Outline of fractureOutline of fracture

Li-dong WULi-dong WUDept. of Orthopaedic surgeryDept. of Orthopaedic surgery

2nd hospital of medical college, Zhejiang univer2nd hospital of medical college, Zhejiang universitysity

吴立东吴立东浙江大学医学院附属二院骨科浙江大学医学院附属二院骨科

Definition of fractureDefinition of fracture

Fracture:Fracture:A bone fracture (sometimes abbrA bone fracture (sometimes abbr

eviated Fx) is a medical conditieviated Fx) is a medical condition in which there is a break in ton in which there is a break in the continuity or the intact of thhe continuity or the intact of the bone. e bone.

Causes Causes

A bone fracture can be the result of high force iA bone fracture can be the result of high force impact or stress, or trivial injury as a result of cmpact or stress, or trivial injury as a result of certain medical conditions that weaken the boertain medical conditions that weaken the bones, such as osteoporosis, bone cancer, or ostnes, such as osteoporosis, bone cancer, or osteogenesis imperfecta, where the fracture is theogenesis imperfecta, where the fracture is then termed pathological fracture.en termed pathological fracture.

force direct forceforce direct force indirect forceindirect force

CumulativeCumulative or fatigue fracture or fatigue fracture

HistoryHistory Relieved in restRelieved in rest Periosteal reactionPeriosteal reaction Callus formationCallus formation Follow-upFollow-up

骨骼疾病骨骼疾病 pathological fracturepathological fracture The goal of fracture treatment is to obtaiThe goal of fracture treatment is to obtai

n union of the fracture in the most anaton union of the fracture in the most anatomical position compatible with maximal mical position compatible with maximal functional return of the extremityfunctional return of the extremity

Classification Classification

Closed fracture: are those in which the sClosed fracture: are those in which the skin is intact (kin is intact ( 闭合性骨折闭合性骨折 ))

Open fracture: involve wounds that comOpen fracture: involve wounds that communicate with the fracture, or where framunicate with the fracture, or where fracture hematoma is exposed, and may thcture hematoma is exposed, and may thus expose bone to contamination. (us expose bone to contamination. ( 开放开放性骨折性骨折 ) )

imcomplete fracture :A fracture in which the bonimcomplete fracture :A fracture in which the bone fragments are still partially joined (e fragments are still partially joined ( 不完全骨折不完全骨折 ) )

裂纹骨折裂纹骨折 (crack fracture)(crack fracture) 青枝骨折青枝骨折 (greenstick fracture): is a fracture in a (greenstick fracture): is a fracture in a

young, soft bone in which the bone bends and payoung, soft bone in which the bone bends and partially breaks. rtially breaks.

A person's bones become harder (calcified) and mA person's bones become harder (calcified) and more brittle with age. Greenstick fractures occur alore brittle with age. Greenstick fractures occur almost exclusively during infancy and childhood wmost exclusively during infancy and childhood when one's bones are soft. The name is by analogy hen one's bones are soft. The name is by analogy with green wood which similarly breaks on the ouwith green wood which similarly breaks on the outside when bent.tside when bent.

There are three basic forms of greenstick fracturThere are three basic forms of greenstick fracture. In the first a transverse fracture occurs in the. In the first a transverse fracture occurs in the cortex, extends into the midportion of the boe cortex, extends into the midportion of the bone and becomes oriented along the longitudinne and becomes oriented along the longitudinal axis of the bone without disrupting the oppal axis of the bone without disrupting the opposite cortex. The second form is a torus or bucosite cortex. The second form is a torus or buckling fracture, caused by impaction. The third ikling fracture, caused by impaction. The third is a bow fracture in which the bone becomes cs a bow fracture in which the bone becomes curved along its longitudinal axis.urved along its longitudinal axis.

complete fracture: A fracture in which bone fragments complete fracture: A fracture in which bone fragments separate completely. separate completely.

