Principles of Fractures

1
 Bone compsosition

‫اﻟﻤﻜﻮن اﻟﺮﺋﯿﺴﻲ‬

‫ ﺑﺘﺘﺤﻮل ل‬O2 ‫إذا ﻣﺎﻓﻲ‬ 5

fibrous tissue mi
'

✓
g In the bone marrow I Osteoblast trapped in I
From bone marrow s Osteoblast > trapping in
the matrix From undifferentiated the matrix > osteoclast
,
From macrophages & mesangial cells
monocytes
Two types of bone:-
1.Cortical bone: dense, makes the outer layer
2.Trabecular (cancellous/ spongy bone): at the
metaphysis, vertebral bodies, ribs, shoulder plate
Bone anatomy
Growth plate (physis) > In children, it’s between diaphysis and epiphysis

s Growth plate (physis)

 * Cartilage is collagen type 2

Articular capsule

4
 Fracture
Of cortex

• it’s the break in the continuity of the bone

• It could be: nondisplaced linear fracture ‫ ھﻮ‬:‫اﻟُﺸﻌﺮ‬
(It’s a fracture)

– Simple (closed) Intact skin

– Compound (open) ‫ﺳﻮاء اﻟﻌﻈﻢ طﻠﻊ أو إﺷﻲ دﺧﻞ‬

 Classification
• Closed or open
– Closed fractures, skin is intact.
– Open (compound) fractures involve wounds that
communicate with the fracture and may expose bone to
contamination, may be from inside or outside.
‫ ﻧﻔﺴﮫ ﺑﻄﻠﻊ‬bone ‫ال‬ bone ‫ﺣﺪﯾﺪة ﺑﺘﺪﺧﻞ ﺑﺎل‬

• Simple or multi-fragmentary (comminuted)

– Simple fractures only occur along one line, splitting the
bone into 2 pieces.
– Multi-fragmentary fractures involve the bone splitting into
multiple pieces. (high energy injury→ soft tissue probably
damaged)
 Types of fracture
7
Bone fragments separate completely from cortex to cortex

1. Complete fractures – line occurs according to mechanism of injury

– Transverse fracture Fracture at a right angle to the bone's long axis.

Oblique fracture – a fracture that is diagonal to a bone's long axis > One line
– Oblique or spiral Spiral Fracture – a fracture where at least one part of the bone has been twisted
> Double line. It results from a twisted injury.

– Impacted
‫ﺑﺪﺧﻠﻮا ﺑﺒﻌﺾ‬ A complete bone fracture in which the broken bones are jammed together

– Comminuted s In thick periosteum

2. In-complete fractures, the bone is incompletely divided and the

periosteum remains in continuity. Common in children; because periosteum is thick

– Greenstick fracture Greenstick fractures in children, the spriny bone in childhood, buckles on
the side opposite to the causal force, where periosteum remains intact.

– Stress fracture
– Compression
‫ﺣﻮل وﻣﻦ ﺧﻼل ال‬
growth plate e
Compression fracture, ex. when the front portion of a vertebra in the spine collapses due to osteoporosis.
*Reduction is not required in vertebral body fracture, But it is necessary when the fractures are part of joint.

3. Physeal fractures – affect growth

4. Fracture displacement Due to direct injury,
gravity, muscle
9
 Displacement of the fracture fragments
• Causes: “Force”

• Primary impact
• Gravity s

• Muscle pull Exp. Fracture of olecranon process due to biceps contraction “avulsion fracture”

• The following Displacements are recognized: Types of displacements of distal fragments

(translation) of the distal fragment.

(alignment) of the distal fragment in relation to
proximal one or the opposite.
(twist) one fragment may be rotated on its
longitudinal axis.
Shift and angulation can remodel, while rotation cannot
 Injury description
1. Bone: Description of a fracture starts by naming the bone
2. Location: the part of the bone involved.
3. Type: simple or multifragmentary and closed or open.
4. Group: transverse, oblique, spiral, or segmental.
5. Subgroup: displacement, angulation and shortening. And rotation

t
L

One line on x-ray Double line on x-ray

Exp. There is a fracture in the distal radius .. with posterior *Contact fracture: axial force, in
dislocation (palmar side is anterior .. dorsal side is posterior) vertebral body, in cancellous bone.
We need AP view to know it is medial or lateral (ulna
medially, radius laterally “thumb”)

Lateral view > anterior / posterior

AP view > Medial / Lateral
*Unstable reduction is an indication for open reduction.

Description
Complete Fracture – bone fragments separate completely.
• Transverse Fracture – fracture at a right angle to the bone's long axis.
• Oblique Fracture – fracture that is diagonal to a bone's long axis. ٣٠ ‫زاوﯾﺔ أﻛﺜﺮ ﻣﻦ‬
• Spiral Fracture – fracture where at least one part of the bone has been
twisted.
• Compacted Fracture – bone fragments are driven into each other. Axial
• Comminuted Fracture.
– Segmental (double) Fx, occur at 2 levels with free segment between
them. Vs butterfly fracture
(‫)ﺑﻜﻮن ﻓﻲ اﺗﺼﺎل‬

Incomplete Fracture – bone fragments are still partially joined.

