FRACTURES

Diagnosis and Treatment

ORTHOPEDIC
ORTHOPEDICAND
ANDTRAUMATOLOGY
TRAUMATOLOGY
MEDICAL
MEDICALFACULTY
FACULTYof
ofDIPONEGORO
DIPONEGOROUNIVERSITY
UNIVERSITY
2010
2010

MIND
MIND MAPPING
MAPPING
DEFINITION
TYPES &
CLASSIFICATION
DEFORMITY
FRACTURE HEALING

FRACTU
RES

DIAGNOSIS
FRACTURE
TREATMENT

SPECIFIC FRACTURE

D
D EE FF II N
N II TT II O
ON
N

Break
in continuity
trauma
( directand
indirect
of bone
its
force )
structures
stress
pathologic
fractures

MIND
MIND MAPPING
MAPPING
DEFINITION
TYPES &
CLASSIFICATION
DEFORMITY
FRACTURE HEALING

FRACTU
RES

DIAGNOSIS
FRACTURE
TREATMENT

SPECIFIC FRACTURE

TYPES
TYPES and
and CLASSIFICATION
CLASSIFICATION

TYPES of FRACTURES

COMPLETE FRACTURE
bone divided into 2 fragments
fractures can be oblique, spiral, impact, or
comminuted in
its configuration

INCOMPLETE FRACTURE
bone incompletely divided, with periosteum still
remain
Ex : greenstick fractures

TYPES
TYPES and
and CLASSIFICATION
CLASSIFICATION

TYPES
TYPES and
and CLASSIFICATION
CLASSIFICATION

TYPES
TYPES and
and CLASSIFICATION
CLASSIFICATION

TYPES
TYPES and
and CLASSIFICATION
CLASSIFICATION

Special Classification
fractures have some variety, through their specific
division

1. Ethiology

Traumatic fractures
caused by sudden force

Pathologic fractures

caused by weakness of bone in according to its pathologic condi

Stress fractures
caused by long-time force / stress on certain location
multiple repetitive strain cycle, result in microcracks of bone

TYPES
TYPES and
and CLASSIFICATION
CLASSIFICATION

Traumatic
fractures

Pathologic fractures

TYPES
TYPES and
and CLASSIFICATION
CLASSIFICATION

TYPES
TYPES and
and CLASSIFICATION
CLASSIFICATION

2. Clinical Classification

Simple fractures
closed fractures
no communication between bone and external surface of body

Compound fractures
open fractures
have communication between bone and external surface of body

Complicated fractures
followed by complication, e.g : union, delayed union, nonunion,
bone infection

TYPES
TYPES and
and CLASSIFICATION
CLASSIFICATION

TYPES
TYPES and
and CLASSIFICATION
CLASSIFICATION

10

3. Radiologic Classification
Localization

Configuration

Bone existence

Diafisial
Metafisial
Intra-artikuler
Fracture w/
dislocation

Transversal
Fracture
Oblik Fracture
Spiral Fracture
Z Fracture
Segmental
Fracture
Wedge Fracture
Avulsion Fracture
Depresion Fracture
Impaction Fracture
Burst Fracture
Epifiseal Fracture

Total Fracture
Crack Fracture
Buckle / torus
Fracture
Hair line Fracture
Greenstick
Fracture

TYPES
TYPES and
and CLASSIFICATION
CLASSIFICATION

11

4. fragmen-to-fragmen connection

Undisplaced
Displaced
displece of bone can be run in 6 ways :
- Apposition
- Rotation
- Overriding
- Angulation : valgus, varus, ant, post
- Impaction

TYPES
TYPES and
and CLASSIFICATION
CLASSIFICATION

12

MIND
MIND MAPPING
MAPPING
DEFINITION
TYPES &
CLASSIFICATION
DEFORMITY
FRACTURE HEALING

FRACTU
RES

DIAGNOSIS
FRACTURE
TREATMENT

SPECIFIC FRACTURE

FRACTURE
FRACTURE HEALING
HEALING
Fracture healing depends on types of bone and amount of movement

Divided into 5 stage :

oTissue injury and haematoma
oInflammation and cellular proliferation
oCallus forming
oConsolidation
oRemodelling

