FRACTURES-

13th
13th Syllabus (bfu) :-
General Principles of Fractures
Clinical Presentation
Treatment and Newer Methods
Fracture Healing and Rehabilitation
& 3rd in Syl- Wounds and ML
Aspects
 *****Bone Fractures*****
• A break in a bone
• Types of bone fractures
Closed (simple) fracture – break that does
not penetrate the skin
Open (compound) fracture – broken bone
penetrates through the skin
• Bone fractures are treated by reduction
and immobilization
Realignment of the bone
 ** Types of Fractures *
 Simple fracture
 Compound fracture
 Comminuted fracture
 Stress fractures
 Others :-
Others in next Slides
 Bone Fractures
(types Other/Terms .)
• Closed (simple)
• Open (compound)  Impacted

 Depressed
• Complete
 Linear
• Incomplete
• Greenstick
 Transverse
• Hairline  Oblique
• Comminuted  Spiral
• Displaced  Colles
• Nondisplaced  Potts
4
**** Open vs. Closed***
• Open fracture
– AKA: “Compound fracture”
– A fracture in which bone
penetrates through skin;
– “Open to air”
– Some define this as a fracture
with any open wound or soft
tissue laceration near the bony
fracture
• Closed fracture
– Fracture with intact overlying
skin
*** Bone Healing ***
• Questions
Little Revision
•Fracture - break in Continuity of bone
•Dislocation.. Of Joint
•Subluxation..Some contact in Articular surfaces Left
•Sprain…tear of ligament painful
 ***Repair of Bone Fractures-
Stages***
1. Hematoma (blood-filled swelling) is formed (1 to 2
days )
2. Cellular stage.. FibroVascular tissue, Fibrous Granulation
3. Break is splinted by fibrocartilage to form a callus
4. Fibrocartilage callus is replaced by a bony callus (8 to
10 week)
5. Bony callus is remodeled to form a permanent patch
 ** Stages of Bone Healing
**
1. Hematoma (1
to 2 days )
• Cellular
stage..
Fibrous
Granulation
2. Break is
splinted by
fibrocartilage to
form a callus
3. bony callus
(8 to 10
week)
4. Bony callus is
remodeled
to form a
permanent
 ***REPAIR OF BONE
FRACTURES
Local Factors FACTORS***
1.Improper immobilisation
2.Infection
3.Interposed Soft Tissue
General :-
1. Poor Blood supply
2. Old Age
3. Proteins deficiency, anaemia
4. Diabetes, HIV, Steroids etc
 5. External
Fixation

• Permits adjustment of length and angulation

• Some allow reduction of the fracture in all 3 planes.
• Especially applicable to the long bones and the pelvis.
• Indications:
1. Fractures associated with severe soft-tissue damage where the wound can be
left open for inspection, dressing, or definitive coverage.
2. Severely comminuted and unstable fractures, which can be held out to length
until healing commences.
3. Fractures of the pelvis, which often cannot be controlled quickly by any other
method.
4. Fractures associated with nerve or vessel damage.
5. Infected fractures, for which internal fixation might not be suitable.
6. Un-united fractures, where dead or sclerotic fragments can be excised and the
remaining ends brought together in the external fixator; sometimes this is
combined with elongation in the normal part of the shaft
 Debridement and Wound
Excision
• In the operating theatre, never in the ER!
• Under GA
• Maintain traction on injured limb and hold it still
• Remove clothing
• Replace dressing with sterile pad
• Clean and shave surrounding skin
• Remove pad and irrigate wound with A LOT of warm normal saline
• Do not use a tourniquet!
• Extend wound and excise ragged margins healthy skin edges
• Remove foreign materials and tissue debris
• Wash out wound again with warm NS (6-12 L)
• Remove devitalized tissue
• Best to leave cut nerves and tendons alone
 After Gen Fractures
Specific Mandible Maxila
and Face will be taken
Separately in Oral and FM
Surgery
• I started with Basic Anatomy of skeletal System
• Next Joint and other Ortho problems in BRIEF ??
Syllabus says only
o General Principles of Fractures
o Clinical Presentation
o Treatment and Newer Methods
o Fracture Healing and Rehabilitation
 Classifications of Wounds and
Medicolegal Aspects
In Syllabus of BFU

