General principles of fractures treatment 1

 Fracture ‐loss of continuity of bone
 Hairline fracture, microscopic fracture, highly

comminuted fracture
 Dislocation ‐loss of congruity between the articulation

surface of joint
 Subluxation‐articulating surface of jointare no longer

congruous but still maintain contact.
Classification of fracture
 According plane of # surface
 Simple – closed
Compound – open
 According to cause
traumatic
pathological
stress or fatigue fracture
 According to number
Single
Multiple
 Complete #, incomplete#
Mechanism of injury
 Spiral (twisting)
 Short oblique
 Bending ‐ Triangular ‘butterfly’ fragment
 Transverse
OPEN AND CLOSED FRACTURES
 Traumatic fracture
Direct violence :
Indirect violence : twisting, bending,
Muscular contraction.
Pathological fracture
It is one in which a bone is broken through an area

weakened by pre‐existing disease , & by a degree of
force that would have left normal bone intact
e.g osteoporosis , O.M. , bone tumours
Stress fracture :
Bone, like other materials, reacts to repeated loading.
On occasion, it becomes fatigued & a crack develops
e.g military installations, ballet dancers & athletes.
How fractures happen
 A single traumatic incident
 Repetitive stress
 Abnormal weakening of the bone
Fractures healing
 Primary  Haematoma
 Secondary  Inflammation
 Callus
 Consolidation
 Remodelling
Fractures healing
Clinical Features of Fracture
 History of trauma
 Symptoms & signs:
1. Pain & tenderness 2. Swelling
3. Deformity 4. Crepitus
5. Loss of function 6. Abnormal move.
7. N.V. injuries
Diagnosis
Clinical picture
Radiography
Principles of treatment
 Anatomical reduction
 Stable internal fixation
 Preservation of blood supply
 Early mobilization
Implants types
 Pin and wire fixation
 Screw fixation
 Plate and screw fixation
 Intramedullary nail fixation
 External fixation
Open fractures
 Wound debridement
 Antibiotic prophylaxis
 Stabilization of the fracture
 Early wound cover

Principles of fractures
Fracture repair is a tissue regeneration process rather
than a healing process the injured bone is replaced by
bone.
The process of repair varies according to:

‐The type of bone involved.
‐The amount of movement at the fracture.
‐The closeness of the fracture surfaces.
Principles of fractures
 Unfavorable factors
 Impairment of blood supply
 Infection
 Excessive movement
 Presence of tumor
 Synovial fluid in intraarticular Fx.
 Interposition of soft tissue
 Any form of Nicotine
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.
 Conservative
 Operative
Principles of Treatment
 Treat the Patient, not only the fracture
 Restriction of movement
 Prevention of displacement
 Alleviation of pain
 Promote soft‐tissue healing
 Try to allow free movement of the unaffected parts
 Splint the fracture, not the entire limb

Principles of Treatment
 Methods of holding reduction:
 Sustained traction
 Cast splintage
 Functional bracing
 Internal fixation
Definitive Fracture Fixation
Options
 Casts and Splints
 Appropriate for many fractures
especially hand and foot
fractures
 Adults typically will get plaster

splints initially transitioned to
fiberglass casts as swelling
decreases
 Kids typically will get fiberglass

casts
CLOSED, UNDISPLACED
CLOSED, REDUCIBLE
 CONSERVATIVE TREATMENT
2- CAST
Below Knee Above Knee

 Complications of cast splintage
 Liable to appear once the patient has left the hospital;
added risk of delay before the problem is attended to
1. Tight cast
2. Pressure sores
3. Skin abrasion or laceration
4. Loose cast
Functional Bracing
 Prevents joint stiffness while still permitting
fracture splintage and loading
 Most commonly for fractures of the femur or tibia
 Since its not very rigid, it is usually applied only when

the fracture is beginning to unite
 Comes out well on all four of the basic requirements:

“hold” “move” “speed” “safe”
Options
 Traction
 Useful in patients who are too sick

for surgery
 Useful to maintain alignment until

definitive fixation
 Traction by gravity
 Eg. Fractures of the humerus
 Balanced Traction
 Skin traction: adhesive strapping kept in place by
bandages
 Skeletal traction: stiff wire/pin inserted through the
bone distal to the fracture
Femur fracture managed with skeletal

traction and use of a Steinmann pin in the
distal femur.
Operative
 ORIF (open reduction internal fixat.)
Indications of ORIF
‐ absolute
‐ relative
Indications of ORIF
‐ Absolute Indications for ORIF of fractures
 Unable to obtain an adequate reduction
 Displaced intra‐articular fractures
 Certain types of displaced epiphyseal fractures
 Major avulsion fractures where there is loss of function of a joint or

muscle group
 Non‐unions
 Re‐ implantations of limbs or extremities

Indications of ORIF
Relative Indications for ORIF of fractures
 Delayed unions
 Multiple fractures to assist in care and general management
 Unable to maintain a reduction
 Pathological fractures
 To assist in nursing care
 To reduce morbidity due to prolonged immobilisation
 For fractures in which closed methods are known to be ineffective

Indications of ORIF
Questionable
 Fractures accompanying nerve of vessel injury
 Open fractures
 Cosmetic considerations
 Economic considerations
Types of Internal Fixation
‐ Pin & wire fixat.
‐ Screw fixat.
‐ Plate & screws fixat.
‐ Intra‐medullary fixat.
Options
 Open Reduction and Internal fixation

with Plates and screws
 Used for many fractures especially
those involving joints
Options
 Intramedullary Nails
 Treatment of choice for most tibia
and femur fractures
 Used in selected humerus and

forearm fractures
Internal Fixation
 “holds” securely with precise reduction
 “movements” can begin at once (no stiffness and

edema)
 “speed”: patient can leave hospital as soon as wound is

healed, but full weight bearing is unsafe for some time
 “safety”= biggest problem! SEPSIS!!!

