FRACTURE

DR SHRIKANT J. GORE M.S.(ORTHO)

PROFESSORDEPT. OF ORTHO.

GMC , LATUR

FRACTURE

Breach in continuity of boneBroken bone

Types

Age Growing age Adult

Covering soft tissue Simple Closed

Compound- Fractured bone exposed to atmosphereComplicated- Fracture associated with injury to vital body parts

Etiological Trauma Pathology Stress

Morphological

Pathological Fracture

Epi-physial injury

Bending - Greenstick

Morphological

Transverse Oblique Spiral Segmental Comminuted Crushed- Compressed Depressed Burst Bone loss Greenstick Buckled

 

Displacement

Un displaced - Incomplete, complete Displaced (Deformed)

- Bent- Angulated-Translated - Shifted-Rotated

-Overriding - Depressed-Compressed-Burst

Undisplaced

BUCKLING COMPLETE

Transverse -Oblique

Comminuted - Segmental

Compressed -Burst

Depressed- Butterfly

Rotation - Spiral

Translation - Rotation

Overriding - Angulation

Compound-Fractures

Fracture Communicating with atmosphere

Type-1 -Punctured wound (less than 1 cm.)

Type- 2 - Wound more than 1 cm but less than 10 cm

Compound-Fractures Type- 3

a) With soft tissue loss, periosteal stripping, communition , wound size >10 cm but soft tissue coverage possible

b) With severe soft tissue injury ,contamination, bone exposed & soft tissue coverage not possible

c) With arterial injury

Complicated Fractures

Fractures associated with injury to vital structures

Brain Lungs Intra-abdominal : Liver, Spleen, Bladder Neurovascular injury

Management Goal

Union in Anatomical position

for maximum functional recovery

Must realize The healing is biological process-Union can not be imposed but to

be encouraged-Vascular supply of bone is the basis

of fracture healing-You need to be a gardener rather

than a carpenter as healing is natural response of the body

Treatment plan Needs to be tailored to the needs of

particular patient considering Patient, Doctor, paramedical staff

Medical Facilities-Patient Age, Sex, occupation, G. C, Type of fracture, Extent of soft tissue injury, Associated diseases like DM,HT, renal etc & Socioeconomic status.

Treatment plan

Infrastructure facilities available,

Training & Experience of -Treating doctors(surgeons-anesthesiologists),- paramedical staff (sisters, physiotherapists, occupational therapists)

Principle of treatment

Reduction in anatomical position & maintaining reduction till fracture unites

Anatomical Reduction

Manipulative reduction

Manipulation under anesthesia Continuous traction (Pin/Skin)I/T/#, S/C

## dislocation cervical spine

*Proper understanding of - Mechanism of injury is essential- Reduction is reversal of the deforming mechanism

External immobilization

Plaster immobilization –Slab, Cast strapping- fingers, Chest, arm

splinting- Mallet splint, Ball bandage, Fixed traction in splint-

Thomas’s Continuous traction-

Skin Traction - Gallow’s Nail- Fracture phalanges Skeletal traction- Bohlar’s

complications of Immobilization

Generalized-Hypostatic pneumonia - Deep vein

thrombosis-Bed sores - Muscle wasting - Osteoporosis-Prolong hospital stay - PsychosisLocalized -Stiffness , contractures , wasting , Sudek’s plaster sore, Tight plaster – constricting band

neurovascular compression, Compartment syndrome & VIC pin tract infection.

Plaster Immobilization Done when proper & stable closed

reduction can be achieved Every joint which dose not need to be

immobilized must be exercised actively from the first day of injury to prevent stiffness

The plaster should extend one joint above & one joint below the fractured bone for its immobilization.

No joint to be immobilized unless it is a must

Post-Immobilizations Stiffness

1) Functional inactivity-lymphatic stasis, water logging –fibrosis

2) Joint injury- sero-fibrinous exudates-capsular fibrosis

3) Recurrent edema –gravitational, reactionary 4) Skeletal traction- Stretching of ligaments-

reactionary effusion pin track infection 5) Sudek’s osteodystrophy- muscular inactivity

Loss of control over vascular musculature

Skin TractionGallow’s

Thomas’s Splint Traction

Skeletal Traction When reduction & /or maintenance of

reduction is not possible due to muscle forces at Fracture site

-Conservative treat. of I/T # femur -Conservative Treat. of # shaft Femur-Post – reduction immo of dislocated hip Complications-Pin tract infection-Excessive traction- Nonunion

