Fractures and Fracture Management

1. Fractures and Fracture Management Resident Orientation Course 2012 Presented By Dr. Shinouri

2. Outline • Definition of Fracture • Radiographic and clinical description of Fractures • Classification of Fractures • Treatment of Fractures

3. Definition of Fracture • Disruption in the integrity of living bone, involving injury to the bone marrow, periosteum and adjacent soft tissues • Described radiographically and clinically

4. Radiograph and Clinical Descriptions • Anatomy: Described in relation to the bones involved and the location within the bone (diaphysis, metaphysis, physis, epiphysis) • Articular surface involvement: Does the fracture have intra-articular involvement?

5. Anatomy and Articular Surface Epiphysis • Which bone? • Thirds (long bones) • Proximal, middle, distal third • Anatomic orientation • Proximal, distal, medial, lateral, anterior, posterior • Anatomic landmarks • Head, neck, body / shaft, base, condyle • Segment (long bones) • Epiphysis, physis, metaphysis, diaphysis Physis Metaphysis Diaphysis (Shaft) Articular Surface

6. Radiograph and Clinical Descriptions • Displacement: Is the distal fracture fragment displaced compared with proximal fragment? To what degree is the fracture displaced? • Angulation: The angular deformity is defined in degrees in terms of the distal fragment in relation to the proximal fragment

7. Radiograph and Clinical Descriptions • Shortening: Has the fracture caused shortening of the involved bone? • Rotation: Described both radiographically and clinically

8. Radiograph and Clinical Descriptions • Fragmentation • Multi-fragmentary fracture: several breaks in bone creating 2 fragments • Wedge fracture: either spiral (low energy) or bending (high energy) and allow the proximal and distal fracture fragments to contact each other • Simple fractures: spiral, oblique or transverse

9. Radiograph and Clinical Descriptions • Soft tissue involvement: • Is the fracture open or closed? • Is associated neurologic or vascular injury present? • Is there muscle damage or compartment syndrome?

10. Different Types of Fractures

11. Direction of the Fracture

12. Closed Fracture • Fracture is not exposed to the environment • All fractures have some degree of soft tissue injury • Commonly classified according to the Tscherne classification

13. Closed Fracture Classification • Tscherne Classification: • Grade 0: Minimal soft tissue injury; Indirect injury • Grade 2: Direct injury; more extensive soft tissue injury and severe bone injury • Grade 3: Severe injury to soft tissue; degloving with destruction of subcutaneous injury (Compartment syndrome is a concern)

14. www.orthoinfo.aaos.org Orthopedic Trauma Association

15. Open Fracture • A break in the skin and underlying soft tissue leading directing into or communicating with the fracture and its hematoma • Serious injury as infection can gain entrance into the body through the wound and endanger limb or life • Described by the Gustilo classification system

16. Orthopedic Trauma Association www.jbjs.org

17. Classification of Open Fractures • Type 1: Wound is smaller < 1 cm, clean and caused by fracture fragment that pierces the skin (Low energy injury) • Type II: Wound > 1cm, not contaminated. And without major soft tissue damage defect (Low energy injury)

18. Classification of Open Fractures • Type III: Wound > 1 cm, with significant soft tissue disruption (High energy trauma)  severely unstable fracture with varying degrees of fragmentation • Type III fractures are subdivided: • IIIA: Wound has sufficient soft tissue to cover the bone without the need for local or distant flap coverage

19. Classification of Open Fractures • Type III fractures: • IIIB: Disruption of soft tissue is extensive, such that local or distant flap coverage is necessary • Wound is often contaminated • IIIC: Associated with an arterial injury that requires repair

20. Epidemiology • Frequency: • Trauma is the leading cause of death ages 1-34 yrs • Causes more years of lost productivity before age 65 than coronary artery disease, cancer, and stroke combined • Facture incidence is multi-factorial such as age, sex, co-morbidities, lifestyle and occupation (In the US, 5.6 million fractures/year)

21. Etiology of Fractures • Occur when the force applied to a bone exceeds the strength of the involved bone • Both intrinsic + extrinsic factors are important • Extrinsic factors: include the rate at which the bone’s mechanical load is imposed and the duration, direction, and magnitude of the forces acting on the bone • Intrinsic factors: include the involved bone’s energy-absorbing capacity, modulus of elasticity, fatigue, strength, and density

22. Etiology of Fractures • Result of direct or indirect trauma • Direct trauma consists of direct force applied to the bone • Direct mechanisms include tapping fractures (eg, bumper injury), penetrating fractures (eg, gunshot wound),and crush fractures • Indirect trauma involves forces acting at a distance from the fracture site such as tension (traction), compressive, and rotational force

23. Pathophysiology • 5 phases of fracture healing: • Fracture and inflammatory phase • Granulation tissue formation • Callus formation • Lamellar bone deposition • Remodeling

24. Fracture and Inflammatory Phase • Actual fracture injuries to the bone include insult to the bone marrow, periosteum, and local soft tissues • The most important stage in fracture healing is the inflammatory phase and subsequent hematoma formation • It is during this stage that the cellular signaling mechanisms work through chemotaxis and an inflammatory mechanism to attract the cells necessary to initiate the healing response

25. Granulation Tissue Formation • Within 7 days, the body forms granulation tissue between the fracture fragments • Various biochemical signaling substances are involved in the formation of the granulation tissue stage, which lasts approximately 2 weeks

26. Callus Formation • During callus formation, cell proliferation and differentiation begin to produce osteoblasts and chondroblasts in the granulation tissue • The osteoblasts and chondroblasts synthesize the extracellular organic matrices of woven bone and cartilage, and then the newly formed bone is mineralized • This stage requires 4-16 weeks.

