Principles of fractures A fracture is a break

Principles of fractures

A fracture is a break in the structural continuity of bone. It may be closed if the skin is intact or compound if the fracture haematoma connected to the surface of the skin or one of the body cavities.

How fracture happed v v v trauma (direct or indirect) repetitive stress. abnormal weakening of the bone (pathological). Green stick fracture. Physeal injuries.

Types of fractures: 1. Fractures due to trauma: Types of fractures in trauma depend on the force applied:

1. Fractures due to trauma: Types of fractures in trauma depend on the force applied:

2. Fatigue or stress fractures: Is the one occurring in the normal bone of a healthy patient due to repetitive stress rather than single traumatic evidence. n Most common sites affected pubic rami , femoral neck , tibial shaft especially in trainee and athletes , distal fibula , metatarsals especially the second. n

3. Pathological fractures: n When abnormal bone gives way. The causes are numerous but the diagnosis not made till biopsy taken.

Causes: n 1. 2. 3. 4. 5. General bone disease osteogenesis imperfecta postmenopausal osteoporosis metabolic bone disease multiple myeloma paget disease

Local benign conditions 1. 2. 3. 4. 5. chronic infection solitary bone cyst fibrous cortical defect aneurysmal bone cyst chondroma

Primary malignant tumours 1. chondrosarcoma 2. osteosarcoma 3. Ewing's tumour Metastatic tumours n Carcinoma from breast, lung, thyroid, kidney …. etc

Clinical features: History: fracture after trivial trauma, ask about previous illnesses and operations, malignant tumours even if old history in the past , malabsorption , chronic alcoholism or prolonged drug therapy suggest metabolic bone disease. Weight loss, pain, lump, cough, haematuria. In younger patients a history of several previous fractures may suggest osteogenesis imperfecta.

Examination: local signs of bone disease (infected sinus, old scar, swelling or deformity) General examination Cushing' syndrome, Paget disease characteristic appearance, the patient may be wasted, liver or LN enlargement. and general examination accordingly. n XR : midshaft fractures in femur or humerus in elderly patients , any cyst or loss of trabeculation any osteolytic n

Investigations: n n n XR of other regions accordingly. Blood investigation: always should include full blood count, ESR , and according to the disease. Urine examination : for RBCs , Bence – Jones protein for m. myeloma. Scanning: whole body scan to exclude other deposits. Biopsy: some times essential for uncertain lesions. And if open reduction done biopsy can be taken easily.

Treatment: Reduce, hold , exercise. n Usually needs internal fixation, but some times can be treated conservatively. n

4. Incomplete fractures (Greenstick fractures) n In which instead of complete fracture of the bone cortex the bone is buckled or bent {like snapping a green twig} this usually seen in children.

5. Injuries to the physis: In children over 10 % of fractures involve the physis. Classification: Salter and Harris classification n Type 1 a transverse fracture across the physis the prognosis is good. n Type 2 like type 1 but on one end there is a triangular piece of the metaphysis the prognosis is good. n Type 3 the fracture split the physis than pass transversely across one side through the physis. n Type 4 like type 3 but the splitting cross the physis towards the metaphysis the prognosis is bad. n Type 5 a longitudinal compression injury to the physis the fracture is not seen at the time of injury but detected retrospectively when its disturbance to the growth is seen.

XR: may need compression to the other side to be detected. n Treatment: if undisplaced treated by splinting the limb , for 2 – 4 wks. If displaced gentle manipulation is important than immobilization for 3 – 6 wks. If type 3 or 4 can not reduced accurately open reduction and internal fixation by smooth k – wire is important. n

Compound fractures Is when the fracture hematoma connects to the skin or one of the body cavities. It usually classified according to Gustillo classification.

Gastillo classification: G. 1 : penetrating wound from within(by spike of bone) less than 1 cm. G. 2: Wound >1 cm but Less than 10 cm. G. 3 A: adequate soft tissue coverage. G. 3 B: inadequate soft tissue covering. G. 3 C: neurovascular injuries regardless the soft tissue covering.

