Principles of Fractures

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Bone compsosition
Bone anatomy
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 Fracture
• it’s the break in the continuity of the bone
• It could be:
– Simple (closed)
– Compound (open)
 Classification
• Closed or open
– Closed fractures, skin is intact.
– Open (compound) fractures involve wounds that
communicate with the fracture and may expose bone to
contamination, may be from inside or outside.
• Simple or multi-fragmentary (comminuted)
– Simple fractures only occur along one line, splitting the
bone into 2 pieces.
– Multi-fragmentary fractures involve the bone splitting into
multiple pieces. (high energy injury→ soft tissue probably
damaged)
 Types of fracture
1. Complete fractures – line occurs according to mechanism of injury
– Transverse fracture
– Oblique or spiral
– Impacted
– Comminuted
2. In-complete fractures, the bone is incompletely divided and the
periosteum remains in continuity.
– Greenstick fracture
– Stress fracture
– Compression
3. Physeal fractures – affect growth
4. Fracture displacement
 Displacement of the fracture fragments
• Causes:
• Primary impact
• Gravity
• Muscle pull
• The following Displacements are recognized:
(translation) of the distal fragment.
(alignment) of the distal fragment in relation to
proximal one or the opposite.
(twist) one fragment may be rotated on its
longitudinal axis.
Shift and angulation can remodel, while rotation cannot
 Injury description
1. Bone: Description of a fracture starts by naming the bone
2. Location: the part of the bone involved.
3. Type: simple or multifragmentary and closed or open.
4. Group: transverse, oblique, spiral, or segmental.
5. Subgroup: displacement, angulation and shortening.
 Description
Complete Fracture – bone fragments separate completely.
• Transverse Fracture – fracture at a right angle to the bone's long axis.
• Oblique Fracture – fracture that is diagonal to a bone's long axis.
• Spiral Fracture – fracture where at least one part of the bone has been
twisted.
• Compacted Fracture – bone fragments are driven into each other.
• Comminuted Fracture.
– Segmental (double) Fx, occur at 2 levels with free segment between
them.
Incomplete Fracture – bone fragments are still partially joined.
– Greenstick fractures in children, the spriny bone in childhood, buckles
on the side opposite to the causal force, where periosteum remains
intact.
• Compression fracture, ex. when the front portion of a vertebra in the spine
collapses due to osteoporosis.
• Reduction is not required in vertebral body fracture, But it is necessary
when the fractures are part of joint.
• Stable fracture is one which is likely to stay in a good
(functional) position while it heals.
• Unstable Fx is likely to angulate or rotate before healing and
lead to poor function in the long term. (can cause malunion)
• Fracture-dislocation is Fracture of the bony components of the
joint, ex:
– Shoulder fracture dislocation
– Elbow fracture dislocation
• Burst fracture, occur in vertebra due to severe violence, acting
vertically on a straight spine.
– Anterior and posterior surfaces of the vertebra are involved – post
involvement may lead to neuro injury
= wedge
Transverse fracture

Usually perpendicular,
but angle is accepted up
to 30 degrees
 Oblique fracture
Shorter than spiral #
Impacted fracture
Spiral fracture
spiral
 Causes of fractures
1. Sudden trauma
2. Stress “fatigue fracture”
3. Pathological fracture
4. Growth plate injury
 Fractures caused by sudden injury in a
normal bone
• Majority of the fractures.
• Caused by single excessive force.

