FRACTURES

Anandkumar Balakrishna
Wong Poh Sean
Mohd Hanafi Ramlee

CONTENT
DEFINITION
PRINCIPLE

MANAGEMENT
COMPLICATIONS

DEFINITION

A fracture is a
break in the
structural
continuity of
bone.

CAUSES
Sudden

trauma

direct(fracture of the ulna caused by blow on

the arm)
indirect(spiral fractures of the tibia and fibula
due to torsion of the leg, vertebral
compression fractures, avulsion fractures)

Stress

or fatigue-repetitive stress(athletes,
dancers, army recruits)
Pathological(osteoporosis, Pagets disease,
bone tumour)

TYPES OF FRACTURES
CLOSED/
SIMPLE

OPEN/
COMPOUND

no
opening in
the skin.

bone
fragments
have
broken
through
the skin.

COMPLETE
bone is
completely
broken into 2 or
more fragments.
-eg:
transverse
fracture
oblique fracture
spiral fracture
impacted
fracture
comminuted
fracture
segmental

INCOMPLETE
bone is
incompletely
divided and the
periosteum
remains in
continuity.
-eg:
greenstick
fracture
torus fracture
stress fracture
compression
fracture.

COMPLETE FRACTURES

OBLIQUE
FRACTURE

SEGMENTAL FRACTURE

TRANSVERSE
FRACTURE

SPIRAL
FRACTURE

COMMINUTED
COMMINUTED FRACTURE
FRACTURE

IMPACTED
IMPACTED
FRACTURE
FRACTURE

INCOMPLETE FRACTURE

GREENSTICK

TORUS

FRACTURES DISPLACEMENT
After

a complete fracture the fragments

usually displaced:

partly by the force of injury

partly by gravity
partly by the pull of muscles attached to them.

types:
Translation/Shift
Alignment/Angulation
Rotation/Twist
Altered length

SHIFT

ANGULATION
/TILT

SIDEWAYS

OVERLAP

IMPACTION

TWIST/
ROTATION

HOW FRACTURES HEAL?

Healing

by callus
Healing without callus

Healing by callus
Callus

is the response to movement at the

fracture site to stabilize the fragments as
rapidly as possible.
Steps:
Tissue destruction and haematoma formation.
Inflammation and cellular proliferation.
Callus formation: dead bone is mopped up & woven
bone(immature) appears in fracture callus.
Consolidation: woven bone(immature) is replaced by
lamellar bone(mature).
Remodelling:Newly formed bone is remodelled to
resemble the normal structure.

Healing without callus

For fracture that is absolutely immobile:

impacted fracture in cancellous bone.

fracture rigidly immobilized by internal fixation

New bone formation occurs directly between

fragments.
Gaps between the fracture surfaces are invaded
by new capillaries & bone forming cells growing
in from edges.
For very narrow crevices(<200um), osteogenesis
produces lamellar bone(mature).
For wider gaps, osteogenesis begins with woven
bone (immature) first which is then remodelled
to lamellar bone (mature bone).

RATE OF REPAIR DEPENDS UPON:

Type of
bone

Type of
fracture

State of
blood
flow

cancell
ous
bone
heals
faster
than
cortical
bone.

spiral
fractur
e heals
faster
than
transv
erse
fractur
e.

poor
circulat
ion will
slow
the
healing
proces
s.

Patients
general
constitut
ion

Patients
age

health
y bone
heals
faster.

healing
is
faster
in
childre
n than
adults.

CAUSES OF DELAYED UNION

OR NON-UNION OF THE
FRACTURES
Distraction &
separation of
the fragments

Interposition of
soft tissues
between the
fragments.

Excessive
movement at
the fracture
site

Poor local
blood supply

Severe damage
to soft tissues
which makes
them
nearly/nonviable.

Infection

Abnormal
bone.

FRACTURESPRINCIPLE OF
TREATMENT

Management
of Closed
Fracture

First aid management

Airway,

Breathing and Circulation

Splint the fracture
Look for other associated injuries
Check distal circulation is distal circulation
satisfactory?
Check neurology are the nerve intact?
AMPLE history- Allergies, Medications, Past
medical history, Last meal, Events
Radiographs 2 views, 2sides, 2 joints, 2
times.

General Resuscitation
Manipulation
(improve position of fragments)
Splintage
(hold fragments together until unite)
Exercise & weight-bearing

Reduce
Hold
Exercise

Principle Of Treatment

Hold
Safety
Speed
Move

The Fracture Quartet

Outlin
e

Closed
Closed
Reduction
Reduction

Closed
Closed
Fracture
Fracture

Reduce
Reduce

Mechanical
Mechanical
Traction
Traction
Open
Open
Reduction
Reduction
Sustained
Sustained
Traction
Traction
Cast
Cast
Splintage
Splintage

Hold
Hold

Functional
Functional
Bracing
Bracing

Exercise
Exercise

Internal
Internal
Fixation
Fixation
External
External
Fixation
Fixation

Reduce
Aim

for adequate apposition and normal

alignment of the bone fragments
The greater contact surface area between
fragments, the more likely is healing to occur

