FRACTURES

Definition:

Break or discontinuity of
the bone caused by
trauma or pathology
 Related Anatomy
• Bone
– Derived from mesenchyme or primitive connective tissue
– 70% inorganic material
• Hydroxyapatite (calcium, phosphate, carbonate)
– 20% organic material
• 90% Type I collagen
– 10% water
– Cellular components
• Osteoprogenitor cells
– Undergo mitosis to develop into osteoblast
• Osteoblast
– Manufacture of organic bone matrix
• Osteoclast
– Associated with Bone resorption
• Osteocytes
– Regulating the flow of mineral into and out of bone
• Two ways of bone growth/ ossification
1. enchondral/ cartilagenous
– Cartilage replaced by bone
– Long bones, spine, scapulae, ribs, sternum, pelvis
2. Membranous
- Gradual replacement of primitive connective tissue
by osteoid matrix
- Bones of the cranial vault, face
• 3 shapes:
– Flat
– Cuboidal
• Inner & outer plate of compact bone
• Cancellous bone or spongy portion
– Long
• Elongated medullary canal
• Fine layer of connective tissue– endosteum
• Cortex of diaphysis
• Outer fibrous covering– periosteum
• Metaphysis
• epiphysis
Parts of a long bone
• Etiology:
a. Pathologic
b. Stress
• Bone fatigue
• Inadequate muscular support
c. Traumatic
• Direct blow
• Indirect forces
 Fracture Classification
• Identify (Salter):
– Site (intra-articular, metaphyseal, etc.)
– Extent (complete or incomplete)
– Configuration
– Relationship of fracture fragments to each other
(displaced/undisplaced)
– Relationship of fracture fragments to the environment
(closed/open)
– Complications
 CLASSIFICATION OF FRACTURES
• According to completeness/ extent
1. Incomplete 2. Complete
a. Simple
a. Greenstick
b. Compound
b. Fissured
c. Impacted
c. Perforating d. Comminuted
d. Depressed e. Complicated
 CLASSIFICATION OF FRACTURES
• According to displacement (configuration):
1. Transverse
2. Oblique
3. Spiral
4. Comminuted
 CLASSIFICATION
Salter and Harris:
I-cartilage plate
II-cartilage plate and triangular
metaphysis
III- cartilage plate and
epiphysis
IV-Cartilage plate+epiphysis
and metaphysis
V-crushing of the growth plate
CLASSIFICATION
• Garden’s Classification
– Grade 1: incomplete,
undisplaced
– Grade 2: complete,
undisplaced
– Grade 3:Incomplete,
displaced
– Grade 4: Complete, displaced
 Gustilo-Anderson Classification for open
fractures
• Used for eval. open fractures and to decide most
appropriate treatment
– Type 1: 1 cm. wound or less; plate and screw
– Type 2: >1 cm. wound with mod. soft tissue damage
– Type 3A: >10 cm, coverage available
– Type 3B: 10 cm, requires soft tissue coverage
– Type 3C: with vascular injury requiring repair
 FRACTURE
• Signs and Symptoms:
1. Abnormal mobility
2. Crepitus
3. Ecchymosis
4. Deformity
5. Pain and tenderness
6. Swelling/edema
7. Absence of active movement due to pain
8. Muscle spasm
 FACTORS AFFECTING REPAIR
 Age  Severity of injury
 Type of fracture  Size and shape of bone
 Vascularity  General condition of
 Immobilization the patient
 Infection  Location of fracture
 Limbs affected
 STAGES OF FRACTURE HEALING
A. Stage of hematoma
formation
B. Stage of granulation
tissue formation
C. Stage of callus formation
D. Stage of consolidation
E. Stage of remodeling
FRACTURE HEALING
 PRINCIPLES OF FRACTURE
TREATMENT
A. Reduction
1. Closed vs. Open Reduction
1. Open reduction poses risk of infection, but
better chances at fixation
2. Closed reduction is faster, but relies heavily on
surgeon’s innate skill
 PRINCIPLES OF FRACTURE
TREATMENT
B. Maintenance of reduction
1. External fixation
1. POP cast
2. Traction
1. Skin: Buck’s extension,
Russel’s traction, Bryant’s
traction
2. Skeletal Traction
 Internal Fixation
• Why ORIF (Open Reduction Internal Fixation)?
Relative Indications:
– delayed union
– multiple fracture
– loss of reduction
– pathologic fractures
– improved nursing care
– reduce mortality
– fracture for which closed methods are ineffective
 Internal Fixation
 Why Not ORIF?
 Contraindications:
active infection
fracture fragments of insufficient size for attachment
bone is weak
surrounding tissue is abnormal and greatly increases risk of
surgery
contraindications to anesthesia
 Disadvantage of ORIF
danger of infection
scar tissue
danger of anesthesia
another operation risk
PRINCIPLES OF FX TREATMENT
• Bucks’s and Russel’s
PRINCIPLES OF FRACTURE
TREATMENT
 PRINCIPLES OF FRACTURE
TREATMENT
C. Preservation and restoration of function
Joint mobility
Increase ms strength
CP endurance
 COMPLICATIONS OF FRACTURE
A. Delayed Union
Causes:
1. Inaccurate reduction
2. Inadequate or interrupted immobilization
3. Severe local traumatization
4. Impairment of bone circulation
5. Infection – staphylococcus aureus
6. Loss of bone substance
7. Distraction or separation of fragments
Femur – 20 weeks
Tibia – 20 weeks
Humerus – 10 weeks
 COMPLICATIONS OF FRACTURE
B. Non-Union
 >6 months after injury
 Infection
 Insufficient fixation
 Pseudoarthrosis
 Common Sites:
1. Femoral neck (15%)
2. Femoral shaft
3. Tibia (lower 1/3-most
common)
4. Humerus
5. Radius and ulna
6. Scaphoid
 COMPLICATIONS OF FRACTURE
C. Malunion
1. Shortening
2. Rotation
3. angulations
 COMPLICATIONS OF FRACTURE
• General Complications
– Venous thrombosis
– ARDS
– Joint problems
• Other complications
– Infection
– Avascular necrosis
 Immobilization Time Necessary for
Union
FRACTURE SITES NUMBER OF WEEKS
Upper Extremity
Phalanx 3-5
Metacarpal 6
Carpal 6
Scaphoid 10
radius/ulna 10-12
 Humerus
Supracondylar 8
Midshaft 8-12
Proximal (impacted) 3
Proximal (displaced) 6-8
Lower Extremity
Toes 3
Metatarsals 6
Calcaneus 12-16
 Immobilization Time Necessary for
Union
Tibia
Proximal 8-12
Shaft 14-20
Malleolus 6-12
Femur
Intracapsular 24
Intertrochanteric 10-12
Shaft 18
Supracondylar 12-15
 Others

