GENERAL

PRINCIPLES OF
FRACTURE
MANAGEMENT

Mr Nagaraj,prashanth
MBBS,MS(Ortho), MRCS Ed, FRCS Ed (Tr&Orth)
 • A FRACTURE IS A BREAK IN THE STRUCTURAL CONTINEUITY OF THE
BONE.
• THE BREAK IS INCOMPLETE/COMPLETE, AND THE BONE FRAGMENTS
MAY BE DISPLACED/UNDISPLACED.

DEFINITION OF
FRACTURE
THE AO DEFINITION
OF FRACTURE

FRACTURE IS A SOFT
TISSUE INJURY WHERE
THE BONE IS
BROKEN!!!!
HOW DO FRACTURES
HAPPEN?
• FRACTURES RESULT FROM:
• 1. INJURY
• 2. REPETITIVE STRESS
• 3. ABNORMAL WEAKENING OF THE BONE (A ‘PATHOLOGICAL’ FRACTURE)
 THE FUNDAMENTALS OF FRACTURE
CLASSIFICATION
•IF THE OVERLYING SKIN REMAINS INTACT IT IS A CLOSED (OR SIMPLE)
FRACTURE

• IF THE SKIN OR ONE OF THE BODY CAVITIES IS BREACHED IT IS AN

OPEN (OR COMPOUND) FRACTURE
THE TYPES OF FRACTURES CAUSED
DUE TO INJURY
 FATIGUE OR STRESS
FRACTURES

• BONE , LIKE OTHER MATERIALS , REACTS TO REPEATED

LOADING .

ON OCCASION , IT BECOMES FATIGUED & A CRACK DEVELOPS .

E.G MILITARY INSTALLATIONS , BALLET DANCERS & ATHLETES.

A SIMILAR PROBLEM OCCURS IN INDIVIDUALS WHO ARE ON

MEDICATION THAT ALTERS THE NORMAL BALANCE OF BONE
RESORPTIONAND REPLACEMENT

E.G. PATIENTS WITH CHRONIC INFLAMMATORY DISEASES WHO

ARE ON TREATMENT WITH STEROIDS OR METHOTREXATE
 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.
THROUGH A LYTIC LESION.
A BONE CYST OR A METASTASIS.
 MECHANISM OF INJURY
CLASSIFICATION
•DIRECT TRAUMA
1. TAPPING FRACTURES
2. CRUSHING FRACTURES
3. PENETRATING FRACTURES:HIGH VELOCITY,LOW VELOCITY
•INDIRECT TRAUMA
1.TRACTION OR TENSION FRACTURES
2.ANGULATION FRACTURES
3.ROTATIONAL FRACTURES
4.COMPRESSION FRACTURES
 WRAPPING UP
CLASSIFICATION….
• ANATOMICAL LOCATION
• CONDITION OF OVERLYING SOFT TISSUE
• DIRECTION OF FRACTURE LINE
• MECHANISM OF INJURY
• WHETHER THE FRACTURE IS LINEAR OR COMMINUTED
THE CLINICAL DIAGNOSIS
OF A FRACTURE
• HISTORY OF TRAUMA
• SYMPTOMS AND SIGNS:
1. PAIN AND TENDERNESS
2. SWELLING
3. DEFORMITY
4. BONY CREPITUS
5. LOSS OF FUNCTION
6. NERVE AND VASCULAR INJURY
THE RADIOLOGICAL
DIAGNOSIS OF A
FRACTURE • X-RAY:
• SHOULD SHOW JOINT ABOVE AND JOINT
BELOW IN AT LEAST 2 VIEWS, SPECIAL
VIEW ON REQUEST.

• CT SCAN

• MRI:
IT IS NOT HELPFUL IN FRACTURE
DIAGNOSIS OTHER THAN DELINEATING
ASSOCIATED INJURIES TO THE CNS ,
SUBTROCHANTERIC (ST) DISRUPTION OR
OCCASIONALLY FATIGUE FRACTURE
 FRACTURE
MANAGEMENT:
•TREATMENT OF CLOSED FRACTURES

•TREATMENT OF OPEN FRACTURES

 TREATMENT OF CLOSED
FRACTURES

•EMERGENCY CARE (SPLINTING)

•DEFINITIVE FRACTURE TREATMENT

•REHABILITATION (MUSCLE ACTIVITY AND EARLY

WEIGHT BEARING ARE ENCOURAGED.
 SPLINTING
•SPLINT THEM WHERE THEY LIE.
•ADEQUATE SPLINTING IS DESIRABLE.
•TYPE OF SPLINTS:
1.IMPROVISED
2.CONVENTIONAL
 DEFINITIVE
FRACTURE TREATMENT
• THE GOAL OF FRACTURE TREATMENT IS TO OBTAIN
UNION OF THE FRACTURE IN THE MOST ANATOMICAL
POSITION COMPATIBLE WITH MAXIMAL FUNCTIONAL
RETURN OF THE EXTREMITY
• 2 TYPES OF DEFINITIVE FRACTURE
TREATMENT:CONSERVATIVE AND SURGICAL
 • REDUCTION: IF DISPLACED UNDER GENERAL
ANASTHESIA, THE SOONER THE BETTER
• STEPS OF REDUCTION: • TRACTION • ALIGN
CONSERVATIVE (WHICH FRAGMENT) • REVERSE MECHANISM
OF INJURY
FRACTURE
TREATMENT • IMMOBILIZATION: POP (PLASTER OF PARIS)
CAST, SLAB, TRACTION (FIXED OR BALANCED)
• REHABILITATION
 SURGICAL
FRACTURE
TREATMENT
•OPEN REDUCTION
INTERNAL FIXATION
(ORIF)

