Fracture

Definition
A fracture is an integrity breaks of bones, usually due to trauma. Fractures wereclassified
according to the type and direction of the fracture line.
Classification of fractures:
According to Hardiyani (1998), the fracture can be classified as follows:
1. Based on its location (fractures of the humerus, tibia, clavicula, and cruris etc.).
2. Based on the extension and the fracture line consists of:
 complete fractures (broken lines through the entire cross-section through bothcortical
bone or bone).
 Incomplete fractures (when the broken line is not through the entire line of bone cross
section)
3. Based on the shape and the number of broken lines:
 Comminuted fractures (broken line is more than one and interconnected).
 Segmental fracture (fracture lines more than one but not related).
 Multiple fracture (fracture lines more than one but at different bone place, forexample a
fracture of the humerus, femur fractures and so on).
4. Based on the position of fragments:
 Undisplaced (not shifted) / complete fracture line but the second fragment isnot shifted.
 Displaced (shift) / shift fracture fragments
5. Based on the relationship with the outside world:
 Closed
 Open (presence of skin injury).
6. Based on the shape of the fracture line and relations with the mechanism of trauma:
 Transverse fracture lines.
 Oblique / slant.
 Spiral / encircling bone.
 Compression
 Avulsion / trauma pull or muscle insertion at insertion
7. Based on the position of the bones:
 Absence of dislocation.
  Presence of dislocation
 At axim : forming an angle.
 At lotus : distracted bone fragment
 At longitudinal : longitudinally distracted bone fragment.
 At lotus cum contractionum : distracted and shortened.

Bone Healing Proccess

There are three primary stages of bone healing:
1. the early inflammatory stage
2. the repair stage
3. the late remodelling stageThese stages are distinct, but there is overlap.

1.Inflammatory Stage
a hematoma (localized blood collection) forms within thefracture site during the first few hours
and days. Inflammatory cells infiltrate the bone, which results in the formation of granulation
tissue (which is important inhealing and repair), vascular tissue (for blood delivery to the new
bone), and immature tissue (which will specialize to form a bridge of tough connective tissue).
This stage can last 2 – 4 weeks after a fracture, and it overlaps with the next stage 2.

Repair Stage
This is the stage where the fracture gets ‘healed’that is, the bone ends become joined and
stabilized. The cells of the body that are capable of changing into bone cells are activated or fired
up to do so, and they start laying down new bone tissue. This tissue, called fracture callus, is
weak; and has to be protected. The hardening of the cartilage begins at each end of the fracture
and sweeps toward the center. During this stage, the new blood vessels for the new growth are
also developed. But it’s during this stage that nicotine from smoking can really slow down this
blood vessel growth, which will impact, in a negativeway, how the bone heals. - this stage can
last 1 – 2 months after a fracture.

3. Remodelling Stage
This is the stage where the body changes the weak bone material into strong bone material.
Because this new material is so strong, the bod ydoes not need a lot of it, and it will remodel the
fracture callus down to normalsized bone. The bone should be restored to its original shape,
structure, andmechanical strength. Remodelling of the bone occurs slowly over months to
yearsand is helped along by mechanical stress (i.e. weight bearing) placed on the bone.

Mechanism and Causes

High-energy injuries
High-energy injuries are typically caused by motor vehicle accidents, falls from height, direct
blows, and gunshots, both civilian and military. Sporting injuries, falls from standing height, and
twisting injuries, usually causes lower-energy injuries. They may also be associated with
pathologic conditions of bone. Complications such as compartment syndrome compared to the
low velocity injury. Low-velocity injuries associated with a muzzle velocity of less than 2000feet
per second are more commonly seen in civilian practice.

Lower-Energy Injuries (Sports-Related Injuries)

Court-Brown has identified soccer-related injuries as the largest contributor to sports-related
tibial shaft fractures, accounting for 80% of sports-related tibial diaphyseal fractures.
Patient may report a history of direct (motor vehicle crash or axial loading) or indirect (twisting)
trauma. Patient may complain of pain, swelling, and in ability to ambulate with tibia fracture.
Ambulation is possible with isolated fibula fracture.

