Outline of Fractures
A fracture is a complete or incomplete break or crack in the continuity of a bone.
Classification - By quality of bone in relation to load
a) Traumatic fractures - Occurs when excessive force is applied to normal bone either directly or indirectly
b) Fatigue/Stress fractures - This occurs if bones are subjected to chronic repetitive forces, none of which alone
would be enough to break the bone but which mean that the mechanical structure of the bone is gradually
fatigued
Examples (in order of frequency);
• March fracture of the 2nd & 3rd metatarsal heads
• Mid & Distal Tibia & Fibula fractures in long distance runners & dancers
• Neck of femur
• Fractures of the pubic rami in severely osteoporotic or osteomalacic patients
Detected early by Scintigraphy or MRI as radiographic changes appear after 2-4wks.
c) Pathological fractures - Produced when the strength of bone is reduced by disease
Orthopaedic Surgery Page 2
,Orthopaedic Surgery Page 3
,d) Partial/Green-stick fractures - Occur because bones in children especially <10 years are very flexible.
Longitudinal compression force leads to crumpling whereas an angulation force tends to bend the bone at one
cortex & to buckle or break it at the other producing an incomplete fracture. They are not mobile due to the thick
periosteum.
Open & Closed Fractures
Open/Compound fractures
Open/Compound fractures can communicate with the outside in 3 ways;
i) Trauma directly damaging skin & breaks bone - outside-in injury
ii) Bone breaks & pierces through skin - inside-out injury
iii) Injury to skin which becomes necrotic & sloughs off exposing bone
Classification
A. Gustilo and Anderson Classification:
• Type 1 fracture is a low-energy injury with a wound <1 cm in length, often from an inside-out injury.
• Type 2 fracture involves a wound >1 cm long and significantly more injury, caused by more energy
absorption during the production of the fracture.
• Type 3 fracture has extensive wounds >10 cm in length, significant fracture fragment
comminution, and a great deal of soft tissue damage & periosteal stripping. It is usually a high-
energy injury. This type of injury results typically from high-velocity gun shots, motorcycle
accidents, or injuries with contamination from outdoor sites such as with tornado disasters or
farming accidents.
* Type 3A fractures do not require major reconstructive surgery to provide skin
coverage.
* Type 3B fractures, in contrast, usually require reconstructive procedures because of soft
tissue defects that provide either poor coverage for bone or no coverage.
* Type 3C injuries involve vascular compromise requiring surgical repair or reconstruction.
B. Mangled Extremity Severity Score (MESS) Scoring:
Table 3-1. Factors in evaluation of the mangled extremity severity score (MESS) variables.1
Points
A. Skeletal and soft tissue injury
Low energy (stab; simple fracture; "civilian" gunshot wound 1
Medium energy (open or multiple fractures, dislocation) 2
High energy (close-range shotgun or "military" gunshot wound, crush injury) 3
Very high energy (above plus gross contamination, soft tissue avulsion) 4
B. Limb ischemia2
Pulse reduced or absent but perfusion normal 1
Pulseless; paresthesia, diminished capillary refilling 2
Cool, paralyzed, insensate, numb 3
C. Shock
Systolic blood pressure almost more than 90 mm Hg 0
Hypotensive transiently 1
Persistent hypotension 2
D. Age
<30 years 0
30-50 years 1
>50 years 2
1Adapted and reproduced, with permission, from Johansen K et al: Objective criteria
accurately predict amputation following lower extremity trauma. J Trauma 1990;30:369.
2Score doubled for ischemia more than 6 hours.
Orthopaedic Surgery Page 4
, Mx of Open Fractures
Principles of Mx;
- Wound debridement
- Antibiotic prophylaxis
- Stabilization of the fracture
- Early wound cover
i) First-Aid
i) Airway with cervical spine control, Breathing, Circulation & haemorrhage control, Disability & Exposure -
30% of patients with an open fracture have other life threatening injuries
- Assess neurovascular status of the limb
- Relieve pain
- IV antibiotics - 70% of open fractures are contaminated with bacteria at the time of injury
Give antibiotics for 48-72Hrs post injury & for 48-72Hrs each time a further procedure is performed;
* Cephalosporins (+ Aminoglycoside - Type II/III) (+ Penicillin - if a farmyard injury to cover
for Clostridium perfringens )
- Tetanus prophylaxis - Toxoid for those previously immunised, human antiserum if not.