•PERCUTANEOUS
PINNING

•EXTERNAL FIXATION
 OPEN REDUCTION INDICATIONS
•OPERATIVE REDUCTION OF THE FRACTURE IS INDICATED:
1.WHEN CLOSED REDUCTION FAILS

2.WHEN THERE IS A LARGE ARTICULAR FRAGMENT THAT NEEDS

ACCURATE POSITIONING

3.FOR TRACTION (AVULSION) FRACTURES IN WHICH THE FRAGMENTS

ARE HELD APART
INTERNAL FIXATION
INDICATION
1. FRACTURES THAT CANNOT BE REDUCED EXCEPT BY
OPERATION

2. FRACTURES THAT ARE INHERENTLY UNSTABLE AND

PRONE TO RE-DISPLACE AFTER REDUCTION

3. FRACTURES THAT UNITE POORLY AND SLOWLY

4. PATHOLOGICAL FRACTURES IN WHICH BONE DISEASE

MAY PREVENT HEALING

5. MULTIPLE FRACTURES WHERE EARLY FIXATION REDUCES

THE RISK OF GENERAL COMPLICATIONS.

6. FRACTURES IN PATIENTS WHO PRESENT NURSING

DIFFICULTIES
EXTERNAL FIXATION
•• INDICATIONS:
INDICATIONS:

• FRACTURES ASSOCIATED WITH

SEVERE SOFT-TISSUE DAMAGE
(INCLUDING OPEN FRACTURES) OR
THOSE THAT ARE CONTAMINATED
• FRACTURES AROUND JOINTS THAT
ARE POTENTIALLY SUITABLE FOR
INTERNAL FIXATION BUT THE SOFT
TISSUES ARE TOO SWOLLEN TO
ALLOW SAFE SURGERY
• PATIENTS WITH SEVERE MULTIPLE
INJURIES
• UNUNITED FRACTURES, WHICH CAN
BE EXCISED AND COMPRESSED
• INFECTED FRACTURES
REHABILITATION
• RESTORE FUNCTION – NOT ONLY TO THE INJURED
PARTS BUT ALSO TO THE PATIENT AS A WHOLE
THE OBJECTIVES ARE:
1. TO REDUCE OEDEMA
2. PRESERVE JOINT MOVEMENT
3. RESTORE MUSCLE POWER
4. GUIDE THE PATIENT BACK TO NORMAL ACTIVITY
 TREATMENT OF OPEN
FRACTURES

•INITIAL MANAGEMENT

•CLASSIFYING THE INJURY

•DEFINITIVE TREATMENT
 INITIAL
MANAGEMENT
• IT IS ESSENTIAL THAT THE STEP-BY-STEP APPROACH IN
ADVANCED TRAUMA LIFE SUPPORT NOT BE FORGOTTEN

• WHEN THE FRACTURE IS READY TO BE DEALT WITH:

• THE WOUND IS CAREFULLY INSPECTED
• ANY GROSS CONTAMINATION IS REMOVED
• THE WOUND IS PHOTOGRAPHED
• THE AREA THEN COVERED WITH A SALINE-SOAKED DRESSING
• THE PATIENT IS GIVEN ANTIBIOTICS
• TETANUS PROPHYLAXIS IS ADMINISTERED
• THE LIMB CIRCULATION AND DISTAL NEUROLOGICAL STATUS CHECKED
REPEATEDLY
 GRADING THE SEVERITY
OF TYPE III
FRACTURES.

• THERE ARE THREE GRADES OF SEVERITY:

• TYPE III A : THE FRACTURED BONE CAN BE ADEQUATELY COVERED BY

SOFT TISSUE DESPITE THE LACERATION.

• TYPE III B : THERE IS EXTENSIVE PERIOSTEAL STRIPPING AND

FRACTURE COVER IS NOT POSSIBLE WITHOUT USE OF LOCAL OR
DISTANT FLAPS.

• TYPE III C : THERE IS AN ARTERIAL INJURY THAT NEEDS TO BE

REPAIRED, REGARDLESS OF THE AMOUNT OF OTHER SOFT-TISSUE
DAMAGE.
 PRINCIPLES OF
TREATMENT

• ALL OPEN FRACTURES, NO MATTER HOW TRIVIAL THEY

MAY SEEM, MUST BE ASSUMED TO BE CONTAMINATED

• THE FOUR ESSENTIALS ARE:

1. ANTIBIOTIC PROPHYLAXIS.
2. URGENT WOUND AND FRACTURE DEBRIDEMENT.

3. STABILIZATION OF THE FRACTURE.

4. EARLY DEFINITIVE WOUND COVER.
AFTERCARE
• IN THE WARD, THE LIMB IS ELEVATED AND
ITS CIRCULATION CAREFULLY WATCHED.
• ANTIBIOTIC COVER IS CONTINUED BUT ONLY
FOR A MAXIMUM OF 72 HOURS IN THE MORE
SEVERE GRADES OF INJURY .
• WOUND CULTURES ARE SELDOM HELPFUL, IF
IT WERE TO ENSUE, IS OFTEN CAUSED BY
HOSPITAL-DERIVED ORGANISMS.
THANK YOU