– Greenstick fractures in children, the spriny bone in childhood, buckles
on the side opposite to the causal force, where periosteum remains
intact.
• Compression fracture, ex. when the front portion of a vertebra in the spine
collapses due to osteoporosis.
• Reduction is not required in vertebral body fracture, But it is necessary
when the fractures are part of joint.
 • Stable fracture is one which is likely to stay in a good
(functional) position while it heals. Can be treated conservatively
>
Especially due to muscle pull “avulsion fracture”

• Unstable Fx is likely to angulate or rotate before healing and

L
lead to poor function in the long term. (can cause malunion) Need surgical fixation

Complex
dislocation • Fracture-dislocation is Fracture of the bony components of the
joint, ex: Simple dislocation > dislocation without shoulder (hip,shoulder)
Complex dislocation > dislocation + Fracture

– Shoulder fracture dislocation With greater tuberosity fracture

– Elbow fracture dislocation

At one side

• Burst fracture, occur in vertebra due to severe violence, acting

vertically on a straight spine.
– Anterior and posterior surfaces of the vertebra are involved – post
involvement may lead to neuro injury
Incomplete Spiral or oblique Open fracture
Simple transverse fracture

Segmental
comminuted
fracture
n

Burst > One vertebrae

 No
communication
^

Connection

Due to tension force Due to rotation

= wedge
Due to binding force
9 Spongy bone
 Transverse fracture

Usually perpendicular,
but angle is accepted up
to 30 degrees

s Spiral fracture

Transverse fracture (<30ْ)

 Oblique fracture
-

Shorter than spiral #

Spiral >
9
double line ‫ﻛﺎﻧﮫ‬
Impacted fracture
Spiral fracture
spiral
 Causes of fractures
1. Sudden trauma Majority of fractures

2. Stress “fatigue fracture” Constant force on same bone

3. Pathological fracture Abnormal bone, like in osteoporosis

Fractures with simple trauma, like falling from same level

4. Growth plate injury

 Fractures caused by sudden injury in a
normal bone
• Majority of the fractures.
• Caused by single excessive force.
Also causes transverse fracture

a. Direct blow that cause a transverse Fx with damage to skin. ( Tensile force )
b. Crushing force that cause comminuted Fx with extensive damage to
soft tissue.
The bone breaks at a distance from where the force is
applied. Have better prognosis, less soft tissue damage
a. Rotational force, leading to spiral fracture.
Butterfly
b. Bending force, leading to transverse fracture. -

c. Bending with compression, leading to transverse fracture with

butterfly third segment. Butterfly + comminuted Compressive force

d. Combined (Rotation, bending & compression) leading to oblique

fracture.
e. Pulling force, in which a tendon pull, causes avulsion fracture.
Exp. Fracture of olecranon process due to biceps contraction
 Need less
energy,
Need higher remodel
energy, heal faster
slow
 Stress fracture – fatigue fracture
Definition: A fracture in a normal bone, that is continuously exposed to stress

• 2 categories:
bone with normal elastic resistance, so
application of abnormal stress or torque causes resorption and
microfractures.
occurs with normal muscular activity
stresses on bone with deficient in mineral or elastic resistance
tibia & fibula ‫ ﻣﺎ ﺑﺘﻮزع ﻋﻠﻰ ال‬،metatarsals ‫ﺑﻀﻞ اﻟﻀﻐﻂ ﻋﻠﻰ ال‬

• Mostly affect athletes (runner) or military recruits n

• Occur anywhere but most commonly 2nd metatarsal followed by

Anterior cortex for tibia
Fibula and Tibia.
• Clinically, Pain with gradual onset, examination will show local
tenderness after weeks there will be swelling.
• X-ray, MRI and Bone scan. The most sensitive test: MRI
 Disease in the minerals of bone, for exp. (Cyst)

Pathological fracture
• Occur through a bone that is weakened by a disease.
• Fx occur either spontaneously or from trivial violence.
Minor

• Local causes
– i Bone infection (osteomyelitis)
– Benign tumors (enchondroma, giant cell tumor).
– Malignant tumor (osteosarcoma , Ewing sarcoma & metastatic
3

carcinoma).
• Generalized causes Deficiency

– Congenital (osteogenesis imperfecta) – type 1 collagen.

I

– Diffuse affection of bone (osteoporosis, rickets, uremic osteodystrophy)

2

– Other causes (Polyostotic fibrous dysplasia, Paget’s disease, Gaucher’s

3

disease).
 Growth plate injury
• Over 10 % of fractures in children involve the growth plate.
• 3 types of injuries:
1. Simple separation. 1

2. Fractures that cross the growth plate. 2,3,4

3. Crush injury. 5 History of trauma, widening of growth plate, tenderness, incongruity of lines.
1. At level of physis (simple)
2. From metaphysis to physis
3. Epiphysis to physis
• Factors that increase suspicion of physeal injury 4. Metaphysis + physis + epiphysis
5. Crush growth plate fracture

1. Widening of physeal gap

2. Incongruity of the joint Lines are not in parallel

3. Tilting of the epiphyseal axis

 Soft tissue damage
*Treat fracture then soft tissue

• It could be either:
• Low energy fractures like closed spiral fractures →
cause moderate soft tissue damage.
• High energy fractures like comminuted fractures →
cause severe tissue damage, no matter whether it open
or close.
 Fracture VS. Soft tissue injury
Pathognomic sign of fracture

• Deformity  more suggestive of a Fx.