Clavicle 6-10

Vertebrae 16

Pelvis 6
 Post-Op Guidelines
• Special implications for PT
– compartment syndrome
– fat embolism (commonly occurs within 1 week post-
injury)
• PT should look into possible occurrences of
– hemorrhage - suction drainage (management)
– edema - elevation
– moist chamber dressing - change/open dressing
 Bennett’s and humeral head
Bennett’s fracture-intraarticular fracture of the 1st metacarpal base
 Colles and Smith
Smith’s fracture-a.k.a. reverse Colles'; spade deformity

Colles’ fracture-distal radius with posterior displacement

 Jones and avulsion fracture
•Jones’ fracture- base of the 5th metatarsal
 Monteggia and Galeazzi

Dupuytren’s fracture-a.k.a. Galeazzi’s fracture, distal radius with dislocation of

the distal radioulnar

Monteggia’s fracture-shaft of the ulna with dislocation of the radial head

 Hangmans and Burst

Jefferson’s fracture-C1 fracture secondary to axial load

Hangman’s fracture-fracture through the C2 pedicle

 Chance fx and Rolando’s fx

Chance fracture-distraction fracture of the spine secondary to seatbelt

injuries

Rolando’s fracture-comminuted Bennett’s fracture

 Fractures by Nomenclature
• Essex-Lopresti fracture-distal radial head
with distal radio-ulnar injury

• Greenstick fracture-a.k.a. Hickory stick

fracture; fractures in children

• Hill-Sach’s fracture-poster lateral humeral

hear with anterior dislocation
• Kocher’s fracture-capitulum fracture

• March fracture-stress fracture of the

metatarsal shaft

• Moore’s fracture-subluxation of the distal ulna

with fracture of distal radius
• Baron Fracture-distal rim of distal radius

• Boxer’s /fighter’s fracture-neck of the 5th

metacarpal

• Chauffeur’s fracture-distal styloid process,

produced by snapping /twisting injuries

• Malgaine’s fracture-double vertical fracture of the

pelvis
• Cotton’s fracture-a.k.a. tri-malleolar fracture;
medial & lateral malleoli & posterior lip of the
tibia

