Principles of fractures

A fracture is a break in the

structural continuity of bone.
It may be closed if the skin is
intact or open if the fracture
haematoma connected to the
surface of the skin or one of the
body cavities.
 How fracture happed
❖ trauma (direct or indirect)
❖ repetitive stress.
❖ abnormal weakening of the bone
(pathological).
 Types of fractures:
1. Fractures due to
trauma: Types of
fractures in trauma
depend on the force
applied:
1. Fractures due to trauma: Types
of fractures in trauma depend on
the force applied:
 2. Fatigue or stress fractures:
■ Is the one occurring in the normal bone of a
healthy patient due to repetitive stress rather
than single traumatic evidence.
■ Most common sites affected pubic rami ,
femoral neck , tibial shaft especially in trainee
and athletes , distal fibula , metatarsals
especially the second.
 3. Pathological fractures:

■ When abnormal bone gives way. The causes are

numerous but the diagnosis not made till biopsy
taken.
 Causes:
■ General bone disease
1. osteogenesis imperfecta
2. postmenopausal osteoporosis
3. metabolic bone disease
4. multiple myeloma
5. paget disease
 Local benign conditions
1. chronic infection
2. solitary bone cyst
3. fibrous cortical defect
4. aneurysmal bone cyst
5. chondroma
 Primary malignant tumours
1. chondrosarcoma
2. osteosarcoma
3. Ewing's tumour
Metastatic tumours
■ Carcinoma from breast, lung, thyroid, kidney
….etc
 Clinical features:
History: fracture after trivial trauma, ask about
previous illnesses and operations, malignant
tumours even if old history in the past ,
malabsorption , chronic alcoholism or
prolonged drug therapy suggest metabolic
bone disease.
Weight loss, pain, lump, cough, haematuria.
In younger patients a history of several previous
fractures may suggest osteogenesis imperfecta.
■ Examination: local signs of bone disease
(infected sinus, old scar, swelling or deformity)
General examination Cushing' syndrome, Paget
disease characteristic appearance, the patient
may be wasted, liver or LN enlargement. and
general examination accordingly .
■ XR : midshaft fractures in femur or humerus
in elderly patients , any cyst or loss of
trabeculation any osteolytic lesions….etc
 Investigations:
■ XR of other regions accordingly .
■ Blood investigation: always should include full
blood count, ESR , and according to the disease.
■ Urine examination : for RBCs , Bence – Jones
protein for m. myeloma.
■ Scanning: whole body scan to exclude other
deposits.
■ Biopsy: some times essential for uncertain lesions.
And if open reduction done biopsy can be taken
easily .
 Treatment:
■ Reduce, Hold , Exercise
 Injuries to the physis:
In children over 10 % of fractures involve the physis.
Classification:
Salter and Harris classification
■ Type 1 a transverse fracture across the physis the prognosis is good.
■ Type 2 like type 1 but on one end there is a triangular piece of the
metaphysis the prognosis is good .
■ Type 3 the fracture split the physis than pass transversely across one
side through the physis.
■ Type 4 like type 3 but the splitting cross the physis towards the
metaphysis the prognosis is bad.
■ Type 5 a longitudinal compression injury to the physis the fracture is
not seen at the time of injury but detected retrospectively when its
disturbance to the growth is seen.
■ XR: may need comparison to the other side
to be detected.
■ Treatment: if undisplaced treated by splinting
the limb , for 2 – 4 wks. If displaced gentle
manipulation is important than immobilization
for 3 – 6 wks. If type 3 or 4 can not reduced
accurately open reduction and internal fixation
by smooth k – wire is important .
 Open fractures