• Children  Green stick Fx
• Elderly  impacted Fx of femoral neck may experience
• Little or no pain
s Usually does’t appear on x-ray > CT should be done

• Loss of function
• Numbness
• Skin pallor, cyanosis
• Blood in urine Pelvic fracture + urethral injury

• Abdominal pain
• Difficulty with breathing Ribs fracture

• Transient loss of consciousness

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 Approach

History
Physical examination
Investigation
 History
• Fracture is not always at the sight of injury (indirect)
• Certain fracture will not affect the function of the
limb, like greenstick fracture or scaphoid fracture.
• Age
• Mech. Of injury
• Pain
• Bruising
• Swelling
• Limitation of movement
• Previous or other musculoskeletal abnormality
• General medical history
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Axillary nerve examination: on dermatomes between two limbs

Examination

1. Scars
2. Skin is intact or not (open VS simple)
3. Color of the skin (signs of nerve or vessel damage)
4. Swelling

:
5. Bruising
6. Deformity

Posture of distal extremities

1. Tenderness
2. Temperature
3. Crepitus on movement
4. Vascular (distal pulses) and peripheral nerve abnormalities
(before and after treatment)
5. Spine and pelvis
6. Examination of the viscera
– Liver and spleen in case of rib fracture.
– Bladder and urethra in case of pelvic fracture.
– Neurological examination for head and spinal injury.

Movement of the joint distal to the affected area;

S Crepitus and abnormal movement indicates a fracture.
31
 Examination
• In any case X-ray diagnosis is more reliable
1. Examine the most obviously injured part
2. Check for arterial damage Pulse + capillary refill time

3. Test for nerve injury

4. Look for injury in distant parts

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External

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 Look
• Swelling
• Bruising
• Deformity
• Skin is intact or not (open VS simple)
• Posture of distal extremities and color of the skin 
signs of nerve or vessel damage

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 Feel
You should know the landmarks

• Tenderness
• Temperature
• Crepitus on movement
• Distal pulses
• Spine and pelvis
• Vascular and peripheral nerve abnormalities (before and after
treatment)
• Examination of the viscera Start by ABC

– Liver and spleen in case of rib fracture.

– Bladder and urethra in case of pelvic fracture.
– Neurological examination for head and spinal injury.
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 Associated injuries
injury may damage brachial plexus or
vessels at base of neck. Neurological and vascular
examination are essential The shoulder girdle or pectoral girdle:
Connects to the arm on each side. In humans it consists of the clavicle and scapula.

2. Thoracic injury (rib or sternum Fx) associated with lung or

heart injury
associated with spinal cord or nerve root
injury
: associated with visceral
injury inquire about urinary function and look for blood in
urethral meatus PR & PV examination

Open-book fracture

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37
 Move
• Movement of the joint distal to the affected area;
• Crepitus and abnormal movement indicates a fracture.

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 Imaging
1. X-ray Rule of 2s

• Two views, AP and lateral.

• Two joints.
• Two limbs. Like in salter haris fracture s Right and left to avoid confusion with growth plate

• Two injuries, like calcaneal fracture you have to suspect

vertebral fracture. Suspected two joints injured in one accident, for example: shaft femur fracture > you suspect neck femur fracture & vice versa

• Two occasions, like stress and scaphoid fractures. On three day of injury & after two weeeks

• Special views
– Calcaneal view
– Shoulder dislocation needs axial view
– Acetabular fractures need 45 degree tilt view.
In occult fracture

2. CT scan and MRI (spinal, pelvic and calcaneal fractures)

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3. Radioisotope scan (scaphoid and stress fractures)
 X-ray & Rule of 2
1. 2 views (AP & lateral): fracture or dislocation may not be
seen in a single X-ray Displacement in AP view: Lateral or medial
Displacement in lateral view: Anterior or posterior

2. 2 joints: above and below Fx, may be dislocated or fractured

3. 2 limbs: in children X-ray of uninjured limb are needed for

comparison, because immature epiphysis may confuse the
diagnosis

4. 2 occasions: some fractures are difficult to detect soon after

injury, another X-ray a week or two later may show the
lesion. Example: undisplaced frx. of distal end of clavicle

5. 2 injuries: severe force causes injury at more than one level

40
 AP view Lateral view

Two occasions: after

e two weeks of
Two views 9
scaphoid fracture

Two joints 9
I Two limbs

41
 Fractures in children
1. Difficult to diagnose: Bone ends are largely cartilaginous
and don’t show up in X-Ray, so X-Ray both limbs and
compare the appearance on both sides. s
Thick periosteum
Plastic deformation: ‫ﺑﺘﻐﯿﺮ وﺑﺜﺒﺖ اﻟﺸﻜﻞ‬
Elastic deformation: ‫ﺑﺘﻐﯿﺮ وﺑﺮﺟﻊ اﻟﺸﻜﻞ‬

2. Bones are less brittle and more liable to plastic deformation.

Higher incidence of incomplete fx. Buckling of the cortex
and green stick frx. are rare in adults.
than adult bones that’s why frx.
. Cellular activity is
increased (frx. heals faster).
4. Non-union is very unusual
5. More capacity to reshape frx. Deformity more modeling and
remodeling.
6. Injury to the physis  damage to growth plate can have
serious consequences.
Disruption of growth, either:
s
1. Partial > Deformity
2. Complete > Shortening
42
 Incomplete fracture

