Fracture

Break in continuity
•Simple #
•Compound # - / from within or from without
•Pathological #
•

•Mechanism of injury – direct or indirect violence, compression # ,avulsion #

•anatomic site – diaphysis ,metaphysis , epiphysis
•epiphysial # - Salter Harris Classfication
•Stable#- unlikely to move further, Unstable – will continue displacement

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 Types of fracture
• Comminuted # - when bone is fractured in to several pieces.
• Spiral # - due to twisting force from indirect force
• Butterfly # -two break lines spread out obliquely from point of contact
• Segmental # - more than one fracture at different sites in the same bone
• Transverse # - due to bending indirect force
• Oblique # - oblique in out line
• Impacted fracture – when fractured ends interlocked
• Greenstick # - incomplete fracture/children/
• Stress or fatigue # - due to repetitive pressure on bones, always incomplete,
radiologically invisible.
• Avulsion /distraction # - when two fragments of bone are pulled apart
,particularly common where strong muscles insert into small bones – e.g. –
patella - quadriceps/ olecranon - triceps / metatarsal head – peroneal tertius

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 Clinical feature of fracture
• Pain at the site of fracture
• Inability to use the fracture site
• Swelling & tenderness over the #
• Deformity / when fracture ends are displaced
• Abnormal movement at fracture site
• Healing = blood at # site g removed by macrophage g fibrous tissue laid down
by Fibroblast/ fibroblasts,chondrocytes,osteoblasts / calcification & ossification
of fibrous tissue = callus , removal of dead bone by osteoclasts continuing
osteogenesis g consolidation & remodeling at the # site = restore normal
anatomy of the bone. Time to unite depends on age, type of bone involved &
types of # , e.g. – adult, upper limb – unite in 6 weeks, while lower limb take 12
weeks. In children upper limb unite in 3 weeks & lower limb takes 6 weeks.
• Signs of healing – less painfull,less tender,less mobile = rigid + x-ray

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 Principles of treatment
• Reduction – if it is displaced. Correction of
deformity + restoration of normal anatomy.
• Immobilization /alignment of bone during
healing/
• Maintenance of joint mobility by active movt
of joints not immobilized.
• Maintenance of muscle tone/ muscle
exercise/

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 Reduction
• Closed reduction – under L/A, or GA manipulation to restore
normal anatomy
• Immobilization – joints above & below the #. after reduction by
splint( POP, may be of wood or metal).
Traction – continuous traction immobilized fracture a) Skin
traction b) skeletal traction
• Open Reduction & internal fixation(ORIF)
indications – failure of closed reduction , interposition of soft
tissue , displacement of fragments, displacement of inaccessible
intra articular fragments, late unreduced # , failure to maintain
reduction e.g spiral & oblique tibial#, # of radius with dislocation,
transverse patella #, fracture around the joints,

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 ,,,
• Internal fixation – wire, screws, pins, plate & intra medullary nailing/ made
up of stainless steel, titanium…
• Advantage of open reduction –
allows early mobilization of muscles
prevent muscle wasting/,
prevents problems of prolonged immobilization DVT,sores
• Disadvantage of open reduction – sepsis, delayed union &
prolonged morbidity
• Treatment of compound # - depending on the size ,site of the wound LA ,GA
is used. Wound washed debrided.
• External fixation – ST- damage,
leg lengthing &
correction of deformity

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 Complications
• Bleeding g hemorrhagic shock
• Severe pain
• Fat embolism
• Neurovascular injury
• Infection – ST , joint, bone , tetanus, gas gangrene g Sepsis
• Compartment syndrome – pain pallor paresthesia, pulselessness,
coldness, swelling later cyanosis of the exposed skin & tissue.
• Volkmann’s ischemic contracture – due to fibrous contracture of muscle.
• Joint stiffness
• Complication of bone healing – malunion , delayed union & non union
• Psychiatric disorder

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 Specific fractures
• Clavicle # - commonly at the middle third
due to indirect violence( fall-on outstretched arm.
Medial1/2 pulled upward & backward , lateral1/2
pulled down & forward. Rx – figure of 8 bandage/ sling
+ active shoulder exercise.
Complications- non, malunion ,shoulder stiffness,
rarely – brachial plexus or vessel damage
Scapular # - as result of direct blow. At neck, body,
acromion process, coracoid process. Arm rest in
triangular sling.
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 ,,,
• Shoulder dislocation
Anterior , posterior & luxatio erecta
Anterior dislocation – due to fall on outstretched hand or on shoulder itself.
Humerus head – downward & forward direction/ mostly with capsular
damage/
Dx – Hx of fall, pain, position of Pt, flat shoulder, gap below
acromion,palpable humeral head below coracoid process, abducted arm
,internally rotated, all movt restricted. X-ray – easily palpable head, lying
anteriorly inferiorly
• Rx – reduction under diazepam/ CPZ + Pethidine/
 Kocher’s manoeuvre / modified/
 Hippocratic Method
 Prone Method

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 ,,,
Complications
1.Nerve injury – circumflex nerve/ neuropraxia / wasting of
deltoid muscle.
2.Vascular injury – axillary artery/ rupture, thrombosis/
3.Muscle injury – supra spinatus + musculo-tendinous tissue
damage gives rotator – cuff syndrome.
4.Bone injury –grater tuberosity, part of head, neck
5.Recurrent dislocation – most common complication

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 ,,,
• Posterior dislocation – resulted from direct blow on the
front of the joint & fall with the arm outstretched in front
of the body.
Pain, limitation of movement
limitation of external rotation by bony block, humeral
head may appear more prominent posterior
Rx – traction in the long axis with the arm in 90* of
abduction & external rotation = Reduce
• Luxatio Erecta – humeral head driven downward &
trapped below glenoid. Rx – traction in abduction position.

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 Fracture of the humerus
• Greater tuberosity
• Neck of humerus/ anatomical, surgical / - joint stiffness,
malunion,dislocation of the shoulder nerve injury/ axillary or circumflex
nerve may damage.
• Shaft – radial nerve injury
• Supracondylar # - commonest #,90% with displacement (lower
fragment moves backward & upward) – injure brachial or median nerve
( by proximal spike or compression by fragments or by big hematoma ).
This # is the most common cause of Volkmann’s contracture. Other
complications other than vascular & nerve injuries are - joint
stiffness,myositis ossificans,malunion.
• Supra condylar # , intercondylar#, fracture of medial & lateral
epicondyle & Capitellum.

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 ,,,
• Elbow dislocation
Usually posterior or posterolateral. Displaced backwards & laterally.
Complications – ulnar or median nerve & brachial artery, myositis ossificans,joint
stiffness.
Fracture of the forearm
1. # of olecranon process
2. # of the Coronoid process
3. # of the head of radius
4. # of the radius & ulna
5. Isolated # of ulna
6. Monteggia # - # of upper third of ulna + radial head dislocation
7. Galleazzi # - radial shaft # + distal radioulnar dislocation.
8. Colles’s # - distal radial # with dorsolateral displacement & dorsal rotation
9. Smith’s # - distal radial # with anterior displacement & anterior rotation.

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