Fractures

Introduction to fracture, mechanism, types, healing, and complication.. full information supported by real images and x-ray images..

1. FRACTURES
By: Ammar Alhakimi – supervision by Dr: Malik Alnaqeeb
Faculty of medicine - Taiz University

2. DEFINITIONS
•A fracture is a break in the structural continuity of
bone. It may be no more than a crack, a crumpling or a
splintering of the cortex; more often the break is
complete and the bone fragments are displaced.

3. Fracture:-

Break in the continuity of bone.
Abbreviated ( FRX or Fx, Fx, or # )

4. •Dislocation:-
Complete separation of the articular surface.
Distal to proximal fragment
Anterior, Posterior, Inferior, Superior

5. •Subluxation:-

Incomplete separation

Joint Function in Anatomical
position Only

6. MECHANISMS
•Amount of Force:-
Low force = Pathological
High force = Non-pathological

•Direction of Force:-
Direct Force
Indirect Force

7. MECHANISMS
Indirect Force
On Long Bones:-

1) Twisting Force

Spiral Line

8. MECHANISMS
Indirect Force
on Long Bones

2) Angulating
+ Axial compression
+ Twisting forces

(short oblique pattern)

9. MECHANISMS
Indirect Force
On Long Bones:-

3) Vertical compression

comminuted

10. MECHANISMS
Direction of Force
On Cancellous
Bones:-

Direct OR Indirect
Comminuted Pattern
Burst

11. MECHANISMS
Force due to
Resisted Muscle Action:-

“Avulsion”
Transverse pattern

12. FRACTURES DUE TO INJURY
Most fractures are caused by sudden and excessive force, which m
ay be direct or indirect.

direct force the bone breaks at the point of impact; the soft
tissues also are damaged.
indirect force the bone breaks at a distance from where the
force is applied; soft-tissue damage at the fracture site is not
inevitable.

13. TYPES OF FRACTURE
1 - COMPLETE FRACTURES
The bone is split into two or more fragments.
•Transverse:
fragment remain in place after reduction,
and usually caused by high energy direct force.
•Oblique and spiral:
they tend to shorten and re-displace
even if the bone is splinted.
usually due to low injury and twisted force.

14. •impacted fracture:
the fragments are jammed tightly together
and the fracture line is indistinct.

•segmental fracture:
double fracture in a long bone diaphysis
,isolated segment between the breaks.

15. comminuted fracture:
is one in which there are more than two fragments
; because there is poor interlocking of the fracture
surfaces, these are often unstable.

16. 2- INCOMPLETE FRACTURES
The bone is incompletely divided and the periosteum
remains in continuity.
• Greenstick fracture
Bone is buckled (like snapping a green twig)
usually in children.

17. Compression fractures:

occur when cancellous bone is crumpled.
This happens in adults and typically where this
type of bone structure is present:
, e.g. in the vertebral bodies, calcaneum and tibial
plateau.

19. •3- Physeal fractures:

Fractures through the growing physis are a special case.
Damage to the cartilaginous growth plate may give rise to
progressive deformity out of all proportion to the apparent severity
of the injury

20. TYPES ACCORDING TO SKIN INTEGRITY
- simple ( closed ) fracture
skin overlying fracture is contact.


-compound ( open ) fracture:
communicated bone with exterior
there is high risk of infection,
and need external fixation.
mostly affect tibia.

21. OESTERN AND TSCHERNE CLASSIFICATION OF
CLOSED FRACTURES
Grade Soft tissue injury Bony injury
0 Minimal Simple fracture pattern
Indirect injury to limb
1 Superficial abrasion/ Mild fracture pattern
contusion
2 Deep abrasion with skin Severe fracture pattern
or muscle contusion
Direct trauma to limb
3 Extensive skin contusion Severe fracture pattern
or crush
Severe damage to underlying muscle
Subcutaneous avulsion, compartmental syndrome

23. :FRACTURECLASSIFICATION OF COMPOUND GUSTILO
•Grade (1):
- low energy and minimal soft tissue damage ,small ( less than 1 cm) ,
clean wound.
- Antibiotic regimen: Cephalosporin for 24 hours.

24. •Grade (2):
- low energy injury , moderate wound (1-10)cm, and soft tissue
damage , usually clean but may be contaminated.
•Antibiotic regimen: Gentamycin for 3 days or more.

25. •Grade (3):
High energy injury , wound (more than 10 )cm, and extensive skin
and soft tissue damage ,with contamination

•Antibiotic regimen: penicillin + clostridial cover
•grade 3 : include shotgun, soil contamination and fracture more 8
hours duration.
Grade 3 may be classify to:
•3 a- bone can be adequately covered by soft tissue.
•3 b- bone can not be covered with periosteal stripping.
•3 c- associated with arterial injury that need surgery.

