Fractures General Principles

Dr. Codrin Huszar University Hospital Bucharest

Fracturile.Principii generale

Definition : loss of continuity in the

substance of the bone, due to a trauma

Requirement : external force should

exceed bone mechanical rezistence

Fractures.General Principles

Mechanism
Direct : direct impact ( car bumpers, bullets) Indirect :
1. torsion (schi) 2. bending (flexion)

3. compresion (spine, calcaneus)

4. traction,avulsion (patella)

Fractures.General Principles

Clasification
According to soft tissue envlope status:

closed
Fractures open

Fractures.General Principles

Clasification
According to location : extraarticular Fractures : articular diafizare metafizare epifizare

Fractures.General Principles

Articular fractures

Fractures.General Principles

Clasificare
According to the structure of the fractured bone
violent trauma normal bone : mild repetetive trauma (stress fractures) Fractures pathologic bone : minimal trauma

Fractures.General Principles

Diaphyseal fractures
A.O. Clasification : simple, complex, cominuted fractures

Fractures.General Principles

Fractures.General Principles

Fractures.General Principles

Fractures.General Principles

Fragment displacement
Angulation

trauma Translation muscle contraction gravitation Rotation

Ad longitudinem (overlapping/distraction)

Fractures.General Principles

Fractures.General Principles

Fractures.General Principles

Complications
Immediate (min. hours) Early (hours days) Late (weeks months)
Local / General

Fractures.General Principles

COMPLICATIONS IMMEDIATE, LOCAL :

Neuro vascular injuries (intimal lesion extensive thrombosis) investigatios : Doppler US, angiography treatment : suture (after fracture stabilisation)

Fractures.General Principles

COMPLICATIONS IMMEDIATE, LOCAL : Neuro vascular injuries : mechanism : contusion, elongation, compresion AP : neuropraxis, axonotmesis, neurotmesis

Fractures.General Principles

COMPLICATIONS IMMEDIATE, LOCAL : Open fractures :

Fractures.General Principles

COMPLICATIONS IMMEDIATE, LOCAL : Visceral injuries Soft tissue interposition

Fractures.General Principles

COMPLICATIONS IMMEDIATE, GENERAL :

Hipovolemic / traumatic shock Fat embolism

Fractures.General Principles

COMPLICATIONS EARLY, LOCAL :

Soft tissue contusions : Skin and subcutaneous tissue : blisters, necrosis, swelling,

Fractures.General Principles

COMPLICATIONS - EARLY, LOCAL :

Infection
Diagnosis : clinic + biochem. + bacteriology Treatment : surgical early excision and debr. antibioteraphy

Fractures.General Principles

COMPLICATIONS EARLY, LOCAL :

Compartment sindrome

Fractures.General Principles

COMPLICATIONS EARLY, LOCAL :

DVT (Thrombembolic disease : DVT +/- PE)

Fractures.General Principles

COMPLICATIONS EARLY, GENERAL :

Pressure sores Respiratory / urinary infections PE

Fractures.General Principles

COMPLICATIONS LATE, LOCAL :

DELAYED UNION NONUNION (PSEUDARTHROSIS) : Ethiology : defic. reduction (interposition) mobility fragment devascularisation Forme : + / - bone loss atrofic/hipertrofic normal / abnormal axis infected nonunion

Fractures.General Principles

Fractures.General Principles

COMPLICATIONS LATE, LOCAL :

MALUNION

Fractures.General Principles

COMPLICATIONS LATE, LOCAL :

JOINT STIFFNES ARTHRITIS AVASCULAR NECROSIS REFLEX SYMPATHETIC DISTROPHY

Fractures.General Principles

Open fractures
Violent trauma * contusion soft tissue vessels, nerves, muscles *cominution => fragment devascularisation + contamination
Fracture healing potential

Fractures.General Principles

Open fractures
Gustilo Anderson clasification
Criteria : - trauma energuy - soft tissue staus - bacterial contamination

Fractures.General Principles

Open fractures
Type I
- low energy - wound ~ 1 cm. - minimal contamination

Fractures.General Principles

Open fractures
Type II - medium energy - wound > 1 cm. - no devitalised tissues - medium contamination

