Principles of Fracture

Management
Learning Outcomes

• By the end of this lecture the student

should be able to:
• Define a fracture

• Discuss the clinical evaluation & investigation of a

patient with a fracture

• Describe the radiological classification of fractures

• Discuss the general principles of management of

fractures
• Discuss the common fractures & their
management

• Outline the differences between

fractures in adults & children

• Enumerate the early, intermediate and

late complications of fractures
Definition

A fracture is a partial or complete

break in the structural continuity of
bone.
Introduction

“All fractures unite:

some how, some
when. Be aware of
the difference you
create and make
use of it rationally.”
–P. Demmer
Introduction

• Bone is the only tissue in the human body

other than liver that heals by regeneration
instead of by scarring.

• For regeneration to occur the bone must

be immobilized to allow uninterrupted
formation of new bone.
How Do Fractures Happen?
Bone is relatively brittle yet it has sufficient strength
and resilience to withstand considerable stress.
Fractures result from:

1. Single traumatic incident ( direct or indirect

force).

2. Repetitive stress (fatigue or stress fractures).

3. Abnormal weakening of the bone (pathological

fractures).
Clinical Assessment

• History – Injury
- Deformity
- Inability to use limb
- Pain, bruising, swelling
- Symptoms of associated
injuries
- Previous injuries
- General medical history
Clinical Assessment

• General signs (A broken bone is part of

a patient!). Look for evidence of:
1. Shock or haemorrhage.

2. Associated damage to brain, spinal

cord or viscera.

3. Predisposing cause.
 Clinical Assessment
Local signs:

1. Look
- Swelling, bruising, deformity.

- Integrity of skin (intact or

broken).
Clinical Assessment

Local signs

2. Feel
- localized tenderness
- warmth
- distal pulses
- sensation
Clinical Assessment

Local signs

3. Move
- motor supply distal to fracture
site
- abnormal movements
- joints distal to injury
Investigations
X-rays
1. Two views (AP & lateral)
2. Two joints (proximal and distal to #)
3. Two limbs (in children, epiphyses
may confuse)
4. Two injuries (e.g. calcaneum vs
pelvis/spine
5. Two occasions (repeat 10-14 days
later)
Types of Fractures

• Closed (simple)- no communication between fracture

site and skin surface.

• Open (compound)- communication between fracture

site and skin surface (e.g. Gustilo & Anderson’s
classification) Licentiate Clinical Officers 9
th

February 2006
Types of Fractures

• Transverse

• Oblique

• Spiral

• Comminuted

• Impacted

• Greenstick

• Pathological
Types of Displacement
• Sideways shift.

• Overlap.

• Impaction.

• Angulation (tilt).

• Rotation.
Licentiate Clinical Officers 9 th
February 2006
Fracture Management -Priorities

• Life takes priority over limb!

“Life before Limb”

Licentiate Clinical Officers 9 th

February 2006
Fracture Management -Priorities
Fractures occur with other injuries!
• Save life! (Resuscitate! Primary & Secondary
Survey)

• Save limb

• Save joints

• Restore function

Licentiate Clinical Officers 9 th

February 2006
Fracture Management

Non-Operative vs Operative
Non-operative Methods of
Reduction

• Closed Manipulation

• Traction
Closed Manipulation
• Increase deformity

• Traction

• Reduce

• Hold

• Exercise

• Rehabilitate
Goal of Reduction

Key is restoration of anatomy:

• Correct axial alignment

• Correct rotational deformity

• Restore length

• Joint alignment
Closed Reduction not necessary when

1. There is no displacement

2. Displacement does not matter

3. Reduction is unlikely to succeed

Principles of Fracture Management
Reduce (closed or open)
Hold (immobilise)
- continuous traction (skeletal vs
skin)
- splintage ( POP)
- functional bracing
- internal fixation
- external fixation
Principles of Fracture Management
Exercise
1. Prevention of oedema

2. Prevention of joint stiffness

3. Prevent muscle wasting

4. Prevent DVT

5. Enhance fracture healing.

Fracture Healing

5 stages:
1. Haematoma formation- tissue
damage and bleeding.

2. Inflammation- inlammatory
cells appear.

3. Callus formation- osteoblasts

and osteoclasts appear.

4. Consolidation- woven bone

replaced by lamellar bone and
fracture united.

