FRACTURE

FRACTURE
• A break in the continuity of a bone and associated soft tissue injury.

Classification of fractures
• there are many classifications of fractures

1. In relation to their communication with the outside environment

• closed / simple: one in which the bone fragments do not communicate with the
external environment
• Open / compound: one in which the bone fragments/ fracture hematoma
communicate with the external environment
◦ Open fractures have two groups: from within and from without
‣ From within: as a result of the fractured fragment piercing through the
overlying skin

H
‣ From without- when the violent force results in a tear of the overlying
soft tissue exposing the fractured fragment

2. In relation to their level of contamination/ Gustilo Anderson classification for

open fractures (1976)

Class 1- open fracture and the wound is less than 1cm and clean
‣ No wound contamination
‣ No periosteal stripping
‣ No soft tissue coverage
‣ No vascular injury

class 2- wound is greater than 1cm and there is moderate wound contamination
 ‣ No wound contamination moderate austria Anderson
‣ No periosteal stripping 1 Lowenergywound tan
‣ No soft tissue coverage 2 1am moderatesoftwaredamage
‣ No vascular injury 3 Highenergywound can
za Adequatesotooissuecoverage
Originally had just class 3 but modified if in 198 35 Peronealsupping inadequate's.IE
Class 3a- there is an extensively large wound(> or =10cm), a Nannasarar compromise
‣ there is significant wound contamination
‣ No periosteal stripping
‣ No adequate soft tissue coverage
‣ No vascular injury

Class 3b- ther is an extensively large wound

‣ There is significant wound contamination
‣ There is periosteal stripping
‣ adequate soft tissue coverage
‣ No vascular injury

Class 3c- there is an extensively large wound

◦ there is significant wound contamination
◦ Periosteal stripping
◦ Adequate soft tissue coverage
◦ Vascular injury

3. In relation to the pattern of the fracture

Transverse fracture - when a fracture cuts across a bone horizontally

‣ Goes through the longitudinal axis of the bone at 90 degrees

it
Oblique fracture - when the fracture line forms an angle less than 90 degrees with
the longitudinal axis of the bone
Spiral fracture - a fracture that covers more than one plane on the bone and goes
around
11
Ht
Impacted fracture- when both fractured fragments are compressed against which
over along the fracture line.

H
Comminuted fracture - when you have more than two fracture fragments at the
site of the fracture
H
19
Segmented fracture- a fracture that occurs at different levels of the bone, divides
the bone into multiple segments

Ii
Green stick fracture- when there is a break in on side of the cortex and a bend at
the opposite side. It is seen in children.

Pathological fracture
it
A fracture that occurs due to an underlying or preexsiting bone disease.
Eg osteoporosis( seen mainly in menopausal women), osteomyelitis

Bone healing

Stages in bone healing

When there is a breakage in the bone, underlying blood vessel rupture
Stage 1- hematoma formation

Stage 2- inflammation

Stage 3- soft callus formation (fibrous cartilage is formed between bones by

chondroblasts). Take about 2- 3 weeks

Stage 4- hard callus formation ( osteoblasts are responsible for this process known
as ossification)

Stage 5- bone remodeling ( months to years )

Stress fracture
• a fracture that occurs as a result of repetitive stress on a bone

4. In relation to mechanism of the fracture

Direct fracture - A fracture that happens at the site of the direct force or impact
of the force

Indirect fractures - one that happens at a site away from the direct force

Clinical presentation of fracture

• pain
• Deformity
• Abnormal movement
• Immobility or loss of function

Physical examination findings

Enquire about
• age
• Overlying skin- whether open or closed and any other associated function
• Length of the limb( always compare with the other one)
• Circumference of the limb( compare)

On palpation
• extent of tenderness
• Check for crepitus- when ends of bones rub against each other

Investigations
• x ray
◦ With two views (AP and lateral view) X Raytradings
◦ Two joints- poximal and distal
◦ Two sides of symmetry Translatein
◦ Two occasions- check in two weeks
Angulation
◦ Two associations - check surrounding tissue Rotation
Shortening
Subluxation
• partial displacement of the head of a joint

Management of a fracture
There are two main management modalities:
• closed reduction and immobilization
• Open reduction and internal fixation

