Principles in Fracture

Management
Definition of fracture
• A fracture is a break in the structural continuity of bone.
• If the overlying skin remains intact it is a closed (or simple) fracture.
• If the skin or one of the body cavities is breached it is an open (or
compound) fracture, liable to contamination and infection.
• Fractures result from:
(1) injury
(2) repetitive stress
(3) abnormal weakening of the bone (a ‘pathological’ fracture).
 Fractures due to injury

(a)spiral pattern (twisting);

(b) short oblique pattern (compression);
(c) triangular ‘butterfly’ fragment (bending) and
(d) transverse pattern (tension).
Spiral and some (long) oblique patterns are usually due to low-energy indirect injuries;
bending and transverse patterns are caused by high-energy direct trauma.
Fatigue or stress fractures
• Bone reacts to repeated loading.
• On occasion, it becomes fatigued and a crack develops.E.g. Athletes
• A similar problem occurs in individuals who are on medication that
alters the normal balance of bone resorption and replacement.
E.g. patients with chronic inflammatory diseases who are on
treatment with steroids or methotrexate.
Pathological fractures
• Fractures may occur even with normal stresses if the bone has been
weakened by a change in its structure.
e.g. in osteoporosis, osteogenesis imperfecta or Paget’s disease
• or through a lytic lesion (e.g. a bone cyst or a metastasis).
Diagnosis
• Clinical features
• Radiology (X-RAY)
Clinical features
• History of trauma
• Symptoms and Signs
1. Pain and tenderness
2. Swelling
3. Deformity
4. Crepitus
5. Loss of function
6. Nerve and vascular injury
Radiographic findings
X-ray
the rule of twos:
• Two views (anteroposterior and lateral)
• Two joints - The joints above and below the fracture
• Two limbs - x-rays of the uninjured limb for comparison.
• Two injuries – Severe force often causes injuries at more than one
level. Thus, with fractures of the calcaneum or femur it is important to
also x-ray the pelvis and spine.
• CT scan
• MRI (associated injuries to the CNS, or occasionally fatigue fractures)
Fracture classification
• Anatomical location
• Condition of overlying structure
• Direction of fracture line
• Mechanism of injury
• Whether the fracture is linear or comminuted
• AO classification
AO Classification
• A: Simple fracture
• B: Wedge fracture
• C: Complex fracture
Mechanism of injury
• Direct injury
• Indirect injury
Direct injury
• Tapping fracture
• Crushing fracture
• Penetrating fracture
High velocity (>2500 F/s)
Low velocity (<2500 F/s)
Indirect injury
• Traction or tension fracture
• Angulation fracture
• Rotational fracture
• Compression fracture
Fracture management
Treatment of closed fractures
• Emergency care (Splinting)
• Definitive fracture treatment
• Rehabilitation (muscle activity and early weightbearing)
Splinting
Types of splints
• Improvised
• Conventional
Definitive fracture treatment
• Goal : to obtain union of the fracture in the most anatomical position
compatible with maximal functional return of extremity
• 2 types : consevative
surgical
Consevative
• Reduction : If displaced under general anaesthesia (the sooner, the
better)
• Immobilization : POP (Plaster of Paris) Cast,Slab
Traction
Surgical
• Open reduction internal fixation (ORIF)
• Percutaneous Pinning
• External fixation
Indications for open reduction
1. When closed reduction fails
2. When there is a large articular fragment that needs accurate
positioning
3. For traction (aulsion) fractures in which the fragments are held
apart
Indications for internal fixation
1. Fractures that cannot be reduced except by operation
2. Fractures that are inherently unstable and prone to re-displace after
reduction
3. Fractures that unite poorly and slowly
4. Pathological fractures in which bone disease may prevent healing
5. Multiple fractures where early fixation (by either internal or external
fixation) reduces the risk of general complications and late multisystem
organ failure
6. Fractures in patients who present nursing difficulties
Types of internal fixation
Internal fixation The method
used must be appropriate to the
situation:
(a)screws – interfragmentary
compression;
(b)plate and screws – most
suitable in the forearm or
around the metaphysis;
(c)flexible intramedullary nails –
for long bones in children,
particularly forearm bones
and the femur;
(d) interlocking nail and screws – ideal
for the femur and tibia;
(e) dynamic compression screw and
plate – ideal for the proximal and distal
ends of the femur;
(f) simple K-wires – for fractures
around the elbow and wrist and
(g) tension-band wiring– for olecranon
or fractures of the patella.
External fixation
Indications :
1. Fractures associated with severe soft-tissue damage (including
open fractures) or those that are contaminated
2. Fractures around joints that are potentially suitable for internal
fixation but the soft tissues are too swollen to allow safe surgery
3. Patients with severe multiple injuries
4. Ununited fractures, which can be excised and compressed
5. Infected fractures
Rehabilitation
• Restore function – not only to the injured parts but also to the patient
• The objectives are :
1. To reduce oedema
2. Preseve joint movement
3. Restore muscle power
4. Guide the patient back to normal activity
Stages of care for open fracture
Firstly, wound is carefully inspected;
- remove any gross contamination
- photograph the wound to record injury
- covered with saline soaked dressing
-give antibiotics & TT injection
-check distal neurovascular status
Debridement
• Wound excision
-wound margins are excised, but only enough to leave healthy skin
edges.

• Wound extension
• Delivery of the fracture
• Removal of devitalized tissue
- All doubtfully viable tissue should be removed.
- muscle viability 4 C’s:
- Colour
- Consistency
- Contractibility
- Capacity to bleed when cut
• leave nerves and tendon alone
• Wound cleansing
- saline shown to be most effective irrigation agent
- On average, 3 L of saline are used for each successive Gustilo type
- type I : 3 L
- type II : 6L
- type III : 9L
Wound closure
The best fracture cover is skin or
muscle – with the help of a
plastic surgeon (a–c).
If none is available, gentamicin
beads can be inserted and
sealed with an impervious
dressing until the second
operation, where a further
debridement and, ideally,
definitive fracture cover is
obtained (d,e).
Stabilizing the fracture
Spanning external fixation is a
useful method of holding the
fracture in the first instance (a,b).
When definitive fracture cover is
carried out, this can be
substituted with internal fixation,
provided the wound is clean and
the interval between the two
procedures is less than 7 days.
Aftercare
• In the ward, the limb is elevated and its circulation carefully watched.
• Antibiotic cover is continued for a maximum of 72 hours in the more
severe grades of injury.