Is when the fracture hematoma

connects to the skin or one of the body
.cavities
It usually classified according to
.Gustillo classification
Gastillo classification:
G. 1 :penetrating wound from within(by
spike of bone) less than 1 cm.
G.2: Wound >1cm but Less than 10 cm.
G.3 A: adequate soft tissue coverage.
G.3 B: inadequate soft tissue covering.
G.3 C:neurovascular injuries regardless
the soft tissue covering.
 How fractures are displaced:
■ After complete fracture the bones may
displaced by the effect of gravity or the pull of
the muscles attached.
■ translation (shift)
■ alignment (angulation)
■ rotation (twist)
 How fracture heal
■ Some times Fractures heal even if not
splinted but we splint it for:
1. Alleviate pain
2. To ensure that union takes place in good
position
3. To permit early movement and return of
function.
 Five stages of healing:
1. tissue distraction and haematoma formation.
2. inflammation and cellular proliferation {within 8 hours of
fracture} which bridged the fracture and haematoma slowly
absorbed.
3. callus formation {the thick cellular mass with its island of
immature bone and cartilage forms the callus or splint on the
periosteal and endosteal surfaces.
4. consolidation {osteoblastic and osteoclastic activity the woven
bone transformed to lamellar bone. It may take several months.
5. remodeling thicker lamellae are laid down where stresses are
high unwanted buttresses are carved away, the medullary cavity
is reformed. The bone especially in children reassume
something like its normal shape.
 Fracture healing calendar:

the upper limbs in children in general 3Wks

The lower limbs in children Double the time i.e. 6 wks

The upper limbs in adults Double the time needed in children i.e. 6 wks

The lower limbs in adults Double the time needed in children i.e. 12
wks
 :Clinical features
History:
❖ usually history of injury , followed by inability to use the
injured limb.
❖ The fracture may be away form the site of injury: a blow to
the knee may fracture the patella , the femoral condyles , the
shaft or even the acetabulum.
❖ The patient age and mechanism of injury is important .
❖ If the fracture follow a trivial trauma suspect a pathological
fracture.
❖ Pain , swelling , bruising are common symptoms. Deformity is
more suggestive.
❖ Ask about associated injuries.
❖ General medical and surgical histories are important.
Examination:
General signs:
❖ A,B,C . cervical spines injuries should be excluded.
And general survey.
Local signs:
❖ Crepitus or abnormal movement may be noted.
❖ Examine the most obvious injured part.
❖ Test for artery and nerve damage.
❖ Look for associated injuries in the region.
❖ Look for associated injuries in distal parts.
Look : swelling , bruising and deformity , is the
skin intact is it broken and the wound
communicate with fracture the injury is then open
or compound.
Feel : the injured part is gently palpated for
localized tenderness. Check for distal pulse and
nerve function.
Move : crepitus and abnormal movement is
tested.
 X – Ray

The rule of two:

Two views the fracture may not be seen in single view (anteroposterior
and lateral views are important)
Two joints in the leg or forearm the bone may be fractured and angulated,
angulation may associated with fracture of the other bone or dislocation so
the joint above and below should be taken.
Two limbs as in children where comparism of the shape of the immature
epiphysis on each side is important.
Two injuries sever injury cause injuries in more than one level. So in
fracture of the calcanium or femur it is important to XR the pelvis and
spine.
Two occasions some fractures not seen at the time of injury but only one
or two weeks later as in fracture scaphoid or stress fractures.
 Special imaging
Some times the fracture not seen in usual XR so
do:
❖ CT