5. Remodelling- new formed

bone remodelled to resemble
normal structure.
Fracture Healing
Fracture Healing

Complications
1. Bone- Infection, AVN, delayed
union, non-nion, malunion.

2. Soft tissue- vascular, nerve,

visceral, compartment
syndrome .

3. Joints- instability, stiffness.

Fracture Healing
Delayed union
1. Inadequate blood supply.

2. Infection.

3. Incorrect splintage.

4. Intact fellow bone.

5. Malnutrition
Fracture Healing
• Non-union
1. The injury – soft tissue loss.

- bone loss

- intact fellow bone

- soft tissue

- interposition
Fracture Healing

• Non-union
2. The bone – poor blood supply

- poor haematoma

- infection

- pathological lesion
Fracture Healing

• Non-union
3. The surgeon – Distraction

- Poor splintage

- Poor fixation

- Impatience
Fracture Healing

• Non-union
4. The patient – Immense

- Immoderate

- Immovable

- Impossible
Operative Management

“Primum, non nocere (First do no Harm!)”-

Hippocrates
Operative Management
• Consider it only if it is the best option.

• Must offer advantages over non-operative

treatment.

• Must be well done!

• Requires adequate planning.

Operative Management

Indications
1. Multiple Fractures

2. Difficult Fractures

3. Pathological Fracture

4. Socioeconomic reasons
Operative Management

Open Reduction & Internal Fixation (ORIF)

Open Fractures
ORTHOPEDIC EMERGENCY!
• Immediate control of hemorrhage.

• Splinting +/- reduction.

• Early administration of sufficient analgesia,

appropriate antibiotics, and tetanus prophylaxis.

• Copious irrigation & thorough Debridement

• Emergent consultation w/ orthopaedics for all Type

II and Type III open Fx’s (and some Type I’s).
Principles of management of Open
Fractures
• Prevent infection (staged surgical
debridement!)

• Achieve healing

• Restore anatomy

• Functional recovery
Fracture Disease

• Muscle atrophy

• Joint stiffness

• Osteoporosis

• Chronic oedema
Conclusion

• Life takes priority over limb

• Reason takes priority over technique

Specific Fractures
Proximal femur

• Generally known as ‘Hip Fractures’

• Include Neck of Femur & Intertrochanteric

fractures

• Common in postmenopausal females

(M:F=1:3)
Risk Factors
• ?Osteoporosis

• Caucasian race

• neurological impairment

• malnutrition

• impaired vision

• malignancy

• decreased physical activity

Clinical Presentation
History
• Trivial fall
• Painful hip
• Failure to walk

Examination
• Elderly patient
• Shortened lower limb
• Externally rotated
• Tender
• Failure/Difficulty to walk
X-rays-Neck of Femur
Classification

Garden’s Classification
Management
• Resuscitation

• Analgesia

• DVT prophylaxis

• Non-operative vs Operative Treatment

• Early Mobilisation

• Follow-up for avascular necrosis (AVN)

Operative Treatment
Intertrochanteric Fractures
Intertrochanteric Fractures
Femoral Shaft

• High energy trauma

• Associated injuries

• Blood loss (1000-1500ml)

Complications
• Early
• Neurovascular injury
• Compartment syndrome (rare)

• Intermediate
• Delayed union
• Joint stiffness

• Late
• Malunion
• Non-union
Management
• Resuscitate

• Non-operative
– Skeletal traction (Perkin’s)
– Skin traction (if < 14 years)
– Closed reduction and spica cast immobilization
– Femoral cast bracing

• Operative
– Intramedullary nailing (1st Generation or Interlocking)
– Plates & Screws
Management
• Perkin’s Traction
• Transtibial Steinmann/Denham pin
• Insertion lateral to medial (mind common peroneal
nerve!)
• 1/7 of patient’s body weight
• Elevate foot end of bed by 4cm/Kg of weight applied.
• Measure leg lengths daily for first 2wks then weekly
thereafter
• Commence exercises 3-4 days after traction applied
• Pin tract care (teach patient!)
Advantages of Perkins Traction
• Prevents muscle atrophy

• Prevents joint stiffness

• Increases blood flow to fracture site

• Allows micromovement at fracture site

• Prevents DVT

• Prevents hypostatic pneumonia

• Prevents decubitus ulcers

• Improves patient’s morale!

