Pizarro, Kaye-Anne Cyrille U.

Salgado, Beatrice P.
 Definition
• What is fracture?
– “Any break in the bone resulting in loss of its
continuity.”

Garg (2011)
2
 Related Anatomy
• Bone
– Living tissue capable of changing its structure
as the result of the stresses to which it is
subjected
– Consists of cells, fibers, and matrix
– Hard and elastic
– Protection, lever, storage

Snell (2012)
3
 Classification of Bones
1. By region
2. By shape

4
Snell (2012)
5
By shape

6
 Cellular Biology of Bones
a. Osteoblast
b. Osteocytes
c. Osteoclasts
d. Osteoprogenitor cells
e. Lining cells

-Author/s (Year)
7
 Types of Ossification
1. Enchondral
2. Intramembranous
3. Appositional

-Author/s (Year)
8
9
10
11
 Related Anatomy
• Two forms
1. Compact
2. Cancellous

Snell (2012)
12
13
14
 Definition
• What is fracture?
– “Any break in the bone resulting in loss of its
continuity.”

Garg (2011)
15
 Classification
• According to etiology
1. Fractures caused solely by sudden injury
2. Fragility fractures
3. Fatigue fractures (stress fractures)
4. Pathological fractures

Hamblen and Simpson (2007)

16
 Closed and Open Fractures
• Closed (simple)
– No communication between the site of
fracture and the exterior of the body
• Open (compound)
– Presence of wound at the skin surface leading
down to the site of fracture

Hamblen and Simpson (2007)

17
Closed and Open Fractures

18
 Gustilo and Anderson
Classification of Open Fractures (1976)
Type I Clean, puncture wound, less than 1 cm in size, no
crushing injury, usually due to low velocity trauma,
simple fracture without contamination
Type II Laceration more than 1 cm and less than 10 cm, no
extensive tissue damage and devitalization. No
contamination, minimal to moderate crushing injury
Type III Extensive soft tissue damage, open segmented fracture,
more than 10 cm, highly crushing injuries, comminuted
fracture component, traumatic amputation

Garg (2011)
19
Classification of Type III Open Fracture
(after Gustilo 1984)
Type III a Adequate soft tissue coverage of bone but
extensive soft tissue laceration
Type III b Extensive soft tissue damage, bone expose
to atmosphere, contaminated
Type III c Open fracture with arterial injuries

Garg (2011)
20
Displaced and Nondisplaced
Fractures

21
Complete vs Incomplete
Fracture

-Author/s (Year)
22
Patterns of Fracture

23
Types of Incomplete Fracture

24
 Clinical Signs of Fracture
• Visible or palpable • Crepitus
deformity • Pain
• Local swelling
• Ecchymosis
• Local tenderness
• Marked impairment
of function and
movement

Garg (2011)
Hamblen and Simpson (2007)
25
 Commonly Missed Fractures
• Impacted fractures
• Fatigue fractures
• Fractures of carpal bones
• Rib fractures
• Greenstick fractures

Hamblen and Simpson (2007)

26
Additional Clinical Investigations
• Skin wound
• State of the circulation
– Color
– Warmth
– Arterial pulses
– Capillary return
– Nerve conductivity
• State of the SC, peripheral nerves, viscera

Hamblen and Simpson (2007)

27
 Imaging Techniques
• Radiographic examination
– AP and lateral views (standard)
– Oblique, skyline, tangential views (special
cases)
• Radioisotope scanning
• CT Scan
• MRI

Hamblen and Simpson (2007)

28
 Other Techniques
• Tomograms
• Stress Radiographs
• Radio Isotope Scanning
• Contrast Studies
• Arthroscopy
• Thermography

Garg (2011)
29
 Tests of Union
Clinical tests of union Radiological criteria
1. Absence of mobility of union
between the fragments 1. Visible callus
2. Absence of bridging the fracture
tenderness on firm and blending with both
palpation over the site fragments
of fracture 2. Continuity of bone
3. Absence of pain trabeculae across the
when angulation stress fracture
is applied at the site of
fracture

Hamblen and Simpson (2007)

30
 Complications of fractures
Complications related to Complications attributable
the fracture itself to associated injury
- Infection - Injury to major blood
- Delayed union vessels
- Injury to nerves
- Non-union
- Injury to viscera
- Avascular necrosis
- Injury to tendons
- Malunion
- Injuries and post-traumatic
- Shortening affections of joints
- Fat embolism
- Compartment syndrome

Garg (2011)
31
 Initial Management
• First aid
• Clinical assessment
• Resuscitation

