Fracture 2

Baoheng
Standards for the bone
union
 No tenderness and longitudinal percussion
pain in the local site
 No abnormal motion in the local site
 Continuous callus in the fracture line and the
fracture line becomes blur on the radiograph
 Hold up with 1 kg load for 1 minute
 Continuous walk for 30 minutes and more
than 30 steps

 No deformation after 2 weeks

Factors influencing
fracture healing
 Systemic factors
 Age
 General health condition

 Local factors
 Type and number of the
fracture
 Blood supply in the
fracture site
 Degree of local soft tissue
damage
 Soft tissue interposition
 infection
Factors depending on the treatment

 Repetitive manual reduction (manipulation)

 Excessive stripping of the periosteum and soft
tissue in the open reduction
 Radical removal of the fragments in open
fracture
 Excessive load in bone traction
 Unstable fixation
 Premature and improper function exercise
Management Goals

 Prevent further injury.

 Obtain satisfactory (not always anatomic)
position of the fracture fragments.
 Obtain rapid union in the satisfactory
position.
 Preserve and/or restore function.
 Use the method with the least risk to the
patient
 First Aid

Relief of discomfort,
prevention of further injury
and control of bleeding until
the patient reaches the site
where definitive treatment will
be instituted.
First aid
 Shock treatment


covering open wounds
 Proper splinting the parts
 Timely transportation
First aid
 Splinting the part and covering open wounds with
pressure bandages.
 Splinting relieves pain and prevents sharp bone
ends from doing further damage to nerves,
arteries, muscles, tendons and skin.
 Simple splints such as magazines, pillows,
strapping the arm to the body, or binding a leg to
the opposite uninjured leg can be effectively
devised at most accident sites.
 Transportation of the patient to the site for
definitive treatment must be done carefully after
first aid measures are completed
 Principles of fracture
treatment
 Reduction
 Fixation (Immobilization) The
fragments must be held still until new bone
unites them

 Function exercise (Preservation and

restoration of function)
Preservation and
restoration of function
 During the immobilization of a
fracture, all nonimmobilized
parts must be moved to avoid
stiffness, muscle atrophy and
joint contractures.
Reduction
 Reduction (verb) is the process of
apposing the fracture fragments. 
 Reduction (noun) also describes the
apposition of the fragments. 
 It is usually described as anatomic
reduction, near anatomic reduction,
or non-anatomic reduction. 
 None of these degrees of reduction is
necessarily better than another but is
dependent on the specific fracture. 
Alignment
 Alignment refers to the relative
orientation or position of the fragments,
or more specifically, the joints above
and below the fracture.  Anatomic
alignment is always strived for as this
has a large bearing on function following
healing. 
 Alignment can be anatomic without
anatomic reduction, however, anatomic
reduction will always achieve anatomic
alignment.
Apposition
 The amount of necessary contact (end to
end or side to side) of one fragment with
the other varies depending upon the site
of the fracture. If the fracture involves an
articular surface, 100 percent apposition
is needed. If the bone is deep, such as
the femur, no end to end apposition is
necessary. Side to side (bayonet)
apposition is acceptable if alignment and
length have been corrected. Remodeling
will correct the offset in the bone with
time.
Reduction of fracture
 Reduction standard
 Anatomical reduction: the
anatomical relation is restored
with excellent alignment and
fully contact of fragmental ends
 Functional reduction:
 Axial rotation and seperation must be
corrected
 Lower extremity shortening less than
1 cm in adult, or 2 cm in children is
acceptable

 The contact of fragments must be

more than 1/3 in transverse fracture
of long bone,3/4 in metaphyseal
fracture.
Functional reduction
 Rotatory Malalignment- the bone will not correct
with time, bone will heal with residual deformity.