Wounds their Classification, Wound Healing,,Repair of

Wounds, Treatment of Wounds and Complications of
Wounds
(indirectly Factors influencing Healing)
MedicoLegal Aspects of Accidental
Wounds
Some terms Willingly, Motive , Intension
 Classifications of Wounds and
Medicolegal Aspects
In Syllabus of BFU
Wounds their Classification ( I will take Tips Practical Only
MedicoLegal Aspects of Accidental Wounds
Some terms Willingly, Motive , Intension

Classifications
– Tidy or Dirty
– Open Closed
– Blunt Incised, Punctured, Gun shot
– Accidental,Homicidal,Self inflicted
 ** Classifications of Wounds
and Medicolegal Aspects **
Wounds their Classification ( I will take Tips Practical Only
Classifications
– Tidy or Dirty
– Open /Closed
– Blunt Incised, Punctured, Gun shot
– Accidental,Homicidal,Self inflicted
o Closed
– Abrasion
– Contusion
o Open Wounds
– Lacerated and Incised Looking
– Incised
– Punctured and Penetrating
– Gunshot
 ** Classifications of Wounds
and Medicolegal Aspects **
Wounds their Classification ( I will take Tips Practical Only
Classifications
– Tidy or Dirty
– Open /Closed
– Blunt Incised, Punctured, Gun shot
– Accidental,Homicidal,Self inflicted
o Closed
– Abrasion
– Contusion
o Open Wounds
– Lacerated and Incised Looking
– Incised
– Punctured and Penetrating
– Gunshot
 ** Classifications of Wounds
and Medicolegal Aspects **
Wounds their Classification ( I will take Tips Practical Only
Classifications
– Tidy or Dirty
– Open /Closed
– Blunt Incised, Punctured, Gun shot

– Accidental,Homicidal,Self inflicted
o Accidental - Associated Injuries lead
o Homicidal -Associated Trauma important
o Self inflicted /Friendly Hand/ By
Doctor/Dental Surgeon
 THANKS

Dr. Satvir Chaudhary,

M.S. (Surg), MISFS, FCGP,
LLB, PgDMC.PgDHRD (PU Chd.)
Retd. Director Gen. Health Services, Haryana,
Panchkula 134109, dr_satvir@yahoo.com
94166-12664
Ass. Prof. (Surgery) Cum Additional Director, SDDDC&H

dr_satvir@yahoo.com .... Phone 94166-12664 19

 After Gen Fractures
Not in Syl -other
Ortho Problems
Specific Mandible Maxila and Face
will be taken Separately in Oral and FM
Surgery
• I started with Basic Anatomy of skeletal System
• Next Joint and other Ortho problems in BRIEF ??
Syllabus says only
o General Principles of Fractures
o Clinical Presentation
o Treatment and Newer Methods
o Fracture Healing and Rehabilitation
 FRACTURES OF THE
FACIAL SKELETON
• FRACTURES OF THE FACIAL
SKELETON may be divided into those of the
1- UPPER THIRD (above the eyebrows)
2 - MIDDLE THIRD (above the mouth
and below Eyebrows) Le Fort
3- LOWER THIRD (Below Mouth ie
the mandible)
Anatomy
Anatomy
Anatomy
 FRACTURES OF THE
FACIAL SKELETON
• FRACTURES OF THE FACIAL SKELETON
may be divided into those of the
1- UPPER THIRD (above the eyebrows)
2 - MIDDLE THIRD (above the mouth
and below Eyebrows) Le Fort
3- LOWER THIRD (Below Mouth ie the
mandible)
 The Upper Third

ie Above Eye brows

• involving the frontal sinuses and the supraorbital
ridges.
• Naso Ethmoidal Orbital
• Zygoma
• Nasal
 Fracture Types and
Prevalence
• Zygomaticomaxillary complex – AKA Tripod fracture
= 40%
• LeFort I = 15%
• LeFort II = 10%
• LeFort III = 10%
• Zygomatic arch = 10%

