Fractures

Definition:
Interruption of bone continuity

Types
Acc. to mech. of inj.
1- Traumatic: dt. significant trauma
2- Path.: dt. mild tr. to a diseased bone e.g. bone cyst
3- Stress: dt. unusual repeated stresses on a normal bone

Trauma may be:

Direct Indirect Ms. violence

# at site of impact # away from Sudden forcible
site of impact uncoordinated
ms. cont. → Avulsion #
Types
Acc. to extent
1- Complete
2- Incomplete = Fissure
3- Green stick in children

Acc. to shape
1- Tv.
2- Oblique
3- Spiral
4- Comm. → > 2 frag.
5- Double level = Segmental
6- Impacted: one fragment is driven into the other.

Acc. to presence of a wound

1- Closed = Simple →→ skin overlying # is intact
2- Open = Compound →→ overlying wd. communicating ѐ # site
 DIAGNOSIS

History →→ age, sex, mech. of trauma

Examination
Tenderness
Swelling
Deformity
Loss of function
Abn. Mobility = Crepitus →→ XXXXXXX

X-ray
To confirm diagnosis & plan R/ acc. to site, type, shape
Rule of “ 2 ”
 TREATMENT

I- 1st aid:

1- Splintage: to relieve pain & prevent soft tissue damage dt. # displacement
ex. UL →→ Sling
LL →→ Thomas or padded pieces of wood.

2- Open #: Sterile dressing & arrest bleeding by bandage & elevation

3- Concomitant conditions: shock, head & visceral inj. →→ PRIORITY

 II- Definitive # R/

1- Reduction of displaced #
 Closed: MUA →→ ↓ pain & provide ms relax.
+ Immobilization external →→ plaster or Ex. Fix.
or IF →→ K-wire, screw, MIPO, IMN.
 ORIF
 Fracture Classification
Why Classify?

• Treatment guide
• Prognosis
• To speak a common
language with others in
order to compare RESULTS
 As a Treatment Guide

• If the same bone is broken,

the surgeon can use a
standard treatment
 To Assist with Prognosis

• You can tell the patient

what to expect with the
results
• PROBLEM: Does not
consider the soft tissues
or other compounding
factors
 To Speak A Common Language

• This will allow results to be

compared
• PROBLEM: Poor interobserver
reliability with existing
fracture classifications
 OTA Classification
• There has been a need for an organized,
systematic fracture classification
• Goal: A comprehensive classification
adaptable to the entire skeletal system!
• Answer: OTA Comprehensive Classification
of Long Bone Fractures
With a Universal Classification…
You go from x-ray….

To…
Treatment
Implant options
Results
 To Classify a Fracture

• Which bone?
• Where in the bone is the fracture?
• Which type?
• Which group?
• Which subgroup?
 Using the OTA Classification
• Which bone? •Where in the bone?
Proximal & Distal Segment Fractures
• Type A
– Extra-articular
• Type B
– Partial articular
• Type C
– Complete disruption of
the articular surface
from the disphysis
 Diaphyseal Fractures
• Type A
– Simple fractures with two
fragments
• Type B
– Wedge fractures
– After reduced, length and
alignment restored
• Type C
– Complex fractures with no
contact between main
fragments
 Grouping-Type A

1. Spiral
2. Oblique
3. Transverse
 Grouping-Type B

1. Spiral wedge
2. Bending wedge
3. Fragmented wedge
 Grouping-Type C

1. Spiral
multifragmentary
wedge
2. Segmental
3. Irregular
 Subgrouping
• Differs from bone to bone
• The purpose is to increase the precision of
the classification
 OTA Classification
• Open for change when appropriate
• Allows consistency in research
• Builds a description of the fracture in an
organized, easy to use manner
 Closed Fractures
 Fracture is not exposed to the environment
 All fractures have some degree of soft tissue
injury
 Commonly classified according to the
Tscherne classification
 Don’t underestimate the soft tissue injury
as this affects treatment and outcome!
 Closed Fracture Considerations
 The energy of the injury
 Degree of contamination
 Patient factors
 Additional injuries
 Tscherne Classification

