1 ORTHOPEDIC SURGERY FRACTURES Jose Fernando Syquia, MD A. Definition a.

Break in the continuity of the bone resulting in the loss of its mechanical and structural integrity b. Soft tissue injury with a bony component B. Etiology a. Single traumatic event i. Direct injury ii. Indirect injury b. Repetitive stresses i. Stress fracture normal bone is continually stressed submaximally in a cyclical fashion until failure occurs ii. An example of a fatigue fracture c. Weakened bone i. Pathologic fracture weakened bone fractures under normal stress C. Signs and Symptoms a. History of injury b. Pain c. Hematoma d. Swelling e. Deformity f. Crepitus g. Abnormal mobility (preternatural mobility) h. Always check for associated injuries such as dyspnea, shock, blood in the urine, neurologic injury, and abdominal injury D. Description of Fractures a. Open or closed i. Open fractures communicate with the environment ii. Surgical debridement should be done within 8 hours iii. Classification (Gustilo and Anderson) 1. Type I a. Low energy injury with a wound less than 1cm b. Clean level of contamination with minimal soft tissue injury c. Fracture is typically a simple transverse or short oblique. Comminution is minimal. 2. Type II a. Low energy injury with a wound more than 1 cm but less than 10 cm b. Moderate level of contamination with moderate soft tissue injury. There may be some muscle damage. c. Fracture has moderate comminution 3. Type III

Orthopedic Surgery: Fractures JF Syquia, MD

2 a. High energy injury with extensive wounds more than 10 cm b. High level of contamination c. Fracture may have moderate to severe comminution d. The following injuries are classified as type III: i. Segmental fractures ii. Farmyard injuries iii. Fractures occurring in a highly contaminated environment iv. Shotgun wounds v. High-velocity gunshot wounds e. Subclassification i. Type IIIA 1. Extensive soft tissue laceration with minimal periosteal stripping and adequate bone coverage 2. There may be severe soft tissue injury with crushing ii. Type IIIB 1. Extensive soft tissue injury with periosteal stripping that will require a flap or soft tissue reconstructive surgery for coverage 2. There is severe loss of soft tissue coverage iii. Type IIIC 1. There is severe loss of soft tissue coverage that will require soft tissue reconstructive surgery for coverage 2. There is vascular compromise that requires repair b. Complete or incomplete i. Complete fractures cortex is completely disrupted ii. Incomplete fractures only one side of the bone was broken 1. Greenstick fracture 2. Torus fracture 3. Compression fracture c. Pattern of failure i. Transverse due to tensile forces ii. Oblique due to compressive forces iii. 3-part with a butterfly fragment due to bending forces iv. Spiral due to torsional forces v. Comminuted fractures 3 or more fragments, due to high loads vi. Segmental fracture due to 4-point bending. There is no contact between the major proximal and distal fragments. d. Location in the bone i. Diaphysis divided into thirds for description purposes ii. Metaphysis either proximal or distal iii. Epiphyseal usually described by name, such as tibial plateau fracture, proximal humerus fracture

Orthopedic Surgery: Fractures JF Syquia, MD

3 e. Bone involved f. Side involved g. Other important findings such as presence of vascular injury or intraarticular injuries E. Treatment: a. Fracture healing will depend on the following: i. Adequate vascular supply ii. Minimal necrosis iii. Anatomic reduction iv. Immobilization of fracture ends v. Presence of physiologic stress vi. Absence of infection b. Methods: i. Reduce the fracture align the fragments 1. Closed reduction fracture hematoma is not violated 2. Open reduction fracture is directly visualized during the reduction a. Indications i. Failure of closed reduction ii. Articular fractures requiring accurate reduction iii. Unstable fractures iv. Fractures that unite poorly v. Pathologic fractures vi. Polytrauma patients b. Complications i. Infection ii. Nonunion iii. Implant failure (if with internal fixation) iv. Refracture ii. Maintain the reduction 1. Casts, splints, traction 2. Internal fixation a. Rigid fixation with plates and screws b. Non-rigid fixation with nails and pins 3. External fixation iii. Preserve or restore function F. Types of bone healing after a fracture: a. Direct or primary fracture healing i. Consists of contact and gap healing ii. Callus free iii. Seen with stable or rigid fixation of a fracture iv. Requires anatomic restoration and fracture stability b. Indirect or secondary fracture healing i. Seen with fixation in which controlled motion is permitted (e.g., with casts, splints, traction, non-locked intramedullary nails) ii. Presence of callus iii. Stages of fracture healing:

Orthopedic Surgery: Fractures JF Syquia, MD

4 1. 2. 3. 4. Impact bone fails Induction stimulation of osteoblastic cells Inflammation granulation tissue forms Soft callus stage primitive osteoid laid down; stability begins 5. Hard callus stage woven bone appears 6. Bone remodeling woven bone is turned into lamellar bone G. Complications of a fracture a. Soft tissue injury b. Infection c. Pulmonary complications like fat emboli syndrome d. Compartment syndrome e. Delayed union f. Non-union i. Causes: 1. Poor blood supply 2. Distraction and separation of the fragments 3. Interposition of soft tissues between the fragments 4. Excessive movement at the fracture site g. Malunion h. Joint stiffness i. Myositis ossificans j. Posttraumatic arthritis k. Avascular necrosis H. Fractures in children a. Different from adults: i. Incomplete fractures are more common ii. Less displacement due to a thicker periosteum iii. Healing is faster and remodeling is better iv. Lesser risk for contractures v. Concerns with these fractures: 1. Malunion 2. Growth plate injuries b. Physeal fractures i. Occurs through the growth plate ii. Classification (Salter-Harris, modified by Ogden) 1. I separation goes through the physis; excellent prognosis 2. II separation with metaphyseal fragment; excellent prognosis 3. III separation with epiphyseal fragment; guarded prognosis 4. IV fracture passes through metaphysis, physis, and epiphysis; guarded prognosis 5. V crushing injury of physis; poor prognosis 6. VI injury to perichondrial ring; formation of physeal bridges or bars common; guarded prognosis 7. VII injury is at the epiphysis only 8. VIII presence of metaphyseal fracture; circulation to the growth plate is disrupted; hypervascularity may cause

Orthopedic Surgery: Fractures JF Syquia, MD

5 angular overgrowth 9. IX diaphyseal fracture present; appositional growth is interrupted; risk of cross union if periosteums intermingle (e.g., cross union of radius and ulna) I. Some common eponyms for fractures: a. Colles fracture b. Smiths fracture c. Monteggias fracture d. Galeazzi fracture e. Jefferson fracture f. Hangmans fracture g. Floating knee h. March fracture i. Lisfranc fracture j. Jones fracture k. Pseudo-Jones fracture

Orthopedic Surgery: Fractures JF Syquia, MD