CMT0509: Surgery

Session 25: Fractures

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 Learning tasks
At the end of this session, students are expected
to be able to:
• Define fracture
• Identify causes and risk factors
• Describe the different descriptions of fractures.
• Describe clinical features
• Identify the investigations
• Describe the management of closed fracture
 Learning tasks cont..
• Describe open fractures
• Describe the assessment of open fractures
• Describe the managements of open fracture
• Identify the complications relating to fractures.
 Activity: Brainstorming

• What is fracture?

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 Introduction
• Definition:
– A fracture is a complete or non-complete
disruption of continuity of the bone tissue.

• Fractures can be classified as

– Open or closed fractures
– Multi-fragmented or simple
– Displaced or undisplaced.
 Activity: Brainstorming

• What are causes of fracture?

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 Causes
• High energy trauma
• Motor vehicle accidents
• Sports injuries
• Fall from height
• Low energy trauma
• Simple fall
• Medical conditions
 Risk factors
• These includes, fractures resulting from:
– Single traumatic incident: eg in traumatic
accidents
– Repetitive stress: eg in athletes
– Abnormal weakening of the bone
(pathological): eg in old patients especially
women, bone weaken due to certain
diseases/ conditions.
 Risk factors cont..
• Traumatic incident may be due:-
• Direct traumatic force
– Bone break at the point of impact and
involves damage to the overlying skin
– Crushing injury usually cause communited
fracture(more than two fragments),with
extensive soft tissues damage
 Risk factors cont..
• Indirect traumatic force:
– Bone breaks at a distant from where the
force is applied
– Most fractures are due to combination of
forces
• Fatigue or stress fracture
– Fracture may occur due to repetitive stress
seen in tibia and fibula
 Risk factors cont..
• Pathological fracture in conditions include:-
– Osteoporosis
– Paget’s diseases
– Osteomyelitis
– Secondary tumors that metastasize to the
bone
– Primary Tumors of the bone eg
osteosarcoma
 Risk factors cont..
• Occurs in a bone that is made weak by some
disease.
• Causes-
– Inflammatory- Osteomyelitis
– Neoplastic- giant cell tumour, Ewings
sarcoma
– Other acquired generalised diseases-
Osteoporosis, osteomalacia, rickets
 Description of fractures
• Open fractures versus Closed fracture :-
– Open fracture : when there is direct
communication between the bone fracture
site and the external environment.
WHILE
– Closed fracture : This is when there is no
communication between one fracture site
and the external environment
 Description of fractures cont..
• Simple fractures versus comminuted fractures:
– A simple fracture: When there are only two
major fragments and one fracture line.
WHILE
– A comminuted fracture: When there are
multiple fragments of bone and multiple
fracture lines.
 Description of fractures cont..
• Complete versus incomplete
– Complete fractures: When the fracture line
goes completely across the bone, separating
the segments into two or more .
WHILE
– Incomplete fractures : When the fracture
line that only crosses one cortex of the bone
involved but some part are still attached.
 Fracture Deformities
• Displacement(Shift):
– refers to the position of the distal fragment in
relation to the assumed stationary proximal
fragment.
– Side ways: could be medial, anterior, posterior
or lateral
– Overriding: there is significant reduction of
original length
– Impaction: the original length is reserved
 Fracture Deformities cont..
• Angulations
– Tilted or angulated in relation to each other
– If uncorrected may lead to deformity of the
limb
• Rotations (twist)
– One fragment rotated on its longitudinal
axis
 Fracture Patterns
• Different fracture patterns includes;-
– Spiral fracture- as a result of twisting
– Oblique fracture-due to compression injury
– Butterfly fragment-mainly due to bending
– Transverse fractures-Tension tend to break
bone Avulsion of small fragment at point or
tendon insertion
 Mechanism of injury
• Include inquiring about the following details:-
– Weather the concerned patient was a
pedestrian, passenger or a driver
– The speed and the direction of travelling will
be important
– Brief story on what really happen??
– Patient’s age is also important
– Weather the patient has underlying
pathologies
 Activity: Brainstorming

• What are the clinical features of fracture?

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 Clinical features
• Bleeding, if present state its severity
• Pain on the affected part(anatomical position)
and its severity
• If there is Bruising or laceration
• Deformity with swelling or loss of movement
• Ability to use the limb
• Range of movement of the affected
joint(weather decreased or increased)
 Clinical features cont..
• Organs involvement associated features
– Abdominal pain: tells whether there is
visceral injury
– Blood in urine: injuries to the bladder or
urethra
– Difficult in breathing: if there is chest
visceral involvement
 Clinical features cont..
• For CNS involvement
– Loss of consciousness(and its duration) and
there was seizure
– Features of fracture of base of the skull
 Activity: Brainstorming

• What are investigations performed to a

fracture patient?