a. Direct blow that cause a transverse Fx with damage to skin. ( Tensile force )
b. Crushing force that cause comminuted Fx with extensive damage to
soft tissue.
The bone breaks at a distance from where the force is
applied. Have better prognosis, less soft tissue damage
a. Rotational force, leading to spiral fracture.
b. Bending force, leading to transverse fracture.
c. Bending with compression, leading to transverse fracture with
butterfly third segment.
d. Combined (Rotation, bending & compression) leading to oblique
fracture.
e. Pulling force, in which a tendon pull, causes avulsion fracture.
 Need less
energy,
Need higher remodel
energy, heal faster
slow
 Stress fracture – fatigue fracture
• 2 categories:
bone with normal elastic resistance, so
application of abnormal stress or torque causes resorption and
microfractures.
occurs with normal muscular activity
stresses on bone with deficient in mineral or elastic resistance
• Mostly affect athletes (runner) or military recruits
• Occur anywhere but most commonly 2nd metatarsal followed by
Fibula and Tibia.
• Clinically, Pain with gradual onset, examination will show local
tenderness after weeks there will be swelling.
• X-ray, MRI and Bone scan.
 Pathological fracture
• Occur through a bone that is weakened by a disease.
• Fx occur either spontaneously or from trivial violence.
• Local causes
– Bone infection (osteomyelitis)
– Benign tumors (enchondroma, giant cell tumor).
– Malignant tumor (osteosarcoma , Ewing sarcoma & metastatic
carcinoma).
• Generalized causes
– Congenital (osteogenesis imperfecta) – type 1 collagen.
– Diffuse affection of bone (osteoporosis, rickets, uremic osteodystrophy)
– Other causes (Polyostotic fibrous dysplasia, Paget’s disease, Gaucher’s
disease).
 Growth plate injury
• Over 10 % of fractures in children involve the growth plate.
• 3 types of injuries:
1. Simple separation.
2. Fractures that cross the growth plate.
3. Crush injury.
• Factors that increase suspicion of physeal injury
1. Widening of physeal gap
2. Incongruity of the joint
3. Tilting of the epiphyseal axis
 Soft tissue damage
• It could be either:
• Low energy fractures like closed spiral fractures →
cause moderate soft tissue damage.
• High energy fractures like comminuted fractures →
cause severe tissue damage, no matter whether it open
or close.
 Fracture VS. Soft tissue injury
• Deformity  more suggestive of a Fx.
• Children  Green stick Fx
• Elderly  impacted Fx of femoral neck may experience
• Little or no pain
• Loss of function
• Numbness
• Skin pallor, cyanosis
• Blood in urine
• Abdominal pain
• Difficulty with breathing
• Transient loss of consciousness

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 Approach

History
Physical examination
Investigation
 History
• Fracture is not always at the sight of injury (indirect)
• Certain fracture will not affect the function of the
limb, like greenstick fracture or scaphoid fracture.
• Age
• Mech. Of injury
• Pain
• Bruising
• Swelling
• Limitation of movement
• Previous or other musculoskeletal abnormality
• General medical history
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Examination
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 Examination
• In any case X-ray diagnosis is more reliable
1. Examine the most obviously injured part
2. Check for arterial damage
3. Test for nerve injury
4. Look for injury in distant parts

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 Look
• Swelling
• Bruising
• Deformity
• Skin is intact or not (open VS simple)
• Posture of distal extremities and color of the skin 
signs of nerve or vessel damage

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 Feel
• Tenderness
• Temperature
• Crepitus on movement
• Distal pulses
• Spine and pelvis
• Vascular and peripheral nerve abnormalities (before and after
treatment)
• Examination of the viscera
– Liver and spleen in case of rib fracture.
– Bladder and urethra in case of pelvic fracture.
– Neurological examination for head and spinal injury.
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 Associated injuries
injury may damage brachial plexus or
vessels at base of neck. Neurological and vascular
examination are essential
2. Thoracic injury (rib or sternum Fx) associated with lung or
heart injury
associated with spinal cord or nerve root
injury
: associated with visceral
injury inquire about urinary function and look for blood in
urethral meatus

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37
 Move
• Movement of the joint distal to the affected area;
• Crepitus and abnormal movement indicates a fracture.