In the etiology of tibial fractures, high-speed trauma is paramount. In areas where people
drive cars at high speeds and engage in activities with high potential for leg trauma (eg, skiing or
soccer), the number of tibial fractures seen in the emergency department is high. Although a
direct blow to the tibia is the most common cause, countless other etiologies for tibial shaft
fractures are encountered. Two of the most prevalent are falls or jumps from significant
height and gunshot wounds to the lowerleg.
Patients with osteoporosis may have a see mingly innocent mechanism of injury and still
sustain fracture.
Classification
Gustilo Classification for Open Fractures
Grade I:
• wound less than 1 cm with minimal soft tissue injury;
• wound bed is clean;
• bone injury is simple with minimal comminution;
• with intramedullary nailing, average time to union is 21–28 weeks
Grade II:
• wound is greater than 1 cm with moderate soft tissue injury;
• wound bed is moderately contaminated;
• fracture contains moderate comminution;
• with intramedullary nailing, average time to union is 26–28 weeks
Grade III: The following fracture types automatically results in classification as type III:
• segmental fracture with displacement
• fracture with diaphyseal segmental loss;
• fracture with associated vascular injury requiring repair;
• farmyard injuries or highly contaminated wounds;
• high velocity gun shot wound;
• fracture caused by crushing force from fast moving vehicle;
Grade IIIA fracture:
• wound less than 10 cm with crushed tissue and contamination;
• soft tissue coverage of bone is usually possible;
• with intramedullary nailing, average time to union is 30–35 weeks;
Grade IIIB fracture:
• wound greater than 10 cm with crushed tissue and contamination;
• soft tissue is inadequate and requires regional or free flap;
• with intramedullary nailing, average time to union is 30–35 weeks;
Grade IIIC fracture:
• fracture in which there is a major vascular injury requiring repair for limb salvage;
• in some cases it will be necessary to consider BKA following tibial fracture
Clinical Presentatition
1. History
A complete medical history is obtained, including prior fractures ororthopedic surgery,
medical conditions (especially any underlying bone disease,neoplasia, arthritis),
medications taken, allergies, and occupation. A descriptionof the mechanism of injury,
including the magnitude, location and direction ofimpact, is helpful. The individual may
report recent trauma, such as a motorvehicle accident, a sports injury, or a severe fall.
 The individual may also reportsevere pain, inability to bear weight on the leg, and
changes insensation. Walking may be possible if only the fibula is fractured.
In the case of stress fractures, the individual may report recent changes in physical
activity level, athletic training intensity, or training surfaces. Pain mayworsen with
weight-bearing activity and decrease with rest.

2. Physical
Visual examination
All clothing should be removed from the extremity.The overall appearance of the
extremity should be noted for open wounds,alignment, contusions, swelling, and color.
Wounds should be assessed for size,location, degree of contamination, and severity of
tissue injury.
Deformities
Often a significant deformity is present at the level of thefracture. Contusions may
indicate the point where a force was applied to theleg to create the fracture, or they may
be incidental. The location of asignificant contusion is important because it can
necessitate a change in thetreatment plan to avoid incising through badly traumatized
tissue.
Comparison to the contralateral leg
Comparison of the injured leg to thecontralateral leg usually reveals a large amount of
swelling. This swelling progresses with time. The amount of swelling present should
serve as a preliminary index of the severity of injury to the tissues.
Color
The color of the extremity reveals essential information about a limb’s perfusion. A
pinkish color indicates oxygenated blood in the capillaries of the skin but reveals little
about th deep circulation. A gray ordusky color, however, indicates circulatory
compromise and a potential for limb loss if proper treatment is not provided promptly.
Movement
After visually inspecting the leg, the physician should observe what the patient can do
with the leg before the physician palpates or manipulates it. Attention should be directed
 at flexion and extension of the knee, ankle, and toes. Occasionally, the patient is too
uncomfortable to comply with this part of the examination.
Palpation
Pulses
An effort should be made to feel for pulses of the popliteal, dorsalis pedis, and posterior
tibial arteries. If strong pulses are not appreciated,Doppler ultrasound should be used to
evaluate the dorsalis pedis and posterior tibial arteries. If triphasic pulses are not present
on Dopplerultrasound and the leg is deformed, traction should be applied to the extremity
and the pulses reevaluated. If the pulses remain abnormal,emergent arteriography and/or
consultation with a vascular surgeon should be obtained.