(‫ )ﻧﺘﻮء‬buckling ‫ﻋﺎﻣﻞ زي‬

43
 Salter-Harris classification
Note the:
1. Widening I

2. Incongruity

Type I:
Congruity
Simple growth plate fracture

• The whole growth plate is

separated.
• No growth disturbances

Type II: Metaphysis + physis

• The growth plate is

separated carrying with it a
triangular metaphyseal
fragment.
• No growth disturbances.
• The most common injury.
Type III: Physis + epiphysis

• Part of the growth plate is

separated. This one is
intra-articular
• May lead to growth
disturbances.
Type IV:
• Separation of part of the
growth plate with a
metaphyseal fragment.
• May lead to growth
disturbances.
Type V:
• Crushing of part or all of the
growth plate.
• Growth disturbances & arrest
are very common.
• The most dangerous injury.
We dx it RETROSPECTIVELY
 Fracture repair

Healing with callus

Healing without callus

46
*Anatomical reduction > always open reduction

Fracture repair
• Fracture repair is a tissue regeneration process rather than a
healing process the injured bone is replaced by bone.

– Type of bone involved

• Tubular bone Cortical bone Secondary or primary healing

• Cancellous bone Spongy bone Primary healing

– Amount of movement at the fracture No movement > primary

Movement > secondary

– The closeness of the fracture surfaces v

 Tubular bone repair
• 2 types:
Depends on:
1. Movement at the fracture site

:
2. Pattern of fracture for stability

1. Haling by callus
Indirect / Secondary healing

1. Tissue destruction and hematoma formation

2. Inflammation and subperiosteal and endosteal
cellular proliferation
3. Callus formation
4. Consolidation
5. Remodeling
2. Healing without callus
Primary healing

Healing by direct union

Repair:
1. Primary bone healing (direct, healing without callus) > low movement at the fracture site, stable fracture size, rigid fixation, absolute stability
2. Secondary (indirect, healing with callus) > No need for (rigid fixation, or absolute stability)

Primary or secondary according to the fracture:

1. In articular surface fracture > it’s primary, because secondary leads to arthritis > so, anatomical reduction by open fixation
2. In diphyseal fracture > you don’t need anatomical reduction > so functional reduction (alignment, rotation, length) > closed reduction “may fail, so do open (primary)”
 Healing by callus

1- Tissue destruction and

hematoma formation.
Contains inflammatory markers

Forms soft callus >> then hard callus (rigid callus) “you remove cast” >> immature bone
(woven bone) >> then consolidation >> then remodeling / mature bone (lamellar bone)

• Disruption of blood vessels

A hematoma forms around
and within fracture
• Few millimeters of the
fracture surfaces dies.
m
2- Inflammation and
subperiosteal and
endosteal cellular
proliferation.

• Need 8 hours.
• Proliferation of fibroblasts,
mesechymal cells, and
osteoproginetor cells.
• New vessels formation.
3- Callus formation.

• Chondrogenic and osteogenic

activity.
• Cartilage in the periphery, woven
bone near the bone ends.
• Marked increase in vascularity.
• Osteoclast activity.
• At the end the pain disappears
and the fragments are rigid w/o
movement.
4- Consolidation.
With continuing osteoclastic and osteoblastic activity, the
9
woven bone is transformed into lamellar bone.

• The primitive woven bone is

transformed into lamellar
bone by osteoclastic and
osteoblastic activity.
• Need several months before
the bone is strong enough to
carry normal loads.
 - NSAIDS > decrease osteoblastic differentiation > delayed union
- Corticosteroids > causes non-union
- Ciprofloxacin > Fluoroquinolones are contraindicated in children, because it has an effect on chondrocyte & growth plate
- Collagen type 2 > Cartilage
- Collagen type 1 > bone

5- Remodeling.
• Callus is reshaped: the
bone along the lines of
stresses are strengthened
while bone outside these
lines removed. S
Thicker lamellae are laid down where the stresses are
high; unwanted buttresses are carved away

 The medullary canal is

reformed.
 The remodeling depends on
age that Fx remodeling in
children is so perfect.
 Intracapsular bone > no callus formation

Healing without callus = primary healing

Healing by direct union

In the absence of rigid fixation (there’s movement) > callus healing (secondary)

 Callus is formed as a response to movement at the fracture

side, to stabilize the fragments rigidly.
If the fracture site is absolutely immobile (e.g. an impacted fracture in cancellous bone, or a fracture rigidly immobilized by
internal fixation) there is no need for callus; instead, new bone formation occurs directly between the fragments > Primary healing

 Primary bone healing occurs directly between the 2

fragments without callus formation, when the fracture site is
absolutely immobile. Cancellous bone repair
Cancelous bone has spongy texture with open meshwork of trabeculae, allowing easier penetration by
vessels and bone forming cells.
The broader area of contact between the fragments with good blood supply allow healing in shorter
period of time w/o need for callus formation.

 Primary bone healing can occur in 2 instances:

◦ Naturally in impacted fractures of the cancellous bone. É

◦ In cortical fractures where the 2 fragments are in complete

contact and rigidly fixed (absolute fixation) by metal device
(plates, screws or intramedullary nails).
Strain (movement ‫)ﻣﻘﯿﺎس ال‬
1. Less than 2% > immobile > Primary bone healing (without callus)
2. 2-10% > little movement > secondary bone healing (with callus)
3. More than 10% > fibrous tissue formation > non-union
• Cortical bone remodels by osteoclastic tunneling (cutting
cone)
• Cutting cones consist of:
1. Osteoclasts
2. Capillary bud
3. Osteoblasts
4. Osteoblasts lay down new osteons
 Cancellous bone repair
Primary

• Cancelous bone has spongy texture with open meshwork of

trabeculae, allowing easier penetration by vessels and bone
forming cells.