However, there are some

situations in which
reduction is unnecessary:
When

there is little or no displacement

When displacement does not matter (e.g. in
some fractures of the clavicle)
When reduction is unlikely to succeed (e.g.
with compression fracture of the vertebrae)

Reduction

Operative

Nonoperative

Closed reduction

Open reduction

Mechanical
Traction

Closed Reduction
Suitable

for

Minimally displaced fractures

Most fractures in children
Fractures that are likely to be stable after
reduction

 Most

effective when the periosteum and

muscles on one side of fracture remain intact
Under anaesthesia and muscle relaxation, a
threefold manoeuvre applied:

Distal part of the limb is pulled in line of the

bone
Disengaged, repositioned
Alignment is adjusted

Mechanical Traction
Some

fractures (example fracture of femoral

shaft) are difficult to reduce by manipulation
because of powerful muscle pull
However, they can be reduced by sustained
muscle mechanical traction; also serves to
hold the fracture until it starts to unite

Open Reduction
Operative

reduction under direct vision

Indications:

When closed reduction fails

When there is a large articular fragment that
needs accurate positioning
For avulsion fractures in which the fragments
are held apart by muscle pull
When an operation is needed for associated
injuries
When a fracture needs an internal fixation

Hold

Non
Operativ
e

Sustained
traction
Cast Splintage
Functional
Bracing

Operativ
e

Internal
Fixation
External
Fixation

HOLD

To prevent
displaceme
nt

To alleviate
pain by
some
restriction
of
movement

To promote
soft-tissue
healing

To allow
free
movement
of the
unaffected
parts

Sustained Traction

Traction is applied to limb distal to the

fracture
To exert continuous pull along the long axis
of the bone

Safety
Hold
Move
Speed

Advantage
Can move joint
Can exercise musle
Indication
Useful for spiral fractures of
long bone shafts:
Shaft of femur
Tibia
Lower humerus

 Disadvantage

and complications

Patient kept on bed for long time

Pressure ulcer
General weakness
Pulmonary infection
Contracture
Pin tract infection
Thromboembolic event

Methods

Traction by gravity
Balanced traction
Fixed traction

Traction By
Gravity
Example:
Fracture of
humerus
Weight of arm to
supply traction
Forearm is
supported in a
wrist sling

Balanced Traction
Traction is applied to
the limb either by way
of adhesive strapping,
kept in place by
bandages skin
traction
Sustain a pull no more than 45 kg
Contraindications:
Abrasion, dermatitis, wound
Vascular insufficiencies
When greater traction force
in needed

Thomass Splint

Traction applied via

stiff wire or pin
inserted through the
bone distal to the
fracture skeletal
traction
Can apply several
times as much force

Complications:
Pin tract infection
Damage to epiphyseal
growth plate
Vertical fracture of the
bone
Injury to the vessels or
nerves

Fixed Traction
Principle

= balanced traction
Useful for when patient has to be
transported
Thomass splint

Cast Splintage

Methods:

Plaster of Paris
Fibreglass

Especially for distal limb # and for most

children #
Disadvantage: joint encased in plaster
cannot move and liable to stiffen
Can be minimized:

Delayed splintage (traction initially)

Replace cast by functional brace after few
weeks

Complications
Tight cast put on
too tightly/limb swells

Safety
Hold
Speed
Move

Pressure sores even

a well-fitting cast may
press upon the skin
over a bony
prominence (the
patella, the heel)
Skin abrasion or
laceration during
removal of the plaster

Functional Bracing

Principle
functional long
Brace
bone is supported
supportive device
externally by POP
Indication
that allows
or by a
fractures of shaft
continued
mouldable plastic of femur or tibia
function of the
material but the
part
function of joints
are preserved

Functional bracing
is not rigid
applied when
fracture is
beginning to unite,
after about 3-6
weeks of traction
or restrictive
splintage
Advantages:
Fractures held reasonably
well
Joints can be moved
Patient can leave hospital
Method is safe

Safety
Hold
Speed
Move

INTERNAL
FIXATION

Principle
Bony fragment
may be fixed with:
screws,
transfixing pins or
nails,
a metal plate held by
screws,
a long intramedullary
nails,
circumferential band,
or a combination with
these method

Indication
1. Fracture that cannot
be reduced except by
operation
3.Fracture that unite
poorly and slowly
Principally fracture of
the femoral neck
5.Multiple fracture
Where early fixation
reduced the risk of
general complication

2. Fracture that are

inherently unstable
and prone to
displacement after
reduction
4.Pathological
fracture
Bone disease may
prevent healing
6.Fracture in patient
who present severe
nursing difficulty

Type of internal fixation

screw
Interfragmentary screw (lag screw) are
used for fixing small fragment onto the
main bone

wires
Kirschner wire (often inserted
percutaneously without exposing the
fracture
Used in situation where fracture healing is
predictably quick

Plates and screw

Useful for treating metaphyseal fracture of
long bones and diaphyseal fracture of
radius and ulna

