OPEN AND CLOSE

FRACTURES

There are multiple causes of fractures, they can be divided into:

1. Fractures due to traumatic accident
Direct force Bone breaks at the point of impact.
Tapping ( momentary blow) usually cause transverse fracture
Crushing is more likely to cause comminuted fracture
Indirect force Bone breaks at distance away from the where the force is applied
Twisting force likely to cause spiral fracture
Bending may lead to transverse fracture
Bending and compression- butterfly fragment
Combination of twisting, bending and compression causes oblique fracture
2.

Fatigue or stress fracture

Cracks that occur in bone, most often seem in tibia or fibula or metatarsal especially in
dancers, athletes and army recruits.

3.

Pathological fracture

Fractures that occur in bone that has been weakened (by tumour or excessively brittle as
in Pagets disease.

Types of Complete fractures (bone completely broken into 2 or more segments).

Types of incomplete fractures ( bone incompletely divided & periosteum remains in continuity)

Greenstick

Compression fracture

Classification
Open ( Compound ) Fracture- Disruption of overlying skin. Fracture site is in direct
contact with environment, therefore liable to contamination and infection.

Close ( Simple ) Fracture - overlying skin remains intact

GUSTILOS CLASSIFICATION
(open fracture)
TYPE

SIZE (CM)

<1

Low energy
Small wound, clean puncture
Little soft tissue damage, no crushing

II

<10

Moderate energy
No skin flap
Not much soft tissue damage, no more than moderate
crushing or comminution of fracture

III

>10

High energy with high degree of contamination

A
B
C

Adequate soft tissue coverage

Massive soft tissue destruction with bone exposed
Vascular injury requiring repair for limb salvage

Open fractures Management

Emergency management
1.
2.
3.
4.

Antibiotic prophylaxis
Urgent wound and fracture debridement
Stabilization of fracture
Early definitive wound cover

Principle management of Closed fracture

Initial steps involved ABC, history and examination.
Principle management is to REDUCE, HOLD and EXERCISE.
Steps

Aim

Method

Reduce

Adequate apposition and achieve normal

alignment of bone fragments

-manipulation
-mechanical traction
-open reduction

Hold

To prevent displacement, alleviate pain by

movement, promote soft tissue healing, while
allowing free movement of unaffected parts

-sustained traction
-cast splintage
-functional bracing
-internal fixation
-external fixation

Exercise

To reduce oedema, preserve joint movement,

restore muscle power, guide patient back to
normal activities.

-elevate and exercise

-active exercise
-assisted movement
-functional activity

Reduction

Two methods: closed and open reduction

Closed: Under adequate anaesthesia and muscle relaxation, fracture is reduced by three-fold manouvre:
1. Distal part of limb is pulled in the line of bone
2. As Fragments disengaged, they are repositioned (by reversing the original direction of force if can be
deduced)
3. Alignment is adjusted in each plane

ex: Closed manual reduction in Colles fracture

Hold
1. Continuous traction
Traction by gravity- applies only to upper limb injuries. By the wrist sling,
weight of the arm provides continuous traction to the humerus
Skin traction- sustain a pull no more than 5 kg
Skeletal traction- by using wires or pin inserted usually at behind tibial
tubercle for hip, thigh abd knee injuries, lower in tibia or calcaneum for tibial
fractures.
Traction must be opposed by counter-traction
Fixed traction Pull is exerted againts a fixed point eg; tapes are tied to the cross piece
of Thomas splint and pull the leg down
Balanced traction Pull is exerted againts an opposing force provided by the weight of
the body when foot of the bed is raised. The cords may be tied to the foot end of the
bed, run over pulleys or have weights attached.

Traction

(a)

(d)

23.14 M ethods of
traction (a) Traction by
gravity. (b,c,d) Skin traction:
(b) xed; (c) balanced;
(d) Russell. (e) Skeletal
traction with a splint and a
knee-exion piece.

(b)

(c)

(e)

 2. Cast splintage
Achieved by using Plaster of Paris
History : 1850s first used during Crimean war (by Dutch army doctor)
Why Paris?
Gypsum plaster, or plaster of Paris, is produced by heating gypsum to about 150 C
2CaSO44H2O + Heat 2CaSO4H2O + 3H2O (released as steam).
Reabsorb water rapidly forming hydrate calcium sulphate and release heat (exothermic reaction)
2 (CaSO4 H2O) + 3 H2O 2 (CaSO4.2H2O) + Heat
Advantages
Cost-effective
Easily molded
Non-allergic
Disadvantages
Non-radiopaque
Heavy
Easily breaks
Advices
Keep dry, clean
Dont put long object inside or scratch
Elevate cast to reduce swelling
Come to hospital ASAP if
Pain, numbness, swelling, bluish discoloration

Complications;
Tight Cast
oPt complained of diffused pain-> signs of vascular compression
Elevate the limb. If doesnt subside during next hour, SPLIT the cast
throughout it length
If swelling anticipated, cast should be apply over thick padding then split
before it set
Pressure sores (esp over bony prominence)
Prevented by padding all bony prominence before casting
Skin Abrasion (during removal)
Loose Cast
Replaced the cast

 3. Functional bracing
-segments of a cast only applied over the shafts of the bones,leaving the joint free (eg in fracture of
femur / tibia)
-usually applied when the fracture is beginning to unite (ie> 3-6 wks)

4. Internal fixation
Types (screws, wires, plates and screws, intramedullary nails)

5. External fixation
Bone is transfixed above and below the fracture with screw/wire then clamped to frame or rigid bars

COMPLICATION OF FRACTURE
EARLY COMPLICATION
1)
2)
3)
4)
5)
6)
7)
8)

Compartment syndrome
Fat embolism
Visceral injury
Vascular injury
Nerve injury
Haemarthrosis
Infection
Gas gangrene

LATE COMPLICATION
1.

delayed union

2.

non-union

3.

malunion

4.

avascular necrosis

5.

growth disturbance

6.

nerve compression

7.

muscle contracture

8.

joint instability

9.

joint stiffness

10. complex regional pain syndromepain, stiffness and osteoporosis

of the hand (algodystrophy)
11. osteoarthritis

Compartment syndrome
Bleeding, oedema or inflammation increase the pressure
within one of the osseofascial compartment -> reduced
capillary flow -> muscle ischaemia -> further oedema
A viscious circle
More to high risk injury-elbow,tibia,forearm bones
features of ischaemia (5 Ps)

Pain(bursting sensation)
Paraesthesia
Pallor
Pulselessness
Paralysis

Mx:

Decompression- removed cast, bandages, dressings

Fasciotomy. 2 incisions, anterolateral & posteromedial

FAT EMBOLISME
Occur in most adults after closed fracture of long bones.
Fat globules can circulate in lungs and other internal
organ
Features (similar to ARDS):

Slight raise in temperature and pulse rate

Breathlessness
Mild mental confusion
Restlessness
Petechiae on trunk, axilla, conjunctival folds, retina
Resp distress & come (severe)

MX:

Supportive
Use of supplemental high inspired O2 concentrations to
reduced symptoms.
Fixation of fractures.