• Grade 0 • Grade 1

 Minimal soft tissue – Injury from within

injury – Superficial contusions
 Indirect injury or abrasions
 Tscherne Classification
• Grade 2
 Direct injury
 More extensive soft
tissue injury with
muscle contusion,
skin abrasions
 More severe bone
injury (usually)
 Tscherne Classification
• Grade 3
 Severe injury to soft tissues
 Degloving with destruction
of subcutaneous tissue and
muscle
 Can include a compartment
syndrome, vascular injury

Closed tibia fracture

Note periosteal stripping
Compartment sundrome
 Open Fractures
 A break in the skin
and underlying soft
tissue leading
directing into or
communicating with
the fracture and its
hematoma
 Open Fractures
 Commonly described by the Gustilo system
 Model is tibia fractures
 Routinely applied to all types of open
fractures
 Gustilo emphasis on size of skin injury
 Open Fractures
 Gustilo classification used for prognosis
 Fracture healing, infection and amputation rate
correlate with the degree of soft tissue injury by
Gustilo
 Fractures should be classified in the operating
room at the time of initial debridement
 Evaluate periosteal stripping
 Consider soft tissue injury
 Type I Open Fractures
 Inside-out injury
 Clean wound
 Minimal soft tissue
damage
 No significant
periosteal stripping
 Type II Open Fractures
 Moderate soft tissue
damage
 Outside-in mechanism
 Higher energy injury
 Some necrotic muscle,
some periosteal stripping
 Type IIIA Open Fractures
 High energy
 Outside-in injury
 Extensive muscle
devitalization
 Bone coverage with
existing soft tissue not
problematic
Note Zone of Injury
 Type IIIB Open Fractures
• High energy
• Outside in injury
• Extensive muscle
devitalization
• Requires a local flap
or free flap for bone
coverage and soft
tissue closure
• Periosteal stripping
 Type IIIC Open Fractures
• High energy
• Increased risk of
amputation and
infection
• Major vascular injury
requiring repair
Mechanics of fractures
Bone can be considered as a biphasic composite material, mineral as one phase, and
collagen and ground substance as the other

The combined substances are stronger for their weight than either substance alone

Cortical bone is stiffer than cancellous bone and more brittle, withstanding less strain
before failure than cancellous bone

• Fracture occurs in cortical bone at strains of only 2%

• Fracture occurs in cancellous bone at strains of > 75%
Bone is VISCOELASTIC (= time dependent
property where the deformation of the
material is related to the rate of loading,
hysteresis, creep, stress relaxation)

Load deformation curve for bone compared to

other materials = the elastic portion of the
graph has a slight curve in bone.
Bone is ANISOTROPIC (i.e. it has different
mechanical properties when loaded along
different axes). This is because the structure of
bone is dissimilar in the transverse and
longitudinal directions

Adult cortical bone is stronger in compression

than tension and weakest in shear.
 Most fractures occur as a result of several loading modes

Tension
At the microscopic level, the failure mechanism
for bone loaded in tension is mainly debonding
at the cement lines and pulling out of the
osteons

The type of fracture occurring in Tension is a

Transverse fracture

Tension #s tend to occur in areas with a large

proportion of cancellous bone eg. calcaneus,
5th metatarsal
 Compression
At the microscopic level the failure mechanism
for bone tissue in compression is mainly
oblique cracking of the osteons

The type of fracture that occurs in compression

is an oblique fracture at an angle of 30 degrees
as shear forces at this angle are responsible for
the failure.

There are few fractures which occur purely due

to compression

These fractures tend to occur in the

metaphyses of bones where there is more
cancellous bone which is weaker.
 Bending

In bending there is a combination of

compression and tension.