• The broader area of contact between the fragments with

good blood supply allow healing in shorter period of time w/o
need for callus formation.
Complete recanalization
Blood Canal
Soft tissue Cartilage Bone
 Test of union
‫ ﻛﯿﻒ ﺗﺘﺄﻛﺪ إﻧﮫ اﻟﻜﺴﺮ اﻟﺘﺄم؟‬،‫ﻟﻤﺎ ﺗﻘﯿﻢ اﻟﺠﺒﺺ‬

• Clinical:
– Absence of mobility.
– Absence of tenderness. In joints
s

– Absence of pain.
• Radiological – X-ray criteria:
1. Callus formation
2. Bone bridging
3. Trabeculation
• Bone can withstand normal (physiologic) loading
Medullary canal formation
 Rate of union
• Favorable factors. • Unfavorable factors. Delayed union

– Age: 3-5 weeks in – Impairment of blood

children while it needs 3- supply.
5 months in adult. – Excessive movement.
– Type of bone: cancellous – Infection
is better healer. – Tumor
– Blood supply – Synovial fluid in
intraarticular Fx.
– Immobilization. Less than 10% strain

– Interposition of soft
– Adequate nutrition tissue (↓ contact btw bony
(including calcium ends).
intake) – Any form of Nicotine.
– Diabetes
 Average time for Upper limb Lower limb
healing

Callus visible 2-3 weeks

Union 4-6 weeks 8-12 weeks

Until hard callus formation

Consolidation Healing
6-8 weeks 12-16 weeks
Normally fractures unite within 2 to 5 months
Causes:
Non union
• Distraction and separation of the fragments. Fragments not connected to each other

• Interposition of soft tissues between the fragments.

• Excessive movement at the fracture site Strain > 10%

• Poor local blood supply.

• Severe damage to soft tissues which makes them non viable.
Severe soft-tissue damage is the most important cause of delayed union and non-union.
• Infection It disrupts the blood supply, reduces osteogenesis from mesenchymal stem cells and impairs the effectiveness of muscle splintage.

• Abnormal bone.
Non union or delayed union, next step:
1. Rule out infection
2. Bone graft
3. Change the modality of fixation (external fixation)
Treatment of Fractures
 Steps
Functional reduction:

1. Reduction 1. Length
2. Alignment
3. Rotation

• Closed (manual) Closed manipulation or by instrument 9 Functional reduction

• Opened (surgery) s Anatomical reduction

2. Maintenance of reduction Fixation / Hold

• Cast (2 joints, except elbow)

• Internal fixation open reduction ‫ ﯾﺴﺒﻘﮫ‬internal fixation ‫ﻟﯿﺲ ﻛﻞ‬
internal fixation ‫ ﯾﻠﯿﮫ‬open reduction ‫وﻟﻜﻦ ﻛﻞ‬

• External fixation
• Traction (skin/skeletal)
3. Rehabilitation (exercise) According to the method of maintenance

Nail is load sharing (secondary healing)

Plate is weight bearing
 The Fracture Quartet
• Dual Conflict
– Hold vs Move
– Speed vs Safety

For example: cast vs nail in tibial fracture

h I

The weakness The weakness

point of casts point of nails
 Reduction
To gain normal bone & position of injured bone or parts

• Reduction unnecessary when:

– There is little or no displacement
– Displacement does not matter Exp. > In some fractures of the clavicle / Fracture of humeral shaft

– Reduction is unlikely to succeed With compression fractures of the vertebrae

Reduction is closed or open according to the anatomical area

• Aim of reduction Articular surface > always open reduction + rigid fixation, primary bone healing,
no gaps, no steps, absolute stability, no callus.

– Adequate apposition
– Normal alignment of the bone fragments Especially functional reduction

• Methods of reduction The greater the contact surface area between fragments the more likely is
healing to occur; a gap between the fragments is a common cause of

– Manipulation Closed reduction

delayed union or non-union.

– Mechanical traction
– Open operation Open reduction
1. Manipulation
• Closed manipulation is suitable for:
1. All minimally displaced fractures
2. Most fractures in children
3. Fractures that are likely to be stable after reduction
• Unstable fractures are sometimes reduced ‘closed’
prior to mechanical fixation (temporarily)
• Three fold maneuver: under anesthesia and muscle
relaxation "Pulling the limb by traction
and counter traction"

1. The distal part of the limb is pulled in the line of the bone
2. The fragments are repositioned as they disengage By reversing the original
direction of force

3. Alignment is adjusted in each plane

 Closed reduction + internal fixation "‫> "أي إﺷﻲ ﺑﺨﺘﺮق اﻟﻜﺴﺮ‬ ‫ﯾﻌﺘﻤﺪ ﻋﻠﻰ اﻟﻤﻜﺎن واﻟﻌﻤﺮ‬
‫( اﻻ ﻟﻮ ﻓﺘﺢ اﻟﻜﺴﺮ‬Nail) Lower limb + diaphyseal fracture > nailing

2. Mechanical Traction e.g. fracture of the femoral shaft because of counterforces exerted by powerful muscles
* The femoral shaft is well padded with muscles
- an advantage in protecting the bone from all but the most powerful forces, but a disadvantage
in that fractures are often severely displaced by muscle pull, making reduction difficult.

