Introduction to Fracture

and Dislocations

Getnet Asnake(Orthopedic Surgeon)

Sept 2018
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 Outline
• Definition
• Mechanism
• Classification
• Fracture repair
• Fractures in Children
• Approach to patients
• Management
• Complications
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 Introduction

• Fracture a break in the continuity of bone.

• Subluxation partial separation of articular
surfaces
• Dislocation complete separation of articular
surfaces

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 Mechanism
Fractures result from:

• Injury

• Repetitive stress

• Abnormal bone weakening

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Fractures caused by sudden injury
• Majority of the fractures.
• Caused by single excessive force.
• Direct or Indirect Force
Direct force:
 site of fracture is at the site of applied force
 low energy causes transverse fracture with damage to skin.
 High energy causes comminuted fracture with extensive
damage to soft tissue.

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Indirect force.
• The bone breaks at a distance from where the
force is applied.
 Rotational force - - - spiral fracture.
 Bending force- - - -transverse fracture.
 Bending with compression- - - - transverse
fracture with butterfly fragment.
 Pulling force- - - - avulsion fracture.

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 Stress fracture
.

–is caused by the application

of abnormal stress on a bone
that has normal elastic
resistance.

– Clinically, Pain with gradual

onset, examination will show
local tenderness after weeks.
There will be swelling.

–X-ray, MRI and Bone scan.

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 Pathological fracture
• Occur through a bone
that is weakened by a
disease.

• Fracture occurs either

spontaneously or from
trivial violence.

• Local or Generalized
disorder of skeleton.
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 Description
• Closed or open fracture
• Complete or incomplete Fracture
• Displaced or non displaced
• Intraarticular or extraarticular
• Transverse Fracture- A fracture that is at a right angle to the
bone's long axis.
• Oblique Fracture- A fracture that is diagonal to a bone's long axis.
• Spiral Fracture- A fracture where at least one part of the bone has
been twisted.
• Impacted Fracture- A fracture caused when bone fragments are
driven into each other.
• Comminuted Fracture
• Segmental Fx, occur at two levels with free segment between
them.
impacted Avulsion

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 Classification
The AO/OTA devised an elaborate classification

system to describe the injury accurately and guide

treatment.

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A
B C
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 Displacement of a fracture

 Position of the distal fragment in

relation to proximal fragment
 The causes of displacement are:
• Primary impact
• Gravity
• Muscle pull
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 Cont’d
• Displacements described interms of:
• Shift (translation) of the distal
fragment.
• Angulation of the distal fragment in
relation to proximal one or the
opposite.
• Rotation (twist) one fragment may be
rotated on its longitudinal axis.
• length(shortening or distraction)
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 Open fractures
 Also called a compound fracture, is a fracture
in which there is a communication with the
external environment or epithelial covered
surface(rectum,vagina….etc)

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 Segmental fractures, Farmyard injuries, High velocity gun shot
wounds are classified as type III.
 Most accurate way to grade open fratures is by intra-operative 21
examination 
Type I Open Fractures

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Type II Open Fractures
Type IIIA Open Fractures
Type IIIB Open Fractures
Type IIIC Open Fractures
 Fracture Healing

• Two types of bone repair:

– Healing by callus

– Healing without callus

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• Average duration of union
Upper extremity Lower extremity

Children 3weeks 6weeks

Adults 6weeks 12weeks

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Healing with callus
 occurs with non-rigid fixation, fracture braces,
external fixation, bridge plating,
intramedullary nailing

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 Healing by callus

1- Tissue destruction and

hematoma formation.

Disruption of blood vessels

A hematoma forms around
and within fracture
Few millimeters of the
fracture surfaces dies.

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 Healing by callus
2- Inflammation and
subperiosteal and
endosteal cellular
proliferation.

• Need 8 hours.
• Proliferation of fibroblasts,
mesechymal cells, and
osteoproginetor cells.
• New vessels formation.

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 Healing by callus
3- Callus formation.

