Morphology Linear fracture: parallel to long axis of bone Transverse fracture: cut cross the long axis Oblique fracture: diagonal to the long axis Spiral fracture: twisted Compression fracture: common in vertebrae Compact (impacted) fracture: bone fragments are driven into each other Pathologic fracture: with underlying bone lesion
Classification of fracture, for Communication among clinicians Decision making Potential problems Treatment options Predicting outcome Documentating cases
OTA Classification Oestern and Tscherne Classification of closed fractures Gustilo and Anderson classification of open fractures Salter-Harris classification of epiphyseal plate injury
OTA Classification The Orthopaedic Trauma Association Classification system to describe the injury accurately and guide treatment Standard for orthopedics surgeon Classification adaptable to the entire skeletal system Allows consistency in research
To Classify a Fracture: OTA Which bone? Where in the bone is the fracture? Which type? Which group? Which subgroup?
Oestern and Tscherne Classification of closed fractures GradeSoft tissue injuryBony injury 0MinimalSimple fracture pattern Indirect injury to limb 1Superficial abrasion/Mild fracture pattern contusion 2Deep abrasion with skinSevere fracture pattern or muscle contusion Direct trauma to limb 3Extensive skin contusionSevere fracture pattern or crush Severe damage to underlying muscle Subcutaneous avulsion, compartmental syndrome
Gustilo and Anderson classification of open fractures (type I – type III) Type I: –Clean wound smaller than 1 cm in diameter –Simple fracture pattern –No skin crushing Type II: –a laceration larger than 1 cm –No significant soft tissue crushing –Fracture pattern may be more complex.
Type III: –Contamination : soil,water, yard,fecal –Open segmental fracture or a single fracture with extensive soft tissue injury –Any opened fracture older than 8 hours Type IIIA: adequate soft tissue coverage of the fracture despite high energy trauma or extensive laceration or skin flaps. Type IIIB: inadequate soft tissue coverage with periosteal stripping. Soft tissue reconstruction is necessary. Type IIIC: any open fracture that is associated with vascular injury that requires repair.
Prerequisites for Bone Healing Adequate blood supply Adequate mechanical stability Proper bone metabolism Periosteum Bone marrow
Fracture healing process Absolute stability : Direct (primary) bone healing: rigidly stabilized fracture with fracture surface held in contact eg. transverse diaphyseal fracture of radius and ulnar treated by ORIF Relative stability : Indirect (secondary) bone healing: unstable closed fracture, not rigidly stabilized eg. closed clavicle fracture without surgery Inadequate stability : non union (pseudoarthrosis)
1. Healing with absolute stability - Rigidly contact between bone ends - Gaps
Rigidly contact between bone ends Lamellar bone can form directly across the fracture line –A cluster of osteoclasts cut across the fracture line –Osteoblasts (following the osteoclasts) deposit new bone –Blood vessels follow the osteoblasts –New haversian system formation
Gaps between bone ends Prevent direct extension of osteoclast –A Osteoblasts fill the defects with woven bone –A cluster of osteoclasts cut across the woven bone –Osteoblasts (following the osteoclasts) deposit new bone –Blood vessels follow the osteoblasts –New haversian system formation
2. Healing with relative stability - Hematoma - Granulation tissue - Soft callus - Hard callus - Remodeling
Hematoma between the fracture ends, in medullary canal, subperiosteal, around bone Death bone at both ends of fracture site due to loss of nutrition Inflammatory mediators from platelets, dead cells Inflammtory cells migrate to the fracture site cytokine angiogenesis and stem cells migration fibroblasts, chondroblasts, osteoblasts Vascular dilatation edema Granulation tissue formation
Treatment General aim of management –Control hemorrhage –Pain relief –Prevent ischemia-reperfusion injury –Remove contamination –Reduction –Immobilization For maximal function and minimized complication
Treatment Non operative therapy –Casting after an appropriate closed reduction –Traction (rarely used) Skin traction Skeletal traction Surgical therapy –Open reduction and internal fixation (ORIF) Kirschner wires (K-wires) Plates and screws Intramedullary nails –External fixation
Complications of fracture Neurologic and vascular injury Compartment syndrome: anterior leg Infection: open fracture and surgery Thromboembolic events Avascular necrosis: femoral head and neck Post-traumatic arthritis Delay union, non-union, malunion