PRINCIPLES OF

FRACTURES
PRINCIPLES OF FRACTURES
A)DEFINITION
A fracture is a break in the structural continuity of a bone leading to loss of structural integrity.

B)TYPES OF BONE
I)Normal bone
II)Growing bone (or adolescent bone)
III)Cortical versus cancellous bone
Most bone in adults, compact or cancellous, is organized as lamellar bone, characterized by
multiple layers or lamellae of calcified matrix, each 3-7 μm thick. The lamellae are organized as
parallel sheets or concentrically around a central canal.
Compact (cortical) bone, which represents 80% of the total bone mass, is the dense outer surface
of bone beneath periosteum that forms a protective layer around the internal marrow cavity.
Cancellous (trabecular) bone, constituting about 20% of total bone mass, is the meshwork of
spongy tissue (trabeculae) of mature adult bone typically found at the core of vertebral bones in
the spine and the ends of the long bones (such as the femur). It is covered by endosteum and lies
adjacent to medullary/marrow cavities.
IV)Pathological bone
C)TYPES OF FRACTURES
I)PEDIATRIC FRACTURES
ANATOMY OF PEDIATRIC BONE
Pediatric long bones can be divided into the following regions: epiphysis, physis, metaphysis,
and diaphysis.

1.Epiphysis
The epiphysis is the region of a long bone between the end of the bone and the growth plate (or
physis). They are composed of cancellous bone covered by a thin layer of compact cortical bone.
At birth, the end of the bones is completely cartilaginous (except for the distal femur), and
termed a chondroepiphysis. Subsequently the epiphysis differentiates into three histologically
distinct regions. These are:
(i) the cartilage at the outermost boundary of the epiphysis adjacent to the joint space
that is the articular cartilage,
(ii) the cartilage adjacent to the metaphysis that forms the physis (growth plate,
epiphyseal growth plate), and
 (iii) the cartilage between the articular cartilage and the physeal cartilage referred to as the
epiphyseal cartilage, which will form a secondary ossification center after vascular
and osteoprogenitor cell invasion.

The histologic structure of the epiphysis of the proximal tibia is illustrated. The entire developing
end of the bone from the articular cartilage surface to the last cells of the hypertrophic zone of
the growth plate is the epiphysis (E). This encompasses 3 regions that are initially cartilage: (a)
the articular cartilage (AC), (b) the growth plate (GP), also referred to as the epiphyseal growth
plate or the physis and (c) the epiphyseal cartilage (EC) which refers to the cartilage mass
between the articular cartilage and the growth plate cartilage. It is within the epiphyseal cartilage
that the secondary ossification center (SOC), also referred to as the bony nucleus, the ossific
nucleus, or the bony epiphysis, forms and expands.
Note:
The epiphysis is sometimes referred to as the chondroepiphysis, but use of this term should be
restricted to the time prior to formation of the secondary ossification center.
2.Physis
The physis, or growth plate, is located between the cartilaginous epiphysis and the newly
generated bone in the metaphysis, is responsible for longitudinal bone growth.
The perichondrium is a layer of dense connective tissue which surrounds the growth plate.
3.Metaphysis
The metaphysis is the flared portion of the bone that lies between the lower part of the physis and
each end of the diaphysis.
4.Diaphysis
The diaphysis or shaft constitutes the major portion of each long bone, and is formed from bone
remodeled from the metaphysis. Mature, lamellar bone is the dominant feature of the diaphyseal
bone, and the developing diaphyseal bone is extremely vascular. The diaphysis is almost totally
dense compact bone, with a thin region of cancellous bone on the inner surface around the
central marrow cavity
Periosteum & Endosteum
The periosteum is organized much like the perichondrium of cartilage, with an outer fibrous
layer of dense connective tissue, containing mostly bundled type I collagen, but also fibroblasts
and blood vessels. The periosteum’s inner layer is more cellular and includes osteoblasts, bone
lining cells, and mesenchymal stem cells referred to as osteoprogenitor cells.
Internally the very thin endosteum covers small trabeculae of bony matrix that project into the
marrow cavities. The endosteum also contains osteoprogenitor cells, osteoblasts, and bone lining
cells, but within a sparse, delicate matrix of collagen fibers.
Apophysis
The apophysis is a normal secondary ossification center that is located in the non-weight-
bearing part of the bone and eventually fuses with it over time. The apophysis is a site of tendon
or ligament attachment, as compared to the epiphysis which contributes to a joint, and for that
reason, it is also called 'traction epiphysis'.

OVERVIEW OF BONE GROWTH

Ossification, or osteogenesis, is the process of bone formation by osteoblasts. Ossification
begins approximately six weeks after fertilization in an embryo. Before this time, the embryonic
skeleton consists entirely of fibrous membranes and hyaline cartilage. Bone growth continues
until approximately age 25. Bones can grow in thickness throughout life, but after age 25,
ossification functions primarily in bone remodeling and repair.
Bone development or osteogenesis occurs by one of two processes:
 Intramembranous ossification
 Endochondral ossification
Intramembranous Ossification
This process involves the direct conversion of mesenchyme to the bone. It is involved in the
formation of the flat bones of the skull, the mandible, and the clavicles.
Five steps can summarize intramembranous ossification:
1. Mesenchymal cells differentiate into osteoblasts and group into ossification centers
 2. Osteoblasts become entrapped by the osteoid they secrete, transforming them to
osteocytes
3. Trabecular bone and periosteum form
4. Cortical bone forms superficially to the trabecular bone
5. Blood vessels form the red marrow
Endochondral Ossification
This process involves the replacement of hyaline cartilage with bone. All of the bones of the
body, except for the flat bones of the skull, mandible, and clavicles, are formed through
endochondral ossification. The process is especially well studied in developing long bones.
While bone is replacing cartilage in the diaphysis, cartilage continues to proliferate at the ends of
the bone, increasing bone length. These proliferative areas become the epiphyseal plates (physeal
plates/growth plates), which provide longitudinal growth of bones after birth and into early
adulthood. After birth, this entire process repeats itself in the epiphyseal region; this is where the
secondary ossification center forms.
An epiphyseal growth plate shows distinct regions of cellular activity and is often discussed in
terms of overlapping but histologically distinct zones, beginning with the zone most distal to the
diaphyseal center of ossification and proceeding toward that center, which are as follows:
1.The zone of reserve cartilage exhibits no cellular proliferation or active matrix production.
2. In the proliferative zone, the cartilage cells divide repeatedly, enlarge and secrete more type
II collagen and proteoglycans, and become organized into columns parallel to the long axis of the
bone.
3. The zone of hypertrophy contains swollen, terminally differentiated chondrocytes which
compress the matrix into aligned spicules and stiffen it by secretion of type X collagen. Unique
to the hypertrophic chondrocytes in developing (or fractured) bone, type X collagen limits
diffusion in the matrix and with growth factors promotes vascularization from the adjacent
primary ossification center.
4. In the zone of calcified cartilage chondrocytes about to undergo apoptosis release matrix
vesicles and osteocalcin to begin matrix calcification by the formation of hydroxyapatite crystals.
5. In the zone of ossification bone tissue first appears. Capillaries and osteoprogenitor cells
invade the now vacant chondrocytic lacunae, many of which merge to form the initial marrow
cavity. Osteoblasts settle in a layer over the spicules of calcified cartilage matrix and secrete
osteoid which becomes woven bone.
Note:
Woven bone is nonlamellar and characterized by random disposition of type I collagen fibers and
is the first bone tissue to appear in embryonic development and in fracture repair. Woven bone is
usually temporary and is replaced in adults by lamellar bone, except in a very few places in the
body, for example, near the sutures of the calvaria and in the insertions of some tendons.
Five steps can summarize endochondral ossification:
1. Mesenchymal cells differentiate into chondrocytes and form the cartilage model for bone
2. Chondrocytes near the center of the cartilage model undergo hypertrophy and alter the
contents of the matrix they secrete, enabling mineralization
3. Chondrocytes undergo apoptosis due to decreased nutrient availability; blood vessels
invade and bring osteogenic cells
4. Primary ossification center forms in the diaphyseal region of the periosteum called the
periosteal collar
5. Secondary ossification centers develop in the epiphyseal region after birth

