FRACTURE AND ITS

MANAGEMENT
DR EMMANUEL PAPA KWADWO ACQUAH
SPECIALIST SURGEON
MBCHB, MGCS
 OUTLINE
• INTRODUCTION
• ETIOLOGY
• CLASSIFICATION
• DIAGNOSIS
• MANAGEMENT
• COMPLICATIONS
• QUESTIONS
 INTRODUCTION
DEFINITION

• A fracture is a soft tissue trauma with a resultant break in the

structural continuity of bone.
 INTRODUCTION

• Can be part of any high-energy mechanism (MVC, fall)

• Spinal and/or visceral injuries may coexist.

• In ED setting, goal is to quickly diagnose or rule out life or limb threatening

injuries
 ETIOLOGY
• Fractures are caused by
1. Injury;

2. Repetitive stress; or

3. Abnormal weakening of the bone (a ‘pathological’ fracture).

 FRACTURES DUE TO INJURY
• Most fractures are caused by sudden and excessive force
(overloading),
• The force may be:
1. Direct Or
2. Indirect.
 FATIGUE OR STRESS FRACTURES
• These fractures occur in Normal Bone which is subjected to repeated
heavy loading,
• Typically in athletes, dancers or military personnel who have gruelling
exercise programmes .
• A similar problem exists in individuals who are on medication that
alters the normal balance of bone resorption and replacement;
 PATHOLOGICAL FRACTURES
• Fractures occurring in an Already Weakened/Diseased Bone.
• Occurs from low energy forces/stress
• Disease that create the weakeness include:
1. osteoporosis,
2. osteogenesis imperfecta or
3. Paget’s disease,
4. bisphosphonate therapy
5. lytic lesion (e.g. a bone cyst
6. Primary or secondary bone tumor
 CLASSIFICATION OF FRACTURES
• BASED ON:
1. INTEGRITY OF SKIN
2. LOCATION
3. FRACTURE PATTERN
4. EXTENT OF FRACTURE LINE
 BASED ON INTEGRITY OF SKIN/SOFT TISSUE
1. Simple or Closed
The overlying skin/soft tissue remains intact.

2. Compound or Open
• The fracture and its hematoma communicates with a break in the
skin/soft tissue or one of the body cavities.
• Any wound within the proximity of the fracture makes it opened #
until proven otherwise.
• Liable to contamination and infection
BASED ON INTEGRITY OF SKIN/SOFT TISSUE
• Closed • Open
GUSTILO-ANDERSON classification of open fracture
Gustilo-Anderson classification
1
3A
2

3C
3B
 BASED ON FRACTURE LOCATION

• Each long bone has three segments – Proximal, Diaphyseal And

Distal;

• Diaphyseal fractures may be simple, wedge or complex

• Proximal and distal fractures may be extra-articular, partial articular

or complete articular.
 BASED ON FRACTURE PATTERN

1. Linear fractures- Transverse, oblique, spiral

2. Comminuted Fractures.

3. Segmental fractures
 BASED ON EXTENT OF FRACTURE LINE:
1. INCOMPLETE FRACTURE
• The bone is split into two or more fragments.
• Eg transverse, impacted, comminuted #

2. COMPLETE FRACTURE – DISPLACED, UNDISPLACED

• The bone is incompletely divided and the periosteum remains in
continuity..
• Eg: greenstick, torus/buckle#
DIAGNOSIS
HISTORY
1. DEMOGRAPHICS: NASOMRA
2. Initial trauma followed by
3. COMPLAINTS: Deformity, pain, swelling, erythema, loss of function,
bleeding, stiffness, weakness
4. Mechanism of injury:
• MVC; pedestrian-automobile impact; Falls; Gunshots;
5. Duration of injury
6. Location of injury
7. Don’t forget about: pathological and stress fractures
 HISTORY

• Other injuries: LOC, breathing difficulties, blood in urine, numbness or

loss of movement.
Do not be distracted by obvious only

• Complications: compartment syndrome

• Previous injuries/other MS abnormalities: create confusion on x-rays.

 Physical Examination

• Follow the ATLS protocol

• Start with PRIMARY SURVERY : ABCDE –look for life-threatening injuries.

• Continue with SECONDARY SURVERY only done after patient is

hemodynamically stable.

• Reassessment.
 STATUS LOCALIS

• Examine the most obviously injured part + overlying soft tissue state
• Test for artery and nerve damage
• Look for associated injuries in the region
• Look for associated injuries in distant parts
• DOCUMENTATION of all injuries important
• CLINCAL PHOTOGRAPHY for all injuries esp. Open fractures
 LOOK
• For swelling, bruising and deformity
• Examine whether the skin/overlying soft tissue is intact.
• Grade any open wounds according to Gustilo-Anderson systems.
• Note also the posture of the distal extremity and the colour of the
skin
• Rule out Compartment syndrome (6P’s)
 FEEL

• The entire limb + joints above and below (ROM) the injury is gently palpated for

localized tenderness, effusions and crepitus.

• The common and characteristic associated injuries should also be felt for, even if the

patient does not complain of them (eg scaphoid, spine)

• Vascular and peripheral nerve abnormalities should be tested for both before and

after treatment.
 MOVE

• Crepitus and abnormal movement may be present

• More important to ascertain if the patient can move the joints distal

to the injury.

• Why inflict pain when x-rays are available?