• De Quervains fracture-trans-scaphoid
perilunate fracture

• Duverney’s fracture-iliac wing

• Nightstick fracture-shaft of the ulna with dislocation
of the radial head

• Nut Cracker fracture-cuboid or anterior calcaneus

• Pillion fracture-T-shape fracture of the distal femur

with displacement of condyle posterior shaft

• Walther’s fracture-fracture line is through pubic

ramus and SI joint.
• Pott’s fracture-fibular fracture above the ankle
mortise

• Posadas’ fracture-transcondylar fracture of

the elbow

• Shepherd’s fracture-lateral tubercle of

posterior process of talus
 Regional Treatment of Fractures
I. Upper Extremities
A. Clavicle
Craig’s Classification
 Group 1 – fx of middle third
 Group 2 – fx of lateral third
type I minimally displaced
type II w/ fx to coracoclavicular ligament
complex
type III fx of articular surface
type IV displaced prox fragment
type V comminuted
 III. Group III – fx of medial third
type I minimally displaced
type II displaced
type III intraarticular
type IV epiphyseal separation
type V comminuted

Further Group III classification by Neer:

type I - lateral to the coracoclavicular lig
type II – medial to the coracoclavicular lig
type III – involving the articular surface
Expected time of bone healing: 6 - 12 weeks
Expected duration of Rehabilitation:
10 - 12 weeks

Methods of Treatment
Sling/supportive immobilization
ORIF
B. Humerus
1. Proximal
Neer classification
greater tuberosity
lesser tuberosity
surgical neck
anatomic neck
• Expected time of bone healing: 6 - 8 weeks

• Expected duration of Rehabilitation: 12 weeks - 1 year

Methods of treatment
 Sling
 ORIF
 Percutaneous fixation
 Prosthetic arthroplasty
 External fixator – severe comminuted fracture
2. Midshaft
Classification
fx above pec. major insertion
fx below pec. major insertion
fx below the deltoid insertion

Expected time of Bone Healing: 8 - 12 weeks

(in uncomplicated cases)

Expected duration of Rehabilitation: 12 - 16 weeks

• Methods of treatment
– Coaptation splint (for initial phase)
– Functional bracing (mc for closed)
– Velpeau dressing (for undisplaced)
– Intramedullary nail/rod
– Plate fixation
– External fixation
• coaptation splintn.A short splint designed to prevent
overriding of the ends of a fractured bone, often
supplemented by a longer splint to fix the entire limb.
 3. Distal humeral fracture

• Intraarticular • Extraarticular
– Single column – Extracapsular
• Supracondylar
• Medial condyle • Medial & lateral epicondylar
• Lateral condyle
– Intracapsular
– Two column • Transcondylar
– Muller's Classfication:
type A: extra-articular
fracture;
type B: uni-condylar fracture;
type C: bi-condylar fracture

• T intercondylar
• Y intercondylar
Expected time of bone healing: 8 - 12 wks
Expected duration of rehabilitation:12 - 24 wks
• Methods of treatment
– Cast or Posterior splints
– Percutaneous pinning
– ORIF
– External fixation (used only for contaminated open
fracture)
– Skeletal traction
C. Olecranon.
Expected time of bone healing: 10 to 12 weeks
Expected duration of rehabilitation: 10 - 12 weeks

Method of treatment
 closed reduction
 ORIF
 excision & triceps advancement & reattachment
D. Forearm
types:
> nightstick
> Monteggia
> Galleazi
> Essex-Lopresti

Expected time of bone healing

8 to 12 weeks. Delayed union is rare

Expected duration of rehabilitation

12 to 24 weeks
 II. Lower Extremity

A. Femoral neck
- fx proximal to the intertrochanteric line (Garden
Classification)
• Expected time of bone healing: 12 - 16 wks
• Expected duration of rehabilitation:
– 15 - 30 wks
• Methods of treatment
– ORIF
– Prosthetic replacement
B. Femoral shaft
Expected time of bone healing: 12 to 16 wks
Expected duration of rehabilitation: 12 to 16 wks

Methods of treatment
- Intramedullary rod fixation
- ORIF
- external fixation
- skeletal traction
C. Patellar fractures
classification
displaced
nondisplaced
*either 1-2 mm articular step-off or
3mm fragment separation
transverse
longitudinal
comminuted
Expected time of bone healing: 8 - 12 wks

Expected duration of rehabilitation:

12 – 15 wks

Methods of treatment
Knee immobilizer
ORIF
Partial/Total Patellectomy - comminuted
D. Tibial shaft fracture
- high energy trauma (transverse)
- low energy trauma (spiral)