FRACTURE
FRACTURE HEALING
HEALING

Fracture healing is influenced by many factors :

Age
Localization and Configuration
Early dislocation of fracture
Vascular supply in both fragments
Reduction and Immobilitation
Immobilitation period

Space between both fragments and soft

tissue interposition
Presence of infection
Synnovial fluid
Passive and active movement of
extremity

FRACTURE
FRACTURE HEALING
HEALING
Fracture healing abnormalities :
oMalunion
oDelayed union
oNonunion

FRACTURE
FRACTURE HEALING
HEALING

Metacarpal shaft malunion with dorsal angulation

Note : red circle shows the location of malunion in the same patients

FRACTURE
FRACTURE HEALING
HEALING

MIND
MIND MAPPING
MAPPING
DEFINITION
TYPES &
CLASSIFICATION
DEFORMITY
FRACTURE HEALING

FRACTU
RES

DIAGNOSIS
FRACTURE
TREATMENT

SPECIFIC FRACTURE

D
D II A
AG
GN
NO
O SS II SS

o History
o General Features
o Local Features

D
D II A
AG
GN
NO
O SS II SS
History
Anamnesa
Age ( pathological fracture ?? )
Symptomps
pain
sensory loss
motor loss
pale
haematuri
abdominal pain
unconsciousness
neurovascular status of extremity distal to the fractures

D
D II A
AG
GN
NO
O SS II SS
General Features
Early Physical Examination
Shock / anemia / bleeding ??
injury of organs within bodys cavity
predispose factors ( e.g : pathological factors )

Local Features
Local Examination
Inspection ( Look )
Palpation

( Feel )

Movement exam.
Neurological exam.

D
D II A
AG
GN
NO
O SS II SS

Inspection
Compare with normal site
Extremity position
Face expression ( pain )

Palpation

Anemic signs (

local temperature

bleeding )

pain

Skin / soft tissue wound

crepitus ( one bone fragments

Subcutan extravasasion

grants on the other )

Deformity of bone

neurovascular status on the distal

fragments

site

Trauma of other organs

Limb length ( compared w /

normal lenght on the other side )

D
D II A
AG
GN
NO
O SS II SS
Movement
allow patient to move at
the site of injury
must be done carefully, to

Neurologic Examination

avoid further injuries of soft

sensoric and motoric

tissues, vascular, and nerves

examination
other neuroligic
consideration :
neuropraksia
aksonotmesis
neurotmesis

D
D II A
AG
GN
NO
O SS II SS

D
D II A
AG
GN
NO
O SS II SS

Radiograph examination
Define :
o Normal structure of bone and joints
o Confirm of fracture
o Fragments structure and movements
o Medical treatments
o Fractures types
o Pathological conditions of bone
o Presence of alienete body ( projectile, etc )

Principles :
Two sides projection Two joints affected Two extremities Two times of radiograph imaging -

D
D II A
AG
GN
NO
O SS II SS

D
D II A
AG
GN
NO
O SS II SS

Lateral view

Superior view

Radiograph shows fracture line at the junction of

the middle and distal one-third diaphysis appears
transverse with no angulation nor displacement.
However, in the lateral view, the fracture line is
oblique and the distal segment is displaced
superiorly

D
D II A
AG
GN
NO
O SS II SS

Tomograph, e.g. : on vertebral

fracture or condylus tibia
CT-scan
MRI
Radioisotop scanning

MIND
MIND MAPPING
MAPPING
DEFINITION
TYPES &
CLASSIFICATION
DEFORMITY
FRACTURE HEALING

FRACTU
RES

DIAGNOSIS
FRACTURE
TREATMENT

SPECIFIC FRACTURE

FRACTURE
FRACTURE TREATMENT
TREATMENT
Early stage treatment :
1. First Aid
- ABC Assesment
- wound closing
- immobilize to relief pain

2. Clinical evaluation
- bone injury ?
- neurovascular injuries ?
- find other condition : DM ? ; Cardiovascular
disease ? ; Allergic ?

