fractures

There are many ways to describe a fracture. A thorough understanding of the basics is necessary before addressing specific fractures.

Fractures can be classified based upon location (e.g., proximal, middle and distal thirds), direction (transverse, spiral, oblique, comminuted, segmental), alignment (angulation [apex], displacement [of distal fragment], articular involvement), and associated factors (open fractures, dislocations, etc.), and classified by a variety of schemes. Many factors come into play in the description and ultimate management of fractures.

The mechanism of injury provides important clues to the nature of the injury and may even be used in the classification schemes for those injuries (e.g., ankle and spine fractures).

For example, traction injuries result in avulsion fractures, compression forces yield angulated or T-type fractures, and rotational forces cause spiral fractures.

A fracture is a break in a bone

It can be open (to air) or closed

It can be transverse, oblique or comminuted

It can be at the end or the middle of a bone

Describe displacement as tilt (angulation), shift (% loss of end to end contact) or twist (rotation, too difficult).

The patient may be young (< 14 years), co-operative or unwell, the bone maybe abnormal (pathological).

Why treat it

To prevent muscle spasm (pain) and malunion.

Fracture blisters

Supracondylar fracture humerus in child - the most difficult fracture - requires traction and expert judgement.

How to treat it

Save patient. Save limb. Debride and later (closure) soft tissues. Reduce (closed, manipulation, or open, surgery) and hold (externally with POP or external fixateur or internally with screw, plates, rods).

Fracture Healing 5 phases .

Haemorrhage (minutes),

granulation tissue (hours),

forget days,

immature callus (weeks, clinical union),

mature callus (months, x-ray union) and

re-modelling (years).

Complications

Late is secondary osteoarthritis. Early is: general (death, fat embolism, DVT, pneumonia) or local (skin: blisters, pressure areas, necrosis, RSD; nerves: - neuro proxia/axonotmesis/ neurotmesis; tendons torn or trapped;, blood vessels blocked with ischaemia, no pulse, or venous swelling; muscles: compartment syndrome with pain at rest / paraesthesia / pain on movement; bone healing. Bone healing be slow to heal (delayed union), won’t heal (non-union), can’t heal (necrosis) or heal crooked (malunion).

Fractures just about always operated on

Multiple trauma, pathological fractures, fractures of femur, displaced fractures into joints or of forearm.

Fractures just about never operated on

Children’s fractures (except of hip), tibial shaft fractures, clavicle fractures.

Try not to operate on

The disturbed, drug addicts, and unreliable people.

Open Fractures (See POT)

Open fractures, whether obvious or subtle, always communicate with the environment. Special consideration should be given to these injuries. Infection and poor healing are frequently the consequences of open fractures (although less so with hand injuries because of an excellent blood supply). Formal careful debridement and irrigation (ideally within 4-8 hours of the injury), IV antibiotics (consisting of a first - or second-generation cephalosposrin and an aminogly-coside [and penicillin for barnyard or clostridium infections]) for 48 hours and after each subsequent procedure, appropriate immobilisation and fixation, and careful wound management will reduce these risks. Early flap coverage (48 hours to 1 week after injury) has also been shown to reduce risk of chronic infections.

Classification - Based on the size of the wound and amount of soft tissue injury (Gustilo): I (< 1cm), II (> 1cm), III (extensive soft tissue with nerve and blood vessel injury).

Gunshot Wounds (GSWs) - Often result in open fractures.

Debridement with lavage in the operating room is essential

General Treatment Principles

Guidelines

Treatment of orthopaedic injuries must follow adequate stabilisation of the patient (life before limb). An adequate airway should be secured before checking for pulses and bleeding.

Nasotracheal intubation is recommended in breathing patients with cervical spine injuries; oral endotracheal intubation with in line traction is favored for all nonbreathing patients.

A chest x-ray should be checked for mediastinal widening and pneumo - or hemothorax, and the C-spine must be evaluated prior to proceeding to the secondary survey.

The Trauma Score (based on respiratory, cardiovascular, and neurological parameters) is predictive of injury severity and prognosis.

