MUSCULOSKELETAL

INJURIES

FRACTURES AND
JOINT INJURIE
 Physical Factors in
the Production of Fractures

Physica
l Nature
Of Bone

Frakt
ur

Nature
Of The
Physica
l Forces
 Cortical Bone

A bending (angulatory) force causes

a long bone to bend slightly
Can withstand compression and
 if the force is great enough, it
shearing forces better than
suddenly causes an almost explosive
tension forces tension failure of the bone on the
convex side of the bend.
 Cortical Bone....

The failure usually then extends across

the entire bone and produces either a
transverse fracture or an oblique
fracture
 Cortical Bone....

In young children,
cortical bone is like green wood (a living
young tree)  an angulatory force may
produce tension failure on the convex side
of the bend and only bending on the
concave side of the greenstick fracture
 Cortical Bone....

A twisting (torsional, rotational) force causes a

spiraling type of tension failure in a long bone
and produces a spiral fracture
 Cortical Bone....

A sudden, straight, pulling (traction) force

exerted on a small bone (such as the patella)
or part of a bone (such as the medial
malleolus of the tibia) through attached
ligaments or muscle attachments may also
result in tension failure of bone and produce
an avulsion fracture
 Cancellous Bo ne

Having a sponge-like structure (spongiosa)

More susceptible to crushing (compression) forces than is cortical bone.

Compression Fracture Of Cancellous Bone

Compression fracture of Compression fracture of a

neck of vertebral body of an adult.
the humerus in an elderly
adult
 Cancellous Bone ...

Buckle fracture in the metaphysis of the

radius of a 7-year-old boy.
The thin cortex has buckled
but has not completely broken
 Descriptive Terms Pertaining to Fractures

Site
●
May be diaphyseal, metaphyseal, epiphyseal,
●
Intra-articular;
●
Fracture-dislocation (associated with a dislocation)

Extent
●
A complete or
●
Incomplete fractures (crack or hairline fractures, buckle
fractures and greenstick fractures)

●
Simple : transverse, oblique, or spiral
Configuration ●

●
> 1 fracture line
> 2 fragments = comminuted fracture

Relationship of the ●
A closed fracture is covering skin is intact.
An open fracture is has communicated with the external environment,
fracture to the external
●

●
either because a fracture fragment has penetrated the skin
environment because a sharp object has penetrated the skin to fracture the bone
●
 Descriptive Terms Pertaining to Fractures

●
Undisplaced / displaced,
Fragments : one or more of the following six ways:
Relationship of the
●

●
1) translated (shifted sideways);
2) angulated;
fracture fragments
●

●
3) rotated;
4) distracted;
to each other.
●

●
5) overriding;
●
6) impacted.

Compli A fracture may be uncomplicated and remain

●

uncomplicated.
●
The complication : local or systemic, and it

cations. may be caused either by the original injury or

by its treatment.
Associated Injury to the Periosteum

Periosteum is an osteogenic sleeve surrounding

bone

An important structure in relation to fracture

healing.

The periosteum is thicker, stronger, and more

osteogenic during the growing years of childhood
than in adult life.

In all ages, it is thicker over portions of bone

surrounded by muscle (such as the diaphysis)
 PERIOSTEUM

Anak-anak : Dewasa : Fungsi sebagai selubung

periosteum tebal, tipis, lebih kuat osteogenik yang relatif
mudah dipisahkan dari menempel pada tulang utuh melintasi site
tulang di bawahnya,  susah dipisahkan, fraktur dan membantu
tidak mudah robek lebih mudah robek penyembuhan fraktur
DIAGNOSIS OF FRACTURE
 PATIENT'S HISTORY
The
often the
a fall, a twisting
mechanism of
injury, a direct blow,
exact
injury :details
or a road accident

pa
tie
nt
s
so
m
eti
m
es
sa
y,
"it
all
ha
pp
en
ed
so
su
dd
en
ly.
"
 PHYSICAL EXAMINATION

General ●
patient's facial expression
patient is protecting the injured part
appereance
●

Local ●

●
Swelling
Deformity (angulation, rotation, shortening)
Inspection ●
Abnormal movement (occurring at the fracture site).

