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TBL 1: Orthopedic Trauma. Husna, Izzati, Ili Safia, Aqilah & Safiyyah. TBL Trigger. A 24 year old man was involved in a road traffic accident. He was a pedestrian when a motorcycle knocked him down when he was crossing the road.

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Tbl 1 orthopedic trauma

TBL 1: Orthopedic Trauma

Husna, Izzati, Ili Safia, Aqilah & Safiyyah

Tbl trigger
TBL Trigger

  • A 24 year old man was involved in a road traffic accident.

  • He was a pedestrian when a motorcycle knocked him down when he was crossing the road.

  • Following that incident, he complained of pain of the left leg and was unable to bear weight on his left lower limb.

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  • In A&E, physical examination was performed:

    • Revealed swollen, tender and deformed proximal region of the left leg.

    • No limb threatening injury noted.

    • No wound overlying the deformed region.

  • An X-ray of the left leg done reported transverse fracture proximal of the left fibula.

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  • He was admitted to the ward:

    • The left leg was elevated on the Bohler Braun frame awaiting for the swelling to subside and to observe for Compartment syndrome.

    • He was told the fracture is best treated with internal fixation but he opted for conservative treatment.

    • Full leg POP cast was applied after 3 days of admission.

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  • Follow up visit (6 weeks post-trauma):

    • X ray was done and it showed no healing signs.

    • The earlier cast was removed and changed to patellar tendon bearing cast for another six weeks.

  • Follow up visit (12 weeks post-trauma):

    • Revealed mobility to the fracture site –painless.

    • He was told to have problem with the fracture healing and needs surgical treatment.

Learning issues
Learning Issues

  • Anatomy of the Leg.

  • Fracture – Definition, Classification and Patterns.

  • Principle of Fracture Management.

  • Acute Complications of Fracture.

  • Process of Fracture Healing.

  • Late Complications of Fracture.

  • Non Union Fracture – Definition, Classification and Management.

The leg
The Leg

  • Bones

  • Muscles

    • Compartments

  • Blood Supply

  • Nerve Supply

I bones
i. Bones

Ii muscles and compartments
ii. Muscles and compartments







PL & B

Tibialis post.






Deep Posterior

Superficial Posterior

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Anterior compartment

Walls :

  • Interosseous membrane

  • Tibia

  • Fibula

    Contents :

  • Extensor muscles of the toes

  • Anterior tibial artery

  • Deep peroneal nerve

  • Most susceptible to compartment syndrome.

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Lateral compartment

Walls :

  • Fibula

  • Intermuscular septums


  • Peroneal muscles

  • Superficial peroneal nerve

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Superficial Posterior compartment


  • Transverse intermuscular septum

    Contents :

  • Gastrocnemius

  • Soleus muscles

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    Deep Posterior compartment

    Walls :

    • Transverse intermuscular septum

    • Interosseous membrane


    • Flexor muscles of the foot

    • Tibial artery

    • Tibial nerve

    Definition of fracture
    Definition of Fracture

    A break in the structural continuity of bone.

    - Apley’s System of Orthopedics & Fractures, 8th Edition

    I open compound fracture
    i. Open (Compound) Fracture

    • Breakage in the bone that breaches the skin or one of the body cavities.

    • Usually due to high-energy injuries e.g. MVA, falls, sports injuries.

    • Liable to contamination and infection hence require immediate treatment and surgery to clean the area.

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    Open Fracture

    Fracture of tibia-fibula with soft-tissue injury

    Ii closed simple fracture
    ii. Closed (Simple) Fracture

    • Breakage in the bone with the overlying skin still intact.

    • 3 types:

      • Compression fracture

        • Occurs when 2 or more bones are compressed against each other – commonly in the spine bone.

        • Due to falling in a standing or sitting position, advanced osteoporosis.

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    • Avulsion fracture

      • Occurs when a piece of bone is broken off by a sudden forceful contraction of a muscle.

      • Common in young athletes.

    • Impacted fracture

      • Occurs when pressure is applied to both ends of one bone causing it to split into fragments that collide with each other.

      • Similar to compression fracture, only it is within one bone.

      • Common in falls and MVA.