(transverse fracture): A fracture that is at a right ang(transverse fracture): A fracture that is at a right angle to the bone's long axis.le to the bone's long axis.

(oblique fracture):A fracture that is diagonal to a bo(oblique fracture):A fracture that is diagonal to a bone's long axis.ne's long axis.

(spiral fracture): A fracture where at least one part (spiral fracture): A fracture where at least one part of the bone has been twistedof the bone has been twisted

(splintered fracture)(splintered fracture) (impacted fracture)(impacted fracture) (compressed fracture):A fracture caused when bon(compressed fracture):A fracture caused when bon

e fragments are driven into each othere fragments are driven into each other 骨骺分离骨骺分离 (epiphyseolysis)(epiphyseolysis) 稳定性骨折（稳定性骨折（ stablestable ）） or or 不稳定性骨折（不稳定性骨折（ unstableunstable ））

Displacement of fractureDisplacement of fracture Force, direction Force, direction Weight of distal extremity Weight of distal extremity 骨折远端肢体的重量骨折远端肢体的重量 Traction of musclesTraction of muscles 肌肉牵拉力肌肉牵拉力 Inappropriate transportation and treatmentInappropriate transportation and treatment 不恰当的不恰当的

搬运及治疗搬运及治疗 displacementdisplacement 移位移位 angulationangulation laterallateral overlapoverlap bayonet appositionbayonet apposition rotationrotation

Clinical appearanceClinical appearance

general conditiongeneral condition shockshock feverfever local conditionlocal condition pain and tenderness pain and tenderness swelling and ecchymosis swelling and ecchymosis dysfunction dysfunction Three special signs of fractureThree special signs of fracture deformity, abnormal movement, crepitusdeformity, abnormal movement, crepitus

Diagnosis Diagnosis X-ray examinationX-ray examination radiographs can be requested to view the bone suspectradiographs can be requested to view the bone suspect

ed of being fractured.ed of being fractured. CT and MRICT and MRI A bone fracture can be diagnosed clinically, based on thA bone fracture can be diagnosed clinically, based on th

e history given and the physical examination performed e history given and the physical examination performed by a healthcare professional. Usually there will be an arby a healthcare professional. Usually there will be an area of swelling, abrasion, bruising and/or tenderness at tea of swelling, abrasion, bruising and/or tenderness at the suspected fracture site.he suspected fracture site.

Open fractures may be obvious if bone is exposed but sOpen fractures may be obvious if bone is exposed but small wounds may need surgical exploration to determinmall wounds may need surgical exploration to determine if they are only superficial or connected to the fracture.e if they are only superficial or connected to the fracture.

In situations where x-ray alone is insufficient, a computIn situations where x-ray alone is insufficient, a computed tomograph (CT scan) or MRI may be performed.ed tomograph (CT scan) or MRI may be performed.

Bone healing (Pathophysiology) Bone healing (Pathophysiology)

First 2 weeks (organization of hematomFirst 2 weeks (organization of hematoma) a)

4-8 weeks (primary callus formation)4-8 weeks (primary callus formation) including intramembranous ossification (iincluding intramembranous ossification (i

nternal callus and external callusnternal callus and external callus ---8-12 weeks (callus modeling period )---8-12 weeks (callus modeling period )

Bone healing (Pathophysiology)Bone healing (Pathophysiology) The natural process of healing a fracture starts when tThe natural process of healing a fracture starts when t

he injured bone and surrounding tissues bleed, forminhe injured bone and surrounding tissues bleed, forming a fracture Hematoma. The blood coagulates to form g a fracture Hematoma. The blood coagulates to form a blood clot situated between the broken fragments. a blood clot situated between the broken fragments. Within a few days blood vessels grow into the jelly-like Within a few days blood vessels grow into the jelly-like matrix of the blood clot. The new blood vessels bring matrix of the blood clot. The new blood vessels bring phagocytes to the area, which gradually remove the nphagocytes to the area, which gradually remove the non-viable material. The blood vessels also bring fibrobon-viable material. The blood vessels also bring fibroblasts in the walls of the vessels and these multiply and lasts in the walls of the vessels and these multiply and produce collagen fibres. In this way the blood clot is rproduce collagen fibres. In this way the blood clot is replaced by a matrix of collagen. Collagen's rubbery coeplaced by a matrix of collagen. Collagen's rubbery consistency allows bone fragments to move only a small nsistency allows bone fragments to move only a small amount unless severe or persistent force is applied.amount unless severe or persistent force is applied.