- Swab wound
- Photograph - to prevent reopening for examination
- Cover wound
- Splint
- X-ray
ii) Surgical debridement - Principles;
- Wound extension - Small wounds should be extended & excised to allow adequate exposure.
- Wound excision - The wound margins are excised, but only enough to leave healthy skin edges.
- Removal of devitalized tissue - Dead muscle can be recognised by;
* Purplish colour
* Mushy consistency
* Failure to contract when stimulated
* Failure to bleed when cut
- Wound cleansing - All foreign material & tissue debris must be carefully removed. Type II/III - Irrigate
with 5-10L NS ± Water & Hydrogen peroxide
- Unattached bone should be discarded
- Nerves & Tendons - It is best to leave cut nerves & tendons alone, though if the wound is absolutely clean &
no dissection is required, they can be sutured.
- Repeat debridement at 48Hr intervals until the wound is clean
Amputation
Indications;
• Congenital anomalies especially of lower limbs so as to enable weight bearing
• Traumatic (Patient specific)
- A MESS score ≥7
- Massive loss of bone
- Extensive neurovascular damage
- Frost bite
• Vascular conditions e.g. Diabetes, Arteriosclerosis, Raynaud's Disease, SLE, Berger's Disease
• Infective conditions e.g. Gas gangrene, Madura foot, Chronic osteomyelitis
• Neoplastic conditions
Ix;
• Clinical Evaluation - T°C, Capillary refill & Pulse
• FHG, ECG
• Ischemic-Brachial Pressure Index - Use doppler pressure probe. Ratio between pressure at
amputation level with SBP of brachial artery - Has to be >0.45 or no healing will occur.
- Normal - 1
- Intermittent claudication - 0.6-0.9
- Resting pain - 0.3-0.6
- Impending gangrene - ≤0.3 or Ankle SBP <50mmHg
• Angiography to check if there is an indication for reconstruction
• Transcutaneous oximetry - Determines the capacity of the vascular system to deliver oxygen to level of
proposed surgery (20-30mmHg)
Orthopaedic Surgery Page 5
A fracture is a complete or incomplete break or crack in the continuity of a bone.
Classification - By quality of bone in relation to load
a) Traumatic fractures - Occurs when excessive force is applied to normal bone either directly or indirectly
b) Fatigue/Stress fractures - This occurs if bones are subjected to chronic repetitive forces, none of which alone
would be enough to break the bone but which mean that the mechanical structure of the bone is gradually
fatigued
Examples (in order of frequency);
• March fracture of the 2nd & 3rd metatarsal heads
• Mid & Distal Tibia & Fibula fractures in long distance runners & dancers
• Neck of femur
• Fractures of the pubic rami in severely osteoporotic or osteomalacic patients
Detected early by Scintigraphy or MRI as radiographic changes appear after 2-4wks.
c) Pathological fractures - Produced when the strength of bone is reduced by disease
Orthopaedic Surgery Page 2
,Orthopaedic Surgery Page 3
,d) Partial/Green-stick fractures - Occur because bones in children especially <10 years are very flexible.
Longitudinal compression force leads to crumpling whereas an angulation force tends to bend the bone at one
cortex & to buckle or break it at the other producing an incomplete fracture. They are not mobile due to the thick
periosteum.
Open & Closed Fractures
Open/Compound fractures
Open/Compound fractures can communicate with the outside in 3 ways;
i) Trauma directly damaging skin & breaks bone - outside-in injury
ii) Bone breaks & pierces through skin - inside-out injury
iii) Injury to skin which becomes necrotic & sloughs off exposing bone
Classification
A. Gustilo and Anderson Classification:
• Type 1 fracture is a low-energy injury with a wound <1 cm in length, often from an inside-out injury.
• Type 2 fracture involves a wound >1 cm long and significantly more injury, caused by more energy
absorption during the production of the fracture.
• Type 3 fracture has extensive wounds >10 cm in length, significant fracture fragment
comminution, and a great deal of soft tissue damage & periosteal stripping. It is usually a high-
energy injury. This type of injury results typically from high-velocity gun shots, motorcycle
accidents, or injuries with contamination from outdoor sites such as with tornado disasters or
farming accidents.
