1. Principles of Fracture Treatment

2. What is a (bony) fracture?
Disruption of a bone’s normal structure or “wholeness”
Crack, break, or rupture in a bone
There are many how’s and why’s to bony fractures
Terms used to describe each are related

3. Definition of Fracture
There are 2 types of # in which this is not so:
Pathological fract.
Stress fract.

4. Pathological fracture :
It is one in which a bone is broken through an area weakened by pre-existing disease , & by a degree of force that would have left normal bone intact e.g osteoporosis , O.M. , bone tumours.

5. Stress fracture :
Bone, like other materials, reacts to repeated loading. On occasion, it becomes fatigued & a crack develops e.g military installations, ballet dancers & athletes.

6. Diagnosis
Clinical picture
Radiography

7. Clinical Features of Fracture
History of trauma
Symptoms & signs:
1. Pain & tenderness Swelling
3. Deformity Crepitus
5. Loss of function Abnormal move.
7. N.V. injuries

8. Orthopaedic History A good general orthopaedic history contains:
Onset, Duration, and Location of a problem
Limitations and debilitation attributed to the problem
Good surgical history, especially with regards to orthopaedic surgeries and prior anesthesia
Co-morbid conditions that contribute to the problem or will preclude healing in some manner

9. Physical Exam Basics
Inspect and Palpate everything- start with normal structures and move to abnormal
Range of motion in all planes
Strength
Sensation
Reflexes
Gait
Stability

10. Physical Exam Basics NVI What does this mean?
Neurologic exam- Always document the neurologic status. Some fractures are associated with nerve injuries and knowing the status of the nerve is critical
Vascular exam- Always check for pulses distal to the fracture sight. Missed vascular injuries can be devastating

11. Pre-reading Musculoskeletal Radiographs
1: Name, date, old films for
comparison
2: What type of view(s)
3: Identify bone(s) & joint(s)
demonstrated
4: Skeletal maturity
(physes: growth plates)
5: Soft tissue swelling
6: Bones & joints
(fractures & dislocations)

12. Physical Exam
NEVER trust someone else’s exam. ALWAYS put your hands on the patient and see for yourself
Always trust your exam- you WILL pick up something that someone else has missed at some point

14. OPEN AND CLOSED FRACTURES

16. Intro to Reading X-rays
Reading a radiograph is essentially describing the anatomy of a certain structure
In order for it to be universal and understandable for others, clarity and precision are essential
A fracture is described based on the findings of the physical exam and a review of radiographs

17. Reading X-rays
Say what it is- what anatomic structure are you looking at and how many different views are there
Regional Location- Diaphysis (rule of 1/3), Metaphysis, Epiphysis including intra and extra-articular
Direction of the fracture line- Transverse, Oblique, Spiral

18. Reading X-rays
Condition of the bone- comminution (3 or more parts), Segmental (middle fragment), Butterfly segment, incomplete, avulsion, stress, impacted
Deformity-Displacemtent (distal with respect to proximal), angulation (varus, valgus), rotation, shortening (in cm’s), distraction

19. Fracture Pattern
Transverse
Produced by a distracting or tensile force

20. Fracture Pattern
Spiral
Produced by a torsional force

21. Fracture Pattern
Produced by pure bending force
Butterfly

22. Fracture Pattern Comminuted
Broken into many pieces- high energy with combined forces

23. Displacement
Characterized by % of bone contact on either view

24. Angulation Distal fragment relative to proximal
Varus, Valgus, Anterior, Posterior
Apex of angle formed by fragments
E.g., Apex Anterior, Apex Medial, Apex Ulnar

25. Location ie distal third of tibia
Commonly described in thirds of affected bone
ie distal third of tibia
ie junction of proximal and middle third of femur
If fractured at two levels describe as segmental

26. Location-Diaphysis
Shaft portion of bone

27. Location-Metaphysis
The ends of the bone (if the fracture goes into a joint it is described as intra- articular)

28. Now All Together
Transverse fracture of the femur at the middle third- distal third junction with 100% displacement and varus (or apex lateral) angulation

29. What do you see?

30. What do you see?

31. What do you see?

32. Mnemonic: OLD ACID O: Open vs. closed L: Location
D: Degree (complete vs. incomplete)
A: Articular extension
C: Comminution / Pattern
I: Intrinsic bone quality
D: Displacement, angulation, rotation

