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FRACTURE

And associated injury

OVERVIEW
Fracture is a structural break in contuinity of
bone
Always produce some degree of soft tissue
injury
Cortical bone can withstand compression
and shearing force; in fact that the majority of
fracture represent tension failure
Explosive tension failure made transverse or
oblique fracture

OVERVIEW
A sudden, straight, pulling (traction) force
exerted small bone or part of a bone produce
avulsion fracture
Cancellous bone, having a sponge like
structure more susceptible to compression
fracture
Greenstick fracture in childern
Direct or indirect injury

DESCRIPTIVE TERM PERTAINING TO FRACTURE


Site
Extent
Configuration
Relationship of the fracture fragment to each
other
Relationship of the fracture to external
environment
complication

DESCRIPTIVE TERM PERTAINING TO FRACTURE

Site
Diaphyseal,

Extent
Complete

epiphyseal, intra-articular

or incomplete

Configuration
Tranverse,

oblique, spiral or comminuted

DESCRIPTIVE TERM PERTAINING TO FRACTURE

Relationship of the fracture fragment to each


other
Undisplaced

or displaced
Traslated, angulated, rotated, distracted,
overriding, impacted

Relationship of the fracture to external


environment
Closed

or open fracture

Complication

DIAGNOSIS OF FRACTURE AND ASSOCIATED


INJURY
Patients history chief complain, present
history, past history, mechanism of injury
Physical examinationlook, feel, movement,
special test
Diagnostic imaging x-ray at least two
projection, CT scan, MRI

NORMAL HEALING OF FRACTURE

Healing fracture in cortical bone

Healing fracture in cancellous bone

Fracture hematomsoft tissue around the


fractureexternal callusinternal callusconsolidation
Clinical union and radiographic union
Wolff law
Almost same
Internal and endosteal callus
Woven bone replace by lamellar boneconsolidated

Healing fracture in articular cartilage

hyaline cartilage of joint surface is extremely limited to


heal
If fracture is reduce usually lead to thin scar and become
local degenerative arthritis
Fibrous tissue regeneration if there is gap

TIME REQUIRED FOR UNCOMPLICATED


FRACTURE HEALING
Age of the patient
Site and configuration of the fracture
Initial displacement of the fracture
Blood supply to the fragment

ABNORMAL HEALING OF FRACTURE


Malunion
Delayed union
Non union
Fibrous union or pseudoarthorsis

COMPLICATION OF FRACTURE
Initial complication
Early complication
Late complication

GENERAL PRINCIPLE OF TREATMENT


First, do not harm
Base treatment on an accurate diagnosis
and prognosis
Select treatment with specific aim
Cooperate with the law of nature
Make treatment realistic and practical
Select treatment for your patient as individual

4R PRINCIPLE
reposition
Reduction
Retention
rehabilitation

BASIC GOAL FOR ALL FRACTURE TREATMENT


To relieve pain
To obtain and maintain satisfactory position
of the fracture fragments
To allow and if necessary encourage bony
union
To restore optimum function

SPECIFIC METHODS OF TREATMENT FOR


CLOSED FRACTURES
1.

2.
3.

4.

5.

Protection alone (without reduction or


immobilization)
Immobilization by external splinting
Closed reduction by manipulation followed by
immobilization
Closed reduction by continous traction followed
by immobilization
Closed reduction followed by functional
fracture-bracing

SPECIFIC METHODS OF TREATMENT FOR


CLOSED FRACTURES
6.

7.

8.

9.

Closed reduction by manipulation followed


external skeletal fixation
Closed reduction by manipulation followed
by internal skeletal fixation
Open reduction followed by internal skeletal
fixation (AO/ASIF system of internal fixation)
Excision of a fracture fragment and
replacement by an endoprosthesis

PLASTER OF PARIS

SKIN TRACTION

SKELETAL TRACTION

FUNCTIONAL FRACTURE BRACING

CLOSED REDUCTION WITH EXTERNAL SKELETAL


FIXATION

OPEN REDUCTION WITH INTERNAL FIXATION

REPLACEMENT BY ENDOPROSTHESIS

REPLACEMENT BY ENDOPROSTHESIS

GUSTILLO CLASSIFICATION FOR OPEN


FRACTURE

TREATMENT OF OPEN FRACTURES


Surgical emergency
Cleansing the wound
Debridement
Open reduction with external fixation
ORIF by indication
Closure the woundafter first golden period
4-7 hours delayed primary closure is
indicated
Antibacterial drugs
Prevention of tetanus

OPEN FRACTURE GRADE I

OPEN FRACTURE GRADE II

OP GRADE III A

OP GRADE III B

OP GRADE IIIC

AFTER CARE REHABILITATION


Continous passive motion (CPM) for 2-3
weeks
Elevation of fracture limb during early phase
of fracture healing
Pshycological consideration
Supervised physiotherapy
Supervised occupational therapy

COMPLICATION OF FRACTURE TREATMENT

Skin complication

Vascular complication

Traction and pressure lesions

Joint complication

Traction and pressure lesion


Volkmann sichemia (compatment syndromes)
Gangren
Venous thrombosis and pulmonary emobolism

Neurological complication

Tatto effect
Pressure lesion

Infection (septic arthritis)

Bony complication

Osteomyelitis

PATHOLOGICAL FRACTURES

Congenital abnormalities

Metabolic bone disease

Rickets, osteomalacia, scurvy, osteoporosis

Disseminated bone disorders of unknown


etiology

Congenital defect of tibia, osteogenesis imperfecta,


osteopetrosis

Polyostotic fibrous dysplasia, skeletal reticuloses,


langerhans cell histiocytoses

Inflammatory disorder

Hematogenous osteomyelitis, osteomyelitis


secunder, tuberculous osteomyelitis

PATHOLOGICAL FRACTURES

Neuromuscular disorder
Poliomyelitis,

paraplegia, muscular dystrophy

Avascular necrosis of bone


Posttraumatic,

post radiation

Neoplasm of bone
True

primary neoplasm of boneosteosarcoma,


benign chondroblastoma, ewing sarcoma
Neoplasm like lesion of boneechondroma,
multiple echondromata, subperiosteal cortical
defect

CHILD VERSUS ADULT FRACTURE


CHILDREN FRACTURE

Fracture more common


Stronger and more active
periosteum
More rapid fracture healing
Special problems of diagnosis
Spontaneous correction of
certain residual deformities
Differences in complication
Different emphasis on method
of treatment
Torn ligament and dislocation
less common
Less tolerance of major blood
loss

ADULT FRACTURE

Fracture less common but


more serious
Weaker and less active
periosteum
Less rapid fracture healing
Fewer problems of diagnosis
No spontaneous correction of
residual fracture deformities
Different emphasis on method
of treatment
torn ligament and dislocation
more common
Better tolerance of major
blood loss