 Angulatory Malalignment- The acceptable degree of

residual angulation depends upon:
 a) the age of the patient. In general, the younger the
child, the more the angulation that will correct with
time;
 b) the location- the nearer the end of a long bone,
the more the angulation that will correct.
 c) The direction of the angulation- it must be in the
plane of greatest motion of the joint. For example,
near the knee anterior-posterior angulation may
correct, but medial and lateral angulation will not.
 Length Restoration

 In displaced fractures the resultant muscle

spasm frequently produces significant
overriding of bone ends with shorting. This
must be corrected.
 Anatomic restoration of length is not always
necessary or perhaps not even desirable. When
fracture fragments of a long bone displace,
blood supply to the extremity increases, and
growth is stimulated. In such instances, if bone
ends are brought back end to end, the
extremity with the fracture may eventually be
longer by about 1 cm. Therefore a 1 cm overlap
with side to side union may be acceptable.
Reduction methods
 Manipulation

 Open reduction
Anesthesia
 If the fracture fragments displace and
need to be replaced, sedation or
anesthesia becomes mandatory.
Anesthesia can be local, regional, or
general, depending both upon the patient
and fracture.

 Local anesthesia : The fracture hematoma

can be infiltrated with a local anesthetic
agent.

 If local anesthesia is not indicated one can

use regional block such an axillary block
for the upper extremity.
Manipulati
on
Fixation of fracture
 Fixation is the mechanism by which the
fracture fragments are stabilized until
sufficient healing occurs.  The
combination of the fixation device and
the fracture segments is called an
osteosynthesis.  In general, the fixation
should allow near normal function
during the healing process. 
Four basic fixation
systems
 External coaptation (casts and splints),
 Intramedullary (IM) fixation (IM pins
and IM nails),
 External skeletal fixation (linear and
ring fixators),
 Plates / screws. 
 Wire may be used with any of the surgical
systems. 
External fixation
 Splinter
 Plaster
 Brace
 Continuous traction
 External fixater
Tension band
Indications for external
fixation

 Acute trauma - open and unstable

fractures
 Non union of fractures
 Arthrodesis
 Correction of joint contracture
 Filling of segmental limb defects -
trauma, tumour and osteomyelitis
 Limb lengthening
Complications of
external fixation

 Overdistraction
 Pin-tract infection
Internal fixation
 Indications

 Intra-articular fractures - to stabilise anatomical

reduction
 Repair of blood vessels and nerves - to protect
vascular and nerve repair
 Multiple injuries
 Elderly patients - to allow early mobilisation
 Long bone fractures - tibia, femur and humerus
 Failure of conservative management
 Pathological fractures
 Fractures that require open reduction
 Unstable fractures
Advantages of the
internal fixation
 The possibility of achieving and
maintaining a high quality
reduction
 Earlier mobilisation of joints with
less risk of permanent stiffness,
disuse osteoporosis, etc.
 Earlier discharge from hospital and
earlier return to full function.
Disadvantages of the
internal fixation
 The possibility of introducing infection.
 Internal fixation techniques require a degree of
mechanical aptitude and experience on the part
of the surgeons
 To cover a wide range of fracture situations, a
fairly formidable number of instruments and
fixation devices will be required.
Complications of internal
fixation

 Infection
 Non-union
 Implant failure
 Refracture
Internal fixation
devices
 Screws
 Nails
 Plates
Gammar nail
Plate
 Functional exercise
 First stage: within the first 1-
2weeks,improve the blood
circulation,reduce the swelling, prevent the
muscle distrophy. Don’t move the adjacent
joints
 Second stage:2weeks later, move the
adjacent joints.
 Third stage: most important stage,
reach the clinical bone union,
The treatment of open
fracture
 Gustillo Classification of Open
fracture:
 Grade I: - wound less than 1 cm w/ minimal
soft tissue injury; - wound bed is clean - bone
injury is simple w/ minimal comminution;

 Grade II: - wound is greater than 1 cm w/
moderate soft tissue injury; - wound bed is
moderatedly contaminated; - fracture
contains moderate comminution;
 Grade III: segmental frx w/ displacement
- frx w/ diaphyseal segmental loss; - frx
w/ associated vascular injury requiring
repair; - farmyard injuries or highly
contaminated wounds;
 Treat all open fractures as an
emergency;
 Perform thorough initial evaluation to
find other life-threatening injuries
 antibiotics:
 Antibiotic prophylaxis
 Begin appropriate antibiotic therapy in
the emergency room & continue for two
or three days only;
 Tetanus prophylaxis
Debridement and
irrigation

 Ideally this should be performed

within 6 hours of injury
 Goal is to avoid infection; -
sufficient debridment & irrigation &
preservation of periosteum are
essential;
 Debridement of all devascularized
bone & soft tissues;
Debridement
 Pressure irrigation:

 Management of devascularized cortical

fragments:

 Replace large free contaminated cortical

fragments in order to add to mechanical
integrity of internal fixation;

 Remove small free devitalized tissue

 Debridement of muscle
 Debridement was originally described by
Napoleon's surgeon Baron Dominique Jean
Larrey;

 Non-viable muscle can be identified by the 4
c's (color, consistency, contraction, and
circulation); - the best indicator of viability is
bleeding during debridement;

 Non viable muscle can be identified by its

dark color, its mushy consistency, its failure
to contract when pinched with forceps (or
cautery), and the absence of bleeding from a
cut surface;
Debridement of muscle
 The fascia should be incised parallel to the
muscle fibers in both directions; - the
underlying muscle surrounding the muscle
tract should be opened in the direction of its
fibers to the degree necessary to achieve
exposure adequate to inspect the tract,
remove foreign bodies, and excise non viable
muscle;
 Staged surgical debridment may be
necessary q24-48 hrs;
 Use of external fixators provides easy access
to wounds during bone healing;
 Soft tissue coverage may be necessary for
large defects;
Stabilize the fracture
 Internal fixation: Gustillo Grade
I ,Grade II

 External fixation: Gustillo

Grade II >6-8 hours, Grade III
Wound closure
 Severe extremity wounds, early radical
debridement combined with early soft
tissue coverage (regional or free flap) will
decrease wound infection, flap loss, &
delayed bone healing;

 Early coverage will decrease infection,

wound desiccation, & necrosis of exposed
tendons and bone;
 Note that tendon is the only type of tissue
in the extremities that is highly vulnerable
to dissecation, and therefore, exposed
tendons will not fair well with dressing
changes and secondary wound closure
Tissue graft
 Autograft = graft from one
part of body to another in the
same individual
 Allograft = graft from one
individual to another in the
same species
 Xenograft = graft from one
species to another
Skin grafts
Open Joint Injuries
 Classifaction of Open Joint Injuries:
 type 1: - single capsular perforation
or laceration w/o extensive soft
tissue injury;
 type 2: - single or multiple capsular
perforations or lacerations w/
extensive soft tissue injury; -
 type 3: - open periarticular frx w/
extension thru the adjacent intra-
articular surface;
 Treatment of the
nonuion, delayed union
and malunion
 Union and consolidation
 Fracture repair is a continuous process
 Union should be regarded as incomplete repair

 Fracture site is still tender

 Minimal movement at the fracture site is present

 Consolidation should be regarded as complete repair

 Radiologically fracture line is obliterated
 Fracture site is non-tender
 No movement is possible at the fracture site

Healing times of
fractures
 It is not possible to precisely estimate the
time that it will take for a fracture to heal.
A rough estimate is:
 Most upper limb fracture repair completely
in 6-8 weeks
 lower limb fractures take twice as long
 children take half as long
 Add 25% if the fracture involves the femur
or is not spiral
Delayed union

 Delayed union is the prolongation of

time to fracture union
 No definite timetable to define delayed
union exists

 Delayed union is due to

– Inadequate blood supply
– Infection
– Incorrect splintage
Delayed union
 Clinical features
 Fracture site remains tender
 Bone may still move when stressed
 On x-ray the fracture remains visible
 May be little callus formation or
periosteal reaction
Delayed union
 Management

 Usually continue previous treatment of

fracture
 May need to replace cast or reduce
traction
 Functional bracing promotes bone union
 If union is delayed more than 6 months
may need to consider
– Internal fixation
– Bone grafting
Non-union

 Non-union has many causes including:

– Bone or soft tissue loss
– Soft tissue interposition
– Poor blood supply
– Infection
– Pathological fracture
– Poor splintage or fixation
– Fracture distraction
Non-union
 Clinical features

 Movement remains present at the fracture

site
 Movement is often relatively painless
 Radiologically the fracture is still visible
 Bone ends on either side of the fracture are
sclerosed
 Non-union can be either hypertrophic or
atrophic
Non-union(10years)
Non-union
 Management
 Asymptomatic non-union may not
require active treatment except
splintage
 For hypertrophic non-union internal or
external fixation may lead to union
 For atrophic non-union bone grafting is
often required
Thank
s