33. O: Open vs. Closed Open fracture Closed fracture
AKA: “Compound fracture”
A fracture in which bone penetrates through skin;
“Open to air”
Some define this as a fracture with any open wound or soft tissue laceration near the bony fracture
Closed fracture
Fracture with intact overlying skin

34. L: Location Which bone? Thirds (long bones) Anatomic orientation
Epiphysis
Which bone?
Thirds (long bones)
Proximal, middle, distal third
Anatomic orientation
E.g. proximal, distal, medial, lateral, anterior, posterior
Anatomic landmarks
E.g. head, neck, body / shaft, base, condyle
Segment (long bones)
Epiphysis, physis, metaphysis, diaphysis
Physis
Metaphysis
Diaphysis
(Shaft)
Articular Surface

35. D: Degree of Fracture Complete Incomplete
Complete cortical circumference involved
Fragments are completely separated
Incomplete
Not fractured all the way through
“Only one cortex” involved
e.g “Greenstick fracture”

36. A: Articular Extension / Involvement
Intra-articular fractures
“Involves the articular surface”
Dislocation
Loss of joint surface / articular congruity
Fracture-dislocation

37. C: Comminution / Pattern
Transverse (Simple)
Oblique (Simple)
Spiral (Simple)
Linear / longitudinal
Segmental
Comminuted
Compression / impacted
“Buckle / Torus”
Distraction / avulsion

38. C: Comminution / Pattern
Transverse (Simple)

39. C: Comminution / Pattern
Oblique (Simple)
Spiral (Simple)
Oblique in 2+ views

40. C: Comminution / Pattern
Linear / longitudinal / split

41. C: Comminution / Pattern
Segmental
Bone broken in 2+ separate places; Fx lines do not connect

42. C: Comminution / Pattern
Comminuted
Broken, splintered, or crushed into >3 pieces

43. C: Comminution / Pattern
Compression
Impacted
(e.g. “Buckle / Torus”)

44. C: Comminution / Pattern
“Buckle / Torus”

45. C: Comminution / Pattern
Distracted
Avulsion

46. I: Intrinsic Bone Quality
Normal
Osteopenia
Decr’d density

47. I: Intrinsic Bone Quality
Osteopetrosis
Incr’d density
Normal

48. I: Intrinsic Bone Quality
Osteopoikilosis
Focal areas of incr’d density
Normal

49. D: Displacement, Angulation, Rotation
Extent to which Fx fragments are not axially aligned
Fragments shifted in various directions relative to each other
Convention: describe displacement of distal fragment relative to proximal
Oblique tibial shaft Fx b/w distal & middle thirds; laterally displaced

50. D: Displacement, Angulation, Rotation
Extent to which Fx fragments are not anatomically aligned
In a angular fashion
Convention: describe angulation as the direction the apex is pointing relative to anatomical long axis of the bone (e.g. apex medial, apex valgus)
R Tibial shaft Fx b/w prox & middle thirds, angulated apex lateral (apex varus)

51. D: Displacement, Angulation, Rotation
Valgus
Apex medial
Parallel
No angulation
Varus
Apex lateral

52. D: Displacement, Angulation, Rotation
Extent to which Fx fragments are rotated relative to each other
Convention: describe which direction the distal fragment is rotated relative to the proximal portion of the bone

53. D: Displacement, Angulation, Rotation
PA view of rotated hip Fx
Greater trochanter perpendicular to film
Normal PA view of hip
Greater trochanter in profile

54. Salter-Harris Fractures

55. Other signs of fractures
Callus / Osteosclerosis
Periosteal reaction

56. Other signs of fractures
Fat pad sign / “Sail sign”

57. Conclusions Know how to read X-rays
(Patients expect this & we order a lot of them)
Communicate and share with your consultants
(It affects patient outcomes)
Pre-reading
Describing fractures

58. Fracture Classification
Anat. Location
Direction of fract. Line
Wherther the fract. Is linear or comminuted
Condition of overlying S.T.
Mechnism of injury
AO classification

59. AO Classification A : Simple fract. B : Wedge fract.
C : Complex fract.

60. AO Classification

62. AO Classification
B= wedge fract.
B3 wedge fract
fragmented wedge

63. AO Classification

66. Mechanism of Injury Classification
Direct trauma
Indirect Trauma

67. Direct trauma : Tapping fractures Crushing fractures
Penetrating fractures
- High velocity missiles > 2500 f/s
- Low velocity missiles < 2500 f/s

68. Indirect Trauma : Traction or tension fract. angulation fract.
Rotational fract.
Compression fract.

69. Principles of fractures Fracture repair
Fracture repair is a tissue regeneration process rather than a healing process the injured bone is replaced by bone.
The process of repair varies according to:
-The type of bone involved.
-The amount of movement at the fracture.
-The closeness of the fracture surfaces.