Intramedullary nail
Suitable for long bones
Nail is inserted onto medullary canal to
splint the fracture
Rotational of fracture are resisted by
introducing locking screw which tranfix
the bone cortices and the nail proximal
and distal to the fracture.

advantages
Precise
reduction
ORIFopen
reduction
and
internal
fixation

Immediate
stability

Early
movement

Hold the
fracture
securely

fracture
disease
like
oedema,s
tifness,et
c may
abolish

Infection
Infection

Refractur
Refractur
e
e

Complicatio
ns

Implant
Implant
failure
failure

NonNonunion
union

Infection

Iatrogenic infection chronic

osteomylitis
Risk of infection depends on:
1)The patient devitalised
tissue, dirty wound, unfit patient
2)The surgeon thorough
training, a high degree of
surgical dexterity and adequate
assistant are all essential
3)The facilities aseptic routine
The infection should be rapidly
controlled by intravenous
antibiotic
If infection cannot be controlled,
the implant should be replaced
with some form of external
fixation

Non union

Cause:
1) excessive
stripping of soft
tissue
2) unnecessary
damage to blood
supply in the course
of operative fixation
3)rigid fixation with a
gap between the
fragment

Implant failure
Metal
Metal
is subjected
is
tosubjected
fatigue
to

fatigue
So, undue
stress should
therefore be
avoided until
the fragment
has united.
Pain at the site
of fracture site
is a danger
signal.

Refracture

It is important
not to remove
the metal implant
too soon
A year is
minimum and 18
to 24 month is
safer
For several
weeks after the
implant removal
the bone is weak
so full weightbearing should
be avoided

EXTERNAL
FIXATION

Principle
The bone is transfixed
above and below the
fracture with screw or
pins or tension wire and
these are then clamped
to a frame or
connected to each
other by rigid bars
outside the skin

Indication
Fracture associated with
soft tissue injury
Where the wound can be left
open for inspection, dressing
and definitive coverage

Severely comminuted
and unstable fracture
Which can be held out to
length until healing
commence

Fracture of the pelvis

Which often cannot be
controlled quickly by any
other method

Fracture associated with

nerve and vessel
damage

Infected fracture
Where internal fixation
might not be suitable

United fracture
Where dead or sclerotic
fragment can be excised and
the remaining ends brought
together in the external
fixator

(a)The patient was fixed with a plate and screw but did not
unite (b) external fixation was applied

Advantages
technically quick
and easy to
perform

no soft tissue
stripping;

ease of removing
hardware;

risk of infection at
the site of the
fracture is
minimal

Complication
Damage
to soft
tissue
structur
e

Over
distracti
on

Pin track
infection

Damage to soft tissue

structure
Transfixing pins and wires may
injure the nerve and vessel or
may tether ligament and inhibit
joint movement
So, the surgeon must be
thoroughly familiar with the safe
corridor for inserting the pins

Over
distraction
If there is no
contact between
the fragment,
union may be
delayed or
prevented

Pin track infection

There is a risk of
infection where the pins
are inserted from the
skin into the bone.
So, meticulous pin-site
care is essential
Antibiotic should be
administered
immediately if infection
occur

Exercise
Prevention

of edema

active exercise and elevation

Active exercise also stimulates the circulation.
Prevents soft-tissue adhesion and promotes
fracture healing.

Preserve

the joint movement

Restore muscle power
Functional activity

Managemen
t of
Open
Fractures
A break in skin
and underlying
soft tissues
leading directly to
communicating
with the fracture

Open Fracture
First Aid & Management of the Whole
Patient
Prompt wound debridement
Antibiotic prophylaxis
Stabilization of the fracture
Definitive wound cover

First Aid & Management of the Whole Patient

Airway
Breathing
Circulation

80

1. Emergency Management of
Open Fracture
A,B,C
Splint the limb
Sterile cover - prevent contamination
Look for other associate injury
Check distal circulation is distal circulation satisfactory?
Check neurology are the nerve intact?
AMPLE history- Allergies, Medications, Past medical history, Last
meal, Events
Radiographs 2 view, 2sides, 2 joints, 2 times.
Relieve pain
Tetanus prophylaxis
Antibiotics
Washout / Irrigation
Wound debridement
fracture stabilisation

Open Fractures
Classification

Preoperative Assessment

HISTORY
Age
General health &
comorbidities
Alcohol & drugs
Ambulatory status
Cause of injury
High or low energy
Potential for infection
Previous injuries

PHYSICAL
EXAMINATION
ATLS
Other injuries
Vascular status of limb
Limb color, pulse, capillary refill

Neurological status of limb

Power, sensation

Preoperative Assessment
EXAMINATION OF
OPEN WOUND
Location & extent of the wound
Length of wound
Number of skin wounds
Degree of skin contamination

RADIOLOGICAL
EXAMINATION

X-ray: AP,
lateral

CT & MRI: open

pelvic, intraarticular,
carpal, tarsal
fractures

Treatment- Outline
Irrigation
Debridement:
Bone

Skin, Fat, Muscle,

Wound closure
Analgesic +
Antitetanus

Antibiotic +
(AAA): IV, IM

Fracture stabilization

1) Analgesic + Antibiotic +
Antitetanus Prophylaxis
Analgesic

Pethidine/morphine

60-70% of open wound are associated with positive cultures,

mostly normal flora

Broad spectrum 3rd generation cephalosporin, aminoglycoside

Gentamicin or metronidazole for gram negative organism.

