FRACTURES

SURGERY DEPARTMENT MEDICAL FACULTY YARSI UNIVERSITY JAKARTA 2008

 Loss of bony continuity

Bony disruption

 Compound fractures

Simple fractures

 Direct violence

Indirect violence

 Pathological fracture
Osteoporosis

Secondary metastases

 Hair line fracture

Greenstick fracture Greenstick fracture March fracture

Fracture type
Depends on
Anatomic location Region (diaphysis , metaphysis, epiphysis,

intra/extra articular) Fracture lines (transverse, oblique, spiral) Condition of bone (comminuting, pathologic, incomplete, segmental)

 Bone loss
Butterfly fragment Stress fracture

Avulsion and impacted fracture

Deformities (length discrepancy, angulations,

rotation, translation) Alignment

Diagnosis
1. Anamnesis
Mechanism of injury, history
A fracture is suspected from history and clinical examination, and confirmed by radiography

2.

Physical examination

Look
Asymmetry of contour Comparing one side with the other Displaced, angled Local bruising, swelling, laceration Asymmetry of posture Femoral neck fracture with external rotation Angulations, shortening

 Feel
Crepitus, tenderness

Movement
false moving/ pseudoarthrosis

Assess NVD and compartment syndrome!

Neurovascular disturbance
Neurologic
Sensor and motor fx distal to fracture site

Vascular
Pulse palpation Capillary refill

Warm or cold skin

Color of skin

 Compartment syndrome
Pain

Pale
Parestesia Paralysis

Pulseless

Pain on passive stretching of the muscle intracompartment

3. Radiological examination
Two projection
Standard projections AP and lateral

Two articulation
Above and below , dislocation?

Two extremity
Comparison, especially in child

Two times
Hair line, callus formation

FRACTURE complications
Delayed union
Non union
Atrophic nonunion

Hypertrophic nonunion

Med malleolar nonunion

Diabetic nonunion

Diabetic nonunion

Pseudoarthrosis nonunion

Mal union

Colles malunion

Bone infection, osteomyelitis

Bone infection, osteomyelitis

Debridement / guttering

 Joint contracture, stiffness Limb shortening Compartment syndrome NVD Avascular necrosis Heterotrophic ossification

Management
Closed reduction
Splinting Casting Traction technique

Skin traction Skeletal traction

Steinmanns pin

 Open reduction

 Splintage
Allows sliding between implant and bone

Bridging
To bridge an area of comminution

 Kirschner wire Lag screw

 Kirschner wire

 Kirschner wire

 Kuntcher nail Screw

 Plate and

screw

 External

fixator

Rehabilitation
Extremely important Part of fracture management Regain optimal function asap Arrangements
Restoring ROM Stretching Strengthening

decrease pain and swelling

 Lower extremity
Cane Crutch walker

Fracture healing
Inflammation stage
Bleeding at fracture site Source of hemopoetic cells

Proliferation
Fibrovascular tissue developed Osteoblast, fibroblast proliferate

Repair stage
Primary callus or bridging callus occur 2wks Fibrocartilage developed Soft callus to hard callus (woven bone) by ossification Medullary callus can supplements the bridging callus

 Remodeling stage
From midpoint repair until the fractures heal

clinically (up 7 yrs) Woven bone replaced by lamellar bone Bone assume its normal configuration

If there is anomaly in biological bone formation in healing process, there will be disturbance in the union of fractures, ex delayed or nonunion.

Factors affecting fracture healing

Type of bone cancellous bone cortical bone Patients age Mobility fracture site Separation bone ends Infection Joint involvement Bone pathology Disturbance of blood supply

Thank you