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General Principles of

Bone Fractures

⁕ Definitions :

• Fracture : Loss of continuity of the bone .

• Dislocation : Complete loss of contact between 2 articular surfaces

.

• Sublaxation : Partial loss of contact between 2 articular surfaces .

• Fracture dislocation : Dislocation with fracture of one or more of

the articulating bones.
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⁕ Aetiology:
I) Usually due to trauma which may be due to:

1- Direct Trauma which is inflicted to the site of the fracture e.g. car
accident.

2- Indirect Trauma: Trauma is inflicted at distance away to the site

of the fracture. The trauma may be traction, bending, torsion,
axial loading or combined.

• In fractures of upper limb : falling on outstretched hand.

• In fractures of lower limb : falling from a height.

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II) Less Commonly Pathological fracture: A bone weakened by

disease (e.g. osteomyelitis, metastasis) → fracture by minor trauma.

III) Rarely stress ( fatigue ) fracture : Fracture due to repeated

loads to the skeleton e.g. marsh fracture in soldiers ( fractures of
metatarsal bones due to prolonged walking ) .

⁕ Pathology :

I) Classification of Fractures :

1- According to the aetiology : traumatic , pathological and

stress .

2-According to the presence of skin wound:

a. Simple (closed) fracture: Overlying skin is intact.

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b. Compound (open) fracture: associated with overlying skin

wound communicating the fracture hematoma with the external
environment .

3- According to the shape of the fracture:

• Transverse fracture : usually due to direct trauma.

• Oblique fracture : usually due to indirect trauma.

• Longitudinal fracture.

• Spiral fracture : usually due to indirect twisting trauma .

• Comminuted fracture : fracture leading to more than 2

fragments .

• Segmental fracture : multiple level fractures .

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4- According to displacement & deformity:

• Undisplaced fracture : After fracture the bone fragments

remain in normal anatomical position .

• Displaced fracture :

➢ After fracture the bone fragments are present in non-

anatomical abnormal position , in one or more planes.
➢ After fracture , displacement of bone fragments and deformity
occur due to force of injury , effect of gravity and reflex
spasm of muscles attached to the bone fragments ( protective
mechanism to avoid pain )
➢ Displacement of bone fragments and deformity are described
according to the position of distal to the proximal
fragments in 3 planes :
 Flexion or extension .
 Abduction or adduction .
 Medial or lateral rotation.
➢ Special types of displacement :
 Overriding & shortening occur when the 2 fracture
fragments are overlapped in relation to each others .
 Distraction & lengthening : The 2 fracture fragments
are held away from each others.
 Angulation: An angle present between the 2 fracture
fragments. It is described in the direction of the apex of
the angulation .
 Rotation around the long axis of the bone
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5- According to extent of the fracture :

• Complete fracture : the bone split completely into 2 or more

fragments .

• Incomplete fracture :

➢ Fissure fracture is incomplete fracture in adults .

➢ Green stick is incomplete fracture in children , the cortex is

fractured in one side and the cortex on the opposite side
bend with intact over lying periosteum .

6- According to impaction :

• Impacted fracture : a bone fragment is driven into

another bone fragment .

• Non-impacted fracture
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7- According to stability after reduction :

• Stable fracture is not liable for further displacement.

• Unstable fracture liable for redisplacement .

8- Complicated or uncomplicated fracture.

II) Healing of fractures :

A- Phases :

1- Formation of granulation tissues :

• Hematoma is formed between the ends of the bone

fragments.

• Granulation tissues invade the hematoma and

bridge the fracture gap within few weeks.

2- Formation of primary callus :

• Trabeculae of cartilage replace the granulation tissues.

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• Bone cells and matrix gradually appears → formation

of irregular vascular bone & calcified cartilage (1ry
callus).

• External callus ( on the outer surface ) first appears ,

then internal callus ( in the medulla ) and final
intermediate callus ( between the cortex ) .

• It ends 2-3 months.

3- Formation of mature bone :

• The intermediate callus is gradually replaced by mature

bone with absorption of internal and external callus.

• It ends 4-6 months .