Hamblen and Simpson (2007)

32
Principles of Fracture Management
1. Reduction
2. Immobilization
3. Rehabilitation

Hamblen and Simpson (2007)

33
 Reduction
• “If necessary”
• Methods:
1. By closed manipulation
2. By mechanical traction with or without
manipulation
3. By open operation

Hamblen and Simpson (2007)

34
 Immobilization
• “If necessary”
• Indications for immobilization
1. To prevent displacement or angulation of
fragments
2. To prevent movement that might interfere
with the union
3. To relieve pain

Hamblen and Simpson (2007)

35
 Methods of Immobilization
1. Plaster of Paris or
other external splint
2. Continuous traction
3. External fixation
4. Internal fixation

Hamblen and Simpson (2007)

36
 Methods of Internal Fixation
• Plate and screws – most common
• Locking plate
• Intramedullary nail
• Compression screw-plate
• Transfixion screws
• Kirschner wire fixation

-Author/s (Year)
37
 Rehabilitation
• Active use
• Active exercises
• Continuous passive motion

Hamblen and Simpson (2007)

38
 Supplementary treatment
• Antibiotics
• Tetanus prophylaxis
• Irrigation
• Debridement
• Exploration and extension of wound
• Skeletal stabilization
• Neurovascular repair
• Redebridement at 24-48 to 72 hours, if necessary
• Soft tissue coverage – primary, delayed primary or
secondary

Hamblen and Simpson (2007)

39
Spinal Fractures

-Author/s (Year)
40
 Occipital Condyle Fracture
• Rare and freq. missed
• Result from high-energy blunt
trauma and is a specific and
localized type of basilar skull
fracture (axial loading and lat •
bending)
• Occur in 3-4% patients with
moderate-severe traumatic
brain injuries
• CT scan in an unconscious pt
• Cervical radiographs rarely
show these fx
Classification
• Type I fracture (15%)
– Impaction fracture of the occipital condyle
– Due to axial compression
– Stable injury
– C-collar
Type II fracture (50%)
– Basilar skull fracture that extends to involve
the occipital condyle
– Due to a direct blow to the skull
– Stable injury
– C-collar
• Type III fracture (35%)
– Avulsion injury of the condyle in the region of
alar ligament attachment
– Due to forced contralateral bending and
rotation
– Potentially unstable injury
– Halo or surgical fixation
Hamblen and Simpson ( 2007)
41
 Atlanto-occipital Dislocation
• Usually fatal
• MOI: Hyperextension and traction
• 3x more common in pediatric pts

42
Atlanto-occipital Dislocation

Traynelis Classification of AOD

– Type I: anterior dislocation
– Type II: vertical dislocation
– Type III: posterior dislocation

43
 Clay Shoveler’s Fracture
• Stable fracture resulting
from hyperflexion
• Avulsion-type spinous
process fracture in the
lower cervical or upper
thoracic spine
• Typically occurs in C6 or
C7
• Best seen on lateral view x-
ray
• Collar and physical therapy

Hamblen and Simpson ( 2007)

44
 Dens Fracture

• Aka odontoid fracture or peg

• Anterior displacement is more common – flexion injuries
• Diagnosed through lat view or open mouth view radiograph. CT scan
best treatment
• Anderson and D’Alonzo classification
– Type I – avulsion of the alar ligament at the tip of the odontoid
– Type II – fracture at base s extension to C2 body
– Type III – fracture through body of C2, no involvement of dens

Hamblen and Simpson ( 2007)

45
 Jefferson Fracture
• Compression fracture
of C1
• Diving accidents
• AP open mouth
radiographic view
• CT scan/MRI often
needed
• Unstable fracture

46
 Jefferson Fracture
• Landell and Van
Peteghem
Classification
– Type 1 = Fracture of either
the anterior or posterior
arches (but not both)
– Type 2 = Fractures of both
anterior and posterior
arches (i.e., a burst
fracture)
– Type 3 = Fracture involving
the lateral masses of C1
• Jefferson
Classification
– Type 1 = Fracture of the
posterior arch only
– Type 2 = Fracture of the
anterior arch only
– Type 3 = Fracture of both
the anterior and posterior
arches (i.e., a burst or
Jefferson's fracture)
– Type 4 = Fracture of the
lateral mass(es) of C1
Hamblen and Simpson ( 2007)
47
 Hangman’s Fracture
• Traumatic spondylolisthesis Typical
of the axis
• B/L fx of pars
interarticularis of C2
• Most frequent in MVA
• Clinical cases result from
hyperextension
• Typical vs atypical Atypical

