Principle of Fractures

BONE

 Serve as scaffold that support and protect the

soft tissue part and enables locomotion and
mechanical function
 Is strong but it breaks under very small
deformation
 when the physical force exerted on the bone
is stronger than the bone itself
Fracture of Bone

 The result of single or multiple over load

 Damage to soft tissue
 Soft tissue
 Bone
 Vascular
 Nerve
 INTRODUCTION
 DEFINITION :
A fracture is a break in the structural
continuity of bone.

 HOW FRACTURES HAPPEN :

i. Single trauma incident
ii. Repetitive stress
iii. Abnormal weakening of the bone
Mechanism of Fractures
 Type of Fracture

 Complete Fracture
The bone can split into two or more fragments
(transverse , spiral, impacted and comminuted)

 Incomplete Fracture
The bone is incompletely divided and the
periosteum remains in continuity
 Type of Fracture

•Closed Fracture
Overlying skin remains intact

•Open Fracture
The skin or one of the body cavities is breached,
liable to contamination and infection
 How Fractures Are Displaced

 Translations (shift)
 Alignment (angulation)
 Rotation (twist )
 Length (shortening of the bone)
 Clinical Features

 History
 A history of injury followed by inability to use the
limb
 Patient’s age and mechanism of injury
 Enquire about symptomps of associated injuries
 History of previous injuries or any musculoskeletal
abnormalities
 A general medical history (for op)
 General Signs

 Priority must be given to dealing with the

general effects of trauma
 The primary survey : ABCD and cervical spine
injury
 The secondary survey :to exclude other
previous unsuspected injuries and possible
predisposing factors
 Local Signs

 A systematic approach is helpfull :

 Examine the most obviously injured part
 Test for artery and nerve damage
 Look for associated injuries in the region
 Look for associated injuries in distant parts
 Look : swelling ,bruising, deformity, skin is intact or not
 Feel : gently palpated for localized tenderness
 Movement : crepitus and abnormal movement
 X-Ray Examinations

Remember the rule of two :

1. Two views
2. Two joints
3. Two limbs
4. Two injuries
5. Two occasions
 Special Imaging

A.CT scan
Lesions of spine or fr of tibial condyles
B. MRI
Fr vertebr that threatens spinal cord
C. Radioisotope scanning
Susp stress Fr or undisplaced Fr
 Treatment Of Fractures

The objective are : The Fracture Quartet

1. Reduce (aim for
adequate
apposition &
normal alignment)
2. Hold hold safety
3. Exercise move
speed safety
speed
move hold
 The Treatment of Fractures

 The most important factor in determining

the natural tendecy to heal is the state of
surrounding soft tissues and local blood
suply.
 Low energy fr cause only moderate soft tissue
damage
 High energy fr cause severe soft tissue damage
 Hold Reduction

1)Continous traction
 Traction is applied to the limb distal of the
fracture
 Traction is safe enough (not excessive) but
have a low speed of unites
 Complications :
circulatory embarassment, nerve injury & pin-
site infection
Hold Reduction

2) Cast splintage
 Move is the weakest part of the quartet
(can be avoided by delayed splintage &
functional brace)
 By using plaster of paris
 Complications :
tight cast, pressure sores, skin abration or
laceration, loose cas.
Hold Reduction

3) Functional bracing
- One way of preventing joint stiffness
- Used widely for fr of the femur and tibia
Hold Reduction

4) Internal fixation
 The greatest danger is sepsis
 The risks depend upon :
a. The patient – devitalized tissues, a dirty wound
and an unfit patient are all dangerous
b. The surgeon – a high degree of surgical dexterity
and adequate assistance
c. The facilities – a guaranted aseptic routine
The chief indication of internal fixation :
1. Fr that can’t be reduced except by operation
2. Fr that inherently unstable and prone to
redisplacement after reduction
3. Fr that unite poorly and slowly (fr femoral of
the neck)
4. Pathological fr
5. Multiple fr
6. Fr in patients with nursing difficulties
Types of Internal Fixation
 Complications of internal fixations :
1. Infection
2. Non-union
3. Implant failure
4. Refracture
Hold Reduction
5) External fixation

 Especially applicable to to the tibia and pelvis.

 External fixation is particularly useful for :
a)Fr associated with severe soft tissue damage
b)Fr associated with tissue damage
c)Severely comminuted and unstable fr
d)Ununited fr (which can be excised and compressed)
e)Fr of the pelvis
f)Infected fr
g)Severe multiple injuries
Complications of external fixation :
• Damage to soft tissue structures
• Overdistraction
• Pin-track infection
 Exercise

 To restore function
(not just the injured parts but as a whole patient)

 The objectives are to reduce :

Oedema, preserve joint movement, restore
muscle power and guide the patient back to
normal activity.
 Active Exercise

 It helps to pump away edema fluid,

stimulates the circulation, prevents soft
tissue adhesion and promotes fr healing.
 Assisted Movement & Functional
Activity

 Force movement should never be permitted

 Gentle assistance during active exercises may help
to retain function or regain movement after fr
involving the articular surfaces
 Nowadays can be used with machine (CPM)
 Encouraged the patients to use injured limbs on
daily activity as much as possible.
 Treatment of Open Fractures

Initial management :
 Multiple injuries and severe shock needs
appropriate treatment
 The wound should be covered with a sterile
dressing and left undisturbed until reach
hospital.
 Classifying Injuries

 Gustillo’s classification :

GRADE 1

1. Wound < 1 cm
2. Usually in-out wound
3. Simple fracture
4. Mild-moderate contamination
GRADE 2

1. Wound > 1 cm
2. Periosteal sleeve exposed
3. No soft tissue avulsion
4. Short oblique fracture
5. Moderate contamination
GRADE 3 A

1. Periosteal stripped
2. Soft tissue avulsion but still
adequate coverage
3. Communitive fracture
4. Moderate – high contaminated
GRADE 3 B

1. Periosteal stripped and no

adequate soft tissue coverage
that need surgical coverage
2. Comminutive fracture
3. High contaminated
GRADE 3 C

Open fracture with major artery

disruption
 Principle of Treatment

 The four essentials :

1. Wound debridemant
2. Antibiotic prophylaxis
3. Stabilization of fractures
4. Early wound cover
 How Fracture Heal

 Commonly supposed :
fracture immobilized unite
 Splint is used to :
a) Alleviate pain
b) Ensure union takes place in good position
c) Permit early movement and return of
function
Five Stages of Healing Process
 Tissue Destruction and Haematoma
Formation

 Vessel are torn and haematoma forms

around and within the fracture
 Bone deprived of blood suply and dies back
for 1-2 mm
 Inflammation and Cellular Proliferation

 8 hours of fractures

The haematoma
Acute The fragments
are absorbed &
inflammatory are surrounded
new capillaries
reaction by cellular tissue
grow to the area
 Callus Formation

• The proliferating cells will start forming bone also cartilage

• The osteoclasts begin to mop up dead bone

• The thick celullar mass, immature bone & cartilage bone form
callus on endosteal and periosteal
• The immature fibre bone becomes more densely mineralized

• Movements at fracture site decreases and ceases when the

fracture unites
 Consolidation

 Continuing osteoclastic and osteoblastic

activity transform the woven bone to
lamellar bone
 This is a slow process and take several
months for bone to carry normal loads.
 Remodelling

 The fracture has been bridged by a cuff of

solid bone, as a result of repeated bone
formation and resorption activity.
 Thicker lamellae are laid down in the place
where stresses are high; unwanted are carve
away.
 The medullary cavity is reformed
COMPLICATIONS OF FRACTURE
Thank You