principles of fracture treatment

Principles of Fracture Treatment

What is a (bony) fracture?

Disruption of a bone’s normal structure or “wholeness”

Crack, break, or rupture in a bone

There are many how’s and why’s to bony fracturesTerms used to describe each are related

Definition of Fracture There are 2 types of # in which this is not

so:

1. Pathological fract.

1. Stress fract.

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.

Diagnosis Clinical picture

Radiography

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

Orthopaedic History A good general orthopaedic history

contains:Onset, Duration, and Location of a problemLimitations and debilitation attributed to the

problemGood surgical history, especially with

regards to orthopaedic surgeries and prior anesthesia

Co-morbid conditions that contribute to the problem or will preclude healing in some manner

Physical Exam Basics Inspect and Palpate everything- start

with normal structures and move to abnormal

Range of motion in all planes Strength Sensation Reflexes Gait Stability

Physical Exam Basics NVI What does this mean?1. Neurologic exam- Always document

the neurologic status. Some fractures are associated with nerve injuries and knowing the status of the nerve is critical

2. Vascular exam- Always check for pulses distal to the fracture sight. Missed vascular injuries can be devastating

Pre-reading Musculoskeletal Radiographs 1: Name, date, old films for

comparison 2: What type of view(s) 3: Identify bone(s) & joint(s)

demonstrated 4: Skeletal maturity

(physes: growth plates) 5: Soft tissue swelling 6: Bones & joints

(fractures & dislocations)

Physical Exam

NEVER trust someone else’s exam. ALWAYS put your hands on the patient and see for yourself

Always trust your exam- you WILL pick up something that someone else has missed at some point

OPEN AND CLOSED FRACTURES

Intro to Reading X-rays

Reading a radiograph is essentially describing the anatomy of a certain structure

In order for it to be universal and understandable for others, clarity and precision are essential

A fracture is described based on the findings of the physical exam and a review of radiographs

Reading X-rays

1. Say what it is- what anatomic structure are you looking at and how many different views are there

2. Regional Location- Diaphysis (rule of 1/3), Metaphysis, Epiphysis including intra and extra-articular

3. Direction of the fracture line- Transverse, Oblique, Spiral

Reading X-rays

5. Condition of the bone- comminution (3 or more parts), Segmental (middle fragment), Butterfly segment, incomplete, avulsion, stress, impacted

6. Deformity-Displacemtent (distal with respect to proximal), angulation (varus, valgus), rotation, shortening (in cm’s), distraction

Fracture Pattern

Transverse Produced by a

distracting or tensile force

Fracture Pattern

Spiral Produced by a

torsional force

Fracture Pattern

Produced by pure bending force

Butterfly

Fracture Pattern

Comminuted Broken into

many pieces- high energy with combined forces

Displacement

Characterized by % of bone contact on either view

Angulation

Distal fragment relative to proximalVarus, Valgus, Anterior, Posterior

Apex of angle formed by fragmentsE.g., Apex Anterior, Apex Medial,

Apex Ulnar

Location

Commonly described in thirds of affected boneie distal third of tibia ie junction of proximal and middle

third of femurIf fractured at two levels describe

as segmental

Location-Diaphysis

Shaft portion of bone

Location-Metaphysis The ends of the bone

(if the fracture goes into a joint it is described as intra- articular)

Now All Together

Transverse fracture of the femur at the middle third- distal third junction with 100% displacement and varus (or apex lateral) angulation

What do you see?

What do you see?

What do you see?

Mnemonic: OLD ACID

O: Open vs. closed L: Location D: Degree (complete vs. incomplete)

A: Articular extension C: Comminution / Pattern I: Intrinsic bone quality D: Displacement, angulation, rotation

O: Open vs. Closed Open fracture

AKA: “Compound fracture” A fracture in which bone

penetrates through skin; “Open to air” Some define this as a

fracture with any open wound or soft tissue laceration near the bony fracture

Closed fracture Fracture with intact overlying

skin

L: Location Which bone? Thirds (long bones)

Proximal, middle, distal third

Anatomic orientation E.g. proximal, distal, medial,

lateral, anterior, posterior

Anatomic landmarks E.g. head, neck, body /

shaft, base, condyle

Segment (long bones) Epiphysis, physis,

metaphysis, diaphysis

Epiphysis

Metaphysis

Diaphysis

)Shaft(

Physis

Articular Surface

D: Degree of Fracture

Complete Complete cortical

circumference involved Fragments are completely

separated

Incomplete Not fractured all the way

through “Only one cortex” involved e.g “Greenstick fracture”

