Fractures

Dr. Haonga
 Definition
• Fracture is the break in the structural
continuity of the bone
• Break may be:
– Complete bone fragments are displaced
– Incomplete
• Crack
• Crumpling
• Splintering
 Etiology
• Fractures results from:
– Single traumatic incident
– Repetitive stress: in athletes
– Abnormal weakening of the bone (pathological):
old patients especially women, bone weaken due
to fracture
• A force which twist the bone
• A weak bone will have a fracture which is
circular
• Low oblique fracture
• High oblique fracture
• A transverse medial fracture
 Traumatic incident
• Sudden and excessive forces which may be :
– Direct force
• Bone break at the point of impact
• Cause: transverse fracture, damage to the overlying
skin
– Crushing:
• Cause: communited fracture(more than two
fragments), extensive soft tissues damage
• Indirect force:
– Bone breaks at a distant from where the force is
applied
– Most fractures are due to combination of forces
• Twisting-spiral fracture
• Compression-short oblique fracture
• Bending-margin butterfly fragment]
• Tension tend to break bone transversely
– Avulsion of small fragment at point or tendon
insertion
• Cancellous bone(vertical bones: vertebra and
calcaneum) sustain a communited crush
fracture
• Resisted extension may cause avalursion
fracture of
– Patella
– Olecranon
 Fatigue or stress fracture
• Fracture may occur due to repetitive stress
seen in:
– Tibia
– Fibula
 Pathological fracture
• Fracture when bone has been weakened by
change in its structure
– Osteoporosis
– Paget’s diseases: fight between bone forming and
bony breaking
– Osteomyelitis
– Lytic lesion: secondary to metastasis to the bone
• Bony cyst
• Metastasis: prostate cancer in male-doesn’t cause a typical
bone lesion, combination btn bone forming and bone lytic,
renal cell carcinoma
– Trauma in multiple myeloma, osteosarcoma
 Types of fractures
• For practical purpose they are divided into few
well defined groups
• Complete fracture
– Bone is completely broken into two or more
fragments
– Transverse-stable
– Oblique or spiral-tend to slip and re-displace
– Impacted fracture fragments are jammed together
– Communited- are more than two fragments
• unstable
• Incomplete fracture
– Bone is incompletely divided
– Periosteum remains in continuity eg green stick
fracture seen in children
– Compression fracture
• Cancellous bone is crumpled eg vertebral bodies
• Reduction is impossible if not operated
 Classification fracture
• An alpha numerical classification of fracture
• Can be used for computer storage and
retrieval
• Developed by Muller
• 1st digit specifies the bone
– 1. Humerus
– 2. Radius and ulnar
– 3. Femur
– 4. Tibia and fibula
• 2nd digit specifies the segments
– 1. proximal
– 2. diaphyseal
– 3. distal
– 4. malleolar
• A letter specifies the type of fracture
– Diaphysis
– A. simple
– B. wedge
– C. complex
 – Proximal/distal
• A-extra articular
• B-partial articular
• C-complete articular
• Tailored classification for specific fracture are
more useful for assessing prognosis and
planning treatments
 How fractures are displaced
• After complete fracture, fragments are displaced
due to:
– Force of injury
– Gravity
– Pull of muscle attaches to them
• Displacement is described in terms of:
– a. Translation (shift)
• Side ways: could be medial, anterior, posterior or lateral
• Back ways or forwards
• Overload
• Impaction:
• b. Alignment (angulations)
– Tilted or angulated in relation to each other
– If uncorrected may lead to deformity of the limb
• c. Rotations (twist)
– One fragment rotated on its longitudinal axis
• Length
– Fragments may be:
• Distracted and separated
• Overlaps: cause slow healing
 Clinical features
• History of injury followed by:
– Inability to use the limb
– Beware fracture may be at the site of injury
– Patient’s age and the mechanism of injury are important
• With trivial trauma- pathologic
• Common symptoms:
– Pain
– Bruising: never bleed
– Swelling
– Deformity is much more suggestive
– Laceration
• Symptoms of associated injuries
– Numbness or loss of movement
– Skin pallor or cyanosis
– Abdominal pain: tells whether there is visceral injury
– Blood in urine: injuries to the bladder or urethra
– Difficult in breathing
– Transient loss of consciousness
• Ask about:-
– Previous injury
– Any other musculoskeletal abnormalities
• General medical history is important
 General signs
• Give priority to dealing with general effect of
trauma
– Follow A, B, C
• Local sign
– Handle gently the injured tissues
– Crepitus or abnormal movements
– Clinical examination: look, feel and move
• Look
– Swelling
– Bruising
– Deformities
• is skin intact:
– If broken, wound communicate with fracture is open
(compound)
– Posture of the digital extremity
– Color of the skin
• Feel
– Gently palpate for localized tenderness
– Common and characteristic associated injuries should be felt for
– In high energy injury examine
• Spine
• Pelvis
• Vascular and peripheral nerve abnormalities
• Move
– Crepitus
– Abnormal movements
– If X-ray available not necessary
• X-ray mandatory
– Remember the rule of two’s
• Two views eg AP, lateral
• Two joint in forearm or leg
– One bone fracture and other dislocated
– Joints above or below fracture must be included
• Two limb e
– X-ray of un injured are needed for the comparison
• Two injuries
– Severe forces causes injuries at more than one leve
• Two occasions
• One X-ray soon after injury, another at a week or two
later may show the lesions eg
– Fracture femoral neck
– Fracture of lateral malleolus
– Fracture of the scaphoid
– Fracture of the
 Special imaging
• Sometimes the fracture is not apparent on the
plain x-ray