    **View video http://video.about.com/orthopedics/Fractures-2.htm for better understanding.

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    Avulsion fracture of the phalanges

    Impacted fracture of the femur

    Impacted fracture of the tibia

    Iii pathological fracture
    iii. Pathological Fracture

    • Breakage of bone in an area that is weakened by another disease process either by:

      • Changing the structure i.e. osteoporosis, Paget’s disease.

      • Presence of lytic lesion i.e. bone cyst or metastasis.

      • Infection.

    • Usually occur during normal daily activities  bone unable to withstand even the normal stresses.

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    Multiple myeloma of humerus with pathological fracture

    Bone cyst resulting in pathological fracture in the neck of femur

    Iv stress fracture
    iv. Stress Fracture

    • Usually fractures are caused by acute, high force to the bone i.e. MVA, fall.

    • In Stress facture, the force applied is much lower but it happens repetitively for a long period of time.

    • Rarely occur in the upper extremity because weight bearing is by lower extremity – common site shin and foot.

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    • Contributing factors:

      • Athletes

        • High demand of activity repetitively.

      • Diet abnormalities

        • Poor nutrition e.g. in aneroxia, bulimia.

      • Menstrual irregularities

        • Irregular cycles/amenorrhea signify lack of estrogen which results in lower bone density.

        • Common in female athletes.

    I incomplete fracture
    i. Incomplete Fracture

    I complete fracture
    i. Complete Fracture

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    **View video http://video.about.com/orthopedics/Fractures-1.htmfor better understanding.

    First general resuscitation

    At the hospital
    At the Hospital

    • Examine HEAD  TOE

    • Level of consciousness  GCS

    • Remember:

    Fractures principles of treatment
    Fractures – Principles of Treatment

    • Manipulation – improve position of fragments.

    • Splintage – hold.


    • Preserving the joint movement and function – exercise and weight bearing.

    1 closed fractures reduce aim adequate apposition and normal alignment of the bone fragments
    1. Closed Fractures – REDUCEAim  adequate apposition and normal alignment of the bone fragments


    2 closed fractures hold aim splint fracture
    2. Closed Fractures – HOLD Aim  splint fracture


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    Transfixing pin passes to:1. Proximal tibia – hip, thigh and knee injuries2. Distal tibia/calcaneum – tibial fractures

    Balanced skin traction

    Braun’s frame

    3 closed fractures exercise aim restore function
    3. Closed Fractures – EXERCISEAim  restore function

    • Prevention of edema

    • Active movement/exercise – stimulate circulation, prevents soft tissue adhesion and promote healing

    • Assisted movement – restore muscle power

    • Functional activity – guide patient in performing normal daily acitivities

    Gustilo s classification
    Gustilo’s Classification

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    Skin graft


    I underlying visceral injury
    i. Underlying Visceral Injury

    • Often in fractures around the trunk.

      • Rib fractures  penetration of lung  life-threatening pneumothorax .

      • Pelvic fractures  rupture of bladder or urethra.

    • Require emergency treatment, before treating fracture.

    Ii nerve injury
    ii. Nerve Injury

    • Common in fractures of the humerus, injuries around elbow & knee.

    • Look for tell tale signs:

      Closed injuries

      • Nerve seldom severed  wait for spontaneous recovery (90% in 4 months).

      • Recovery x occur/nerve studies shows no recovery explore nerve.

        Open fracture

      • Likely complete nerve lesion.

      • Explore during debridement/secondary procedure  repaired.

    Iii vascular injury
    iii. Vascular Injury

    • Fracture around knee and elbow, humeral and femoral shafts  ↑ ass. w. damage to major artery.

    • Cut, torn, compressed, contused by initial injury/jagged bone fragments.

    • N outward appearance  intima may be detached, vessel blocked by thrombus, spasm.

    • Effects vary : transient diminutive of blood flow, profound inchaemia, tissue death, peripheral gangrene.

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    Clinical features

    • Paraesthesia /numbness of toes/fingers

    • Cold, pale, slightly cyanosed weak/absent pulse

    • X ray shows high risk fractures


    • Angiogram

    • Remove bandages/splint

    • X ray – kinking or compressed  reduction

    • Reassess circulation

    • No improvement  explore via operation

      • Torn  Suture/ replace by vein graft

      • Thrombosed  endarterectomyto restore blood flow

    Iv compartment syndrome
    iv. Compartment Syndrome

    • A group of conditions that result from ↑ pressure within a limited anatomic space (limb compartments), acutely compromising the microcirculation and leading to ischaemia of the muscle.

