FRACTURES

Diagnosis and Treatment

ORTHOPEDIC
ORTHOPEDICAND ANDTRAUMATOLOGY
TRAUMATOLOGY
MEDICAL
MEDICALFACULTY
FACULTYofofDIPONEGORO
DIPONEGOROUNIVERSITY
UNIVERSITY
2010
2010
 MIND
MINDMAPPING
MAPPING
DEFINITION
TYPES & CLASSIFICATION

DEFORMITY
FRACTURE HEALING

FRACTURES
DIAGNOSIS

FRACTURE TREATMENT

SPECIFIC FRACTURE
DD EE FF II NN II TT II OO NN

Break
 trauma in continuity
of bone and its
( direct – indirect force )
 stress
structures
 pathologic fractures
 MIND
MINDMAPPING
MAPPING
DEFINITION
TYPES & CLASSIFICATION

DEFORMITY
FRACTURE HEALING

FRACTURES
DIAGNOSIS

FRACTURE TREATMENT

SPECIFIC FRACTURE
 TYPES
TYPES and
and CLASSIFICATION
CLASSIFICATION 1

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 2
TYPES
TYPES and
and CLASSIFICATION
CLASSIFICATION 3
TYPES
TYPES and
and CLASSIFICATION
CLASSIFICATION 4
 TYPES
TYPES and
and CLASSIFICATION
CLASSIFICATION 5

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 condition

 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 6

Traumatic fractures
Pathologic fractures
TYPES
TYPES and
and CLASSIFICATION
CLASSIFICATION 7
 TYPES
TYPES and
and CLASSIFICATION
CLASSIFICATION 8

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 9
 TYPES
TYPES and
and CLASSIFICATION
CLASSIFICATION 10

3. Radiologic Classification

• Localization • Configuration • Bone existence

– Diafisial Transversal Fracture Total Fracture

– Metafisial
– Intra-artikuler
– Fracture w/ dislocation
Oblik Fracture Crack Fracture
Spiral Fracture Buckle / torus Fracture
Z Fracture Hair line Fracture
Segmental Fracture Greenstick Fracture
Wedge Fracture
Avulsion Fracture
Depresion Fracture
Impaction Fracture
Burst Fracture
Epifiseal 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
MINDMAPPING
MAPPING
DEFINITION
TYPES & CLASSIFICATION

DEFORMITY
FRACTURE HEALING

FRACTURES
DIAGNOSIS

FRACTURE TREATMENT

SPECIFIC FRACTURE
 FRACTURE
FRACTURE HEALING
HEALING 1

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 2

Fracture healing is influenced by many factors :

Age
 Space between both fragments and soft
tissue interposition
Localization and Configuration
 Presence of infection
Early dislocation of fracture
 Synnovial fluid
Vascular supply in both fragments
 Passive and active movement of
Reduction and Immobilitation
extremity
Immobilitation period
 FRACTURE
FRACTURE HEALING
HEALING 3

Fracture healing abnormalities :

oMalunion

oDelayed union

oNonunion
 FRACTURE
FRACTURE HEALING
HEALING 4

Metacarpal shaft malunion with dorsal angulation

Note : red circle shows the location of malunion in the same patients
FRACTURE
FRACTURE HEALING
HEALING 5
 MIND
MINDMAPPING
MAPPING
DEFINITION
TYPES & CLASSIFICATION

DEFORMITY
FRACTURE HEALING

FRACTURES
DIAGNOSIS

FRACTURE TREATMENT

SPECIFIC FRACTURE
DD II AA GG NN OO SS II SS 1

o History

o General Features

o Local Features
 DD II AA GG NN OO SS II SS 2

History
Anamnesa
Age ( pathological fracture ?? )
Symptomps
pain
sensory loss
motor loss
pale
haematuri
abdominal pain
unconsciousness
 neurovascular status of extremity distal to the fractures
 DD II AA GG NN OO SS II SS 3

General Features
Early Physical Examination
Shock / anemia / bleeding ??
injury of organs within body’s cavity
predispose factors ( e.g : pathological factors )

