This document discusses principles of fracture management. It defines fractures and classifies them as closed or open. The main types of fractures are due to injury, repetitive stress, or pathological weakening of bone. Clinical diagnosis involves history, symptoms, and radiography. Fractures are classified based on location, stability, direction, and mechanism of injury. Treatment depends on if the fracture is closed or open. Closed fractures are typically treated conservatively with splinting, casting, or traction, or surgically with internal or external fixation. Open fractures require urgent debridement, antibiotics, stabilization, and wound coverage.

1. PRINCIPLES IN FRACTURES
MANAGEMENT
ISA BASUKI

2. DEFINITION OF FRACTURE
• A FRACTURE IS A BREAK IN THE STRUCTURAL CONTINUITY OF BONE.
• 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
• FRACTURES RESULT FROM:
1. INJURY
2. REPETITIVE STRESS
3. ABNORMAL WEAKENING OF THE BONE (A ‘PATHOLOGICAL’ FRACTURE)

3. FRACTURES DUE TO INJURY

4. 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 RESORPTION AND REPLACEMENT
• E.G. PATIENTS WITH CHRONIC INFLAMMATORY DISEASES WHO ARE ON
TREATMENT WITH STEROIDS OR METHOTREXATE

5. 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.

6. DIAGNOSIS
•CLINICAL FEATURES
•RADIOLOGY (X-RAY)

7. CLINICAL FEATURES
• HISTORY OF TRAUMA
• SYMPTOMS AND SIGNS:
1. PAIN AND TENDERNESS
2. SWELLING
3. DEFORMITY
4. CREPITUS
5. LOSS OF FUNCTION
6. NERVE AND VASCULAR INJURY

9. RADIOGRAPHIC FINDINGS
• PLAIN 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

10. FRACTURE CLASSIFICATION
• ANATOMICAL LOCATION
• CONDITION OF OVERLYING ST
• DIRECTION OF FRACTURE LINE
• MECHANISM OF INJURY
• WHETHER THE FRACTURE IS LINEAR OR COMMINUTED
• AO CLASSIFICATION

11. AO CLASSIFICATION
•A: SIMPLE FRACTURE
•B: WEDGE FRACTURE
•C: COMPLEX FRACTURE

12. AO CLASSIFICATION
A= simple fract.
A1 simple fract.
Spiral
A2 simple fract.
Oblique(≥30)
A3 simple fract.
Transverse(<30)

13. AO CLASSIFICATION
B1 wedge fract
Spiral wedge
B2 wedge fract
Bending wedge
B= Wedge fract.
B1 wedge fract
Spiral wedge
B2 wedge fract
Bending wedge
B3 wedge fract
fragmented wedge

14. AO CLASSIFICATION
C= complex
fract.
C1 complex
fract.
spiral
C2 complex
fract.
segmental
C3 complex
fract.
irregular

16. OPEN AND CLOSE FRACTURE

17. MECHANISM OF INJURY
CLASSIFICATION
•DIRECT TRAUMA
•INDIRECT TRAUMA

18. DIRECT TRAUMA
• TAPPING FRACTURES
• CRUSHING FRACTURES
• PENETRATING FRACTURES:
• HIGH VELOCITY  > 2500 F/S
• LOW VELOCITY  < 2500 F/S

19. INDIRECT TRAUMA
• TRACTION OR TENSION FRACTURES
• ANGULATION FRACTURES
• ROTATIONAL FRACTURES
• COMPRESSION FRACTURES

20. FRACTURE
MANAGEMENT
•TREATMENT OF CLOSED
FRACTURES
•TREATMENT OF OPEN
FRACTURES

21. TREATMENT OF CLOSED
FRACTURES
•EMERGENCY CARE (SPLINTING)
•DEFINITIVE FRACTURE TREATMENT
•REHABILITATION (MUSCLE ACTIVITY AND
EARLY WEIGHTBEARING ARE
ENCOURAGED)

22. EMERGENCY CARE (SPLINTING)
• SPLINT THEM WHERE THEY LIE
• ADEQUATE SPLINTING IS DESIRABLE
• TYPE OF SPLINTS:
• IMPROVISED
• CONVENTIONAL

23. 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
• SURGICAL

24. CONSERVATIVE
• 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

25. CLOSED REDUCTION
TRACTION IN THE
LINE OF THE BONE DISIMPACTION
PRESSING FRAGMENT
INTO REDUCED
POSITION

26. CLOSED UNDISPLACED
CLOSED, REDUCIBLE
 CONSERVATIVE TREATMENT
Below knee
Above knee

28. PLASTER OF PARIS (POP)

29. SLAB OR SPLINT

30. TRACTION

31. SURGICAL
•OPEN REDUCTION INTERNAL
FIXATION (ORIF)
•PERCUTANEOUS PINNING
•EXTERNAL FIXATION

32. 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

33. 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 AND LATE MULTISYSTEM ORGAN FAILURE
6. FRACTURES IN PATIENTS WHO PRESENT NURSING DIFFICULTIES

