Ortho 10; Principles of Fracture TreatmentPediatrics conservative treatment (Reduction and casting) Fast healing (bone

still growing) + less joint stiffness.Adults Surgical intervention Slow healing + joint stiffness with casting (they

need physiotherapy for range of motion) + if bedridden for a while there will be complications.

Natural Bone Healing: Fracture Hematoma Cellular Response Tissue Differentiation

Callus Formation Bone Mineralization Remodeling. Movement at the fracture site initiates a healing process—callus formation Vascular and cellular response leads to tissue differentiation and

mineralization resulting in restoration of mechanical integrity

Cascade of tissue differentiation following a fracture (Histology):1. Hematoma2. Granulation tissue3. Connective tissue4. Fibrocartilage5. Mineral deposition6. Bone

Fracture healing:1. Inflammation

Hematoma Mesenchymal cells

2. Soft callus Granulation tissue

Cartilage bone mineralization bone3. Hard callus

Intramembranous bone formation Enchondral ossification

4. Remodeling

Healing time and strength:Process TimeHematoma 2 hoursInflammation 2 daysSoft Callus 2 weeks

Hard Callus 2 months(Partial weight baring with support; crutches Complete)

Remodeling 2 years

Bone Healing Types: Indirect Bone Healing:

Ordinary bone healing with callus formation occurs in conditions of relative stability

- Fracture held stable (by cast/splint, or operative fixation, K-wires)- Some movement is still possible

Large range of motion no healing no union. Direct Bone Healing:

With strong fixation and absolute stability- Compression across the fracture- No movement at all at fracture site- Direct bone healing occurs without callus formation- Like plates and screws.

Indirect DirectCallus Formation No Callus FormationRelative Stability(Slight movement)

Strong Fixation(No movement at all)

Fracture Healing Conditions: Good blood supply (hematoma) Controlled motion

(Relative / Absolute Stability) No infection

Unfavorable Fracture Healing Factors: They lead to delayed, mal-union or non-union.

Impairment of blood supply Infection Excessive movement (fracture not stable) Presence of tumor/cyst Interposition of soft tissue Any form of Nicotine (smoking) Bad nutrition

Average Healing Time:Children Adults

Upper Limb 3 – 4 weeks 6 – 8 weeks

Lower Limb 6 – 8 weeks(Upper X2)

12 – 16 weeks(Upper X2)

Aim of fracture treatment

1. Aid healing,2. In normal position,3. Avoiding complications

Principles of Fracture Treatment: Treat the patient, not only the fracture Reduce the fracture Immobilize the fracture

Prevents displacement Alleviates pain Promotes soft tissue healing

Mobilize the patient Avoid complications

Reduce The Fracture Closed reduction Fracture cannot be seen by eyes.

Followed by cast/splint or internal fixationLike K wire fixation, IMN.

Open reduction Fracture is in contact with the outer environment.

Followed by internal fixation

When to do open and when to do closed reduction? Articular fractures:

Need anatomical reduction: usually openNeeds early mobilization (internal fixation better)

Diaphyseal fractures:Need functional reduction: usually closedRestore: Length, Axis (angulation), and RotationExact anatomical reduction of all fragments not necessary

Methods of Holding Reduction

1. Sustained Traction2. Cast splint3. Functional bracing4. Internal fixation5. External fixation

Fracture Treatment:A. Closed & Open Fractures:

Treatment of Closed Fractures: Emergency care (splinting) Definitive fracture treatment

Reduce properly (close or open) Hold reduction (cast or surgery)

Rehabilitation Muscle activity and Early weight bearing are encouraged

Emergency care (splinting) Splint them as they are (reduce major displacements) Adequate splinting is desirable Type of splints:

ImprovisedConventional

Conservative Reduction: (if displaced)

Under general anesthesia, the sooner the betterVery painful

Steps of Reduction:TractionAlign (which fragment)Reverse mechanism of injury

Immobilization:POP (Plaster of Paris) cast, slab, and traction

Rehabilitation

Closed Reduction1. Traction in the line of the bone2. Pressing fragment into reduced position3. Dis-impaction

Treatment of Open Fractures: Indications:

Absolute:1. When closed reduction fails2. When there is an articular fragment that needs accurate positioning3. Or for traction (avulsion) fractures in which the fragments are held

apart Relative:

1. Multiple fractures2. Pathological fractures prone to mal-union, so we should open &

clean the bone.3. To encourage early mobilization and avoid joint stiffness. E.g.