26. GUSTILO TYPE III
that vascular injuryany open fracture that is associated with Type IIIC:
requires repair.

27. AETIOLOGYACCORDING TO
•1-Traumatic fracture: direct or indirect
usually due to major trauma in healthy bone.

28. AETIOLOGYACCORDING TO
•2-Stress (fatigue) fracture:
fracture due to repeated minor trauma.
•Sites usually affected are metatarsal bones
(the so-called march fracture), the distal
shaft of fibula (runner’s fracture),the proximal
half of the tibia, the femoral neck, the pubic
rami the pars interarticularis of the fifth lumbar
vertebra and the ala of the sacrum.
•Stress fractures are often missed or wrongly
diagnosed, with osteomyelitis, osteosarcoma,
and scurvy

29. AETIOLOGYACCORDING TO
• 3- pathological fracture abnormal weakening of the bone.
Usually in elderly and due to minor trauma.
mostly affect neck of femur, and confirm diagnosis by taking biopsy
e.g:
1- Congenital diseases (O.I).
2- Infection (osteomyelitis).
3- Fracture through a cyst .
4- Metastatic bone tumors
5- Primary bone tumors.
6- Metabolic diseases ( Osteoporosis, Osteomalacia, Paget's disease)..

30. :DISPLACEMENTFRACTURE
•After a complete fracture the fragments usually become displaced, p
artly by the force of the injury, partly by gravity and partly by the pull
of muscles attached to them.
•1- Translation (shift):
the fragments may be shifted sideways, backwards
or forwards in relation to each other, such that the
fracture surfaces lose contact.
•2- Alignment (angulation):
the fragments may be angulated in relation to each other.
and detected only by X-Ray.

31. •3- Rotation (twist):
long-bone fragments may be rotated in relation
to each other; the bone looks straight but the
limb ends up with a torsional deformity.

•4- Length:
the fragments may be distracted and separated
, or they may overlap, due to muscle spasm,
causing shortening of the bone.

33. DAMAGETISSUE -SOFT
•Low-energy (low-velocity)
fractures cause only moderate soft-tissue damage; the classic
example is a closed spiral fracture.
•High-energy (highvelocity)
fractures cause severe soft-tissue damage; examples are segmental
and comminuted fractures, no matter whether open or closed.
•Remember:
Soft tissues has a significant effect on fracture healing. A full description of
the fracture should therefore include comment on the soft tissues.

34. SOFT TISSUE INVOLVEMENT: NERVE, VESSEL,
MUSCLE, FAT, SKIN DAMAGE

35. HEALINGFRACTURE
•Fractures heal by two different methods:
1- with callus. 2- without callus

A - Healing with callus: Callus is the response to movement at
the fracture site.
•Five stages of healing:

36. :CALUSHEALING WITH FIVE STAGES OF
•(1)hematoma formation:
Tissue damage and bleeding at the fracture site:
The bone ends die back for a few millimeters.
• (2) Inflammatory and cellular proliferation:
-inflammatory cells appear in the hematoma
with in 8 hours, acute inflammatory reaction .
- proliferation of mesenchymal stem cells.
-the end of fragment become surrounded by
cellular tissue, which bridges the fracture site.

38. •(3) Callus formation:
the cell population changes to osteoblasts
and osteoclasts;
dead bone is mopped up and immature
(woven) bone appears in the fracture callus.
•(4) Consolidation:
woven bone is replaced by( mature) lamellar
bone; the fracture has united.
•(5) Re-modelling:
the newly formed bone is re-modelled to
resemble the normal structure.

40. STAGES OF HEALING:

42. •B-with out callus (Healing by direct union):
• If the fracture site is absolutely immobile (e.g. an impacted
fracture in cancellous bone, or a fracture rigidly immobilized by
internal fixation)
•there is no need for callus; instead, new bone formation occurs
directly between the fragments.
•Gaps at the fracture surfaces are invaded by new capillaries
and bone-forming cells growing in from the edges.

- Rigidly contact between bone ends

44. )FACTORS AFFECTING HEALING: (DELAY HEALING
•1- Age: elderly.
•2- Infection
•3- Bone disease: infection, tumor..
•4- General health: low immunity ,DM ,HIV, Malnutrition.
•5- Interposition of soft tissue.
•6- decrease blood supply.
•7- Type of bone.
•8- Inadequate immobilization: delay movment.
•9- A vascular necrosis: occurs in bones largely covered by cartilge or
bone only supplied from distal to proximal.
e.g: femoral head, Scaphoid..

