Orthopedic Surgery

Fractures
By the end of this session you should be
able to describe:

What is a fracture?
 Types of fractures..
 Causes..
 Clinical Features..
 Healing of fractures..
 Complications..
Principles of management..
Definition

“Loss of continuity in the substance of a

bone is called a fracture.”
 Spectrum extends from a microscopic
fracture to a hair line fracture and than to
grossly notable fractures.
Types of fractures

 Open

 Closed
Types (cont,d)
 Avulsion fracture:
Muscle or ligament pulls on a bone fracturing it.
 Comminuted fracture:
Bone is shattered into many pieces
 Compression fracture:
Collapse of bone usually vertebra in osteoporosis
 Fracture dislocation:
 Greenstick fracture:
One side of bone fractures, not complete and bone bends
 Hair line fracture:
 Impacted fracture:
Fragments of bone got impacted
 Intraarticular fracture:
Types (cont,d)
 Longitudinal fracture:
Along the length of bone
 Oblique fracture:
Fracture is diagonal to bones long axis
 Pathological fracture:
 Spiral fracture:
Atleast one part of bone has twisted
 Stress fracture:
Bone breaks because of repeated stresses and strains e.g. athletes
 Transverse fracture:
A straight break right across a bone
Anatomic description - Type
 Type is the overall
fracture pattern
 Examples are:
 Simple
 Spiral
 segmental
Anatomic description of fractures

 Type
 Comminution
 Location
 Displacement
Anatomic description - Comminution

 Comminution is the measure of the

number of pieces of broken bone that
there are.
 Examples are: non-comminuted or mildly
comminuted or severely comminuted
 Anatomic description - Location

 Location is the anatomic location of the

fracture usually described by giving the
bone involved and location on the bone
 Examples are: distal radial shaft, proximal
1/3 humeral shaft, intra-articular distal
tibial
Anatomic description - Displacement

 Displacement is the amount the pieces of

a fracture have moved from their normal
location
 Can be displaced or non-displaced
 Subdivided into 3 sub-categories:
translation, angulation, and shortening
Displacement - Translation
 Translation is
sideways motion of
the fracture - usually
described as a
percentage of
movement when
compared to the
diameter of the bone.
Displacement - Angulation
 Angulation is the
amount of bend at a
fracture described in
degrees. Described
with respect to the
apex of the angle or
with respect to
direction of distal
fragment.
Displacement - Shortening
 Shortening is the
amount a fracture is
collapsed expressed
in centimeters.
Anatomic description?
Anatomic description
 Simple, transverse,
non-communited
midshaft radial and
ulnar fracture with 30
degrees apex radial
angulation.
Why classify fractures?

 Classification or description of fractures is

only used when it is useful in providing
treatment or outcomes.
Types of classifications
 Anatomic description
 AO classification for Long bone fracture
( Humerus, Radius/ Ulna, Femur, Tibia/
Fibula)
 Salter-Harris classification for Epiphysial
plate fracture
 Gustillo anderson classification for open
fracture
AO Classification
AO Classification

 1st number = long bone

 2nd number = bone segment
 Letter = fracture type (A,B,C)
 Then 3rd & 4th numbers classify fracture group
& subgroup
 Oblique fracture Proximal Femoral Shaft :
(32 A2.1)

 3 … the bone … femur

(1= Humerus, 2= Radius/ Ulna, 3= Femur, 4= Tibia/
Fibula)
 2 … the segment … diaphysis
(1= Epiphysis, 2= Diaphysis, 3= Metaphysis)

 A … the type … least severe

(A= least severe, B= Intermediate, C= Most severe)
 2 … the group … Gp. 2 includes oblique fractures
 1 … the subgroup … 1 includes fracture in proximal
part of diaphysis
Salter-Harris Classification