• Some fractures are difficult to reduce by manipulation

• They can often be reduced by sustained mechanical
traction, which then serves also to hold the fracture
until it starts to unite
Traction is a method for reduction & hold

• In some cases, rapid mechanical traction is applied

prior to internal fixation
 3. Open Operation
It means primary bone healing > open reduction internal fixation

• Operative reduction under direct vision is indicated:

1. When closed reduction fails Either because of difficulty in holding the fragments together or because
soft tissues are interposed between them

2. When there is a large articular fragment that needs accurate

Needs anatomical open reduction
positioning
Open (unstable)

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

Unlikely to succeed If there is intra-articular extension (intra-articular fracture), do CT (to see al the

by muscle pull
9

fragments and do appropriate reduction)

Then anatomical reduction to minimize the risk of post-traumatic osteoarthritis
Intra-articular fracture complication: post-traumatic osteoarthritis

4. When an operation is needed for associated injuries Arterial damage

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

Generally open reduction is the first step to internal fixation
 Hold (maintenance of reduction)
• Restriction of movement
– Prevention of displacement
– Alleviation of pain
– Promote soft-tissue healing
– Try to allow free movement of the unaffected parts To avoid stiffness of these parts

• Splint the fracture, not the entire limb

• Methods of holding reduction:
– Cast splintage
– Internal fixation
– External fixation
– Traction From book:
Closed methods are most suitable for fractures with intact soft tissues (the muscles surrounding a fracture act as
a fluid compartment; traction or compression creates a hydraulic effect that is capable of splinting the fracture)
– Bracing and are liable to fail if they are used for fractures with severe soft-tissue damage.
Contraindications to non-operative methods:
1. Soft tissue damage

• Closed vs. operative methods 2. Unstable fractures

3. Multiple fractures
4. Fractures in confused or uncooperative patients.
 Cast Splintage
It shouldn’t be tightened to avoid compartment syndrome

• Used for distal limb fractures and for most children’s fractures
• Safe: not applied too tightly or unevenly
As long as

• Speed: of union same as traction, but pt goes home sooner

• Hold: patients with tibial fractures can bear weight on the cast
• Move: joints encased in plaster cannot “move” and are liable
to stiffen. This complication can be minimized by:
1. Delayed splintage- using traction until movement has
been regained, and then applying plaster
2. Starting with a cast but after a few weeks replacing it by a
functional brace which permits joint movement
 Complications of cast splintage
1. Tight cast
The cast may be put on too tightly, or it may become tight if the limb swells.
The patient complains of diffuse pain; only later - sometimes much later - do the signs of vascular compression appear.
The limb should be elevated, but if the pain does not subside during the next hour, the only safe course is to split the cast. (Compartment syndrome)

2. Pressure sores
Even a well-fitting cast may press upon the skin over a bony prominence (the patella, the heel, the elbow or the head of the ulna).
The patient complains of localized pain precisely over the pressure spot.
Such localized pain demands immediate inspection through a window in the cast.

3. Skin abrasion or laceration This is really a complication of removing the cast, especially if an electric saw is used.
Complaints of nipping or pinching during plaster removal should never be ignored.

4. Loose cast
Once the swelling has subsided, the cast may no longer hold the fracture securely.
If it is loose the cast should be replaced
 Internal Fixation Can cause sepsis

• Hold: securely with precise reduction

• Move: can begin at once (no stiffness & edema)
• Speed: patient can leave hospital as soon as wound is healed, but
full weight bearing is unsafe for some time
• Safe: biggest problem is sepsis

1. Open reduction
2. Fractures that are inherently unstable and prone to re-
displacement after reduction (e.g. midshaft fractures of the forearm and some ankle fractures or avulsion fractures)

3. Fractures that unite poorly and slowly e.g. fractures of the femoral neck)

4. Pathological fractures Bone disease may prevent healing

5. Multiple fractures Early fixation reduces the risk of general complications

6. Fractures in patients who present severe nursing difficulties

 Internal Fixation
• Hold: securely with precise reduction
• Move: can begin at once (no stiffness & edema)
• Speed: patient can leave hospital as soon as wound is healed, but
full weight bearing is unsafe for some time
• Safe: biggest problem is sepsis

1. Open reduction
2. Fractures that are inherently unstable and prone to re-
displacement after reduction
3. Fractures that unite poorly and slowly
4. Pathological fractures
5. Multiple fractures
6. Fractures in patients who present severe nursing difficulties
 Internal fixation
1. Plates (on the surface of bone)
o Metaphyseal fractures of long bones
o Diaphyseal fractures of the radius and ulnaMonteggia and galeazzi fracture

2. Intramedullary nails (inside the bone)

o Long bones
o Locking screws resist rotational forces
3. Screws, fixing small fragments onto the main bone
4. Wires (condular or trochlear Fx), hold fragments together where
fracture healing is predictably quick

74
 Plates and screws
Rigid fixation
‫اﻟﻤﺴﺎﻣﯿﺮ ﺑﺘﺘﻜﺴﺮ إذا دﻋﺲ ﻋﻠﯿﮭﺎ‬

Plate

Screw
:

75
Nails
Screws

77
Elastic

Wires
K-Wires
Nonrigid fixation

78
Complications of internal fixation
• Most are due to poor technique, equipment or operating
conditions

:
• Infection If the infection is not rapidly controlled by intravenous antibiotic treatment, the implants should be replaced with some form of external fixation.