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 Imaging
1. X-ray
• Two views, AP and lateral.
• Two joints.
• Two limbs.
• Two injuries, like calcaneal fracture you have to suspect
vertebral fracture.
• Two occasions, like stress and scaphoid fractures.
• Special views
– Calcaneal view
– Shoulder dislocation needs axial view
– Acetabular fractures need 45 degree tilt view.
2. CT scan and MRI (spinal, pelvic and calcaneal fractures)
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3. Radioisotope scan (scaphoid and stress fractures)
 X-ray & Rule of 2
1. 2 views (AP & lateral): fracture or dislocation may not be
seen in a single X-ray

2. 2 joints: above and below Fx, may be dislocated or fractured

3. 2 limbs: in children X-ray of uninjured limb are needed for

comparison, because immature epiphysis may confuse the
diagnosis

4. 2 occasions: some fractures are difficult to detect soon after

injury, another X-ray a week or two later may show the
lesion. Example: undisplaced frx. of distal end of clavicle

5. 2 injuries: severe force causes injury at more than one level

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 Fractures in children
1. Difficult to diagnose: Bone ends are largely cartilaginous
and don’t show up in X-Ray, so X-Ray both limbs and
compare the appearance on both sides.
2. Bones are less brittle and more liable to plastic deformation.
Higher incidence of incomplete fx. Buckling of the cortex
and green stick frx. are rare in adults.
than adult bones that’s why frx.
. Cellular activity is
increased (frx. heals faster).
4. Non-union is very unusual
5. More capacity to reshape frx. Deformity more modeling and
remodeling.
6. Injury to the physis  damage to growth plate can have
serious consequences.
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 Salter-Harris classification

Type I:
• The whole growth plate is
separated.
• No growth disturbances

Type II:
• The growth plate is
separated carrying with it a
triangular metaphyseal
fragment.
• No growth disturbances.
• The most common injury.
Type III:
• Part of the growth plate is
This one is
separated. intra-articular
• May lead to growth
disturbances.
Type IV:
• Separation of part of the
growth plate with a
metaphyseal fragment.
• May lead to growth
disturbances.
Type V:
• Crushing of part or all of the
growth plate.
• Growth disturbances & arrest
are very common.
• The most dangerous injury.
We dx it RETROSPECTIVELY
 Fracture repair

Healing with callus

Healing without callus

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 Fracture repair
• Fracture repair is a tissue regeneration process rather than a
healing process the injured bone is replaced by bone.

– Type of bone involved

• Tubular bone Cortical bone
• Cancellous bone Spongy bone
– Amount of movement at the fracture
– The closeness of the fracture surfaces
 Tubular bone repair
• 2 types:
1. Haling by callus
1. Tissue destruction and hematoma formation
2. Inflammation and subperiosteal and endosteal
cellular proliferation
3. Callus formation
4. Consolidation
5. Remodeling
2. Healing without callus
 Healing by callus

1- Tissue destruction and

hematoma formation.

• Disruption of blood vessels

A hematoma forms around
and within fracture
• Few millimeters of the
fracture surfaces dies.
2- Inflammation and
subperiosteal and
endosteal cellular
proliferation.

• Need 8 hours.
• Proliferation of fibroblasts,
mesechymal cells, and
osteoproginetor cells.
• New vessels formation.
3- Callus formation.

• Chondrogenic and osteogenic

activity.
• Cartilage in the periphery, woven
bone near the bone ends.
• Marked increase in vascularity.
• Osteoclast activity.
• At the end the pain disappears
and the fragments are rigid w/o
movement.
4- Consolidation.

• The primitive woven bone is

transformed into lamellar
bone by osteoclastic and
osteoblastic activity.
• Need several months before
the bone is strong enough to
carry normal loads.
5- Remodeling.
• Callus is reshaped: the
bone along the lines of
stresses are strengthened
while bone outside these
lines removed.
 The medullary canal is
reformed.
 The remodeling depends on
age that Fx remodeling in
children is so perfect.
 Healing without callus = primary healing

 Callus is formed as a response to movement at the fracture

side, to stabilize the fragments rigidly.

 Primary bone healing occurs directly between the 2

fragments without callus formation, when the fracture site is
absolutely immobile.