Local Features
Local Examination
Inspection ( Look )
Palpation ( Feel )
Movement exam.
Neurological exam.
 DD II AA GG NN OO SS II SS 4

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

Anemic signs (  bleeding )  local temperature

Skin / soft tissue wound  pain

Subcutan extravasasion  crepitus ( one bone fragments grants on

Deformity of bone fragments the other )

Trauma of other organs  neurovascular status on the distal site

 Limb length ( compared w / normal lenght
on the other side )
 DD II AA GG NN OO SS II SS 5

Movement
 allow patient to move at the site of
injury
 must be done carefully, to avoid Neurologic Examination
further injuries of soft tissues,  sensoric and motoric examination
vascular, and nerves  other neuroligic consideration :
neuropraksia
aksonotmesis
neurotmesis
DD II AA GG NN OO SS II SS 6
 DD II AA GG NN OO SS II SS 7

Radiograph examination
Define : Principles :
o Normal structure of bone and joints Two sides projection -
o Confirm of fracture Two joints affected -
o Fragments structure and movements Two extremities -
o Medical treatments Two times of radiograph imaging -
o Fractures types
o Pathological conditions of bone
o Presence of alienete body ( projectile, etc )
DD II AA GG NN OO SS II SS 8
 DD II AA GG NN OO SS II SS 9

Lateral view

Radiograph shows fracture line at the junction of

the middle and distal one-third diaphysis appears
Superior view transverse with no angulation nor displacement.
However, in the lateral view, the fracture line is
oblique and the distal segment is displaced
superiorly
 DD II AA GG NN OO SS II SS 6

 Tomograph, e.g. : on vertebral

fracture or condylus tibia
 CT-scan
 MRI
 Radioisotop scanning
 MIND
MINDMAPPING
MAPPING
DEFINITION
TYPES & CLASSIFICATION

DEFORMITY
FRACTURE HEALING

FRACTURES
DIAGNOSIS

FRACTURE TREATMENT

SPECIFIC FRACTURE
 FRACTURE
FRACTURE TREATMENT
TREATMENT 1

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 2

BASIC CONSIDERATION

1. Do not worsen the patient’s 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 3

BASIC PRINCIPLES

Recognition
Reduction
Retention
Rehabilitation
 FRACTURE
FRACTURE TREATMENT
TREATMENT 4

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 5

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 6

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 7

1. Reduction
- Close reduction
- Open reduction

2. Immobilization
- Traction
- Dressing ( Gips )
- Internal Fixation
- External Fixation

3. Excersise
 FRACTURE
FRACTURE TREATMENT
TREATMENT 8

Traction

Open reduction
 FRACTURE
FRACTURE TREATMENT
TREATMENT 9

Figure-of-eight splint dressing

Long-arm hanging cast

FRACTURE
FRACTURE TREATMENT
TREATMENT 10

Figure-of-eight dressing

Long-leg plaster
 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 12

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
 FRACTURE
FRACTURE TREATMENT
TREATMENT 13

FIGURE 1
Grade IIIC distal tibia injury of 57-year-old involved in high velocity
motorcycle accident.
 FRACTURE
FRACTURE TREATMENT
TREATMENT 14

FIGURE 2
Grade IIIB foot injury of 9-year-old run over by an ice cream truck.
FRACTURE
FRACTURE TREATMENT
TREATMENT 15

FIGURE 6
Versajet™ debridement and
gravity irrigation.
FRACTURE
FRACTURE TREATMENT
TREATMENT 16

FIGURE 7
Final appearance after
debridement and irrigation.
FRACTURE
FRACTURE TREATMENT
TREATMENT 17

FIGURE 13
6 month post-operative anteroposterior
radiograph after
debridement, treatment of infection, bone
grafting and
open reduction internal fixation.
FRACTURE
FRACTURE TREATMENT
TREATMENT 18

internal fixation material

Screw, pen, metal plate, circumferential
bands, etc
 FRACTURE
FRACTURE TREATMENT
TREATMENT 19

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,
couldn’t tolerate a prolonged salvage procedure
- the patient has severe chronic medical illness ( DM /
vascular disease )
“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