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
• Which bone?
• Femur, tibia, radius,
ulna, ???
S : Site
• What part of
A
Bone:
B •Proximal
• Epiphysis
• Metaphysis •Distal
C

• Diaphysis
D
E
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 ⤵
Bone exposé (-)
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 ⤵
Bone exposé (+)
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 veloc ity/ 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 ve l oc i ty/ High velocity/ High velocity/

energy energy energy
Soft Tissue Extensivesoft Extensive soft tissue Same as type III B
tissue laceration, injury with periosteal
adequate bone
coverage after stripping & exposed
debridement. Free b o ne a f ter
f l a p a r e n o t 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
 Thanks
Ref : SALTER TEXT BOOK OF
MUSCULOSKELETAL INJURY