Antitetanus
Toxoid for immunised

Human antiserum for nonimmunised

Antibiotic

Gustilo Grade I- first generation of cephalosporin

for 72 hours
Gustilo Grade II- first generation cephalosporin
for 72 hours + Gram negative coverage
(gentamicin) for at least 72 hours
Gustilo Grade III- first generation cephalosporin
+G ve coverage for at least 72 hours
For soil contamination- penicillin is added for
clostridial coverage

2) Irrigation

Fluids such as
normal isotonic
saline or
antibiotic
solutions +
hydrogen
peroxide
A method of wound
cleansing by removing
debris mechanically
with pressurised fluid.

Advantages:
Flushes away
the foreign
matter and
contaminated
blood clot
Helps in
assessment of
viability of
tissues
Reduces
bacterial
population

3) Debridement
All dead and contaminated
tissues must be removed
Performed in a systematic
manner

Skin & fascia

Muscles
Tendon
Bone

89

Surgical Debridement
Type

II and type III require surgical

debridement.
Important aspect of wound
management.
Reduce bacteria, remove foreign
bodies, remove devitalized tissue.
Removal of dead tissue reduces
bacterial burden and accelerate
healing.

4) Wound Closure
Primary closure

Delayed primary
closure (<5days)
Another
debridement

Secondary closure

Skin grafting

For wounds less than 8 hours old

after debridement
Wound left open after
debridement for 2-3 days
If clean, close the wound
Type III

For infected wound

Partial thickness
Full thickness

Wound Closure
Uncontaminated

I & II can be sutured

provided without tension
All other wounds left open, packed with
moist sterile gauze, to be inspected 24-48
hours primary delayed closure
If wound cannot be closed without tension
skin grafting

5) Fracture Stabilization
Immobilisation
in a plaster

A window is made in the plaster over the

wound for dressing

Skeletal
traction

Eg. open fracture of tibia

External
fixator

Internal fixator

Can be easily applied

Readily reduced and adjusted
Wound can be assessed for dressing
Excellent stability

Rarely used

Stabilization of the fracture

To reduce infection and assist recovery of soft
tissue
Depends on:

If <8 hours: up to IIIA treated as closed fractures:

degree of contamination
length of time from injury to operation
amount of soft tissue damage
Splintage
Intramedullary nailing
Plating
External fixation

Others: External fixation

Aftercare
The limb is
elevated &
it's
circulation
carefully
monitored
If the
wound has
been left
open, it is
inspected
after 2-3
days &
covered
appropriate
ly

Antibiotic
cover

Physiothera
py and
rehabilitatio
n

COMPLICATIO
N OF
FRACTURE

General

Early

Late

Shock
Diffuse Coagulopathy
Tetanus
Respiratory Dysfunction
DVT & Pulmonary Emb.
Fat Emboli Syndrome

Crush Syndrome
Chest Infection
Urinary Tract Infection
Gas Gangrene

Infection

Non-union / Mal-union / Delayed

union
Avascular Necrosis
Length discrepancy
Disuse Osteoporosis

GENERAL

Bone

BONE
Joint

Haemarthrosis
Ligament injury

Soft
Tissue

Plaster Sore
Tendon Rupture
Neurovascular Injury
Compartment Syndrome
Visceral injury

Instability / Mal-alignment
Osteoarthritis
Stiffness
Overuse injuries

JOINT

Nerve compression
Volkmanns contracture
Bedsores
Myositis Ossificans
Tendinitis & Tendon rupture

SOFT TISSUE

General
Complication
s

1.
2.
3.
4.
5.
6.
7.
8.

Shock
Diffuse coagulopathy
Respiratory
dysfunction
Crush syndrome
Venous thrombosis &
Pulmonary embolism
Fat embolism
Gas Gangrene
Tetanus

General 1: Shock
Altered
Altered physiologic
physiologic status
status with
with generalized
generalized
inadequate
inadequate tissue
tissue perfusion
perfusion relative
relative to
to
metabolic
metabolic requirements.
requirements.
irreversible
irreversible
damage
damage to
to vital
vital organs
organs

Cardiogenic

direct injury to heart effect the pump functions

Neurogenic

injury to brain stem (vasomotor center) spinal cord

loss of sympathetic tone increase venous
capacitance low venous return low cardiac
output (but bradycardia)

Hypovolemi
c

reduction of blood volume

1500-3000ml

500-1000ml

1500-3000ml
100-300ml

1000-2000ml

1000-2000ml

VOLUME DISTRIBUTION

General 1: Shock
Why we need to treat
shock?
Blood redistribution
Renal shutdown
Intestinal ischemia
Tissue hypoxia
Metabolic acidosis
Reduced hepatic blood
flow
Acute Respiratory
Distress Sydrome
Altered consciousness

How to manage shock?

