Fractures and Fracture Management Resident Orientation Course 2012 Presented By Dr. Shinouri

Outline Definition of Fracture Radiographic and clinical description of Fractures Classification of Fractures Treatment of Fractures

Definition of Fracture Disruption in the integrity of living bone, involving injury to the bone marrow, periosteum and adjacent soft tissues Described radiographically and clinically

Radiograph and Clinical Descriptions Anatomy: Described in relation to the bones involved and the location within the bone (diaphysis, metaphysis, physis, epiphysis) Articular surface involvement: Does the fracture have intra-articular involvement?

Anatomy and Articular Surface Epiphysis Which bone? Thirds (long bones) Proximal, middle, distal third Anatomic orientation Proximal, distal, medial, lateral, anterior, posterior Anatomic landmarks Head, neck, body / shaft, base, condyle Segment (long bones) Epiphysis, physis, metaphysis, diaphysis Physis Metaphysis Diaphysis (Shaft) Articular Surface

Radiograph and Clinical Descriptions Displacement: Is the distal fracture fragment displaced compared with proximal fragment? To what degree is the fracture displaced? Angulation: The angular deformity is defined in degrees in terms of the distal fragment in relation to the proximal fragment

Radiograph and Clinical Descriptions Shortening: Has the fracture caused shortening of the involved bone? Rotation: Described both radiographically and clinically

Radiograph and Clinical Descriptions Fragmentation Multi-fragmentary fracture: several breaks in bone creating 2 fragments Wedge fracture: either spiral (low energy) or bending (high energy) and allow the proximal and distal fracture fragments to contact each other Simple fractures: spiral, oblique or transverse

Radiograph and Clinical Descriptions Soft tissue involvement: Is the fracture open or closed? Is associated neurologic or vascular injury present? Is there muscle damage or compartment syndrome?

Different Types of Fractures - Open or compound fracture. The skin may be pierced by the bone or by a blow that breaks the skin at the time of the fracture. The bone may or may not be visible in the wound. - Closed or simple fracture. The bone is broken, but the skin is not lacerated. - Comminuted fracture. A fracture that results in three or more bone fragments

Direction of the Fracture - The direction of the fracture is described as transverse (fracture line is straight across the bone), spiral (fracture line spirals down the bone), oblique (slanted fracture line), comminuted (more than two fragments), or segmental (several large fractures in the same bone)

Closed Fracture Fracture is not exposed to the environment All fractures have some degree of soft tissue injury Commonly classified according to the Tscherne classification

Closed Fracture Classification Tscherne Classification: Grade 0: Minimal soft tissue injury; Indirect injury Grade 2: Direct injury; more extensive soft tissue injury and severe bone injury Grade 3: Severe injury to soft tissue; degloving with destruction of subcutaneous injury (Compartment syndrome is a concern)

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Open Fracture A break in the skin and underlying soft tissue leading directing into or communicating with the fracture and its hematoma Serious injury as infection can gain entrance into the body through the wound and endanger limb or life Described by the Gustilo classification system -Model is tibia fractures and is routinely applied to all fractures. Emphasis is on size of skin injury.

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Classification of Open Fractures Type 1: Wound is smaller < 1 cm, clean and caused by fracture fragment that pierces the skin (Low energy injury) Type II: Wound > 1cm, not contaminated. And without major soft tissue damage defect (Low energy injury) The Gustilo classification system has been shown to have only moderate intraobserver and interobserver reliabilty in terms of fracture classification. The Tscherne and hanover fracture scales are classifications systems that allow for greater evaluation of soft tissue injury relative to wound size, area of skin loss and underlying soft tissue damage - The use a classification system is important as it facilitates communication among clinicians, as well as assists clinicians in the following : decision making, anticipating problems, suggesting treatment options and surgical outcomes and documenting cases

Classification of Open Fractures Type III: Wound > 1 cm, with significant soft tissue disruption (High energy trauma)  severely unstable fracture with varying degrees of fragmentation Type III fractures are subdivided: IIIA: Wound has sufficient soft tissue to cover the bone without the need for local or distant flap coverage

Classification of Open Fractures Type III fractures: IIIB: Disruption of soft tissue is extensive, such that local or distant flap coverage is necessary Wound is often contaminated IIIC: Associated with an arterial injury that requires repair