TYPES OF PEDIATRIC FRACTURES

Fractures in long bone
a)Greenstick fracture
Is an incomplete fracture
Occurs in children, especially before the age of 10 years, whose bones are springy and resilient
like the branches of a young tree
Results from an angulation force applied to one side of the periosteum. The disruption of one
cortex occurs while the other is bent.
b) Buckle/Torus fracture
Is an incomplete fracture
A torus fracture results from a compressive force acting on the metaphysis of the bone, which is
a point of decreased strength
(A torus is commonly the lowest molding at the base of a column)
c) Plastic deformation
Children can also sustain injuries where the bone is plastically deformed (misshapen) without
there being any crack visible on the x-ray.
Salter Harris Fractures
These are fractures of the epiphyseal plate also known as the growth plate or physis of long
bones.
Only arise in children and adolescents whose skeletal growth is not yet complete
Most of these injuries occur during the time of a child's growth spurt when physis are the
weakest. Active children are the most likely to encounter injuries involving the growth plate as
the ligaments and joint capsules surrounding the growth plate tend to be much stronger and more
stable. The ligaments and capsules are thereby able to sustain greater external loads to the joint,
relative to the growth plate itself.
The Salter-Harris classification system grades fractures according to the involvement of the
physis, metaphysis, and epiphysis:
Type 1
Fracture through the physis or growth plate which splits the epiphysis from the metaphysis.
This is a transverse fracture through the hypertrophic or calcified zone of the plate. Even if the
fracture is quite alarmingly displaced, the growing zone of the physis is usually not injured and
growth disturbance is uncommon.
Usually occurs in infants but is also seen at puberty as a slipped femoral epiphysis
Type 2
Fracture extends through both the physis and metaphysis resulting in epiphyseal injury and
metaphyseal fragment
This is essentially similar to type 1, but towards the edge the fracture deviates away from the
physis and splits off a triangular metaphyseal fragment of bone (sometimes referred to as the
Thurston–Holland fragment).
Is the commonest. It occurs in older children and seldom results in abnormal growth.
Type 3
An intra-articular fracture of the epiphysis (Splits the epiphysis and then veers off transversely
to one or the other side, through the physis)
This is a fracture that splits the epiphysis and then veers off transversely to one or the other side,
through the hypertrophic layer of the physis. Inevitably it damages the ‘reproductive’ layers of
the physis (as these layers are closer to the epiphysis than the metaphysis) and may result in
growth disturbance.
Needs accurate reduction to restore the joint surface
Type 4
Fracture passes through the epiphysis, physis, and metaphysis
As with type 3, the fracture splits the epiphysis, but it extends into the metaphysis. These
fractures are liable to displacement and a consequent misfit between the separated parts of the
physis, resulting in asymmetrical growth.
(Splitting of the physis and epiphysis. Damages the articular surface and may also cause
abnormal growth; if it is displaced it needs open reduction.)
Type 5
Compression injury or crushing of the growth plate.
This is a longitudinal compression injury of the physis. There is no visible fracture but the
growth plate is crushed and this may result in growth arrest.
II)ADULT FRACTURES
ETIOLOGY OF FRACTURES
Fractures result from:
 Injury
 Repetitive stress
 Abnormal weakening of the bone
A)Traumatic fractures
Most fractures are caused by sudden and excessive force, which may be direct or indirect.
With a direct force:
 The bone breaks at the point of impact; the soft tissues also are damaged.
 A direct blow usually splits the bone transversely or may bend it over a fulcrum so as to
create a break with a ‘butterfly’ fragment.
 Damage to the overlying skin is common.
 If crushing occurs, the fracture pattern will be comminuted with extensive soft-tissue
damage.
With an indirect force:
 The bone breaks at a distance from where the force is applied; soft-tissue damage at the
fracture site is not inevitable.
Radiological patterns of normal bone fractures
1. Transverse: Tension tends to break the bone transversely
2. Oblique: Compression causes a short oblique fracture
3. Comminuted
4. Spiral: Twisting causes a spiral fracture
5. Segmental

B)Fatigue or Stress fractures

These fractures occur in normal bone which is subject to repeated heavy loading
Typically in athletes, dancers or military personnel who have gruelling exercise programmes.
These high loads create minute deformations that initiate the normal process of remodelling – a
combination of bone resorption and new bone formation in accordance with Wolff’s law. When
exposure to stress and deformation is repeated and prolonged, resorption occurs faster than
replacement and leaves the area liable to fracture.
A similar problem occurs in individuals who are on medication that alters the normal balance of
bone resorption and replacement; stress fractures are increasingly seen in patients with chronic
inflammatory diseases who are on treatment with steroids or methotrexate.
Examples (in order of frequency);
 March fracture of the 2nd & 3rd metatarsal heads
 Mid & Distal Tibia & Fibula fractures in long distance runners & dancers
 Neck of femur
 Fractures of the pubic rami in severely osteoporotic or osteomalacic patients
Detected early by Scintigraphy or MRI as radiographic changes appear after 2-4wks

C)Pathological fractures
Fractures may occur even with normal stresses if the bone has been weakened by a change in its
structure (e.g. in osteoporosis, osteogenesis imperfecta or Paget’s disease) or through a lytic
lesion (e.g. a bone cyst or a metastasis).
 The term osteopenia refers to decreased bone mass, while osteoporosis is defined as
osteopenia that is severe enough to significantly increase the risk of fracture.
 Osteogenesis imperfecta (OI), the most common inherited disorder of connective tissue,
usually results from autosomal dominant mutations in the genes that encode the α1 and
α2 chains of type I collagen. OI principally affects bone and other tissues rich in type I
collagen (joints, eyes, ears, skin, and teeth). The fundamental abnormality in OI is too
little bone, resulting in extreme skeletal fragility. Other findings include blue sclerae
caused by decreased collagen content, making the sclera translucent and allowing partial
visualization of the underlying choroid; hearing loss related to a sensorineural deficit and
impeded conduction due to abnormalities in the bones of the middle ear; and dental
imperfections (small, misshapen, and blue-yellow teeth) secondary to a deficiency in
dentin.
 Paget disease of bone (Osteitis deformans) is a skeletal growth disorder in which
abnormalities such as unusual bone growth can occur in several multifactoral ways. This
is often manifested by diffuse pain throughout the musculoskeletal system. The condition
presents with excess osteoclastic activity followed by a compensatory increase in
osteoblastic activity, leading to the formation of disorganized bone, which is less
compact, mechanically weaker, highly vascular and more susceptible to fracture.
Fortunately, more than 3/4 of patients with Paget disease are asymptomatic. It is the 2nd
most common bone disorder in elderly individuals, after osteoporosis. The condition can
affect one or multiple bones but the axial skeleton is most often involved (spine, pelvis,
and skull). The condition does not spread to other bones but can progress in the
preexisting site.
CAUSES OF PATHOLOGICAL FRACTURES
I)Localized Bone Disease

II)Generalized Bone Disease

MORPHOLOGY OF FRACTURES
Complete fractures
The bone is split into two or more fragments.
The fracture pattern on x-ray can help predict behaviour after reduction:
 In a transverse fracture the fragments usually remain in place after reduction;
 If it is oblique or spiral, they tend to shorten and re-displace even if the bone is
splinted.
 In an impacted fracture the fragments are jammed tightly together and the fracture
line is indistinct.
 A comminuted fracture is one in which there are more than two fragments; because
there is poor interlocking of the fracture surfaces, these are often unstable.
Incomplete fractures
Here the bone is incompletely divided and the periosteum remains in continuity.
 In a greenstick fracture the bone is buckled or bent (like snapping a green twig); this
is seen in children, whose bones are more springy than those of adults. Children can
also sustain injuries where the bone is plastically deformed (misshapen) without there
being any crack visible on the x-ray.
 In contrast, compression fractures occur when cancellous bone is crumpled. This
happens in adults and typically where this type of bone structure is present, e.g. in the
vertebral bodies, calcaneum and tibial plateau
TYPES OF FRACTURE (BASED ON FRACTURE COMMUNICATION WITH THE
ENVIRONMENT)
CLOSED (OR SIMPLE) FRACTURE
If the overlying skin remains intact it is a closed (or simple) fracture
Closed fractures are further classified using the Ostern and Tscherne system:
GRADE DESCRIPTION
0 Indirect injury to limb
Negligible soft tissue damage

1 Simple fracture pattern

Superficial abrasion or contusion

2 Direct trauma to limb

Severe fracture pattern
Deep abrasions
Muscle/skin contusion
Impending compartment syndrome

3 Severe damage to underlying muscle

Crushed skin
Extensive skin contusion
Subcutaneous degloving
Acute compartment syndrome
Rupture of a major blood vessel or nerve

Abrasion is the superficial denudation of the epithelium due to scraping, impact, or pressure.
A contusion (also called bruise) is any mechanical injury (usually caused by a blow) resulting in
hemorrhage beneath unbroken skin
A degloving injury is a traumatic injury that results in the skin and subcutaneous tissue being
torn away from the underlying muscle, connective tissue or bone, thereby depleting its blood
supply and increasing the risk of tissue necrosis.