The most common abdominal injuries include rupture of the spleen followed by liver injuries (10-20% mortality rate).

Diagnostic peritoneal lavage is favored over CT for abdominal assessment. Pericardial tamponade should be suspected with a narrow pulse pressure and an elevated diastolic blood pressure. IVP studies are indicated for gross hematuria only.

Head injuries are the most common cause of early death with trauma (Glasgow Coma Scale score <8 being severe).

Haemorrhage can occur from ruptured viscera and is also commonly seen with pelvic fractures (see page Manual Sports Medicine).

The orthopaedic surgeon plays a key role in these latter injuries with early application of external fixation to select pelvic fractures.

Once stabilised, the patients should be carefully assessed for extremity injuries which should be reduced and stabilised.

Determining the mechanism of injury, careful physical exam, and obtaining appropriate radiographs should be done in every trauma patient.

Reduce -

Generally, less than anatomic reduction is better than angulation in reduction of fractures. Joint surface involvement demands near-anatomic reduction.

Age and function of the patient is important in considering the goals in reduction.

Reduction can be closed (manipulation or traction) or open (usually combined with internal fixation).

Manipulative reduction usually involves exaggeration of the mechanism of injury followed by reversal of these forces. Traction, often applied to the femur or cervical spine through weights and skeletal fixation, may be temporary or prolonged. Open reduction, either primarily or after failure of other methods, should restore the fracture to as near anatomic alignment as possible.

fracture talk.

Hold (immobization) -

Used to prevent displacement or angulation, to decrease movement at the fracture site, or to relieve pain. Immobilisation can be through casting, splinting orthotics, traction, external fixation, or internal fixation. Internal fixation is indicated when closed methods have failed.

Restoration of Function - Rehabilitation during and after fracture treatment is essential for good results.

Fracture Healing is by formation of haematoma (within minutes) granulation tissue (hours) immature callus ( 4 to 6 weeks) mature callus (months) and re-modelling (years).

Radiographs

Standard AP and lateral radiographs, to include the joint above and below the fracture level, are the minimal requirement for most fractures. Special fractures require special x-rays but best to train yourself to get most of your information from AP + lat. views).

Complications

Complications occur commonly following trauma, and can be a direct result of the injury (intrinsic) or can be associated with other organ systems (extrinsic). General complications are discussed in this section;

Bone Healing Problems - Include delayed union, nonunion, malunion, and avascular necrosis. More common with high-energy injuries and in bones with limited blood supply/healing potential. (eg. scaphoid, head of femur).

Delayed Union/Nonunion - Although the distinction is not always clear, fractures that still allow free movement of the bone ends at 3-4 months after injury demonstrate delayed union, and if this persists (usually for more than 6 months) then a diagnosis of nonunion can be made. Too much or too little motion at the fracture site, excessive space between fracture fragments, inadequate fixation, infection, soft tissue interposition, inadequate blood supply, and many other factors can lead to delay in bone healing. Nonunions are classified as hypervascular (hypertrophic) or avascular (atrophic) based upon their capability of biologic reaction (vitality of the bone ends).

Malunion - Union in a clinically significant imperfect position. Initial fracture care is critical to help avoid this result, but it often cannot be avoided.

Avascular Necrosis - Caused by disruption of the blood supply and can lead to nonunion, osteoarthritis, collapse, and other problems. It is more common with intra-articular fractures, especially of the femoral head/neck, femoral cordyles, proximal and talar neck.

Infection

Usually is a complication of open fractures and can lead to osteomyelitis (often chronic involvement of joints leads to persistent pain, stiffness, and progressive concentric joint space narrowing. Soft tissue infections may produce soft tissue air on radiographs from gangrene (Clostridium - a gram-positive anaerobe) and gas-producing gram-negative organisms. The most critical factor in avoiding infection in open injuries is

adequate debridement. Prophylactic antibiotics for grade III open fractures should include a first-generation cephalosporin, penicillin, and an aminoglycoside. Tetanus (caused by Clostridium tetani) can lead to devastating systemic complications and requires early treatment with boosters and toxoid for susceptible injuries.

