Principle of Fracture Management

Dr. C. Mpanga

Fracture types• Defn: A break in the continuity of bone. Once

broken, does not fulfill its role of support

• A: whether they are in communication with skin surface i.e Open/ Compound or Closed

– Regard all open fractures as being contaminated– Give TTV– Give antibiotic– Early debridement within 6 hours– The solution to pollution is dilution

• B: There appearance on x-ray image– Transverse– Oblique– Comminuted– Spiral

• C: Cause of the fracture– Acute traumatic fractures– Stress Fractures– Pathological Fractures

• C: Anatomical site:– Intra- articular– Metaphyseal– Epiphyseal– Diaphyseal

• NB: Diaphyseal fractures are classified with the bone divided into 3 parts

• Children:– Bones are pliable– Hence the cortex does not break but bend– Called green stick fractures– Have open physeal plate and hence get epiphyseal

injury

Describing A Fracture

• Name of bone fractured• The part of the bone fractured• Displacement• Angulation• Translation • Shortened • Rotated

Fracture Management• Goal: Restore injured part & individual to normal. Don’t

forget soft tissues

• How?– Identify the parts injured– Identifying the role we have to play in facilitating their recovery– Support the individual in their environment whilst undergo

recovery process– Identify those who will not fully recover

– 4 Rs of fracture management

– Recognising the fracture– Reduction of the fracture – Retaining/ Immobilisation of the fracture – Rehabilitation

• Immobilisation is required until fracture union

Recognising the fracture• History– Fall, hit by car, limb pain, unable/reluctance to use

limb

• Physical Examination– Swelling over limb acutely, bruising, deformity, tender

area, crepitus, reduced range of motion

• Investigations– Confirms diagnosis– Use of plain x-rays– Use of specialised x-ray images for particular fractures

Reduction • Need for reduction varies from fracture to

fracture• • Undisplaced fractures do not need reduction

• Intra-articular fractures need anatomical reduction

• • Reduction can be performed as either an open or

closed procedure

Reduction and Retention • Displaced fractures are manipulated with some anaesthesia

• External methods include – Plaster casts – Traction – External fixation

• Internal methods include – Plates – Intramedullary nails – K-wires

• Closed• Open

Indications for internal fixation• Intra-articular fractures - to stabilise anatomical

reduction • Repair of blood vessels and nerves - to protect vascular

and nerve repair • Multiple injuries (poly trauma and poly fractured patients) • Elderly patients - to allow early mobilisation • Long bone fractures - tibia, femur and humerus • Failure of conservative management • Pathological fractures • Fractures that require open reduction • Unstable fractures

Role of classication systems• Epiphyseal injuries• Type I: opening/fracture through physis• Type II:# through physis with metaphyseal

fragment• Type III: through physis and Epiphysis• Type IV: metaphyseal and Diaphyseal

fragment• Type V: Crushing physeal injury

Gustillo-Anderson Classification

• Grade I• A wound caused by a bone spike from within

out, less than 1cm long

• Grade II• A wound between 1-10cm with minimal soft

tissue crushing or stripping

Gostillo Anderson Classification

• Grade IIIA• A high energy injury, with soft tissue crushing or stripping but

adequate cover of bone after debridement• Grade IIIB• A high energy injury, soft tissue crushing or stripping with

exposed bone after debridement• Grade IIIC• Any open fracture with an associated arterial injury, or a

‘farmyard’ injury with gross bacterial contamination

Complications