OPEN (OR COMPOUND) FRACTURE

If the skin or one of the body cavities is breached it is an open (or compound) fracture, liable to
contamination and infection.
Open fractures are further classified using the Gustillo-Anderson system which is based on:
 Mechanism of injury
  Size of wound
 Presence or absence of associated injuries
 Degree of soft tissue injury/contamination

CHARACTERISTIC I II IIIa IIIb IIIc

Energy Low Moderate High High High

Mechanism Inside-out Outside in Outside in Outside in Outside in

Wound size < 2cm 2-10 cm > 10 cm > 10 cm > 10 cm

Soft tissue damage Minimal Moderate Extensive Extensive Extensive

Contamination Clean Moderate Extensive Extensive Extensive

Fracture pattern Simple Moderate Segmental or Segmental or Segmental or

Minimal comminution highly highly highly
comminution comminuted comminuted comminuted

Periosteal stripping No Some* Yes Yes Yes

Coverage Local (Bone Local(Bone Local(Bone Requires a local Typically

coverage with coverage with coverage with flap or free flap requires flap
existing soft existing soft existing soft for bone coverage
tissue) tissue) tissue) coverage and
soft tissue
closure
(Proximal-
gastrocnemius
rotational flap
Middle- soleus
rotational flap
Distal-free flap)

Neurovascular injury None None None None Yes

that requires surgical
exploration

Infection rate 0-2 % 2-7% 10-25 % 10-50% 25-50%

Antibiotics* 1st gen 1st gen 1st gen 1st gen 1st gen
cephalosporin cephalosporin cephalosporin + cephalosporin + cephalosporin +
aminoglycoside aminoglycoside aminoglycoside
NOTE:
1.)According to Prof :Type IIIC fractures have 3 distinct features:
 Neurovascular injury that requires surgical exploration
 All gunshot wounds
 Segmental fracture pattern
2.)Type 3 fracture is usually a high energy injury. This type of injury results typically from high-
velocity gun shots, motorcycle accidents, or injuries with contamination from outdoor sites such
as with tornado disasters or farming accidents.
 Type 3A fractures do not require major reconstructive surgery to provide skin coverage.
 Type 3B fractures, in contrast, usually require reconstructive procedures because of soft
tissue defects that provide either poor coverage for bone or no coverage.
 Type 3C injuries involve vascular compromise requiring surgical repair or reconstruction.
3.)Examples of first-generation cephalosporins include:
 cephalexin (Keflex)
 cefadroxil (Duricef)
 cephradine (Velosef)
 cephazolin (ancef)
4.)The aminoglycosides include:
 Gentamicin
 Amikacin
 Tobramycin
 Neomycin
 Streptomycin

Note: Special considerations in Antibiotic administration

 Penicillin should be added if concern for anaerobic organism (farm injury)
 Flouroquinolones (e.g. ciprofloxacin) should be used for fresh water wounds or salt water
wounds (can be used if allergic to cephalosporins or clindamycin)
 Doxycycline and 3rd or 4th-generation cephalosporin (e.g. ceftazidime) can be used for
salt water wounds
CLASSIFICATION OF FRACTURES
1.)OTA(ORTHOPAEDIC TRAUMA ASSOCIATION) /AO CLASSIFICATION
In this system:
1.The first digit specifies the bone:
1 = humerus
2 = radius/ulna
3 = femur
4 = tibia/fibula
5 = Spine
6 = Pelvis/acetabulum
7 = Hand
8 = Foot
9 = Craniomaxillofacial
2.The second digit specifies the segment:
1 = proximal
2 = diaphyseal
3 = distal
4 = malleolar (only used with tibia and fibula)
3.A letter specifies the fracture pattern:
i)For the diaphysis:
A = simple
B = wedge
C = complex
ii)For the metaphysis:
A = extra-articular
B = partial articular
C = complete articular
4.Two further numbers specify the detailed morphology of the fracture:
i)For the diaphysis:
A – Simple
A1 – Spiral
A2 – Oblique, angle > 30 deg
A3 – Transverse, angle < 30 deg
B – Wedge
B1 – Spiral wedge
B2 – Bending wedge
B3 – Fragmented wedge
C – Complex
C1 – Spiral
C2 – Segmental
C3 – Irregular
ii)For the metaphysis:
A - Extra-Articular
A1 - simple
A2 – wedge
A3 - complex
B-Partial Articular
B1 - split
B2 - depression
B3 – split-depression
C-Complete Articular
C1 - simple articular, simple metaphyseal
C2 - simple articular, complex metaphyseal
C3 - complex articular, complex metaphyseal
DIAPHYSEAL FRACTURES
METAPHYSEAL FRACTURES

2.)SPECIFIC/ANATOMICAL CLASSIFICATION
Example - Femoral Neck:
i)The Garden classification
ii)Pauwels Classification
iii)Anatomical Classification
HOW FRACTURES ARE DISPLACED
After a complete fracture the fragments usually become displaced, partly by the force of the
injury, partly by gravity and partly by the pull of muscles attached to them. Displacement is
usually described in terms of translation, alignment, rotation and altered length:
1. Translation (shift) – The fragments may be shifted sideways, backward or forward in
relation to each other, such that the fracture surfaces lose contact. The fracture will usually
unite as long as sufficient contact between surfaces is achieved; this may occur even if
reduction is imperfect, or indeed even if the fracture ends are off-ended but the bone
segments come to lie side by side.
2. Angulation (tilt) – The fragments may be tilted or angulated in relation to each other.
Malalignment, if uncorrected, may lead to deformity of the limb.
3. Rotation (twist) – One of the fragments may be twisted on its longitudinal axis; the bone
looks straight but the limb ends up with a rotational deformity.
4. Altered Length – The fragments may be distracted and separated, or they may overlap, due
to muscle spasm, causing shortening of the bone.

CLINICAL FEATURES
HISTORY
 There is usually a history of injury, followed by inability to use the injured limb – but Note:
The fracture is not always at the site of the injury
 The patient’s age and mechanism of injury are important.
 If a fracture occurs with trivial trauma, suspect a pathological lesion.
 Pain, bruising and swelling are common symptoms but they do not distinguish a fracture
from a soft-tissue injury. Deformity is much more suggestive.
 Always enquire about symptoms of associated injuries: pain and swelling elsewhere (it is a
common mistake to get distracted by the main injury, particularly if it is severe), numbness
or loss of movement, skin pallor or cyanosis, blood in the urine, abdominal pain, difficulty
with breathing or transient loss of consciousness.
 Once the acute emergency has been dealt with, ask about previous injuries, or any other
musculoskeletal abnormality that might cause confusion when the x-ray is seen. Finally, a
general medical history is important, in preparation for anaesthesia or operation.
GENERAL SIGNS
Unless it is obvious from the history that the patient has sustained a localized and fairly modest
injury, priority must be given to dealing with the general effects of trauma
Follow the ABCs: look for, and if necessary attend to, Airway obstruction, Breathing problems,
Circulatory problems and Cervical spine injury.
During the secondary survey it will also be necessary to exclude other previously unsuspected
injuries and to be alert to any possible predisposing cause (such as Paget’s disease or a
metastasis).
LOCAL SIGNS
A systematic approach is always helpful:
 Examine the most obviously injured part.
 Test for artery and nerve damage.
 Look for associated injuries in the region.
 Look for associated injuries in distant parts.
Look
 Swelling, bruising and deformity may be obvious, but the important point is whether the
skin is intact
 If the skin is broken and the wound communicates with the fracture, the injury is ‘open’
(‘compound’).
 Note also the posture of the distal extremity and the colour of the skin (for tell-tale signs
of nerve or vessel damage).
Feel
 The injured part is gently palpated for localized tenderness.
 The common and characteristic associated injuries should also be felt for, even if the
patient does not complain of them.
 In high-energy injuries always examine the spine and pelvis.
 Vascular and peripheral nerve abnormalities should be tested for both before and after
treatment.
Move
Crepitus and abnormal movement may be present, but why inflict pain when x-rays are
available?
It is more important to ask if the patient can move the joints distal to the injury.
X-RAY
X-ray examination is mandatory. Remember the rule of twos:
 Two views – A fracture or a dislocation may not be seen on a single x-ray film, and at least
two views (anteroposterior and lateral) must be taken.
 Two joints – In the forearm or leg, one bone may be fractured and angulated. Angulation,
however, is impossible unless the other bone is also broken, or a joint dislocated. The joints
above and below the fracture must both be included on the x-ray films.
 Two limbs – In children, the appearance of immature epiphyses may confuse the diagnosis
of a fracture; x-rays of the uninjured limb are needed for comparison.
 Two injuries – Severe force often causes injuries at more than one level. Thus, with
fractures of the calcaneum or femur it is important to also x-ray the pelvis and spine.
 Two occasions – Some fractures are notoriously difficult to detect soon after injury, but
another x-ray examination a week or two later may show the lesion. Common examples are
undisplaced fractures of the distal end of the clavicle, scaphoid, femoral neck and lateral
malleolus, and also stress fractures and physeal injuries wherever they occur.
DESCRIPTION