* Type 3A fractures do not require major reconstructive surgery to provide skin
coverage.
* Type 3B fractures, in contrast, usually require reconstructive procedures because of soft
tissue defects that provide either poor coverage for bone or no coverage.
* Type 3C injuries involve vascular compromise requiring surgical repair or reconstruction.
B. Mangled Extremity Severity Score (MESS) Scoring:
Table 3-1. Factors in evaluation of the mangled extremity severity score (MESS) variables.1
Points
A. Skeletal and soft tissue injury
Low energy (stab; simple fracture; "civilian" gunshot wound 1
Medium energy (open or multiple fractures, dislocation) 2
High energy (close-range shotgun or "military" gunshot wound, crush injury) 3
Very high energy (above plus gross contamination, soft tissue avulsion) 4
B. Limb ischemia2
Pulse reduced or absent but perfusion normal 1
Pulseless; paresthesia, diminished capillary refilling 2
Cool, paralyzed, insensate, numb 3
C. Shock
Systolic blood pressure almost more than 90 mm Hg 0
Hypotensive transiently 1
Persistent hypotension 2
D. Age
<30 years 0
30-50 years 1
>50 years 2
1Adapted and reproduced, with permission, from Johansen K et al: Objective criteria
accurately predict amputation following lower extremity trauma. J Trauma 1990;30:369.
2Score doubled for ischemia more than 6 hours.
Orthopaedic Surgery Page 4
, Mx of Open Fractures
Principles of Mx;
- Wound debridement
- Antibiotic prophylaxis
- Stabilization of the fracture
- Early wound cover
i) First-Aid
i) Airway with cervical spine control, Breathing, Circulation & haemorrhage control, Disability & Exposure -
30% of patients with an open fracture have other life threatening injuries
- Assess neurovascular status of the limb
- Relieve pain
- IV antibiotics - 70% of open fractures are contaminated with bacteria at the time of injury
Give antibiotics for 48-72Hrs post injury & for 48-72Hrs each time a further procedure is performed;
* Cephalosporins (+ Aminoglycoside - Type II/III) (+ Penicillin - if a farmyard injury to cover
for Clostridium perfringens )
- Tetanus prophylaxis - Toxoid for those previously immunised, human antiserum if not.
- Swab wound
- Photograph - to prevent reopening for examination
- Cover wound
- Splint
- X-ray
ii) Surgical debridement - Principles;
- Wound extension - Small wounds should be extended & excised to allow adequate exposure.
- Wound excision - The wound margins are excised, but only enough to leave healthy skin edges.
- Removal of devitalized tissue - Dead muscle can be recognised by;
* Purplish colour
* Mushy consistency
* Failure to contract when stimulated
* Failure to bleed when cut
- Wound cleansing - All foreign material & tissue debris must be carefully removed. Type II/III - Irrigate
with 5-10L NS ± Water & Hydrogen peroxide
- Unattached bone should be discarded
- Nerves & Tendons - It is best to leave cut nerves & tendons alone, though if the wound is absolutely clean &
no dissection is required, they can be sutured.
- Repeat debridement at 48Hr intervals until the wound is clean
Amputation
Indications;
• Congenital anomalies especially of lower limbs so as to enable weight bearing
• Traumatic (Patient specific)
- A MESS score ≥7
- Massive loss of bone
- Extensive neurovascular damage
- Frost bite
• Vascular conditions e.g. Diabetes, Arteriosclerosis, Raynaud's Disease, SLE, Berger's Disease
• Infective conditions e.g. Gas gangrene, Madura foot, Chronic osteomyelitis
• Neoplastic conditions
Ix;
• Clinical Evaluation - T°C, Capillary refill & Pulse
• FHG, ECG
• Ischemic-Brachial Pressure Index - Use doppler pressure probe. Ratio between pressure at
amputation level with SBP of brachial artery - Has to be >0.45 or no healing will occur.
- Normal - 1
- Intermittent claudication - 0.6-0.9
- Resting pain - 0.3-0.6
- Impending gangrene - ≤0.3 or Ankle SBP <50mmHg
• Angiography to check if there is an indication for reconstruction
• Transcutaneous oximetry - Determines the capacity of the vascular system to deliver oxygen to level of
proposed surgery (20-30mmHg)
Orthopaedic Surgery Page 5