Bone healing (Pathophysiology)Bone healing (Pathophysiology) some of the fibroblasts begin to lay down bonsome of the fibroblasts begin to lay down bon

e matrix (calcium hydroxyapatite) in the form e matrix (calcium hydroxyapatite) in the form of insoluble crystals. This mineralization of the of insoluble crystals. This mineralization of the collagen matrix stiffens it and transforms it intcollagen matrix stiffens it and transforms it into bone. In fact, bone is a mineralized collagen o bone. In fact, bone is a mineralized collagen matrix; if the mineral is dissolved out of bone, imatrix; if the mineral is dissolved out of bone, it becomes rubbery. Healing bone callus is on at becomes rubbery. Healing bone callus is on average sufficiently mineralized to show up on verage sufficiently mineralized to show up on X-ray within 6 weeks in adults and less in childX-ray within 6 weeks in adults and less in childrenren

Bone healing (Pathophysiology)Bone healing (Pathophysiology)

This initial “woven” bone does not haThis initial “woven” bone does not have the strong mechanical properties of ve the strong mechanical properties of mature bone. By a process of remodelinmature bone. By a process of remodeling, the woven bone is replaced by mature g, the woven bone is replaced by mature “lamellar" bone. The whole process ma“lamellar" bone. The whole process may take up to 18 months, but in adults the y take up to 18 months, but in adults the strength of the healing bone is usually 8strength of the healing bone is usually 80% of normal by 3 months after the injur0% of normal by 3 months after the injury.y.

Bone healing (Pathophysiology)Bone healing (Pathophysiology) Several factors can help or hinder the bone healing prSeveral factors can help or hinder the bone healing pr

ocess. For example, any form of nicotine hinders the pocess. For example, any form of nicotine hinders the process of bone healing, and adequate nutrition (includrocess of bone healing, and adequate nutrition (including calcium intake) will help the bone healing process. ing calcium intake) will help the bone healing process. Weight-bearing stress on bone, after the bone has heaWeight-bearing stress on bone, after the bone has healed sufficiently to bear the weight, also builds bone strled sufficiently to bear the weight, also builds bone strength. The bone shards can also embed in the muscle ength. The bone shards can also embed in the muscle causing great pain. Although there are theoretical concausing great pain. Although there are theoretical concerns about NSAIDs slowing the rate of healing, there icerns about NSAIDs slowing the rate of healing, there is not enough evidence to warrant withholding the use s not enough evidence to warrant withholding the use of this type analgesic in simple fractures.of this type analgesic in simple fractures.

Fracture healing is a complex process that requires thFracture healing is a complex process that requires the recruitment of appropriate cell (fibroblasts, macrope recruitment of appropriate cell (fibroblasts, macrophages, chondroblasts, osteoblasts, osteoclasts) and thages, chondroblasts, osteoblasts, osteoclasts) and the subsequent expression of the appropriate genes (the subsequent expression of the appropriate genes (those that control matrix production and organization, hose that control matrix production and organization, growth factors, transcription factors) at the right time growth factors, transcription factors) at the right time and in the right anatomical location.and in the right anatomical location.

A fracture initiates a sequence of inflammation, repaiA fracture initiates a sequence of inflammation, repair, and remodeling that can restore the injured bone to r, and remodeling that can restore the injured bone to its original state within a few months if each stage of tits original state within a few months if each stage of this complex interdependent cascade proceeds undisthis complex interdependent cascade proceeds undisturbed. urbed.