Identify: Thirst, rapid
shallow breathing, the
lips and skin are pale
and the extremities
feel cold, impaired
renal function test and
decreased urinary
output.
ABC
IV lines: fluids and blood
Oxygenation/Ventilation
Urinary Catheter
Central Venous Pressure
Ionotropic drugs

General 2: DIFFUSE
COAGULOPATHY
Consumptive
Coagulopathy
activation by
tissue
thromboplastin
endothelial injury
activating
platelets
massive blood
transfusion

Management
Stop the bleeding
Fresh Frozen
Plasma (FFP)
Cryoprecipitate
Platelet
transfusion
Heparin

General 3: RESPIRATORY
DYSFUNCTION
Pathophysiology
Alveolar edema
endothelial
injury
capillary
permeability
Poor lung
compliance
inactivated
surfactant
Arterial
hypoxemia

Management
Oxygenation
Ventilation
positive end
expiratory
pressure (PEEP)

General 4: Crush Syndrome

[traumatic rhabdomyolitis]

Serious medical condition

characterized by major shock &
renal failure following a crushing
injury to skeletal muscles or
tourniquet left too long
Bywaters
Bywaters Syndrome
Syndrome

When
compressi
on
released

Myohaema
tin release
from cells

Nephrotoxi
c effects

Block
tubules

Oliguria,
uremia,
metabolic
acidosis

General 4: Crush Syndrome

Clinically

Management

Shock
Pulseless limb redness
swelling
Loss of muscle sensation
and power
Decrease renal secretion
Uremia, acidosis
Prognosis
If renal secretion return
within 1 week the patient
survive
But most of them die
within 14 days

PREVENTION
Strict tourniquet timing
Amputation
limb crushed severely
tourniquet left on > 6 hrs
above site of compression
& before compression
released
Monitor intake & output
Dialysis
Correct electrolytes &
acidosis
Antibiotics

General 5: Deep vein thrombosis

and pulmonary embolism.
triad factor Clot formation
in large vein thrombus breaks off
Emboli
Site: leg, thigh and pelvic vein.
Risk factors:
Virchows

Knee and hip

replacement

Elderly

Cardiovascul
ar disease

Immobility

Trauma

Malignancy

Hypercoagul
able status

General 5: Management Deep vein

thrombosis and pulmonary
embolism.
PREVENTION
Correct hypovolemia
Calf muscle exercise
Proper positioning
Well fitting bandages &
cast
Limb elevation
Graduated compression
stockings
Calf muscle stimulation

Anticoagulation
Ambulate

patient
Established
thrombosis/embolism

Limb elevation
Heparinization
Thrombolysis
Oxygenation or
ventilation

General 6: Fat Embolism

Fat globules from marrow pushed into
circulation by the force of trauma that
causing embolic phenomena
Fractures
that most
often
cause FES
Long
bones
Ribs
Tibia
Pelvis

Closed/ope
n Fracture

Fat in
bone
marrow
escape

Formation
of fat
globules in
vessels

Triad of
symptoms

Stick in
target
organ

Fat
embolus

General 6: Fat Embolism

Triad of Symptoms
Brain: mental
confusion
Lung:
breathlessness,
ARDS
Skin: Petechia

Management
Prevent hypoxemia
oxygenation or
ventilation
Rule out head
injury
CT Scan of brain
Monitor fluid &
electrolyte balance
CVP, urinary
catheter

General 6: Fat Embolism

SKIN:
SKIN: Fat
Fat droplets
droplets

obstruct
obstruct alveolar
alveolar
capillaries
capillaries

thromboplastin
thromboplastin release
release

consumption
consumption of
of
coagulation
coagulation fx
fx &
&
platelets
platelets
DIVC/Skin
DIVC/Skin
necrosis
necrosis
Petechia
Petechia
LUNG:
LUNG: Fat
Fat droplets
droplets

obstruct
obstruct alveolar
alveolar
capillaries
capillaries

thromboplastin
thromboplastin
release
release
alter
alter
membrane
membrane
permeability
permeability // lung
lung
surfactant
surfactant
oedema
oedema

respiratiory
respiratiory failure
failure
[V/Q
[V/Q Mismatch]
Mismatch]

BRAIN:
BRAIN: Fat
Fat droplets
droplets

obstruct
obstruct capillaries
capillaries

confusion
confusion
coma/fits
coma/fits

death
death

General 7: Gas Gangrene

Rapid and extensive necrosis of the muscle
accompanied by gas formation and systemic
toxicity due to clostridium perfringens
infection
Clinical Features
sudden onset of pain
localized to the infected
area.
swelling , edema
+/- pyrexia
profuse serous discharge
with sweetish and mousy
odor .
Gas production

Management
early diagnosis .
surgical intervention and
debridement are the
mainstay of treatment.
IV antibiotics
fluid replacement.
hyperbaric Oxygen

General 7: Gas Gangrene

Prevention:
Prevention: ALL
ALL DEAD
DEAD TISSUE
TISSUE
[4C]
[4C] SHOULD
SHOULD BE
BE COMPLETELY
COMPLETELY
EXCISED,
EXCISED,

General 8: Tetanus
A condition after clostridium tetani infection
that passes to anterior horn cells where it
fixed and cant be neutralized later produces
hyper-excitability and reflex muscle spasm
Clinical Features

Management

Tonic and clonic

contractions of esp.
jaw, face, around the
wound itself ,neck
,trunk, finally spasm of
the diaphragm and
intercostal muscles
leads to asphyxia and
death.