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 Investigations
• Full Blood Count
• Blood Group
• PT, PTT
• Specific tests depending on patient condition
and past medical history
 Investigations cont..
• X-ray mandatory (Remember the rule of
two’s)
– Two views eg AP, lateral
– Two joints (affected joint and other
contralateral joint)
– Two occasions(One X-ray soon after injury,
another at a week or two later)
 Activity: Brainstorming

• What are the management of closed fracture?

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 Management of closed fractures
• Always assess the status of distal circulation
and neurological function.
• Give strong analgesics
• Apply splintage for all fractures before
sending the patient for x-ray or referring.
– Use back slab cast until the swelling
subsided
 Management of closed fractures cont..
• Then perform fracture reduction ;
– Reduction may be done in various ways
including:- open(operative) reduction and
closed reduction
• Open (operative) reduction
– Indicated when closed reduction fails
– Or when there is a larger articular fragment
 Management of closed fractures cont..
• Closed reduction
– This is done under appropriate anesthesia and
muscle relaxants.
– It is used for all minimal displaced fracture
• Fracture is reduced by three fold maneuvers
– Distal part of the limb is pulled in line of the
bone
– Reposition of the fragments
– Alignment is adjusted in each plane
 Management of closed fractures cont..
• Perform immobilization or fixation
– The purpose of immobilization is to:
• prevent re displacement of a reduced
fracture
• decrease movement at the site of fracture
and prevent further soft tissue injury
 Management of closed fractures cont..

Methods of Immobilization includes:-

• Plaster of Paris (POP) cast
– It is a widely used method
• Traction methods includes:-
– Skin traction: A method of applying traction
using bandage
– Skeletal traction: Traction applied via a pin
inserted into the bone distal to the fracture.
 Management of closed fractures cont..
• External fixation
– This is a method of fixing the fracture by
metal pins passed through the bone above
and below the fracture and connected to a
metal frame.
• Internal fixation
– Internal fixation is a method of operative
fixation of fractures by plates, nails, screws,
pins and wires
 Management of closed fractures cont..
• Followed by limb rehabilitation
– Preserving muscle and joint function both
during and after treatment is an essential
component of fracture treatment for a good
result
 Open fracture
• This is a fracture in which the fracture
hematoma communicates with skin or mucous
membrane.
• Infection is the most feared complication of
compound fractures and may cause delayed
healing, non union, sepsis or even death.
• It is a surgical emergency
Open fracture
 Severity assessment using Gustillo-
Anderson classification
• Grade I:
– The wound is less than 1cm long.
– It is usually a moderately clean puncture (from
inside-out).
• Grade II:
– The laceration is more than 1 cm long, and there is
no extensive soft-tissue damage.
– There is a slight or moderate crushing injury,
moderate comminution of the fracture, and
moderate contamination.
 Severity assessment using Gustillo-
Anderson classification cont..
• Grade III:
– These are characterized by extensive damage to
soft-tissues, including muscles, skin, and
neurovascular structures, and a high degree of
contamination (Bone is exposed).
• III A: Bone is exposed but there is no periosteal
stripping
• III B: Bone is exposed but there is periosteal stripping
• III C: There is association of vascular injury that
requires repair
 Activity: Brainstorming

• What is the management of open fracture?

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 Management of open fractures
• Adequate wound care and immobilization.
• Give strong analgesics
• Tetanus prophylaxis
• Rigid immobilization with access to the wound
e.g. external fixation
• Delayed wound closure!
• DVT prophylaxis if indicated
 Management of open fractures cont..
• Give antibiotics
– Grade 1: 1st generation cephalosporin
– Grade 2: 1st generation cephalosporin + or –
an aminoglycoside depending on the level of
wound contamination.
– Grade 3: 1st generation cephalosporin and an
aminoglycoside
– All forms of injuries are treated as Grade 3
with addition of penicillin to cover for
staphylococcal infection
 Management of open fractures cont..
• Surgical debridement and irrigation
– Surgical debridement should be done in
theatre after thorough washing of the wound
– Debridement has been suggested to be done
within 6 hours of injury
Note:
• For gustillo type III, external fixation is the
golden standard form of fracture fixation and
stabilization
 Early complications
• Vascular injury
• Nerve injury
• Haemarthrosis
• Early infection
• Compartment syndrome
• Gas gangrene
• Plaster and pressure sores
 Late complications
• Non-union
• Delayed union
• Mal-union
• Bed sores
• Muscle contracture
• Osteoarthritis
 Key points
• A fracture is a complete or non-complete
disruption of continuity of the bone tissue
• In Tanzania, motor vehicle accidents are the
leading causes of fractures
• For open fractures, surgical debridement has
been suggested to be done within 6 hours of
injury
• Fractures are sometimes associated with
vascular and nerve injury
 Review questions
1. What is fracture?

2. Mention are the causes of fracture?

3.Describe management of open fracture.

4. Describe the complications of fracture.

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 References
• Sam W. Wiesel, John N. Delahay : Essentials
of Orthopedic Surgery, Third Edition
• T Duckworth, C M blundell : Lecture Notes
On Orthopedics And Fracture.