In the inflammatory phase of fracture healing, In the inflammatory phase of fracture healing, a hematoma is formed from the blood vessels a hematoma is formed from the blood vessels ruptured by the injury. ruptured by the injury.

The reparative phase, which usually begins 4 oThe reparative phase, which usually begins 4 or 5 days after injury, is characterized by the invr 5 days after injury, is characterized by the invasion of pluripotential mesenchymal cells, whiasion of pluripotential mesenchymal cells, which differentiate into fibroblasts, chondroblasts,ch differentiate into fibroblasts, chondroblasts, and osteoblasts and form a soft fracture callu and osteoblasts and form a soft fracture callus. Proliferation of blood vessels (angiogenesis) s. Proliferation of blood vessels (angiogenesis) within the periosteal tissues and marrow spacwithin the periosteal tissues and marrow space helps route the appropriate cells to the fracte helps route the appropriate cells to the fracture site and contributes to the formation of a ure site and contributes to the formation of a bed of granulation tissue. bed of granulation tissue.

The transition of the fracture callus to woven bThe transition of the fracture callus to woven bone and the process of mineralization, which sone and the process of mineralization, which stiffens and strengthens the newly formed bontiffens and strengthens the newly formed bone, signal the beginning of the remodeling phase, signal the beginning of the remodeling phase, which may last for months or even years. The, which may last for months or even years. The woven bone is replaced by lamellar bone, the woven bone is replaced by lamellar bone, the medullary canal is restored, and the bone is re medullary canal is restored, and the bone is restored to normal or nearly normal morpholoestored to normal or nearly normal morphology and mechanical strength. Each of these stagy and mechanical strength. Each of these stages overlaps the end of the stage preceding it, ges overlaps the end of the stage preceding it, so fracture healing is a continuous process. so fracture healing is a continuous process.

During the complex fracture-repair process, four basic During the complex fracture-repair process, four basic types of new bone formation occur: osteochondral ostypes of new bone formation occur: osteochondral ossification, intramembranous ossificationsification, intramembranous ossification 膜内化骨膜内化骨 , op, oppositional new bone formation, and osteonal migratiopositional new bone formation, and osteonal migration (creeping substitution). The type, amount, and locatn (creeping substitution). The type, amount, and location of bone formed can be influenced by fracture type, ion of bone formed can be influenced by fracture type, gap condition, fixation rigidity, loading, and biological gap condition, fixation rigidity, loading, and biological environment. Research showed that cells subjected to environment. Research showed that cells subjected to compression and low oxygen tension differentiated incompression and low oxygen tension differentiated into chondroblasts and cartilage, while those under tento chondroblasts and cartilage, while those under tension and high oxygen tension differentiated into fibrosion and high oxygen tension differentiated into fibroblasts and produced fibrous tissue. blasts and produced fibrous tissue.

clinical union criterion clinical union criterion

Clinical unionClinical union occurs when progressively incre occurs when progressively increasing stiffness and strength provided by the miasing stiffness and strength provided by the mineralization process makes the fracture site stneralization process makes the fracture site stable and pain free. able and pain free.

Local criterion: no abnormal movement, no paLocal criterion: no abnormal movement, no pain and tenderness in and tenderness

Roentgenographic unionRoentgenographic union is present when plain is present when plain roentgenograms show bone trabeculae or cortroentgenograms show bone trabeculae or cortical bone crossing the fracture site. ical bone crossing the fracture site.