70. Principles of fractures Rate of union
Unfavorable factors
Impairment of blood supply
Infection
Excessive movement
Presence of tumor
Synovial fluid in intraarticular Fx.
Interposition of soft tissue
Any form of Nicotine

71. Definitive fracture treatment
The goal of fracture treatment is to obtain union of the fracture in the most anatomical position compatible with maximal functional return of the extremity.
Conservative
Operative

72. Principles of Treatment
Treat the Patient, not only the fracture
Restriction of movement
Prevention of displacement
Alleviation of pain
Promote soft-tissue healing
Try to allow free movement of the unaffected parts
Splint the fracture, not the entire limb 72

73. Principles of Treatment
Methods of holding reduction:
Sustained traction
Cast splintage
Functional bracing
Internal fixation
External fixation 73

74. Definitive Fracture Fixation Options
Casts and Splints
Appropriate for many fractures especially hand and foot fractures
Adults typically will get plaster splints initially transitioned to fiberglass casts as swelling decreases
Kids typically will get fiberglass casts 74

76.  CONSERVATIVE TREATMENT 2- CAST
CLOSED, UNDISPLACED
CLOSED, REDUCIBLE
 CONSERVATIVE TREATMENT
2- CAST
Below Knee
Above Knee

77. Complications of cast splintage
Liable to appear once the patient has left the hospital; added risk of delay before the problem is attended to
Tight cast
Pressure sores
Skin abrasion or laceration
Loose cast 77

78. Functional Bracing
Prevents joint stiffness while still permitting fracture splintage and loading
Most commonly for fractures of the femur or tibia
Since its not very rigid, it is usually applied only when the fracture is beginning to unite
Comes out well on all four of the basic requirements: “hold” “move” “speed” “safe” 78

79. Definitive Fracture Fixation Options
Traction
Useful in patients who are too sick for surgery
Useful to maintain alignment until definitive fixation 79

80. Traction by gravity Balanced Traction Eg. Fractures of the humerus
Skin traction: adhesive strapping kept in place by bandages
Skeletal traction: stiff wire/pin inserted through the bone distal to the fracture
Femur fracture managed with skeletal traction and use of a Steinmann pin in the distal femur. 80

81. Operative
ORIF (open reduction internal fixat.)
External fixation

82. Indications of ORIF
- absolute
- relative

83. Indications of ORIF Absolute Indications for ORIF of fractures
Unable to obtain an adequate reduction
Displaced intra-articular fractures
Certain types of displaced epiphyseal fractures
Major avulsion fractures where there is loss of function of a joint or muscle group
Non-unions
Re- implantations of limbs or extremities

84. Indications of ORIF Relative Indications for ORIF of fractures
Delayed unions
Multiple fractures to assist in care and general management
Unable to maintain a reduction
Pathological fractures
To assist in nursing care
To reduce morbidity due to prolonged immobilisation
For fractures in which closed methods are known to be ineffective

85. Indications of ORIF Fractures accompanying nerve of vessel injury
Questionable
Fractures accompanying nerve of vessel injury
Open fractures
Cosmetic considerations
Economic considerations

86. Open Operation Operative reduction under direct vision is indicated:
When closed reduction fails
When there is a large articular fragment that needs accurate positioning 86

87. Open Operation
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 87

89. Types of Internal Fixation
- Pin & wire fixat.
- Screw fixat.
- Plate & screws fixat.
- Intra-medullary fixat.

90. Plate & screws fixat. Functional types: Compression plates
Neutralization plates
Buttress plates
Bridge plates
LC- DCP
Liss plates
Locking plates & screws

91. Definitive Fracture Fixation Options
Open Reduction and Internal fixation with Plates and screws
Used for many fractures especially those involving joints 91

94. Intra-medullary fixat.
Centro-medullary
- Unlocked
-Interlocking(static – dynamic – double locked)
Condylocephalic
Cephalomedullary

95. Definitive Fracture Fixation Options
Intramedullary Nails
Treatment of choice for most tibia and femur fractures
Used in selected humerus and forearm fractures 95