• Alveolar process of maxilla = 5%

• Smash Fractures = 5%
• Other = 5%
 Nasal Fractures
• Clinical findings:
– Nasal deformity
– Edema and tenderness
– Epistaxis
– Crepitus and mobility
 Naso-Ethmoidal-Orbital
Fracture
• Fractures that extend into
the nose through the
ethmoid bones.
• Associated with lacrimal
disruption and dural tears.
• Suspect if there is trauma
to the nose or medial
orbit.
• Patients complain of pain
on eye movement.
 Zygoma Tripod Fractures
• Tripod fractures
consist of fractures
through:
– Zygomatic arch
– Zygomaticofrontal
suture
– Inferior orbital rim and
floor
Zygomatic Fractures
• Tripod fracture:
zygomaticofrontal suture,
zygomaticotemporal
suture, and infraorbital
foramen
• Present with flatness of
the cheek, anesthesia in
the distribution of the
infraorbital nerve,
diplopia, or palpable step
defect
 Zygoma Tripod Fractures
Clinical Features
• Clinical features:
– Periorbital edema and
ecchymosis
– Hypesthesia of the
infraorbital nerve
– Palpation may reveal
step off
– Concomitant globe
injuries are common
Nasal Fractures
• Most common site of
facial trauma due to
location
• May be displaced
laterally or
posteriorly
• Requires control of
epistaxis and
drainage of septal
hematoma, if present
 The Middle Third
• In 1911, Rene Le Fort classified fractures
according to patterns which he created on
cadavers using various degrees of force
• He classified the fractures from superior to
inferior, the custom today is that the classification
runs inferiorly(Mouth) to superiorly(Orbit).
 Le Fort I
• The Le Fort I fracture effectively separates the alveolus and
palate from the facial skeleton above.
• Fracture line runs through points of weakness from nasal
piriform aperture, through the lateral and medial walls of
maxillary sinus runs posteriorly to include the lower part of
pterygoid plates.
• It is also known as a Guerin fracture or 'floating palate'
Le Fort I Fracture
Le Fort I Fracture
 Le Fort II Fracture
• Pyramidal in shape
• Fracture involves the orbit, running through
the bridge of the nose and the ethmoids whose
cribriform plates may be fractured, leading
to dural tear and CSF Rhinorrhoea.
• It continues to medial part of infraorbital rim
and through infraorbital foramen
 Maxillary Fractures
LeFort II
• Radiographic imaging:
– Fracture involves:
• Nasal bones
• Medial orbit
• Maxillary sinus
• Frontal process of the
maxilla
• CT of the face and
head
 Maxillary Fractures
LeFort III
• Definition:
– Fractures through:
• Maxilla
• Zygoma
• Nasal bones
• Ethmoid bones
• Base of the skull
 Maxillary Fractures
LeFort III
• Radiographic imaging:
– Fractures through:
• Zygomaticfrontal suture
• Zygoma
• Medial orbital wall
• Nasal bone
• CT Face and the Head
Maxillary Fractures
• Le Fort I – maxilla
• Le Fort II – maxilla, nasal
bones, and medial aspects
of orbits (pyramidal
disjunction)
• Le Fort III – maxilla,
zygoma, nasal bones,
ethmoids, vomer, and all
lesser bones of the cranial
base (craniofacial
disjunction)
• Usually in combination
Le Fort II Fracture
 Le Fort III Fracture
• Le Fort III Fracture effectively separates the facial skeleton from base of the skull.
• The fracture line runs high through the nasal bridge, septum and ethmoids, again
with the potential for dural tear and CSF leak, and irregularly through the bones of the
orbit to the frontozygomatic suture
Le Fort III Fracture
 CT: Blowout Fracture of Orbit