 X-RAY INVESTIGATION
• X-ray examination is mandatory.
• Remember the ‘rule of twos’
• Two views
• Two joints
• Two limbs
• Two injuries
• Two occasions
• Two observers
 DESCRIPTION OF XRAY- 5A’s

1. Anatomy (eg, proximal tibia)

2. Articular (eg, intra- vs extra-articular)

3. Alignment/shortening (eg, first plane)

4. Angulation (eg, second plane): varus/valgus

5. Apposition/displacement (eg, 75% or 0%)

6. fragmentations : simple or multifragmentary

 Special Joint-specific radiographs other than
AP, lateral, or oblique images:
• Cervical spine – Odontoid view
• Spine instability – Flexion and extension
• Shoulder – Axillary
• Clavicle – AP in 30° cephalic tilt
• Scapula – Y view
• Glenohumeral joint – Axillary (Because of pain from the fracture, the surgeon
ordering these views may need to supervise the imaging examination.)
• Acromioclavicular joint – No stress views required
• Radial head – 45° Lateral
• Comminuted elbow - traction views (the surgeon will likely need to provide the
traction)
 Special Joint-specific radiographs other than
AP, lateral, or oblique images:
• Scaphoid – Posteroanterior (PA) in ulnar deviation
• Pelvis – Inlet and outlet
• Acetabulum – Iliac oblique, obturator oblique (Judet views)
• Femoral neck – AP view with 15° internal rotation [35]
• Knee joint – Notch view and/or Merchant view
• Ankle joint – Mortise view
• Calcaneus – Broden views
• Talus – Canale view
SPECIAL IMAGING

1. CT-scan : spine, complex fracture, difficult sites (acetabulum)

2. MRI: cord compression from a fractured vertebra

3. Radioisotope scanning: for suspected stress(fatigue) fracture/

undisplaced fracture.

4. USG: for children

 Tests that can be performed preoperatively
but are not mandatory are as follows:
1. Complete blood count (CBC)
2. Electrolyte, creatinine, and glucose levels
3. Urinalysis
4. Coagulation studies, including measurement of the activated partial
thromboplastin time (aPTT) and international normalized ratio (INR)
5. Cross-matching and typing of the patient's blood
6. Alcohol and toxicology screening
MANAGEMENT PRINCIPLES

Treat the whole patient, not only the fracture (X-RAY)

TREAT BOTH SOFT TISSUE AND THE BONE EQUALLY.

 MANAGEMENT PRINCIPLES
• Identification and treatment of life threating conditions
• Identification and treatment of limb threating conditions
• Definitive fracture management :
Conservative
Surgical
• Prevention and Treatment of complications
• Rehabilitation
LIFE THREATENING CONDITIONS
• HEAD & NECK
• CHEST
• ABDOMEN
• PELVIS
• massive long bone injuries (high risk of fat emboli)
• vascular injury proximal to knee and/or elbow
• traumatic amputations
 LIMB-THREATENING CONDITIONS
1. Compartment syndrome
2. Open fractures
3. Knee dislocation
4. Fracture proximal to knee and/or elbow
5. Crush injuries
6. Fracture/dislocation of ankle
 DEFINITIVE TREATMENT PRINCIPLE
• Initial management involves the following (RICE)
Reduction
Immobilization
Cold compression
Elevation
DVT prophylaxis
• Definitive fracture treatment may either be Surgical Or Conservative
REDUCTION OF FRACTURE

• Reduction means the restoration of the normal anatomical

aligment of fragments in fractures.

• This procedure should be painless and with relaxed muscles

obtained by anaesthesia.
 CONSERVATIVE TREATMENT
• Can be CLOSED OR OPEN
CLOSED REDUCTION
• traction applied in long axis of limb to reverse mechanism that produced fracture
• this fatigues the contracted muscles so that proper alignment can be achieved
• intravenous sedation and muscle relaxation used
OPEN REDUCTION
• used if closed reduction fails, cast or traction cannot be applied due to site (e.g.,
hip)
• used if fracture is pathologic (endocrinological, oncological)
• used in open fractures
• Close reduction • Opened reduction
 MAINTENANCE OF REDUCTION
(IMMOBILIZATION)
• Reduction is maintained via external or internal stabilization
1. External stabilization
• splints, paster casts, traction, external fixator
OPERATIVE TREATMENT OF FRACTURES
OPENED FRACTURE – INITIAL MANAGEMENT
While contacting the orthopedic team for definitive surgical tx:
• Rule out life threatening injuries
• Identify and treat LIMB threatening injuries
• Emergency room management of Status localis:
1. Infection prevention
i. Antibiotics : asap
• first-generation cephalosporins for gram-positives
• vancomycin if MRSA positive
• aminoglycosides for gram-negatives
• penicillin added if soil-contaminated for Clostridium perfringens

ii. Tetanus prophylaxis: as needed - ATS/T.T

iii. Gross debris removal
 OPENED FRACTURE – INITIAL MANAGEMENT
iv. Local Irrigation with saline/clean tap water (1-2L)
v. Clinical Photography
vi. Sterile compressive wound dressing (impermeable film cover)

2. Pain Control:
• Realign and splint (temporal)
• Analgesics
• Nerve blocks
• Hematoma blocks

Recheck pulse, motor and sensation before and after your

intervention
 PHYSIOTHERAPY AND REHABILITATION

• Rehabilitation starts from pre-op through intra-op to the post-op

period

• Restores the patient as close to pre-injury functional level as possible

• REST, ELEVATION, MOBILIZATION (active/passive)

• Work assessment and re-employment

 REFERENCES

1. MEDBULLET; Orthopedic Trauma-Updated: 12/28/2021

2. MEDSCAPE; General Principles of Fracture Care Treatment &

Management- Updated: Mar 18, 2020

3. APLEY & SOLOMON’S - principles of fractures chapter 23

4. Slideshare