3. Resusitation
- patient w/ shock

FRACTURE
FRACTURE TREATMENT
TREATMENT
BASIC CONSIDERATION
1. Do not worsen the patients condition
2. Treatment is based on correct diagnosis and prognosis
3. Treatment with spesific aim
-

Relief pain

Reposition of fragments

Support bone union

Restore normal function

4. Based on physioligic fracture healing

5. Realistic and practice treatment
6. According to individual condition of patient

FRACTURE
FRACTURE TREATMENT
TREATMENT
BASIC PRINCIPLES

Recognition
Reduction
Retention
Rehabilitation

FRACTURE
FRACTURE TREATMENT
TREATMENT
Recognition
o Diagnosis and evaluation
o Anamnesis, clinical exam, radiograph exam
o Consider :
- fracture localization
- types of fracture
- complication prediction
- treatment technique

FRACTURE
FRACTURE TREATMENT
TREATMENT
Reduction
o if necessary
o place bone fragments in proper relationship to each other
o Alignment and Apposition

Retention
o immobilize fracture free of motion

Rehabilitation
o restore function of invovled part

FRACTURE
FRACTURE TREATMENT
TREATMENT
CLOSED FRACTURE
Tscherne ( 1984 ) classification of closed fracture
Level 1 : fracture with shallow abrasion or oedema on skin and
subcutaneous tissue
Level 2 : higher fracture with contusion of soft tissue and oedema
Level 3 : severe injury with obviously soft tissue damage and
compartement syndrome threats

FRACTURE
FRACTURE TREATMENT
TREATMENT
1. Reduction
-

Close reduction

Open reduction

2. Immobilization
-

Traction

Dressing ( Gips )

Internal Fixation

External Fixation

3. Excersise

FRACTURE
FRACTURE TREATMENT
TREATMENT
Traction

Open reduction

FRACTURE
FRACTURE TREATMENT
TREATMENT

Figure-of-eight splint dressing

Long-arm hanging cast

FRACTURE
FRACTURE TREATMENT
TREATMENT
Figure-of-eight dressing

Long-leg plaster

10

FRACTURE
FRACTURE TREATMENT
TREATMENT

11

OPEN FRACTURE
Gustillo - Anderson classification of open fracture
Type I

: have small opening ( < 1 cm ) in the skin and no signficant

muscle necrosis or stripping of bone periosteum

Type II

: have larger skin disruption ( > 1cm, < 10cm ), no significant

stripping of periosteum, gross contamination

Type IIIA

: have extensive lacerations of tissue flaps ( >10cm ), or lesser

skin lesion with gross contamination

Type IIIB

: have significant stripping of periosteum, require soft tissue flap for

coverage

Type IIIC

: have major vascular injury that requires repair

FRACTURE
FRACTURE TREATMENT
TREATMENT
o Treated with emergency surgery to minimize the risk of infection
and non-union
o Debridement
o Wound closing
o Fracture stabilization ( fixation )
o Post-operative care

12

FRACTURE
FRACTURE TREATMENT
TREATMENT

FIGURE 1
Grade IIIC distal tibia injury of 57-year-old involved in high velocity
motorcycle accident.

13

FRACTURE
FRACTURE TREATMENT
TREATMENT

FIGURE 2
Grade IIIB foot injury of 9-year-old run over by an ice cream truck.

14

FRACTURE
FRACTURE TREATMENT
TREATMENT

15

FIGURE 6
Versajet debridement and
gravity irrigation.

FRACTURE
FRACTURE TREATMENT
TREATMENT

FIGURE 7
Final appearance after
debridement and irrigation.

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FRACTURE
FRACTURE TREATMENT
TREATMENT

FIGURE 13
6 month post-operative anteroposterior
radiograph after
debridement, treatment of infection, bone
grafting and
open reduction internal fixation.

17

FRACTURE
FRACTURE TREATMENT
TREATMENT

18

internal fixation material

Screw, pen, metal plate, circumferential
bands, etc

FRACTURE
FRACTURE TREATMENT
TREATMENT
AMPUTATION
o Patient with severely injured extremity
o early amputation indicated under following circumstances :
- The limb is nonviable
- the patient has shock and severe multisystem injuries,
couldnt tolerate a prolonged salvage procedure
- the patient has severe chronic medical illness ( DM /
vascular disease )

19

When one has a thorough knowledge of both the enemy and

oneself, victory is assured. When one has a thorough
knowledge
of both heaven and earth, victory will be complete.

-- General Sun Tzu, China