Epidemiology Frequency: Trauma is the leading cause of death ages 1-34 yrs Causes more years of lost productivity before age 65 than coronary artery disease, cancer, and stroke combined Facture incidence is multi-factorial such as age, sex, co-morbidities, lifestyle and occupation (In the US, 5.6 million fractures/year) - In the United States, 5.6 million fractures occur each year, corresponding to a 2% incidence.[14] Almost 6000 fractures were treated in an orthopedic trauma unit in Edinburgh, Scotland, in one year. The overall fracture incidence in the Scottish case series was 1.13% in men and 1.16% in women. Interestingly, there was a bimodal distribution of fractures in males, with a high incidence in young men and a second rise in men starting at the age of 60 years. In women, there was a unimodal distribution of fractures, with a rise around the time of menopause. For a study of tibial shaft fractures among Canadian orthopedia trauma surgeons, see Busse et al.

Etiology of Fractures Occur when the force applied to a bone exceeds the strength of the involved bone Both intrinsic + extrinsic factors are important Extrinsic factors: include the rate at which the bone’s mechanical load is imposed and the duration, direction, and magnitude of the forces acting on the bone Intrinsic factors: include the involved bone’s energy-absorbing capacity, modulus of elasticity, fatigue, strength, and density

Etiology of Fractures Result of direct or indirect trauma Direct trauma consists of direct force applied to the bone Direct mechanisms include tapping fractures (eg, bumper injury), penetrating fractures (eg, gunshot wound), and crush fractures Indirect trauma involves forces acting at a distance from the fracture site such as tension (traction), compressive, and rotational force

Pathophysiology 5 phases of fracture healing: Fracture and inflammatory phase Granulation tissue formation Callus formation Lamellar bone deposition Remodeling

Fracture and Inflammatory Phase Actual fracture injuries to the bone include insult to the bone marrow, periosteum, and local soft tissues The most important stage in fracture healing is the inflammatory phase and subsequent hematoma formation It is during this stage that the cellular signaling mechanisms work through chemotaxis and an inflammatory mechanism to attract the cells necessary to initiate the healing response

Granulation Tissue Formation Within 7 days, the body forms granulation tissue between the fracture fragments Various biochemical signaling substances are involved in the formation of the granulation tissue stage, which lasts approximately 2 weeks

Callus Formation During callus formation, cell proliferation and differentiation begin to produce osteoblasts and chondroblasts in the granulation tissue The osteoblasts and chondroblasts synthesize the extracellular organic matrices of woven bone and cartilage, and then the newly formed bone is mineralized This stage requires 4-16 weeks.

Lamellar bone Formation and Remodeling During the fourth stage: Meshlike callus of woven bone is replaced by lamellar bone, which is organized parallel to the axis of the bone Final stage: remodeling of the bone at the site of the healing fracture by various cellular types such as osteoclasts The final 2 stages require 1-4 years

Patient Factors and Fracture Healing Ideal Problematic Age, y Youth Advanced age (>40 y) Comorbidities None Multiple medical comorbidities (eg, diabetes) Medications Nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids Social factors Nonsmoker Smoker Nutrition Well nourished Poor nutrition Fracture type Closed fracture, neurovascularly intact Open fracture with poor blood supply Trauma Single limb Multiple traumatic injuries Local factors No infection Local infection

Presentation of Single Limb Injury Obtain through hisotiry for the mechanism of injury Obtain history of any previous injury or fracture is mandatory Obtain complete past medical and surgical history Including medications and allergies, as well as a social (smoking and illicit drug use) and occupational history

Physical Examination in Single Limb Injury Physical exam must include a thorough inspection of the integument (with documentation) If the fracture is open, a clinical photograph may be taken for documentation purposes Distal neurologic and vascular status must be assessed and documented

Physical Examination in Single Limb Injury Palpate the entire limb including the joints above + below the injury -- check for areas of pain, effusions, and crepitus Often, other associated injuries may be present (eg, injuries to the spine with a jumping mechanism of injury) Assessment of range of motion (ROM) may not be possible, but this should be documented Assessments for ligamentous injury and tendon rupture