Soft Tissue Injuries

Include direct injuries to vessels, nerves, and soft tissues as well as indirect compromise of these tissues.

Arterial Injury.

Compartment Syndrome

Increased pressure within enclosed soft tissue compartments of the extremities can lead to serious sequelae. Elevated compartment pressures commonly follow significant injuries to the forearm and leg and should be diagnosed early with careful patient monitoring. Pain (especially with passive flexion of the digits) is the earliest and most reliable indicator, but pallor, paralysis, paraesthesia, and pulselessness are also indicative of elevated pressures.

Nerve Injuries.

Compartment syndrome fasciotomy

Pulmonary Complications

Adult Respiratory Distress Syndrome (ARDS) - Pulmonary edema and decreased function commonly follow severe trauma. ARDS can be a result of direct (aspiration, inhalation, etc.) insults.

Fat Emboli Syndrome (FES) - A form of ARDS that follows major long bone fractures (0.5-2% of patients with multiple fractures).

Pulmonary Embolism - Thromboembolic disease is the most on complication following surgery on the extremities.

Bleeding Disorders - (DIC).

GI Complications - Can be a result of the trauma itself (the spleen is the most commonly injured organ with blunt trauma.)

Reflex Sympathetic Dystrophy (RSD) - Pain, swelling, discoloration, and stiffness of the affected extremity.

Late Complications - Can be systemic or involve local soft tissue, bones, and joints. Myosotis ossificans can follow injuries. Posttraumatic osteoarthritis. Immobilisation hypercalcemia.

Pathologic Fractures

Pathologic fractures occur through abnormal bone. Most of these fractures involve the elderly (osteoporosis is the most common cause), but should be suspected in any patient when minimal trauma causes a major fracture. Repeated fractures, a history of prior malignancies, increased pain, and patients with metabolic disorders.

Systemic Skeletal Disease.

Benign Local Lesion - Generally should be removed after fracture healing if it caused a pathologic fracture (except in the hand).

Malignant Primary Bone Disease.

Metastatic Disease - The second most common cause of pathologic fractures. The most common primary tumours involved are breast, lung, thyroid, prostate, and kidney.

Stress Fractures - Stress fractures are the result of repetitive loading below the yield strength and are in elderly women (insufficiency fractures), athletes, and military recruits (fatigue fractures), steroid use.

Soft Tissue Trauma

Snake Bites

Thermal Injuries

Electrical Injuries.

High-Pressure Injection Injuries.

Quick review of all fractures

Orthopaedics starts at tip of odontoid process. Cervical spine reduce: hold in traction/collar, exclude neuro loss; thoracic spine: high neuro loss; lumbar spine: seldom operate. Pelvis maybe life threatening (give blood). Fractures of hip and femur need ORIF, most foot fractures need reduction with K-wire fixation. Fractures clavicle need sling, shoulder and humerus are forgiving, elbow fractures often need ORIF, forearm fractures often need ORIF, colles fractures closed reduction, most hand fractures closed reduction with K-wire fixation. Growth plate (end of bones) injuries in children may result in growth arrest and shortening or angulation of limb (use Salter Harris classification).

Never apply a full POP to a new fracture; always follow up all fractures.

Know how to reduce a Colles fracture and a shoulder dislocation before finishing medical school.