●
Localized tenderness at the site of fracture

Palpation Feeling or listening for the crepitus

●

●
Look and feel for other less apparent injuries in the same
limb and elsewhere
DIAGNOSTIC IMAGING

To determine the exact nature and extent of the

fracture

The radiograph should include the entire length of

the injured bone and the joints at each end

At least two projections at right angles to each

other (anteroposterior and lateral)

For certain fractures (particularly those of small

bones, the ankle, the pelvis, and the vertebrae) 
oblique projections
Normal Healing of Fractures

Bone
Healing

The interleukins (IL) -- Transforming

known as cytokines
that also enhance Growth Factor
fracture repair. Beta (TGF-13)

Bone Insulin-like
Morphogenetic Growth Factor
Proteins (BMPs). (IGF),

Platelet-Derived
Growth Factor
(PDGF),
FRACTURE HEALING
HEALING OF A FRACTURE
IN CORTICAL BONE

(DIAPHYSEAL BONE;
TUBULAR BONE)
Initial Effects of the Fracture
 Early Stages of Healing from Soft Tissues

The fracture hematoma

Proliferation of osteogenic cell

The fracture callus consists of a thick enveloping mass of osteogenic tissue.

At this stage the callus does not contain bone and is radiolucent

The osteogenic cells differentiate into osteoblasts, and primary woven bone is
formed
Stage of Clinical Union
Stage of Consolidation
(Radiographic Union)
The stages of fracture healing in cortical bone
HEALING OF A FRACTURE IN
CORTICAL BONE

WITH RIGID
INTERNAL FLXATION
 ●
ORIF : the fracture fragments have
been compressed and then held by
rigid internal fixation by metallic
devices (osteosynthesis)

(AO/ ●
There is no stimulus for the
production of either external callus
from the periosteum or internal callus
ASIF) from the endosteum  the fracture
healing occurs directly between the
cortex of one fracture fragment and
the cortex of the other fracture
fragment  primary bone healing
 As long as the The normal stresses
metallic device bypass the bone
(remains in place) through the plate

The bone underlying

the plate continues
to be stress
protected

The bone develop If the fracture has united,

the plate and screws must
disuse be removed to allow
osteoporosis reversal of this osteoporosis
HEALING OF A FRACTURE IN
CANCELLOUS BONE

(METAPHYSEAL BONE
AND
CUBOIDAL BONES)
 CANCELLOUS BONE

Cancellous bone (sponge

bone)
Consists of a The surrounding
In the flared out
spongelike lattice of
metaphysis of long cortex, which is a
delicate
bones and in the relatively thin shell
interconnected
bodies of short bones, of cortical bone
trabeculae.
 Healing Of Fracture

in undisplaced fractures
principally : and in well-reduced
The resultant internal
callus fills the open spaces
through the fractures in cancellous of the spongy cancellous
formation of an bone, union of the fracture surfaces and
fragments proceeds spreads across the
internal fracture site wherever
more rapidly than in
(endosteal) callus, cortical bone. there is good contact
HEALING OF A FRACTURE IN CANCELLOUS BONE

Unlike cortical bone, is particularly susceptible to forces that result in a compression, or crush-type fracture.

Impaction of cancellous fragments provides a broad surface contact for fracture healing.

Remainding

If the crushed surfaces area pulled apart (during reduction of the fracture), a space, or gap, is created, healing is delayed, and there may be subsequent collapse at the fracture site
before bony union is consolidated.
The stages of fracture healing in cancellous bone
HEALING OF A FRACTURE

IN
ARTICULAR CARTILAGE
The hyaline cartilage of joint surfaces is extremely limited in its ability to
either heal or regenerate.

A fracture through articular cartilage either heals by fibrous scar tissue or

fails to heal at all.

If the fracture surfaces of the cartilage are perfectly reduced, the thin scar
leads to local degenerative arthritis.

If there is a gap, the fibrous tissue that comes to fill this gap will not withstand the normal
wear and tear of joint function and more widespread degenerative changes ensue.