 Risk depends on: the patient, the surgeon, the facilities
Options
 Joint Replacement
 Used in displaced femoral neck

fractures in geriatric patients
 Allows for early ambulation
 Occasionally used in geriatric pts

with comminuted shoulder or
elbow fractures
Complications of internal fixation
 Most are due to poor technique, equipment, or operating
conditions
 Infection
○ Iatrogenic infection is now the most common cause of chronic
osteomyelitis
 Non‐union
○ Excessive stripping of the soft tissues
○ unnecessary damage to the blood supply in the course of
operative fixation
○ rigid fixation with a gap between the fragments
 Implant failure
 Refracture
Definitive Fracture Fixation Options
 External Fixation
 Used primarily in the treatment

of open fractures and pelvis
fractures
 Also useful as temporary

stabilization prior to definitive
fixation
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 of the pelvis, which often cannot be controlled
quickly by any other method.
2. Fractures associated with severe soft‐tissue damage where

the wound can be left open for inspection, dressing, or
definitive coverage.
External Fixation
3. Severely comminuted and unstable fractures, which can be
held out to length until healing commences.
4. Fractures of the pelvis, which often cannot be controlled

quickly by any other method.
5. Fractures associated with nerve or vessel damage.
6. Infected fractures, for which internal fixation might not be

suitable.
7. 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
Complications of external fixation
 High degree of training and skill! Often used for the most
difficult fractures increased likelihood of complications
 Damage to soft‐tissue structures
 Over‐distraction
 No contact between the fragments union delayed/prevented
 Pin‐track infection
OPEN FRACTURES
 Initial Management
 At the scene of the accident
 In the hospital
Types of Open Fractures
‐ The incidence of wound infection
‐ correlates directly with the extent of

soft‐tissue damage, <2% in type 1
>10% in type 3
‐ rises with increasing delay in

obtaining soft tissue coverage of the
fracture.
Principles of Treatment of Open
Fractures
 All open fractures assumed to be contaminated Prevent infection!
 The essentials:
 Prompt wound debridement
 Antibiotic prophylaxis
 Stabilization of the fracture
 Early definitive wound cover
 Repeated examination of the limb because open fractures can also

be associated with compartment syndrome
Complications of fractures
 Early visceral injury  Late delayed union
‐ ‐ ‐ non‐union
‐ vascular injury ‐ avascular necrosis
‐ nerve injury ‐ bed sores
‐ compartment ‐ myositis ossificans
syndrome ‐ tendon lesion
‐ haemarthrosis ‐ nerve compression
‐ infection ‐ muscle contracture
‐ joint instability
‐ gas gangrene ‐ joint stiffness
‐ fracture blisters ‐ algodystrophy RSD
‐ plaster and pressure sores ‐ osteoarthritis
Thank you

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 Fracture ‐loss of continuity of bone

 Hairline fracture, microscopic fracture, highly

 Dislocation ‐loss of congruity between the articulation

 Subluxation‐articulating surface of jointare no longer

Indirect violence : twisting, bending,

It is one in which a bone is broken through an area

 Stable internal fixation

 Preservation of blood supply

 Plate and screw fixation

 Intramedullary nail fixation

 Stabilization of the fracture

 Early wound cover

The process of repair varies according to:

 Splint the fracture, not the entire limb

 Adults typically will get plaster

 Kids typically will get fiberglass

Below Knee Above Knee

 Most commonly for fractures of the femur or tibia

 Since its not very rigid, it is usually applied only when

 Comes out well on all four of the basic requirements:

 Useful in patients who are too sick

 Useful to maintain alignment until

Femur fracture managed with skeletal

 ORIF (open reduction internal fixat.)

 Unable to obtain an adequate reduction

 Displaced intra‐articular fractures

 Certain types of displaced epiphyseal fractures

 Major avulsion fractures where there is loss of function of a joint or

 Re‐ implantations of limbs or extremities

 Multiple fractures to assist in care and general management

 Unable to maintain a reduction

 To assist in nursing care

 To reduce morbidity due to prolonged immobilisation

 For fractures in which closed methods are known to be ineffective

 Open Reduction and Internal fixation

 Used in selected humerus and

 “movements” can begin at once (no stiffness and

 “speed”: patient can leave hospital as soon as wound is

 “safety”= biggest problem! SEPSIS!!!

 Used in displaced femoral neck

 Allows for early ambulation

 Occasionally used in geriatric pts

 Used primarily in the treatment

 Also useful as temporary

 Some allow reduction of the fracture in all 3 planes.

 Especially applicable to the long bones and the pelvis.

2. Fractures associated with severe soft‐tissue damage where

4. Fractures of the pelvis, which often cannot be controlled

5. Fractures associated with nerve or vessel damage.

6. Infected fractures, for which internal fixation might not be

7. Un‐united fractures, where dead or sclerotic fragments can be

 At the scene of the accident

‐ correlates directly with the extent of

‐ rises with increasing delay in

 Stabilization of the fracture

 Early definitive wound cover

 Repeated examination of the limb because open fractures can also

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