Multiple Traumatic Injuries Initial assessment of a patient with polytrauma follows the advanced trauma life support (ATLS) protocols Includes the identification and treatment of life-threatening injuries The first step is evaluation of the individual's airway, breathing, and circulation Immediate endotracheal intubation and rapid administration of intravenous fluids may be necessary

Multiple Traumatic Injuries Spinal precautions must be maintained until injury to the spine can be excluded clinically and radiographically Radiographs or computed tomography [CT] scans Once patient is hemodynamically stable The secondary survey, a complete systems-based physical examination, is performed

Initial Management of Fractures Consists of realignment of the broken limb segment and then immobilizing the fractured extremity in a splint Distal neurologic + vascular status must be clinically assessed and documented before and after realignment and splinting

Initial Management of Fractures If a patient sustains an open fracture, achieving hemostasis as rapidly as possible at the injury site is essential This is achieved by placing a sterile pressure dressing over the injury Splinting is critical in providing symptomatic relief for the patient, preventing potential neurologic + vascular injury and further injury to the local soft tissues Patients should receive adequate analgesics in the form of acetaminophen or opiates, if necessary.

Management of Open Fractures Treatment goals for open fractures are to: Prevent infection, to allow the fracture to heal, and to restore function in the injured limb Once initial assessment, evaluation, and management of any life-threatening injuries are complete, the open fracture is treated Hemostasis should be obtained, followed by antibiotic administration and tetanus vaccination - Tetanus prophylaxis and immunization should be administered to patients who have not been previously immunized.

Management of Open Fractures Cefazolin or clindamycin is adequate for type I + type II fractures Aminoglycoside (eg, gentamicin) can be added for a severely contaminated wound (type III) If injury is a "barnyard injury" or water-type injury, penicillin should also be added to provide prophylaxis against Clostridium perfringens

Management of Open Fractures Urgent irrigation and debridement (I&D) of the wound in the operating room is mandatory For type II and type III injuries, serial I&Ds are recommended every 24-48 hours after the initial debridement until a clean surgical wound is ensured The wound is closed when it is clean and antibiotics are generally continued until 2 days after the final I&D Prophylactic use of quinolones should not be used because of the rapid development of resistant staphylococci and because quinolones are important drugs in the treatment of implant-related infections

Management of Open Fractures Management of the open fracture depends on the site of injury and type of open fracture Wound is subsequently stabilized either temporarily or definitively If soft-tissue coverage over the injury is inadequate Soft-tissue transfers or free flaps are performed when the wound is clean and the fracture is definitively treated

Fracture Management Divided into non-operative and operative techniques Non-operative technique: consists of closed reduction if required  followed by a period of immobilization with casting or splinting Closed reduction is needed if the fracture is significantly displaced or angulated If the fracture cannot be reduced, surgical intervention may be required

Fracture Management – Surgical Indications Failed nonoperative (closed) management Unstable fractures that can’t be maintained in a reduced position Displaced intra-articular fractures (>2 mm) Fractures that are known to heal poorly following non- operative management (eg, femoral neck fractures)

Fracture Management – Surgical Indications Large avulsion fractures that disrupt the muscle-tendon or ligamentous function of an affected joint Example patella fracture Impending pathologic fractures Multiple traumatic injuries involving pelvis, femur, or vertebrae Unstable open fractures or complicated open fractures

Fracture Management – Surgical Indications Individuals who are poor candidates for non-operative management that requires prolonged immobilization Example: elderly patients with proximal femur fractures Fractures in skeletally immature individuals that have increased risk for growth arrest Example: Salter-Harris types III-V) Nonunions or malunions that have failed to respond to non-operative treatment

Contraindications Active infection (local or systemic) or osteomyelitis Soft tissues that compromise the overlying fracture or the surgical approach Medical conditions that contraindicate surgery or anesthesia Example: recent myocardial infarction Cases in which amputation would better serve the limb and the patient - Soft tissues that compromise the overlying fracture or the surgical approach because of poor soft-tissue quality due to soft-tissue injury or burns, previous surgical scars, or active infection

Any Questions??

References Buckley, R. General Principles of Fracture Care. Medscape Jan 2010. Orthopedic Trauma Association. www.ota.org