeling
Rapid Slow
Young age
Old Age
Metaphyseal Diaphyseal
Any displacement except Rotation
Rotation

Angulation in Plane of Angulation > 200

Movement of Nearby joint

Intra-articular
Pediatric Fractures ( Types )
Epiphyseal
• Injury or Separation of Epiphyseal plate → Arrest of Growth

Plastic Deforman
• Bending of Long Bone instead of Fracture by ↓Mineralization → Permanent Deformity.
• Mostly in Forearm, Fibula, Femur

Greenstick Fracture
• Incomplete by Bending of one side at metaphysis /diaphysis junction → Fracture of
opposite side (Tension side).
• Can be compression or buckle (Torus Fracture) → May Need to complete Fracture for TTT
 Pediatric Fractures ( Remodeling )
Rapid healing • Less immobilization → Less Joint stiffness

Weak Healing (Early • Need to avoid severe activities for 2-4 weeks
callous is fibrous)
• Simplest during treatment (Over is worse)
High Remodeling • Not essential reduction except Rotation

Thick loose adherent • Easily stripped + Highly vascular active

Periosteum