• Closed reduction and immobilization

• non surgical reduction of a fracture fragment only if there is a displacement.
• This is to restore anatomical integrity of the bone
• After reduction you immobilize to maintain the anatomical integrity of the bone
◦ Using a cast, splint, external fixator( CREF- closed reduction and external
fixation), traction
‣ Traction -attach limb to a non elastic string, two types,
• skin traction- weight < 5 kg
• Skeletal traction : usually used got lower limbs and head
•
‣ Cast( eg POP- plastic of Paris)
• Has a high risk of compartment syndrome normalcompartmentpressure
Incompartmentsoon me pressuresgoesupn socommits
Differentialpressure
DBp co
ReFascists
my
 • Can compress the muscle compartment and their blood vessels
causing edema and further swelling Initiate
• Restricting the amount of blood supply to the region
• Causing ischemia, nerve injury and persistent pain
• Because of this they splint the ends of the POP

‣ External fixators :illizarov fixator, Oxford fixator, Hoffman fixator

• Open reduction and internal fixation( ORIF)

• surgical incision is made and components are used to provide stability of the
fracture and are positioned entirely within the patient’s body.
eg. Pins, plates and screws, kirchsners wire, intramedullary rods and nails, DHS

INDICATIONS FOR OPEN REDUCTION

• if a closed reduction fails
◦ Due to late presentation
◦ Being an elderly
◦ Neurovascular injury
• muscles entrapped between fragments
• Muscles contracting to pull fractured fragments
• Intra-articular fractures ( epiphysis)
• Inability to maintain a closed reduction
• Pathological fractures
• Fractures that delay in healing

Managing infected wounds to be managed by ORIF

• is the wound infection or at risk of being infected
◦ Shave hair
◦ Debride the wound
◦ Clean wound with antiseptics, eg savlon
◦ Clean with spirit and chlohexidine
◦ Drape the the area around the wound
◦ Suture the wound and leave a drain in situ.

Complications of fractures

Early complications
• hemorrhage
• Ischemia keypoints in managingtractive
• Dislocation or subluxation Immosinethe fracture including the
• Muscle tear
• Hematoma primal and distal joints
caretrlymannn and document new vasure
• Compartment syndrome
• Infections ( cellulitis , etc) anyfollowingreduction and
stares partial
immobilization
Manage intern includingtetanus puppets
Generalised early complications Ix antibiotics for openinjuries
• PE (fat embolism is common) x As ageneral principle all openfractures
• DVT shard be thawing debuted and internal
• Orthostatic pneumonia texamin dares avoided or usedwith
extreme caution
Late complications
• Mal union openfractures constitute an emergency and
• Non union (no callus formation) should be derided and laxaged wither
• Delayed union Ohn ofinjury
• Volkmann’s ischemic contracture
• Sudecks osteodystrophy
• Avascular necrosis
• Myositis ossificans
• Osteoarthritis

Supracondylar fracture
• this is most common in children between the ages of 5-8.
◦ Occur around the elbow joint/ involving the distal humerus region
◦ Due to a fall on an out-stretched arm
◦ Dispalcement could be anterior or posterior, with posterior more common
◦ The brachial nerve and median nerve pass medially, hence a displacement can
pierce the brachial artery and put pressure on the median nerve.
◦ Usually present with claw hand if there is median nerve injury.

Presentation Holstein Lewis fracture - A supracondylar

• pain and swelling at the elbow fracture with radial tooo
artery entrapment, ie loss
of radial pulse nerve
• Inability to move elbow joint
• Absent radial pulse
Check pulses before surgery and after surgery
Check if thumb can appose.

Muscles innervated by the median nerve ( LOAF) - 1st nd 2nd lumbricales ( lateral ) ,
opponeus pollicis, abductor pollicis brevis, flexor pollicis brevis

Management of supracondylar fracture

Generally supracondylar fractures are managed by ORIF but If it is an

◦ anterior deplacement- can use closed reduction and immobilization
◦ Posterior displacement- always open reduction and internal fixation (due to
neurovascular injury)
◦ Advice patient to wiggle fingers to prevent disuse atrophy

Classification of supracondylar fracture/ gartland classification

• 4 grades

• Grade 1- non displaced fracture He

• Grade 2- angulation with an intact posterior cortex

◦ 2a- angulation with intact posterior cortex
is
◦ 2b- angulation with rotation

• Grade 3- complete displacement with an intact periosteum

◦ 3a- when the medial periosteum hinge is intact and distal fragments move
posterio- medially
◦ 3b- lateral periosteal hinge is intact and the distal fragments move posterio-
laterally

• grade 4- periosteal disruption with instability in extension or flexion

Investigations of supracondylar fracture
• X- ray
• FBC
• bue creatinine

Important Complications of supracondylar fracture

• median nerve injury
• Volkmann’s ischemic contraction
• Myositis ossificans panofmusclewincanaimdeposition manm ithad T

