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6 Introduction
6 Types of fracture
6 Management of fracture
- in general
- specific types of fracture
6 Complications
 
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- Bone has its own mechanism to ward off the unnatural
forces and keep itself intact.
- but, if the force is :
   and  (as in MVA, fall etc), OR
-   (eg prolonged standing/used);
OR
- when    
  (eg tumor, infection etc),
that a bone succumbs to the insult and breaks.
- When it breaks, it is bound to injure the surrounding soft
tissue like muscles, ligaments etc.
 Reverity ranges from trivial sprains to life-
life- or limb
limb--
threatening trauma.
Often acute trauma is the cause of the presentation.
Y? are the main symptoms

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£     £  

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£ a break in the surface of a bone, either across its cortex

or through its articular surface.
£ µDs¶ in fracture :
Deformity is seen often in displaced fractures
Displacement could be anterior, posterior, medial or
lateral
Distal fragment is the reference point to suggest the type
of displacement

"Y?àà

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u. Rimple / closed vs Compound / open

2. Based on the patterns of fracture
u







The bone breaks within its soft tissue envelope and not
communicate to the exterior.
i







The bone breaks / rip through its soft tissues or the soft
tissue itself may be damaged by the external forces,
exposing the bone to the external atmosphere
(communicate to the exterior)

a 

 #$  ?
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Y

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u





£ Transverse, oblique or
spiral
- # angle < 30¶ with the
horizontal line : 
- angle > 30¶ :


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The fracture fragments >2 in
number







£ Breaks into segments
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%
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%
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"Y?àà

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Reen in children
The bone is elastic, usually bends due to buckling or
breaking of one cortex when a force is applied.









As a result of being subject to uncustomary repetitive
forces before the bone and its supporting tissues have
had adequate time to accommodate to such forces.
Eg. 
 in soldiers





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Occurs in diseased bone, from a relatively minor trauma
  


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· # involving the physis, the cartilaginous epiphyseal plate near the ends
of the long bones of 
#
 
· The damage may destroy part or all of its ability to produce new bone
substance, resulting in aborted or deformed growth of the bone thereafter.
› 
" fracture is when there is › 
"" fracture is when there is
a fracture across the physis a fracture across the physis
with no metaphysial or which extends into the
epiphysial injury metaphysis
  


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› 
""" fracture is › 
"$ fracture is › 
$ fracture is

when there is a when there is a when there is a
fracture across the fracture through crush injury to the
physis which extends metaphysis, physis, physis
into the epiphysis and epiphysis
   &
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OOAL :
- to restore the anatomy back to its normal or as near to
normal as possible.
   &
 !

Y'!
Identify the life threatening injuries
ABCDE must be observed in all injuries be it serious or
trivial
( )  :
- completely undress the patient for total
assessment of the limbs

 !
Oive greater attention to the extremities
Look for perfusion, alignment, function of the involved
limbs / extremities
   &
 
&
 
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o Pain, tenderness on palpation

o Loss of function ± unable to move
o Deformity ± angulation, shortening, rotated
o Rwelling
o Abnormal posture
o Crepitus ± gritty feeling at fracture site

* exam of the  and 



 is
mandatory in all fractures
   &
 
&
 
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u & ± for deformity, wounds, swelling, colour and
general appearance of the limbs
i '' ± for the distal pulses and detect loss of
sensation
 $' ± the joints above and below the fracture

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To convert a contaminated wound into a clean wound
and thus help to convert an open fracture into a closed
one
To establish a union in a good position
To prevent pyogenic and clostridial infections




u. Careful and detailed examination
2. Removal of any gross contamination (by thorough
irrigation), application of sterile dressing and splinting
of fracture
3. Tetanus prophylaxis
4. Admin. of IV antibiotics
àor muscle, non viable tissue has to be removed ± å (

 $ *



Colour Pink Pale

Consistency àirm àlabby
Capacity to bleed Preserved Lost
Circulation Present Absent
Contractility Present Absent

* "
)
 ± key in the Rx of MR trauma
Prevent further RTI
Relieves pain
Possibly decreases the incidence of fat embolism and
shock
àacilitates transportation
Y,
à


 Yà
Least common fracture (3%)
Most are result of MVA (60%)
Commonly associated with other injuries
- 50% have intraabd. Injuries
- u5% have urethral injuries
- u0% have bladder injuries
Pelvis contains many important structures :
- Iliac vessels
- dense presacral venous plexus
- urogenital organs
Major ligaments :
- sacroiliac, sacrospinatus, sacrotuberous
Patients can sustain large volume blood loss
½


+
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Based on pattern of injury

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Horizontal fracture of pubic rami
I - crush injury to sacrum on side of impact
II - crescent (iliac wing) # on side of impact
III - I or II injury; contralat. open-book (APC)
injury
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½|! ,
½iå
, 
àracture of diastasis of pubic symphysis or
longitudinal rami
I - diastasis but ligaments intact
II - widened RI jt, anterior lig. disrupted,
posterior ligament intact
III - complete RI jt and ligament disruption