Prophylaxis
Treatment
Antitoxin & antibiotic
Muscle relaxant
Tracheal intubation
Respiration control

Early
Complication
s

1.
2.
3.
4.
5.
6.

Visceral Injury
Vascular Injury
Compartment
Syndromes
Nerve injury
Haemarthrosis
Infection

Early 1: Visceral injury

Fractures

around the trunk are

often complicated by visceral
injury.

E.g. Rib fractures

pneumothorax / spleen trauma /
liver injuries.
E.g. Pelvic injuries bladder
or urethral rupture / severe
hematoma in the retroperitoneum .

Rx:

Surgery of visceral injuries

Early 2: Vascular injury

Commonly associated with highenergy open fractures. They are rare

but well-recognized.
Mechanism of injuries:

The artery may be cut or torn.

Compressed by the fragment of bone.
normal appearance, with intimal
detachment that lead to thrombus
formation.
segment of artery may be in spasm.
It may cause

Transient diminution of blood flow

Profound ischaemia
Tissue death and gangrene

Early 2: Vascular injury

5Ps of
ischemia

Pain
Pallor
Pulseless
Paralysis
Paraesthesi
a

X-ray: suggest high-risk fracture.

Angiogram should be performed to confirm diagnosis.

Early 2: Vascular injury

muscle ischaemic is
irrevesible after 6 hours.

Remove all bandages

and splint & assess
circulation
Skeletal stabilization
temporary external
fixation.
Definitive vascular
repair.
Vessel sutured
endarterectomy

Vessel

Injury

subclavi
an

1st rib fracture

Axillary

Shoulder dislocation

Brachial

Humeral
supracondylar
fracture

Brachial

Elbow dislocation

Presacra
l and
internal
iliac

Pelvic fracture

Femoral

Femoral
supracondylar
fracture

Popliteal

Knee dislocation

Popliteal
or its

Proximal tibial
fracture

Early 3: Compartment Syndrome

A condition in which increase in pressure
within a closed fascial compartment leads to
decreased tissue perfusion.
Untreated, progresses to tissue ischaemia
and eventual necrosis
Leg

Forearm

4 compartments:
anterior, lateral,
superficial and deep
posterior
NOT interconnected

3 compartments:
dorsal, superficial
and deep volar
interconnected,
hence fasciotomy of
1 compartment may
decompress the
other 2

Early 3: Compartment Syndrome

Most

common sites (in freq): leg (after

tibial fracture) forearm thigh upper arm.
Other sites: hand, foot, abdomen, gluteal and
cervical regions.

High

risk injuries:

# of elbow, forearm bones, and proximal 3rd of

tibia (30-70% after tibial #)
multiple fracture of the foot or hand
crush injuries
circumferential burns

Early 3: Compartment Syndrome

[aetiology]
Compartmental volume (
fluid content)
Trauma fractures
/osteotomies, crush injury
Vascular haemorrhage,
post-ischaemic swelling
Soft tissue injury burns,
prolonged limb
compression
Iatrogenic intraosseous
fluid resuscitation in
children, intraarterial drug
injection
Extreme muscular
exertion

Compartment volume
(constriction of the
compartment)
Constrictive
dressings/plaster casts
Thermal injuries with
eschar formation
Pneumatic antishock
garments (MAST)
Surgical closure of fascial
defects

Early 3: Compartment
Syndrome

Vicious cycle
fluid content

Constriction of compartment

INTRACOMPARTMENTAL PRESSURE
Obstruct venous return

Capillary basement
membranes become
leaky oedema

Vascular congestion
Muscle and nerve
ischaemia
Further intracompartmental
pressure

capillary perfusion

Compromise arterial circulation

PROGRESSIVE NECROSIS OF MUSCLES AND NERVES !!