Salter-Harris fractures

classification of epiphyseal fractures

pure epiphyseal separation

if non-displaced, jt effusion may be only sign

metaphyseal fracture + epiphyseal separation

III

epiphyseal fracture

vertically oriented fx thru epiphysis + metaphysis

crush injury of epiphysis (not detected acutely)

most common: type II

type I (best) --> type V (worst)

seen in kiddies before the physes close

scoliosis

1. idiopathic adolescent

9:1 F:M

12-18y

2. painful - osteoid osteoma of a pedicle

3. post radiation - rx of Wilm's tumor on affected side

d/t cartilage damage

proportional to dose

worse if rx at younger age

shoulder dislocation

anterior (subcoracoid)

humerus --> beneath coracoid process, anterior to glenoid

most frequent site + type of dislocation of any joint

easily detected

repeated dislocation ==> Hill-Sachs deformity and/or Bankart deformity

posterior

2 - 4% of shoulder dislocations

50% d/t seizures; trauma, electrical shock

often missed on AP view: use "Y" or axillary view

"rim" sign in acute dislocation

increased glenohumeral space (normal 6 mm --> widened to 14 mm)

+/- compression fx of anterior surface of humeral head

20% ==> associated fx

Hill-Sachs deformity

indentation or groove on posterolateral aspect of humeral head

probably d/t compression of humeral head on posterior lip of glenoid

may occur after one episode of shoulder dislocation

a/w: Bankart lesion of glenoid

tear drop fracture

avulsion of anterioinferior corner of cervical vertebral body by anterior ligament

most severe and unstable injury of the C-spine

often the result of diving into shallow water

may be secondary to hyperflexion or hyperextension

typically at C2

see: cervical spine fractures

wrist fractures

Colles

fx distal radius

DORSAL angulation of distal fragment

Smith

fx distal radius ("reverse Colles")

volar angulation of distal fragment

Barton

intra-articular fx thru DORSAL aspect of radius

"ventral Barton": thru VENTRAL aspect

chauffeur's

fx of radial styloid (intra-articular)

Colles fracture

radial fracture in distal 2 cm

+/- ulnar styloid fracture

dorsal displacement of distal fragment

"silver-fork" deformity

most common fracture in this region

mechanism: fall on an outstretched hand

complication: post-traumatic arthritis

Barton fracture

intra-articular fracture of distal radius

dorsal displacement of separated fragment

due to fall on outstretched hand

chauffeur's fracture

radial styloid fracture due to direct blow

(so named because of trauma from hand-cranked starters

Piedmont fracture

closed fracture of radius

at the junction of the middle and distal thirds

no associated ulnar fracture

due to direct blow

Monteggia fracture

angulated fracture at the junction of the proximal and middle third of ulna accompained by ANTERIOR dislocation of the radial head

etiology:

transmission of force thorugh the hand and forearm with the elbow partially flexed

interosseous ligament "drags" the radius with the distal two-thirds of the ulna

MUGR mnemonic

Monteggia with ulna (proximal)

Galeazzi with radius (distal)

Malgaigne fracture

two vertical fractures involving one side of the pelvic ring

one fracture anterior to the acetabulum

usually through the pubic ramus

one fracture posterior to the acetabulum

usually through the ilium

separation of the SI joint may occur instead

usually the result of direct trauma

march fracture

stress or fatigue fracture of the metatarsals

seen in military recruits (a/w marching

LisFranc fracture-dislocation

tarsal-metatarsal fracture-dislocation

trauma

diabetes (neuropathic)

Little Leaguer's elbow

avulsion fx of MEDIAL epicondyle

see also:

atlas fractures

cervical spine fractures

atlas fracture

incidence: 4% of cervical spine injuries

site:

posterior arch

anterior arch

massa lateralis

Jefferson fracture

associated with:

fractures of C7 (25%)

fractures of C2 pedicle (15%)

extraspinal fractures (58%)

cervical spine fractures

HYPERFLEXION INJURY (46-79%)

odontoid fracture

simple wedge fracture (stable)

tear drop fracture

anterior subluxation

bilateral locked facets (unstable)

anterior disc space narrowing

widened interspinous distance

clay shoveler's fracture

HYPEREXTENSION INJURY (20-38%)

anteriorly widened disc space

prevertebral swelling

tear drop fracture

neural arch fracture of C1

subluxation (anterior/posterior)

hangman's fracture

FLEXION-ROTATION INJURY (12%)

unilateral locked facets (stable)

VERTICAL COMPRESSION (12%)