1) Is it open or closed?
2) Which bone is broken, and where?
3) Has it involved a joint surface?
4) What is the shape of the break?- transverse, oblique, comminuted, spiral, segmental
5) Is it stable or unstable? – Displacement: For every fracture, three components must be
assessed:
 Shift or translation – backwards, forwards, sideways, or longitudinally with impaction or
overlap.
 Tilt or angulation – sideways, backwards or forwards.
 Twist or rotation – in any direction.
6) Is it a high-energy or a low-energy injury?
7) Who is the person with the injury?
SECONDARY INJURIES
Certain fractures are apt to cause secondary injuries and these should always be assumed to have
occurred until proved otherwise:
a) Thoracic injuries – Fractured ribs or sternum may be associated with injury to the lungs or
heart. It is essential to check cardiorespiratory function.
b) Spinal cord injury – With any fracture of the spine, neurological examination is essential to:
(1) establish whether the spinal cord or nerve roots have been damaged and (2) obtain a
baseline for later comparison if neurological signs should change.
c) Pelvic and abdominal injuries– Fractures of the pelvis may be associated with visceral injury.
It is especially important to enquire about urinary function; if a urethral or bladder injury is
suspected, diagnostic urethrograms or cystograms may be necessary.
d) Pectoral girdle injuries – Fractures and dislocations around the pectoral girdle may damage
the brachial plexus or the large vessels at the base of the neck. Neurological and vascular
examination is essential.
D)MANAGEMENT OF FRACTURES
TREATMENT OF CLOSED FRACTURES
The principles of fracture management can be summarized in four R’s:
1. Resuscitate
2. Reduce
3. Restrict/Hold
4. Rehabilitate/Exercise

1.RESUSCITATION AS PER ATLS PROTOCOL

1. Primary survey with simultaneous resuscitation
A. Airway maintenance with C-spine protection
B. Breathing and ventilation
C. Circulation with hemorrhage control
D. Disability – Neurological Status
E. Exposure and environment control
2. Rescucitation
3. Adjuncts to the primary survey
4. Secondary survey
5. Adjuncts to the secondary survey
6. Re-evaluation
7. Definitive care

2.REDUCTION
Aim
Reduction should aim for adequate apposition and normal alignment of the bone fragments.
The greater the contact surface area between fragments the more likely healing is to occur. A gap
between the fragment ends is a common cause of delayed union or nonunion. On the other hand,
so long as there is contact and the fragments are properly aligned, some overlap at the fracture
surfaces is permissible. The exception is a fracture involving an articular surface; this should be
reduced as near to perfection as possible because any irregularity will cause abnormal load
distribution between the surfaces and predispose to degenerative changes in the articular
cartilage.
Acceptable reduction:
 Lateral shift of up to 50%
 5° for varus or valgus angulation
 10° for anterior or posterior angulation
 ≤10° for rotation in reference to the opposite extremity
 ≤1cm for length discrepancy; No distraction should be tolerated

There are some situations in which reduction is unnecessary:

 When there is little or no displacement
 When displacement does not matter initially (e.g. In fractures of the clavicle)
 When reduction is unlikely to succeed (e.g. With compression fractures of the vertebrae).

A)Closed Reduction
Definition
Realignment of a fractured bone without incision into the fracture site.
Technique
Under appropriate anaesthesia and muscle relaxation, the fracture is reduced by a three-fold
manoeuvre:
 The distal part of the limb is pulled in the line of the bone
 As the fragments disengage, they are repositioned (by reversing the original direction of
force if this can be deduced)
 Alignment is adjusted in each plane
This is most effective when the periosteum and muscles on one side of the fracture remain intact;
the soft-tissue strap prevents over-reduction and stabilizes the fracture after it has been reduced.
Indications For Closed Reduction
Closed reduction is used for:
 All minimally displaced fractures
 For most fractures in children
 For fractures that are not unstable after reduction and can be held in some form of splint
or cast
  Unstable fractures can also be reduced using closed methods prior to stabilization with
internal or external fixation. This avoids direct manipulation of the fracture site by open
reduction, which damages the local blood supply and may lead to slower healing

Advantages;
 Minimises damage to blood supply & soft tissues

Disadvantages;
 Relies on soft-tissue attachments to reduce the fragments
 Is rarely adequate for intra-articular fractures
 In children, lack of ossification makes checking closed reduction impossible.

B)Open Reduction
Definition
Realignment of a fractured bone after incision into the fracture site.
Indications For Open Reduction
Operative reduction of the fracture under direct vision is indicated:
 When closed reduction fails, either because of difficulty in controlling the fragments or
because soft tissues are interposed between them
 When there is a large articular fragment that needs accurate positioning
 For avulsion (distraction*) fractures in which the fragments are held apart. As a rule,
however, open reduction is merely the first step to internal fixation.
Note:
Avulsion/Distraction fractures
An avulsion fracture is a fracture in which a bone fragment is pulled away from its main body
by soft tissue that is attached to it.
A joint capsule, muscle, or ligament insertion or origin can pulled from the bone as a result of a
sprain dislocation or strong contracture of the muscle against resistance; as the soft tissue is
pulled away from the bone, a fragment or fragments of the bone may come away with it.
Examples;
 Patella - The quadriceps muscle
 The Olecranon - Triceps
  The 5th Metatarsal head - Peroneous tertius
 Inferior boarder of ischium - Hamstrings
 Anterior Inferior Iliac Spine - Rectus femoris
 Lesser trochanter - Iliopsoas

Controversial;
 Tibial apophyseal stress lesion of Osgood-Schlatter disease
 Sinding-Larson-Johansson syndrome

Advantages of Open Reduction;

 Allows wounds to be cleaned & fragments to be reduced exactly
Disadvantages;
 Risks damage to the blood supply of the bone
 Incision must be extensile - able to be extended if necessary
 Soft tissue cover must be possible