Hamblen and Simpson ( 2007)

48
 Subaxial Fractures (C3-C7)
• Facet joint injuries
– MC dislocations at C5-C6 and C6-C7
• Compression fractures
– MOI: hyperflexion and compression
– C4-C5 and C5-C6, rigid orthosis for 8-12 wks
• Burst fracture
– Common, unstable, caused by compression-flexion or vertical
axial load
– Injury to spinal cord 2º to displacement of posterior fragments
is common

49
 Thoracic and Lumbar Fractures
• MC at the
thoracolumbar junction
(T11-L1)
• 3 major types of spine
fracture patterns :
– Flexion
– Extension
– Rotation

Hamblen and Simpson ( 2007)

50
 Thoracic and Lumbar Fractures
• Flexion Fracture Pattern
– Compression fracture
– Axial burst fracture
• Extension Fracture Pattern
– Flexion/distraction (Chance) fracture
– Seat Belt Fractures
• Rotation Fracture Pattern
– Transverse process fracture
– Fracture-dislocation

Hamblen and Simpson ( 2007)

51
Minor Fractures of the Spinal Column

• Fracture of transverse processes

• Fracture of the sacrum
• Fracture of the coccyx

Hamblen and Simpson ( 2007)

52
 Fractures of the Thoracic Cage
• Fractures of the ribs
• Fractures of the sternum

Hamblen and Simpson ( 2007)

53
Shoulder and the Upper Arm

-Author/s (Year)
54
Sternoclavicular Joint Injures
• Degrees: (1) Sprain, (2)
subluxation, (3) Dislocation
• Rare cases: dislocation
– Anterior: more common, the
end of the clavicle is pushed
forward, in front of the sternum
– Posterior—the end of the
clavicle is pushed backward,
behind the sternum and deep
into the upper chest
• MOI:
– Posterior dislocations – direct
force over SC jt
– Fall on shoulder

55
 Acromioclavicular Joint Injuries
• Classification (by degrees):
1. Sprain – AC lig
stretched/torn
2. Subluxation – AC lig torn, CC
lig stretched/partially torn
3. Dislocation – AC and CC lig
torn
4. Displacement
1. Type IV – displacement post
2. Type V – displacement sup
3. Type VI – displacement inf

56
57
Acromioclavicular Joint
Separation

58
Glenohumeral Joint Dislocations

59
Glenohumeral Joint Dislocations

60
 Complications
Hill-Sachs Deformity Bankart’s Fracture
• Compression fracture of • When both the labrum
the humeral head from and the capsule along
the force of hitting the the anterior margin of
hard glenoid the glenoid cavity are
avulsed
• 3/4 of the patients with
a Bankart lesion will also
have a Hill-Sach's lesion

61
 Clavicle Fracture
• MC site: middle 3rd (80%)
• MOI
– Fall on the outer side of the shoulder
– Fall on outstretched hand
– Direct blow to the shoulder
– Violent mm. contraction during epilepsy, stress fx, or any pathology
• Almost always displaced, producing a lump
– Lateral fragment: displaced downwards and medially
• Middle 3rd fx: support arm in sling until pain subsides (1-3 wks)
• Outer 3rd fx: ORIF
• Complications: Malunion, nonunion, neurovascular injury, OA

Solomon, Warwick, & Nayagam, 2014; Garg, 2011; Hamblen &

Simpson, 2007 62
Clavicle Fracture

63
Textbook of Orthopedics and Trauma (2016)
64
 Scapular Fracture
• Uncommon
• Occurs between 40 years and 60 y/o
• Associated with multiple rib fractures,
vertebral fractures, pneumothorax and
humeral fractures
• Sites:
– Body of the scapula (MC)
– Neck, spine, glenoid and the acromion
• Multiple fracture patterns are common.
• Tx: Sling and active exercises, operative
tx is rare

Textbook of Orthopedics and Trauma (2016)

Solomon, Warwick, and Nayagam (2014)
65
 Proximal Humerus Fractures
• True osteoporotic fx
• Low energy fall
• Treated
nonoperatively

66
 Neer Classification System
Displacement defined as
greater than 45 degrees of
angulation or 1 cm of separation
4 Segments:
1. Anatomic Neck (articular
segment, head)
2. Surgical Neck (humeral shaft)
3. Greater Tuberosity
4. Lesser Tuberosity

Garg (2011)
Miller and Thompson (2016)
67
 Neer Classification System
• Type I - One Part Fractures
– No segments are displaced or angulated.
• Type II - Two Part Fractures
– One segment displaced by 1.0 cm or 45 degrees.
• Type III - Three Part Fracture
– Two segments displaced by 1.0 cm or 45 degrees.
• Type IV - Four Part Fracture
– All four major segments are displaced by 1.0 cm or 45
degrees.