Diaphyseal fractures

The four essentials are:1. Antibiotic prophylaxis2. Urgent wound and fracture debridement3. Stabilization of the fracture4. Early definitive wound cover

B. Types of Internal Fixation:

Wires

K Wires

Simple, quickEasy to applyEasy to remove

Percutaneous Not very stable

Needs additional cast/splint Mostly used in children Relative stability

Tension Band

Special mechanics in: Patella Olecranon Malleolar fractures

Screws

Good fixation- stableCan apply good inter-fragmentary compression

In simple fractures Can be applied percutaneous

Plates & Screws Metaphyseal fractures Diaphyseal fractures Pelvis

IMN

Best fixation for diaphyseal long bone fracturesFemur, Tibia…Preferred over plating allows weight bearing earlier & less invasive.

Locked IMN provide stable fixation

Operative Vs. non-operative:Criteria Operative Non-Operative

Risk of joint stiffness Low PresentRehabilitation Rapid SlowRisk of mal-union Low PresentRisk of non-union Present Present

Speed of healingSlow

Clean the wound no hematoma low healing

Rapid

Risk of infection Present LowCost High High

C. External Fixation: Indications in acute trauma:

Fractures associated with severe soft-tissue damage (including open fractures) or those that are contaminated

Fractures around joints that are potentially suitable for internal fixation but the soft tissues are too swollen to allow safe surgery

Patients with severe multiple injuries

Rehabilitation: Restore function of the

Injured parts and, Patient as a whole

The objectives are: To reduce edema Preserve joint movement Restore muscle power Guide the patient back to normal activity

Fracture Complications:1. Mal-union: Healing in poor position

DeformityShorteningLoss of function: e.g.? Risk of early osteoarthritis:

Related to:Poor reduction or poor fixation

2. Non-union: Failure to heal

3% overall 50% of some specific fractures Related to:

Treatment: (infection, AVN)Local problems: AVN- blood supplySystemic problems (Disease, Smoking)

3. Fat embolism: Usually in long bones A syndrome

Marrow elements (fat) released into the vascular system and travel to the lungs

Triglycerides (fat) metabolized to FFA by pneumatocytes and these FFA are toxic to tissue

Especially brain, blood vessels, kidneys ARDS {acute respiratory distress syndrome} Risk of death

Diagnosis ARDS Mental status changes Petechial hemorrhage

Treatment Respiratory Support Early recognition

Proximal tibial fracture, healed in an angulation (varus angulation) mal-united bone.When walking, most of the weight will go on the medial surface osteoarthritis in 10 – 20 years.

4. DVT / Pulmonary embolism Causes of DVT after fracture:

Immobilization causes blood stasisHypercoagulabilityIntimal injury of vessels

Thrombosis of LL veins Embolism to heart and then lungs Mechanical blockage Ventilation/perfusion mismatch

Prevention: Mobilization:

PatientLimb

Mechanical:Skeletal stabilizationSCD (Sequential device), foot pumpsCompression

Chemical anticoagulation:Heparin

5. Avascular necrosis: More related to specific fractures:

Peculiar blood supply arrangement1. Neck of femur

AVL of femoral head + mal-union at fracture site joint replacement.

2. ScaphoidPoor blood supply non-union at fracture site.

3. TalusPoor blood supply + it’s from distal to proximal non-union at fracture site.

6. Stiffness7. Neurological: Nerve Injuries

Peripheral nerves in relation to boneE.g. Radial nerve in fracture of humeral shaft

Long thoracic nerve in rib fractures Spinal nerves

In injuries of spine (vertebral column)

8. Vascular: Kinking of vessels more common than tears Compartment syndrome

E.g. Brachial artery in supracondylar fracture ofhumerusE.g. Popliteal artery in knee dislocation

9. Complication of surgery1) Infection:

After open fractures:

More if more severe injuryMore if delayed treatment (Time)More in contaminated open wounds

Closed fracture after open reduction and internal fixation:More if prolonged surgeryMore if tissues not respectedWith foreign material of internal fixation

Pitfalls in Fracture Management: History of mechanism of injury not obtained

Combination injury missedSoft tissue not considered

Failure to consider occult fractures X-rays not proper; exposure, views….etc. Inadequate film accepted