 Primary bone healing can occur in 2 instances:

◦ Naturally in impacted fractures of the cancellous bone.
◦ In cortical fractures where the 2 fragments are in complete
contact and rigidly fixed (absolute fixation) by metal device
(plates, screws or intramedullary nails).
• Cortical bone remodels by osteoclastic tunneling (cutting
cone)
• Cutting cones consist of:
1. Osteoclasts
2. Capillary bud
3. Osteoblasts
4. Osteoblasts lay down new osteons
 Cancellous bone repair
• Cancelous bone has spongy texture with open meshwork of
trabeculae, allowing easier penetration by vessels and bone
forming cells.

• The broader area of contact between the fragments with

good blood supply allow healing in shorter period of time w/o
need for callus formation.
Complete recanalization
Blood Canal
Soft tissue Cartilage Bone
 Test of union
• Clinical:
– Absence of mobility.
– Absence of tenderness.
– Absence of pain.
• Radiological – X-ray criteria:
1. Callus formation
2. Bone bridging
3. Trabeculation
• Bone can withstand normal (physiologic) loading
 Rate of union
• Favorable factors.
– Age: 3-5 weeks in
children while it needs 3-
5 months in adult.
– Type of bone: cancellous
is better healer.
– Blood supply
– Immobilization.
– Adequate nutrition
(including calcium
intake)
• Unfavorable factors.
– Impairment of blood
supply.
– Excessive movement.
– Infection
– Tumor
– Synovial fluid in
intraarticular Fx.
– Interposition of soft
tissue (↓ contact btw bony
ends).
– Any form of Nicotine.
Average time for Upper limb Lower limb
healing

Callus visible 2-3 weeks

Union 4-6 weeks 8-12 weeks

Consolidation 6-8 weeks 12-16 weeks

 Non union
• Distraction and separation of the fragments.
• Interposition of soft tissues between the fragments.
• Excessive movement at the fracture site
• Poor local blood supply.
• Severe damage to soft tissues which makes them non viable.
• Infection
• Abnormal bone.
Treatment of Fractures
 Steps
1. Reduction
• Closed (manual)
• Opened (surgery)
2. Maintenance of reduction
• Cast (2 joints, except elbow)
• Internal fixation
• External fixation
• Traction (skin/skeletal)
3. Rehabilitation (exercise)
 The Fracture Quartet
• Dual Conflict
– Hold vs Move
– Speed vs Safety
 Reduction
• Reduction unnecessary when:
– There is little or no displacement
– Displacement does not matter
– Reduction is unlikely to succeed
• Aim of reduction
– Adequate apposition
– Normal alignment of the bone fragments
• Methods of reduction
– Manipulation
– Mechanical traction
– Open operation
1. Manipulation
• Closed manipulation is suitable for:
1. All minimally displaced fractures
2. Most fractures in children
3. Fractures that are likely to be stable after reduction
• Unstable fractures are sometimes reduced ‘closed’
prior to mechanical fixation (temporarily)
• Three fold maneuver: under anesthesia and muscle
relaxation
1. The distal part of the limb is pulled in the line of the bone
2. The fragments are repositioned as they disengage
3. Alignment is adjusted in each plane
 2. Mechanical Traction
• Some fractures are difficult to reduce by manipulation
• They can often be reduced by sustained mechanical
traction, which then serves also to hold the fracture
until it starts to unite
• In some cases, rapid mechanical traction is applied
prior to internal fixation
 3. Open Operation
• Operative reduction under direct vision is indicated:
1. When closed reduction fails
2. When there is a large articular fragment that needs accurate
positioning
3. For avulsion fractures in which the fragments are held apart
by muscle pull
4. When an operation is needed for associated injuries
5. When a fracture will anyhow need internal fixation to hold it
 Hold (maintenance of reduction)
• Restriction of movement
– Prevention of displacement
– Alleviation of pain
– Promote soft-tissue healing
– Try to allow free movement of the unaffected parts
• Splint the fracture, not the entire limb
• Methods of holding reduction:
– Cast splintage
– Internal fixation
– External fixation
– Traction
– Bracing
• Closed vs. operative methods
 Cast Splintage
• Used for distal limb fractures and for most children’s fractures
• Safe: not applied too tightly or unevenly
• Speed: of union same as traction, but pt goes home sooner
• Hold: patients with tibial fractures can bear weight on the cast
• Move: joints encased in plaster cannot “move” and are liable
to stiffen. This complication can be minimized by:
1. Delayed splintage- using traction until movement has
been regained, and then applying plaster
2. Starting with a cast but after a few weeks replacing it by a
functional brace which permits joint movement
 Complications of cast splintage
1. Tight cast
2. Pressure sores
3. Skin abrasion or laceration
4. Loose cast
 Internal Fixation
• Hold: securely with precise reduction
• Move: can begin at once (no stiffness & edema)
• Speed: patient can leave hospital as soon as wound is healed, but
full weight bearing is unsafe for some time
• Safe: biggest problem is sepsis