Any irregularity, such as a "step" in the fractured joint surface, that

produces joint to degenerative arthritis
 TIME REQUIRED
F OR
UNCOMPLICATED FRACTURE
HEALING
 Age

Remarkably active at
birth, becomes
Healing in bone with age
progressively less active Related to the osteogenic
> in any other tissue in
with each year of activity of periosteum
the body, particularly
childhood and constant and endosteum
during childhood
from early adult life to
old age.
Site and Configuration of the Fracture

●
Fractures that are surrounded by muscle
Location : heal > that lie subcutaneously or within
joints.

●
Cancellous bone heal > cortical bone
Site ●
Epiphyseal separations heal 2x >
cancellous metaphyseal

Line Fracture ●
Long oblique fractures and spiral fractures
(surface) of the shaft heal > transverse fractures
 Initial Displacement of the Fracture

More extensive is the More prolonged is the

The greater the initial
tearing of the healing time of the
displacement
periosteal sleeve fracture.

Undisplaced fractures heal 2x > displaced fractures.

 Blood Supply to the Fragments

If both fracture fragments ●

The fracture will heal provided there are no
have a good blood supply other complications

●
The living fragment become united or fused, to
If one fragment has lost
the dead fragment / bone graft.
blood supply and is dead ●
Union will be slow and need rigid immobilization

●
Bony union cannot occur until they are
If both fragments are
revascularized, despite rigid immobilization of
avascular
the fracture
 ASSESSMENT
O F
FRACTURE HEALING
IN PATIENTS
 The state of union

Clinical Examination Radiographic examination

 Abnormal Healing of Fractures

The fracture may heal in the normally

●

Malunion expected time but in an unsatisfactory

position with residual bony deformity

Delayed The fracture may heal eventually but it

●

takes considerably longer than the normally

union expected time to do

The fracture may fail completely to heal by

●

Nonunion bone with resultant formation of either a

fibrous union or a false joint (pseudarthrosis)
 CLASSIFICATION OF
THE COMPLICATIONS OF
THE ORIGINAL INJURY
 I. Initial (Immediate) Complications

A. Local Complications (Associated Injuries)

1. Skin injuries
a. From without: abrasions, laceration, puncture wound, penetrating missile
wound, avulsion, loss of skin
b. From within: penetration of the skin by a fracture fragment
2. Vascular injuries
a. Injury to a major artery : division, contusion, arterial spasm
b. Injury to a major vein: division, contusion
c. Local hemorrhage
i. External
ii. Internal
iii. Into soft tissues-hematoma
iv. Into body cavities-intracranial hemorrhage, hemothorax,
hemoperitoneum, hemarthrosis
 I. Initial (Immediate) Complications

A. Local Complications (Associated Injuries)

3. Neurological injuries
a. Brain
b. Spinal cord
c. Peripheral nerves
4. Muscular injuries
a. Division (usually incomplete)
5. Visceral injuries
b. Thoracic-heart and great vessels, trachea, bronchi and lungs
c. Intra-abdominal gastrointestinal tract, liver, spleen, urinary tract
 I. Initial (Immediate) Complications

B. Remote Complications
1. Multiple injuries
Simultaneous injuries to other parts of the body (unrelated to a
fracture)
2. Hemorrhagic shock
 II. Early Complications
A. Local Complications
1. Sequelae of immediate complications : Skin necrosis, gangrene,
Volkmann‘s Ischemia (compartment syndromes), gas gangrene, venous
thrombosis, visceral complications
2. Joint complications : Infection (septic arthritis ) - from an open injury
3. Bony complications : Infection (osteomyelitis) at fracture site-from an
open injury Avascular necrosis of bone - usually of one fragment

B. Remote Complications
4. Fat embolism
5. Pulmonary embolism
6. Pneumonia
7. Tetanus
8. Delirium tremens
 III. Late Complications

A. Local Complications
1. Joint complications
a. Persistent joint stiffness
b. Posttraumatic degenerative arthritis

2. Bony Complications
c. Abnormal fracture healing : malunion, delayed union, nonunion
d. Growth disturbance – from epiphyseal plate (physeal) injury
e. Persistent infection (chronic osteomyelitis)
f. Posttraumatic osteoporosis
g. Sudeck's post traumatic painful osteoporosis (reflex sympathetic
dystrophy, sympathetically mediated pain syndrome)
h. Refracture
 III. Late Complications

3. Muscular complications
a. Posttraumatic myositis ossificans
b. Late rupture of tendons
4. Neurological complications : Tardy nerve palsy

B. Remote Complications
1. Renal calculi
2. Accident neurosis
GENERAL PRINCIPLES
O F
FRACTURE TREATMENT
1. Do No Harm

Some of the problems and complications of fractures are

caused by the original injury, others are caused by the
treatment of the injury and are iatrogenic.