 Only used for pediatric fractures that

involve the growth plate (Physis)
 Five types (I-V)
Salter-Harris type I fracture
 Type I fracture is
when there is a
fracture across the
physis with no
metaphysial or
epiphysial injury
Salter-Harris type II fracture
 Type II fracture is
when there is a
fracture across the
physis which extends
into the metaphysis
Salter-Harris type III fracture
 Type III fracture is
when there is a
fracture across the
physis which extends
into the epiphysis
Salter-Harris type IV fracture
 Type IV fracture is
when there is a
fracture through
metaphysis, physis,
and epiphysis
Salter-Harris type V fracture
 Type V fracture is
when there is a crush
injury to the physis
Gustillo classification

 The Gustillo classification is used to

classify open fracture - ones in which the
skin has been disrupted
 Three grades that try to quantify the
amount of soft tissue damage associated
with the fracture
Open fractures - grade 1

 wound less than 1 cm with minimal soft tissue

injury
 wound bed is clean
 bone injury is simple with minimal
comminution
 With IM nailing, average time to union is 21-
28 weeks
Open fractures - grade 2

 wound is greater than 1 cm with moderate soft

tissue injury
 wound bed is moderately contaminated
 fracture contains moderate comminution
 With IM nailing, average time to union is 26-
28 weeks
Open fractures - grade 3A

 wound greater than 10 cm with crushed tissue

and contamination
 soft tissue coverage of bone is usually possible
 With IM nailing, average time to union is 30-
35 weeks
Open fractures - grade 3B

 wound greater than 10 cm with crushed tissue

and contamination
 soft tissue is inadequate and requires regional
or free flap
 with IM nailing, average time to union is 30-
35 weeks
Open fractures - grade 3C

 is fracture in which there is a major vascular

injury requiring repair for limb salvage
 in some cases it will be necessary to consider
BKA following tibial fracture
Causes of Fractures
 Fall (Elderly)
 RTA (Younger)
 Underlying illnesses that weaken
bones.. Pathological fractures e.g;
Osteoporosis, infection, tumor
 Repeated stresses & strains e.g;
athletes .. Stress fractures
Clinical Features
 Depends which bone affected, patients age, general health, severity
of injury.
 Pain
 Swelling
 Bruising
 Discoloured area around affected area
 Angulation
 Inabbility to bear weight
 Inability to move/ painful active or passive movements
 Grating sensation/ crepitus
 Bleeding if open fractures
 If large bone leading to occult bleeding … pallor and dizziness,
feeling of sickness & nausea
Healing of Fractures

 Proper alignment & immobility, healing is

straightforward
 Osteoclasts absorbs old & damaged bone
 Osteoblasts create new bone
 Callus is new bone formed around fracture
site
Setting a Break

 Bone is constantly in a state of turnover, even

when not damaged or injured.
 In order for the fracture to heal without any
deformity, a good ‘reduction,’ or placement, of
the bones must be attained.
 If the reduction cannot be satisfactorily
achieved then a further procedure may be
necessary, such as an operation with fixation
of the bone with plates, screws or nails.
Factors affecting healing process

 Patient,s age
 Bone affected
 Type of fracture
 Patient general health condition
 Smokers
Complications in Fracture Healing
 Heals in wrong position
Known as Malunion … either heals in wrong position
or fracture shifts
 Disruption of bone growth
If fracture affects growth plate, subsequent deformity
 Persistent bone or bone marrow infection
If break in skin … can lead to chronic osteomyelitis
 Bone death (Avascular necrosis)
If bone loses its essential blood supply
Principles of General Fracture
Management (REST)
 Rest
 Elevation
 Support & Immobilization:
Bones are aligned in anatomical position &
must stay align during process of healing.
 Temperature (warmth)
Methods of Immobilization

 Plaster casts or plastic functional braces

 Metal plates & screws
 Intra medullary nails
 External fixators
 O.R.I.F.
Definition:
Open Reduction Internal Fixation.

Open reduction internal fixation is a method

of surgically repairing a fractured bone.

Generally, this involves either the use of

plates and screws or an intramedullary (IM)
rod to stabilize the bone.
 Intra medullary Rods
 Definition: Intra medullary nails or
rods are devices used to stabilize
fractures and allow for bone healing.

 IM nails are inserted into the

medullary (bone marrow) canal in the
center of the long bones of the
extremities (e.g. femur, tibia, etc.).