Definition:
Complete or incomplete break in the structural continuity of a bone.

Type of fractures:

1) Close (simple)

  • Best treated with closed method
    • unless there is indication to use open method
    • once opened there are risks of infection

2) Open (compound)

image

    • Definition: Fractures communicating outside through a rent in the skin
      • Fracture with lacerated wound
      • More common in subcutaneous bone
        • subcutaneous bone – tibia
    • Gustilo classification
      • Type 1
        • wound small < 1cm long
        • little soft tissue damage
        • minimal contamination
        • fracture not comminuted
          • crushed or splintered bone
      • Type 2
        • wound 1-5cm long
        • soft tissue damage
        • moderate contamination
        • fracture may be comminuted
      • Type 3
        • extensive damage to skin
        • soft tissue & neurovascular damage
        • contaminated
        • fracture comminuted
        • Sub-classification
          • Type 3a
            • loss of skin and muscles
          • Type 3b
            • loss of periosteum
          • Type 3c
            • associated neuro-vascular injury
      • Complications
        • Bleeding
        • Infection
          • Chronic osteomyelitis
        • Delayed union
        • Non-union
        • Joint stiffness
          • Restriction
        • Muscle fibrosis

3) Pathological fracture

4) Stress fracture

Displacement of fracture:

  • fragments may be
    • displaced, due to
      • muscle spasm
      • gravity
    • tilted/angulated
    • twisted/rotated
    • overlapped/lengthened

Clinical features

    • History
    • Mechanism of fracture
      • twisting
      • bending
      • compression
      • combination of forces
      • avulsion
      • traction
      • flexion
      • extension
    • Pain
    • Swelling
    • Tenderness
    • Deformity
    • Abnormal mobility
    • Loss of function

Union of fractures

  • Blount’s law
    • Fractures in children unite faster
    • Fractures closer to the joints unite faster
    • Displacements at the fracture will remodel
    • Angulations in the plane of movement of the joint < 20 degrees are acceptable
    • Rotations will never remodel
  • Intra-articular fractures
    • The break crosses into the surface of a joint
    • They always result in some degree of cartilage damage
    • Reduced anatomically
      • the joint surfaces should be restored to their original position and held there strongly enough that movement may be started in the early postoperative period
    • However, a step of more than 2mm is not acceptable

When a patient is brought into the A&E with a fracture..

  • ABCD
    • airway
    • breathing
    • circulation
    • deformity
  • 4 questions to ask (to classify fracture)
    • Nature of the wound
    • State of skin around the wound and bone
    • Is circulation intact?
    • Are nerves intact?
  • Splint the fracture
    • treat life threatening injuries 1st
  • Reduce the fracture
    • Closed method
      • Anaesthesize/Sedate
      • Traction
        • counter traction
          • skin traction
          • skeletal traction
        • straighten broken bones
      • Once the fracture fragments disengage,  reduction is attempted
      • Immobilisation of fracture
        • External
          • Continuous traction
            • skin / skeletal
          • Plaster of paris cast
          • Functional bracing
          • External fixation
        • Internal
          • Plates & Screws
          • Intramedullary nails
          • Interlocking nails
          • K-wire
      • Check neurovascular
    • Open method
      • This method used when
        • When closed method fails, due to
          • soft tissue interpositioned
          • difficulty in controlling the fragments
        • Intra-articular fractures
        • Avulsion fractures
          • patella & olecrenon fractures
        • Unstable fractures
        • Multiple fractures
          • head & spinal injury
        • Uncooperative patients with vascular injury
  • Immobilize the fracture
  • Treat systemic disorders