Sequence
Sequence started
started with:
with:
severe
severe pain/bursting
pain/bursting sensation
sensation
(early)
(early)
paraesthesia/hypoaesthesia
paraesthesia/hypoaesthesia

motor
motor weakness
weakness
loss
loss of
of peripheral
peripheral pulses
pulses and
and
capillary
capillary refill
refill (late
(late signs,
signs, poor
poor
prognosis)
prognosis)

A vicious circle that ends after 12 hours or less

Necrosis of the nerve and muscle within the compartment

Nerve
-capable to regenerate

Muscle
-infarcted

Never recover

Replaced by inelastic fibrous tissue

( Volkmanns ischaemic contracture)

Investigations of compartment
sydromes
Intra-compartment

Pressure

Measurement (ICP)

Use of slit catheter; quick and easy

Indications:
Unconscious

patient
Those who are difficult to assess
Concomitant neurovascular injury
Equivocal symptoms

Especially long bone # in lower limb

Perform as soon as dx considered
> 40mmHg urgent Rx! (normal 0 10 mmHg)

Investigations of compartment syndromes

Other

Ix limited value; +ve only when

CS is advanced

Plasma creatinine and CPK

Urinanalysis myoglobinuria
Nerve conduction studies

Ix

to establish underlying cause or

exclude differentials

X-ray of affected extremity

Doppler US/arteriograms determine presence
of pulses; exclude vascular injuries and DVT
PT/APTT exclude bleeding disorder

Management
Prompt

DECOMPRESSION of affected
compartment
Remove all bandages, casts and dressings
Examination of whole limb
Limb should be maintained at heart level

Elevation may arterio-venous pressure

gradient on which perfusion depends

Ensure

patient is normotensive.

Hypotension tissue perfusion, aggravate the

tissue injury.

Management
Measure

intra-compartment pressure

If > 40mmHg
Immediate

open fasciotomy

If < 40mmHg
Close

observation and re-examine over next hour

If condition improve, repeated clinical evaluation
until danger has passed

Dont wait for the obvious sings of ischemia to appear. If you suspect
An impending compartment syndrome, start treatment straightaway

Fasciotomy
Opening

all 4 compartments
Divide skin and deep fascia for the whole
length of compartment
Wound left open
Inspect 5 days later
If muscle necrosis, do debridement
If healthy tissue, for delayed closure or skin
grafting

Complications
Volkmanns ischaemic contracture
Motor/sensory deficits
Kidney failure from rhabdomyolysis (if very severe)
Infection fasciotomy converts closed # to open #
Loss of limb
Delay in bone union

Prognosis
excellent to poor, depending on how quickly CS
is treated and whether complications develop

Early 4: Nerve Injury

Its more common than
arterial injuries.
The most commonly injured
nerve is the radial nerve

[in its groove or in the lower third

of the upper arm especially in
oblique fracture of the humerus]

Common with humerus,

elbow and knee fractures
Most nerve injuries are due
to tension neuropraxia.

nerve

Injury

Axillary

1. Shoulder
dislocation

Radial

2. Humeral shaft
fracture

Median

3. Lower end of
radius

Radial or
median(ant.inteross
eous)

4. Humeral
supracondylar
(esp. children)

Ulnar

5. Medial condyle

Ulnar

6. Elbow dislocation

Sciatic

7. Hip dislocation

Peroneal

8. Knee dislocation

Peroneal

9. Fracture of
fibular neck

Early 4: Nerve Injury

Damaged

by laceration, traction, pressure

or prolonged ischaemia

Neurapraxia

Axonotmesis

axon remains
intact but
conduction
ceases due to
segmental
demyelination.
Spontaneous
recovery in a
few days or
weeks

axonal
separation
with
degeneration
of distal
portions.
Sheath
remains intact,
thus recovery
likely but
delayed

Neurotmesis
nerve
completely
divided.
Spontaneous
recovery
unlikely.

Early 4: Nerve Injury

Clinical features
Numbness and
weakness
Skin smooth and
shiny but feels dry
Muscle wasting
and weakness
Sensation blunted
Tinels sign +ve

Investigations
Electromyography
Nerve conduction study
May help to establish
level and severity of
lesion

Early 4: Nerve Injury

Open injuries

Closed injuries

Exploration
Cleanly divided repair
immediately
Torn/crushed left alone
or ends lightly tacked
together, re-explore 2
3 weeks later for scar
tissue removal and
suturing

Usually nerve sheath

intact
Rate of axonal
regeneration =
1mm/day
If no sign of recovery
re-exploration with
excision of scar tissue
and suturing of cleancut ends, nerve grafting
if gap too large
Splinting 3-6 weeks
then physiotherapy

Early 5: Haemarthrosis
Bleeding

into a joint spaces.

Occurs if a joint is involved in
the fracture.
Presentation:

swollen tense joint; the patient

resists any attempt to moving it

treatment:

blood aspiration before dealing

with the fracture; to prevent the
development of synovial
adhesions.

Early 6: INFECTION
Closed

fractures hardly ever

Open fractures may become infected
Post traumatic wound may lead to
chronic osteomyelitis
Clinical features

Treatment

wound is inflammed
draining seropurulent
fluid

antibiotic
excise the devitalised
tissue
tissues opened &
drained the pus

Late
Complication
s

1.
2.
3.
4.
5.
6.

