General Principles of Fracture Management: Presentation by Dr. Kunal Shrivastava

GENERAL PRINCIPLES OF
FRACTURE MANAGEMENT
PRESENTATION BY DR. KUNAL SHRIVASTAVA
THE CLASSICAL DEFINITION OF FRACTURE
• A FRACTURE IS A BREAK IN THE STRUCTURAL CONTINEUITY OF THE
BONE.
• THE BREAK IS INCOMPLETE/COMPLETE, AND THE BONE FRAGMENTS
MAY BE DISPLACED/UNDISPLACED.
THE AO DEFINITION OF FRACTURE
• FRACTURE IS A SOFT TISSUE INJURY WHERE THE BONE IS BROKEN.
HOW DO FRACTURES HAPPEN?
• FRACTURES RESULT FROM:
• 1. INJURY
• 2. REPETITIVE STRESS
• 3. ABNORMAL WEAKENING OF THE BONE (A ‘PATHOLOGICAL’
FRACTURE)
THE FUNDAMENTALS OF FRACTURE
CLASSIFICATION
•IF THE OVERLYING SKIN REMAINS INTACT IT IS A CLOSED (OR SIMPLE)
FRACTURE
• IF THE SKIN OR ONE OF THE BODY CAVITIES IS BREACHED IT IS AN

OPEN (OR COMPOUND) FRACTURE
THE TYPES OF FRACTURES CAUSED DUE TO
INJURY
FATIGUE OR STRESS FRACTURES
• BONE , LIKE OTHER MATERIALS , REACTS TO REPEATED LOADING .
• ON OCCASION , IT BECOMES FATIGUED & A CRACK DEVELOPS .
• E.G MILITARY INSTALLATIONS , BALLET DANCERS & ATHLETES.
• A SIMILAR PROBLEM OCCURS IN INDIVIDUALS WHO ARE ON

MEDICATION THAT ALTERS THE NORMAL BALANCE OF BONE
RESORPTIONAND REPLACEMENT
• E.G. PATIENTS WITH CHRONIC INFLAMMATORY DISEASES WHO ARE

ON TREATMENT WITH STEROIDS OR METHOTREXATE
PATHOLOGICAL FRACTURES
• FRACTURES MAY OCCUR EVEN WITH NORMAL STRESSES IF THE BONE
HAS BEEN WEAKENED BY A CHANGE IN ITS STRUCTURE.
• E.G. IN OSTEOPOROSIS, OSTEOGENESIS IMPERFECTA OR PAGET’S

DISEASE.
• OR THROUGH A LYTIC LESION.
• E.G. A BONE CYST OR A METASTASIS.

MECHANISM OF INJURY CLASSIFICATION
•DIRECT TRAUMA
1. TAPPING FRACTURES
2. CRUSHING FRACTURES
3. PENETRATING FRACTURES:HIGH VELOCITY,LOW VELOCITY
•INDIRECT TRAUMA
1.TRACTION OR TENSION FRACTURES
2.ANGULATION FRACTURES
3.ROTATIONAL FRACTURES
4.COMPRESSION FRACTURES
WRAPPING UP CLASSIFICATION….
• ANATOMICAL LOCATION
• CONDITION OF OVERLYING SOFT TISSUE
• DIRECTION OF FRACTURE LINE
• MECHANISM OF INJURY
• WHETHER THE FRACTURE IS LINEAR OR
COMMINUTED
THE CLINICAL DIAGNOSIS OF A FRACTURE
• HISTORY OF TRAUMA
• SYMPTOMS AND SIGNS:
1. PAIN AND TENDERNESS
2. SWELLING
3. DEFORMITY
4. BONY CREPITUS
5. LOSS OF FUNCTION
6. NERVE AND VASCULAR INJURY
THE RADIOLOGICAL DIAGNOSIS OF A
FRACTURE
• X-RAY:
• SHOULD SHOW JOINT ABOVE AND JOINT BELOW IN AT LEAST 2 VIEWS, SPECIAL VIEW ON
REQUEST.
• CT SCAN
• MRI:
IT IS NOT HELPFUL IN FRACTURE DIAGNOSIS OTHER THAN DELINEATING ASSOCIATED
INJURIES TO THE CNS , SUBTROCHANTERIC (ST) DISRUPTION OR OCCASIONALLY FATIGUE
FRACTURE
FRACTURE MANAGEMENT:
•TREATMENT OF CLOSED
FRACTURES
•TREATMENT OF OPEN FRACTURES

TREATMENT OF CLOSED FRACTURES
•EMERGENCY CARE (SPLINTING)
•DEFINITIVE FRACTURE TREATMENT
•REHABILITATION (MUSCLE ACTIVITY AND EARLY WEIGHT BEARING ARE

ENCOURAGED.
SPLINTING
•SPLINT THEM WHERE THEY LIE.
•ADEQUATE SPLINTING IS DESIRABLE.
•TYPE OF SPLINTS:
1.IMPROVISED
2.CONVENTIONAL
DEFINITIVE FRACTURE TREATMENT
• THE GOAL OF FRACTURE TREATMENT IS TO OBTAIN UNION OF THE
FRACTURE IN THE MOST ANATOMICAL POSITION COMPATIBLE WITH
MAXIMAL FUNCTIONAL RETURN OF THE EXTREMITY
• 2 TYPES OF DEFINITIVE FRACTURE TREATMENT:CONSERVATIVE AND
SURGICAL
CONSERVATIVE FRACTURE TREATMENT
• REDUCTION: IF DISPLACED UNDER GENERAL
ANASTHESIA, THE SOONER THE BETTER
• STEPS OF REDUCTION: • TRACTION • ALIGN (WHICH
FRAGMENT) • REVERSE MECHANISM OF INJURY
• IMMOBILIZATION: POP (PLASTER OF PARIS) CAST,
SLAB, TRACTION (FIXED OR BALANCED)
• REHABILITATION
SURGICAL FRACTURE TREATMENT
•OPEN REDUCTION INTERNAL FIXATION (ORIF)
•PERCUTANEOUS PINNING
•EXTERNAL FIXATION
OPEN REDUCTION INDICATIONS
•OPERATIVE REDUCTION OF THE FRACTURE IS INDICATED:
1.WHEN CLOSED REDUCTION FAILS
2.WHEN THERE IS A LARGE ARTICULAR FRAGMENT THAT NEEDS

ACCURATE POSITIONING
3.FOR TRACTION (AVULSION) FRACTURES IN WHICH THE FRAGMENTS

ARE HELD APART
INTERNAL FIXATION INDICATION
• 1. FRACTURES THAT CANNOT BE REDUCED EXCEPT BY OPERATION

• 2. FRACTURES THAT ARE INHERENTLY UNSTABLE AND PRONE TO RE-
DISPLACE AFTER REDUCTION
• 3. FRACTURES THAT UNITE POORLY AND SLOWLY
• 4. PATHOLOGICAL FRACTURES IN WHICH BONE DISEASE MAY
PREVENT HEALING
• 5. MULTIPLE FRACTURES WHERE EARLY FIXATION REDUCES THE RISK
OF GENERAL COMPLICATIONS.
• 6. FRACTURES IN PATIENTS WHO PRESENT NURSING DIFFICULTIES
EXTERNAL FIXATION
• INDICATIONS:
1. FRACTURES ASSOCIATED WITH SEVERE SOFT-TISSUE DAMAGE
(INCLUDING OPEN FRACTURES) OR THOSE THAT ARE
CONTAMINATED
2. FRACTURES AROUND JOINTS THAT ARE POTENTIALLY SUITABLE FOR
INTERNAL FIXATION BUT THE SOFT TISSUES ARE TOO SWOLLEN TO
ALLOW SAFE SURGERY
3. PATIENTS WITH SEVERE MULTIPLE INJURIES
4. UNUNITED FRACTURES, WHICH CAN BE EXCISED AND COMPRESSED
5. INFECTED FRACTURES
REHABILITATION
• RESTORE FUNCTION – NOT ONLY TO THE INJURED PARTS BUT ALSO TO
THE PATIENT AS A WHOLE
THE OBJECTIVES ARE:
1. TO REDUCE OEDEMA
2. PRESERVE JOINT MOVEMENT
3. RESTORE MUSCLE POWER
4. GUIDE THE PATIENT BACK TO NORMAL ACTIVITY
TREATMENT OF OPEN FRACTURES
•INITIAL MANAGEMENT
•CLASSIFYING THE INJURY
•DEFINITIVE TREATMENT
INITIAL MANAGEMENT
• IT IS ESSENTIAL THAT THE STEP-BY-STEP APPROACH IN ADVANCED
TRAUMA LIFE SUPPORT NOT BE FORGOTTEN
• WHEN THE FRACTURE IS READY TO BE DEALT WITH:
1. THE WOUND IS CAREFULLY INSPECTED
2. ANY GROSS CONTAMINATION IS REMOVED
3. THE WOUND IS PHOTOGRAPHED
4. THE AREA THEN COVERED WITH A SALINE-SOAKED DRESSING
5. THE PATIENT IS GIVEN ANTIBIOTICS
6. TETANUS PROPHYLAXIS IS ADMINISTERED
7. THE LIMB CIRCULATION AND DISTAL NEUROLOGICAL STATUS CHECKED
REPEATEDLY
CLASSIFYING THE INJURY WITH GUSTILO’S
CLASSIFICATION
• TYPE 1 – THE WOUND IS USUALLY A SMALL, CLEAN PUNCTURE
THROUGH WHICH A BONE SPIKE HAS PROTRUDED. THERE IS LITTLE
SOFT-TISSUE DAMAGE WITH NO CRUSHING AND THE FRACTURE IS NOT
COMMINUTED (I.E. A LOW-ENERGY FRACTURE).
• TYPE II – THE WOUND IS MORE THAN 1 CM LONG, BUT THERE IS NO
SKIN FLAP. THERE IS NOT MUCH SOFT-TISSUE DAMAGE AND NO MORE
THAN MODERATE CRUSHING OR COMMINUTION OF THE FRACTURE
(ALSO A LOW- TO MODERATEENERGY FRACTURE).
• TYPE III – THERE IS A LARGE LACERATION, EXTENSIVE DAMAGE TO
SKIN AND UNDERLYING SOFT TISSUE AND, IN THE MOST SEVERE
EXAMPLES, VASCULAR INJURY MAY ACCOMPANY THE FRCTURE.
GRADING THE SEVERITY OF TYPE III
FRACTURES.
• THERE ARE THREE GRADES OF SEVERITY:
• TYPE III A : THE FRACTURED BONE CAN BE ADEQUATELY COVERED BY
SOFT TISSUE DESPITE THE LACERATION.
• TYPE III B : THERE IS EXTENSIVE PERIOSTEAL STRIPPING AND
FRACTURE COVER IS NOT POSSIBLE WITHOUT USE OF LOCAL OR
DISTANT FLAPS.
• TYPE III C : THERE IS AN ARTERIAL INJURY THAT NEEDS TO BE
REPAIRED, REGARDLESS OF THE AMOUNT OF OTHER SOFT-TISSUE
DAMAGE.
PRINCIPLES OF TREATMENT
• ALL OPEN FRACTURES, NO MATTER HOW TRIVIAL THEY MAY SEEM,

MUST BE ASSUMED TO BE CONTAMINATED
• THE FOUR ESSENTIALS ARE:

1. ANTIBIOTIC PROPHYLAXIS.
2. URGENT WOUND AND FRACTURE DEBRIDEMENT.
3. STABILIZATION OF THE FRACTURE.
4. EARLY DEFINITIVE WOUND COVER.
AFTERCARE
• IN THE WARD, THE LIMB IS ELEVATED AND ITS CIRCULATION
CAREFULLY WATCHED.
• ANTIBIOTIC COVER IS CONTINUED BUT ONLY FOR A MAXIMUM OF 72
HOURS IN THE MORE SEVERE GRADES OF INJURY .
• WOUND CULTURES ARE SELDOM HELPFUL, IF IT WERE TO ENSUE, IS
OFTEN CAUSED BY HOSPITAL-DERIVED ORGANISMS.
THANK YOU
INVICTUS-by William Ernest Henley
Out of the night that covers me,
Beyond this place of wrath and tears,
Black as the pit from pole to pole,
Looms but the Horror of the shade,
I thank whatever the gods may be,
And yet the menace of the years,
For my unconquerable soul.
Finds and shall find me unafraid.
In the fell clutch of circumstance,

It matters not how strait the gate,
I have not winced nor cried aloud.
How charged with punishments the scroll,
Under the bludgeonings of fate,
I am the master of my fate,
My head is bloody, but unbowed.
I am the captain of my soul.

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GENERAL PRINCIPLES OF

• IF THE SKIN OR ONE OF THE BODY CAVITIES IS BREACHED IT IS AN

• ON OCCASION , IT BECOMES FATIGUED & A CRACK DEVELOPS .

• E.G MILITARY INSTALLATIONS , BALLET DANCERS & ATHLETES.

• A SIMILAR PROBLEM OCCURS IN INDIVIDUALS WHO ARE ON

• E.G. PATIENTS WITH CHRONIC INFLAMMATORY DISEASES WHO ARE

• E.G. IN OSTEOPOROSIS, OSTEOGENESIS IMPERFECTA OR PAGET’S

• OR THROUGH A LYTIC LESION.

• E.G. A BONE CYST OR A METASTASIS.

•TREATMENT OF OPEN FRACTURES

•DEFINITIVE FRACTURE TREATMENT

•REHABILITATION (MUSCLE ACTIVITY AND EARLY WEIGHT BEARING ARE

2.WHEN THERE IS A LARGE ARTICULAR FRAGMENT THAT NEEDS

3.FOR TRACTION (AVULSION) FRACTURES IN WHICH THE FRAGMENTS

• 1. FRACTURES THAT CANNOT BE REDUCED EXCEPT BY OPERATION

•CLASSIFYING THE INJURY

• ALL OPEN FRACTURES, NO MATTER HOW TRIVIAL THEY MAY SEEM,

• THE FOUR ESSENTIALS ARE:

In the fell clutch of circumstance,

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