❖ MRI may be the only way to show whether the

fractured vertebra compress the spinal cord.
❖ Radioisotope scan is helpful in stress fractures.
 :Treatment of closed fractures
Three important rules:
reduce
hold
exercise
generally the healing of the fracture depends on the state of the
surrounding soft tissues and the local blood supply, a
transverse fracture is slow to join because the area of contact
is small; it the broken surfaces are accurately apposed, the
fracture is stable on compression. A spiral fracture joins more
rapidly because the contact area is larger; but not stable on
compression. Comminuted fractures are often slow to join
because they associated with more sever soft-tissue damage
and because they are unstable.
 Reduce:
■ Reduction should aim for adequate apposition and
normal alignment of the bone fragments. The greater
the contact surface area between the fragments the
more likely the healing to occur. So gap lead to delay
union or non union. If the alignment is good some
overlap at the fracture surfaces is permissible. This
rule is not true for the fractures involve the articular
surfaces otherwise early osteoarthritis occur due to
the irregularity of the joint surface.
■ There are two methods of reduction:
 closed reduction: under proper anesthesia and muscle
relaxation the fracture reduced by 1. the distal part
of the bone is pulled in line of the bone 2. as the
fragments disengaged ,they are repositioned
open reduction: by operation
indications:
1. failure of closed reduction
2. displaced articular fractures which need accurate
reduction.
3. for traction fractures where the fragments are hold
apart.
 Hold
Immobilization is performed by:
1. continuous traction
2. cast splintage
3. functional brace
4. internal fixation
5. external fixation
 continious traction
the problem with traction that it does not maintain
accurate reduction and the patient remain in bed for
long period. Two types of traction:
1. skin traction: for pull not more than 5 kg using
adhesive straps
2. skeletal traction: by pin inserted in the bone distal
to the fracture , this when high weight is needed.
Complication of traction:
1. circulatory embarrasement. Especially in children.
2. nerve injury . in older people, drop foot may
happen
3. pin-site infection.
 Cast splintage:
■ Plaster of Paris (POP) is a common method of
fixation of fractures after reduction rotation of
the fracture shaft can be prevented by
including the joint above and the joint below,
in the children and fracture of the distal parts
of the extremities it is very useful. The patient
can leave the bed early in LL fractures using of
crutches allow ambulation.
 Complications:
1. stiffness of the joints 'fracture disease' this avoided by avoiding long
unnecessary splintage and early physiotherapy.
2. tight cast this either because the cast applied tight, or the limb swells. The
patient complain from diffuse pain, or some time compartment syndrome
may happens. If this complication happen the limb should be elevated and
the cast open 1.through out its length and 2. through all the padding down
to the skin.
3. pressure sores usually over the bony promenances , the patient complain
from localized pain precisely over the pressure spot. This should inspected
immediately. The bony promeninces should be well padded to prevent
this.
4. skin abrasion or laceration this usually during removal so should be
careful.
5. lose cast this after swelling subside, so should be replaced.
 Functional bracing
Using POP or plastic materials, it prevents joint
stiffness, segments of cast are applied over the
shaft of the bones leaving the joints free, the
cast segments are connected by metal or
plastic hinges which allow movement in one
plane. Since the brace is not rigid, it applied
only when the fracture is beginning to unite.
 Internal fixation
Bone fragments can be fixed by screws,
transfixing pins , or nails , plate and screws ,
intramedullary nail, circumferential bands or
combination.
Advantages:
1. hold fractures securely so allow early
movement and prevent stiffness, and edema.
2. allow early leaving of hospital.
3. accurate reduction as in intraarticular
fractures.
 Indications:
1. failure of closed method.
2. unstable fractures which are likely to displaced, as in
ankle fractures , or those liable to muscle pull as in
transverse patellar fracture or olecranon.
3. fractures that unite poorly or slowly as in fracture neck
femur.
4. pathological fractures.
5. multiple fractures.
6. in patient with nursing difficulties as in paraplegics ,
and multiple injuries.
 Complications:
1. Infection : due to poor technique or poor equipment ,
or poor tissue conditions.
2. Non – union: if the bone ends fixed rigidly with a gap
between the ends, or in stripping of the soft tissues.
3. Implant failure: so the patient should walk with
crutches and weight bearing should allowed gradually
after the fracture heals.
4. Refracture if the implant removed too soon and care
should be taken after removal.
 External fixation:
The bone is transfixed below and above the fracture by screws or
pins or tensioned wires and these connected to each other by
rigid bars.
Indications:
1. Fractures associated with sever soft tissue damage. So it
makes dressing easier.
2. Fractures associated with sever nerve or vessels damage.
3. Severely comminuted and unstable fractures.
4. Ununited fractures which can be excised and compressed ,
and some times combined with bone elongation.
5. Pelvic fractures if cannot controlled by other methods.
6. Infected fractures.
7. Sever multiple injuries.
 Complications
1. Damage to soft – tissue structures if the
transfixing pins injure the nerves or vessels.
Or may tether ligaments or muscles.
2. Over distraction
3. Pin – tract infection.
 Exercise
This important after any fracture because:
1. prevention of oedema. This by muscle
exercises and elevation.
2. active exercises which pumps the edema
away prevents adhesion of soft tissues, and
help fracture healing, and prevent muscle
atrophy.
3. assisted movement this by special machines.
FRACTURES BELOW THE
ELBOW
Radial head , Mason classification
Olecranon Fracture , Mayo Classification
Monteggia Fracture . Bado classification
Galleazzi Fracture
Distal Radius Fractures
Scaphoid
Boxer fracture