Miller and Thompson (2016)

68
69
70
71
72
73
74
 Humeral Shaft Fracture
• MC MOI is fall at ground level
followed by MVA
• Spiral fx – fall on the hand may
twist humerus
• Oblique or transverse fx – fall on
the elbow with the arm abducted
• Transverse or comminuted -
direct blow to the arm
• Assoc. injuries: shoulder
dislocation, rotator cuff tear,
subacromion bursitis, floating
elbow, radial nerve injuries

Solomon, Warwick, & Nayagam, 2014

75
 Humeral Shaft Fracture
• Tenderness, ecchymosis and bruising
• Management
– Conservative
• Closed acute and isolated humeral fx
• Plaster casts
• Functional bracing
– Operative
• Failure of nonoperative treatment tissue to
noncompliance of patient, obesity with
polytrauma, B/L fx, open fx, vascular injury,
floating elbow
• Plates and screws
• Intramedullary nails
– External fixator
• Open contaminated fracture, infected
nonunions.

Textbook of Orthopedics and Trauma (2016)

76
 Distal Humerus Fracture in
Adults
• Uncommon
• Frequent in elderly women
• 3 types:
1. Extra-articular supracondylar fx
- Rare in adults, displaced, unstable,
severely comminuted (high energy
injuries)
2. Intra-articular unicondylar fx
- High energy injury except for
osteoporotic women
3. Bicondylar fx

Solomon, Warwick, & Nayagam, 2014

77
 Distal Humerus Fracture in
Children
• Boys > girls
• ½ pts under 10 y/o
• MC MOI: fall directly on the point of the elbow
or onto the outstretched hand with the elbow
forced into valgus or varus
• Marked swelling and pain
• X-ray interpretation is difficult

Solomon, Warwick, & Nayagam, 2014

78
Elbow Injuries

79
 Supracondylar Fracture
• MC in children
• 2 types:
1. Supracondylar extension fx - fall
on outstretched hand
2. Supracondylar flexion fx – direct
blow to posterior aspect of flexed
elbow
• Lower fragment is displaced
backwards and titled backwards
• Brachial artery occlusion, median
nerve injury, ulnar nerve injury,
malunion, deformity

Hamblen and Simpson ( 2007)

80
 Fracture of the Condyles
• Uncommon
• Occur mainly in
children
• Lateral condyle is
fractured MC
• Simple crack – plaster
• Displaced –
manipulation, plaster
or operation (if
manipulation fails)

Hamblen and Simpson ( 2007)

81
 Fracture of the Epicondyles
• MC: medial epicondyle fx
• Common in children
• Caused by direct violence
but often an avulsion injury
• Epicondyle being pulled off
by attached flexor muscle
during a fall
• Assoc. with dislocation or
subluxation of the elbow

Hamblen and Simpson ( 2007)

82
 Dislocation of the Elbow
• Fall on outstretched hand may
dislocate the elbow
• In 90% cases, the FA bones are
pushed backwards and
dislocate posteriorly or
posterolaterally
• (+) Deformity and bony
landmarks are displaced
• In severe injuries, pain and
swelling are marke
• Tx:
– (1) uncomplicated dislocation
– (2) fracture dislocation

Solomon, Warwick, & Nayagam, 2014

83
 Olecranon Process Fracture
• MC: fall onto flexed elbow
• Olecranon process fx may take 3 forms:
1. Crack s displacement
2. Clean break c separation of the 2 fragments
3. Comminuted fx

Hamblen and Simpson ( 2007)

84
 Coronoid Process Fracture
• Seldom fractured except in association
with posterior dislocation of the elbow
• Marked displacement is prevented by the
strong aponeurotic fibers, prolonged from
the insertion of the brachialis muscle that
invest the bone

Hamblen and Simpson ( 2007)

85
Coronoid Process Fracture

86
Coronoid Process Fracture

87
EBP

88
 Fronza et. al. (2013)
http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.864.56
47&rep=rep1&type=pdf 89
http://www.jamda.com/article/S1525-8610(14)00840-8/abstract
90
https://link.springer.com/article/10.1007/s11999-011-2157-7
91
https://bmccomplementalternmed.biomedcentral.com/articles/10.
1186/1472-6882-12-7
92