• Iatrogenic infection is now the most common cause of

chronic osteomyelitis Most common organism: Staph epidermidis
Biofilm formation increase the resistance for microorganism ..
increase the likehold of osteomyelitis

• Non-union Classification:
1. Early: Within the first 2 weeks
2. Delayed: 2-10 weeks
3. Late: After 10 weeks
• Excessive stripping of the soft tissues Presentation:
1. Pain at the site of fracture

• Damage to the blood supply

2. Fever
3. Draining sinus

• Rigid fixation with a gap between the fragments

Metal is subject to fatigue, and undue stresses should therefore be

• Implant failure
Investigations:
avoided until the fracture has united. 1. CBC,ESR, CRP (CRP is more important than ESR)
Patients with femoral or tibial fractures should still use crutches until 2. X-ray: Periosteal rn,
there are signs of fracture healing (6 weeks at least) 3. CT: to see the sequestrum

• Refracture It is important not to remove metal implants too soon, or the bone may re-fracture;
a year is the minimum and 18 or 24 months safer.
4. MRI: to evaluate the soft tissues

Surgery:
For several weeks after implant removal the bone is weak, so full weightbearing - the aim is to collect at least 5 samples
should be avoided. - then we order culture for aerobes, anaerobes, fungal
- then according to culture . give Antibiotics for at least 6 weeks
Tx is surgical, antibiotic is not enough
 External Fixation
Not stable, no rigid fixation

• Need High degree of training and skill Mnemonic: COIN PN

• Indications:
1. Wound can be left open for inspection, dressing, or definitive
coverage (like open fractures). Or for fractures associated with severe soft-tissue damage where internal fixation is risky.

2. Infected fractures, for which internal fixation might not be

suitable.
3. Fractures associated with nerve or vessel damage.
4. Severely comminuted & unstable fractures
5. Pelvis fractures
6. 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
 of -0
risk at

infectionof '
'

ggye

Complications of external fixation:

• Damage to soft-tissue structures Nerves or vessels may be inadvertently injured, or ligaments may be tethered.

• Over-distraction, no contact between the fragments union

delayed/prevented
• Pin-track infection May lead to chronic osteomyelitis
 Sustained Traction
• Traction is applied to the limb distal to the fracture, so as to exert a
continuous pull in the long axis of the bone
• In most cases a counterforce will be needed (to prevent the patient simply being dragged along the bed)
• Particularly useful for spiral fractures of long-bone shafts, which are
easily displaced by muscle contraction Reduction by mechanical traction is used for femoral shaft fracture for the same reason
• “Hold” is not perfect, but it is “safe” and the patient can “move” the joints
and exercise the muscles. The problem is speed (or rather lack of it): not because the fracture
unites slowly (it does not) but because sustained lower limb traction
keeps the patient in bed for a long time, thus increasing the

• The problem is the lack of “speed”complications likelihood of complications such as thromboembolism, respiratory
problems "PE" and general weakness.
For this reason sustained traction is best avoided in elderly patients,

• Types: and even in younger patients traction should be replaced by cast

splintage or functional bracing as soon as the fracture becomes
'sticky' (deformable but not displaceable).

– Traction by gravity (Fractures of the humerus)

Traction by gravity is suitable only for upper limb injuries (Fractures of the humerus “shaft”)

– Balanced Traction Thus, with a wrist sling the weight of the arm provides continuous traction to the humerus.
For comfort and stability, a U-slab of plaster may be bandaged on or, better, a removable
plastic sleeve from the axilla to just above the elbow is held on with Velcro (humeral bracing).

• Skin traction: adhesive strapping kept in place by bandages For femoral

shaft fracture
• Skeletal traction: stiff wire/pin inserted through the bone distal to +supracondylar femoral

the fracture Can withstand much greater force and is therefore used mainly for lower limb injuries. (if dislocation >
pin)
 Doesn’t hold the fracture in a sufficient way

Femur fracture managed with skeletal traction

and use of a Steinmann pin in the distal femur.
 Functional Bracing
• Prevents joint stiffness while still
permitting fracture splintage and
loading
• Most commonly for fractures of the
femur or tibia
Allow for movement
9

• Since its not very rigid, it is usually

applied only when the fracture is
beginning to unite i.e. after 3–6 weeks of traction or restrictive splintage

• Comes out well on all four of the basic

requirements: “hold” “move” “speed”
“safe” Prevents joint stiffness while still permitting fracture splintage and loading
Segments of a cast are applied only over the shafts of the bones, leaving the joints free.
 Rehabilitation
• Restore function to the injured parts and the patient as a whole
• Active Exercise, Assisted movement (continuous passive motion by
machines), Functional activity
• Objectives:
– Restore circulation
– Prevent soft tissue adhesions
– Promote fracture healing
– Reduce edema
• Swelling  tissue tension and blistering, joint stiffness
• Soft Tissue care: elevate and exercise, never dangle, never
force
– Preserve joint movement
– Restore muscle power
– Guide patient back to normal activity
 OPEN FRACTURES
• Initial Management ABCs +