Direct palpation

Occasionally, the injured leg appears fairly normal, andthe results of the neurovascular
exam are unremarkable. Direct palpation ofthe fracture, however, elicits pain and
possible crepitation, which are indicative of a tibial shaft fracture.

Compartment syndrome
After ruling out vascular injury, the physician mustevaluate for compartment syndrome. If the
patient can actively flex and extendthe ankle and toes without severe pain, compartment
syndrome is not likely to
be present at that time. Compartment syndrome can, however, evolve with time;thus serial
examination and attention to the pa
tient’s symptoms are necessary.

Open fractures
It must be assumed that open wounds in the vicinity of a tibialshaft fracture communicate with
the fracture, and urgent irrigation and debridement should be planned. Open wounds a distance
away from the fracture may communicate with the fracture. Probing or inspection of extremity
wounds for communication with the fracture should be performed in the operating room after
sterile preparation and draping of the extremity.
Supporting Examination

Plain x-rays will usually establish the diagnosis of a tibia and/or fibula fracture. X-rays of the
knee or ankle may also be needed, depending on the location of the fracture. CTscan and MRI
are rarely needed, unless the fracture extends into the knee joint. Because plain film radiographs
usually do not show stress fractures until 2 to 8 weeks after the fracture has occurred, a bone
scan is sometimes used to detect a stress fracture in the earliest stages. A triple phase nuclear
medicine bone scan is often used to confirm the diagnosis. An arteriogram may be done if there
is a problem with blood circulation (vascular compromise) is suspected. A complete blood count
(CBC), blood typing, coagulation profiles, and electrocardiogram (ECG) are part of routine
preparation for surgery. The necessity of other laboratory studies depends on the extent of injury
and comorbid conditions.

Management

Prehospital Care
 Address airway, breathing, and circulation.
 Check and document neurovascular status.
 Apply sterile dressing to open wounds.
 Apply gentle traction to reduce gross deformities; splint the extremity.

Emergency Department
Care Parenteral analgesia should be administered when appropriate. Although
management of pain has improved, pain due to long bone fractures is notably undertreated in the
emergency department. Inpatient admission may be advised to observe development of
compartment syndrome. Continuous compartment pressure monitoring in asymptomatic patients
with tibia fractures is not recommended. Open fractures must be diagnosed and treated
appropriately. Tetanus vaccination should be updated, and appropriate antibiotics should be
given in a timely manner. Some recommend antibiotics within 3 hours of the accident. This
should involve anti staphylococcal coverage and consideration of an aminoglycoside for more
severe wounds. Orthopedics should be consulted for emergent debridement and wound care.
Fractures with tissue at risk for opening should be protected to prevent further morbidity. Open
fractures require debridement and irrigation in the operating room. According to one study, delay
of the first operative procedure beyond the day of admission appears to be associated with a
significantly increased probability of amputation in patients with open tibia fracture. In this
study, data were analyzed from the Nationwide Inpatient Sample, 2003 to 2009.