34. TYPE OF INTERNAL FIXATION
• INTERFRAGMENTARY SCREWS
• WIRES (TRANSFIXING, CERCLAGE AND TENSION-
BAND)
• PLATES AND SCREWS
• INTRAMEDULLARY NAILS

35. PLATES AND SCREWS
• PLATES HAVE FIVE DIFFERENT FUNCTIONS:
1. NEUTRALIZATION
• TO BRIDGE A FRACTURE AND SUPPLEMENT THE EFFECT OF INTERFRAGMENTARY LAG SCREWS
2. COMPRESSION
• USED IN METAPHYSEAL FRACTURES WHERE HEALING ACROSS THE CANCELLOUS FRACTURE
GAP MAY OCCUR DIRECTLY
3. BUTTRESSING
• ‘OVERHANG’ OF THE EXPANDED METAPHYSES OF LONG BONES
4. TENSION-BAND
• ALLOWS COMPRESSION TO BE APPLIED TO THE BIOMECHANICALLY MORE ADVANTAGEOUS
SIDE OF THE FRACTURE
5. ANTI-GLIDE
• TO PREVENT SHORTENING AND RECURRENT DISPLACEMENT OF THE FRAGMENTS

37. INTRA-MEDULLARY FIXATION
• CENTRO-MEDULLARY
• UNLOCKED
• INTERLOCKING (STATIC – DYNAMIC – DOUBLE
LOCKED)
• CONDYLOCEPHALIC
• CEPHALLOMEDULLARY

38. AN OBLIQUE FRACTURE OF THE SHAFT OF THE FEMUR, BEFORE AND AFTER REAMED
INTRAMEDULLARY FIXATION WITH A STOUT NAIL AND INTERLOCKING SCREWS. THIS TREATMENT
ALLOWS NEAR IMMEDIATE AMBULATION FOR THE PATIENT.

39. 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

41. 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

43. TREATMENT OF OPEN FRACTURES
•INITIAL MANAGEMENT
•CLASSIFYING THE INJURY
•DEFINITIVE TREATMENT

44. 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

45. CLASSIFYING THE INJURY
• WITH GUSTILO’S CLASSIFICATION OF OPEN FRACTURES (GUSTILO ET AL.,
1984):
• 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 MODERATE-
ENERGY FRACTURE).
• TYPE III – THERE IS A LARGE LACERATION, EXTENSIVE DAMAGE TO SKIN AND

46. CLASSIFYING THE INJURY
• 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

47. 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.

49. WOUND EXTENSIONS FOR
ACCESS IN OPEN
FRACTURES OF THE TIBIA
WOUND INCISIONS (EXTENSIONS) FOR ADEQUATE
ACCESS TO AN OPEN TIBIAL FRACTURE ARE MADE
ALONG STANDARD FASCIOTOMY INCISIONS: 1 CM
BEHIND THE POSTEROMEDIAL BORDER OF THE TIBIA
AND 2–3 CM LATERAL TO THE CREST OF THE TIBIA AS
SHOWN IN THIS EXAMPLE OF A TWO-INCISION
FASCIOTOMY. THE DOTTED LINES MARK OUT THE CREST
(C) AND POSTEROMEDIAL CORNER (PM) OF THE TIBIA
THESE INCISIONS AVOID INJURY TO THE PERFORATING
BRANCHES THAT SUPPLY AREAS OF SKIN THAT CAN BE
USED AS FLAPS TO COVER THE EXPOSED FRACTURE
THIS CLINICAL EXAMPLE SHOWS HOW LOCAL SKIN
NECROSIS AROUND AN OPEN FRACTURE IS EXCISED
AND THE WOUND EXTENDED PROXIMALLY ALONG A

51. • THE EXTERNAL FIXATOR MAY BE EXCHANGED FOR INTERNAL FIXATION AT THE TIME OF
DEFINITIVE WOUND COVER AS LONG AS:
1. THE DELAY TO WOUND COVER IS LESS THAN 7 DAYS
2. WOUND CONTAMINATION IS NOT VISIBLE
3. INTERNAL FIXATION CAN CONTROL THE FRACTURE AS WELL AS THE EXTERNAL FIXATOR

52. 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

53. REFERENCES
1. SOLOMON L, WARWICK DJ, NAYAGAM S. APLEY’S SYSTEM OF ORTHOPAEDICS
AND FRACTURES. CRC PRESS; 2010.
2. F. CHARLES BRUNICARDI, DANA K. ANDERSEN, TIMOTHY R. BILLIAR, DAVID L.
DUNN, JOHN G. HUNTER, RAPHAEL E. POLLOCK, ET AL. SCHWARTZ’S
PRINCIPLES OF SURGERY. 9TH ED. NEW YORK/US: MCGRAW-HILL EDUCATION
- EUROPE; 2009.