• A: Orbital blowout fracture with displacement of the floor (arrow),

distortion of the inferior rectus, and herniation of orbital fat through
defect. Arrowhead indicates medial fracture.
• B: Note opacified left anterior ethmoid air cells and displaced medial
orbital fracture (arrowheads).
 Blowout Fracture
• MOI – blow to the eye, forces are transmitted by the soft tissues of the
orbit downward to the thin floor of the orbit
• Symptoms – enophthalmos and diplopia (usually an upward gaze)
• 24% are associated with ocular injury
 Ring Bone Rule – ( Pretzel-Bagel
Spectrum )
• If you see a fracture or dislocation in a ring
bone or ring bone equivalent, look for another
fracture or dislocation
 Lines of Dolan
• Three anatomic contours
The 2nd and 3rd lines together form the profile of an
elephant
 TREATMENT -
FRACTURES OF MAXILLA
• Fractures of the frontal bone, supraorbital ridge
and nasal root may be approached through a
bicorornal incision, at the vault of the skull, high
in the hairline.
• The incision is taken from just in front of each ear
across the vault of the skull and reflected
forwardsuntil the supraorbital ridges are exposed
• All the fractured bones may be reduced and fixed
by stainless steel wire or titanium mini-/micro
plates, under direct vision
• The lower part of maxilla may be approached
through a gingival sulcus incision above
maxillary teeth as far as back as the second
molar.
• The principle of treatment is to restore the
fragments to their original position.
 Summary
• Assess ABC's first
• Do complete exam as part of secondary
survey
• Obtain standard X-rays and / or CT scan
as indicated
• Decide if specialist referral and / or
operative repair indicated
 Mandibular Fractures

• Any patient with malocclusion after facial trauma

is assumed to have mandibular fracture until
proven otherwise. .. Why ? Ring Bone Rule
Mandibular Fractures
Mandibular Fractures
 TREATMENT -
FRACTURES OF Mandible
• They are fixed with Intermaxillary
Fixation (IMF).
• IMF is simply a means of splinting the upper
and lower arches of teeth together.
• The majority of mandible fractures require reduction
and fixation under general anaestheic. The fractures
may be explored through extraoral or intraoral
incisionsaccording to access required.
INTERMAXILLARY
FIXATION
• Generally, fractures of the Edentulous
mandible are platedusing miniplates.
• Fracture of the Mand. Condyle may cause
disturbance of the occlusion, with deviation of
the mand. the side of fracture.
 Mandibular Fractures
Common Sites and Prevalence
• Body 30-40%
• Angle 25-31%
• Condyle 15-17%
• Symphysis 7-15%
• Ramus 3-9%
• Alveolar 2-4%
• Coronoid Process 1-2%
 Double Mandibular
Fractures
• Usually contralateral sides of the symphysis
• Common combinations include:
Angle plus the contralateral body or condyle
 Ring Bone Rule – Also Known As
Pretzel-Bagel Spectrum

• If you see a fracture or dislocation in a ring

bone or ring bone equivalent ( eg Mandible,
Pelvic girdle, Rib cage in Chest) look for
another fracture or dislocation
 Mandibular Dislocation
• May occur spontaneously during a large yawn
• Considerable pain
• Condyle (c) is anterior to the articular eminence (e)
 Important Thoughts About
Mandibular Fractures
• Remember the ring bone rule
• Symphyseal fractures can be hard to see
• Panorex view provides the best single view of the
mandible
• Look carefully along the cortical margin of the whole
mandible for discontinuities
• Carefully examine the mandibular canal for
discontinuities
• Pathologic fractures can occur in the mandible – look
for tumors or abscesses
 Panoramic X-Ray Film (ORTHO
PANTAMO GRAM) of the
Mandible

• Note fractures in left angle and right body of mandible

• Multiple fractures are present more than 50% of the time
and are usually on contralateral sides of the symphysis
 Mandibular Dislocation
• The mandible can be
dislocated:

– Anterior 70%
– Posterior
– Lateral
– Superior
• Dislocations are
mostly bilateral.
 MANAGEMENT Mandibular
Dislocation
• Treatment:
– Muscle relaxant
– Analgesic
– Closed reduction in the
emergency room
 THE STEPS OF
Chest C
Examination
Chest GPE and other systems will be taken
in in details Medicine Department