Definitive Treatments for Tibia and Fibula Shaft Fracture

The aims of the therapy of tibial shaft fractures are
1. reach full weight bearing fast
2. reach solid bony union and avoid pseudarthrosis
3. regain full range of motion of the knee and ankle joint
4. avoiding infections and further soft tissue damage

Open fractures with precarious blood supply and weak soft tissue covering are vulnerable
to complications and remain a challenge for every treating surgeon. Reconstruction of axis,
length and rotation is essential for a good outcome. In particular axial deviation should
be avoided to prevent secondary osteoarthritis of the knee and ankle. The choice of technique
depends on fracture localization, type of fracture, history of concomitant disorders and soft tissue
damage

Conservative management
Casting
Initially, all tibial shaft fractures should be stabilized with a long posterior splint with the
knee in 10-15° of flexion and the ankle flexed at 90°. Admission to the hospital may also be
necessary to control pain and to monitor closely for compartment syndrome.
Closed fractures with minimal displacement or stable reduction may be treated non
operatively with a long leg cast, but cast application should be delayed or 3-5 days to allow early
swelling to diminish. The cast should extend from the mid thigh to the metatarsal heads, with the
ankle at 90° of flexion and the knee extended. The cast increases tibial stability and can decrease
pain and swelling.
 Early ambulation with weight-bearing as tolerated should be encouraged. Tibial shaft
fractures treated with casting must be monitored closely with frequent radiographs to ensure that
the fracture has maintained adequate alignment. Adequate callus formation generally takes 6-8
weeks before cast therapy can be discontinued.
Despite proper casting techniques and adequate follow-up, not all non operatively treated
tibial shaft fractures heal successfully. In addition, 6 week swith out knee motion often results in
a stiff joint. In fact, Kyro et al found that 53%of patients reported a fair or poor result using long
leg casts to treat tibial shaft fractures. This and many other studies have shown that simply
putting a tibial fracture in a long leg cast may lead to increased joint stiffness, some difficulty
ambulating, and increased union times.
Another type of cast, the patellar tendon-bearing cast, was proposed by Sarmiento for use
early in treatment of tibial shaft fractures in place of the long leg cast, and good results were
reported. In general, however, better results are reported with internal fixation of displaced tibial
shaft fractures than with non operative treatment. Hooper et al found that the results of treatment
of displaced tibial shaft fractures were not as satisfactory as those with intramedullary nailing.

Bracing
Three years after describing the patellar tendon-bearing cast, Sarmiento proposed another
treatment, the functional brace. This device has replaced the long leg cast in many circumstances
because it can be put on within 2-4 weeks of injury. It allows more movement of the knee and
ankle while still protecting the tibial fracture. Movement of the knee and ankle may decrease the
stiffness that patients encounter after the fracture is healed. However, the long leg cast is still
used for the first few weeks until the fracture begins to stabilize. As with the patellar cast,
Sarmiento found very good results with the functional brace; however, others subsequently
discovered problems, including a40% nonunion rate in one trial. Although no definitive non
operative treatment has been determined for tibial fractures, many authors have noted increased
nonunion and healing time with casts and braces as compared with surgical fixation. Therefore,
casts and braces have limited use, especially with displaced fractures. The ideal candidate for
non operative treatment is a young patient with a non displaced fracture.

