Fracture

Dr Vishwabharathi T
Definition
 Loss of continuity
of a bone
 It includes hairline,

microscopic and
highly comminuted
fracture
Classification of fracture
Variously classified
A. According to the plane of fracture surface
i. Transverse fracture: plane of fracture surface is
perpendicular to the long axis of the bone
ii. Spiral fracture: fracture surface is spiral and caused
by torsional stress
iii. Oblique fracture: fracture surface forms an angle
with the long axis of the shaft
iv. Comminuted fracture: when there are more than
two fragments present
v. Compression fracture: results from a compression
force. Leads to compression of bony trabeculae
resulting in decreased length /width of a portion of
the bone
B. Fractures may be
classified as
i. Simple / closed
fracture: fracture
surface doesn't
communicate with the
exterior through the
skin/ mucous
membrane
ii. Open fracture/
compound fracture:
communication
between the fracture
and exterior through
the skin/ mucous
membrane
C. According to the cause of the fracture
i. Traumatic fracture
ii. Pathological fracture: fracture occurring in
the bone at an area of weakness caused by
pathologic process. Eg: tumour, infection,
bone diseases
iii. Stress/fatigue fracture: occurs due to
repeated stress
 D. According to number
i. Single
ii. Multiple
E. Fracture may be
iii. Complete: whole
thickness of the bone
is discontinued
iv. Incomplete: does not
involve the whole
breadth of the shaft
and a portion remains
impacted
Healing of fracture
5 stages
1. Stage of haematoma formation
2. Stage of cellular proliferation
3. Stage of callus formation
4. Stage of new bone formation
5. Stage of remodelling
Stage of haematoma formation
 Tearing of periosteum and injury to the
surrounding tissues
 Disruption of the Haversian systems of the

bone
 Bleeding occurs from the bone ends, marrow

vessels and damaged soft tissues

 Formation of fracture haematoma
 Inflammatory exudate formed around and

between the broken ends of the bone

 Amount of haematoma formation depends on

accuracy of apposition of the two fragments

 Amount of subsequent callus formation is

largely dependent on the amount of

Stage of cellular proliferation
 There is rapid cellular activity
 Fibrovascular tissue replaces the clot
 Collagen fibres are laid down and mineral salts are

deposited
 Exudate is quickly invaded by cells and new

capillaries
 New cells are derived from endothelial cells of the

capillaries of the newly formed granulation tissue

 New osteoblasts are also derived partly from the

deeper layer of the periosteum and partly from the

cortical layer of the bone
 Gradually metaplasia of the fibroblasts to

chondroblasts and isolated islands of cartilage

appear follwed by development of osteoid tissue
Stage of callus formation
 New woven bone is formed beneath the periosteum at
the ends of the bone
 The cells responsible are derived from the periosteum
 If blood supply is poor / if it is disturbed by excessive
mobility at the fracture site, cartilage may be formed
instead and remain until better blood supply is
established
 Osteoblats form the new bone formation in the
cartilaginous mass
 Near the fracture site the osteogenic cells proliferate in
massive fashion
 Callus formation is a process of enchondral ossification
 Mass of new bone formation at the site of a fracture is
know as callus
 3 parts of callus
1. External callus:- part which ensheathes the
broken ends, seen out side the bone. This is
responsible in establishing external
continuity of the fracture
2. Intermediate callus:- part which forms a
direct union between the fracture surfaces
3. Internal callus:- is one which fills up the
marrow cavity
- Callus formation starts from 10th day and is
well formed by the end of 3rd week
Stage of new bone formation
 Callus formation is beginning of the fracture
union
 But actual union only occurs through a slow

process of moulding
 External callus and internal callus are

removed by large multinucleated osteoclasts

 By this process of internal adjustment,

haphazardly arranged fibrous bone is

replaced by trabeculated lamellar bone
 Gradually new haversian systems are formed
Stage of remodelling
 After clinical union, new Haversian syatems are
laid down along the lines of stress
 The area of free from stress, bone is removed

by osteoclasts
 External callus almost disappears
 Power of remodelling of bone is great in

children
 Traces of fracture displacement disappear
Clinical features of fracture
 History:
 Symptoms:

◦ Pain: fracture usually followed by pain and loss of

function
◦ Patient will complain of tremendous pain after injury
◦ Fracture pain is only felt during movement of the
fracture site
◦ Loss of function: patient will be unable to move the
fractured limb
◦ Deformity/ swelling: it is often due to displacement of
bone fragment and / haematoma
 Local examination:
 Injured side should always be
compared with sound side
A. Inspection:-
i. Abnormal swelling
and deformity:
 First thing that attracts the
clinician’s eye is the
deformity and / swelling
 Deformity is mostly due to
displaced fractured
segments
 Swelling is mostly due to
haematoma and edema
 If fracture is near a joint,
effusion will lead to swelling
ii. Attitude:
 In certain fractures the patient

adopt particular attitudes which are

very diagnostic
 Ex: fracture neck of femur, patient

lies helpless with lower limb

externally rotated
iii. Shortening: a little amount of
shortening is almost always
expected in fracture due to
overlapping of the segments
iv. Overlying skin: important point of
inspection
 If there is wound which

communicates with the fracture site,

fracture is said to be compound
 In closed fracture, edema, blebs

and bullae are common due to

interference with venous return
 B. Palpation:-
i. Tenderness:
 Local bony tenderness is a valuable sign of a
fracture
 Palpation to elicit tenderness should be made
through a healthy soft tissue- local bony
tenderness
ii. Bony irregularities:
 The whole length of the injured bone should be
palpated to note to note if any irregularity such as
a sharp elevation or a gap etc-definite sign of a
fracture
iii. Abnormal movements:
 This is also a definite sign of fracture
 Can be elicited by moving one fragment against

the other
 This test should be used only to exclude the

presence of a fracture
iv. Crepitus:
 it is a sensation of grating which may be felt or

heard, when the bone ends are moved against

each other
v. Pain elicited by manipulation from a distance:
 By rotating the bone in case of humerus/ femur
 By squeezing both the bones of the leg or the

forearm- springing of the radius/fibula

 By making axial pressure in the line of the bone

as can be applied in case of metacarpals or

metatarsals
vi. Swelling:
 Characteristics of swelling should be noted
 Bony/ swelling arises from the neighbouring joint

vii. Wound: wound should be explored to note the

position of the broken fragments
C. Measurement:
 Longitudinal measurement: to know the

shortening
 Circumferential: to know any wasting due to

injury
D. Movements:
E. Complications:
 Injury to the nerve, injury to the blood vessel,

injury to the internal organs within the thorax or

abdomen which are dreadful and fatal
Treatment of closed fracture
 General management
 Local management

General management:-
 Pain :

◦ Splintage of the fracture site to decrease the

movement
◦ Analgesics
 Blood loss:
◦ Closed fracture of femoarl shaft- ½ to 1 L blood loss
◦ Fracture of pelvis- 2-3 L
◦ Haemothorax- 1-2 l
 External haemorrhage: loss is 1 L/ less, blood
transfusion is not required in adults
 Plasma / plasma expandaers may be infused
 2 Ls loss- 1 L whole blood and 1 L plasma

expanders
 Associated injuries
 Drugs
Local management:
AIM:
 To attain sound bony union without deformity
 To restore function of the fracture site as quickly

as possible
 3 headings:
Reduction
Retention
Rehabilitation
Reduction:-
 To bring the fracture

segments in
alignments without any
displacements
 Displaced fracture

needs reduction
 Reduction – restoration

of normal or atleast an
acceptable anatomy of
fractured bone
 Closed reduction:

◦ Closed manipulation
◦ Gravity
◦ Traction
 Open reduction:-
Indication:
 Soft tissues are interposed

between fracture
segments
 Fracture leaves a small

fragments which is difficult

to manipulate
 Small fragments trapped in

a joint
 Where closed reduction is

inaccurate-in case of joint

surface
 Where closed reduction

cannot be maintained
Retention:- Immobilization
of fracture fragments which
have been reduced
Types:
 Traction
 Plaster

 Internal fixation

 Traction: to maintain
fracture fragments in
reduced position continuous
traction is necessary
Traction by gravity
Skin traction – fracture of
femur/hip
Skeletal traction
By skin traction - two adhesive strips
are stuck on to either side of the leg
and weights are attached to these
strips by a rope (for femoral shaft
fractures in children).
By skeletal traction - through a pin
placed in the tibia for femoral shaft
fractures in adults. This can be fixed
or balanced

By gravity - a hanging cast for

displaced fractures of the
humeral shaft
 Plaster:
 Complete plastering
 Plaster cast
 Internal fixation:

done
◦ When closed reduction is
impossible
◦ When reduction cannot be
maintained by external
splintage
 Inlay fixation:
 Trafin nails
 Intramedulary nails
 Only fixation:
 Mainly by a plate
 Fixed with screws
Rehabilitation:
Elevation
Exercises
Physiotherapy