Monteggia fracture
A fracture of the proximal 1/3 of the ulnar with associated displacement of the
radial head explanation

Classification of monteggia fractures / bado classification

• class 1- fracture of promixal 1/3 of ulnar with anterior dislocation fo the radial
head.
• Class 2- fracture of proximal 1/3 of the ulnar with posterior dislocation of the
radial head
• Class 3- fracture of the proximal 1/3 of the ulnar with lateral dislocation of the
radial head
• Class 4- fracture of the proximal 1/3 of the ulnar and radius with dislocation of
the radial head in any direction

Treatment
Class 1- closed reduction and immobilization
Class 2,3 and 4- ORIF

Galeazzi fracture
- fracture of the distal 1/3 of the radius with dislocation of the distal radio-ulnar
joint(DRUJ)
OTA classification
• TYPE 1- Transverse fracture
• Type 2- fracture that goes into the dorsal articular surface
• Type 3- fracture involves a radio carpal joint

X ray findings for galaezzi

• increased space in the DRUJ
• In the lateral views- lateral rotation of the fracture
• Shortening of the radius

Treatment for galaezzi fractures

• ORIF

COLLES’S FRACTURE
• fracture of the distal radius or distal 3cm of the radius
• Due to a fall on outstretched hand( NB supracondylar is out-stretched arm)
• Has a bimodal distribution, ie extremes of age
• Known as a supination fracture.
• Classic Findings: Dorsal displacement and dorso-lateral rotation of the fracture
fragments.

• causes a dinner fork deformity/ or bayonet deformity Dinner fork

X ray findings The thee 3 Features of cones'sfracture
• dorsal displacement e Transversefracture of a radius
• Dorsal rotation 2 I inch proximal to the radiocarpal joint
• Lateral rotation 3 Dorsal displacement andangulation
• Shortening of the radius

Treatment of colles fracture

If stable - you can do a closed reduction and immobilization
unstable - ORIF

Findings I Listento hem

Smith fracture Reverse contests
• fracture of distal radius or distal 3cm of the radius due to a fall on a flexed
wrist
• This is a pronation fracture and associated with a volar displacement

X ray findings
• Ventral displacement Smithfracture is a type of
• Shortening of the radius Garden spade
deformity
Treatment
• if stable - closed reduction
• If unstable -ORIF
•

Fracture of radial styloid process- chauffeur fracture

Fracture with depression of the lunate fossa of the radius- die punch fracture

Fracture of the radio-carpal joint with a scapho-lunate dislocation- Barton’s

fracture

Fracture of the first metacarpal which extends into the carpo-metacarpal joint -
bennet fracture.

too
Femoral neck fracture
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femoris

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our here and reverse

Blood supply of the femoral head

When the external iliac artery passes below the inguinal ligament it becomes the
femoral artery, which give off the profunda femoris artery
causesof Areasaranen of
The profunda femoris artery give of the eternal head
• Lateral circumflex artery: supplies anterior femoral neck v seen
• Middle circumflex artery- passes along the posterior part to come and meet the
lateral circumflex
• Anterior cervical arteries( the middle and lateral circumflex ascend and form this)
• Ligamentum teres artery -There is a hole in the femoral head known as the
fovea, an artery passes through this fovea to the head of the femur.,
◦ The obturator artery is what gives of this artery.

Classification of femoral neck fractures

Anatomic classification Intraeapsular

Can be divided into :

• Intracapsular and
• extracapsular

Intracapsular - subcapital and transcervical

Extracapsular - pertrochanteric( around the trochanter),subtrochanteric (beneath
the trochanter ), basocervical(at the base of the neck of femur)

• Common in the elderly mostly post menopausal women

• If it occurs in a young person, due to a high velocity fracture

Garden’s classification
classification systems
elderlyineacapsuar Gardens
Young 11 Powers
Interonchanterttracene Evans
sustmenanoenz i RusselTaylor
 I e's face
Type 1- an incomplete fracture of the femoral neck 254 Displacement
Type 2- complete undispalced femoral neck fracture
Type 3- complete femoral neck fracture with partial displacement
Type 4- complete femoral neck fracture with a full displacement

Investigation
• x ray
• Check femoral and popliteal pulses
◦ When the femoral artery passes through the hunter canal it becomes the
popliteal artery.
• Check dorsalis pedis pulse especially
MRI Goldstandard It can vinative é soft tissue
Hernia muscle here