• Chondrogenic and osteogenic

activity.
• Cartilage in the periphery, woven
bone near the bone ends.
• Marked increase in vascularity.
• Osteoclast activity.
• At the end the pain disappears
and the fragments are rigid w/o
movement.

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 Healing by callus

4- Consolidation.
• The primitive woven bone is
transformed into lamellar
bone by osteoclastic and
osteoblastic activity.
• Need several months before
the bone is strong enough
to carry normal loads.

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 Healing by callus

5- Remodeling.
Callus is reshaped: the bone
along the lines of stresses
are strengthened while bone
outside these lines removed.
The medullary canal is
reformed.
The remodeling depends on
age that Fx remodeling in
children is so perfect.

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 Healing without callus

In 2 instances:

◦ Impacted fractures

◦ Rigid fixation of fractures

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 Variables that influence fracture
healing
1)Injury variables
 Open fractures
 Severity of the injury
 Intra-articular fractures
 Segmental fractures
 Soft tissue interposition
 Damage to blood supply

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 Cont’d
2)Patient variables

 Age

 Nutrition

 Medical Conditions

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 Cont’d
3) Tissue Variables

 Form of bone(cortical or cancellous)

 Bone necrosis

 Bone disease

 Infection
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 Cont’d
4) Treatment variables

 Apposition of Fracture Fragments

 Loading and Micromotion

 Fracture Stabilization

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 Signs of healing

1. Absences of pain during daily

activities

2. Absences of tenderness at Fracture

Site

3. Absences of pain on stressing the

Fracture

4. Absences of mobility at Fracture site

5. X-ray signs of callus formation, bone

bridging, and finally trabeculation

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 Fractures in children
1. Difficult to diagnose

2. Their bones are less brittle and more liable to

plastic deformation.
3. Periosteum is thicker than adult; Cellular activity is
increased

4. More capacity to reshape fracture deformity

5. Injury to the physis

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 Pediatric Fracture Patterns
Plastic deformation

Buckle fracture(torus)

Greenstick fracture

Physeal fractures

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• gre

Green stick fracture

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Injuries of the Physis(growth plate)
• 10% of fractures in children involve injury to
the physis (growth plate)

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Approach to patients

(ATLS!!!)
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 History
• Usually includes a history of trauma followed
by inability to use it
• Fracture is not always at the sight of injury.
• Patient age and mech. of injury are important
• Trivial trauma  path. Fracture
• Pain, bruising, and swelling are common
symptoms.

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 Cont’d
• Fracture VS. Soft tissue injury
• Deformity  more suggestive of a FX.
• Green stick FX. and elderly with impacted FX. of
femoral neck may experience little or no pain, or
loss of function.
• Enquire about symptoms of associated injury:
numbness, loss of movement, skin pallor,
cyanosis, blood in urine, difficulty with breathing
and transient loss of consciousness.
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 Examination
• Unless purely local injury priority must be
given to deal with the general effects of
trauma
• In any case X-ray diagnosis is more reliable
1. Examine the most obviously injured part
2. Check for arterial damage
3. Test for nerve injury
4. Look for injury in distant parts

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 Look
• Swelling
• Bruising
• Deformity
• If skin is intact or not (open VS simple)
• Posture of distal extremities and color of the
skin  signs of nerve or vessel damage

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 Feel
• Palpate for localized tenderness

• In high energy injuries, always examine spine

and pelvis

• Vascular and peripheral nerve abnormalities

should be tested for both before and after
treatment
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 Move

• Crepitus and abnormal movement tested - in

unconscious patients

• Ask if patient can move the joint distal to the

injury

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 Imaging
Radiograph
 Rule of two:

1. Two views
2. Two joints
3. Two limbs

4. Two occasions
5. Two injuries
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 . . . cont’d

CT and MRI
In difficult sites such as vertebral

column and acetabulum, and

calcaneum
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Treatment of Fractures

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 Principles of Treatment
• Treat the Patient, not only the fracture