 Healing of fractures (Stages)

image

  • Haematoma formation
    • Tearing of:
      • endosteal vessels
        • haematoma around the fracture site
      • periosteal arteries
        • bone in the immediate vicinity of the fracture dies & undergoes necrosis
  • Subperiosteal & endosteal cellular proliferation
    • Cells from deep layer of the periosteum & medullary canal proliferate
      • form osteoblasts
        • lays down intercellular substance
    • Haematoma gets pushed aside by the proliferating cells & gets resorbed
  • Soft callus formation (woven bone)
    • 6-8 weeks
    • Cellular tissue from both ends differentiate into osteoblasts and chondroblasts
      • Formation of Intercellular martix (collagen & polysaccharides) with calcium salts
    • Provides stability to the fracture
      • felt as hard mass around the fracture
      • Xray – 1st sign of fracture union
  • Consolidation of callus
    • 12-18 weeks
    • Soft callus + osteoblastic activity
      • mature bone
      • has a lamellar structure
  • Remodeling
    • 1-2 yrs
      • depends on the lines of stress
    • Forms a bulbous swelling around the fracture
    • Closes the medullary canal

Epiphyseal injury (involving the epiphyseal plate)

 Salter-Harris classification

image

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Fracture complications

Early complication

  • Hypovolaemic shock
  • Neurological
  • Vascular
  • Compartment syndrome
  • Crush syndrome
  • Deep vein thrombosis
  • Infection
    • Gangrene
    • Tetanus
  • Visceral injury
    • Urethra
    • Bladder
    • Lung

Late complication

  • Mal-union
  • Non-union
  • Joint stiffness
  • Re-fracture
  • Arthritis
  • Necrosis
  • Osteopenic
  • Reflex sympathetic dystrophy
  • Muscle contracture
    • fibrosis

Dislocation complications

  • Vascular
  • Neural
  • Avascular necrosis
  • Recurrent dislocation
  • Traumatic arthritis
  • Heterotopic ossification
    • process by which bone tissue forms outside of the skeleton
  • Unstable joint

_____________________________________________________________________

Management of fractures

Factors in bone healing

        1. Age.
        2. Vascularity.
        3. Anatomical Reduction.
        4. Stability.
        5. Nutrition.
        6. Co-morbidity.
        7. Medication.
        8. Smoking.
        9. Infection.
      10. Type of Fractures.

Investigation

  • X-ray
    • AP
    • Lateral
    • Special
      • 2 joints
      • 2 times
      • 2 limbs
  • CT
    • 3D reconstruction
  • MRI
  • Angiogram
  • Bone scan

Fracture management depends on:

  • Closed / open fracture
  • Age of patient
  • Intra-articular fracture
  • Site of fracture
  • Presence of associated injuries
  • Systemic disorders

What is the ‘golden period’ ?

  • The 1st 6 hours after fracture
    • better results
    • non-infected
  • Aim:
    • Wound debridement (Stages)
      • Irrigation with saline
      • H2O2 (Hydrogen peroxide)
      • Antibiotics
      • Exploration
      • Culture sample
        • before and after
      • Removal of foreign materials
      • Tissue debridement (removal of dead tissues)
        • Blood vessels
        • Nerves
        • Tendon
        • Fascia
        • Joint closure
        • Plastic surgery procedures
          • Skin graft
          • Flap
          • Free flap
          • Rotation
        • External fixation
          • image
          • easy dressing
          • better wound healing
          • prevent infection
          • for intra-articular fractures
        • Dressing
      • Drain
      • Immobilisation
    • tetanus toxoid injection
    • antibiotics administration
      • Broad spectrum
        • Gram +/-
        • Aerobic/anaerobic
  • Aftercare – Open fracture
    • Keep limb elevated
    • Observation
      • neurovascular
    • Continue antibiotic prophylaxis
    • Re-debridement necessary
    • Drainage removal
    • Limit mobilisation
      • to prevent complications

    _____________________________________________________________________

    OLIS

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    Terri is obsessed with making medical school as painless as possible. She studies and compiles medical school notes in a concise, easy-to-understand format. She also enjoys reading contributions by others. She is an investor in sustainability projects. Her ideal weekend is wine tasting and experimenting on bread-making. She has yet to master the art of Sourdough baking.

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