Principles of Fractures

Principles of FracturesPrinciples of Fractures

Dr. Abdulrahman Algarni, MD, SSC (Ortho), ABOSDr. Abdulrahman Algarni, MD, SSC (Ortho), ABOSAssist. ProfessorAssist. Professor

consultant orthopedic and arthroplasty surgeonconsultant orthopedic and arthroplasty surgeon

Introduction.Introduction.

• Defintions.

• Mechanisms.

• Diagnosis.

• Classification.

• Fracture healing.

Introduction Introduction

• Fractures in children.

• Pathological fractures.

• Management techniques.

• Open fractures.

• Complications of injury.

Fracture:-Fracture:- Break in the continuity of bone Break in the continuity of bone

Defintions.Defintions.

CompleteIncomplete


• Closed fracture (simple).

• Open fracture (compound).

• Complicated fracture.


• Closed Fracture (simple ):-

Does NOT communicate with external environment


• Open Fracture (compound ):-

Communicate with external environment

Infection !!


• Complicated Fracture:-

Associated with damage to nerves, vessels or internal organs


• Dislocation.

• Subluxation.

• Fracture disloction.

Defintions.Defintions.• Dislocation:-

Complete separation of the articular surface.

Distal to proximal fragment

Anterior, Posterior, Inferior, Superior

Defintions.Defintions.• Subluxation:-

Incomplete separation

Joint Function in Anatomical position Only


• Fracture Dislocation:-

Association!

Always X-Ray Joint Above and Below


• Pathological Fracture:-

Fracture abnormal bone

Cyst, Tumour, Infection

Defintions.Defintions.• Pathological fracture.

MechanismsMechanisms

• Amount of Force:- * Trivial force = Pathological * Magnitude = Non-pathological

• Direction of Force:- * Direct Force * Indirect Force

MechanismsMechanismsIndirect Force On Long

Bones:-

1) Twisting Force

Spiral Line

MechanismsMechanisms

Indirect Force On Long

Bones:-

2) Angulating Force Transverse pattern

MechanismsMechanismsIndirect Force on Long Bones

3) Angulating + Axial compression

Transverse line + Triangular

“Butterfly”

MechanismsMechanismsIndirect Force on Long Bones

4) Angulating + Axial compression + Twisting forces

(short oblique pattern)

MechanismsMechanismsIndirect Force On Long

Bones:-

5) Vertical compression

comminuted

MechanismsMechanismsDirection of

ForceOn CancellousBones:-

Direct OR Indirect Comminuted

Pattern Burst

MechanismsMechanismsForce due to Resisted

Muscle Action:-

“Avulsion” Transverse

pattern

I- HISTORY

II- EXAMINAION A- General B- Local

III- INVESTIGATIONS

DiagnosisDiagnosis

I- HISTORY 1) Trauma * Pathological (trivial) * Non-pathological ( magnitude)2) Mechanism * Fall from height, * RTA, pedestrian, Driver….?

DiagnosisDiagnosis

I- HISTORY 3) Complaint: a) Pain sharp, increase by

movement, Not radiating b) Loss of Function c) Deformity d) Symptoms of complications e) Other organs: head, chest, abdomen

DiagnosisDiagnosis

II- EXAMINATION

A- General examination

B- Local examination

DiagnosisDiagnosis

A- General examination :

1) Signs resulting from fracture or trauma: a) Vital signs, Shock A,B,C b) Associated Head, Chest, Abdomen 2) Signs related to cause of fracture: Pathological # …CA Lung, Prostate..

DiagnosisDiagnosis

B- Local Examination• LOOK : Skin damage, deformity, swelling• FEEL : Localized tenderness• MOVE : Abnormal movement, crepitus• DO : a) Special tests : Circulation & Nerves b) Measurements : shortening [Always compare]

DiagnosisDiagnosis

DiagnosisDiagnosisINVESTIGATIONS X-RAY:-

A- Essential requirements: 1) Two views AP & Lateral.

2) Two joints Above & below #.

INVESTIGATIONS X-RAY:-B- Occasional Requirements * Two Limbs “ Compare “ * Two Occasions “Scaphiod” * Special X-rays Stress, CT..