27. Lamellar bone Formation and Remodeling • During the fourth stage: Meshlike callus of woven bone is replaced by lamellar bone, which is organized parallel to the axis of the bone • Final stage: remodeling of the bone at the site of the healing fracture by various cellular types such as osteoclasts • The final 2 stages require 1-4 years

28. Patient Factors and Fracture Healing

29. Presentation of Single Limb Injury • Obtain through hisotiry for the mechanism of injury • Obtain history of any previous injury or fracture is mandatory • Obtain complete past medical and surgical history • Including medications and allergies, as well as a social (smoking and illicit drug use) and occupational history

30. Physical Examination in Single Limb Injury • Physical exam must include a thorough inspection of the integument (with documentation) • If the fracture is open, a clinical photograph may be taken for documentation purposes • Distal neurologic and vascular status must be assessed and documented

31. Physical Examination in Single Limb Injury • Palpate the entire limb including the joints above + below the injury -- check for areas of pain, effusions, and crepitus • Often, other associated injuries may be present (eg, injuries to the spine with a jumping mechanism of injury) • Assessment of range of motion (ROM) may not be possible, but this should be documented • Assessments for ligamentous injury and tendon rupture

32. Multiple Traumatic Injuries • Initial assessment of a patient with polytrauma follows the advanced trauma life support (ATLS) protocols • Includes the identification and treatment of life-threatening injuries • The first step is evaluation of the individual's airway, breathing, and circulation • Immediate endotracheal intubation and rapid administration of intravenous fluids may be necessary

33. Multiple Traumatic Injuries • Spinal precautions must be maintained until injury to the spine can be excluded clinically and radiographically • Radiographs or computed tomography [CT] scans • Once patient is hemodynamically stable • The secondary survey, a complete systems-based physical examination, is performed

34. Initial Management of Fractures • Consists of realignment of the broken limb segment and then immobilizing the fractured extremity in a splint • Distal neurologic + vascular status must be clinically assessed and documented before and after realignment and splinting

35. Initial Management of Fractures • If a patient sustains an open fracture, achieving hemostasis as rapidly as possible at the injury site is essential • This is achieved by placing a sterile pressure dressing over the injury • Splinting is critical in providing symptomatic relief for the patient, preventing potential neurologic + vascular injury and further injury to the local soft tissues • Patients should receive adequate analgesics in the form of acetaminophen or opiates, if necessary.

36. Management of Open Fractures • Treatment goals for open fractures are to: • Prevent infection, to allow the fracture to heal, and to restore function in the injured limb • Once initial assessment, evaluation, and management of any life-threatening injuries are complete, the open fracture is treated • Hemostasis should be obtained, followed by antibiotic administration and tetanus vaccination

37. Management of Open Fractures • Cefazolin or clindamycin is adequate for type I + type II fractures • Aminoglycoside (eg, gentamicin) can be added for a severely contaminated wound (type III) • If injury is a "barnyard injury" or water-type injury, penicillin should also be added to provide prophylaxis against Clostridium perfringens

38. Management of Open Fractures • Urgent irrigation and debridement (I&D) of the wound in the operating room is mandatory • For type II and type III injuries, serial I&Ds are recommended every 24-48 hours after the initial debridement until a clean surgical wound is ensured • The wound is closed when it is clean and antibiotics are generally continued until 2 days after the final I&D

39. Management of Open Fractures • Management of the open fracture depends on the site of injury and type of open fracture • Wound is subsequently stabilized either temporarily or definitively • If soft-tissue coverage over the injury is inadequate • Soft-tissue transfers or free flaps are performed when the wound is clean and the fracture is definitively treated

40. Fracture Management • Divided into non-operative and operative techniques • Non-operative technique: consists of closed reduction if required  followed by a period of immobilization with casting or splinting • Closed reduction is needed if the fracture is significantly displaced or angulated • If the fracture cannot be reduced, surgical intervention may be required

41. Fracture Management – Surgical Indications • Failed nonoperative (closed) management • Unstable fractures that can’t be maintained in a reduced position • Displaced intra-articular fractures (>2 mm) • Fractures that are known to heal poorly following non- operative management (eg, femoral neck fractures)

42. Fracture Management – Surgical Indications • Large avulsion fractures that disrupt the muscle-tendon or ligamentous function of an affected joint • Example patella fracture • Impending pathologic fractures • Multiple traumatic injuries involving pelvis, femur, or vertebrae • Unstable open fractures or complicated open fractures

43. Fracture Management – Surgical Indications • Individuals who are poor candidates for non-operative management that requires prolonged immobilization • Example: elderly patients with proximal femur fractures • Fractures in skeletally immature individuals that have increased risk for growth arrest • Example: Salter-Harris types III-V) • Nonunions or malunions that have failed to respond to non-operative treatment

44. Contraindications • Active infection (local or systemic) or osteomyelitis • Soft tissues that compromise the overlying fracture or the surgical approach • Medical conditions that contraindicate surgery or anesthesia • Example: recent myocardial infarction • Cases in which amputation would better serve the limb and the patient

45. Any Questions??

46. References • Buckley, R. General Principles of Fracture Care. Medscape Jan 2010. • Orthopedic Trauma Association.www.ota.org