3.HOLD REDUCTION
The available methods of holding reduction are:
a) Continuous traction
b) Cast splintage
c) Functional bracing
d) Internal fixation
e) External fixation
A)Continuous Traction
Definition
Traction is the application of a pulling force to the limb distal to the fracture, so as to exert a
continuous pull in the long axis of the bone, with a counterforce in the opposite direction (to
prevent the patient being merely dragged along the bed).
This is particularly useful for shaft fractures that are oblique or spiral and easily displaced by
muscle contraction.
Purpose
1. Reduction of fractures or dislocations
2. Immobilization of fractures or joints after reduction (Restrict/maintain reduction)
 3. Relieve or prevent muscle spasms: Muscle spasms are a deforming force and result in
over-riding/displacement of fracture fragments
4. Relieve pain
5. Relieve pressure on nerves
6. To regain normal length of a bone
7. To prevent or reduce skeletal deformities or muscle contractures
8. Keeping the patient comfortable until definitive treatment
Note:
A muscle spasm is a sudden involuntary contraction of one or more muscles; includes cramps,
and contractures.
Classification
Classification based on method of application
1. Traction by gravity
2. Skin traction
3. Skeletal traction
Classification based on the mechanism
1.Fixed
Pull is exerted against a fixed point of counter traction i.e. the appliance obtains purchase on a
part of the body. Examples:
 Fixed traction in Thomas’s splint (counter traction is provided by ischial tuberosity)
 Roger Anderson well-leg traction ( the skeletal traction is applied to the injured leg while
counter-traction is provided by the well/normal leg)
 Halo-pelvic traction
2.Balanced / Dynamic
Pull is exerted against an opposing force. This opposing force is provided by the weight of the
body and bed adjustments. Examples:
 Perkins
 90-90
 Pelvic
 Tulloch-brown
 Gallows
 Bucks
 Hamilton-Russel
 Olecranon pin
 Metarcarpal pin
 Dunlop
  Spinal traction (cervical, halopelvic)
3.Combined
If a Thomas’ splint is used, the tapes are tied to the end of the splint and the entire splint is then
suspended, as in balanced traction.
Equipment Needed For Traction
 Adjustable orthopedic bed
 Balken beam frame
 Trapeze
 Traction cords
 Pulleys
 Weights
 Skeletal and skin traction apparatus
 Splints –Thomas splint, Fisk splint
Disadvantages Of Traction
1. Costly
2. Requires continuous nursing care
3. Hazards of prolonged bed rest e.g. DVT, hypostatic pneumonia, decubitus ulcers
4. Contracture development
Note:
Contracture
Contracture is the shortening or stiffening of muscles, skin, or connective tissues resulting in
decreased movement and range of motion. Contractures may be caused by injury, scarring, and
nerve damage, or by not using the muscles.
  Traction by gravity
This applies only to upper limb injuries. Thus, with a wrist sling the weight of the arm provides
continuous traction to the humerus.
For comfort and stability, especially with a transverse fracture, a U-slab of plaster may be
bandaged on or, better, a removable plastic sleeve from the axilla to just above the elbow is held
on with Velcro.

 Skin Traction
Mechanism
 Traction is applied over a large area and is transmitted to the skeleton through the soft
tissues.
 Traction is applied distal to fracture
Types of Skin Traction
There are two kinds of skin tractions:
1.Adhesive skin traction
Adhesive material is used for strapping which is applied antero-medial and postero-lateral on
either side of the lower limbs.
Application
 Shave and clean skin
 Ensure skin is dry
  Apply adhesive strapping
 Avoid placing over bony prominences
 Leave a loop of 5cm to allow dorsi and plantar flexion
 Duration- 4 to 6 weeks
2.Non-adhesive skin traction
 Useful in thin and atrophic skin
 Used in patients sensitive to adhesive strap.
 Less secure than adhesive hence may need frequent reapplications
Weight
Skin traction will sustain a pull of no more than 4 or 5 kg (Acc. To Apleys N Outline)
(Acc. to Muongoya: Weight -10% of body weight. Maximum of 6.7 kg for adhesive skin
traction. Maximum of 4.5 kg for non-adhesive skin traction)*
Indications
 Temporary management of the neck of the femur fracture
 Femoral shaft fracture in children
 Undisplaced fracture of the acetabulum
 After reduction of dislocation of the hip
 To correct minor fixed flexion deformities of the hip and knee
Contraindications
 Abrasions and Lacerations of skin in the area to which traction is to be applied
 Impaired circulation; Varicose veins, Impending gangrene
 Dermatitis
 When there is marked shortening of bone fragments (in this case more weight would be
needed than can be applied using skin traction)
 Allergy to adhesive
Note:
A laceration is any tear to soft tissue resulting in an irregular or jagged (rough and with sharp
points) wound. Another term for a laceration is a cut.
Dermatitis is inflammation of the skin

Complications
 Allergic reactions from the adhesive material
 Pressure sores around the malleoli and tendoachilles from slipping straps
 Compartment syndrome from over-tight wrap
  Common peroneal nerve palsy from wraps around the knee
 Excoriation of skin (due to slipping of adhesive strapping)
 Muscular atrophy
 Paralysis
 Oedema

Note:
Acute Compartment Syndrome
Acute compartment syndrome occurs when the tissue pressure within a closed anatomical
compartment exceeds the perfusion pressure and results in muscle and nerve ischemia.
Site
Fascia is a thin, inelastic sheet of connective tissue that surrounds muscle compartments and
limits the capacity for rapid expansion. In the leg, there are four muscle compartments: anterior,
lateral, deep posterior, and superficial posterior. The anterior compartment of the leg is the most
common location for compartment syndrome. This compartment contains the extensor muscles
of the toes, the tibialis anterior muscle, the deep peroneal nerve, and the tibial artery.
Other locations in which acute compartment syndrome is seen include the forearm, thigh,
buttock, shoulder, hand, and foot. It can also be seen in the abdomen, but more commonly, it
presents in the limbs.
Causes
 Fractures (75% of the cases): Typically occurs after a long bone fracture, with tibial
fractures being the most common cause of the condition, followed by distal radius
fractures. In children, supracondylar fractures of the humerus and both ulnar and radial
forearm fractures are associated with compartment syndrome.
 Soft tissue injuries: the second most common cause of acute compartment syndrome
Other causes of acute compartment syndrome include:
 Burns
 Vascular injuries
 Crush injuries
 Drug overdoses / Alcohol abuse
 Reperfusion injuries
 Deep Venous Thrombosis
 Bleeding disorders e.g. Autoimmune Vasculitis
 Infections e.g Influenza myositis
 Improperly placed casts or splints
 Tight circumferential bandages
  Penetrating trauma
 Intense athletic activity
 Poor positioning during surgery
Pathophysiology
Acute compartment syndrome occurs due to decreased intracompartmental space or increased
intracompartmental fluid volume because the surrounding fascia is inherently non-compliant. As
the compartment pressure increases, hemodynamics are impaired. There is normally an
equilibrium between venous outflow and arterial inflow. When there is an increase in
compartmental pressure, there is a reduction in venous outflow. This causes venous pressure and,
thus, venous capillary pressure to increase. If the intracompartmental pressure becomes higher
than arterial pressure, a decrease in arterial inflow will also occur. The reduction of venous
outflow and arterial inflow result in decreased oxygenation of tissues causing ischemia. If the
deficit of oxygenation becomes high enough, irreversible necrosis may occur.
The normal pressure within a compartment is less than 10 mmHg. If the intracompartmental
pressure reaches 30 mmHg or greater, acute compartment syndrome is present. However, a
single normal ICP reading does not exclude acute compartment syndrome. ICP should be
monitored serially or continuously.
Presentation
Classically, the presentation of acute compartment syndrome has been remembered by "The Five
P's":
 Pain
 Pulselessness
 Paresthesia – Tingling or prickling, “pins and needles” sensation
 Paralysis
 Pallor
 Poikilothermia – Is inability to maintain a constant core body temperature with variation
in temperature according to the temperature of the surrounding environment
However, aside from paresthesia, which may occur earlier in the course of the condition, these
are typically late findings.
Acute compartment syndrome typically occurs within a few hours of inciting trauma. However,
it can present up to 48 hours after. The earliest objective physical finding is the tense, or ''wood-
like" feeling of the involved compartment. Pain is typically severe, out of proportion to the
injury. Early on, pain may only be present with passive stretching. However, this symptom may
be absent in advanced acute compartment syndrome. In the initial stages, pain may be
characterized as a burning sensation or as a deep ache of the involved compartment. Paresthesia,
hypoesthesia, or poorly localized deep muscular pain may also be present.
Treatment / Management
Acute compartment syndrome is an emergency condition. Less time should be spent on
confirmation of the diagnosis, as delayed treatment may result in loss of limb.
 Immediate surgical consult
 Provide supplemental oxygen.
 Remove any restrictive casts, dressings, or bandages to relieve pressure.
 Keep the extremity at the level of the heart to prevent hypo-perfusion.
 Prevent hypotension and provide blood pressure support in patients with hypotension.
 If ICP is greater than or equal to 30 mmHg or delta pressure is less than or equal to
30 mmHg, fasciotomy should be done.
Acute compartment syndrome is a surgical emergency, so prompt diagnosis and treatment are
critical. Once the diagnosis is confirmed, immediate surgical fasciotomy is needed to reduce the
intracompartmental pressure. The ideal timeframe for fasciotomy is within six hours of injury,
and fasciotomy is not recommended after 36 hours following injury. When tissue pressure
remains elevated for that amount of time, irreversible damage may occur, and fasciotomy may
not be beneficial in this situation.
If necrosis occurs before fasciotomy is performed, there is a high likelihood of infection which
may require amputation. If infection occurs, debridement is necessary to prevent systemic spread
or other complications.
After a fasciotomy is performed and swelling dissipates, a skin graft is commonly used for
incision closure. Patients must be closely monitored for complications which include infection,
acute renal failure, and rhabdomyolysis.
Examples of Skin Traction
Cervical
 Head halter
Upper limb
 Dunlop’s
Lower limb
 Buck’s traction
 Hamilton-Russell’s
 Gallow’s/ Bryant’s
 Modified Bryant’s
 Agnes Hunt
 Pelvic traction
Head halter traction