Factors affect the bone healingFactors affect the bone healing

general conditiongeneral condition age, health, age, health, local factorslocal factors 1. classification1. classification 2. blood supply2. blood supply ；； good in both fragmentsgood in both fragments poor in one of the fragmentspoor in one of the fragments poor in both fragments poor in both fragments fragments without blood supplyfragments without blood supply3. soft tissues injury3. soft tissues injury4. infection4. infection5. soft tissue embedded in fragments 5. soft tissue embedded in fragments

Factors affect the bone healingFactors affect the bone healing

inappropriate treatmentinappropriate treatmentrepeated manipulationrepeated manipulationopen reductionopen reductionover tractionover tractionfixation unreliabilityfixation unreliability inappropriate debridementinappropriate debridementinappropriate exerciseinappropriate exercise

clinical union criterionclinical union criterion

Functional criterion:Functional criterion: upper extremities holding weight 1KG ovupper extremities holding weight 1KG ov

er 1 minute;er 1 minute; lower extremities can walk 3 minutes ovlower extremities can walk 3 minutes ov

er 30 steps without assistant, er 30 steps without assistant, the fx site does not show any deformitiethe fx site does not show any deformitie

s in 2 weekss in 2 weeks

Emergent Treatment of fracturesEmergent Treatment of fractures

Save lives Save lives （（ The first consideration in managemeThe first consideration in management is the patient‘s general conditionnt is the patient‘s general condition ））

Bandaged wound Bandaged wound （（ Hemorrhage should be coHemorrhage should be controlled with pressurentrolled with pressure ）） . .

Properly fixedProperly fixed Rapid transportationRapid transportation

Principle of treatmentPrinciple of treatment

reductionreduction criterioncriterion anatomic reductionanatomic reduction functional reductionfunctional reduction rotation,bayonet apposition displacementrotation,bayonet apposition displacementoverlap displacementoverlap displacementangulation displacementangulation displacementlateral displacementlateral displacement

Reduction Reduction

Closed reductionClosed reduction Open reductionOpen reduction

Immobilization Immobilization

a fractured limb is usually immobilized a fractured limb is usually immobilized with a plaster or fiberglass cast or splint with a plaster or fiberglass cast or splint which holds the bones in position and iwhich holds the bones in position and immobilizes the joints above and below tmmobilizes the joints above and below the fracture. he fracture.

external fixationexternal fixation internal fixationinternal fixation

External FixatorExternal Fixator

Interfragmentary screw fixation alone is well Interfragmentary screw fixation alone is well suited for repair of avulsion fractures, in whicsuited for repair of avulsion fractures, in which shear forces cause epiphyseal and metaphyh shear forces cause epiphyseal and metaphyseal intraarticular fractures seal intraarticular fractures

If a screw is threaded its entire length, iIf a screw is threaded its entire length, it can function only as a positional scret can function only as a positional screw unless the near cortex is overdrilled sw unless the near cortex is overdrilled so that the threads purchase only in the o that the threads purchase only in the far cortex; then as the screw is tightenefar cortex; then as the screw is tightened, compression across the fracture line d, compression across the fracture line may be produced. If the screw is threadmay be produced. If the screw is threaded over only part of its length, with the ed over only part of its length, with the portion nearer the head being unthreaportion nearer the head being unthreaded, then compression across the fractded, then compression across the fracture line can be obtained without overdure line can be obtained without overdrilling the proximal cortex, but the threrilling the proximal cortex, but the threaded portion that has purchase should aded portion that has purchase should not cross the fracture line, or interfragnot cross the fracture line, or interfragmentary compression will not be possimentary compression will not be possible ble

Cannulated screws Cannulated screws are available from sare available from several companies. Feveral companies. For small fracture fraor small fracture fragments, the ideal prgments, the ideal provisional fixation freovisional fixation frequently is in the saquently is in the same location as the dme location as the desired definitive scresired definitive screw fixation. ew fixation.

Plates are used in conjunctioPlates are used in conjunction with interfragmentary scren with interfragmentary screw fixation and neutralize torsw fixation and neutralize torsional, bending, and shear forional, bending, and shear forces. These are used commonlces. These are used commonly in fractures with butterfly oy in fractures with butterfly or wedge-type fragments after r wedge-type fragments after interfragmentary screw fixatiinterfragmentary screw fixation of the wedge portion of thon of the wedge portion of the fracture e fracture

Dynamic and static locking of intramedullaDynamic and static locking of intramedullary nail.ry nail.