Complications of Perkin’s Traction
• Pin tract infection

• Nonunion (over distraction!)

• Malunion

• Shortening (inadequate weight)

Types of Non-union
• Atrophic

• Hypertrophic

• Oligotrophic

• Fibrous

• Septic
Femoral fractures in Children

• Neonate  Leave
alone or strap to
abdomen.

• < 3 years, <15 kg 

Gallows traction.

• > 3 years 
Extension skin
traction.
Open Tibial Fractures
• By its location, the tibia is exposed to frequent injury.

• It is the most commonly fractured long bone.

• Because one third of the tibial surface is subcutaneous throughout

most of its length, open fractures are more common in the tibia than
in any other major long bone.

• Blood supply to the tibia is more precarious than that of bones

enclosed by heavy muscles.

• High-energy tibial fractures may be associated with compartment

syndrome or neural or vascular injury.

• Delayed union, nonunion, and infection are relatively common

complications of tibial shaft fractures
Evaluation
• Detailed history and physical examination.

• Inspect limb for open wounds and soft tissue crush or

contusion.

• Thorough neurovascular examination

• Look for signs of compartment syndrome or vascular

injury & treat immediately.
•
• Examine ipsilateral femur, knee, ankle, and foot.
Initial Treatment
• After examination realign limb gently & splint it.

• Open wounds are irrigated gently and dressed

under sterile conditions.

• Appropriate tetanus and antibiotic prophylaxis is

administered.

• Plain AP and lateral X-rays that include the knee

& ankle are taken.
 Gustilo and Anderson Classification of
Open Fractures
• Type I clean wound < 1 cm long (puncture by bone spike)

• Type II laceration > 1 cm long but is without extensive soft tissue damage,
skin flaps, or avulsions.

• Type III

– IIIA - extensive soft tissue lacerations or flaps but maintain adequate soft tissue
coverage of bone, or they result from high-energy trauma regardless of the size
of the wound. This group includes segmental or severely comminuted fractures,
even those with 1-cm lacerations.

– IIIB -extensive soft tissue loss with periosteal stripping and bony exposure. They
usually are massively contaminated.

– IIIC -include open fractures with an arterial injury that requires repair regardless
of the size of the soft tissue wound.
Definitive Treatment
• Treat open fractures as emergencies

• Perform a thorough initial evaluation to diagnose life- and limb-threatening

injuries

• Begin appropriate antibiotic therapy in the emergency room or at the latest

in the operating room and continue treatment for 2 to 3 days.

• Immediately debride the wound of contaminated and devitalized tissue,

copiously irrigate (10 litres!), and repeat debridement within 24 to 72 hours.
•
• Stabilize the fracture with the method determined at initial evaluation.

• Perform early autogenous cancellous bone grafting.

• Rehabilitate the involved extremity aggressively

Stabilization Methods

• External Fixator

• POP cast

• Calcaneal pin (only

3wks)

• Internal fixation
(only for Type I)
Colles Fracture
Introduction
• Common fracture in elderly patients (Abraham
Colles, 1814), consisting of:
• A transverse fracture of the distal radial metaphysis proximal
to the joint( 2.5cm)

• Dorsal displacement of the distal fragment

• Apex volar angulation

• Radial deviation

• Impaction (with loss of radial length).

• Characteristic ‘dinner fork’ deformity

Mechanism of Injury

• It results from a fall on an outstretched

hand
Deformity
Treatment
• MUA + POP/or back slab- Check position after
10 days (keep POP for 6wks)

• Closed Reduction & Percutaneous

Pinning (CRPP) + POP

• External Fixator

• ORIF (plate + screws)

• Exercise all free joints

 Complications

Malunion

Subluxation of radioulnar joint

Tendon rupture (extensor pollicis longus)

Stiffness

Complex Regional Pain Syndrome (CRPS)-

formerly called Sudeck’s Atrophy
Paediatric Fractures
Pathophysiology and Biomechanics
The immature skeleton is biologically and mechanically different from
the adult skeleton:

• As bone matures it undergoes changes in apparent porosity,

collagen fiber composition and mineral content.

• Elasticity of bone in children allows incomplete fractures and plastic

deformation to occur such as greenstick and buckle (torus)
fractures.

