Introduction to fractures

Introduction to Fractures for medical students.
Prepared in collaboration with Dr. Mohammed Alharbi.

1. Introduction to Fractures Dr. Yasser Alwabli

2. Contents Definitions Mechanisms Classifications Fracture description Management – conservative or surgical Fracture healing Complications Non-union and delayed union Bone grafts

3. Axial skeleton vs Appenicular skeleton Long bone vs flat bone

4. What is a fracture? Discontinuation in the bone cortex A broken bone Normal Fractured

5. fracture extends 360° of bone circumference (all around) Complete fracture

6. Incomplete: seen almost in children: Greensick Incomplete fracture

7. Mechanism : High energy vs. low energy Multiple injuries vs. isolated injury. Pathological fracture: normal load in presences of weakened bone (tumor, osteoporosis, infection) Stress fracture: normal bone subjected to repeated load (military recruits).

8. Fracture patterns (descriptive classification) Transverse Oblique Comminuted Spiral Segmental Impacted Avulsed

9. Transverse : loading mode is bending

10. Oblique : loading mode is compression .

11. Spiral : loading mode is torsion.

12. Fracture with Butterfly fragment: loading mode is bending and compression

13. Comminuted fracture: 3 or more fragments Segmental fracture

14. Fracture description Name of injured bone Integrity of skin Skeletal maturity Location Fracture pattern Alignment

15. Integrity of skin Closed fracture Open fracture

16. Integrity of skin Closed fracture Skin\soft tissues intact Open fracture Fracture exposed to the outside environment

17. Skeletal maturity Pediatric Adult ? Geriatric

18. Why pediatric fractures are unique? Thicker periosteum Presence of growth plate Anatomic reduction is not necessary Time to heal is shorter Think of child abuse

19. Classifications Why we use classifications? Ease of communication Occasionally helps in treatment Research uses

20. Classifications Every fracture has a unique classification system Unified classification system, e.g. AO classification

21. Example: Garden classification for femoral neck fractures Type 1 Type 2 Type 3 Type 4

22. AO Classification

23. PRINCIPLES OF EVALUATION

24. Diagnosis: History Patients complain of pain and inability to use the limb (if they are conscious and able to communicate) What information can help you make the diagnosis?

25. Diagnosis: History Onset : When and how did the symptoms begin? Specific traumatic incident vs. gradual onset? If there was a specific trauma, the details of the event are essential information: Mechanism of injury ? Circumstances of the event? Work-related? Severity of symptoms at the time of injury and progression after ?

26. Diagnosis: Physical exam Inspection Swelling Ecchymosis Deformity If fracture is open: Bleeding Protruding bone

27. Diagnosis: Physical exam Palpation Bony tenderness

28. Diagnosis: Physical exam If a fracture is suspected what should we rule out? Neurovascular injury (N/V exam) Compartment syndrome Associated MSK injuries (examine joint above and below at minimum)

29. How to describe a fracture Clinical parameters Radiographic parameters

30. Clinical Parameters Open vs. closed ANY break in the skin in proximity to the fracture site is OPEN until proven otherwise Neurovascular status Presence of clinical deformity

31. Location Which bone? Which part of the bone? Epiphysis -intraarticular? Metaphysis Diaphysis -divide into 1/3s Use anatomic landmarks when possible e.g. medial malleolus, ulnar styloid, etc

32. Location Epiphyseal Metaphyseal Diaphyseal Physeal (growth plate) Articular

33. Pattern Simple vs. comminuted Complete vs. incomplete Orientation of fracture line Transverse Oblique Spiral

34. Displacement Displacement is the opposite of apposition Position of distal fragment relative to proximal Expressed as a percentage

35. Angulation Deviation from normal alignment Direction of angulation defined by apex of Expressed in degrees

36. Fracture description: Summary Clinical parameters Open vs. Closed Neurovascular status Clinical deformity Radiographic parameters Location Pattern Displacement Angulation Shortening

37. Exercises

38. Bone healing

39. Fracture healing

40. Primary bone healing : Absolute fixation No callus formation Plate Secondary bone healing : Relative fixation callus formation Cast + Nail + EX- fix

41. Management Reduction (if needed) Maintain reduction Rehabilitation

42. General scheme for fracture management Follow trauma protocols Immobilize the limb X-Ray the injured bone Determine the fracture pattern Plan treatment accordingly Reduce if needed (closed) X-Ray after reduction Immobilize and follow Rehabilitate early

43. How to maintain the reduction after closed reduction (CR)? Splints Cast External fixators (Ex. Fix.) [for specific indications]

44. Initial (Immobilization)

45. What if closed reduction failed? May need re-reduction Other options? Open reduction aka needs Surgery

46. How to maintain reduction after open reduction (OR)? Internal fixation = ORIF The first surgery we learned is ORIF Options Intramedullary device, e.g. IM rod, wires Extramedullary devices, e.g. plates and screws Sometimes can be treated by external fixator

47. Summary of fracture treatment Immobilization Closed reduction and immobilization (stabilization\fixation) Open reduction and external or internal fixation

48. Complications

49. Non-union and delayed union Non-union when fracture never heals Causes are diverse Types Treatment Treatment is to optimize local and systemic factors Almost always needs surgery Delayed union when the fracture passes the typical time of healing of such fracture

50. Bone grafts Adjuncts used to stimulate bone healing Variety of types Autografts Allograft Synthetic