– At the scene of the accident splinting

Coverage +
+ Abx
if available

– In the hospital
ABCs Cervical spine protection, vital signs, 2-large bore cannulas >
examine the limb (neurovascular) > stabilize the limb (by splint

↓ for exp) to prevent pain and further soft tissue damage > x-ray
give fluids, abx, analgesia, tetanus ppx, and cover to prevent further
contamination
↓
neurovascular exam (look out for compartment syndrome)
↓
splint fracture (external fixation) as damage control – emergent, non-definitive
↓
manage soft tissue injuries, debride necrotic
↓
definitive repair
 Gustilo’s classification of open fractures
– For type 1 > Antibiotic with gram +ve coverage

• Type 1: low-energy fracture with: < 1cm – For types 2 & 3 > Antibiotics with gram +ve & -ve & anaerobic coverage

– Small, clean wound

– Little soft-tissue damage
• Type 2: moderate-energy fracture with 1-10 cm
– Clean wound more than 1 cm long
– Not much soft-tissue damage
– Moderate comminution of the fracture. Primary closure
• Type 3: high-energy fracture with > 10 cm Fracture of femur less than 1 cm but there is arterial damage > 3С
Fracture in femur less than 1 cm but the mechanism is gunshot > ЗА

– Extensive damage to skin, soft tissue and neurovascular structures

– Contamination of the wound. You can close the wound primarily or with skin graft Comminuted fracture / segmental
fracture / gunshot wound > 3A

• 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 Needs Plastic interventional No primary closure but close with skin flap
(muscle & skin)

• Type 3 C: if there is an arterial injury that needs to be repaired, regardless

of the amount of other soft-tissue damage. Vascular injury repair
 Incidence of wound infection
In open fx

• 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.

88
• All open fractures assumed to be contaminated Prevent
infection!
• The essentials:
Tetanus prophylaxis (toxoid for previously immunized), Analgesics

– Prompt wound debridement

– Antibiotic prophylaxis Within first 3 hours to prevent infection

– Stabilization of the fracture

– Early definitive wound cover Then irrigation in the OR

– Repeated examination of the limb because open fractures

can also be associated with compartment syndrome
In open & closed fractures
 Sterility & Antibiotic cover
• The wound must be kept covered until the patient reaches the
operating theatre
• Antibiotics ASAP
• Most cases: Benzylpenicillin and flucloxacillin
• Even better: 2nd generation cephalosporin, every 6 hrs/48
hrs
• If heavily contaminated, cover for G-ve organisms and
anaerobes by adding gentamicin or metronidazole and
continuing treatment for 4 or 5 days
 Open fracture is contaminated (not infected)

Debridement &
in the first 6 hours, after that it is infected

Wound Excision
• In the operating theatre, never in the ER!
• Under GA
In OR, you have to treat the fractures and the soft tissues

• Maintain traction on injured limb and hold it still 1. Do the debridement first
2. For fractures, apply external fixation
* If there is vascular injury, orthopedic must start first with
external fixator, then vascular surgeon
• Remove clothing 3. Later on (after 2 weeks), do the definitive treatment

• Replace dressing with sterile pad

• Clean and shave surrounding skin
• Remove pad and irrigate wound with A LOT of warm normal saline
• Do not use a tourniquet!
• Extend wound and excise ragged margins healthy skin edges
• Remove foreign materials and tissue debris
• Wash out wound again with warm NS (6-12 L)
• Remove devitalized tissue S

• Best to leave cut nerves and tendons alone

 You have to do a second lock in the theater
Then after 48 hours (if infected, do debritment again)

Wound Closure
Do not close until you are sure there is 100% debridement

• To close or not the skin= difficult decision

– Uncontaminated types 1 & 2 wounds may be sutured
Why we dont close?
– All other wounds: delayed primary closure 1. To avoid bacterial infection - close environment-
2. To avoid compartment syndrome
3A > you can close

– Type 3 wounds may occasionally have to be debrided

3B, 3C > you can’t close

more than once and skin closure may call for plastic
surgery.
• Skin grafting= most appropriate if the wound cant be closed w/o
tension and the recipient bed is clear, free of obvious infxn, and
well vascularized
 Stabilization of the Fracture
• Stability of the fracture is imp in:
– Reducing the likelihood of infection
– Assisting in recovery of the soft tissues
• Method of fixation depends on:
– Degree of contamination
– Length of time from injury to operation
– Amount of soft tissue damage
• Open fractures of all grades up to 3A treated as for closed injuries
• More severe injuries: combined approach by plastic and ortho
surgeons
– The precise method depends on the type of soft-tissue cover that
will be employed, although external fixation using a circular
frame can accommodate to most problems
 After care and Team Work
• Post-op
– Limb is elevated
– Circulation carefully monitored
– Antibiotic cover continued; swab samples will dictate whether a
diff. antibiotic is needed
– If wound has been left open, inspect in 2-3 days. Delayed
primary suture is then often safe or, if there has been much skin
loss, plastic surgery for grafting may be necessary
• Teamwork
– For optimal results, open fractures with skin and soft-T damage
are best managed by a partnership of ortho and plastic surgeons,
ideally from the outset rather than by later referral
– If no plastic surgeon on site, use a digital camera for image
transmission by internet to communicate and consult.