100. Internal Fixation “holds” securely with precise reduction
“movements” can begin at once (no stiffness and edema)
“speed”: patient can leave hospital as soon as wound is healed, but full weight bearing is unsafe for some time
“safety”= biggest problem! SEPSIS!!!
Risk depends on: the patient, the surgeon, the facilities
100

101. Indications for internal fixation
Fractures that cannot be reduced except by operation
Fractures that are inherently unstable and prone to re-displacement after reduction
Fractures that unite poorly and slowly
Pathological fractures
Multiple fractures
Fractures in patients who present severe nursing difficulties
101

102. Interfragmentary/Lag Screws: Fixing small fragments onto the main bone
Plates and screws
Metaphyseal fractures of long bones
Diaphyseal fractures of the radius and ulna
Intramedullary nails
Long bones
Locking screwsresist rotational forces
Kirschner Wires
Hold fragments together where fracture healing is predictably quick
102

103. Definitive Fracture Fixation Options
Joint Replacement
Used in displaced femoral neck fractures in geriatric patients
Allows for early ambulation
Occasionally used in geriatric pts with comminuted shoulder or elbow fractures
103

104. Complications of internal fixation
Most are due to poor technique, equipment, or operating conditions
Infection
Iatrogenic infection is now the most common cause of chronic osteomyelitis
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
104

105. Definitive Fracture Fixation Options
External Fixation
Used primarily in the treatment of open fractures and pelvis fractures
Also useful as temporary stabilization prior to definitive fixation
105

106. External Fixation Permits adjustment of length and angulation
Some allow reduction of the fracture in all 3 planes.
Especially applicable to the long bones and the pelvis.
Indications:
Fractures of the pelvis, which often cannot be controlled quickly by any other method.
Fractures associated with severe soft-tissue damage where the wound can be left open for inspection, dressing, or definitive coverage.
106

107. External Fixation
3. Severely comminuted and unstable fractures, which can be held out to length until healing commences.
4. Fractures of the pelvis, which often cannot be controlled quickly by any other method.
5. Fractures associated with nerve or vessel damage.
6. Infected fractures, for which internal fixation might not be suitable.
7. 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
107

108. 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
108

109. OPEN FRACTURES Initial Management At the scene of the accident
In the hospital
109

110. Types of Open Fractures
Gustilo’s classification of open fractures:
Type 1: low-energy fracture with a small, clean wound and little soft-tissue damage
Type 2: moderate-energy fracture with a clean wound more than 1 cm long, but not much soft-tissue damage and no more than moderate comminution of the fracture.
Type 3: high-energy fracture with extensive damage to skin, soft tissue and neurovascular structures, and contamination of the wound.
110

111. Types of Open Fractures
Type 3 A: the fractured bone can be adequately covered by soft tissue
Type 3 B: can’t be adequately covered, and there is also periosteal stripping, and severe comminution of the fracture
Type 3 C: if there is an arterial injury that needs to be repaired, regardless of the amount of other soft-tissue damage
111

112. Types of Open Fractures
The incidence of wound infection
correlates directly with the extent of soft-tissue damage, <2% in type 1 >10% in type 3
rises with increasing delay in obtaining soft tissue coverage of the fracture.
112

113. Principles of Treatment of Open Fractures
All open fractures assumed to be contaminated Prevent infection!
The essentials:
Prompt wound debridement
Antibiotic prophylaxis
Stabilization of the fracture
Early definitive wound cover
Repeated examination of the limb because open fractures can also be associated with compartment syndrome
113

114. CONTRAINDICATIONS TO SURGICAL REDUCTION AND STABILIZATION
Situations in which there is a high probability for failure with operative treatment are as follows:
1. Osteoporotic bone that is too fragile to allow stabilization by internal or external fixation.
2. Soft tissues overlying the fracture or planned surgical approach of such poor quality because of scarring, burns,active infection, or dermatitis .
3. Active infection or osteomyelitis.

115. CONTRAINDICATIONS TO SURGICAL REDUCTION AND STABILIZATION
4. Fracture comminution to a degree that does not allow successful reconstruction. This is most commonly seen in severe intraarticular fractures.
5. General medical conditions that are contraindications to anesthesia are generally contraindications to the surgical treatment of fractures.
6. Undisplaced or stable impacted fractures in acceptable position do not require surgical exposure or reduction.
7. Inadequate equipment, manpower, training, and experience.

116. Thank you