1. General Principles of Fracture Care
Presented By:
Fadel Naim M.D.
Orthopedic Surgeon
Faculty of Medicine
IUG

2. Fracture The problem is not the damage to the bone
The problem is the damage the bone does to the surrounding soft tissues.
Evaluate Neurovascular Function Distally

3. Fracture
A disruption in the integrity of a living bone involving injury to:
Bone
Bone marrow
Periosteum
Adjacent soft tissues

4. Mechanisms of Musculoskeletal Injury
Direct force
Indirect force
Twisting (rotational) force
Point to Emphasize: There are three types of mechanisms that cause musculoskeletal injuries: direct force, indirect force, and twisting force.
Talking Points: Direct force is a person being struck by an automobile. Twisting or rotational force can cause stretching or tearing of muscles and ligaments. Indirect force causes injuries to the body away from the actual impact and can be more serious than the original injury.
Discussion Topic: Describe the three mechanisms that cause musculoskeletal injuries.
Knowledge Application: Have students work in small groups. Hand out sticks and have each group present an example of a specific force that causes musculoskeletal injury. Have groups discuss their examples.

5. Direct trauma: Consists of direct force applied to the bone
Tapping fractures (eg, bumper injury)
Penetrating fractures (eg, gunshot wound)
Crush fractures

6. Indirect trauma
Involves forces acting at a distance from the fracture site
Tension (traction)
Compressive forces
Rotational forces

7. Indirect Trauma
Rotation
Tension
Compression
Combination
Angulation

8. Classification of Fractures
Evidence based medicine
Communication
Treatment plan (personality of the fracture...)

9. Fracture Discription Anatomical location - ? joint Direct / indirect
Fracture configuration
Simple or comminuted
Open or closed
Pathological
Stress fracture
Greenstick fracture

10. The Rule of A's Radiographs should be described as follows:
Anatomy (eg, proximal tibia)
Articular (eg, extra-articular)
Alignment (eg, first plane)
Angulation (eg, second plane)
Apex (eg, apex pointing medially)
Apposition (eg, 75% or 0%)

11. Anatomical and Clinical Discreption
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
Epiphysis
Physis
Metaphysis
Diaphysis
(Shaft)
Articular Surface

12. Articular Extension / Involvement
Anatomical and Clinical Discreption
Articular Extension / Involvement
Intra-articular fractures
“Involves the articular surface”
Dislocation
Loss of joint surface / articular congruity
Fracture-dislocation

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

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

16. Displacement, Angulation, Rotation
Extent to which Fx fragments are not anatomically aligned
In a angular fashion
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)

17. Displacement, Angulation, Rotation
Valgus
Apex medial
Parallel
No angulation
Varus
Apex lateral

18. 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

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

20. Displacement, Angulation, Rotation
Shortening
Has the fracture caused shortening of the bone involved?
To what extent has shortening occurred?

22. Intrinsic Bone Quality
Normal
Osteopenia
Decr’d density

23. Intrinsic Bone Quality
Osteopetrosis
Incr’d density
Normal

24. Intrinsic Bone Quality
Osteopoikilosis
Focal areas of incr’d density
Normal

25. Soft tissue involvement
Is the fracture open or closed?
Is associated neurological and or vascular injury present?
Is there muscle damage or compartment syndrome evident?

26. Open fracture implies communication between external environment and the fracture.
A soft tissue injury complicated by a broken bone.

27. Components of open fracture
Soft-tissue damage
Neurovascular compromise
Contamination
Extent of each component must be assessed individually in order to achieve a comprehensive understanding of the injury, upon which the treatment plan can be based.

28. Gustilo and Anderson Classification
Model is tibia, however applied to all types of open fractures
Emphasis on wound size
Crush injury assoc with small wounds
Sharp injury assoc with large wounds
Better to emphasize
Degree of soft tissue injury
Degree of contamination
Most widely used today

29. Why use this classification?
Grades of soft tissue injury correlates with infection and fracture healing
Grade 1 2 3A 3B 3C
Infection
Rates
0-2%
2-7%
10-25%
10-50%
25-50%
Fracture Healing (weeks)
21-28
28-28
30-35
Amputation Rate
50%

30. Cover the wounds quickly
Nocosomial infection?!!!!
Cover the wounds quickly
Only 8% of infections were caused by the same organism initially isolated in the perioperative cultures
92% of open fracture infections were caused by bacteria acquired while the patient was in the hospital

31. Gustilo Classification of Open Fracture
Type I:
Wound is shorter than 1 cm.
It is clean and generally is caused by a fracture fragment piercing the skin (ie, inside-out injury).
This is a low-energy injury.