45. UNION-NONDELAYED UNION AND
•Delayed union: usually with (3-6) months.
is when a fracture takes unusually long to heal.
The rate of repair depends upon:
-the type of bone involved (cancellous bone heals faster than cortical
bone)
-the type of fracture (a transverse fracture takes longer than a spiral
fracture)
- the state of the blood supply (poor circulation means slow healing)
- the patient’s general condition (healthy bone heals faster)
- the patient’s age (healing is almost twice as fast in children as in adults).

46. •Non-union: usually more than 6 months.
is when a fracture fails altogether to unite
Causes are:
■ Severe damage to soft tissues, rendering them
non-viable (or nearly so).
■ Distraction and separation of the fragments.
■ Interposition of soft tissues between the fragments.
■ Excessive movement at the fracture site.
■ Poor local blood supply.
■ Abnormal bone.
■ Infection.

47. •In such cases cell proliferation is predominantly
fibroblastic; the fracture gap is filled by fibrous
tissue and the bone fragments remain mobile,
eventually creating a false joint or
pseudarthrosis.
•In some cases callus formation starts off quite
well; the fragment ends become thickened and
even splayed, suggesting that periosteal
new bone formation is florid but bridging of the
fracture gap is prevented hypertrophic non-union

48. (atrophic non-union)

The fragments will never unite unless
they are immobilized and helped along
with bone grafts.

50. :SECONDARY INJURIES
•Certain fractures are tend to cause secondary injuries and these
should always be assumed to have occurred until proved otherwise.
■ Thoracic injuries: fractured ribs or sternum may be associated
with injury to the lungs or heart. It is essential to check
cardiorespiratory function.

51. ■ Spinal cord injury: with any fracture of
the spine, neurological examination is
essential to establish whether the spinal cord
or nerve roots have been damaged; and to
obtain a baseline for later comparison if
neurological signs should change.

52. ■ Pelvic and abdominal injuries: fractures of the pelvis may be
associated with visceral injury. Enquire about urinary function and
look for blood at the urethral meatus. Diagnostic urethro-grams or
cysto-grams may be necessary.

53. ■ Pectoral girdle injuries: fractures and dislocations around the
pectoral girdle may damage the brachial plexus or the large vessels
at the base of the neck. Neurological and vascular examinations are
essential.

54. CHILDRENFRACTURES IN
•Fractures in growing bones are subject to influences which do not
apply to adult bones:
■ In very young children the bone ends are largely cartilaginous and
therefore do not show up in x-ray images. Fractures at these sites are
therefore difficult to diagnose: always x-ray both limbs (for comparison)
and an ultrasound scan may be helpful.

■ Children’s bones are less brittle, and more liable to plastic
deformation, than those of adults; hence the frequency of cortical
‘buckling’ and ‘greenstick’ fractures.

55. ■ In childhood the periosteum is thicker than in adult bones; this may
explain why fracture displacement is more controlled. Cellular activity is
also more marked, which is why children’s fractures heal so much more
rapidly than those of adults. The younger the child, the quicker the rate
of union. Femoral shaft fractures in infants will heal within 3 weeks, and
in young children in 4–6 weeks, compared to 14 weeks
or longer in adults.
■ Non-union is very unusual in children’s fractures.
■ Bone growth involves considerable modelling and re-modelling,
processes which determine both structure and form. This makes for
a great capacity to re-shape fracture deformities (other than rotational
deformities) over time.

56. PHYSISINJURIES OF THE
■ Injuries of the physis have no equivalent in adults. Damage to
the growth plate can have serious consequences however rapidly
and securely the fracture might heal.

■ Over 10% of childhood fractures involve injury to the growth
plate (or physis). Because this is a relatively weak part of the bone,
injuries that cause ligament strains in adults are liable to disrupt the
physis in children.

57. ((CLASSIFICATION PHYSISOF THE INJURIES
The most widely used classification of physeal injuries is that of
(Salter and Harris) , which h distinguishes five basic types of injury:
■ Type 1: separation of the epiphysis.
■ Type 2: fracture through the physis and metaphysis (the commonest
type).
■ Type 3 : here the fracture runs along the physis and then veers off int
o the joint, splitting the epiphysis.
■ Type 4: vertical fracture through the epiphysis and the adjacent metap
hysis.
■ Type 5: crushing of the physis without visible fracture.