    • Causes : high risk fractures, infection, operation.

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    Bleeding, oedema or inflammation

    ↑Tissue pressures in a compartment

    Compromise perfusion

    Tissue hypoxia

    Damage to the structures coursing through that compartment (nerves & muscles)

    Prolonged muscle hypoxia

    Necrosis and permanent posttraumatic muscle contracture (Volkmann's ischemia)

    12 hours or less



    Clinical features
    Clinical Features

    • Ischaemia (5 Ps):

      • Pain : Earliest symptom  bursting sensation

      • Paraesthesia

      • Pallor

      • Paralysis

      • Pulselessness

    • Muscles sensitive to touch  ↑ calf/forearm pain when is hyper-extended.

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    • Pressure of fascial compartment:

      • Introduce catheter into compartment  measure P close to compartment.

      • Diastolic P – compartment P.

      • Differential less than 30 mmHg.


    • Decompression

      • Remove bandage, casts, dressings.

    • Fasciotomy

    V haemarthrosis
    v. Haemarthrosis

    • Joint is swollen, tense.

    • Pt resists any attempt to move it.

       Aspirate blood first.

    Vi infection
    vi. Infection

    • Common in open fractures, unless closed fracture is opened.

    • Chronic osteomyelitis.

    • Slow union, w ↑ chance of re-fracturing

    • Imflamed wound, w seropurulent discharge.

    • Send for C&S.

    • Start antibiotic.

    Vii gas gangrene
    vii. Gas gangrene

    • Produced by clostridial infection esp Clostridum welchii in dirty wounds

    • Destroy cell walls  necrosis  spread of disease

    • Appear within 24 hours on injury

    • Intense pain,swelling,brownish discharge, ↑ HR, characteristic smell, gas formation

    • Toxaemic  coma  death

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    How Fracture Heal?




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    Fracture Healing Process

    • Stage 1: start few days after injury and continue for about a month.

    • Stage 2: starts within a week or two and continues for many months.

    • Stage 3: continues for many month to a few years.

    Local complication
    Local Complication

    • Deformity

    • Osteoarthritis of adjacent / distant joint

    • Aseptic necrosis

    • Traumatic Chondomalacia

    • Reflex sympathetic dystrophy

    Local complication cont
    Local Complication (cont’)

    • Contractures

    • Myositis ossificans

    • Avascular necrosis

    • Algodystrophy (or Sudeck's atrophy)

    • Osteomyelitis

    Systemic complication
    Systemic Complication

    • Gangrene

    • Tetanus

    • Septicemia

    • Fear of mobilizing

    • Osteoarthritis

    What is mobility to the fracture site but painless
    What is mobility to the fracture site but painless? Management

    A sign of non-union (pseudoarthorsis)

    Non union
    Non- Union Management

    • The fracture will never unites without intervention

    • Clinical features:

      • Movement can be elicited at the fracture site

      • Pain diminishes

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    • Causes: Management

      • Distraction and separation of fragments

      • Interposition of soft tissues between the fragments

      • excessive movements at the fracture site

      • Poor local blood supply

      • Severe damage to soft tissues

      • Infection

      • Abnormal bone

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    • Classification: Management

      • Hypertrophic (hypervascular)

      • Oligotrophic

      • Atrophic (avascular)

    Delayed union
    Delayed Union Management

    • The period in which the fracture is expected to unite and consolidate is prolonged

    • Causes (as non-union)

    • Clinical features:

      • Tenderness persists

      • Mobilization at the fracture site

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    • X-ray: Management

      • Fracture line visible

      • Little callus formation

      • Bone ends not sclerosed or atrophic

      • The appearance suggests the fracture has not united but eventually will

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    • Treatment: Management

      • Conservatives

        • Eliminate possible causes of delayed union

        • Promote healing i.e. immobilization

      • Operative

        • Internal fixator & bone grafting are indicated when there is delayed > 6 months & no sign of callus formation

    Take home message

    Take Home Message! Management

    • Read up the Anatomy!

    • Fracture – Types and Patterns

    • Reduce! Hold! Exercise!

    • Acute and Late Complications

    • Process of Fracture healing

    • Non Union Fracture – Classification, Clinical features and Management