How fractures are displaced: After complete fracture the bones may displaced by the effect of gravity or the pull of the muscles attached. n translation (shift) n alignment (angulation) n rotation (twist) n

How fracture heal n 1. 2. 3. Fractures heal even if not splinted but we splint it for: Alleviate pain To ensure that union takes place in good position To permit early movement and return of function.

Five stages of healing: 1. 2. 3. 4. 5. tissue distraction and haematoma formation. inflammation and cellular proliferation {within 8 hours of fracture} which bridged the fracture and haematoma slowly absorbed. callus formation {the thick cellular mass with its island of immature bone and cartilage forms the callus or splint on the periosteal and endosteal surfaces. consolidation {osteoblastic and osteoclastic activity the woven bone transformed to lamellar bone. It may take several months. remodeling thicker lamellae are laid down where stresses are high unwanted buttresses are carved away, the medullary cavity is reformed. The bone especially in children reassume something like its normal shape.

Fracture healing calendar: the upper limbs in children in general 3 Wks The lower limbs in children Double the time i. e. 6 wks The upper limbs in adults Double the time needed in children i. e. 6 wks The lower limbs in adults Double the time needed in children i. e. 12 wks

Clinical features: History: v usually history of injury , followed by inability to use the injured limb. v The fracture may be away form the site of injury: a blow to the knee may fracture the patella , the femoral condyles , the shaft or even the acetabulum. v The patient age and mechanism of injury is important. v If the fracture follow a trivial trauma suspect a pathological fracture. v Pain , swelling , bruising are common symptoms. Deformity is more suggestive. v Ask about associated injuries. v General medical and surgical histories are important.

Examination: General signs: v A, B, C. cervical spines injuries should be excluded. And general survey. Local signs: v Crepitus or abnormal movement may be noted. v Examine the most obvious injured part. v Test for artery and nerve damage. v Look for associated injuries in the region. v Look for associated injuries in distal parts.

Look : swelling , bruising and deformity , is the skin intact is it broken and the wound communicate with fracture the injury is then open or compound. Feel : the injured part is gently palpated for localized tenderness. Check for distal pulse and nerve function. Move : crepitus and abnormal movement is tested.

X – Ray The rule of two: a Two views the fracture may not be seen in single view (anteroposterior and lateral views are important) a Two joints in the leg or forearm the bone may be fractured angulated, angulation may associated with fracture of the other bone or dislocation so the joint above and below should be taken. a Two limbs as in children where comparism of the shape of the immature epiphysis on each side is important. a Two injuries sever injury cause injuries in more than one level. So in fracture of the calcanium or femur it is important to XR the pelvis and spine. a Two occasions some fractures not seen at the time of injury but only one or two weeks later as in fracture scaphoid or stress fractures.

Special imaging Some times the fracture not seen in usual XR so do: v Tomography as in spine. v CT v MRI may be the only way to show whether the fractured vertebra compress the spinal cord. v Radioisotope scan is helpful in stress fractures.

Treatment of closed fractures: Three important rules: Ó reduce Ó hold Ó exercise generally the healing of the fracture depends on the state of the surrounding soft tissues and the local blood supply, a transverse fracture is slow to join because the area of contact is small; it the broken surfaces are accurately apposed, the fracture is stable on compression. A spiral fracture joins more rapidly because the contact area is larger; but not stable on compression. Comminuted fractures are often slow to join because they associated with more sever soft-tissue damage and because they are unstable.

Reduce: n n Reduction should aim for adequate apposition and normal alignment of the bone fragments. The greater the contact surface area between the fragments the more likely the healing to occur. So gap lead to delay union or non union. If the alignment is good some overlap at the fracture surfaces is permissible. This rule is not true for the fractures involve the articular surfaces otherwise early osteoarthritis occur due to the irregularity of the joint surface. There are two methods of reduction:

closed reduction: under proper anesthesia and muscle relaxation the fracture reduced by 1. the distal part of the bone is pulled in line of the bone 2. as the fragments disengaged , they are repositioned open reduction: by operation indications: 1. failure of closed reduction 2. displaced articular fractures which need accurate reduction. 3. for traction fractures where the fragments are hold apart.