DiagnosisDiagnosis

DiagnosisDiagnosis

C- Description of X-ray : 1) Situation : side, site, localization 2) Pattern : line of fracture 3) Displacement : a) Shift : lateral,medial,anterior,posterior b) Tilt : angulations c) Twist : rotation , internal, external d) Shortening: overriding, impaction

DiagnosisDiagnosis

Repair of FractureRepair of Fracture

A - Primary repair

• With Rigid Internal Fixation• No Callus formation• Active Haversian remolding• Long time


B - Secondary Repair

• Without rigid fixation

• Commonest type even with I.F.

• Stages :

Time Factor- Perkin’s formulaTime Factor- Perkin’s formula

Union Consolidation

Upper limb Spiral 3Transverse 6

6 weeks 12 =

Lower Limb Spiral 6Transverse 12

12 = 24 =

Children Half this time is needed

Fracture in childrenFracture in children• Different from those in adults. • Children's bones are more malleable,

allowing a plastic type of "bowing" injury.

Fracture in childrenFracture in children• The periosteum is thicker than in adults and

usually remains intact on one side of the fracture which helps to:

1. stabilize any reduction, 2. decreases the amount of displacement, and 3. lower incidence of open fractures in children

than in adults.

Fracture in childrenFracture in children• Healing is more rapid.• Open reduction is rarely indicated.• High remolding rate.• Growth disturbance.• Often missed (poor communication).• X-rays of both limbs for comparison.

Fracture in childrenFracture in children Physeal Injuries • 30% of the fractures• twice as often in the upper

extremities as in the lower extremities.

• Salter-Harris classification: based on the radiographic appearance of the fracture

Fracture in childrenFracture in children

Fracture in childrenFracture in children

Birth Fractures

• most commonly in the clavicle, humerus, hip, and femur.

• They rarely require surgery but frequently are diagnosed as pseudopalsy, infection, or dislocation.

Fracture in childrenFracture in children Fractures Caused by Child Abuse

• Between birth and 2 years of age.

• Multiple fractures in different stages of healing are almost always indicative of child abuse.

• Multiple areas of large ecchymoses in different stages of resolution (from black and blue to brown and green) also are pathognomonic of child abuse.

Fracture in childrenFracture in children• The most common sites of

fractures caused by child abuse are the humerus, tibia, and femur

• bone scan or a skeletal survey generally is indicated

Pathological FracturesPathological Fractures• Fracture within an abnormal bone structure due

to:1- congenital diseases (O.I).2- Infection (osteomyelitis).3- Fracture through a cyst .4- Metabolic diseases ( Osteoporosis,

Osteomalacia, Pagets disease). 5- Primary bone tumours.6- Metastatic bone tumours.

Pathological FracturesPathological Fractures

Diagnosis:History: 1- insignificant amount of trauma. 2- constitutional symptoms. 3- history of malignancy.

Pathological FracturesPathological Fractures• Examination : A / General: S/S of malignancy or

infection.

B / Local : 1- tenderness, pain, swelling. 2- muscle spasm and deformity is

minimal.

Pathological FracturesPathological Fractures• Investigation: A/ Radiology: 1- X-rays of the lesion , MRI, CT-scan. 2- X-ray / CT-chest ( pulmonary Mets.) 3- Bone Scan.

B/ Laboratory: 1- CBC & dif., ESR, CRP. 2- Acid phosphatase P, B J P, 3- LDH, ec..

Pathological FracturesPathological Fractures• Management:• Aim: to make patient more functional and

pain free for the remaining life span.

• Early operative stability should be carried out.

• Chemotherapy, Radiation, Hormonal.

Pathological FracturesPathological Fractures• Indication for prophylactic fixation due to (metastasis):1- involvement of the cortex.

2- increased pain.

3- pure lysis.

4- weight bearing area.

Fracture ManagementFracture Management

GENERAL AIM : To Save the Life of Patient

LOCAL AIM : Rapid Recovery * Of Injured Part * Of Its Function

Management.Management.

GENERAL management :

LIFE THREATENING Inj. Shock , Head, Chest, AbdomenLOCAL management Dangers to viability : * Ischaemia * Infection


*SAVE LIFE

*SAVE LIMB

*SAVE FUNCTION


SAVE FUNCTION1) REDUCTION2) IMMOBILISATION3) SOFT TISSUE TREATMENT4) FUNCTIONAL ACTIVITY &

REHABILITATION


I- Reduction – Methods:

• Should be Under Anesthesia• Closed or Open• Study X-Ray and direction of force• The basic Maneuvers : * Traction * Reverse mechanism of Inj * Direct pressure


I- Reduction - Standards

• Anatomical Reduction is Ideal for all• Anatomical Reduction is a MUST in : * Dislocation * Intra-articular fractures * Fractures Both bones Forearm• X-Ray Image Intensifier help control reduction• Remember to Assess Reduction after 10 Days !