$
 
½$,
½å
, 
Vertically oriented # through anterior and
posterior pelvis with superior displacement of
injured hemipelvis.
Yà
 !
Yà

Any patient assessment begins with the ABCDE¶s

Complete neurologic and vascular exam
Have high suspicion of intra-
intra-abdominal injuries ½å
,
Physical exam :
± Ecchymosis or contusion around hips, perineum
± Pelvic instability with stressing
± Ruspect if signs of urologic findings : blood at
urethral meatus, high-
high-riding prostate
± High force mechanisms also associated (MVA,
femur #)
 Yà( '!
Yà(

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Hemorrhage / hypovolemic shock - the most significant
complication of pelvic #
- require blood transfusion (maintain HCT > 20%)

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External fixation techniques ± pelvic clamp, hammock
application
These can help in controlling ongoing bleeding

. Rurgical management of the broken bone can proceed

LATER after life-
life-threatening conditions are controlled.
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  $ à!

àractures of the femur, humerus, tibia / fibula

Blunt and penetrating trauma
Requires 
 to break bone, therefore
look for other injuries.
# cause localized bleeding and this can be
substantial resulting in hypovolemic shock.

± Humerus # : 0.5 ± u.5 L

± Unilateral tibia / fibula # : 0.5 ± u.5 L
± àemur # : u.0 ± 2.5 L
 $ à(
 $ à( '!

ABCDE¶s
Neurovascular exam (vascular +/-+/- nerve injury)
Rplint involved extremity
± Reduction decreases pain, bleeding
Orthopedic consultation for definitive
management
Complications :
± àat
àat--emboli syndrome
± Blood loss
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± Most commonly occur in

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at sites where the vessels lie
in close proximity to the bone  at sites where the
vessels are held in a relatively fixed position.

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± Location of # and MOI dictate need to assess for
potential vascular injury in asymptomatic patient.
 à
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/#.
± Occur 

 than vascular injuries in
assoc. with #.
± Can occur due to blunt trauma, along path of
penetrating trauma, or be caused by the # fragments
themselves.
± Nerves are at increased risk of injury when they are :
superficial to the skin,
lie close to the bone, or
over a joint, making them susceptible to stretch
injury.
 à
' !
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± Most common form of non non--thrombotic embolism.

± Ringle or multiple long bone fractures in young or pelvic / hip fractures
in elderly predispose to àER.
± 20% of patients with pelvic or long bone fractures have detectable fat
droplets in their blood. Vast majority remain asymptomatic.
± Has  




u. àracture sustained.
2. Other than fracture-
fracture-associated pain, patient is asymptomatic for
u2--36 hours.
u2
3. Rudden onset of life-
life-threatening syndrome characterized by rapid
cardiopulmonary and neurologic deterioration, agitation,
hallucinations, delirium, coma, hypoxia, dyspnea, tachypnea, and
tachycardia leading to 2"$

|/2
ü#
'' '

Occurs when pressure within soft tissues in a fixed body

compartment  to level that exceeds  
pressure, compromising venous blood flow, and limiting
capillary perfusion.
Leads to muscle ischemia and necrosis.
›/-'
/›
!'2"
''/'* 2

à !

'%



± Conditions that reduced size of muscle compartment -
tight casts / splints, occlusive dressing, burn scar
"


Conditions that increase compartment volume :
± bleeding
± swelling
± fluid extravasation into tissue
CR - Common in crush injuries or # with marked swelling.
- much more often in lower (rather than upper) extremities.

'' '!
  !
Ruspect with long bone #, crush injuries
Presents as pain out of proportion to physical
findings, +/-
+/- hypoesthesia, pulselessness (late).

'!
Remove compressive dressings or casts
Apply ice to the affected extremity, do no
elevate
- keeping the area dependant will
increase the perfusion pressure
Treatment ± 



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 à

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"
 - wound < u cm, minimal RTI & comminution
- wound bed is clean ; bone injury is simple
- with IM nailing, average time to union is 2u
2u--28 weeks;

""
 - wound is u ± u0 cm, moderate RTI & contamination ,
comminution
- with IM nailing, average time to union is 26
26--28 weeks;

"""

- segmental # with displacement, # with diaphyseal segmental loss, # with
associated vascular injury requiring repair;
- highly contaminated wounds

"""|
0

- wound > u0 cm, crushed tissue and contamination;
- soft tissue coverage of bone is usually possible;
- with IM nailing, average time to union is 30
30--35 weeks;

""".
0

- wound > u0 cm, crushed tissue and contamination;
- soft tissue is inadequate and requires regional or free flap
- with IM nailing, average time to union is 30
30--35 weeks;

"""
0

- involving major vascular injury requiring repair for limb salvage
 /'|/

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