Hold Immobilization is performed by: 1. continuous traction 2. cast splintage 3. functional brace 4. internal fixation 5. external fixation

continious traction the problem with traction that it does not maintain accurate reduction and the patient remain in bed for long period. Two types of traction: 1. skin traction: for pull not more than 5 kg using adhesive straps 2. skeletal traction: by pin inserted in the bone distal to the fracture , this when high weight is needed. Complication of traction: 1. circulatory embarrasement. Especially in children. 2. nerve injury. in older people, drop foot may happen

Cast splintage: n Plaster of Paris (POP) is a common method of fixation of fractures after reduction rotation of the fracture shaft can be prevented by including the joint above and the joint below, in the children and fracture of the distal parts of the extremities it is very useful. The patient can leave the bed early in LL fractures using of crutches allow ambulation.

Complications: 1. stiffness of the joints 'fracture disease' this avoided by avoiding long unnecessary splintage and early physiotherapy. 2. tight cast this either because the cast applied tight, or the limb swells. The patient complain from diffuse pain, or some time compartment syndrome may happens. If this complication happen the limb should be elevated and the cast open 1. through out its length and 2. through all the padding down to the skin. 3. pressure sores usually over the bony promenances , the patient complain from localized pain precisely over the pressure spot. This should inspected immediately. The bony promeninces should be well padded to prevent this. 4. skin abrasion or laceration this usually during removal so should be careful. 5. lose cast this after swelling subside, so should be replaced.

Functional bracing Using POP or plastic materials, it prevents joint stiffness, segments of cast are applied over the shaft of the bones leaving the joints free, the cast segments are connected by metal or plastic hinges which allow movement in one plane. Since the brace is not rigid, it applied only when the fracture is beginning to unite.

Internal fixation Bone fragments can be fixed by screws, transfixing pins , or nails , plate and screws , intramedullary nail, circumferential bands or combination. Advantages: 1. hold fractures securely so allow early movement and prevent stiffness, and edema. 2. allow early leaving of hospital. 3. accurate reduction as in intraarticular fractures.

Indications: 1. failure of closed method. 2. unstable fractures which are likely to displaced, as in ankle fractures , or those liable to muscle pull as in transverse patellar fracture or olecranon. 3. fractures that unite poorly or slowly as in fracture neck femur. 4. pathological fractures. 5. multiple fractures. 6. in patient with nursing difficulties as in paraplegics , and multiple injuries.

Complications: 1. Infection : due to poor technique or poor equipment , or poor tissue conditions. 2. Non – union: if the bone ends fixed rigidly with a gap between the ends, or in stripping of the soft tissues. 3. Implant failure: so the patient should walk with crutches and weight bearing should allowed gradually after the fracture heals. 4. Refracture if the implant removed too soon and care should be taken after removal.

External fixation: The bone is transfixed below and above the fracture by screws or pins or tensioned wires and these connected to each other by rigid bars. Indications: 1. Fractures associated with sever soft tissue damage. So it makes dressing easier. 2. Fractures associated with sever nerve or vessels damage. 3. Severely comminuted and unstable fractures. 4. Ununited fractures which can be excised and compressed , and some times combined with bone elongation. 5. Pelvic fractures if cannot controlled by other methods. 6. Infected fractures. 7. Sever multiple injuries.

Complications 1. Damage to soft – tissue structures if the transfixing pins injure the nerves or vessels. Or may tether ligaments or muscles. 2. Over distraction 3. Pin – tract infection.

Exercise This important after any fracture because: 1. prevention of oedema. This by muscle exercises and elevation. 2. active exercises which pumps the edema away prevents adhesion of soft tissues, and help fracture healing, and prevent muscle atrophy. 3. assisted movement this by special machines.