Operative management
Intramedullary nailing
Biomechanical stability and minimally invasive approach with distance to the fracture are
the major advantages of intramedullary nailing. Evidence supports the use of intramedullary
nailing in diaphyseal tibial fractures as the implant of choice. There is also strong evidence that
intramedullary nails offer a benefit over external fixation in open fractures if wound closure is
performed soon. Intramedullary nailing is indicated for open and closed isolated tibia shaft
fractures and even extraarticular distal tibial fractures. This includes oblique, transverse
fractures, segmental fractures, torsion fractures and debris fractures of the tibial shaft as well as
open fractures even with bone loss. Immediately intramedullary nailing is not indicated for
severe soft tissue injuries, multiple trauma patients, thoracic trauma, infection, non-union or
children with joint growth.
Intramedullary nailing is well established as a standard treatment for diaphyseal fractures
of the long bone despite the negative effects such as endosteal necrosis and systematic fat
embolism. The resulting biological osteosynthesis conserves the fracture hematoma. Angular
stable locking screws facilitate the control of rotation, length and axis and expand the indication
for intramedullary nailing. There is considerable controversy concerning intramedullary nailing.
One key area is whether intramedullary nails should be inserted with reaming or unreamed.
Another issue is whether intramedullary nails should be locked with locking screws or not.
Intramedullary reaming deposits the debris formed by reaming at the fracture site, acting like an
autologous bone graft and also improves cortical contact with improved stability. In vitro studies
have shown that intramedullary reaming in combination with an irrigation and aspiration
system(Reamer/Irrigator/Aspirator (RIA), Synthes, West Chester, Pennsylvania) and
replantation of reaming’s into the bone void improve the volume stiffness and
strength of callus during the early phase of healin. Unreamed nailing preserves endostal blood
supply with quicker healing and lower incidence of infection. Blood supply and soft tissue
covering are the major problems in tibial shaft fractures while fat embolism is more relevant in
femur fractures. Trauma to endosteal blood supply has shown to be responsible for the negative
effects of intramedullary reaming. For this reason unreamed intramedullary nailing has
experienced widespread clinical application in open and closed tibial shaft fractures. Court-
Brown et al. pointed out that reamed nailing is associated with a significantly lower time to
union and a reduced requirement for a further operation. They recommended not to use
unreamed nailing in the treatment of the common Tscherne C1 tibial fracture with a spiral
wedge. Coles et al. presented superior results obtained by reaming with less delayed union, non-
union, mal-union and Distal tibial shaft fracture, Typ 43 A2.2 with primary intramedullary
nailing and 6 months postoperative of a 33-year-old male patient. screw break agein a review of
prospective literature on closed tibial shaft fractures . Their finding swere supported by Forster et
al. Lam et al. also described a beneficial effect of reaming in closed tibial shaft fractures, which
was not reflected in open tibial shaft fractures. They concluded that reaming on the one hand
disrupts the blood flow to the cortex but on the other hand induces a six fold increase in
periosteal blood flow.
This reaction does not occur in open fractures with frequent severe periosteal
damage possibly contributing to the lack of benefit in open fractures. A recent Cochrane review
published by Duan X et al outlined that there is no clear difference in the rate of major re-
operations and complications between reamed or unreamed nailing. Low quality evidence could
be found that reamed nailing reduces the incidence of major reoperations related to non- union in
closed fractures rather than in open fractures. In conclusion reaming acts like an osteogenic
debris similar to an autologous bone graft. Improved union rates following reaming have been
described in closed tibial shaft fractures while the benefit in open fractures has not yet been
proven. Recently Fuchs et al. published their first short term results using a gentamicin coated
intramedullary nail (UTNPROtect®) and demonstrated the possible use in open and closed
fractures as the gentamicin coated intramedullary nail was associated with the absence of deep
wound infections, good-fracture healing and an increasing weight bearing capacity after six
months. Certainly further studies monitoring longer terms of follow up and larger patient cohorts
are required.

Plate osteosynthesis

Conventional plate osteosynthesis used to be the method of choice for tibial shaft
fractures without soft tissue injury until recently being replaced by intramedullary nailing with
locking screws. Former developments in plate osteosynthesis led to a surgical technique that
attempted to adapt every fragment exactly to anatomy. Such traumatic surgical techniques led to
denudation of these fragments, whilst wide exposure of the fracture zone caused delayed healing,
nonunion and a tendency towards infection. Subsequently the concept of bridging plate and
biological osteosynthesis where implemented with the use of angular locking screws. These
developments allowed careful surgical techniques with the prevention of soft tissue damage.
Nevertheless indication for plate osteosynthesis in tibial shaft fractures is rare. In current
literature indication for plate osteosynthesis can be found in fractures close to metaphysis,
intraarticular components, segmental tibial fractures or growth joint. Plate osteosynthesis is
contraindicated in open fractures or patients with former injuries to their lower limb or vessel
diseases. If fractures cannot be treated by intramedullary nailing there is evidence that internal
plate fixation is superior to external fixation.

