FRACTURES

1. Definition

• A disruption or break in the continuity of

the structure of bone
• Traumatic injuries account for the majority
of fractures
 2. Classification
• Described and classified according to:
– Type
– Communication or noncommunication
with external environment
– Anatomic location
Types of Fractures

Fig. 61-4
Classification by Fracture Location

Fig. 61-6
 Classification
• Closed (also called simple)

• Open (also called compound)

Break in the skin and underlying soft tissue
leading directly into or communicating with
the fracture and its hematoma
Classification by Communication with
External Environment

Fig. 61-5
Open Fractures
 Type 1 Open Fractures
• Wound less than 1 cm,
• Inside-out injury
• Clean wound
• Minimal soft tissue damage
• No significant periosteal
stripping

http://www.unboundedmedicine.com/2005/11/08/open-fractures-classification-and-its-clinical-manifestations-3/
 Type 2 Open Fractures
• Moderate soft tissue
damage
• Outside-in
• Higher energy
• Some necrotic muscle
• Some periosteal
stripping
Type 3a Open Fractures
• High energy
• Outside-in
• Extensive muscle
devitalization
• Bone coverage with
existing soft tissue
 Type 3b Open Fractures
• High energy
• Outside in
• Extensive muscle
devitalization
• Requires a flap for
bone coverage
and soft tissue
closure
• Periosteal stripping
 Type 3c Open Fractures

• High energy
• Increased risk of
amputation and
infection
• Any grade 3 with
major vascular injury
requiring repair
 Why use this classification?
• Grades of soft tissue injury correlates with infection
and fracture healing
Grade 1 2 3A 3B 3C
Infection
0-2% 2-7% 10-25% 10-50% 25-50%
Rates

Fracture
Healing 21-28 28-28 30-35 30-35
(weeks)

Amputation
50%
Rate
 Epidemiology
Open fractures
• 3% of all limb fractures
• 21.3 per 100,000 per year
Epidemiology
 Clinical Manifestations

– Immediate localized pain

–  Function
– Inability to bear weight or use affected
part
– Guarding
– May or may not see obvious bone
deformity
 Diagnosis
1. Anamnesis
- Main Complaints : Swelling, bending, short after trauma
- Mechanism of trauma :Direct / Indirect
- Past disease history & family history: To explain basic
diseases

2. Physical Examination
General
Weight: shock
Other accompanying trauma
Local
Deformity udema, angulation, shorthening
Wound / No
Pain Press & Axis Pain
Acral / distal part: Artery, Veins, Nervus
3. supporting investigation

a. x-ray
Photo requirements on fracture: RULE OF TWO
- Two view (two way): AP & Lateral
- Two Joint :Two joints
- Two limb : Two side members
- Two Time : Two time intervals

From the results of X-rays, photos can be classified

- Configure fracture lines
- Anatomical location of fracture
- Aligment part of the fracture
 Treatment
Fracture Management (4 R)
1. Recognizing = Diagnosis am Anamnesa, PE,
Support
2. Reduction = Reposition
Returns the fracture position before the fracture
3. Retaining = Fixation / Immobilization
Maintaining the results of repositioned fragments
4. Rehabilitation= Restores the function of the last
 Open Fractures Treatment
Goals of treatment:
1. preserve life
2. preserve limb
3. preserve function
4. Prevent infection
5. Fracture stabilization
6. Soft tissue coverage
http://www.lww.com/static/docs/product/samplechapters/978-0-7817-5096-7_Chapter%204.pdf
Stages of care for open fractures
 Initial assessment & management
• ABC’s
• Assess entire patient
• Careful PE, neurovasc
• Abx and tetanus
• Local irrigation 1-2 liters

Lee J. Efficacy of cultures in the management of open fractures. Clin Orthop Relat Res. 1997;339:71-5.
 Initial assessment & management
• Sterile compressive dressings
• Realign fracture and splint
• Do not culture wound in the
ED*
– 8% of bugs grown caused deep
infection
– cultures were of no value and not
to be done
• Recheck pulse, motor and
sensation