●
Damage to soft tissues such as skin, blood vessels, and nerves by incorrectly
applied plaster casts as well as by excessive traction;

many of the iatrogenic complications themselves are preventable, for example :

2. Base Treatment on an Accurate Diagnosis and Prognosis

●
First : whether the fracture requires reduction
and if so, what type is best-closed or open
Decision ●
Second : concerns the type of immobilization, if
any, required-external or internal

●
perfect reduction and rigid fixation are not essential
●
when good external (periosteal) callus can be expected, as in a shaft
fracture without excessive periosteal disruption

Example when a combination of periosteal and internal (endosteal) callus can be

●

expected, as in an impacted metaphyseal fracture

●
when healing can be expected from endosteal callus alone (ex : fracture of
the neck of the femur or in an intra-articular fracture of a small bone) :
perfect reduction and rigid fixation are essential.
3. Select Treatment with Specific Aims

The pain from the associated injury to the soft tissues,

To relieve
●

including periosteum and endosteum.

●
Aggravated by movement of the fracture fragments,
muscle spasm, and progressive swelling in a closed
pain ●
space.
Can be relieved by immobilizing the fracture site

To obtain and ●
Reduction is indicated to obtain good function, to prevent subsequent
maintain ●
degenerative arthritis, or to obtain an acceptable clinical appearance
Some fractures are either undisplaced, or displaced so little that no
satisfactory ●
reduction is indicated.
Maintenance of position : including continuous traction, a plaster /
position of the cast, external fixation, and internal fixation, depending on the degree
of stability or instability of the reduction.
fracture fragments
3. Select Treatment with Specific Aims

●
union will occur provided that the natural
To encourage ●
healing processes are allowed.
Some cases : with severe tearing of the
bony union periosteum and surrounding soft tissues or those
with avascular necrosis of one or both fragments

●
During immobilization, disuse atrophy of regional
To restore muscles must be prevented by active static (isometric)
exercises of those muscles that control the immobilized
optimum joints and active dynamic (isotonic) exercises of all other
muscles in the limb or trunk.
function ●
After immobilization, active exercises should be
continued even more vigorously.
EMERGENCY LIFE SUPPORT
SYSTEMS

PRELIMINARY CARE
F O R
PATIENTS WITH FRACTURES
1. Immediate Care Outside a Hospital
(First Aid)

A. Airway (Obstruction)

B. Breathing (Respiratory Arrest)

C. Circulation
(Cardiac Arrest or Severe Bleeding)
●
For cardiac arrest  CPR is required.
●
For severe external bleeding  control with manual pressure Vs tourniquet
1. Immediate Care Outside a Hospital
(First Aid)

●
Manifestations of shock : Pallor combined with cold,
moist skin and a weak, rapid pulse
D. Shock ●
Careless and rough handling of an injured person
aggravates both pain and shock
●
Prevent : by controlling hemorrhage & minimizing pain

●
Fractures and dislocations of the limbs
E. Fractures and should be splinted before the person is
Dislocations moved to minimize pain and to prevent
further injury to the soft tissues.
2. Transportation

They should not be squeezed into the narrow confines of a

car seat.

For spinal injury : should be lifted into a stretcher or

suitable alternative, a cervical collar should be applied
in case there is a cervical spine injury.

Motorcycle or football helmets should not be removed at

this time.

During the trip to hospital in an ambulance, good care and

comfort are much more important to the injured person
than careless speed.
The modern ambulance should be a mobile minor
emergency room complete with suction and an oxygen
inhalator, and well-trained paramedics.