Delayed Union
Non-union
Mal-union
Avascular Necrosis
Osteoarthritis
Joint Stiffness

Late 1: DELAYED UNION

Union

of the upper limbs - 4-6

weeks
Union of the lower limbs - 8-12
weeks(rough guide)
Any prolong time taken is
considered delayed

Late 1: DELAYED UNION

Factors are either biological or biomechanical
Biological :

Poor blood supply

Tear of periosteum, interruption of intramedullary
circulation
Necrosis of surface# and healing process will take longer

Severe soft tissue damage

Most important factor
Longer time for bone healing due less inflammatory cell
supply

Infection: bone lysis, tissue necrosis and pus

Periosteal stripping

Less blood circulation to bone

Late 1: DELAYED UNION

Mechanical

Over-rigid fixation-fixation devise

Imperfect splintage
Excessive

traction creates a gap#(delay

ossification in the callus)

Late1: DELAYED UNION

Clinical

features:

Tenderness persist
Acute pain if bone is subjected to stress*
( * ask pt to walk, move affected limb)

X RAYS -visible line# and very little callus

formation/periosteal reaction
- bone ends are not sclerosed/ atrophic
(it will eventually unite)

Late 1: DELAYED UNION

Tx:

conservative and operative

Eliminate possible causes of delay

Promote healing

Immobilization should be sufficient to prevent movement

at # site(cast / internal fixation)
Not to neglect # loading so, encourage muscle exercise
and weight bearing in the cast/brace

Operation
> 6 mths & no signs of callus formation
Internal fixation and bone graffting
(operation-least possible damage to the soft tissue)

Late 2 : NON-UNION
In a minority of cases, delayed union--non-union
Factors contributing to non-union:

inadequate treatment of delayed union

too large gap
interposition of soft tissues between the fragments

The growth has stopped and pain diminishedreplaced by fibrous tissue - pseudoarthrosis
Treatment :

conservative / operative
atrophic non-union fixation and grafting
hypertrophic non-union rigid fixation

Late 2: NON UNION

bone

ends are rounded off or exuberant

Hypertrophic non union
Bone

ends are enlarged, osteogenesis is still

active but not capable of bridging the gap
elephant feet on X ray
Atrophic

non union

Cessation

of osteogenesis
No suggestion of new bone formation

Non-union
X- ray
A Atrophic nonunion
B Hypertrophic nonunion

Late 2: Non union

Tx:

Mostly symptomless
Conservative

Removable splint
For hypertrophic non-union, functional bracing-induce
union
Pulsed electromagnetic fields and low frequency pulsed
u/s can also be used to stimulate union.

Operative

Hypertrophic--Rigid fixation (internal or external)

Atrophic--Excision of fibrous tissue ,sclerotic tissue at bone
end, bone grafts packed around the fracture

Late 3: MALUNION
fragments that are joined
in an unsatisfactory
position
Factors:

failure to reduce the fracture

failure to hold the reduction while healing
proceed
gradual collapse of comminuted / osteoporotic
bone

MALUNION

Late 3: Mal-union
X-ray are essential to check the position of
the fracture while uniting. important- the first
3 weeks so it can be easily corrected
Clinical features:

Deformity

usually obvious , but sometimes the

true extent of malunion is apparent only on x-ray
Rotational deformity can be missed in the femur,
tibia, humerus or forearm unless is compared
with its opposite fellow

Treatment
Decision

about the need for remanipulation and correction-difficult

In adults

Fracture-reduced as near to the anatomical position as

possible
apposition for healing
alignment and rotation is important for function
Angulation(>10-15) in long bone or apparent rotational
deformity may need correction by re-manipulation or by
osteotomy and internal fixation

In children

angular deformity near the bone ends often remodel with

time
Rotational deformity will not

In lower limb
shortening

Shortening less than 2 cm: compensated by shoe raise

Shortening more than 2 cm: limb lengthening should be
consider.
Long term effect of mal-alignment (>15) results in
asymmetrical loading of joint and results in late development
of 2 osteoarthritis.

Late 4: AVASCULAR NECROSIS

Certain region-known for their propensity to
develop ischaemia and bone necrosis
Head of femur
Proximal part of scaphoid
Lunate
Body of talus

(Actually this is an early complication however

the clinical and radiological effects are not seen
until weeks or even months)

No clinical feature of avascular necrosis but if

there is a failure to unite or bone collapse-pain

The cardinal X-ray feature increased bone density in the weightbearing part of the joint(new bone ingrowth in necrotic segment)

Treatment: Avascular

necrosis can be prevented by early

reduction of susceptible fractures and
dislocations.
Arthroplasty - Old people with necrosis of the
femoral head.
Realignment osteotomy or arthrodesis - for
younger people with necrosis of the femoral
head
Symptomatic treatment for scaphoid or talus

Late 5: OSTEOARTHRITIS
A

fracture-joint may damage the articular

cartilage and give rise to post traumatic
osteoarthritis within a period of months.
Even if the cartilage heals, irregularity of the
joint surface may cause localized stress and
so predispose to secondary osteoarthritis
years later

Late 6: JOINT STIFFNESS

Commonly occur at the joints close to
malunion or bone loss eg: knee, elbow,
shoulder
Causes of joint stiffness

haemarthrosis lead to synovial adhesion

oedema and fibrosis
adhesion of the soft tissues

Worsen by prolong immobilization

Treatment

prevented with exercise

physiotherapy

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