FRACTURE

Jafri Hasan,MD
Definition
Structural break in continuity
of bone, cartilaginous joint
surface, or epiphyseal plate
caused by trauma
How to diagnose
Anamnesis :
Trauma (direct, indirect, gunshot)
Feeling something breaks
Pain
Abnormality
How to diagnose
Primary survey :
A,B,C,D,E
stabilize
Secondary survey :
From head to toe
How to diagnose
Physical examination local status:
Look : swelling, bruish, wound
deformity :
S : shortening
A : Angulation
R : Rotation
Feel : tenderness, crepitation,
Move : ROM (rarely performed)
Case
How to Describe
History
Physical examination
Radiograph:
plain X-ray
Density
can differentiate between air, soft tissue and bone
Rules of 2 :
2 projection
2 joints
2 sites
2 occasion
How to Describe
S : Site
E : Extent
C : Configuration
R : Relationship between fracture fragment
E : Environment
C : Complication
S : Site
What part of
A Bone:
B Epiphysis Proximal
Metaphysis Distal
C

Diaphysis / shaft
D
E
S : Site
Which bone?
Femur, tibia, radius,
ulna, ???
S : Site
What side ?
Right or Left?
E : Extent
Complete configuration
Incomplete
Hairline.
Green stick
Torus/buckle fracture
Incomplete
C : Configuration
Simple :
T : Transverse
O: Oblique
S : Spiral
Complex :
Comminutive
Segmental
Simple Complex
Comminutive

Segmental
R : Relationship..
Undisplaced
Displaced
S : Shifted sideways (ad longitudinam)
A : Angulated (ad axin)
R : Rotated
D : Distraction (ad longitudinam cum distractionum)
O : Over riding (ad longitudinam cum contractionum)
I : Impacted
 Shifted sideways
Distraction

Angulasi

Overriding

impacted

Rotasi
E : Environment
Closed
Fracture is not exposed to the environment

Open
A break in the skin and underlying soft tissue leading
directing into or communicating with the fracture and
its hematoma
Grading Gustilo Anderson grade I,II,III
Open fracture
Described by Gustilo system
Based on soft tissue damage, force and fracture
configuration
Type I Open Fractures
Inside-out injury
Clean wound
Minimal soft tissue
damage
No significant
periosteal stripping
Type II Open Fractures
Moderate soft tissue
damage
Outside-in
mechanism
Higher energy injury
Some necrotic
muscle, some
periosteal stripping
Type IIIA Open Fractures
High energy
Outside-in injury
Extensive muscle
devitalization
Bone coverage with
existing soft tissue
not problematic
After operation
Expose bone (-)
Type IIIB Open Fractures
High energy
Outside in injury
Extensive muscle
devitalization
Requires a local flap
or free flap for bone
coverage and soft
tissue closure
Periosteal stripping
After operation
Exposed bone(+)
Type IIIC Open Fractures
High energy
Increased risk of
amputation and
infection
Major vascular injury
requiring repair
 Table 1. The Gustilo Anderson Classification of Soft-Tissue
Injury in Open Fracture (1976)
Type I Type II Type III

Wound Size < 1 cm > 1 cm

Injury Low velocity/ High velocity/ High velocity/

energy energy energy
Soft tissue Minimal soft No extensive soft Extensive soft tissue
tissue damage tissue damage, flap, damage, including
or avulsion muscles, skin, & neuro-
vascular structures

Crush No signs of crush Slight to moderate Extensive crush

crush
Fracture Usually simple., Moderate fracture Great degree of
transverse, or short comminution f r a c t u r e
oblique with little comminution &
comminution instability
Contaminati Little Moderate High degree
on
 Table 2. Type III Soft Tissue Injury in The Gustilo Open Fractures
Classification (1984)

Type A Type B Type C

Injury High velocity/ High velocity/ High velocity/

energy energy energy
Soft Tissue Extensive soft Extensive soft tissue Same as type III B
tissue laceration, injury with periosteal
adequate bone
coverage after stripping & exposed
debridement. Free bone after
flap are not debridement. Requires
necessary to cover
bone. Segmental local or free flap to
fractures, such as cover bone.
gunshot injury

Va s c u l a r Va s c u l a r i n j u r y
Injury Not significant Not significant requiring repair for
limb salvage

Contaminat- High degree Massive Massive

ion
C : Complication
Uncomplicated
Complicated:
Local : neuro or vascular
injury
Systemic
SUMMARY
S : Site R : Relationship between
What bone fracture fragment
What part of bone : Undisplaced
epi,meta,diaphysis Displaced : S,A,R,D,O,I
What side : L/ E : Environment
E : Extent Closed
Complete configuration Open grade
incomplete C : Complication
C : Configuration Local
Simple : T,O,S Systemic
Complex : comminutive,
segmental
 Fraktur diaphysis femur sinistra komplit transverse displaced ad longitudinam
cum distractionum tertutup tanpa komplikasi
(closed fracture of left shaft femur complete transverse displaced distraction
uncomplicated)
Fraktur diaphysis radius dx komplit oblik displaced ad longitudinam cum
contractionum..
 Fr diaphsysis tibia dx komplit spiral displaced rotasi
terbuka Gr II dengan cedera n.peroneus profundus
General principle of
treatment
Principle fundamentals truths that provide both a
basis for reasoning and a guide for conduct.

It's formulated from "laws of nature

Important not only to know "what" also to know the

reason "why"
General principle of
treatment
- First do no harm ( primum non Nocere)
all treatment methods have a potential for great
benefit but also great harm
iatrogenic disease

. Base treatment on accurate diagnosis & prognosis

treat not only the symptoms but to know the
underlying disease
General principle of
treatment
/ Select treatment with specific aim
chief complaint in MS problems are
pain
relief of pain
decrease in function
improvement of function
physical appearance of either a deformity or an
Abnormal gait
prevention or correction of deformity
improvement of gait
General principle of
treatment
3 Cooperate with the laws of nature
natural laws of the behavior of body tissues under
various circumstances

4 Be realistic and practical in your treatment

ask your self 3 questions :
1. Precisely what am I aiming to accomplish by this
method of treatment ~ what is its specific aim or goal?
2. Am I, in fact, likely to accomplish this aim or goal by
this method of treatment?
General principle of
treatment
NO > find another treatment
YES > 3
3. Will it worth for the patient the end result? Better or
worst?

5 select treatment for your patient as individual

General principle of
treatment
All comes to 4 R :
Recognition
Reduction
Retainment
Rehabilitation
 Thanks
Ref : SALTER TEXT BOOK OF
MUSCULOSKELETAL INJURY