Tensile stresses and strains on one side of the

neutral axis and compressive stresses and
strains on the other side.

Because bone is asymmetrical, the

compressive and tensile stresses may not be
equal

Bending causes transverse fractures as failure

on the tension side progresses transversely
across the bone and the neutral axis shifts.
Three point bending- three forces act on a
structure produce 2 equal moments, each
being the product of one of the two peripheral
forces and the distance to the axis of rotation
(the point at which the middle force is applied.

If loading continues to yield point assuming the

structure is homogenous and symmetrical, it
will break at the point of application of the
middle force. Fracture begins on the tension
side in adult bone as bone is weaker in tension
than compression.

Examples include skiboot fractures of the tibia.

In immature bone it may fail by compression
causing buckling on the compression side
Four point bending- Two force couples acting
on a structure produce two equal moments.
The magnitude of the bending moment is the
same throughout the area between the two
force couples. The structure will break at its
weakest point between them.

Eg a previous unhealed fracture.

Compression and bending combined
A combination of fracture type occurs. Bending
produces a transverse crack on the tensile side
of the bone, compression causes an oblique
fracture on the other side. Where they meet a
butterfly segment results
Torsion
A load is placed on a structure so that twisting
occurs about an axis. A torque or moment is
produced within the structure.
Maximal shear stresses act in planes parallel
and perpendicular to the neutral axis
Maximal tensile and compressive forces act on
planes diagonal to the neutral axis

• The fracture for a bone loaded in torsion is

a spiral fracture.
• It begins with failure in shear, with the
formation of a crack parallel to the neutral
axis of the bone
• Followed by failure in tension along the line
of maximal tensile stress at a diagonal to
the axis
Shear
• A structure subjected to shear loading
deforms internally in an angular manner,
right angles on a plane surface within the
structure become obtuse or acute.
• Whenever a structure is subject to
compressive or tensile loading, shear stress
is also produced
• The value for the stiffness of a material
under shear loading is known as the shear
modulus, not elastic modulus
• Shear fractures tend to occur in cancellous
bone eg. Femoral condyles, tibial plateau.
Influence of muscle activity & loading on
stress distribution in bone
When bone is loaded in vivo, simultaneous
contraction of surrounding muscles act to
oppose these loads, so that it can withstand
higher loads.

Wolff's Law (Julius Wolff, 1884)

'Form Follows Function‘

Bone has the ability to adapt, by changing its

size, shape, and structure, to the mechanical
demands placed on it.
Bone is laid down where needed and resorbed
where not needed.
The remodelling may be either external (a
change in the external shape of the bone) or
internal (a change in the porosity, mineral
content, and density of bone).
Fatigue fracture of bone
Caused by repeated applications of a load
below the ultimate strength/stress of the bone
The fatigue process in living bone is affected by
the amount of load, the number of repetitions
and the frequency of loading. Fatigue fracture
only occurs when the rate of remodelling is
outpaced by the fatigue process.

Fatigue fractures tend to occur during

continuous strenuous physical activity causing
the muscles to fatigue and reduces their ability
to contract and counteract the imposed
loading.
Bone remodelling

• Wolff’s law – Bone is laid down where

needed and resorbed where not needed
• Thus disuse leads to sub-periosteal and
periosteal bone resorption, reducing its
stiffness and strength.
• Stress protection of bone- is a phenomenon
whereby an implant, by sharing the
imposed load can cause resorption of the
underlying/surrounding bone as this bone
carries less load than normal.
• Bone hypertrophy can also occur at implant
attachment sites, eg. Around screws.
• Laying down of bone can occur as a result
of strenuous exercise, or resorption can
occur in prolonged weightlessness or
inactivity.
Changes in bone associated with aging
Progressive loss of bone density occurs with
age
Young bone is more ductile /less brittle than
older bone, so more strain before breakage is
allowed in young bone.
Thank You!