Jefferson fracture

burst fracture

LATERAL FLEXION/SHEARING (4-6%)

uncinate fracture

isolated pillar fracture

transverse process fracture

lateral vertebral compression

LOCATION (by frequency):

C2,C6 > C5,C7 > C3,C4 > C1

hangman's fracture

bilateral fracture of pedicles of axis (C2)

hamate fracture

a/w racquet-sport injury

best evaluated by CT

Galeazzi fracture

fracture of the radius at the junction of the middle and distal thirds, with associated subluxation of the distal ulna

forearm fractures

Monteggia

proximal ulnar fx

dislocated radial head

Galeazzi

radial fx

dislocated distal ulna

mnemonic: "MUGR" (Monteggia ulna, Galeazzi radius)

Monteggia More common

Essex-Lopresti fracture

comminuted fracture of radial head

dislocation of distal radio-ulnar joint

due to longitudinal compression force

Bennett fracture

mechanism: forced abduction of thumb

findings:

intraarticular fracture/dislocation of the base of the 1st metacarpal at the ulnar aspect

small fragment of metacarpal continues to articulate with the trapezium

lateral retraction of metacarpal shaft by abductor pollicis longus

difficult to keep in anatomical alignment

complication: pseudoarthrosis

better prognosis than Rolando fracture

thumb fractures

base of 1st metacarpal

Bennett

ULNAR side

Rolando

RADIAL side (mnemonic "R=R")

base of 1st proximal phalanx

Gamekeeper

avulsion fx

arthrodesis

Fracture Types of the Diaphyseal Segment

They are either «simple» (type A) or «multi-fragmentary». Multifragmentary fractures are either «wedge fractures» (type B) or «complex» fractures (type C).

Fracture Types of the Proximal and Distal Segments

They are either «extra-articular» (type A) or «articular». The articular fractures are either «partial articular» (type B) or «complete articular» (type C).

Exceptions. The 3 exceptions are: the proximal humerus (A= extra-articular unifocal, B = extra-articular bifocal, and C = articular), the proximal femur (A = trochanteric area, a = neck, C = head), and the malleolar segment (A = infrasyndesmotic, B = transsyndesmotic, and C = suprasyndesmotic).

Remark: A long bone is usually divided into two epiphyseal, two metaphyseal, and one diaphyseal

Humerus Proximal

A1 Extra-articular unifocal fracture, tuberosity

.1 greater tuberosity, not displaced

.2 greater tuberosity, displaced

.3 with a glenohumeral dislocation

A2 Extra-articular unifocal fracture, impacted metaphyseal

.1 without frontal malalignment

.2 with varus malalignment

.3 with valgus malalignment

A3 Extra-articular unifocal fracture, non-impacted metaphyseal

.1 simple, with angulation

.2 simple, with translation

.3 multifragmentary

B1 BA extra-articular bifocal fracture, with metaphyseal impaction

.1 lateral + greater tuberosity

.2 medial + lesser tuberosity

.3 posterior + greater tuberosity

B2 Extra-articular bifocal fracture, without metaphyseal impaction

.1 without rotatory displacement of the epiphyseal fragment

.2 with rotatory displacement of the epiphyseal fragment

.3 multifragmentary metaphyseal + one of the tuberosities

B3 Extra-articular bifocal fracture, with glenohumeral dislocation

.1 "vertical" cervical line + greater tuberosity intact + anterior and medical dislocation

.2 "vertical" cervical line + greater tuberosity fractured + anterior and medial dislocation

.3 lesser tuberosity fractured + posterior dislocation

C1 Articular fracture, with slight displacement

.1 cephaotubercular, with valgus malalignment

.2 cephalotubercular, with varus malalignment

.3 anatomical neck

C2 Articular fracture, impacted with marked displacement

.1 cephalotubercular, with valgus malalignment

.2 cephalotubercular, with varus malalignment

.3 transcephalic and tubercular, with varus malalignment

C3 Articular fracture, dislocated

.1 anatomical neck

.2 anatomical neck and tuberosities

.3 cephaltubercular fragmentation

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