REDUCTION

IMMOBILIZATION

REHABILITATION

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REDUCTION
• No undue delay in attending to the fracture
• Reduction unnecessary when:
– There is little or no displacement
– Displacement does not matter
– Reduction is unlikely to succeed

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 Cont’d

• Aim of reduction
– Adequate apposition
– Normal alignment of the bone fragments
• Methods of reduction
– Close reduction
– Mechanical traction
– Open reduction

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 1. Closed reduction
• Closed manipulation is suitable for
1. All minimally displaced fractures
2. Most fractures in children
3. Fractures that are likely to be stable after
reduction

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 Cont’d
• Three fold maneuver: under anesthesia and
muscle relaxation
1. The distal part of the limb is pulled in the line of
the bone
2. The fragments are repositioned as they
disengage
3. Alignment is adjusted in each plane

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 2. Mechanical Traction
• certain fractures can be reduced by sustained
mechanical traction, which then serves also to
hold the fracture until it starts to unite

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 3. Open reduction
• Operative reduction under direct vision is indicated:
1. When closed reduction fails
2. When there is a large articular fragment that needs
accurate positioning
3. For avulsion fractures in which the fragments are
held apart by muscle pull
4. When an operation is needed for associated injuries
5. When a fracture will anyhow need internal fixation
to hold it

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 Immobilization
• Restriction of movement

– Prevention of displacement

– Alleviation of pain

– Promote soft-tissue healing

– Allow free movement of the unaffected parts

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 Cont’d
• Methods of holding reduction:

– Sustained traction

– Cast splintage

– Functional bracing

– Internal fixation

– External fixation

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 1. Sustained Traction

• Traction is applied to the limb distal to the

fracture, so as to exert a continuous pull in the
long axis of the bone

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 Types of traction

• Traction by gravity
E.g. # of the humerus

• Skin traction

• Skeletal traction

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 Skin traction Skeletal traction
Age Preferably in children preferably in Adults
Applied with Adhesive plaster Steinman pin
weight Up to 5kg Up to 20% of body weight
Common problem Skin sloughing Pin site infection,
Neurovascular injury

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2. Cast Splintage

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 Basic principles of casting/splinting
• Expose the extremity completely before the splint is applied.
• Remove ornaments
• Clean, repair, and dress skin lesions before applying the
splint.
• Immobilize the joints above and below the fracture .
• Immobilize the bones above and below the dislocated joint .
• Never splint fractures circumferentially, if the patient has
impaired sensation, excessive swelling, or circulatory
insufficiency.

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• Evaluate neurovascular status before and after
application of the splint.
• Make the plaster wide enough to cover one-half of the
circumference of the extremity.
• Place Padding
– on the bony prominences;
– between the digits to prevent maceration;
– over the fracture site.
• To prevent stiffness and loss of function, splint the
involved joints in their positions of function.
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• Joint position for immobilization

joints POI

DIP and PIP extension

Wrist 20 degree dorsiflexion

elbow 90 degree flexion

knee 20 degree flexion

Ankle Neutral (90degree)

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• Complications of cast splintage
1. Tight cast LEADING TO COMPARTMENT
STNDROME
2. Pressure sores
3. Skin abrasion or laceration
4. Loose cast leading to loss of reduction

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 3. Functional Bracing
• Prevents joint stiffness while still
permitting fracture splintage and loading

• Since its not very rigid, it is usually applied

only when the fracture is beginning to unite

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4. Internal Fixation

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 Cont’d
• Indications for internal fixation
1. Fractures that cannot be reduced except by operation
2. Fractures that are inherently unstable and prone to
re-displacement after reduction
3. Fractures that unite poorly and slowly
4. Pathological fractures
5. Multiple fractures
6. Fractures in patients who present severe nursing
difficulties

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1. Interfragmentary/Lag 3. Plates and screws
Screws: o Metaphyseal
o Fixing small fractures of long
fragments onto the bones
main bone o Diaphyseal
fractures of the
radius and ulna