1. Open reduction
2. Fractures that are inherently unstable and prone to re-
displacement after reduction
3. Fractures that unite poorly and slowly
4. Pathological fractures
5. Multiple fractures
6. Fractures in patients who present severe nursing difficulties
 Internal fixation
1. Plates (on the surface of bone)
o Metaphyseal fractures of long bones
o Diaphyseal fractures of the radius and ulna
2. Intramedullary nails (inside the bone)
o Long bones
o Locking screws resist rotational forces
3. Screws, fixing small fragments onto the main bone
4. Wires (condular or trochlear Fx), hold fragments together where
fracture healing is predictably quick

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Plates and screws

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Nails
Screws

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Elastic

Wires

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Complications of internal fixation
• Most are due to poor technique, equipment or operating
conditions
• Infection
• Iatrogenic infection is now the most common cause of
chronic osteomyelitis
• Non-union
• Excessive stripping of the soft tissues
• Damage to the blood supply
• Rigid fixation with a gap between the fragments
• Implant failure
• Refracture
 External Fixation
• Need High degree of training and skill Mnemonic: COIN PN
• Indications:
1. Wound can be left open for inspection, dressing, or definitive
coverage (like open fractures).
2. Infected fractures, for which internal fixation might not be
suitable.
3. Fractures associated with nerve or vessel damage.
4. Severely comminuted & unstable fractures
5. Pelvis fractures
6. Un-united fractures, where dead or sclerotic fragments can
be excised and the remaining ends brought together in the
external fixator; sometimes this is combined with elongation in
the normal part of the shaft
Complications of external fixation:
• Damage to soft-tissue structures
• Over-distraction, no contact between the fragments union
delayed/prevented
• Pin-track infection
 Sustained Traction
• Traction is applied to the limb distal to the fracture, so as to exert a
continuous pull in the long axis of the bone
• In most cases a counterforce will be needed
• Particularly useful for spiral fractures of long-bone shafts, which are
easily displaced by muscle contraction
• “Hold” is not perfect, but it is “safe” and the patient can “move” the joints
and exercise the muscles.
• The problem is the lack of “speed”complications
• Types:
– Traction by gravity (Fractures of the humerus)
– Balanced Traction
• Skin traction: adhesive strapping kept in place by bandages
• Skeletal traction: stiff wire/pin inserted through the bone distal to
the fracture
Femur fracture managed with skeletal traction
and use of a Steinmann pin in the distal femur.
 Functional Bracing
• Prevents joint stiffness while still
permitting fracture splintage and
loading
• Most commonly for fractures of the
femur or tibia
• Since its not very rigid, it is usually
applied only when the fracture is
beginning to unite
• Comes out well on all four of the basic
requirements: “hold” “move” “speed”
“safe”
 Rehabilitation
• Restore function to the injured parts and the patient as a whole
• Active Exercise, Assisted movement (continuous passive motion by
machines), Functional activity
• Objectives:
– Restore circulation
– Prevent soft tissue adhesions
– Promote fracture healing
– Reduce edema
• Swelling  tissue tension and blistering, joint stiffness
• Soft Tissue care: elevate and exercise, never dangle, never
force
– Preserve joint movement
– Restore muscle power
– Guide patient back to normal activity
 OPEN FRACTURES
• Initial Management ABCs +

