Slide 1

Orthopedic Fracture
DR. ARNEL GUINTO MERTOLA, RN, MD, FPOA
ORTHOPEDIC SURGEON

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Slide 2

• Fracture is defined as a break in the continuity of bone.

Fracture results in loss of its mechanical stability and also
partial destruction of blood supply.
- Rockwood and Wilkins
• Complete or incomplete break in a bone from the application of
excessive force

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Slide 3

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Slide 4

Clinical Manifestation
• Pain in the injured area
• Swelling/tenderness/discoloration
• Loss of function
• Deformity
• Shortening
• Abnormal mobility and crepitus
• Radiographic findings

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Slide 5

Mechanism of Injury
• Injury
• Repetitive stress
• Pathological fractures

AGM 5

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Slide 6

INJURY
• DIRECT FORCE
• Bone breaks at point of the impact, soft tissue damage

• INDIRECT FORCE
• Bone breaks at the distance from where the force is applied

AGM 6

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Slide 7

• Spiral = twisting
• Oblique = compression
• Wedge fracture = bending
• Transverse = tension

AGM 7

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Slide 8

FATIGUE OR STRESS FRACTURE

• Repeated heavy loading
• Use of steroids and methotrexate

AGM 8

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Slide 9

PATHOLOGICAL FRACTURES
• Cause by disease or malignancy
• Such as osteomyelitism, Neoplasm

AGM 9

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Slide 10

Diagnosis of Fracture
• History and Physical Examination
• Diagnostic such as Xray, CT scan and MRI

AGM 10

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Slide 11

General Signs
• ABC
• Airway Obstruction
• Breathing problem
• Circulatory problems
• Cervical spine injury
• Secondary survey = examine the main injury, identify the type of
fracture, classify, plan of management and look for complications

AGM 11

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Slide 12

XRAY INVESTIGATION

• Xray examination is mandatory

• Rules of two
• Two views – fracture or dislocation may not be seen in single xray view at
least two views ( anteposterior and lateral view)

• Two limbs – In children, the appearance of immature epiphysis may confused

the diagnosis of a fracture

AGM 12

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Slide 13

AGM 13

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Slide 14

• Two joints = in forearm and leg, one bone may be fractured or

angulated

• Two injuries – severe force often cause injuries at more than one level

• Two occasions = some fracture may not be seen or difficult to detect

at the time of injury

AGM 14

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AGM 15

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Slide 16

AGM 16

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Slide 17

AGM 17

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Slide 18

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Slide 19

AGM 19

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Slide 20

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Slide 21

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Slide 22

Open Vs Closed Fractures

AGM 22

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Slide 23

AGM 23

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Slide 24

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Slide 25

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Slide 26

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Slide 27

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Slide 28

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Slide 29

AGM 29

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Slide 30

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Slide 31

PATHOPHYSIOLOGY
Due to any etiology(crushing movement)
•|
Fracture occurs , muscle that were attached to bone are
disrupted and cause spasm
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Proximal portion of bone remains in place, the distal portion
can become displaced in response to both causative force & spasm
in the associated muscles

AGM 31

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Slide 32

In addition, the periosteum and blood vessels in the cortex and

marrow are disrupted
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Soft tissue damage occurs, leads to bleeding and formation
of hematoma between the fracture fragment and beneath the
periosteum
•|
Bone tissue surroundings the fracture site dies, creating an
intense inflammatory response

AGM 32

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Slide 33

release chemical mediators

histamins,prostaglandins
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Resulting in vasodilation, edema, pain, loss of function,
leukocytes and infiltration of WBC

AGM 33

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Slide 34

ORTHOPEDICS MANAGEMENT

AGM 34

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Slide 35

• Reduction
•Reduction of a fracture (“setting” the bone) refers to restoration of
the fracture fragments to anatomic alignment and rotation.
OPEN REDUCTION

• It’s a surgical approach, the fracture fragments are reduced.

• External/Internal fixation devices (metallic pins, wires, screws, plates, nails, or
rods) may be used to hold the bone fragments in position until solid bone
healing occurs.

AGM 35

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Slide 36

Internal fixation

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Slide 37

External
fixation

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Slide 38

Difference between internal or

external fixation

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Slide 39

Closed reduction
• closed reduction is accomplished by bringing the bone fragments into
apposition (ie, placing the ends in contact) through manipulation and
manual traction.
• Extremity is held in the desired position while the
physician applies a cast, splint, or other device.
• X - rays are obtained to verify that the bone fragments are correctly
aligned.
• Traction (skin or skeletal) may be used to effect fracture reduction and
immobilization.