32. Gustilo Classification of Open Fracture
Type II:
The wound is longer than 1 cm.
It is not contaminated and without major soft tissue damage or defect.
This is also a low-energy injury.

33. Gustilo Classification of Open Fracture
Type III:
Wound longer than 1 cm, with significant soft tissue disruption
High-energy trauma resulting in a severely unstable fracture with varying degrees of fragmentation
IIIa:
Sufficient soft tissue to cover the bone without the need for local or distant flap coverage

34. Gustilo Classification of Open Fracture
Type III:
IIIb:
Extensive soft tissue disruption
Local or distant flap coverage is necessary to cover the bone
The wound may be contaminated, and serial irrigation and debridement procedures are necessary to ensure a clean surgical wound

35. Gustilo Classification of Open Fracture
Type III:
IIIc:
Any open fracture associated with an arterial injury, which requires repair is considered type IIIC
Involvement of vascular surgeons is generally required

36. Gustilo Classification of Open Fracture
Type I:
Wound is shorter than 1 cm.
It is clean and generally is caused by a fracture fragment piercing the skin (ie, inside-out injury).
This is a low-energy injury.
Type II:
The wound is longer than 1 cm.
It is not contaminated and without major soft tissue damage or defect.
This is also a low-energy injury.
Type III:
Wound longer than 1 cm, with significant soft tissue disruption
High-energy trauma resulting in a severely unstable fracture with varying degrees of fragmentation
IIIa:
Sufficient soft tissue to cover the bone without the need for local or distant flap coverage
IIIb:
Extensive soft tissue disruption
Local or distant flap coverage is necessary to cover the bone
The wound may be contaminated, and serial irrigation and debridement procedures are necessary to ensure a clean surgical wound
IIIc:
Any open fracture associated with an arterial injury, which requires repair is considered type IIIC
Involvement of vascular surgeons is generally required

37. IIIA I II
IIIB
IIIC

38. Clinical Manifestations of fracture
Edema
Pain and Tenderness
Muscle spasm
Deformity
Ecchymosis
Loss of Function
Crepitation

39. The six “P”s of musculoskeletal assessment
Pain
on palpation
on movement
constant
Pallor - pale skin or poor cap refill
Paresthesia - “pins and needles” sensation
Pulses - diminished or absent
Paralysis
Pressure

40. 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)

41. Reading X-rays Say what it is- Regional Location-
what anatomic structure are you looking at
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

42. Reading X-rays Condition of the bone- Deformity
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

43. Diagnosis of Fracture X-Ray The Rule of 2s
Two views:
Anteroposterior (AP) and lateral views of the injured limb (2 views 90° orthogonal to each other)
Two joints:
The joint above and the joint below the injury
Two limbs:
Radiographs of both the injured and noninjured limbs especially in children with epiphyseal-plate injuries
Two times:
1 prereduction image and 1 postreduction or postfixation image

44. What do you see?

45. What do you see?

46. What do you see?

47. CT Scanning Not indicated for routine evaluation of common fractures
Preoperative planning for complicated fractures
Provide information about the architecture of fracture lines especially about intra-articular fractures
Evaluate severely fragmented fractures and those involving the epiphyseal segment
Is indicated in assessing the spinal column for injury

48. Fracture Healing Primary healing
Non displaced fractures, fractures with compressive fixation across the fracture site
Osteoblasts traverse the fracture site and lay down lamellar bone without forming immature bone when there is direct contact between cortical bone ends

49. Fracture Healing Secondary healing
No compression across fracture site, motion can occur
Fracture callus forms to stop motion, stage of consolidation and remodeling

50. Patient Factors Influencing Fracture Healing
Ideal
Problematic
Age
Youth
Advanced age (>40 y)
Trauma
Single limb
Multiple traumatic injuries
Comorbidities
None
Multiple medical comorbidities (eg, diabetes)
Medications
Nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids
Social factors
Nonsmoking
Smoking
Local factors
No infection
Local infection
Type
Closed fracture, neurovascularly intact
Open fracture with poor blood supply
Nutrition
Well nourished
Poor nutrition

51. Fracture Management
Don’t treat the X-rays of the fracture, but treat the patient
Life saving measures
Diagnose and treat life threatening injuries (head injuries, Chest & abdominal injuries)
Emergency orthopaedic involvement
Life saving
Complication saving
Emergency orthopaedic management (day 1)
Monitoring of fracture (days to weeks)
Rehabilitation and treatment of complications (weeks to months)

52. GOALS OF FRACTURE TREATMENT
Restore the patient to optimal functional state
Prevent fracture and soft-tissue complications
Get the fracture to heal, and in a position which will produce optimal functional recovery
Rehabilitate the patient as early as possible