B- Factors affecting healing of fractures :

1- Age :

• Healing of fractures is more rapid in children .

• Senile osteoporosis delay healing of fractures in elderly

2- Vascularity of bone fragments :

• Poor blood supply delay healing of fractures .Typical

example is fracture neck of femur in which injury of
blood supply leads to avascular necrosis and non union

3- Type of the fracture :

• Spiral & oblique fractures heal more rapidly than

transverse fracture.

4- Position of the fragments :

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• Impacted fracture heals rapidly while distraction of

fracture fragments markedly delays healing .

5- Proper fixation is essential for proper healing while lack

of proper fixation of the fracture fragment leads to non-
union .

6- Infection : It is disaster which interfere with healing of

fractures .
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⁕ Clinical picture of a fracture:

1- Mention the characteristic incidence e.g. fracture neck femur

and Colle’s fracture are common in old age.

2- History of trauma ( ask about nature & time ) , followed by severe

pain and inability to move the injured part .

3- Examination :

a) General : ( ABCD)

• Examine air way & confirm free breathing ( AB)

• Hemorrhage & shock (C)

• Careful exam. To exclude associated injuries e.g spinal cord

or visceral injuries.

b) Local: (Exam. should be bilateral and compare both sides

)

• Deformity

• Swelling due to oedema, hematoma & displaced fragments.

• Tenderness: maximum at the site of the fracture.

• Length discrepancy ( shortening or lengthening )

• Skin : wound , bruises or hematoma .

• Diagnosis of any associated vascular or nerve injuries are more

important than diagnosis of the fracture by careful exam. of
distal pulsation with motor and sensory evaluation .

• Examine the related joints to avoid missing of joint injuries.

• Crepitus & abnormal mobility (never try to perform these

signs to avoid complications).
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• Measurements, special tests & D.D: (if present).

Deformity & Length discrepancy are most important

features to diagnose fracture .
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⁕ Investigation:

1) Plain X-ray : (main investigation)

• At least 2 views should be taken as the fracture may not appear

in one view.

• The joint above & below the fracture should be included in the X-
ray film.

• This should be done for 3 times :

➢ One for diagnosis.

➢ One after reduction .

➢ One before removal of the plaster cast to ensure complete

healing .

2) CT scan : only to evaluate intra-articular , spine & pelvis fracture .

3) MRI : only to evaluate spinal cord injury , meniscus or ligaments

injury of knee joint .

⁕ Treatment of Fractures :

I. General measures & 1st aid: (ABCD in major fractures)

1. Keep patent airway, fixation of cervical spine & maintenance of

breathing.

2. Control external bleeding: Better by packing & local pressure

bandage.

3. Anti-shock measures (Mention in short).

4. Dressing for compound fracture, do not reduce prolapsed

bones.

5. Immediate fixation & analgesics to relieve pain.

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a. In the upper limb :

• Usually nowadays upper limb splint by orthosis or

• Arm: Bandage the arm to the chest.

• Forearm : Arm to neck sling .

b. In the lower limb: Lower limb splint by orthosis.

c. Cervical Spine: By collar .

6. Immediate transfer to hospital.

7. In the hospital, immediate clinical exam, to exclude:

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a. Associated chest , hge, , head or visceral injuries which have 1st

priority

b. Major arterial or nerve injuries.

8. Antibiotics, tetanus & gas gangrene prophylaxis for compound

fracture.

II- Local Treatment: Depends on the type of the fracture as follows:

A. Treatment of simple fracture:

1. Reduction of the fracture:

• Aim: bring the 2 fragments in anatomical position & correct

deformity.

• Time : Early before the part gets swollen .

• Methods :

 Reduction is not necessary if displacement is minimal or if

displacement will not leave no functional or cosmetic
disability.

a. Closed reduction: under anesthesia (commonly tried first )

➢ By traction in the long axis of the limb with counter-

traction in the opposite side, followed by restoration of
alignment by direct pressure, against the line of deformity,
on the distal fragment.

b. Open ( surgical ) reduction:

➢ Method: The fracture is exposed & reduced under vision.