Important Complications
• avascular necrosis

Treatment
In the elderly - THR- total hip replacement is preferred

Extracapsular - DHS- Dynamic hip screw

intracapsular- THR

Ngno of Femoral hear trade

Differentials for femoral neck fractures Best Practice Tant
• hip dislocation Inoacapsmar

• Pelvic fracture toning

• Osteomalacia Edeny

• Paget disease of the bone

• Osteomyelitis masinemmonestreosoer

• Osteosarcoma w
nacasmaneyi mpaired
meaicangorenanemarcipman

• Rickets
• Hyperparathyroidism
• Ostitis fibrosa cystica
• Multiple myeloma
• Prostate cancer www.pepaamen aemiamnmas aacapsua pereocnanoenc

sustenance

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Dynamic
tip Intrameanagnan
fractures
A fracture is the break in the continuity of a bone and associated soft tissue
injury
Classification of fractures
In relation to communication with theexternal environment
1 Closedfracture A closed fracture is one where gonefragments do not communicate
with the external environment or breech an epithelial lining
fracturehematoma
2 Open fractureAn open fracture is one wherebone fragments communicates with
theexternalenvironment or breech an epithelial lining
Gustillo Andersons classification of open fractures
class I Open fracture andthewound is lessthan
2cmandclean
ClassE wound is greaterthan 1cm and there
is moderatewoundcontamination
Class FI Open segmental fracture or a single
fracture with extensive softtissue 210cm
injury
Subdividedinto 3
Ia There is significantwoundcontamination
with adequatesofttissue coverage
IIIb There is significantwoundcontamination
There is penostealstripping
Ciii Inadequate soft tissue coverage
HIC There is significantwound contamination
There is peeriosteal stripping
Inadequate
softtissue coverage irrespective of édegreeoferasuretissue
Cwsvascular
injury thatrequires immediate
e repair
dans

Classification in relation to pattern offracture

2TransverseFracture cthe fare use has atransverse
fashion
The fracture cuts across the length of bone horizontally
caused
byan adroitbendingtonescanalsobecaused
fore bydirecttapping
2Oblique fracture indie and
This iswhere the fracture forms an angle lessthan90
of
with thelongitudinal axisof thebone go page lineis
3 Spiral fractures
This is when a fracture covers morethan one planeof the bone
and goes around it og In twistingfractures
4Impacted fracture
when both fractures fragments are compressed against
each other along the fracture linethis is usually due to
highimpact falls
5Comminuted fracture
 ha
multifragmented fracture
f g id f frd
G Segmented fracture
this is a fracture that ears at different levels of thebone and divides it into
multiplesegments
7 Greenstick fracture
This is when theres a breakon one side of the cortex and a bend at the opposite
side This is Usually seen in children
PATHOLOGICAL
fractures
A fracture that occurs due to an underlying or preexisting bonecondition Osteoporosis
osteomalaciaosteomyelitisrenalfailurehyperparathyroidism
eg

STRESS FRACTURES
This is a fracture that occurs dueto repetitivestress on the bone
Classification in relation to Mechanism of fracture
1 Direct fracturesfracture thatoccurs at the site of directforce or impact
violence

2 Indirect fracture fracture that occurs away from the site ofdirectface or Impact
violence

STAGES OF BONE HEATING egsupracondylar

Stage 2 Hematoma formation

stage 2 Inflammation Cklithin 3 5days

stage3 Soft callousformationCFibrows cartilageformed between bones bychondroplasts

stage4 Hard callousformationCBone remodeling monthsto

years
Myositis ossificanns is a
complication of fractures
clinical Presentation
offracture Formation
of bone inside
musclesdue to bonefragmo
Pain
Swelling deposited in muscles during
Immobility fractureHenefore freaking
Deformity process involves thefragment
Abnormal movement in themusclesformingbones
the muscles
PhysicalEXAMINATION
Tenderness
Swelling
Pulsecdestaltothefracture
Crepitus
Perforations oftheskin frombonefragments
Comparethe lengthTheremay be fimbshortening
Range of motion of limb
 INVESTIGATIONS
z X rays X Rayfindings
Two views CAPand lateral
Twojoints'CProximal and distal tothefractures
Two occasions of X ray
Two sites ofsymmetry Translation
Two associations other structurecloseto thefracture Angulation
Rotation
Shortening
MANAGEMENT OF A FRACTURE CYR's
1 Reduce Resuscitation
2RestrainImmobilize Reduce
3 Rehabilitate Restrain
Rehabilitate