DirigationDirigation 功能锻炼功能锻炼 功能锻炼功能锻炼 DirigationDirigation 肌肉训练肌肉训练 Muscle strengthMuscle strength 关节活动训练关节活动训练 Joint movementJoint movement

RehabilitationRehabilitation We usually incorporate immobilization We usually incorporate immobilization

of adjacent joints with splints, braces, of adjacent joints with splints, braces, or foot attachments to external or foot attachments to external fixation systems. Physical therapy fixation systems. Physical therapy should include active and active-should include active and active-assisted exercises for joint assisted exercises for joint mobilization as soon as soft tissue mobilization as soon as soft tissue healing permits. The appropriate healing permits. The appropriate joints should be splinted in functional joints should be splinted in functional positions to avoid contractures. positions to avoid contractures.

RehabilitationRehabilitation Weight-bearing should be limited, depending on the sWeight-bearing should be limited, depending on the s

tability of fixation, the type of fixation and its inherent tability of fixation, the type of fixation and its inherent fatigue life, and the systemic condition of the patient. fatigue life, and the systemic condition of the patient. Progression of weight-bearing should be monitored roProgression of weight-bearing should be monitored roentgenographically according to evidence of stability entgenographically according to evidence of stability and bone regeneration. Range-of-motion and strengtand bone regeneration. Range-of-motion and strengthening exercises should be monitored and directed by hening exercises should be monitored and directed by the physician and physical therapist; however, the patthe physician and physical therapist; however, the patient should be instructed as to his responsibility for mient should be instructed as to his responsibility for maximal functional return of the extremity. aximal functional return of the extremity.

Classification of Soft Tissue InjuriesClassification of Soft Tissue Injuries The modified classification is based on the sizThe modified classification is based on the siz

e of the wound, periosteal soft tissue damage, e of the wound, periosteal soft tissue damage, periosteal stripping, and vascular injury. periosteal stripping, and vascular injury.

Type I have a clean wound less than 1 cm long.Type I have a clean wound less than 1 cm long. In type II wounds the laceration is more than 1 In type II wounds the laceration is more than 1

cm long but is without extensive soft tissue dacm long but is without extensive soft tissue damage, skin flaps, or avulsions. mage, skin flaps, or avulsions.

Classification of Soft Tissue InjuriesClassification of Soft Tissue Injuries

Type IIIA have extensive soft tissue lacerations or flaps Type IIIA have extensive soft tissue lacerations or flaps but maintain adequate soft tissue coverage of bone, obut maintain adequate soft tissue coverage of bone, or they result from high-energy trauma regardless of thr they result from high-energy trauma regardless of the size of the wound. This group includes segmental or e size of the wound. This group includes segmental or severely comminuted fractures, even those with 1-cm severely comminuted fractures, even those with 1-cm lacerations. lacerations.

Type IIIB have extensive soft tissue loss with periosteaType IIIB have extensive soft tissue loss with periosteal stripping and bony exposure. They usually are massil stripping and bony exposure. They usually are massively contaminated. vely contaminated.

Type IIIC include open fractures with an arterial injury Type IIIC include open fractures with an arterial injury that requires repair regardless of the size of the soft tithat requires repair regardless of the size of the soft tissue wound. ssue wound.

OPEN FRACTURESOPEN FRACTURES

life preservation, limb preservation, infection avlife preservation, limb preservation, infection avoidance, and functional preservation.oidance, and functional preservation.