A: Articular Extension / Involvement Intra-articular

fractures “Involves the

articular surface” Dislocation

Loss of joint surface / articular congruity

Fracture-dislocation

C: Comminution / Pattern Transverse (Simple) Oblique (Simple) Spiral (Simple) Linear / longitudinal Segmental Comminuted Compression / impacted

“Buckle / Torus”

Distraction / avulsion

C: Comminution / Pattern Transverse (Simple)

C: Comminution / Pattern Oblique (Simple) Spiral (Simple)

Oblique in 2+ views

C: Comminution / Pattern Linear / longitudinal / split

C: Comminution / Pattern Segmental

Bone broken in 2+ separate places; Fx lines do not connect

C: Comminution / Pattern Comminuted

Broken, splintered, or crushed into >3 pieces

C: Comminution / Pattern

Compression Impacted

(e.g. “Buckle / Torus”)

C: Comminution / Pattern “Buckle / Torus”

C: Comminution / Pattern Distracted Avulsion

I: Intrinsic Bone QualityOsteopenia

–Decr’d density

Normal

I: Intrinsic Bone Quality

Normal Osteopetrosis–Incr’d density

I: Intrinsic Bone Quality Osteopoikilosis

Focal areas of incr’d density

Normal

D: Displacement, Angulation, Rotation

Displacement–Extent to which Fx

fragments are not axially aligned

–Fragments shifted in various directions

relative to each other

–Convention: describe displacement of distal

fragment relative to proximal Oblique tibial shaft Fx b/w

distal & middle thirds; laterally displaced

D: Displacement, Angulation, Rotation

Angulation–Extent to which Fx

fragments are not anatomically aligned

In a angular fashion

–Convention: describe angulation as the

direction the apex is pointing relative to

anatomical long axis of the bone (e.g. apex

medial, apex valgus)

R Tibial shaft Fx b/w prox & middle thirds,

angulated apex lateral (apex varus)

D: Displacement, Angulation, Rotation

Angulation

VarusApex lateral

ValgusApex medial

ParallelNo angulation

D: Displacement, Angulation, Rotation

Rotation–Extent to which Fx

fragments are rotated relative to each other

–Convention: describe which direction the distal

fragment is rotated relative to the proximal

portion of the bone

D: Displacement, Angulation, Rotation

Rotation

Normal PA view of hip–Greater trochanter in

profile

PA view of rotated hip Fx–Greater trochanter

perpendicular to film

Salter-Harris Fractures

Other signs of fractures

Periosteal reaction Callus / Osteosclerosis

Other signs of fractures Fat pad sign / “Sail sign”

Conclusions

Know how to read X-rays

(Patients expect this & we order a lot of them)

Communicate and share with your consultants

(It affects patient outcomes)Pre-readingDescribing fractures

Fracture Classification

Anat. Location

Direction of fract. Line

Wherther the fract. Is linear or comminuted

Condition of overlying S.T.

Mechnism of injury

AO classification

AO Classification

A : Simple fract.

B : Wedge fract.

C : Complex fract.

AO Classification

A= simple fract.

A1 simple fract.Spiral

A2 simple fract.Oblique(≥30)

A3 simple fract.Transverse(<30)

AO Classification

B1 wedge fractSpiral wedge

B2 wedge fractBending wedge

B= wedge fract.

B3 wedge fractfragmented wedge

B= Wedge fract.

B1 wedge fractSpiral wedge

B2 wedge fractBending wedge

B3 wedge fractfragmented wedge

AO Classification

C= complex fract.

C1 complex fract.spiral

C2 complex fract.segmental

C3 complex fract.irregular

Mechanism of Injury Classification

Direct trauma

Indirect Trauma

Direct trauma :

Tapping fractures

Crushing fractures

Penetrating fractures

- High velocity missiles > 2500 f/s

- Low velocity missiles < 2500 f/s

Indirect Trauma : Traction or tension fract.

angulation fract.

Rotational fract.

Compression fract.