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Slide 40

Immobilization
• Immobilization may be accomplished by external or
internal fixation.
• Methods of external fixation include bandages, casts, splints, continuous
traction, and external fixators.
• Metal implants used for internal fixation serve as internal splints to immobilize
the fracture.

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Slide 41

Traction
• Traction is the use of weights, ropes and pulleys to
apply force to tissues surrounding a broken bone.

AGM 41

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Slide 42

Traction
1. Skin traction-
• Bucks traction used for knee,hip bone fracture
• Weight usually 5-7 pounds attach to skin
2. Skeletal traction –
• Needs invasive procedure
• Weight is upto 10 kg attached to bone

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Slide 43

Splinting
• Splinting is the most common procedure for
immobilizing an injury.

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Slide 44

Why Do We Splint?

• To stabilize the extremity

• To decrease pain
• Actually treat the injury

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Slide 45

Possible items for

Splinting
• Soft materials. Towels, blankets, or pillows,
tied with bandaging materials or soft cloths.

• Rigid materials. A board, metal strip, folded

magazine or newspaper, or other rigid item.

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Slide 46

Soft Splints

• Splinting Using a Towel

• Splinting using a towel, in which the towel is rolled up and wrapped
around the limb, then tied in place.

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Slide 47

Guidelines for Splinting

1. Support the injured area.
2. Splint injury in the position
that you find it.
3. Don’t try to realign bones.
4. Check for color, warmth, and
sensation.
5. Immobilize above and below
the injury.

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Slide 48

The splint should go beyond the joints above and

below the fractured or dislocated bone to prevent
these from moving

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Slide 49

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Slide 50

Maintaining and restoring function

• Restlessness, anxiety, and discomfort are controlled with a
variety of approaches, such as reassurance, position changes,
and pain relief strategies, including use of analgesics.

• exercises are encouraged to minimize disuse atrophy and to

promote circulation.
• Participation in activities of daily living (ADLs) is encouraged
to promote independent functioning and self-esteem.

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Slide 51

Complications of Fracture

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Slide 52

EARLY COMPLICATIONS
• Shock
• fat embolism
• compartment syndrome
• deep vein thrombosis
• disseminated intravascular coagulopathy
• infection

AGM 52

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Slide 53

VISCERAL INJURIES

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Slide 54

• Often occur in fractures around the trunk

• Penetration of lung by rib fractures which causes
pneumothorax
• Rupture of bladder or urethra in pelvic fractures
• Require emergency treatment

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Slide 55

VASCULAR INJURY

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Slide 56

Injury Vessel
First rib fracture Subcalvian
Shoulder dislocation Axillary
Humeral supracondylar fracture Brachial
Elbow dislocation Brachial
Pelvic fracture Presacral and internal iliac
Femoral supracondylar fracture Femoral
Knee dislocation Popliteal
Proximal tibial Popliteal or its branches

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Slide 57

Clinical features
• Paraesthesia or numbness
• Injured limb is cold and pale or slightly
cyanosed
• Weak or absent pulse

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Slide 58

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Slide 59

Treament
• All bandages and splints should be remove
• Fractures re-x-rayed and if artery is being
compressed prompt reduction is required
• Circulation reassessed repeatedly over the
next half hour
• If no improvement, vessels must be explored
by operation with pre or peroperative
angiography

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Slide 60

• Cut vessel can be sutured, or a segment may

be replaced by a vein graft, if it is thrombosed,
endarterectomy may restore blood flow
• If vessel repair is done, stable fixation is a
must and fracture should be fixed internally

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Slide 61

NERVE INJURY

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Slide 62

Injury Nerve

Shoulder dislocation Axillary

Humeral shaft fracture Radial

Humeral supracondylar fracture Radial or median

Elbow medial condyle Ulnar

Moteggia fracture-dislocation Posterior-interosseous

Hip dislocation Sciatic

Knee dislocation peroneal

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Slide 63

Closed nerve injuries

• Seldom severe and spontaneous recovery
occurs in 90% within 4 months
• Nerve should be explored if no recovery, nerve
conduction studies and EMG fail to show
evidence of recovery

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Slide 64

Open nerve injuries

• Nerve should be explored at the time of
debridement and repair at the time or at
wound closure

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Slide 65

Acute nerve compression

• Sometimes occurs with fracture or
dislocations around the wrist
• Numbness or paraesthesia in distribution of
the median or ulnar nerves
• fracture reduction or splitting of bandages
around the splint
• If no improvement within 48 hours, nerve
should be explored and decompressed