External fixator
Before implementation of intramedullary nailing with locking screws, external fixation
was the most common surgical treatment for open fractures of the tibial shaft. A minimally
invasive approach and implantation with distance to the fracture side, as well as biological osteo
- synthesis and improvements in vacuum wound closure and plastic surgery, extended the field to
intramedullary nailing. Even type IIIb open fractures can nowadays be treated by primarily
intramedullary nailing. External fixation is indicated as primary stabilization for multiple trauma
patients, severe soft tissue injury close to the joints or generally inoperable patients. There are no
contraindications for external fixation in tibial shaft fractures. For the treatment of multiple
trauma pa - tients following the damage control principle, the initial external fixation is the
method of choice. Further patients at risk are those suffering thoracic trauma, craniocervical
injury, hypothermia or coagulopathy. If procedural change can be performed within 5– 10days
there is no increase in the rate of infection. Primary external fixation is also often useful in severe
soft tissue injuries without any fractures and provides immobilization. External fixators are still
used for the definitive treatment of juvenile tibia shaft fractures.

Postoperative Care
After the surgical procedure, the patient should be monitored in the post anesthesia care
unit until stable. Depending on the extent of the other injuries, the patient may be transferred to
the surgical intensive care unit or to a regular ward bed. Initially, the patient's vital signs should
be monitored repeatedly, with careful attention paid to any abnormalities. If a complication
occurs, early discovery almost always improves the prognosis.
On the postoperative day 1, the patient should be examined by the surgical team, and a
complete blood count should be obtained. Once the patient has recovered from surgery and is
considered safe to leave the hospital, he or she should be discharged home or to a suitable
rehabilitation facility.

Medication
As with all fractures, pain management should be a primary concern. Often,
acetaminophen or an NSAID is prescribed for the acute pain of a fracture. However, additional
pain relief may be necessary if the patient does not have relief with acetaminophen or NSAIDs
alone. In this case, an opiate may be required, particularly for breakthrough pain. Adjustment of
pain medications may be necessary, especially in the acute phase.

Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort,
promote pulmonary toilet, and have sedating properties, which are beneficial for patients who
have sustained injuries.
 Acetaminophen (Tylenol, Feverall, Tempera, Aspirin-Free Anacin, Tylenol-3)Indicated
for mild to moderate pain. DOC for pain in patients with documented hypersensitivity to
aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
 Ibuprofen (Motrin, Ibuprin)DOC for patients with mild to moderate pain. Inhibits
inflammatory reactions and pain by decreasing prostaglandin synthesis.
 Oxycodone (OxyContin, Percocet, Roxicet, Roxilox, OxyIR, Tylox, Roxiprin)Analgesic
with multiple actions similar to those of morphine; may produce less constipation,
smooth muscle spasm, and depression of cough reflex than similar analgesic doses of
morphine.

Antibiotics
 Various antimicrobial substances have been shown to be effective in perioperative
prophylaxis. The drug should be active against the most common infecting agents in volvedin
implant-associated infection. This spectrum of germs is well known; however, the susceptibility
of these microorganisms may differ in various hospitals. Therefore, each hospital needs its up-to-
date analysis of the resistance pattern of surgical site isolates. Another prerequisite for the use of
a drug in antimicrobial prophylaxis is that its risk of causing toxic or allergic reactions is
minimal. Antimicrobial substances with a high potency to produce resistant strains should be
avoided, for example, strong β-lactamase inducers like cefoxitin or ceftazidime. If two drugs
have similar efficacy, cost should also be considered in the choice of prophylaxis. In fracture
surgery, first-generation or second-generation cephalosporins suchas cefazolin, cefamandole, or
cefuroxime, are a rational choice. If the patient is allergic to cephalosporins, or in settings with
high prevalence of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin or
teicoplanin are alternative options.