Principles of fractures Fracture repair

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 fracturesRate of union

Unfavorable factorsImpairment of blood supplyInfectionExcessive movementPresence of tumorSynovial fluid in intraarticular Fx.Interposition of soft tissueAny 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 movementPrevention of displacementAlleviation of painPromote soft-tissue healingTry to allow free movement of the

unaffected parts Splint the fracture, not the entire limb

Principles of Treatment

Methods of holding reduction:Sustained tractionCast splintageFunctional bracingInternal fixationExternal fixation

Definitive Fracture Fixation Options

Casts and SplintsAppropriate 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, UNDISPLACEDCLOSED, REDUCIBLE

CONSERVATIVE TREATMENT

2- CAST

Below Knee Above Knee

Complications of cast splintageLiable 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 uniteComes out well on all four of the basic

requirements: “hold” “move” “speed” “safe”

Definitive Fracture Fixation Options

TractionUseful in

patients who are too sick for surgery

Useful to maintain alignment until definitive fixation

Traction by gravityEg. Fractures of the humerus

Balanced TractionSkin traction: adhesive strapping kept in place by

bandagesSkeletal 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.)

External fixation

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

Open Operation

Operative reduction under direct vision is indicated:

1. When closed reduction fails2. When there is a large articular

fragment that needs accurate positioning

Open Operation

3. For avulsion fractures in which the fragments are held apart by muscle pull

4. When an operation is needed for associated injuries

5. When a fracture will anyhow need internal fixation to hold it

Types of Internal Fixation

- Pin & wire fixat.

- Screw fixat.

- Plate & screws fixat.

- Intra-medullary fixat.

Plate & screws fixat.

Functional types: Compression plates Neutralization plates Buttress plates Bridge plates LC- DCP Liss plates Locking plates & screws

Definitive Fracture Fixation Options

Open Reduction and Internal fixation with Plates and screwsUsed for many

fractures especially those involving joints

Intra-medullary fixat.

Centro-medullary - Unlocked -Interlocking(static – dynamic – double

locked)

Condylocephalic

Cephalomedullary

Definitive Fracture Fixation Options

Intramedullary NailsTreatment 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

Indications for internal fixation

1. Fractures that cannot be reduced except by operation

2. Fractures that are inherently unstable and prone to re-displacement after reduction

3. Fractures that unite poorly and slowly4. Pathological fractures5. Multiple fractures6. Fractures in patients who present severe

nursing difficulties

1. Interfragmentary/Lag Screws:o Fixing small

fragments onto the main bone

2. Kirschner Wireso Hold fragments together where

fracture healing is predictably quick

3. Plates and screwso Metaphyseal

fractures of long bones

o Diaphyseal fractures of the radius and ulna

4. Intramedullary nailso Long boneso Locking screwsresist rotational forces

Joint ReplacementUsed in displaced femoral

neck fractures in geriatric patients

Allows for early ambulationOccasionally used in geriatric

pts with comminuted shoulder or elbow fractures

Definitive Fracture Fixation Options

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 osteomyelitisNon-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 failureRefracture

Definitive Fracture Fixation Options

External FixationUsed 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 structuresOver-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 Gustilo’s classification of open fractures:

Type 1: low-energy fracture with a small, clean wound and little soft-tissue damage

Type 2: moderate-energy fracture with a clean wound more than 1 cm long, but not much soft-tissue damage and no more than moderate comminution of the fracture.

Type 3: high-energy fracture with extensive damage to skin, soft tissue and neurovascular structures, and contamination of the wound.

Types of Open Fractures

○Type 3 A: the fractured bone can be adequately covered by soft tissue

○Type 3 B: can’t be adequately covered, and there is also periosteal stripping, and severe comminution of the fracture

○Type 3 C: if there is an arterial injury that needs to be repaired, regardless of the amount of other soft-tissue damage

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 debridementAntibiotic prophylaxisStabilization of the fractureEarly definitive wound coverRepeated examination of the limb because open

fractures can also be associated with compartment syndrome

CONTRAINDICATIONS TO SURGICAL REDUCTION AND STABILIZATION

Situations in which there is a high probability for failure with operative treatment are as follows:

1. Osteoporotic bone that is too fragile to allow stabilization by internal or external fixation.

2. Soft tissues overlying the fracture or planned surgical approach of such poor quality because of scarring, burns,active infection, or dermatitis .

3. Active infection or osteomyelitis.

CONTRAINDICATIONS TO SURGICAL REDUCTION AND STABILIZATION

4. Fracture comminution to a degree that does not allow successful reconstruction. This is most commonly seen in severe intraarticular fractures.

5. General medical conditions that are contraindications to anesthesia are generally contraindications to the surgical treatment of fractures.

6. Undisplaced or stable impacted fractures in acceptable position do not require surgical exposure or reduction.

7. Inadequate equipment, manpower, training, and experience.

Thank you