➢ Indications: for closed fracture only if :

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1. Failure of closed reduction.

2. Internal fixation is needed.

3. Unstable or avulsion fracture.

4. Fracture dislocation or intra-articular fracture.

5. Associated injuries as arterial or nerve injury .

➢ Contraindications: Compound fracture, infection or in

children.

➢ Complications: Infection & stiffness.

c. Traction: (see fracture shaft of femur)

➢ Aim : skin or skeletal traction to maintain reduction &

fixation.

➢ Indication: Usually used for fractures of long bones of L.L.

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2. Fixation ( immobilization ) of the fracture :

• Aim : Maintain reduction and fixation of fracture fragments till

evidences of union are established as follows:

➢ Loss of pain & tenderness.

➢ Plain X-ray: shows disappearance of the fracture line.

• Methods of fixation:

1) External fixation by plaster of paris (POP):

➢ Indication: Tried first after closed reduction.

➢ Advantages : cheap , safe and does not need extensive

facilities .

➢ Shape : This may be used as a cast , slab, spica (shoulder

or hip), , jacket, collar, Minerva or cast braces (e.g. in
fracture femur, plaster cast is applied to thigh & leg with
connection of the 2 parts with a hinge).
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➢ Duration of application :

 Minor fractures in trunk ( clavicle or ribs ) :For 3 weeks .

 Major fracture in femur, pelvis & spine: For 3 months.

 Shoulder : 4 weeks .

 Arm: For 4-6 weeks .

 Forearm: For 6-8 weeks .

 Leg: For 10-12 weeks.

 Thigh: For 12 weeks.

➢ Rules of application of plaster of paris:

1. The limb is padded with cotton.

2. It should be accurately molded to the limb.

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3. The joint above & below the fracture are included in the
cast.

4. After its application, watch the limb for 24 hours for

circulatory impairment.

5. The edges should not be sharp or press on the skin.

➢ Complications:

 Tight cast may lead to compartment syndrome or

Volkmann’s ischemic contracture.

 Compression of VAN (edema, ischemia & nerve injury).

 Pressure sores :due to tight cast over bony prominence

with little cotton padding .

 Atrophy of muscles & stiffness of joints.

 Loose cast → redisplacement of the fracture fragments.

Cast Slab

Spica
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Minerva

Cast brace

2) Nowadays Orthosis is type of brace which fix a limb or the spine .

It is increasingly popular as it is more comfortable and more safe
than plaster cast .

Knee , ankle & foot arthosis Forearm & wrist arthosis

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3) External fixation by external skeletal fixator: Pins are passed

through the proximal & distal fragments & then connect the pins by
a special metal frame.

• Indication:

➢ Compound fracture (access is required to a wound).

➢ In polytrauma to stabilize the fracture rapidly without adding

more surgical time or trauma .

➢ Open book fracture pelvis.

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3) Traction: a method of reduction & fixation .

4) Internal fixation by operation:

• Indications:

1. After open reduction

2. Liability to non-union or mal-union

3. Pathological fractures

4. Multiple fractures

• Methods:

a. Wire sutures of the fragment e.g. patellar injury.

b. Screws for oblique fracture & fracture near a joint .

c. Plate & screws for transverse & comminuted fractures or

fracture near a joint.

d. Intramedullary nail e.g. fracture neck & shaft of femur or

shaft of tibia.

e. Bone grafts which may be done as ships, inlay or onlay graft

& intra-medullary graft. The donor area may be upper 3/4 of
fibula, anterior border of tibia, iliac crest & ribs. Nowadays
artificial bone graft substitute is available .

• Advantages: Very accurate reduction, perfect fixation & early

mobilization.
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3. Rehabilitation:

• Aim : To prevent stiffness of joints , wasting of muscles and

osteoporosis of bones .

• Methods :

a. While in the plaster cast : Active movement of the joints

which aren't fixed.

b. After removal of the plaster cast: Active & passive

exercises for the joints which were fixed in the cast.

B. Treatment of compound fracture: (see later compound

fracture).

C. Treatment of complications.