53. LIFE SAVING MEASURES A Airway and cervical spine immobilisation
B Breathing
C Circulation (treatment and diagnosis of cause)
D Disability (head injury)
E Exposure (musculo-skeletal injury)

54. EMERGENCY ORTHOPAEDIC MANAGEMENT
Life saving measures
Reducing a pelvic fracture in haemodynamically unstable patient
Applying pressure to reduce haemorrhage from open fracture
Complication saving
Early and complete diagnosis of the extent of injuries
Diagnosing and treating soft-tissue injuries

56. Fracture management Either
The ideal goal of fracture management is anatomical reduction and function restoration compatible with the severity of injury, age, occupation and activity of daily living of injured patient.
Either
Operative
Non operative (Conservative)
Traction
Splint (Cast / Slab)

57. Nonoperative Fracture Management
Nonoperative technique consists
A closed reduction if required
Followed by a period of immobilization with casting or splinting
Closed reduction is needed if the fracture is significant displaced or angulated

58. Closed Reduction Contraindicated under the following conditions:
For any fracture that is
Displaced
Shortened
Angulated
Applying traction to the long axis of the injured limb and then reversing the mechanism of injury
Contraindicated under the following conditions:
If significant displacement is unappreciable
If displacement exists but is not relevant (eg, humeral shaft fracture)
If reduction is impossible (severely comminuted fracture)
If the reduction, when achieved, cannot be maintained
If the fracture has been produced by traction forces (eg, displaced patellar fracture)

60. Common Casts Used in Treatment of Disorders of the Musculoskeletal System

61. Traction
Traction is the application of a pulling force to a part of the body
Purpose:
to reduce, align, and immobilize fractures;
Unstable and unfixable
When reduction and/or proper length cannot be maintained by static immobilization
to minimize muscle spasm
to prevent or reduce skeletal deformities or muscle contractures.

62. Classification of Traction
Skin Traction : is maintained by direct application of a pulling force on the patient’s skin . Generally temporary measure.
To reduce muscle spasms
To maintain immobilization before surgery
In children

63. Classification of Traction
Skeletal Traction :
applied to bone by means of a pin or wire surgically inserted into the bone,
providing a strong steady, continuous pull, and
can be used for prolonged periods .

65. Complications of traction
Neurovascular compromise.
Inadequate fracture alignment..
Skin breakdown .
Soft tissue injury
Pin tract infection .
Osteomyelitis can occur with skeletal traction.

66. Surgical Therapy Treatment goals
Anatomic reduction of the fracture fragments:
For the diaphysis, assuring that length, angulation, and rotation are corrected
For intra-articular fractures anatomic reduction of all fragments required
Stable internal fixation to fulfill biomechanical demands
Preservation of blood supply
Active pain-free early mobilization to prevent the development of fracture disease

67. Indications for ORIF of Fractures:
Absolute:
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

68. Indications for ORIF of Fractures:
Relative:
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

69. Contraindications to Surgical Reconstruction
Active infection (local or systemic) or osteomyelitis
Osteoporotic bone that is too weak to sustain internal or external fixation
Soft tissues overlying the fracture or surgical approach that are poor in quality due to burns, surgical scars, or infection (in such scenarios, soft tissue coverage is recommended.)
Medical conditions that contraindicate surgery or anesthesia (eg, recent myocardial infarction)
Cases in which amputation would better serve the limb and the patient

70. Kirschner Wires
Commonly used for temporary and definitive treatment of fractures
They do not resist rotation and have poor resistance to torque and bending forces
Usually casting or splinting is used in conjunction
Be placed percutaneously or through a mini-open mechanism

72. Plates Buttress plates Compression plates Neutralizing plates
Counteract compression and shear forces
Commonly used around joints to support intra-articular fractures
Compression plates
Counteract bending, shear, and torsion forces
Eccentrically loaded holes in the plate
Commonly used in long bones
Neutralizing plates
Used in combination with interfragmentary screw fixation
Commonly used for fractures involving the fibula, radius and ulna, and humerus
Bridge plates
Useful in the management of multifragmented diaphyseal and metaphyseal fractures

73. Intramedullary Nailing
Operate like an internal splint that shares the load with the bone
Flexible or rigid, locked or unlocked, and the intramedullary canal can be reamed or unreamed
Allows for compressive forces at the fracture site, which stimulates bone healing
Advantages :
Minimally invasive procedures
Early postoperative ambulation
Early ROM

74. Hybrid Fixation

75. External Fixation
Provides stabilization of a fracture at a distance from the fracture site without interfering with the soft tissue near the fracture.
Provides stability for the extremity and maintains length, alignment, and rotation without requiring casting.
It also allows for inspection of the soft tissue structures vital for fracture healing.