OPEN FRACTURESOPEN FRACTURES The era of limb preservation encompassed botThe era of limb preservation encompassed bot

h World Wars but was marked by a high incideh World Wars but was marked by a high incidence of amputations and resulting interest in arnce of amputations and resulting interest in artificial limb prosthetic designs. dated the third tificial limb prosthetic designs. dated the third era as lasting until the mid-1960s, during whicera as lasting until the mid-1960s, during which time attention was focused on the avoidanch time attention was focused on the avoidance of infection and the use of antibiotics. the foe of infection and the use of antibiotics. the fourth era—functional preservation—characteriurth era—functional preservation—characterized by aggressive wound debridement, definitzed by aggressive wound debridement, definitive fracture stabilization with internal or exterive fracture stabilization with internal or external fixation, and delayed wound closure. nal fixation, and delayed wound closure.

Complications of fractureComplications of fracture

early stageearly stage shockshock infection, osteomyelitisinfection, osteomyelitis multiple system organs injurymultiple system organs injury blood vessel injuryblood vessel injury nerve injurynerve injury fat embollism syndromefat embollism syndrome osteofascial compartmentosteofascial compartment syndromesyndrome DVT Deep venous thrombosis or PEDVT Deep venous thrombosis or PE

Complications of fractureComplications of fracture

middle or late stagemiddle or late stage hypostatic pneumoniahypostatic pneumonia bedsorebedsore myositis ossificationmyositis ossification traumatic arthritistraumatic arthritis Anchylosis or stiffnessAnchylosis or stiffness acute bone atrophyacute bone atrophy ，， Sudeck’s atrophySudeck’s atrophy ischemic bone necrosisischemic bone necrosis ischemic muscle contractureischemic muscle contracture

Deep venous thrombosis, pulmonary embolism PE are the Deep venous thrombosis, pulmonary embolism PE are the most common causes of morbidity and mortality in orthopamost common causes of morbidity and mortality in orthopa

edic patientsedic patients

Hemodynamic changes (stasis, turbulence

Endothelial injury/dysfunction

Hypercoagulability

cementcoagultorniqueposition

Positiontorniquepain,restedemaOperation

Injurykidney

InfectionTumorPreganentdrug

VIRCHOWS triad

Delay union, ununion and malunionDelay union, ununion and malunion

delay uniondelay union 骨折经过治疗，超过通常愈合所需要的时间（骨折经过治疗，超过通常愈合所需要的时间（ 4-8month4-8month

ss ），骨折端仍未出现连接），骨折端仍未出现连接 nonunionnonunion 超过通常愈合时间，再度延长治疗时间（超过通常愈合时间，再度延长治疗时间（ 8months8months ），），

仍达不到骨性愈合仍达不到骨性愈合 Nonunion is permanent failure of healing following a brNonunion is permanent failure of healing following a br

oken boneoken bone malunionmalunion healing of the fracture in a distorted positionhealing of the fracture in a distorted position 愈合后未达到功能复位的要求，存在成角、旋转、重叠或愈合后未达到功能复位的要求，存在成角、旋转、重叠或

短缩畸形短缩畸形

The choice of fracture treatment is The choice of fracture treatment is not a clear-cut decision because of not a clear-cut decision because of the number of treatment options the number of treatment options available. Each has its benefits and available. Each has its benefits and potential complications. A thorough potential complications. A thorough knowledge of the underlying knowledge of the underlying principles is essential to determining principles is essential to determining the right procedure to be done at the the right procedure to be done at the right time. right time.

Injury of physis and the epiphysisInjury of physis and the epiphysis

cessation of growth and resultant angular dcessation of growth and resultant angular deformitieseformities

Salter and Harris classification ( based on thSalter and Harris classification ( based on the x-ray appearance of the fracture). This clae x-ray appearance of the fracture). This classification depicts the amount of involvemessification depicts the amount of involvement of the physis, the epiphysis, and the joint.nt of the physis, the epiphysis, and the joint. The higher the classification, the more likel The higher the classification, the more likely is physeal arrest or joint incongruity to ocy is physeal arrest or joint incongruity to occur.cur.