Skeletal Traction

Pin Tract infection

Advantages of closed reduction

Simple procedure No surgical trauma Minimum soft tissue injury Maintaince of fracture hematoma

Advantages of CR

Hence Earlier healing No chance of infection Less chances for fibrosis due to tissue

trauma Minimum anesthesia Minimum use of drugs Less expensive

Disadvantages of CR

Not possible when Soft tissue interposition - # med

malleolus Small fragments - # Muscle attachment to fracture fragments

(active force) - # patella Depressed fracture -# tibial platue Combination injuries – gallezia #

dislocation Non accessible fragments - # neck femur

Complications of immobilization

Immobilization stiffness Muscle wasting Sudek's osteodystrophy Prolonged bed rest (lower limb) Hypostatic pneumonia Bed sore Deep vein thrombosis

Advantages of surgery & internal fixation

Reduction can be achieved Rigid fixation Early mobilization – to reduce stiffness

Disadvantages of OR

Soft tissue injury Periosteal stripping Damage to blood supply – bone & soft

tissue Delayed union Infection Post surgical fibrosis

Surgical reduction & internal fixation

No surgery is possible without adding injury to the body

Minimally invasive technique should be preferred .

Every form of fixation is splinting device

Healing is biological process.

Failure of closed reduction

Soft tissue interposition -# medial malleolus Muscle attachments pulling a fragment

# lat condyle Humerus Lack of control over fragment -T/C # Femur,

# upper end Tibia , Small fragments avulsion Depressed # (elevation & Support)

Combination injuries- Monttaggia Fracture, Gallessia Fracture, Fracture shaft femur with Fracture neck Femur

Failure of maintenance of reduction

Unstable Fracture -Transverse # R/U Fracture site difficult to immobilize

# around hip, shoulder, shaft femur Intra-Articular # (tibial condyle) Collapse or compression at Fracture

site Dynamic forces - Muscle pull (#

Patella)

Surgery as treatment option

Better choice – Complications of immobilization more than surgical complications Lower limb # in old age

Fracture shaft Femur ,Tibia shaft, Humerus shaft, I/T #, R/U shaft #

Surgical complications

Soft tissue injury , Periosteal striping

Damage to blood supply – delayed union, Infection, Implant failure, Growth disturbance

Anesthesia - Antibiotics

Indications Failure of closed reduction Failure of maintenance of

reduction for internal fixation

Nonunion- to freshen the bone end

- to put bone grafts

Surgical Reduction

Study principles rather than methods

A mind that grasps principles will device its own methods

 

Surgical planning -general

Assessment of -patient’s general health – Hemogram, Urine, BSL,

BUN, S.Creatinin, ECG, X-Ray Chest, HIV, Hbsag, LFT, Blood grouping, & As needed

-Local condition Skin –abrasion, infection, circulation,

-Socioeconomic status, Age, Profession, etc.-Treating Doctor’s Training & experience-Paramedics Training & experience-Infrastructural & Paramedical Facilities at the hospital

-cost of the treatment

Surgical planning -general

The O.T. -Equipment Surgical & Anesthesia

-Surgical instruments & implants of proper design & size -Preparation of part one day prior & in OT-Minimally invasive, soft tissue respect(least

traumatic), short duration, anatomical closure-Use of Antibiotics, care of wound

Post op

-Early mobilization (physiotherapy) & rehabilitation

Surgical planning – The part

Skin condition – abrasion, wound, infection, circulation.

Cleaning –Painting with antiseptic solution to form film –covering the part with sterile towel

After proper anesthesia – judicious use of tourniquet

scrubbing with detergent- painting with antiseptic ( Iodine) – Removal of iodine paint using volatile antiseptic spirit -isolating the part by sterile DRAPES

Surgical procedure

Minimally invasive (small) Least injurious (Tissue planes- proper

handling of tissues -least dead tissue –less inflammation)

Minimal surgical time (to minimize the chances of infection)

Anatomical closure in layers (minimizes adhesions)

Management of compound fracture

Cleaning , debridement of wound Stabilization of # fragments with external

fixator Avoid Internal fixation – chances of

vascular damage – infection Advantages of external fixator – less

vascular damage - # fragment stability – wound care possible

External fixator