• Immature bone is more resilient- absorbs more energy before

breaking
Pathophysiology and Biomechanics
• Periosteum is attached loosely to diaphysis
consequently is easily stripped over considerable length
by subperiosteal haematoma.

• Angulation of a child’s bone after fracture can often be

corrected this is termed remodelling. However rotational
malalignment does not effectively correct itself.

• In the immature skeleton, remodelling occurs

simultaneously with bone growth hence most childhood
fractures can be treated with minimal surgical
intervention.
Sites of Fractures
Common sites include

• Distal forearm

• Femoral shaft

• Tibia & fibula

• Supracondylar fractures of the humerus

• Fractures of the epicondyles of the humerus

• Epiphyseal fractures (mostly distal femur)

Healing

• Healing of childhood fractures is nearly

always rapid- the younger the child the more
rapid the healing.
Upper Limb Lower Limb
Adult Child Adult Child
Callus 2-3 1-1.5 2-3 1-1.5
visible
Union 4-6 2-3 8-12 4-6
Consolidatio 6-8 3-4 12-16 6-8
n
Effect on Growth

• Growth often accelerated after fracture of

long bone- probably due to hyperaemia of
neighbouring epiphyseal cartilage but
consequent discrepancy in length is slight.

• Growth may be impaired if there is

damage to epiphyseal cartilage
Physeal Fractures
Physeal Fractures
• Cartilaginous growth plates present at each end of the
major long bones.

• Greater proportion of growth and later closure occurs:

» Humerus- proximal end.
» Radius & ulna- distal end.
» Femur- distal end.
» Tibia and fibula- proximal end.

• Most growth occurs “away from the elbow and towards the knee.”

• About 15% of children’s injuries involve the physis.

• Salter-Harris Classification used to classify physeal fractures.

Salter-Harris Classification of
Physeal Fractures
• Type I injury: complete separation at
physis without damage to metaphysis or
epiphysis.

• Type II injury: The most common,

triangular fragment of metaphysis
attached to displaced epiphysis.

• Type III injury: involves articular surface

with separation of an epiphyseal
fragment.

• Type IV injury: fracture of articular

surface with extension into metaphysis.

• Type V injury: compression fracture

involving part or all of the physis.

• Type VI injury: fracture involves part of

the cortex of both epiphysis and
metaphysis on the edge of the physeal
plate.

These fractures should be reduced well to

prevent impairment of growth.
X-rays of Physeal Fractures
Supracondylar Fractures
Types

Extension Type
• Most common type

Flexion Type
• Rare
Anatomy

• At age of 6.5 yrs, supracondylar area is

remodelling, and is thinner than at other
ages.

• Elbow also tends to hyperextend in this

age group, contributing to the mechanism
of injury.
Mechanism of Injury
• Fall onto outstretched hand.

• The elbow becomes locked in hyperextension.

• The linear applied force then produces tension forces

anteriorly.

• The olecranon is forced into the olecranon fossa.

• As the anterior bending force continues, the distal

humerus fails in tension at the supracondylar region.

• Triceps causes posterior and proximal migration of

distal fracture fragment.
Gartland’s Classification of
Supracondylar Fractures (1959)
Type 1 Undisplaced

Type 2 Displaced with intact

posterior cortex

Type 3 Displaced, no cortical

contact, posteromedial,
posterolateral

Licentiate Clinical Officers 9 th

February 2006
Gartland Types 2 & 3
Definitive Management
1. Undisplaced fractures
• Collar + cuff
• Above elbow backslab
• Mobilise at 3 weeks

2. Displaced fracture with intact posterior cortex (Type 2)

• MUA
• Collar + cuff /figure of 8 POP
• Mobilize at 3 weeks

3. Totally displaced fractures (Type 3) without vascular

deficit:
• Reduction
• Fixation (percutaneous K-wires)
• Post op care (observe for neurological deficit)
• Rehabilitation
Percutaneous pinning of Type 3
Fractures
Percutaneous pinning of Type 3
Fractures
Complications of Supracondylar
Fractures
Early
• Vascular damage
• Compartment syndrome
• Nerve damage

Late
• Volkmann’s ischaemic contracture
• Myositis ossificans
• Malunion (cubitus valgus or varus)
• Elbow stiffness