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Slide 66

• Indications for early exploration

1. Associated with open fracture that
need internal fixation
2. Presence of concomitant vascular injury
3. Diagnosed after manipulation of the
fracture

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Slide 67

HAEMARTHROSIS

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Slide 68

• fracture involving joint

• Joint is swollen, tense and patient resist any
attempt at moving at
• Blood should be aspirated before dealing with
fracture

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Slide 69

INFECTION

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Slide 70

Early infection
• May present as wound inflammation without
discharge
• Causal organism
1. S. aureus
2. Pseudomonas
• Antibiotics may allow fracture to proceed to
union as long as fixation remains stable
• But further surgery is likely later, when antibiotics
are stopped

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Slide 71

Late presentation
• May present with a sinus and xray evidence of
sequestra
• Implants and all avascular pieces of bone
should be removed
• External fixator can be used to bridge the
fracture If resulting defect too large for bone
grafting, patient should be referred to a limb
reconstruction centre

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Slide 72

• When infection involves a joint, principles of

treatment are the same as with bone
infection, namely debridement and drainage,
drugs and splintage
• On resolution of infection, fracture is stabilize
so that joint movement can recommence
• If fracture cannot be stablized, joint
should be splinted in the optimum
position
• Can lead to permanent stiffness

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Slide 73

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Slide 74

Compartment Syndrome

• Occurs with fracture of elbow, forearm bones,

proximal third of tibia, hands or foot ;
• Crush injuries and circumferential burns
• Increase of pressure within the osseofascial
compartment
• Due to bleeding , oedema or inflammation

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Slide 75

Clinical Diagnosis
• The six ‘Ps’:
• Pain – early sign
• Pressure
• Pallor
• Paresthesia
• Paralysis
• Pulselessness

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Slide 76

• Confirmation of diagnosis
– Measuring the intracompartmental pressures
• Introduced a split catheter into the
compartment
• Pressure measured close to level of the fracture
• Differential pressure (difference between the
diastolic pressure and compartment pressure ) is
<30mmHg – immediate decompression

• Management
– Remove any casts, bandages and dressings
– Differential pressure < 30mmHg – immediate
fasciotomy

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Slide 77

Gas gangrene
• Produced by Clostridial infection
• Present in dirty wound with dead muscle that
are closed without adequate debridement
• Toxins can cause necrosis of tissue and
promote the spread of the disease

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Slide 78

• Clinical features
– Within 24 hours of injury
– Intense pain
– swelling around the wound
– Brownish discharge
– Little or no pyrexia
– Increase pulse rate
– Characteristic smell
– Patient rapidly become toxemia and may lapse
into coma and death

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Slide 79

• Prevention
– All dead tissue should be completely excised
– Doubt about tissue viability – wound should be
left open

• Treatment
– Early diagnosis
– Fluid replacement & IV antibiotics
– Hyperbaric O2 – limit the spread of gangrene
– Prompt decompression of the wound and removal
of dead tissue
– Amputation in advance cases

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Slide 80

Fracture Blisters
• 2 types
– Clear fluid filled vesicles
– Blood stained
• Occur during limb swelling
• Due to elevation of the epidermal layer of the
skin from the dermis
• No advantage in puncturing the blister ( cause
local infection )
• Surgical incision can be done after the limb
swelling decrease

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Slide 81

Plaster and Pressure Sores

• Occur where the skin presses directly onto
bone
• Traction on a Thomas Splint ( wrong ring size,
excessive fixed traction and neglect)
• Prevention
– Padding the bony points
– Moulding the wet plaster so that pressure is
distributed to the soft tissue around the bony
points

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Slide 82

• Treatment
– Patient feels the localised burning pain ( warning
sign )
– Window must be immediately cut in the plaster
– If unnoticed, skin necrosis will progress

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Slide 83

LATE COMPLICATIONS

DELAYED UNION
When a fracture takes more than usual time to
unite, it is said to have gone in ‘delayed union’.

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Slide 84

Causes

Factors causing delayed union can be summarized as:

biological, biomechanical or patient-related.

BIOLOGICAL
--Inadequate blood supply
--Severe soft tissue damage affects fracture healing by:
(1) reducing the effectiveness of muscle splintage
(2) damaging the local blood supply and
(3)diminishing or eliminating the osteogenic input
from mesenchymal stem cells within muscle
--Periosteal stripping

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Slide 85

BIOMECHANICAL
--Imperfect splintage
--Over-rigid fixation
--Infection

PATIENT RELATED
In a less than ideal world, there are patients who are:
• Immense
• Immoderate
• Immovable
• Impossible.
These factors must be accommodated in an
appropriate fashion.