Reduction Standards cont…• Reduction can be “Acceptable” if :- * Alignment will NOT affect Function * Remolding CAN correct deformity • Remolding can correct :-

*Angular NOT Rotational deformities *Children MORE than Adults


I- Reduction - Timing• Immediate R. is a MUST in: * Vascular Inj * Spinal Cord or Nerve Inj• Urgent R. in OPEN fractures ; “Save Limb”• Dislocations Need Urgent reduction for Pain• CLOSED fractures CAN wait If Facilities do

not permit Urgent management


II- Immobilization

“Life is Movement, and Movement is Life”

Do NOT Immobilize Any Joint Unnecessarily


II- Immobilization –Methods

• Plaster of Paris• Traction• Internal Fixation• External Fixator

Open fractures.Open fractures.• Fracture site

communicate with the external enviroment.

• Emergency management.

• Infection will occur with delayed or inadequate treatment.

Open fractures.Open fractures.1. General care:

• ATLS (save life, save limb, then save function (.

• Antibiotics directed against staphylococci (most common), and as needed.

• Tetanus prophylaxis.

Open fractures.Open fractures.• Local care :

1. Clean.2. Irrigation: Dilution is the Solution For pollution3. Debridement.4. Decontamination of the bone.5. Closure???.6. Immobilize.

COMPLICATIONSCOMPLICATIONS• Boney Complications:• Delayed Union:- • Healing Slow but Active, Remove the cause!• Fracture Site Tender• X- Ray little Callus, Medulla Open• Non Union:-• Reparative process Stopped, Need Intervention• Painless, Abnormal Movement, Psudoarthrosis!• X- Ray: Sclerosis, Blocked Medulla.

COMPLICATIONSCOMPLICATIONS• Delayed Union & Nonunion Causes:-• Local :-1.Poor Blood Supply2.Soft Tissue Interposition3. Infection4. Inadequate Immobilization5.Over-Distraction6.Pathology, Tumors

COMPLICATIONSCOMPLICATIONSDelayed Union &Nonunion

Causes:-• General:-• Nutrition• Bone Disease• Old Age

COMPLICATIONSCOMPLICATIONS• Malunion:-• 1- Primary Neglected #

• 2- After Reduction! Watch X-Ray After 10 Days.

• 3- Epiphyseal Growth plate Cause Deformities…Time

Coxa Vara

COMPLICATIONSCOMPLICATIONS• Avascular Necrosis:-• Death of Bone from; • * Impairment or • * Loss of blood Supply

• Anatomical Sites:------

• Sclerosis = X-Ray Dense

• Delayed or Nonunion

COMPLICATIONSCOMPLICATIONS• Myositis Ossificans:- “Not myo! or itis! “

• Heterotopic Ossification• May follow minor trauma• Susceptibility• Elbow ; Knee; Hip

COMPLICATIONSCOMPLICATIONS• Myositis Ossificans:-• • Pain & Limitation of movement• X-Ray Calcification then Ossification• After severe Head Injuries• Prevention : Avoid Passive Massage• Rest Susceptible site after injury • May Need Excision When Mature • There is Primary Congenital Form !• “Myositis Ossificans Progressiva”

COMPLICATIONSCOMPLICATIONS• Complex Regional Pain

Syndrome(Reflex Sympathetic Dystrophy)

• “Sudeck’s Acute Bone Atrophy”• Commonest Hand and foot # Arm or Leg!• Pain, Swelling, Restriction Movement• Skin :Glossy, Smooth, Stretched

COMPLICATIONSCOMPLICATIONS• Reflex Sympathetic

Dystrophy

• X-Ray: Osteoporosis• Increased Blood Flow in the limb• Reflex Sympathetic Activity !!• Physiotherapy• Sympathetic Block• * Medical : Drugs, • * Surgical: Regional Block• Sympathectomy

COMPLICATIONSCOMPLICATIONS• Compartment Syndrome : elevation of the interstitial pressure in a

closed osseofascial compartment that results in microvascular compromise.

• The most common causes of acute compartment syndrome are:

• fractures,

COMPLICATIONSCOMPLICATIONS• soft tissue trauma,• arterial injury, • limb compression during altered

consciousness, • and burns. • Other causes include intravenous fluid

extravasation and anticoagulants

Principles of Fractures

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