General Principles of Fracture

Management
SWOTA 2010
Thomas A. DeCoster, M.D.
Chief, Division of Trauma
Vice Chair, Orthopedics
University of New Mexico
President, SWOTA

Which is the clearest description of a

forearm fracture?

A. Radius and ulna shaft fracture.

B. BBFA
C. Fracture of necessity
D. Piedmont fracture
E. Broken Arm

OUTLINE
1 Fracture Definition
2 Classification
OTA

3 Healing response
4 Common treatments
5 Complications

Fracture Definition
A broken bone

Your fracture pt evaluation

ER
Respond quickly and nicely
Talk to the patient
EXAMINE the patient
Review radiograph
Call/notify superior
Document (pre-op, f/u, etc.)

Fracture evaluation
Clinic

Review current and prior radiographs

Review prior notes
Examine the patient
Identify normal and abnormal healing
Formulate a plan

Type and length of immobilization

Return to work
Analgesia
Follow-up

Diagnosis
Physical Exam
Palpate the bones
Crepitus
Related
Skin
Neurovascular exam

X-ray
Linear radiolucency through bone
Indirect signs

Whats the diagnosis in this case?

Correct answer
Right femur shaft (R32)fracture
Even better
Wedge Comminution (32-A)
Transverse
(32-A3)
Middle 1/3 (32-A3.3)

Right patella fracture (R34)

Insufficient information for further designation

Incorrect
broken leg
subtroch
femur fracture (not specific enough-need Right
femur shaft to be correct)

Fracture Classification

Name the bone!!!

Sounds easy, but its not
Then the bone part (proximal, shaft, distal)
for sufficient specificity

Fracture Classification
General Principles

Group similar injuries

Separate dissimilar injuries
IMPROVE communication
Identify prognosis and complication risk
DIRECT TREATMENT
Enhance research

Qualities of a good classification

system

All inclusive
Mutually exclusive
Reliable
Reproducible
Clinically relevant
Logical
Oxford Textbook of Orthopaedics 2002 DeCoster

Eponyms

Formerly prevalent
Fortunately passing into disrepute
Unfortunately persist as jargon/code
You need to be aware of them but you do
not need to use them
Distal radius fracture NOT Colles fx

Fracture Classification
Name the bone
Proximal, Shaft or Distal
Use rule of squares
Know the exceptions

OTA/AO 2007 JOT November

Examples

Fracture classification example

Right femur shaft (R32) p S35
Not distal femur (rule of squares)
Not proximal femur (distal to lesser troch)
Wedge comminution R32-B
Wedge=butterfly
Not simple (A)
Not complex=segmental comminution (C)

Example 32-B
Transverse (32-B3)
Not spiral (B1)
Not oblique more than 30 degrees (B2)
Less than 30 degrees is transverse (B3)

Middle zone (32-B3.2) p S37

Not subtrochanteric zone (.1)
Not distal zone (.3)
Middle 1/3 OF THE SHAFT (.2)

More examples
Saturday evening
Other talks

How do fractures heal?

(one word)

Fracture healing
in a word
CALLUS

Callus
Fracture healing occurs as mesenchymal cells
differentiate and produce progressively stiffer
matrix.
Phases
Hematoma
Inflammation
Callus
Soft
Hard

Re-modelling

Timing of Callus formation in

humans

Hematoma
Inflammation
Soft Callus
Hard Callus
Re-modelling

2 hrs
2 days
2 weeks
2 months
2 years

Healing strength

Hematoma
Inflammation
Soft callus
Hard callus
Re-modelling

1%
5%
25%
75%
110%

Fracture healing is spontaneous and

natural and does not require surgical
intervention
You do not NEED to operate on a fracture to
make it heal
Most interventions interfere with healing more
than they help
But there are many advantages to operative
treatment of fractures-but making the fracture
heal is not generally one of them

Impact of treatment on healing

Reduce displacement and improve
alignment so that when it heals there is
good function
Stabilization of the fracture allows
mobilization of the patient
But also many negative impacts

Fracture treatment

Immobilize the fracture

Mobilize the patient
Avoid fracture disease
Avoid complications
Allow healing

Fracture
Initial Treatment

Splint
Analgesia
Elevation
Follow-up

Fracture Treatment
OPTIONS
Closed

Non-operative
Splint
Cast
Traction

Fracture Treatment
Options
Operative

Closed reduction
Percutaneous pinning
External fixation
Internal fixation
Prosthetic replacement

Internal Fixation
Open reduction internal fixation ORIF
Classic plate and screws
Screws alone (rare)
Locked plating (recent)

Internal Fixation-Types
Intramedullary nailing

Reamed vs. unreamed

Rigid vs. flexible
Closed vs. Open
Locked vs. unlocked
Statically locked vs. dynamic

Initial Post-op Care-PGY2 issues

Incision
Swelling
Pain
Elevation
Patient mobilization

Rehabilitation
Mobilization of the body part
Mobilization of the patient
Progressive weight bearing
Fixation type
Healing time

Open Fractures
Skin is broken
Infection the big problem
Closed fx infection rate = 0%
Open fx infection rate = 20%

Osteomyelitis is forever

Fractures
Local Complications
Nonunion
Failure to heal
3% overall
50% of some particular fractures
Related to treatment, local problems,
systemic problems (e.g. Smoking)

Nonunion Treatment
Stabilization
Hypertrophic Nonunions
New fixation

Stimulation
Atrophic nonunions
Bone graft
Other (Estim, ultrasound, BMP)

Malunion
Healing in poor position
Crooked = deformity
Displaced - risk of arthritis

Malunion
Treatment
Prevention
Straightening
Salvage

Fracture
Systemic Complications
Fat embolism syndrome
Marrow elements (fat) released into the
vascular system and travel to the lungs
Triglycerides (fat) metabolized to FFA by
pneumatocytes and these FFS are toxic to tissue
Especially brain, blood vessels, kidney
ARDS
Risk of death

Diagnosis of Fat Embolism

ARDS
Mental status changes
Petechiae
Other

Treatment of Fat Embolism

Respiratory Support
Early recognition

Systemic complication
DVT/Pulmonary embolism

Fracture leads to immobilization

Stasis, hypercoagulability, intimal injury
Thrombosis of LE veins
Embolism to heart and then lungs
Mechanical blockage
Ventilation/perfusion mismatch

DVT/PE
Respiratory depression
Cardiac
Death

DVT Prevention
Mobilization
Patient
Limb

Mechanical
Skeletal stabilization
SCD, foot pumps
Compression

Chemical anticoagulation

Fractures
Summary
1. Classification
OTA 2007
Name the bone
Proximal/Shaft/Distal

2. Healing Callus
3. Treatment options
4. Complications

SWOTA : 2010

Resident Course - Fundamentals

of Fracture Care
CLOSED TREATMENT OF FRACTURES

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SWOTA : 2010
Resident Course - Fundamentals of Fracture Care

CLOSED TREATMENT OF FRACTURES

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