4. Intramedullary nails
o Long bones
2. Kirschner Wires o Locking screwsresist rotational forces
o Hold fragments together where o T
fracture healing is predictably
quick

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 Cont’d
• Complications of internal fixation
– Most are due to poor technique, equipment, or operating
conditions
– Infection
– Non-union
• Excessive stripping of the soft tissues
• unnecessary damage to the blood supply in the course of
operative fixation
• rigid fixation with a gap between the fragments
– Implant failure
– Refracture

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 5. External Fixation

Indications:
1. Fractures associated with severe soft-tissue
damage

2. Severely comminuted and unstable fractures

3. Fractures of the pelvis, which often cannot be

controlled quickly by any other method.

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 Cont’d

4. Fractures associated with nerve or vessel damage.

5. Infected fractures

6. Un-united fractures, where dead or sclerotic

fragments can be excised and the remaining
ends brought together in the external fixator;
sometimes this is combined with elongation in
the normal part of the shaft

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 Cont’d
• Complications of external fixation
• High degree of training and skill! Often used for the
most difficult fractures increased likelihood of
complications
– Damage to soft-tissue structures
– Over-distraction
• No contact between the fragments union
delayed/prevented
– Pin-track infection

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 Rehabilitation
• Restore function to the injured parts and the
patient as a whole
• Active Exercise,
• Assisted movement (continuous passive
motion by machines),

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 Cont’d
• Objectives:
– Restore circulation
– Prevent soft tissue adhesions
– Promote fracture healing
– Reduce edema
• Swelling  tissue tension, joint stiffness
• Soft Tissue care: elevate and exercise, never force
– Preserve joint movement
– Restore muscle power
– Guide patient back to normal activity

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OPEN FRACTURES

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Principles of Treatment of Open
Fractures
• All open fractures are assumed to be
contaminated Prevent infection!

• The essentials:
– Antibiotic prophylaxis
– Prompt wound debridement
– Stabilization of the fracture
– Early definitive wound cover

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JOINT DISLOCATIONS

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• Complete separation of articular surfaces in
which at least part of the supporting joint
capsule and some of its ligaments are
disrupted

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Commonly dislocated joints
• Shoulder-1st
• Elbow-2nd
• Hip-3rd

No joint is immune from dislocation

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 SYMPTOMS
• History of injury
• Pain
• Swelling
• Difficulty moving the joint
• Numbness and paresthesias

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 SIGNS
• Visibly out-of-place, discolored, or misshapen
joint
• Limited joint movement
• Swollen or bruised
• Intensely painful, especially if you try to use
the joint or bear weight on it or move it.
• Decreased sensation distal to the joint
• Decreased pulse, cool extremity distal to the
joint
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 RADIOGRAPHS
• Two planes at 90
degrees to each other
• Good quality
• See the entire joint

Dislocated Elbow
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• Check Neurovascular function distally

• Take post reduction radiograph

• Immobilize the joint

• Initiate ROM exercise when feasible

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 Complications of Fracture

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1. Complications Of Any tissue damage
• Haemorrhage
• Infection

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2. Complications Of prolonged recumbence
• Hypostatic pneumonia
• UTI
• Pressure sore
• DVT
• Muscle wasting
• Osteoporosis

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3. Comp. Of Anaesthesia and surgery
4. Comp. Of specific methods of treatment
• Cast
• Traction
• External fixator
•
Internal fixation
5. Comp. Peculiar to fracture

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 Classification
Early complications
Local:
· Vascular injury
· Visceral injury
· Nerve injury
· Compartment syndrome
· Wound infection, more common in open
fractures
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Systemic:
· Fat embolism
· Shock
· Thromboembolism (pulmonary or venous)
· Infections

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Late Complications
· Delayed Union
· Non-union
· Malunion
· Joint stiffness
· Contractures
· Myositis ossificans
· Avascular necrosis
· Osteomyelitis
· Growth disturbance or deformity
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Thank You!

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