The use of helicopters or even fixed-wing aircrafts as air

ambulances (MEDEVAC) has become very common
3. Emergency Care in a Hospital

●
Persistent obstruction  relieved by suction and the
A. Airway insertion of a pharyngeal airway / tracheal intubation /
(Obstruction) tracheostomy
●
Supportive oxygen therapy

●
If the patient is still not breathing
B. Breathing
(Respiratory Arrest)
spontaneously, mechanically assisted
respiration is indicated

C. Circulation (Cardiac
●
For cardiac arrest that has not responded to CPR,
electrical defibrillation should be considered.
Arrest or Severe ●
If local pressure is not adequate to clamp one or more
Bleeding) vessels
3. Emergency Care in a Hospital

●
Monitoring and recording Vital signs (HR, RR, BP, GCS)
●
Blood is obtained for cross-matching.
●
An intravenous infusion is started using two large
cannulas and large tubing.
In severe shock, the CVP should be monitored.
D. Shock
●

●
While waiting for blood, IVFD such as Ringer's lactate
or plasma
●
Provided there is no head injury or significant
abdominal injury, relieved pain by morphine or a
comparable narcotic

E. Responsibilities for the Care of the Critically Injured

3. Emergency Care in a Hospital

F. ●
A rapid & systematic physical examination
(include vascular impairment and nerve injury

Fractu should be assessed before definitive fracture

treatment is initiated)
All body systems must be examined for other
res and
●

fractures and for soft tissue injuries and visceral

lesions.
Before to radiographic examination, the fracture
Disloc
●

should be splinted to minimize pain and to

protect the related soft tissues from further

ations
injury
Terima kasih
4. Cooperate with the " Laws of Nature"

The musculoskeletal tissues react to a fracture in accordance with "laws of

nature," as described in a previous section of this chapter dealing with the
normal healing of uncomplicated fractures. Treatment must respect and
cooperate with these natural laws oftissue behavior to avoid preventing or
even delaying normal healing. For example, inadequate protection and
immobilization, excessive traction with resultant distraction at the fracture
site, operative destruction of blood supply to fragments, and postoperative
infection all delay fracture healing and may prevent it.

Treatment of a fracture should be planned to create the ideal setting and

circumstances so that the patient's natural restorative powers and tissues
can reach their full potential. In addition, a knowledge of the natural laws
oflate remodeling of a healed fracture at various sites and at various ages is
important in determining how much deformity at the site of a fracture can
be accepted.
5. Make Treatment Realistic and
Practical

When considering a specific method of treatment for a fracture, common sense and
sound judgement will lead you to ask yourself three important questions
concerning the proposed method.

a. Precisely what am I aiming to accomplish by this method; what is its specific

aim or goal? The specific aims of fracture treatment have been discussed above.

b. Am I likely to accomplish this aim or goal by this method of treatment? This

question can be answered in part as a result of your knowledge of the previously
discussed factors in the prognosis of fractures. In addition, as will be discussed
later, certain fractures, such as displaced fractures of the lateral condyle of the
humerus in children and displaced fractures of the neck of the femur in adults,
cannot be adequately treated by means of external immobilization alone. Such
fractures require accurate reduction and internal fixation.
c. Will the anticipated end result justify the means or method; will it be
worth it to your patient in terms of what he or she will have to
endure-the risks, the discomfort, the period away .from home, work,
or school? This question is of particular importance in fracture
treatment. For example, intertrochanteric fractures of the femur in
the elderly will nearly always unite whether treated by continuous
traction and prolonged immobilization of the patient (bed rest) and
the limb, or by operative reduction with internal skeletal fixation and
early mobilization of both patient and limb. For an elderly patient,
however, the risk of prolonged bed rest is too great, in that it may
initiate a series of pathological events that lead to progressive
deterioration and even to death . Under such circumstances,
operative treatment is preferable because it carries less risk for the
elderly person than prolonged bed rest.
6. Select Treatment for Your Patient as an Individual

A given fracture may present an entirely different problem for

one individual than for another, particularly in relation to age,
sex, occupation, and any coexistent disease. For example,
residual deformity of a healed fracture (malunion) of the
clavicle presents little problem for a young child (because it
will re model over the growing years) or for a laboring man
(because he is not concerned about its appearance), but it may
be quite distressing for a female model or an actress. Likewise,
malunion of a finger fracture may not interfere significantly
with hand function for a taxi driver but it may be catastrophic
for a concert pianist. Therefore, the choice offracture
treatment must be tailored to fit the needs of your patient.