Fractures.General Principles

Open fractures
Type IIIA - high energiy - extensive lacerations and soft tissue devitaliation - posible coverage of the fracture site - important contamination

Fractures.General Principles

Fractures.General Principles

Open fractures
Type IIIB -fracture site exposure, periostal stripping - gros contamination

Fractures.General Principles

Open fractures
Type IIIC = type IIIB + arterial lesions

limb salvage procedures or amputation

Fractures.General Principles

Open fractures
TREATMENT
Issues = wound closure = fracture fixation

Fractures.General Principles

Open fractures
TRATAMENT WOUND = excision = debridement = fracture coverage * suture * flaps (* epitelisation per secundam) = ATPA, AB, antigangrenous serum

Fractures.General Principles

Open fractures
TREATMENT Fracture fixation
= intramedulary nails ( I, II, +/-IIIA?) = external fixation

Fractures.General Principles

Le fixateur facilite le traitement des lsions cutanes

Fractures.General Principles

Fractures.General Principles

Treatment
Ortophedic/Sururgical/Functional
reduction imobilisation / fixation functional rehabilitation

Fractures.General Principles

Orthopedic treatment
Reduction
closed red. : follow the opposite sense of the fracture displacement ( main maneuvre = axial traction) manual methods : instrumental (transskeletal extension) consolidation goals : complication prophilaxy functional aesthetic

Fractures.General Principles

Orthopedic treatment
Reduction
Anesthesia : local / regional general : i.v. / IOT

spinal

Fractures.General Principles

Orthopedic treatment
Reduction Skeletal traction
Goals fights musc. contraction fragments alignament restore length

Kirschner wire + orthopedic horseshoe

Fractures.General Principles

Orthopedic treatment
Imobilisation 1. Plaster casts
circular / partial rules : non costrictive non compresive

imobilise adiacent joints

joints : neutral position

Fractures.General Principles

Orthopedic treatment
Imobilisation
1. Plaster casts Complications :
nervous / vascular compresion pressure sores

Contraindications :
diabetus
arterial insuficiency blisters skin conditions

joint stifness

Fractures.General Principles

Contrle de lalignement obtenu par radioscopie F et P Confection dun pltre circulaire en flexion Ablation de la traction

Fractures.General Principles

Orthopedic treatment
Imobilisation
2. Skeletal traction (Bhler) 3. Hanging cast (Caldwell)

4. Plaster cast + K wires (Bhler)

Fractures.General Principles

Contrle de lalignement obtenu par radioscopie F et P Confection dun pltre circulaire en flexion Ablation de la traction

Fractures.General Principles

Surgical treatment
Reduction
Open :

Closed :orthopedic table traction

indications : closed reduction - imposible

open fractures advantages : anatomical reduction osteoplasty higher infectious risk disadv.: soft tissue strippingdevascularisation delayed - / nonunion bleeding

Fractures.General Principles

Fractures.General Principles

Surgical treatment
Internal fixation (Osteosynthesis)
1. Screws

2. Plate and screws

Fractures.General Principles

Surgical treatment
Internal fixation (Osteosynthesis)
3. Dynamic hip screw 4. Tension band wiring (DHS / DKS)

Fractures.General Principles

Surgical treatment
Internal fixation (Osteosynthesis)
5. Rigid Intramedulary nails : implantation : reaming locking din. / /staticly types : Kuntscher Grosse Kempf Gamma nail retronail

Fractures.General Principles

Surgical treatment
Internal fixation (Osteosynthesis)

5. Elastic intramedulary nails Ender / Haketal / Zieckler

Fractures.General Principles

Surgical treatment
Internal fixation (Osteosynthesis) Complications :
infection (0.5 1.5%)

Sec. displacement
Device failling

Delayed- / nonunion

Fractures.General Principles

Surgical tretament
External fixation Indications :
Open fractures (grd. II-III G.A.)

Closed fractures (pelvis)

cominuted fractures

old fractures
secvential fixation

Fractures.General Principles

Surgical treatment
External fixation

Fractures.General Principles

The EndThe End (Sfarsit) (Sfarsit)