– 1. Tomography
• Lesion of the spine
• Fracture of tibia condyla
– 2. CT or MRI
• Fracture of vertebral is threatening to compress the SC
• Acetabulum
• Calcaneum
– 3. Radioscope scanning
• Stress fracture
• Undisplaced fracture
 Treatment of closed fracture
• General treatment
– Treat the patient not only the fracture
– Treatment of fracture consist of:-
• Manipulation to improve the position of fragments
• Splintage to hold them together
• Joint movement or function must be preserved
• Reduce
– After general treatment and resuscitation
– Reduction must be performed within 12 hours
• Situation in which reduction is unnecessary
– 1. When there is no displacement
– 2. When displacement does not matter- eg fracture of
clavicle
– 3. Reduction is unlikely to succeed-eg compression
fracture of the vertebra
• Reduction should aim for:
– Adequate apposition
– Normal alignment-putting the two fragment in
contact
• Fracture involving the articular surface, should be
reduced as near to perfection as possible t
prevent degenerative arthritis
• Methods of reduction
– A: closed reduction-under appropriate anesthesia-
muscle relaxation
• Fracture is reduced by 3 fold maneuvers
– 1. Distal part of the limb is pulled in line of the bone
– 3. Reposition of the fragments
– 3. Alignment is adjusted in each plane
• Closed reduction is used for all minimal
displaced fracture
• B: Open reduction
– Operative reduction-indication:
• 1. When closed reduction fails
– Difficulties in controlling the fragments
– Soft tissue ate interposed between them
• 2. When there is a larger articular fragment
• 3. For traction fracture which the fragment are held
apart
 Hold reduction
• Prevention of displacement
• Some restriction of the movements is needed
to promote soft tissue healing and to allow
free movements of un affected parts
• Methods of holding reduction are:
– 1. Continuous traction
• Traction by gravity- to upper injuries fracture ligaments
by triangular arm-string
– 2. Skin traction
• Pull of more than 4 or 5 kg
• In old patient and children
– 3. Skeletal tractions
• Pins are inserted-behind the tibia-tubercle for hip, thighs and
knee fracture
• Through the calcaneum-for tibia fracture
– Is held in:-
• 1. Fixed traction-pull is against a fixed point
• 2. Balanced traction-traction cord are guided over pulled at
the foot of bed
• 3. Combined tractions
 Complication
• Circulatory embarrassment
• Nerve injury-in older people, perineal nerve
injury hence foot drop
• Pin site infection: apply using aseptic
technique
 Cast Splintage
• Plaster of Paris is still widely used
• Patient can go home soon
• Joint in cast are liable to stiffness
• Technique:-
– Reduce the fracture
– Stockinet is threaded over the limb bone points
protected by wool
– Plaster is applied (then mould it following the medial
arch of the patient’s foot)
– If the fracture resent, the plaster is split from the top
to bottom exposing the skin
 Complication
• Tight cast
– Vascular comprtession appears
– Elevate the limb, if pain persit splint the cast
• Pressure sore
• Skin abrasions or lacerations
– Complication of removing the plaster
• Electric saw
• Loose cast
– Not holding the fracture seecurely
– Should be displaced
 Functional bracing
• Segment of the cast are applied only over the
shafts of the bone, leaving the joints free
• Casts segments are connected
 Internal fixation
• Bone fragments may be fixed with
– Screw
– Transfixing pins or nails
– Metal plate hold by screw
– A long inter medullary nail
• The greater danger is sepsis
– Risk of infection depends on:
• 1. The patient
– Devitalized tissue
– Dirty wounds
– Unfit patients
 • 2. the surgeon
• 3. facilities
– Aseptic routine
– Full rang of implatrs
– Indication for internal fixation
• 1. Fracture that cant be reduced except by operation
• F that are unstable and prone to re-displacement
– Mid shaft fracture of forearm
– Displaced ankle fracture
– Those liable to be pulled apart by muscles eg transverse
fracture of patella and olecranon
 • 3. fracture that unite poorly and slowly eg femoral neck
• 4. pathological fracture in which bone disease may
prevent healing
• 5. multiple fracture in which early fixation reduces the
risk of general complication
– Fracture in patient who present nursing
difficulties:
• Paraplegia
• With multiple injuries
• Very elderly
 Types of internal fixation
• Inter fragmentary screws
– Partial threaded
– Exert a compression of lag effect when inserted
across two fragment
• Wires (transfixing, cerclage and tension band)
– Trans fixing wires
• Past percutenilly used in fracture which healing is quick
eg in children
– Cerclage
• Plate and screws
– Has five different fxn
– 1. neutralization- when used to bridge a fracture
and supplement the effect inter fragmentary lag
screw
– 2. compressio-used in metaphysea;
– 3. buttressing
– 4.antiglide
• Inter-medullary nails
– Suitable for long bones
– Nails is inserted into medullary canal to splint the
fracture
– Interlocking screw can be introduced to prevent
rotational forces
– Nails are used with or without prior reaming of
medullary canal
– Reaming cause temporarily loss of inter-medullary
blood supply
 Complication of internal fixation
• Due to:
– Poor technique
– Poor equipments
– Poor operating condition
1.Infections: iatrogenic is common cause of
chronic osteomyelitis
2.Non-union: if bones are fixed rigidly with a
gap between the ends
1.Stripping of the soft tissue and the blood
• 3. implant failure
– Avoid stress to the metal plate
– Patient should start to walk with crutches with
minimal weight bearing for 1st 3 months
• 4. re-fracture
– Do not remove metal implants soon
– A year is minimum
– 18-24 months safer