Injury of physis and the epiphysisInjury of physis and the epiphysis

Type I--epiphyseal separations through the physis only, Type I--epiphyseal separations through the physis only, with or without displacement. Stress roentgenograms awith or without displacement. Stress roentgenograms are useful in determining whether this fracture is present. re useful in determining whether this fracture is present.

Type II--a metaphyseal spike attached to the separated Type II--a metaphyseal spike attached to the separated epiphysis with the separation also through the physis. epiphysis with the separation also through the physis.

Type III is a physeal separation with a fracture through tType III is a physeal separation with a fracture through the epiphysis into the joint with joint incongruity when thhe epiphysis into the joint with joint incongruity when the fracture is displaced.e fracture is displaced.

Type IV is a fracture through the metaphysis, through thType IV is a fracture through the metaphysis, through the physis, through the epiphysis, and into the joint, also e physis, through the epiphysis, and into the joint, also with possible joint incongruity. with possible joint incongruity.

Type V fracture, which can be diagnosed only in retrospType V fracture, which can be diagnosed only in retrospect, is a compression fracture of the physis, producing pect, is a compression fracture of the physis, producing permanent damage. ermanent damage.

Fractures involving joints or physes may requirFractures involving joints or physes may require internal fixation to maintain alignment of the internal fixation to maintain alignment of the articular surfaces and physes. Usually Kirsche articular surfaces and physes. Usually Kirschner wires or limited internal fixation with or winer wires or limited internal fixation with or without external fixation is sufficient to accomplithout external fixation is sufficient to accomplish this purpose without introducing much foresh this purpose without introducing much foreign material. If possible, treat the soft tissues aign material. If possible, treat the soft tissues and the wound, allow the soft tissues to heal, and the wound, allow the soft tissues to heal, and then proceed with open reduction and intend then proceed with open reduction and internal fixation of intraarticular fractures through rnal fixation of intraarticular fractures through a clean surgical wound. a clean surgical wound.

Joint dislocationJoint dislocation, , luxationluxation

occurs when bones in a occurs when bones in a jointjoint become dis become displaced or misaligned. It is often caused placed or misaligned. It is often caused by a sudden impact to the joint. The ligaby a sudden impact to the joint. The ligaments always become damaged as a resments always become damaged as a result of a dislocation. A subluxation is a pault of a dislocation. A subluxation is a partial dislocation. rtial dislocation.

Knee dislocation. Knee dislocation. A,A, Anterior dislocation. Anterior dislocation. B,B, Reduced anterior dislocation. Reduced anterior dislocation. C,C, Lateral Lateral dislocation. dislocation. D,D, Anterior dislocation Anterior dislocation

The shoulder, by virtue of its anatomy and The shoulder, by virtue of its anatomy and biomechanics, is one of the most unstable and biomechanics, is one of the most unstable and frequently dislocated joints in the body, frequently dislocated joints in the body, accounting for nearly 50% of all dislocations. accounting for nearly 50% of all dislocations.

A dislocated joint usually can only be successfully 'redA dislocated joint usually can only be successfully 'reduced' into its normal position by a trained medical prouced' into its normal position by a trained medical professional.fessional.

X-rays are usually taken to confirm a diagnosis and deX-rays are usually taken to confirm a diagnosis and detect any fractures which may also have occurred at thtect any fractures which may also have occurred at the time of dislocation. A dislocation is easily seen on an e time of dislocation. A dislocation is easily seen on an X-ray.X-ray.

Once a diagnosis is confirmed, the joint is usually manOnce a diagnosis is confirmed, the joint is usually manipulated back into position. This can be a very painful ipulated back into position. This can be a very painful process, therefore this is typically done either in A&E uprocess, therefore this is typically done either in A&E under sedation or in an Operating Room under a genernder sedation or in an Operating Room under a general anaesthetic.al anaesthetic.

Thank you very much fThank you very much for your attention!!!or your attention!!!