Dunlop traction

Buck’s traction
 Hamilton–Russell traction

Bryants/Gallows traction
Pelvic traction
  Skeletal Traction
Mechanism
Traction force is applied directly to the bone either by a pin or wire transfixing bone
Utility/Indications
1. Cases in which skin traction is contraindicated
2. Patients with lacerated wounds
3. Patients with external fixator in situ
4. Temporary management of musculo-skeletal disorders
5. Definitive management of musculo-skeletal disorders
Equipment
 Steinmann pin
 Denham pin
 Kirschner wires
Principles of application
1. Applied under general or local anesthesia
2. Follow strict aseptic measures
3. Pin should be at right angles to the limb and parallel to the ground.
4. Direction of pin insertion is chosen such that neurovascular structures and other soft
tissues are not injured
• Lateral to medial in case of upper tibial traction, to avoid injuring the common
peroneal nerve.
• Medial to lateral in distal femur traction
• Medial to lateral in case of olecranon pin traction to avoid injury to ulnar nerve
5. Cover the sharp tip on the medial side with a stopper bottle to prevent damage to the
normal limb
Site
A Stiff wire, Steinmann pin or Denham pin (threaded at the centre) is inserted;
 Behind the tibial tuberosity/tubercle - For hip, thigh & knee injuries -Inserted from lateral
to medial to avoid injuring the common peroneal nerve that goes round the head of the
fibula
 Calcaneum - For tibial fractures
 Olecranon for supracondylar fractures of the humerus
 Traction upon the skull for cervical spine injury - Use weights up to ⅓rd patients weight
  Distal femur - If there is concurrent ligamentous injury to the knee
 Distal Tibia
 Greater trochanter - For sideways traction in hip dislocation
Weight
Use weights 1/10th - 1/7th the patient's body weight
Complications
a)At the time of application
 Anesthetic problems.
 Vasovagal shock.
b)During application
 Injury to the nerves (lateral popliteal nerve).
 Injury to the vessels.
 Injury to the muscles, ligaments and tendons.
 Injury to the epiphysis in children (e.g. upper tibial epiphysis).
 Pain due to equalization of intraosseus pressure and atmospheric pressure due to the hole
made in the bone
c)When pin is in situ
 Infection—due to improper aseptic measures.
 Migration—due to loosening.
 Breakage—thin pin or more weight.
 Bending—same reasons as above.
 Loosening—due to osteoporosis, infection, etc.
 Distraction of fracture fragments and ligament damage—due to excessive weight/large
traction force.
d)Late effects
 Pin site infection.
 Chronic osteomyelitis with ring sequestra at the site.
 Genu recurvatum due to damage to the anterior epiphysis of tibia in children. [Genu
recurvatum (also called the back knee) is defined as hyperextension of the knee such that
the lower limb has a forward curvature]
 Depressed scar.
Examples of Skeletal Traction
Cervical
 Crutchfield tongs
 Gardner-Wells tongs
 Halo traction
Upper limb
 Olecranon pin traction
 Metacarpal pin traction
Lower limb
 Perkin’s traction
 Ninety-ninety
 Tulloch Brown
 Upper Femoral traction (Lateral Upper Femoral traction)
 Distal Femoral traction
 Distal tibial traction
 Calcaneal traction
 Olecranon pin traction

Metacarpal pin traction

 Ninety-ninety
s traction

Ninety-ninety traction
 Perkins traction

Perkins traction
Tulloch Brown traction

Lateral Upper Femoral traction

 Distal Femoral traction

Distal Femoral Traction

Distal tibial traction

Calcaneal traction
B)Cast splintage
I)Cast
Methods
1. Plaster of Paris
2. Fiber glass
Indications
1. For most fractures in children
2. Undisplaced fracture
3. Poor bone quality: osteoporosis
4. Unfixable fracture e.g severely comminuted
5. Systemic contraindication
6. Local contraindication
7. Psychosocial problem
Contraindications
1. Skin infection or ulcers
2. Swelling of the limb
3. Open fractures
4. Impeding compartment syndrome
Function
1. To prevent or correct deformity
2. To immobilize a reduced fracture
3. To apply uniform pressure to underlying soft tissue
4. To support and stabilize weakened joints
Plaster of Paris (POP)
POP is hemihydrated Calcium sulfate (CaSO4) which reacts with water to form hydrated CaSO4
and heat, evidenced by noticeable warming of the plaster during setting. A thin lining of
stockinet or cellulose bandage is applied to prevent the plaster from sticking to the hairs & skin.
If marked swelling is expected, as after an operation upon the limb, a more bulky padding of
surgical cotton wool should be used.
Plaster bandages are applied in 2 forms;
 Round-&-round bandages
 Longitudinal strips or 'slabs' to reinforce a particular area of weakness or stress
A plaster is best dried by exposure to air.
The plaster is removed by;
 Electrically powered oscillating plaster saws - useful for removing a very thick plaster &
for cutting a window through a plaster
 Plaster-cutting shears
Precautions;
 Monitor for possible impairment of circulation 2° to undue swelling within a closely
fitting plaster or splint- Severe pain within the plaster & marked swelling of the digits are
warning signs - The period of greatest danger is 12-36hrs after injury or operation

Types Of Cast, Molds And Indications

1. Airplane cast – for humerus and shoulder joint with compound fracture.
2. Basket cast – for severe leg trauma with open wound or inflammation.
3. Body cast – for lower dorso-lumbar spine affectation.
4. Boot leg cast – for hip and femoral fracture.
5. Cast brace – for fracture of femur (distal curve) with flexion and extension.
6. Collar cast – for cervical affectation.
7. Cylindrical leg cast – for fractured patella.
8. Delbit cast – for fracture of tibia or fibula.
9. Double hip spica cast – for fracture of hip and femur.
10. Double hip spica mold – cervical affectation with callus formation.
11. Frog cast – for congenital hip dislocation.
12. Functional cast – for fractured humerus with abduction and adduction.
13. Hanging cast – for fractured shaft of the humerus.
14. Internal rotator splint – for post hip operation.
15. Long arm circular cast – for fractured radius or ulna
16. Long arm posterior mold – for fractured radius or ulna with compound affectation.
17. Long leg circular cast – for fractured tibia-fibula.
18. Long leg posterior mold – for fracture tibia-fibula with compound affectation.
19. Minerva cast – for upper dorsal or cervical affectation.
20. Munster cast – for fractured radius or ulna with callus formation.
21. Night splint – for post polio.
22. Pantalon cast – for pelvic bone fracture
23. Patella tendon bearing cast – for fractured tibia-fibula with callus formation.
24. Quadrilateral (ischial weight bearing) cast – for shaft of femur with callus formation.
25. Rizzer’s jacket – for scoliosis
26. Short arm circular cast – for wrist and fingers.
27. Short arm posterior mold – for wrist and fingers with compound affectation.
28. Short leg circular cast – for ankle and foot fracture.
29. Short leg posterior mold – for ankle and foot with compound affectation.
30. Shoulder spica – for humerus and shoulder joint.
31. Single hip spica – for hip and 1 femur.
32. Single hip spica mold – for pelvic fracture with callus formation.
33. 1 and ½ hip spica – for hip and femur.
34. 1 and ½ spica mold – for hip and femur with compound affectation.
Complications Of Casts
II)Splints
Definition Of A Splint

Indications For Splinting

Note:
Gout is a disorder of purine metabolism, occurring especially in men, characterized by a raised
but variable blood uric acid level and severe recurrent acute arthritis of sudden onset resulting
from deposition of crystals of sodium urate in connective tissues and articular cartilage.
Tenosynovitis is inflammation of a tendon and its enveloping sheath
A sprain is an injury to a ligament as a result of abnormal or excessive force applied to a joint,
but without dislocation or fracture