Inspection
Palpation
Percussion
Auscultation
 FRACTURES OF THE
FACIAL SKELETON
• FRACTURES OF THE FACIAL
SKELETON may be divided into those of the
1- UPPER THIRD (above the eyebrows)
2 - MIDDLE THIRD (above the mouth
and below Eyebrows) Le Fort
3- LOWER THIRD (Below Mouth ie
the mandible)
 JOINTS

• Articulations of bones
• Functions of joints
Hold bones together
Allow for mobility
• Ways joints are classified
Functionally
Structurally
 JOINTS
• Structural classification of
joints
1. fibrous joints
2. cartilaginous joints
3. synovial joints
 Fibrous
Joints

Cartilaginous Synovial
Joints Joints

•Has joint cavity

•Bone ends connected by
cartilage •Has synovial fluid

•Slightly moveable •Freely moveable

•Immovable
 Fibrous Joints
• Bones united by fibrous tissue
Sutures of the skull
Distal ends of the tibia and fibula
 Cartilaginous Joints
• The ends of the
bones are
connected by
cartilage.
Pubic
symphysis
Intervertebral
joints
 Synovial Joints Ex TM Joint

• When the articulating bones ends are

separated by a joint cavity containing
synovial fluid.
General structure of
a synovial joint
 TYPES OF SYNOVIAL
JOINTS
• plane joint
• hinge joint
• condyloid joint
• saddle joint
• pivot joint
• ball-and-socket
joint
Inflammatory conditions associated
with joints

• bursitis
• tendonitis
• arthritis
 Bursitis
• Inflammation of the bursae (flattened fibrous
sacs lined with synovial membrane and filled
with synovial fluid
 Tendonitis
• Inflammation of the tendons
 Bone Disease
(Non Traumatic Problems)
Range from problems related to:
• Abnormal stress on bones
• Problems of metabolism and growth
• Infectious organisms and tumours
• Heredity
 Arthritis
• Inflammatory or degenerative diseased that
cause damage and pain to joints

1. Osteoarthritis (OA)
2. Rheumatoid Arthritis (RA)
3. Gouty Arthritis (Gout)
 Osteoarthritis

• Most common chronic arthritis

• Probably related to normal aging process

Osteoarthritis
Osteoarthritis
 Bone DiseaseS

Osteomyelitis
Infectious organisms (including tumours) that attack the bone
and compromise strength.
 Bone Disease
Rickets = Deficient mineralization in children. Bone growth
and repair are compromised.
Osteomalacia = Same as rickets but for adults.
Hypophosphatasia = Inherited enzyme deficiency.
 Bone Disease
Kyphosis:
Stooped
posture
caused by
collapsed
vertebrae
in elderly.
 Bones and Aging…
- Osteoporosis = Porous bones.
- Degenerative condition that involves low bone
mass and deterioration of bones.
- Post-menopausal women > Risk.
- Increase susceptibility to bone fracture –
especially in hip, spine and wrist.
Osteoporosis…
 Preventing Osteoporosis
Building strong bones during childhood and
adolescence is the best defense.
1. A balanced diet rich in calcium and vitamin D.
2. Weight bearing exercise.
3. A healthy lifestyle – no smoking or excessive
alcohol.
4. Bone density testing and medication when
appropriate.
* There is still no cure for Osteoporosis *
 Rheumatoid Arthritis
• An autoimmune disease – the immune system
attacks the joints

• Symptoms begin with bilateral inflammation

of certain joints

• Often leads to deformities

Rheumatoid Arthritis
Rheumatoid Arthritis
 Gouty Arthritis (Gout)

• Inflammation of joints caused by a

deposit of urate crystals from the blood

• Can usually be controlled by diet

Gouty Arthritis (Gout)
 OSTEOPOROSIS ?
• Osteoporosis is a disease of bone in
which the bone mineral density (BMD) is
reduced
• Bone micro architecture is disrupted
• The amount and variety of non-
collagenous proteins in bone is altered
• Osteoporotic bones are more at risk of
fracture.
Osteoporosis
 Joint dislocations and
subluxations

• Dislocation is when the bone ends have

completely moved out of the joint space

• Subluxation is a partial dislocation

Joint dislocations and subluxations
 MENISCUS TEAR

Normal Knee
Bucket Handle Meniscus Tear