1Closereduction and immobilization

This is the non surgical reduction of fracture fragments Tf there hasbeen a displacement
It is done to restore theanatomical integrity of the bone
After reduction theres immediate immobilization with the use of a castsplint or
external fixators tractors

2 Open reduction and Internal fixation

Asurgicalincision is made and the components usedto provide stabilityofthefracture
are positioned entirely in the patients body
examples pinsplatesscrewsKirchsnerswire inframesallay rods andnailsdynamichipscrews

INDICATIONS OF OkeF
EIf closedreduction and immobilizationfouls
Dueto latepresentation
Being an oldperson
2 Neurovascularinjury
3 Pathologicalfracture
4 Intraarticular fractures
EMuscle entrapmentwithin fracturedsegments
G Comminuted fractures
7 Muscularcontraction separating fragmentsof bones
8 Inability to maintain closedredaction
9 fractures thatdelay in healing
lo Malunion

COMPLICATIONS of FRACTURES Sublaxation is a partial displacement

Early of head of a
joint
Hemorrhage
compartment syndrome
Infections
Hematoma formation
Dislocation and sablaxation
Tissue ischemia
 Fat embolism
Late complication
Malunion Union of fracture in
a a non anatomical position
Delayedunion Union is said to be made if by theexpectimetime forhealing thefracture
has notunitedeg Decreased blood supply interposition of softtissueinfections inadequate
immobilization malnutrition
Non union This is whenthehealing process stopswhilethe fracture has not waited
radiologically fracture edges are smooth edges
thiscauses a falsejoint welldefined
AvascularNecrosis a sclerotic

Myositis ossificans
tissue
Volkmanns Ischaemic contracturesCmuscles undergoing necrosis proliferating as connective
Osleodystrophy
Osteoarthritis

Generalized early
Deep venous thrombosis
5Dp.LT Pulmonary Embolism
orthostaticpneumonia

THE HUMERUS
Intraarticularfractures
at the head ofthe
humerus are not so
common

SUPRACONDYLARFRACTURES
Mostcommonfractures in children betweenthe
ages of 5 and 8 no theelbow
theanatomicalneckis the partof the

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sina.naa.name
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oIIIIIonImI IEEE's e
eosut
sina.ieimiiais.ua
commonly posterior bonewhere fractures usually occur
Thebrachial artery andthemedialnerve lie medially to thehumerus and can therefore be
damaged
MANAGEMENT
Generally managedby ORIE due to close proximity to neurovascular bundles
Perkin's rule It is used to estimatethe duration
Adults children
of healing afracture
f
6W few Upper Cerritos
Dislocation of theelbow
It is characterized by the unusual prominence oftheolecranon process so a linedrawn
from the medialepicondyle throughthe tip oftheolecranon to the lateralepicondyl which
is normallystraight is angulated

Monteggiafractures
racket head
Fracture of proximal 43
of the ulnar withassociated displacement of the
usually anteriorly
Galeazzi fracture
fractureof the distal 43 of the radius with dislocation of theradioulnarjoint
Arebothmanaged by ORIE
COLLE's fracture withwristinextensors
fracture of distal3cm of theradius due to fallingon an outstretched hand It iscommon
in children andthe classical finding is a dorsal displacement of thefracturesegment
This causes a dinnerfork or bayonet deformity

X rayfindings
Dorsal displacement
Dorsal rotation
shortening oftheradius

Managed by ORIF but if stable can perform CRI

SMITH'sFRACTURE
of
fracture the distal 3cm of the radius with ventral displacement of thedistal fragment
withwrist in flexion Gardenspade deformity
rayfindings
ventral displacement
shortening of theradius
Managed by OMF but if stable can perform CRI

FEMORAL NECK FRACTURES

Traditionalclassification Listen Intacapala
Gardens classification nestperlesuscapital Intertrochanteri
transeneral sustnchantari
Gardens classification of femoral fractures
Basing I
TYPE 2 Incomplete fractureof femoralneck
TYPE 2 Complete unoisplacedfemoral neckfracture
THE 3 complete fracture with partial displacement
TYPE 4 Complete fracture with completedisplacement

There can beanterior or posterior dislocation mostcommonly anterior displacement

 I f f I fa
Hipdislocation Most important complication of
Pelvicfracture femoral head fracture is arasaek
Osteomalacia necrosis ofthe femur head
osteosarcoma Shenton's line is a semicircularmargin
Rickets between thefemoral headand thepubis
Alulteplemyeloma seenonanx
prostateCA kay.me
For management of femoralneck surgery a total hipreplacement is preferred in
a nonelderly
And a CRI in an elderly