Contraindications For Splints

Splinting Equipment And Materials
Types Of Splints
Thomas splint
Parts

Indication
Used mainly for transportation of patients with fractures of shaft of femur
Measuring For A Thomas Splint
For length, measure the pelvic attachment of the adductor longus tendon to the heel and add 25
cm. For the ring size, measure the oblique circumference of the groin (around ischial tuberosity
and greater trochanter) of the uninjured side, and add 5 cm (to account for swelling).
Note: Pelvic attachment of the adductor longus - body of pubis in the angle between pubic Crest
and pubic symphysis (subpubic angle)
A Thomas Splint
Bohler-Braun Splint
Indications
 Application of traction to the lower end of the tibia
 When the lower leg and foot are to be elevated to reduce or prevent edema

Parts
C)Functional Bracing
Mechanism
Functional bracing, using either plaster of Paris or one of the lighter thermoplastic materials, is
one way of preventing joint stiffness while still permitting fracture splintage and loading.
Segments of a cast are applied only over the shafts of the bones, leaving the joints free; the cast
segments are connected by metal or plastic hinges that allow movement in one plane.
The splints are ‘functional’ in that joint movements are much less restricted than with
conventional casts.
Indications
Functional bracing is used most widely for fractures of the femur or tibia, but since the brace is
not very rigid, it is usually applied only when the fracture is beginning to unite, i.e. after 3–6
weeks of traction or conventional plaster.
Advantages
 The fracture can be held reasonably well
 The joints can be moved
 The fracture joins at normal speed (or perhaps slightly quicker) without keeping the
patient in hospital
 The method is safe.

Tibial Functional Brace

Functional Humeral Brace
D)Internal Fixation
Indications
1.Fractures that cannot be reduced except by operation.
2.Pathological fractures in which bone disease may prevent healing.
3.Fractures in patients who present nursing difficulties (paraplegics, those with multiple injuries
and the very elderly).
4.Fractures that are inherently unstable and prone to re-displace after reduction (e.g. mid-shaft
fractures of the forearm and some displaced ankle fractures).
Also included are those fractures liable to be pulled apart by muscle action (e.g. transverse
fracture of the patella or olecranon).
5.Multiple fractures where early fixation (by either internal or external fixation) reduces the risk
of general complications and late multisystem organ failure.
6.Fractures that unite poorly and slowly, principally fractures of the femoral neck.
Types of internal fixation
 Interfragmentary screws
 Wires (transfixing, cerclage and tension-band)
 Plates and screws
 Intramedullary nails
i)Interfragmentary screws
Mechanism
Screws that are only partially threaded (a similar effect is achieved by overdrilling the ‘near’
cortex of bone) exert a compression or ‘lag’ effect when inserted across two fragments.
Indication
The technique is useful for reducing single fragments onto the main shaft of a tubular bone or
fitting together fragments of a metaphyseal fracture.
(The use of a transfixion screw has wide application in the fixation of small detached fragments -
for instance the capitulum of the humerus, the olecranon process of the ulna or the medial
malleolus of the tibia.)
ii)Wires
 Transfixing wires
Examples of transfixing wires
Kirschner wires or K-wires
Indication
Transfixing wires, often passed percutaneously, can hold major fracture fragments together. They
are used in situations where fracture healing is predictably quick (e.g. in children or for distal
radius fractures), and some form of external splintage (usually a cast) is applied as
supplementary support.
(Acc. To Outline: Provide a useful alternative to transfixion screws for the fixation of small bony
fragments or for fractures of the small bones in the hand and foot)

 Cerclage and tension-band wires

Mechanism
Cerclage and tension-band wires are essentially loops of wire passed around two bone fragments
and then tightened to compress the fragments together.
When using cerclage wires, make sure that the wires hug the bone and do not embrace any of the
close-lying nerves or vessels.
Indication
Both techniques are used for patellar fractures: the tension-band wire is placed such that the
maximum compressive force is over the tensile surface, which is usually the convex side of the
bone.
(Acc. To Outline: Tension band wiring is most commonly used in the patella and olecranon but
can be applied to other small metaphyseal fragment such as the medial malleolus)

iii)Plates and screws

Functions
Plates have the following functions:
1. Buttressing – here the plate props up the ‘overhang’ of the expanded metaphyses of long
bones (e.g. in treating fractures of the proximal tibial plateau).
2. Bridging – The plate bridges simple or multifragmentary fractures to restore correct
length, axis and rotation with minimal stripping of soft tissues.
3. Anti-glide – by fixing a plate over the tip of a spiral or oblique fracture line and then
using the plate as a reduction aid, the anatomy is restored with minimal stripping of soft
tissues. The position of the plate acts to prevent shortening and recurrent displacement of
the fragments.
4. Tension-band – using a plate in this manner, again on the tensile surface of the bone,
allows compression to be applied to the biomechanically more advantageous side of the
fracture.
 5. Neutralization – when used to bridge a fracture and supplement the effect of
interfragmentary lag screws; the plate is to resist torque and shortening.
6. Compression – often used in metaphyseal fractures where healing across the cancellous
fracture gap may occur directly, without periosteal callus. This technique is less
appropriate for diaphyseal fractures and there has been a move towards the use of long
plates that span the fracture, thus achieving some stability without totally sacrificing the
biological (and callus producing) effect of movement.

Indication
This form of fixation is useful for treating metaphyseal fractures of long bones and diaphyseal
fractures of the radius and ulna.

iv)Intramedullary nails
Also Called
An intramedullary rod, also known as an intramedullary nail (IM nail)
Types:
 Inter-locking nail
 Kuntscher nail (K Nail)
Mechanism
A nail (or long rod) is inserted into the medullary canal to splint the fracture; rotational forces
are resisted by introducing transverse interlocking screws that transfix the bone cortices and the
nail proximal and distal to the fracture. Nails are used with or without prior reaming of the
medullary canal; reamed nails achieve an interference fit in addition to the added stability from
interlocking screws, but at the expense of temporary loss of the intramedullary blood supply.
Indication
These are suitable for many fractures of the long bones especially when the fracture is near the
middle of the shaft.
It is used regularly for fractures of the femur and tibia and less commonly in the humerus.
 Interfragmentary screws

Simple Kirschner Wires

Cerclage wires
 Tension band wiring with K-wires

Tension band wiring with K-wires

Compression plate
Locking compression plate

Dynamic/Sliding hip screw

Dynamic condylar screw

 Interlocking nail and screws

Interlocking nail and screws

Flexible Intramedullary nails
Complications of internal fixation
Most of the complications of internal fixation are due to poor technique, poor equipment or poor
operating conditions:
Infection
Iatrogenic infection is now the most common cause of chronic osteomyelitis; the metal does not
predispose to infection but the operation and quality of the patient’s tissues do.
Non-union
If the bones have been fixed rigidly with a gap between the ends, the fracture may fail to unite.
This is more likely in the leg or the forearm if one bone is fractured and the other remains intact.
Other causes of non-union are stripping of the soft tissues and damage to the blood supply in the
course of operative fixation.
Implant failure
Metal is subject to fatigue and can fail unless some union of the fracture has occurred. Stress
must therefore be avoided and a patient with a broken tibia internally fixed should walk with
crutches and stay away from partial weightbearing for 6 weeks or longer, until callus or other
radiological sign of fracture healing is seen on x-ray. Pain at the fracture site is a danger signal
and must be investigated.
Refracture
It is important not to remove metal implants too soon, or the bone may refracture. A year is the
minimum and 18 or 24 months safer; for several weeks after removal the bone is weak, and care
or protection is needed.
E)External Fixation
Mechanism
A fracture may be held by transfixing screws or tensioned wires that pass through the bone above
and below the fracture and are attached to an external frame.
Indications
External fixation is particularly useful for:
1.Fractures around joints that are potentially suitable for internal fixation but the soft tissues are
too swollen to allow safe surgery; here, a spanning external fixator provides stability until soft-
tissue conditions improve.
2.Ununited fractures, which can be excised and compressed; sometimes this is combined with
bone lengthening to replace the excised segment.
3.Patients with severe multiple injuries, especially if there are bilateral femoral fractures, pelvic
fractures with severe bleeding, and those with limb and associated chest or head injuries.
4.Infected fractures, for which internal fixation might not be suitable.
5.Fractures associated with severe soft-tissue damage (including open fractures) or those that are
contaminated, where internal fixation is risky and repeated access is needed for wound
inspection, dressing or plastic surgery.
Classification;
a)Based on the plane of action
Uniplanar, Biplanar, Multiplanar
b)Based on material
 Carbon fibre
 Stainless steel
 Titanium
c)Static And Modular External Fixators
Application
This is especially applicable to the tibia and pelvis, but the method is also used for fractures of
the femur, humerus, lower radius and even bones of the hand.
Complications
Damage to soft-tissue structures
Transfixing pins or wires may injure nerves or vessels, or may tether ligaments and inhibit joint
movement. The surgeon must be thoroughly familiar with the cross-sectional anatomy before
operating.
Overdistraction
If there is no contact between the fragments, union is unlikely.
Pin-track infection
This is less likely with good operative technique. Nevertheless, meticulous pin-site care is
essential, and antibiotics should be administered immediately if infection occurs.
Advantages;
• Minimally invasive
• Can be used when soft-tissue cover is compromised
• Allows early mobilisation
• Can be adjusted later
 Uniplanar external fixator