– At the scene of the accident splinting

Coverage +
+ Abx
if available

– In the hospital
ABCs
↓
give fluids, abx, analgesia, tetanus ppx, and cover to prevent further
contamination
↓
neurovascular exam (look out for compartment syndrome)
↓
splint fracture (external fixation) as damage control – emergent, non-definitive
↓
manage soft tissue injuries, debride necrotic
↓
definitive repair
 Gustilo’s classification of open fractures
• Type 1: low-energy fracture with:
– Small, clean wound
– Little soft-tissue damage
• Type 2: moderate-energy fracture with
– Clean wound more than 1 cm long
– Not much soft-tissue damage
– Moderate comminution of the fracture.
• Type 3: high-energy fracture with
– Extensive damage to skin, soft tissue and neurovascular structures
– Contamination of the wound.
• Type 3 A: the fractured bone can be adequately covered by soft tissue
• Type 3 B: can’t be adequately covered, and there is also periosteal
stripping, and severe comminution of the fracture
• Type 3 C: if there is an arterial injury that needs to be repaired, regardless
of the amount of other soft-tissue damage.
 Incidence of wound infection
In open fx

• Correlates directly with the extent of soft-tissue

damage
– <2% in type 1
– >10% in type 3
• Rises with increasing delay in obtaining soft tissue
coverage of the fracture.

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• All open fractures assumed to be contaminated Prevent
infection!
• The essentials:
– Prompt wound debridement
– Antibiotic prophylaxis
– Stabilization of the fracture
– Early definitive wound cover
– Repeated examination of the limb because open fractures
can also be associated with compartment syndrome
 Sterility & Antibiotic cover
• The wound must be kept covered until the patient reaches the
operating theatre
• Antibiotics ASAP
• Most cases: Benzylpenicillin and flucloxacillin
• Even better: 2nd generation cephalosporin, every 6 hrs/48
hrs
• If heavily contaminated, cover for G-ve organisms and
anaerobes by adding gentamicin or metronidazole and
continuing treatment for 4 or 5 days
 Debridement &
Wound Excision
• In the operating theatre, never in the ER!
• Under GA
• Maintain traction on injured limb and hold it still
• Remove clothing
• Replace dressing with sterile pad
• Clean and shave surrounding skin
• Remove pad and irrigate wound with A LOT of warm normal saline
• Do not use a tourniquet!
• Extend wound and excise ragged margins healthy skin edges
• Remove foreign materials and tissue debris
• Wash out wound again with warm NS (6-12 L)
• Remove devitalized tissue
• Best to leave cut nerves and tendons alone
 Wound Closure
• To close or not the skin= difficult decision
– Uncontaminated types 1 & 2 wounds may be sutured
– All other wounds: delayed primary closure
– Type 3 wounds may occasionally have to be debrided
more than once and skin closure may call for plastic
surgery.
• Skin grafting= most appropriate if the wound cant be closed w/o
tension and the recipient bed is clear, free of obvious infxn, and
well vascularized
 Stabilization of the Fracture
• Stability of the fracture is imp in:
– Reducing the likelihood of infection
– Assisting in recovery of the soft tissues
• Method of fixation depends on:
– Degree of contamination
– Length of time from injury to operation
– Amount of soft tissue damage
• Open fractures of all grades up to 3A treated as for closed injuries
• More severe injuries: combined approach by plastic and ortho
surgeons
– The precise method depends on the type of soft-tissue cover that
will be employed, although external fixation using a circular
frame can accommodate to most problems
 After care and Team Work
• Post-op
– Limb is elevated
– Circulation carefully monitored
– Antibiotic cover continued; swab samples will dictate whether a
diff. antibiotic is needed
– If wound has been left open, inspect in 2-3 days. Delayed
primary suture is then often safe or, if there has been much skin
loss, plastic surgery for grafting may be necessary
• Teamwork
– For optimal results, open fractures with skin and soft-T damage
are best managed by a partnership of ortho and plastic surgeons,
ideally from the outset rather than by later referral
– If no plastic surgeon on site, use a digital camera for image
transmission by internet to communicate and consult.