Displacement

Described as: Distal in relation to proximal

Un-displaced

ShiftSidewaysShorteningDistraction

Angulation In all planes

Rotation

Fracture Diagnosis

Clinical features

Imaging: Radiology (x-Ray)

Clinical Features

History of Trauma

Symptoms and signs:1. Pain

2. Swelling

3. Deformity

4. Bony tenderness

5. Abnormal movement

6. Crepitus

7. Loss of function

Approach - history

Details of injuryMechanism, force, bleeding, consciousness, …

Details of factureDeformity, pain, loss of function, ..

Other medical problems

Anti-tetanus status if open injuries

Careful:Fractures are not always at the site of impactSome fractures do not need severe force

Approach – clinical exam

General medical conditionshould be evaluated to exclude

shockbrain injuryother problems

Vital signsshould be observed and followed up

Approach – clinical exam

Look:Adequate exposureGeneral on patientLocal:

Swelling, deformity, bruises, color, …Special attention is to be paid to wounds

Approach – clinical exam

Feel:Tenderness, distal pulses, temperature and crepitus

on movementSensory and motor deficitsPulse distal to injuryCompartment syndrome

Move:With care

make sure not to cause more pain or injuryCrepitus & abnormal movement indicates a fractureJoints distal to the affected area

Approach – clinical exam

Examination of the visceraLiver and spleen in rib fracturesUrinary bladder and urethra in pelvic fracturesNeurological examination in head and spinal injury

Investigations - Imaging

X-rays:Low of 2s

Two views: AP and LateralTwo joints: Above and BelowTwo sides: Right and LeftTwo occasionsTwo Doctors !

Special views:Obliques, Tunnel view, skyline, functional flexion /

extensionArthrography:

Shows intra-articular structuresFunctional in hip

Imaging

Plain x-ray: (law of twos)Two views:AP and Lateral

Apley’s System of Orthopedics & Fractures

AP

AP

Lat

Lat

Imaging

Plain x-ray: (law of twos)Two views: AP and LateralTwo joints: joint above and joint below

Apley’s System of Orthopedics & Fractures

Imaging

Plain x-ray: (law of twos)Two views: AP and LateralTwo joints: joint above and joint belowTwo limbs: for comparison

more in children to

compare epiphysis

Apley’s System of Orthopedics & Fractures

Imaging

Plain x-ray: (law of twos)Two views: AP and LateralTwo joints: joint above and joint belowTwo limbs: for comparison

more in children to

compare epiphysisTwo occasions

e.g. stress fracturese.g. scaphoid fracture

Apley’s System of Orthopedics & Fractures

Imaging

Plain x-ray: (law of twos)Two views: AP and LateralTwo joints: joint above and joint belowTwo limbs: for comparison

more in children to

compare epiphysisTwo occasions

e.g. stress fracturese.g. scaphoid fracture

Two injuriese.g. patellar fracture and hip injurye.g. calcaneal fractures & spine injuries

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Imaging

Plain x-ray: (law of twos)Two views: AP and LateralTwo joints: joint above and joint belowTwo limbs: for comparison

more in children to

compare epiphysisTwo occasions

e.g. stress fracturese.g. scaphoid fracture

Two injuriese.g. calcaneal fractures & spine injuries

.....and two Doctors!

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Imaging

Plain x-ray: (law of twos)

Special views:Calcaneal viewShoulder dislocation: axial viewScaphoid viewsAcetabular fractures: 45o tilt views

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Imaging

CT Scan:In complex and ntra-articular fracturesIn spineIn pelvic and acetabular fracturesIn calcaneal fractures

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Imaging

MRIShow associated injuries in spinal fracturesAssociated soft tissue injuries – e.g. kneeHidden fractures:

Subtrochanteric (ST) disruptionStress (fatigue) fracturesScaphoid fracture

Suspected avascular

necrosis

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Fracture healing

A broken bone heels because …..it is broken !

Alan Apley

Natural bone healing

Movement at the fracture site initiates a healing process—callus formation

Vascular and cellular response leads to tissue differentiation and mineralization resulting in restoration of mechanical integrity

Natural bone healing

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Cascade of tissue differentiation

Following a Fracture:

1. Hematoma

2. Granulation tissue

3. Connective tissue

4. Fibrocartilage

5. Mineral deposition

6. Bone

Fracture healing1. Inflammation

Hematoma Mesenchymal cells

2. Soft callus Granualation tissue

3. Hard callus Intramembranous bone

formation Enchondral ossification

4. Remodeling bony bridging

Cellular and Vascular Reaction

cells haematoma granulation tissue

Tissue Differentiation

connective tissue

granulation tissue

Giemsa

Tissue Differentiation Cascade

Cartilage formation

BoneMineral deposition

Masson-Goldner

Healing time & strength

Process Timing Strength

Hematoma 2 hrs 1%

Inflammation 2 days 5%

Soft callus 2 weeks 25%

Hard callus 2 months 74%

Re-modelling 2 years 100%

Fracture Healing

Conditions necessary for bone healing:Good blood supplyControlled motionNo infection

Fracture Healing

Unfavorable factorsImpairment of blood supplyInfectionExcessive movementPresence of tumorInterposition of soft tissueAny form of Nicotine (smoking)Bad nutrition

Average healing time

Children: Upper limb: 3-4 weeksLower limb: 2X upper limb (6-8 weeks)

Adults:Upper limb: 2X children (6-8 weeks)Lower limb: 2X upper limb (12-16 weeks)

Fracture Treatment

Aim of fracture treatmentaid healing,in normal position,avoiding complications

Fracture treatment

Treat the patient, not only the fracture

Reduce the fracture

Immobilize the fracturePrevents displacementAlleviates painPromotes soft tissue healing

Mobilize the patient

Avoid complications