Uniplanar, Biplanar, Uniplanar both -side and Multiplanar -circular external fixators
respectively
4.REHABILITATE/EXERCISE
More correctly, restore function – not only to the injured parts but also to the patient as a whole.
The objectives are to:
1. Reduce oedema,
2. Preserve joint movement,
3. Restore muscle power
4. Guide the patient back to normal activity
TREATMENT OF OPEN FRACTURES
PRINCIPLES OF TREATMENT
All open fractures, no matter how trivial they may seem, must be assumed to be contaminated; it
is important to try to prevent them from becoming infected.
According to Outline (Prof ?)*;
The five essentials are:
1. Antibiotic prophylaxis
2. Urgent Wound and fracture debridement
3. Stabilization of the fracture
4. Aftercare
5. Early Definitive wound cover
Note:
According to Apley;
The four essentials are:
 Antibiotic Prophylaxis
 Urgent Wound And Fracture Debridement
 Early Definitive Wound Cover
 Stabilization Of The Fracture
 Then Aftercare

FIRST AID AS PER ATLS PROTOCOL

A. Airway maintenance with C-spine protection
B. Breathing and ventilation
C. Circulation with hemorrhage control
D. Disability – Neurological Status
E. Exposure and environment control
1.ANTIBIOTIC PROPHYLAXIS

Note:
Co-amoxiclav (Augmentin) is a broad-spectrum penicillin used for bacterial infections. It
contains amoxicillin (an antibiotic from the penicillin group of medicines) mixed with clavulanic
acid. The clavulanic acid stops bacteria from breaking down amoxicillin by blocking beta-
lactamase.
Gentamicin is an aminoglycoside antibiotic.
Vancomycin is in a class of medications called glycopeptide antibiotics.
Cefuroxime belongs to a class of drugs called cephalosporins, 2nd Generation.
Clindamycin is a lincosamide antibiotic.
Teicoplanin is a glycopeptide antibiotic with a similar mechanism of action and spectrum of
activity to vancomycin

Tetanus Prophylaxis
• Initiate in emergency room or trauma bay
• Two forms of prophylaxis And dosage
• Toxoid dose 0.5 ml, regardless of age
 • Immune globulin dosing
• <5-years-old receives 75U
• 5-10-years-old receives 125U
• >10-years-old receives 250U
• Toxoid and immunoglobulin should be given intramuscularly with two different syringes
in two different locations
• Guidelines for tetanus prophylaxis depend on 3 factors
• Complete or incomplete vaccination history (3 doses)
• Date of most recent vaccination
• Severity of wound

Tetanus prophylaxis recommendations

Tetanus immunization status Recommended dosing

Tetanus booster within last 5 years No further treatment

More than 5 years since booster or has not Tetanus toxoid (if wound tetanus prone, give
completed immunization series HTIG)

More than 10 years since booster or immune Tetanus toxoid and HTIG
system compromised

HTIG: Human tetanus immune globulin.

Note:
1.In Kenya, tetanus immunization via tetanus toxoid is given at 6,10 and 14 weeks.
2.Available evidence indicates that complete primary vaccination with tetanus toxoid provides
long-lasting protection ≥10 years for most recipients.
2.URGENT WOUND AND FRACTURE DEBRIDEMENT
Aim
The operation aims to render the wound free from foreign material and of dead tissue (for
example, avascular bone fragments), leaving a clean surgical field and tissues with a good blood
supply throughout.
Procedure
Under general anaesthesia the patient’s clothing is removed, while an assistant maintains traction
on the injured limb and holds it still. The dressing previously applied to the wound is replaced by
a sterile pad and the surrounding skin is cleaned. The pad is then taken off and the wound is
irrigated thoroughly with copious amounts of physiological saline. The wound is covered again
and the patient’s limb then prepped and draped for surgery.

The following principles must be observed:

 Wound excision
 Wound extension
 Delivery of the fracture
 Removal of devitalized tissue
 Wound cleansing
 Nerves and tendons
Wound excision
The wound margins are excised, but only enough to leave healthy skin edges.
Wound extension
Small wounds should be extended & excised to allow adequate exposure.
Thorough cleansing necessitates adequate exposure; poking around in a small wound to remove
debris can be dangerous. If extensions are needed, they should not jeopardize the creation of skin
flaps for wound cover if this should be needed. The safest extensions are to follow the line of
fasciotomy incisions; these avoid damaging important perforator vessels that can be used to raise
skin flaps for eventual fracture cover.
Delivery of the fracture
Examination of the fracture surfaces cannot be adequately performed without extracting
(exposing) the bone from within the wound.
The simplest (and gentlest) method is to bend the limb in the manner in which it was forced at
the moment of injury; the fracture surfaces will be exposed through the wound without any
additional damage to the soft tissues. Large bone levers and retractors should not be used.
Removal of devitalized tissue
Devitalized tissue provides a nutrient medium for bacteria.
Dead muscle can be recognized by:
 Its purplish colour,
 Its mushy consistency
 Its failure to contract when stimulated
 Its failure to bleed when cut
All doubtfully viable tissue, whether soft or bony, should be removed. The fracture ends can be
curetted or nibbled away until seen to bleed.
Wound cleansing
All foreign material and tissue debris is removed by excision or through a wash with copious
quantities of normal saline.
For Gustilo type II and III fractures- Irrigate with 5-10L NS ± Water & Hydrogen peroxide
Adding antibiotics or antiseptics to the solution has no added benefit.
Irrigation principles in the open fracture management**
Gustilo fracture type Irrigation volume/additives

I 3 L normal saline with liquid castile soap

additive only. Alternatively, no additive may
be used.

II 6 L normal saline with liquid castile soap

additive only.

III A – C 9 L normal saline with liquid castile soap

additive. Highly contaminated wounds may
benefit from antibiotic in the irrigation
solution.

Nerves and tendons

As a general rule it is best to leave cut nerves and tendons alone, though if the wound is
absolutely clean and no dissection is required they can be sutured.
3.STABILIZATION OF THE FRACTURE
Stabilizing the fracture is important in reducing the likelihood of infection and assisting recovery
of the soft tissues.
The method of fixation selected depends on the degree of contamination, time from injury to
operation and amount of soft-tissue damage.
If there is no obvious contamination and definitive wound cover can be achieved at the time of
debridement, open fractures of all types can be treated as for a closed injury; internal or
external fixation may be appropriate depending on the individual characteristics of the fracture
and wound.
If wound cover is delayed, external fixation can be used as a temporary measure; however, the
surgeon must take care to insert the fixator pins away from potential flaps needed by the plastic
surgeon.
The external fixator may be exchanged for internal fixation at the time of definitive wound cover
as long as: (1) the delay to wound cover is less than 7 days; (2) wound contamination is not
visible; and (3) internal fixation can control the fracture as well as the external fixator. This
approach is less risky than introducing internal fixation at the time of initial surgery and leaving
both metalwork and bone exposed until definitive cover several days later.

4.AFTERCARE
 In the ward, the limb is elevated and its circulation carefully watched.
 Antibiotic cover
 If the wound has been left open, it is inspected at 2-3days & covered appropriately

5.EARLY DEFINITIVE WOUND COVER

A small, uncontaminated wound in a Gustillo type I or II fracture may be sutured after
debridement, provided this can be done without tension.
All other wounds:
 All other wounds must be left open until the dangers of tension & infection have passed.
 The wound is lightly packed with sterile gauze & is inspected after 2 days.
 If it is clean, it is sutured (i.e.For Gustillo type I – IIIA) or skin grafted (i.e.Flap coverage
for Gustillo type IIIB and IIIC)
 The wound must be covered in 5-7days unless there is infection.
E)COMPLICATIONS OF FRACTURES
Local complications can be divided into early (arising during the first few weeks following
injury) and late: