General Principles of Fractures

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General Principles of Fractures
Department of Orthopaedic Surgery Liu
Xueyong (???)
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Introduction
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Definition

• A fracture indicates disruption of the continuity
  or integrity of bone

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Etiology

• direct trauma
• indirect trauma
• by transmission of stress e.g. fracture of
  clavicle
• by muscular (quardriceps) contraction e.g.
  fracture of patella

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• continuous stress (fatigue fracture) e.g.
  fracture of lower 1/3 fibular shaft , fracture of
  the 2nd and 3rd metatarsal bone
• pathological fracture because of cortical
  desruption which resulted from bone diseases such
  as osteomyelitis and benign, malignant, or
  metastatic lesions of bone, the fracture happened
  with slight trauma

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Classification

• close fracture the end of fracture did not
  communicate with the environment
• open fracture the end of fracture communicated
  with the environment, e.g. pubic fracture with
  bladder or urethra injury, coccyx fracture with
  rectal injury

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• incomplete fracture crack(fissure) fracture and
  green stick fracture(in children)
• complete fracture

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Complete fracture

• transverse fracture
• oblique fracture
• spiral fracture
• comminuted fracture T or Y type or butterfly
• impacted fracture
• compression fracture e.g. vertebral body or
  calcaneus fracture
• sunken fracture skull fracture
• epiphyseal injury

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• Stable fracture crack, green stick , transverse
  , compressive, impacted fracture
• Unstable fracture easily displace, e.g. oblique
  fracture, spiral fracture, comminuted
  fracture

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OTA classification of long bone fractures
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• Taylor and Martin proposed a
  classification of metaphyseal fractures (SUD) in
  which the main fracture is characterized as
  stable (S), unstable (U), or with diaphyseal
  extension (D). These are further divided into
  three subtypes 0, extraarticular 1, less than 2
  mm of displacement and 2, more than 2 mm of
  displacement

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Classification of metaphyseal fractures (SUD)
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Displacement of fracture

• angular displacement
• lateral displacement
• shortening displacement
•   separated displacement
•   rotational displacement

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Clinical findings and Radiological findings
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Systemic features

• Shock resulting from loss of blood in patients
  with pelvic, femoral or multiple fracture ,
  severe open fracture or fracture complicating
  with vital viscreal injury
• Fever resulting from absorption of hematoma,
  usually lt38º

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loss of blood(ml)
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Local features

• Specific signs
•    Deformity
•    Abnormal motion
• Bony crepitus or grafting

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Unspecific signs

• pain and tenderness
•  swelling and visible
• bruising (ecchymosis)
•  dysfunction

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Radiological findings

• A-P and lateral view X-ray including upper or low
  joint
• X-ray findings fracture line
• If necessary, radiological examination is
  performned again after 2 weeks

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Some special views

• AP and oblique view for fractures of metacarpus
  and metatarsus
• lateral and axial view for calcaneus fracture
• AP and butterfly view for fractures of scaphoid

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Complications of fracture
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Early period

•  shock
• visceral injury such as liver, spleen, lung,
  bladder and urethra, rectum injury
• vital tissues injury such as arteries, spinal
  cord, peripheral nerves
• fat embolism syndrome(FES)
• Compartment syndrome

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Fat embolism syndrome(FES)

• FES is the unexpected occurrence of hypoxia,
  confusion, and patechiae a few days after long
  bone fractures

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The etiology of FES

• The broken bones liberate marrow fat that
  embolizes to the lungs and brain in which fat
  droplets enter the venous circulation via torn
  veins adjacent to the fracture site
• The biochemical theory suggests that mediators
  from the fracture site alter lipid solubility
  causing coalescence, since normal chylomicrons
  are less than 1 µm in diameter
• Elevated serum lipase levels hydrolyzes neutral
  fat to free fatty acids and causes local
  endothelial damages in the lungs and other tissues

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Compartment syndrome

• Compartment syndrome is a condition
  characterized by raised pressure within a closed
  space with a potential to cause irreversible
  damage to the contents of the closed space

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• The prerequisites for the development of
  a compartment syndrome include a cause of raised
  pressure within a confined tissue space called
  osteofascial compartment which is composed of
  bone, deep fascia, interosseous membrane and
  intermuscular septum.

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• Any condition that increases the contents or
  reduces the volume of a compartment could be
  related to the development of an acute
  compartment syndrome.

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• The most common cause associated with decrease
  in the size of the compartment is
• the application of a tight cast, constrictive
  dressings, or pneumatic antishock garments.
  Closure of fascial defects has been shown to be
  associated with the development of an acute
  compartment syndrome. This condition most
  commonly occurs in anterior compartment of the
  leg, in patients who present with symptomatic
  muscle hernias.

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• A number of conditions have been shown to
  increase the compartment contents and lead to
  compartment syndrome.
• These involove hemorrage within the
  compartment, or to accumulation of fluid(edema)
  within the compartment . The former is most
  commonly associated with fractures of the tibia,
  elbow, forearm, or femur, whereas the latter is
  most commonly associated with postischemic
  swelling after arterial injuries or restoration
  of arterial flow after thromosis of a major
  artery

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• The symptom of pain out of proportion to the
  known injury and the findings of a tense, swollen
  compartment with some degree of passively induced
  strench pain represent the earliest
  manifestations of an acute compartment syndrome
• By the time sensory deficits is obvious,
  irreversible changes to nerves or muscles may
  already have occurred. To wait the development of
  frank motor weakness is to invite diaster.
  Paresis is a late finding and, if present,
  demands immediated surgical intervention

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• The only effective way to decompress an
  acute compartment syndrome is by surgical
  fasciotomy.

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Late period complication of fracture

• hypostatic pneumonia
• bedsore
• deep venous thrombosis(DVT) of lower limbs
• patients with injuries to the pelvis and lower
  extremities are especially prone to DVT

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• Infection open fractures
• myositis ossificans the ossification of soft
  tissues adjacent to joints(elbow commonly)
• traumatic arthritis common in intraarticular
  fractures

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• joint stiffness
• the most common
• avascular necrosis of bonecommon in fractures of
  hand scaphoid and femoral neck
• ischaemic contracture of muscle the consequence
  of compartment syndrome, claw hand

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• acute bone atrophy (Sudeck atrophy)
• the osteoporosis with pain adjacent to the
  fracture site, commonly in fractures of hand and
  foot. The pain and vascular systolic-diastolic
  disorders are main features.

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Biology of fracture healing
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Hunter and Brighton described the classic stages
of natural bone repair

• 1. The impact stage the interval from the
  first application of force to the bone until the
  energy of the force is completely dissipated,
  resulting in energy absorption by the bone until
  fracture occurs.
• 2. Inflammation stage lasts 1 to 3 days, and
  is evidenced by pain, swelling, and heat.
  Inflammatory cells arrive at the injured site
  accompanied by vascular ingrowth and cellular
  proliferation.

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• 3.induction stage begins during the impact and
  inflammatory stages and involves the formation of
  inducers and humoral factors that direct the
  regeneration of bone.
• 4.soft callus stage corresponds clinically to
  the time when clinical union occurs by fibrous or
  cartilaginous tissue. Histologically it is
  characterized by vascular ingrowth of capillaries
  into the fracture callus and the appearance of
  chondroblasts.

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• 5.Hard callus stage the fibrocartilaginous union
  is replaced by fibroosseous union. Clinically
  this usually occurs at 3 to 4 months
• 6. Stage of remodeling begins with clinical and
  roentgenographic union and persists until the
  bone is returned to normal, including restoration
  of the medullary canal. Histologically the
  fibrous bone is replaced with lamellar one.

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Two groups of growth-producing substances at the
site of fractures

• Peptide-signaling molecules (growth factors)
  bone morphogenetic proteins, fibroblast growth
  factors, platelet-derived growth factor
• Immunomodulatory cytokines interleukin-1 and
  interleukin-6
• These substances are known to be produced during
  fracture healing and to participate in the
  regulation of the associated responses

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In a word, the Process of fracture Healing

• Organization of haemotoma and interfragment
  stabilization by fibrocartilage differentiation
  2 weeks
• Formation of original callusrestoration of
  continuity by intramembranous and endochondral
  ossification, 4-8 weeks
• Remodeling of the fracture site
• 8-12 weeks

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The standard of healing

• No tenderness
•  No abnormal mobility
•  X-ray continuous callus, fracture line is
  opaque
•  After removing the external fixation,
  rehabilitation of function, and no deformity
  within 2 weeks

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Delayed union

• Depending on the individual bone,its
  vascularity, and its biochemical environment,
  fracture healing occurs in 2 to 6 months. failure
  of a fracture to heal in the usual time is called
  delayed union

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Nonunion

• Failure to heal 2 to 6 months, with arrest
  of healing process demonstrated by
  radiographically persistent fracture lines,
  sclerosis at the fracture ends, a gap, and
  hypertrophic or no callus, constitutes nonunion.
  Clinically, there may be motion, pain,
  tenderness, and thickening, or deformity at
  fracture site

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Factors influencing fracture healing
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The systmic and local factors

• 1.   age
• 2.   health status
• 3.   the types and quantity of
• fractures
• 4.   blood supply
• 5.   the degree of soft tissue injury
• 6.   interposition of soft tissue
• 7.   infetion

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Iatrogenic factors

• 1.  imperfect reduction
• 2.  inadequate immoilisation
• 3.  excessive traction
• 4.  surgical interference
• 5. inappropriate rehabilitation

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Uhthoff proposed a more detailed classification

• It emphasizes factors under the physicians
  control .His system divides by the injury, depend
  on treatment, or are associated with
  complications

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Systemic factors

• A. Age
• B. Activity level including
• 1.General immobilization
• 2.Space flight
• C. Nutritional status
• D. Hormonal factors
• 1.Growth hormone
• 2.Corticosteroids (microvascular
  avascular necrosis AVN)
• 3.Others (thyroid, estrogen, androgen,
  calcitonin, parathyroid hormone PTH,
  prostaglandins)

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• E.Diseases diabetes, anemia, neuropathies,
• F.Vitamin deficiencies A, C, D, K
• G.Drugs nonsteroidal antiinflammatory drugs
  (NSAIDs), anticoagulants, factor XIII, calcium
  channel blockers
• H.Other substances (nicotine, alcohol)
• I.Hyperoxia
• J.Systemic growth factors
• K.Environmental temperature
• L.Central nervous system trauma

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Local factors A. Factors independent of injury,
treatment, or complications

• 1.Type of bone
• 2.Abnormal bone
• a.Radiation necrosis
• b.Infection
• c.Tumors and other pathological
  conditions
• 3.Denervation

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B.Factors depending on injury

• 1.Degree of local damage
• a.Compound fracture
• b.Comminution of fracture
• c.Velocity of injury
• d.Low circulatory levels of
• vitamin K1

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• 2.Extent of disruption of vascular supply to
  bone, its fragments (macrovascular AVN), or soft
  tissues severity of injury
• 3.Type and location of fracture (one or two
  bones, e.g., tibia and fibula or tibia alone)
• 4.Loss of bone
• 5.Soft tissue interposition
• 6.Local growth factors

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C.Factors depending on treatment

• 1.Extent of surgical trauma (blood supply, heat)
• 2.Implant-induced altered blood flow
• 3.Degree and kind of rigidity of internal or
  external fixation and the influence of timing
• 4.Degree, duration, and direction of load-induced
  deformation of bone and soft tissues

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• 5.Extent of contact between fragments (gap,
  displacement, overdistraction)
• 6.Factors stimulating posttraumatic osteogenesis
  (bone grafts, bone morphogenetic protein BMP,
  electrical stimulation, surgical
  technique, intermittent venous stasis)

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D.Factors associated with complications

• 1.Infection
• 2.Venous stasis
• 3.Metal allergy

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Treatment of fracture

• Our goal is to conserve as much functional
  potential of the injured extremity as possible

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Priciples of fracture treatment

• Reduction
• Immobilization
• Rehabilitation

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Reduction

• Manipulation
• Traction
• Open reduction
• anatomical reduction
• functional reduction

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The criteria of functional reduction

• 1) Alignment of the axis of the bone should be
  corrected in anteroposterior and mediolateral
  planes
• 2) Length correction is difficult when bone is
  lost, and up to 1 cm of shortening or lengthening
  is well tolerated if it does not compromise
  fracture regeneration biology

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• 3) Rotation of the axis of the bone should be
  corrected to be as close as possible to that of
  the normal opposite extremity. Malrotation is
  better tolerated in the upper extremity than in
  the lower extremity .External malrotation seems
  better tolerated than internal malrotation in the
  lower extremity. 5 to 10 degrees of angulatory
  deformation and 10 to 15 degrees of rotary
  deformity may be functionally tolerated.

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Immobilization

• splint
• casting
• Traction (skin, skeletal)
• external fixation
• internal fixation (pin and wire fixation, screw
  fixation, plate and screw fixation,
  intramedullary nail fixation)

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The indications of open reduction and internal
fixation

• 1) Major avulsion fractures associated with
  disruption of important musculotendinous units or
  ligamentous groups that have been shown to have a
  poor result with nonoperative treatment
• 2) Multiple fracture
• 3) Displaced intraarticular fractures suitable
  for surgical reduction and stabilization

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• 4) Unstable fractures in which an appropriate
  trial of nonoperative management has failed
• 5) Fractures associated with vascular or
  neurological deficits that require surgical
  repair, including long bone fractures in patients
  with spinal cord, conus, or proximal nerve root
  lesions
• 6) Fractures for which nonoperative treatment is
  known to yield poor functional results, such as
  femoral neck fractures, Galeazzi
  racture-dislocations, and Monteggia
  fracture-dislocations

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Disadvantages of surgical reduction and
stabilization

• 1)Operative treatment adds further trauma to any
  injury
• 2) It increases the dangers of infection and
  further vascular destruction to the injured
  tissues
• 3) Any surgical dissection will produce scar
  tissue to heal the incision, the dissection in
  itself may create complications of contracture
  and debilitation of the muscle-tendon units

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• 4) The possibility of nerve and vascular damage
  is constant
• 5)  Surgical treatment also involves the use of
  anesthesia and its attendant risks
• 6) Blood transfusions carry the risks of
  hepatitis, acquired immune deficiency syndrome
  (AIDS), and immunological reactions etc
• 7) Implants or external fixation systems
  frequently require removal, with the attendant
  risks of a second operative procedure.
  Refractures have been reported after implant and
  external fixation removal.

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External fixation

• External fixation with hybrid fixators and frames

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Screw fixation of articular fragment combined
with external fixation.
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Internal fixation

• Examples of screws for fracture fixation
  cancellous and cortical, lag, pretapped and
  self-tapping

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Lag screw technique

• A, To determine best location and inclination,
  forceps temporarily compress fracture. B, Lag
  screw replaces forceps in location and position
  (inclination). C, Lag screw is best positioned at
  right angle to fracture plane. Use of bisecting
  angle is correct only for osteotomies with less
  than 40 degrees of inclination. If inclination
  is, for example, 60 degrees, osteotomy will be
  displaced because of insufficient inclination of
  lag screw.

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Dynamic and static locking of intramedullary
nail
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Intraarticular epiphyseal and metaphyseal
fractures reconstructed with lag screws

• A, Cancellous screw (6.4 mm) for posterior lip
  ankle fracture. B, Two 4-mm partially threaded
  small fragment cancellous bone screws used for
  medial malleolar fracture. C, Two 4-mm partially
  threaded small fragment cancellous bone screws
  used for type A fracture of medial malleolus. D,
  Two 4-mm partially threaded small fragment
  cancellous bone screws used for lag screw
  fixation of epiphysis and fixation of condyle to
  metaphysis of distal humerus.

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Plate is acting as protection plate and
compression plate
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Open fractures

• Open fractures are surgical emergencies

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• Open fractures are surgical emergencies
• Surgery should be begun as soon as the patients
  general condition will permit it
• With the passage of time the probability of
  infection rapidly increases. A contaminated wound
  usually is considered to be infected after 12
  hours

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The care of the open fracture

• 1.Treat all open fractures as an emergency
• 2.Perform a thorough initial evaluation to
  diagnose other life-threatening injuries
• 3.Begin appropriate antibiotic therapy in the
  emergency room or (at the latest) in the
  operating room and continue the therapy for 2 or
  3 days only

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• 4.Immediately debride the wound using copious
  irrigation and, for types II and III fractures,
  repeat the debridement in 24 to 72 hours
• Debridement is a term that cover the
  following procedure exploration of the wound,
  excision of devitalized tissue, and removal of
  foreign material

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Assessment of viability of damaged muscle

• Color, consistency, and the capacity of the
  muscle to bleed can be used as guidelines and
  will assist in determining viability
• Muscle that is a normal, beefy-red color
  usually is viable. Viable muscle usually is firm
  in consistency, usually will contract when
  incised with a scalpel or touched with
  eletrocautery, and will demonstrate its
  vascularity by punctate bleeding from the cut
  edges

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• 5.Stabilize the fracture
• 6.Leave the wound open for 5 to
• 7 days
• 7.Perform early autogenous cancellous bone
  grafting
• 8.Rehabilitate the involved extremity