77. External Fixation Indications for external fixation are as follows:
Open fractures that have significant soft tissue disruption (eg, type II or III open fractures)
Soft tissue injury (eg, burns)
Acetabular and pelvic fractures
Severely comminuted and unstable fractures
Fractures that are associated with bony deficits
Limb-lengthening procedures
Fractures associated with infection or nonunion

78. Management of Open Fractures
The goals of treatment of open fractures:
To prevent infection
To allow the fracture to heal
To restore function in the injured limb

79. Stages of care for open fractures

80. Antibiotic Therapy
Cefazolin is adequate for type I and type II injuries
If the wound is severely contaminated (type III), an aminoglycoside can be added (eg, gentamycin or tobramycin)
If the injury is a “barnyard injury” and if clostridium perfringens prophylaxis is required, penicillin is added
Tetanus prophylaxis and immunization should be administered to patients who have not been previously immunized

81. Urgent irrigation and debridement (I&D) of the wound in the operating room is mandatory.
For type II and type III injuries, serial I&D is recommended every hours after the initial debridement.
The wound is closed when it is clean.
Antibiotics are generally given for 2 days after final I&D.
Management of the fracture depends on the site of injury and type of open fracture.
If soft tissue coverage is inadequate, soft tissue transfers or free flaps are performed when the wound is clean and the fracture reduced and stabilized definitively.

83. vfdsawrerty

84. Complications of fractures
General complications
Shock
ARDS
Fat embolism
Head, chest, abdomen and pelvic injuries
Crush syndrome
Tetanus
Gas gangrene
Infections – UTI, Chest
DVT/PE
Bed sores
Depression/PTSD

85. Complications of fractures
Early
Visceral injury
Vascular injury
Compartment
syndrome (later
Volkmann conctracture)
Nerve injury
Haemarthrosis
Infection
Late
Delayed union
Non-union
Mal-union
Tendon rupture
Myositis ossificans
Osteonecrosis
Algodystrophy
Osteoarthritis and
joint stiffness

86. Bleeding After Long Bone Fractures
Fx’s cause localized bleeding and this can be substantial resulting in hypovolemic shock
Humerus: cc
Unilateral tibia/fibula: cc
Femur fx: cc

87. Fractures in Children
Not just small adults

88. Children’s bones are different

89. Anatomy Unique to Skeletally Immature Bones
Periosteum
Thicker
More osteogenic
Attached firmly at periphery of physes
Bone
More porous
More ductile

90. Salter Harris Classification
N I II III IV V
S A L T E R:
The fracture line is
I -Same as the growth plate,
II -Above the growth plate,
III -Lower than the growth plate,
IV -Through the growth plate,
V -Epiphyseal crush

92. The power of remodeling
Tremendous power of remodeling
Can accept more angulation and displacement
Rotational mal-alignment ?does not remodel

93. The power of remodeling
Factors affecting remodeling potential
Years of remaining growth – most important factor
Position in the bone – the nearer to physis the better
Plane of motion –
greatest in sagittal, the frontal, and least for transverse plane
Physeal status – if damaged, less potential for correction
Growth potential of adjacent physis
e.g. upper humerus better than lower humerus

94. Indications for operative fixation
Open fractures
Displaced intra articular fractures
( Salter-Harris III-IV )
fractures with vascular injury
? Compartment syndrome
Fractures not reduced by closed reduction
( soft tissue interposition, button-holing of periosteum )
If reduction could be only maintained in an abnormal position

95. Methods of fixation Casting - still the commonest K-wires
most commonly used
Metaphyseal fractures
Intramedullary wires, elastic nails
Very useful
Diaphyseal fractures
Screws
Plates – multiple trauma
IMN - adolescents
Ex-fix
Combination

96. Complications Ma-lunion is not usually a problem
( except cubitus varus )
Non-union is hardly seen
( except in the lateral condyle )
Growth disturbance – epiphyseal damage
Vascular – volkmann’s ischemia
Infection - rare

97. Pathological Fractures
1. Stress fractures
Patient usually healthy
Fracture site often tender and pain
May present with a lump which turns out to be fracture callus
May not be evident on x-ray, only becoming evident as callus begins to form
Most need only avoidance of the aggravating activity

99. Pathological Fractures
2. Abnormal bone
54% are secondary to metastatic disease
5% are due to primary bone tumours
41% are secondary to benign bone conditions
Breast ca leading cause 41% of pathological fracture
Other tumours 43% (kidney, lung, prostate, bowel and thyroid)
Myeloma or lymphoma account for 16%
More than half of the secondary deposits are in the femur

100. Pathologic fracture

101. Thank You