58. commonest type

59. HISTORY
•There is usually a history of injury, followed by inability to use the
injured limb.
•The patient’s age and the mechanism of injury are important.
•Pain, bruising and swelling are common symptoms.
•Deformity may be suggestive .
•symptoms of associated injuries: numbness or loss of movement,
skin pallor or cyanosis, blood in the urine, abdominal pain, difficulty
with breathing or transient loss of consciousness. A common mistake
is to get distracted by the main injury, particularly if it is severe.
Remember also that some children with greenstick fractures and elderly
people with impacted fractures of the femoral neck may experience little
or no pain or loss of function.

60. •Ask about previous injuries or any other musculoskeletal
abnormality that might cause confusion when the x-ray is seen.
Finally, a general medical history is important, in preparation
for anaesthesia or operation.

61. EXAMINATION
•Injured tissues must be handled gently. To try and elicit crepitus
or abnormal movement is unnecessarily painful; in any case, x-r
ay diagnosis is more reliable. Nevertheless, a systematic approa
ch is essential.
■ Examine the most obviously injured part.
■ Check for arterial damage.
■ Test for nerve injury.
■ Look for injuries of local soft tissues and viscera.
■ Look for injuries in distant parts.
(check the pulse) (sensation and joint movement)

62. A- General examination :
1) Signs resulting from fracture or trauma:
a) Vital signs, Shock A,B,C
b) Associated Head, Chest, Abdomen
2) Signs related to cause of fracture:
Pathological # …CA Lung, Prostate..
DIAGNOSIS

63. B- Local Examination
•LOOK : Skin damage, deformity, swelling
•FEEL : Localized tenderness
•MOVE : Abnormal movement, crepitus
•DO :
a) Special tests : Circulation & Nerves
b) Measurements : shortening
[Always compare]

DIAGNOSIS , and bruising

64. ( Look )
•Swelling, bruising and deformity may be obvious, but the important point is
whether the skin is intact.
•also look for the posture of the distal extremity and the colour of the skin
(for tell-tale signs of nerve or vessel damage).
( Feel )
The injured part is gently palpated for localized tenderness.
•Isolated fracture of the ulna may be associated with a dislocated head of radius.
•In high-energy injuries always examine the spine and pelvis.
( Move )
•Crepitus and abnormal movement should be tested for only in unconscious
patients. Usually it is more important to ask if the patient can move the joints
distal to the injury.
•Imaging

65. •X-ray examination is mandatory.
Remember the (rule of twos):

■ Two views: a fracture or a dislocation
may not be seen on a single x-ray film;
at least two views (anteroposterior and
lateral) must be obtained.
■ Two joints: the joints above and
below the fracture must always be
included on the x-ray images; they may
be dislocated or fractured.

66. •Fractures of proximal ulna
often characterized by
anterior angulation of ulna
and anterior dislocation
•of radial head (Monteggia
fracture)

67. ■ Two limbs: a pre-existing constitutional
abnormality may be mistakenly attributed to
the recent injury; and in children, the appea
rance of immature epiphyses may confuse
the diagnosis of a periarticular fracture.
X-rays of the uninjured limb are essential
for comparison.


■ Two injuries: severe force often causes
injuries at more than one level. Thus,
with fractures of the calcaneum or femur
it is important also to x-ray the pelvis and
spine.

68. ■ Two occasions: some fractures are notoriously difficult to detect soon
after injury, but another x-ray examination a week or two later may show
the lesion.

Computed tomography (CT)
and magnetic resonance imaging (MRI)
are useful for displaying fracture patterns
in ‘difficult’ sites such as the vertebral
column.

69. Complications
Immediate
complications
Early
complications
Late
complications

70. COMPLICATIONSIMMEDIATE
Systemic
•Hypovolemic shock

Local
•Injury to major vessels
•Injury to muscles and tendons
•Injury to joints
•Injury to viscera
(due to severe uncontrolled bleeding) and Nerves

71. COMPLICATIONSEARLY
Local
•Infection
•Compartment syndrome

Systemic
•Hypovolemic shock
•ARDS – Adult respiratory
distress syndrome
•Fat embolism syndrome
•Deep vein thrombosis
•Pulmonary syndrome
•Aseptic traumatic fever
•Sepsis (in open fracture )
•Crush syndrome
(also traumatic rhabdomyolysis or Bywaters' syndrome) is a medical condition
characterized by major shock and kidney failure after a crushing injury to skeletal muscle.

72. LATE COMPLICATIONS
Imperfect union of the fracture
•Delayed union
•Non union
•Mal union
•Cross union

Others
•Avascular necrosis
•Shortening
•Joint stiffness
•Sudeck's dystrophy
•Osteomyelitis
•Ischaemic contracture
•Myositis ossificans
•Osteoarthritis

73. THANKS