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

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

3. 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

4. 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?

5. 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

6. 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

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

8. 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

9. 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?

10. 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

11. 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)

12. 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

13. 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)

14.
Orthopedic Trauma Association

15. 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.

16. Orthopedic Trauma Association

17. 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

18. 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

19. 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

20. 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.

21. 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

22. 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

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

24. 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

25. 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

26. 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.

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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.

36. 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.

37. 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

38. 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 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

39. 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

40. 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

41. 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)

42. 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

43. 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

44. 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

45. Any Questions??

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