Lee J. Efficacy of cultures in the management of open fractures. Clin Orthop Relat Res. 1997;339:71-5.
 Primary surgery

• Objectives of initial surgical

management
– Preservation of life and limb
– Wound debridement
– Definitive injury assessment
– Fracture stabilization
Stages of open fracture management in the OR
 Complications of Fractures
Infection
• Open fractures and soft tissue injuries have 
incidence
• Osteomyelitis can become chronic
 Complications of Fractures
Infection
• Collaborative Care
– Open fractures require aggressive surgical
debridement
– Post-op IV antibiotics for 3 to 7 days
(prophylactic)
 Complications of Fractures
Compartment Syndrome
• Condition in which elevated
intracompartmental pressure within a confined
myofascial compartment compromises the
neurovascular function of tissues within that
space
• Causes capillary perfusion to be reduced below
a level necessary for tissue viability
 Complications of Fractures
Compartment Syndrome
• Two basic etiologies create compartment
syndrome:
– Decreased compartment size (dressings,
splints, casts)
– Increased compartment content (bleeding,
edema)
 Complications of Fractures
Compartment Syndrome
• Clinical Manifestations
– Six Ps
1. Paresthesia (unrelieved by narcotics)
2. Pain (unrelieved by narcotics)
3. Pressure
 Complications of Fractures
Compartment Syndrome
• Clinical Manifestations
– Six Ps:
4. Pallor (loss of normal color, coolness)
5. Paralysis
6. Pulselessness (decreased/absent pulses)
 Complications of Fractures
Compartment Syndrome
• Clinical Manifestations
– Six Ps:
• Patient may present with one or all of the
six Ps
• Compare extemities
 Complications of Fractures
Compartment Syndrome
• Clinical Manifestations
– Absence of peripheral pulse = ominous late
sign
– Myoglobinuria
• Dark reddish-brown urine
 Complications of Fractures
Compartment Syndrome
• Collaborative Care
– Prompt, accurate diagnosis is critical
– Early recognition is the key
– Do not apply ice or elevate above heart level
 Complications of Fractures
Compartment Syndrome
• Collaborative Care
– Remove/loosen the bandage and bivalve the
cast
– Reduce traction weight
– Surgical decompression (fasciotomy)
 Complications of Fractures
Venous Thrombosis
• Veins of the lower extremities and pelvis are
highly susceptible to thrombus formation after
fracture, especially hip fracture
 Complications of Fractures
Venous Thrombosis
• Precipitating factors:
– Venous stasis caused by incorrectly applied
casts or traction
– Local pressure on a vein
– Immobility
• Prevent with anticoagulant medications
 Complications of Fractures
Fat Embolism Syndrome (FES)
• Characterized by the presence of fat globules in
tissues and organs after a traumatic skeletal
injury
 Complications of Fractures
Fat Embolism Syndrome (FES)
• Fractures that most often cause FES:
– Long bones
– Ribs
– Tibia
– Pelvis
 Complications of Fractures
Fat Embolism Syndrome (FES)
• Tissues most often affected:
– Lungs
– Brain
– Heart
– Kidneys
– Skin
 Complications of Fractures
Fat Embolism Syndrome (FES)
• Clinical Manifestations
– Usually occur 24-48 hours after injury
– Interstitial pneumonitis
• Produce symptoms of ARDS
 Complications of Fractures
Fat Embolism Syndrome (FES)
• Clinical Manifestations
– Symptoms of ARDS:
• Chest pain
• Tachypnea
• Cyanosis
•  PaO2
 Complications of Fractures
Fat Embolism Syndrome (FES)
• Clinical Manifestations
– Symptoms of ARDS:
• Dyspnea
• Apprehension
• Tachycardia