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Slide 86

Clinical features

-Fracture tenderness persists

-Pain may be acute
-On x-ray- fracture line remains visible
-there is very little or incomplete callus
formation or periosteal reaction
- However, the bone ends are not

sclerosed or atrophic (suggest that,

although the fracture has not united, it
eventually will)

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Slide 87

Treatment

• Conservative principles are:

(1) to eliminate any possible cause of delayed union

(2) to promote healing by providing the most appropriate environment

• Immobilization (whether by cast or by internal fixation) should be

sufficient to prevent shear at the fracture site,
• but fracture loading is an important stimulus to union and can be
enhanced by:
(1) encouraging muscular exercise
(2) by weightbearing in the cast or brace

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Slide 88

OPERATIVE

--If union is delayed for more than 6 months and there

is no sign of callus formation, internal fixation and bone
grafting are indicated.

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Slide 89

NON-UNION

Delayed union gradually turns into non-union – that is it becomes apparent

that the fracture will never unite without intervention

Movement can be elicited at the fracture site and pain

diminishes; the fracture gap becomes a type of pseudoarthrosis.

The X-ray shows a

This patient has an
typical hypertrophic
obvious pseudarthrosis
non union
of the humerus.

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Slide 90

X-ray
-The fracture is clearly visible but the bone on either side of it
may show either exuberant callus or atrophy

-This contrasting appearance has led to nonunion being

divided into hypertrophic and atrophic types.

-In hypertrophic non-union the bone ends are enlarged,

suggesting that osteogenesis is still active but not quite
capable of bridging the gap

-In atrophic non-union, osteogenesis seems to have ceased

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Slide 91

Causes

Biological and patient related:

(1) poor soft tissues (from either the injury or surgery)

(2)local infection

(3)associated drug abuse, anti-inflammatory or

cytotoxic immunosuppressant medication

(4) non-compliance on the part of the patient.

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Slide 92

TREATMENT
CONSERVATIVE

Non-union is occasionally symptomless, needing no

treatment or, at most, a removable splint with
hypertrophic non-union, functional bracing may be
sufficient to induce union, but splintage often needs to
be prolonged.

Pulsed electromagnetic fields and low-frequency,

pulsed ultrasound can
also be used to stimulate union.

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Slide 93

OPERATIVE

--hypertrophic non-union -- very rigid fixation alone

(internal or external) may lead to union.
--atrophic non-union, fixation alone is not enough.
Fibrous tissue in the fracture gap, as well as the
hard, sclerotic bone ends is excised and bone grafts
are packed around the fracture. If there is
significant ‘die-back’, this will require more
extensive excision and the gap is then dealt with by
bone advancement using the Ilizarov technique.

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Slide 94

Malunion
• the fragments join in an unsatisfactory
position (unacceptable angulation, rotation or
shortening)
• Causes are :
failure to reduce a fracture adequately
failure to hold reduction while healing
proceeds
gradual collapse of comminuted or
osteoporotic bone.

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Slide 95

• Common sites: fractures at the ends of a bone

• E.g. supracondylar fracture of the humerus,
Colles fracture.
• Consequences:
Deformity
Shortening of the limb
Limitation of movements

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Slide 96

• X-rays are essential to check the position of

the fracture while it is uniting.
• Important during the first 3 weeks, when the
situation may change without warning.

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Slide 97

• Treatment
1. In adults,
• fractures should be reduced as near to the
anatomical position as possible.
• Angulation of more than 10–15 degrees in a
long bone or a noticeable rotational deformity
may need correction by remanipulation, or by
osteotomy and fixation.

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Slide 98

2. In children,
• angular deformities near the bone ends (and
especially if the deformity is in the same plane
as that of movement of the nearby joint) will
usually remodel with time;
• rotational deformities will not.

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Slide 99

3. In the lower limb,

• shortening of more than 2.0 cm is seldom
acceptable to the patient
• a limb length equalizing procedure may be
indicated.

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Slide 100

Avascular Necrosis
• Certain regions are notorious for their propensity
to develop ischaemia and bone necrosis after
injury
• Common sites:
 the head of the femur (after fracture of the
femoral neck or dislocation of the hip)
 the proximal part of the scaphoid (after fracture
through its waist)
 the lunate (following dislocation)
 the body of the talus (after fracture of its neck).

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Slide 101

• Consequences
Deformation of the bone
Leads to secondary osteoarthritis a few years
later
Painful limitation of joint movement

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Slide 102