Expected time of bone healing: 10 - 12 weeks

Expected duration of rehabilitation: 12 - 24 weeks

• Methods of treatment
– Casts
– Intramedullary rods
– External fixator
– ORIF w/ plates
E. Tibial Plafond fracture
- horizontal wt. bearing surface of the distal tibia
- high energy impacts, Vehicular accidents
(Tibial plafond fractures occur just above the ankle joint and
often involve the cartilage surface of the ankle joint. The other
major factor that must be considered with these injuries is the
soft-tissue around the ankle region. )
Expected time of bone healing: 6 - 8 weeks
Expected duration of rehabilitation: 3 - 6 months

 Methods of treatment
ORIF (first choice)
External fixation
Casts
Primary arthrodesis (last resort)
Tibial plafond fracture
F. Ankle fractures
specifically described:
1. isolated lateral malleolar
2. bimalleolar
3. medial malleolar fx
4. bimalleolar equivalent – lateral is fx &
mortise is widened
5. trimalleolar fx – includes posterior
aspect of tibial plafond
Expected time of bone healing
6 - 10 weeks (isolated lat melleolar)
8 - 12 weeks (bi, bi equi, trimalleolar,
medial malleolar)
Expected duration of rehabilitation (after cast removal)
12 - 16 weeks (extraarticular)
16 - 24 weeks (intraarticular)

Methods of treatment
- Casts

- ORIF
G. Foot fractures
involves:
> Lisfranc jt (tarsometatarsal)
> cuneiform
> navicular (scaphoid)
> cuboids
most common causes:
> twisting
> axial loading
> crushing
Expected time of bone healing
Lisfranc - 8 - 10 weeks
Navicular – 6 - 10 weeks

Expected duration of rehabilitation

Lisfranc – 8 weeks to 4 months
Navicular – 6 weeks to 4 months
Methods of treatment
- ORIF
- Percutaneous pinning(Kirschner)
- Casts (navicular)
 Spine Fractures
A. C1 (Jefferson fx)
- burst fx of the atlas
- caused by axial compression

Orthopedic objectives
1. maintain spinal alignment
2. provide spinal stability
3. prevent new neurologic deficits
4. prevent future spinal deformity
Expected time of bone healing:
8 - 16 wks
Expected duration of rehabilitation:
3 - 6 mos

Methods of treatment
- Orthosis
- posterior spinal fusion
B. C2 (Hangman’s fx)
- fracture of the pedicles
- types:
type 1: minimally displaced
type 2: angulation of the body >10° &
displacements of the body >3mm
type 3: severe angulation & displacement
Expected time of bone healing
8 to 12 weeks

Expected duration of rehabilitation

3 to 6 months

Methods of treatment
- orthosis (hard collar, SOMI, CTO)
- direct osteosynthesis
C. Odontoid fractures
Classification:
type I: rare avulsion of the alar & apical
ligaments
type II: junction of dens w/ central axis of C2
body
type III: fx that extends into the body of the axis
Expected time of bone healing: 12 - 16 wks.
Expected duration of rehabilitation: 3 - 6 mos.

Methods of treatment
- orthosis (soft, hard collar, halo vest)
- post. arthrodesis
- anterior odontoid screw fixation
 PHYSICAL THERAPY PRINCIPLES AND
CONSIDERATIONS
A. Tissue response and guidelines after period
of immobilization
 Local Tissue response
 Immobilization in bed
 Functional adaptations
B. Post immobilization Period
1. Determine bone healing
2. Examine the pt
3. Joint mobilization
4. Neuromuscular inhibition
5. Self stretching
6. Activities
7. Muscle performance
8. Scar tissue mobilization
 PT Management

1. Educate the patient

 Inform the pt of limitations until the fracture site is
healed radiographically
 Teach home exercise program
2. Provide protection until radiographically healed
 Use partial weight bearing in LE and nonstressful
activities in the UE
3. Initiate active exercises
 Active ROM; multiple joint isometrics
4. Increase joint and soft tissue mobility
 Initiate joint stretching techniques with the force
applied to the proximal site
5.Increase strength and muscle endurance
6. Improve CP fitness
IMPLANT REMOVAL
Exceptions:
– elderly patients
– non weight bearing bones
– single screws (metaphysis)
• Metaphyseal screws 3-6 months
• Screws and plates
• tibia - 1 year
• femur - 2 years
• forearm/humerus - 1.5-2 years
• Intramedullary nail - 2 years
Safeguard after Removal
50 % torsion resistance is lost
Normal use - 3 months
Athletes - 4 months
Thank you for listening…