Basic of Fracture Flashcards
Learning outcome:
- Definition of fracture
- Types of fracture
- Mechanism of fracture and its pattern
- Displacement of fracture
- High energy vs lowe energy injury
- Stages of bone healing
- Modes of bone healing
- Time taken for bone healing
- Clinical features of fracture
- Complication of fracture
- Roles of X-ray in fracture
- Principles of X-ray in fracture
- Principles of treatment in closed fracture
- Principles of treatment in open fracture
What is the definition of fracture?
Structural break in normal continuity of bone
Classification of fracture
- Degree of fracture (complete, incomplete)
- Fracture pattern and it’s associated mechanism
- Fracture haematoma communication
- Displacement of fracture
- Sites of fracture
What are the types of fracture?
Complete
- all components detached
- type:
1. transverse
2. oblique
3. spiral
4. impacted
5. comminuted
Incomplete
- periosteum remains intact
1. bowing
2. buckle/torus
3. greenstick
4. hairline
Give 4 mechanism of fracture and its associated pattern of fracture
- Direct Trauma : Transverse or Comminuted
* bone breaks at point of impact
- taping (small force, small area)
- crush (large force, large area)
- penetrating (large force, small area) - Indirect Trauma
* bone breaks at a distance from impact
- Transverse: Avulsion or traction
- Spiral: Rotational
- Oblique or impacted: Compression
- Buttery: Bending - Repetetive Stress
- Pathological
++Transverse: slow to join (small area, but stable for compression)
++ Spiral: Fast to join (large area, but may not be stable for compression)
++ Comminuted: slow to heal (more soft tissue damage, likely unstable for compression)
High energy vs Low energy fracture?
High energy
- associate with distant injury as well
- more severe soft tissue injury
- likely open fracture (predispose to infection)
Low energy
- opposites
How do you describe the site of fracture?
- Long bone
- proximal third
- middle third
- distal third - Joint
- extraarticular
- intraarticular
What is Wolff’s Law?
The higher the stress, the higher the rate of bone resorption than replacement, the higher the liability to fracture
(More stress, the stronger the bones)
What are the displacement of fracture?
- Translation/shift
- side to side
- backward/forward
- longlitudinally with impaction - Angulation
- anterior
- posterior - Rotation
- medial
- lateral - Altered length
- shortening
- distraction
Stages of healing of fracture?
- Haematoma
- torn blood vessels
- disruption of blood supply cause death of bone abt 2mm - Inflammation
- occurs within 8 hours
- migration of inflammatory cells
- inititation of proliferation of mesenchymal cells from periosteum - Soft callus
- differentiation of mesenchymal cells into osteogenic and chondrogenic cell population - Hard Callus
- formation of woven bone by mineralization (union)
- union: incomplete repair, callus is calcified,
- cf: fracture still a bit tender, attempted angulation is painful
- x-ray: fracture line still visible with fluffy callus
- mx: pt not safe to subject unprotected bone to stress - Remodelling
- conversion of woven bone into lamellar bone (consolidation)
- bridging of blood vessels
- bone resumes normal shape (alternating process of bone resorption and formation)
- consolidation: complete repair, calcified callus is ossified
- cf: fracture site not tender, attempted angulation is painless
- x-ray: fracture line almost obliterated and crossed by bony trabeculae, well-defined callus
- mx: further protection is unnecessary
Modes of healing of fracture?
- Primary/Direct bone healing
- intramembranous healing via haversian canal
- occur when mechanical strain <2%
- occurs in rigid fixation (plate, impacted fracture)
- bone integrity depends on metal
- less callus formation
- two types:
i. Contact Healing
- exposed fracture in intimate contact
- bridging may occur without intermediate stages
ii. Gap Healing
- gaps invaded by new capillaries and osteoprogenitor cells
- woven coverts to lamellar
- penetration and bridging by bone remodelling units (4 weeks)
- Secondary/Indirect bone healing
- healing by echondroal ossification
- occurs when mechanical strain is between 2-10%
- occurs in non-rigid fixation (cast, external fixation, intramedullary nailing)
- more callus formation
Calculate time taken for fracture healing?
Perkins’s Table:
UL x Spiral x Union = 3 weeks
LL / Transverse / Consolidation = x2
Children = /2
How do you differentiate union and consolidation?
Union
- callus formation
- pain, tender on attempt of angulation
- x-ray: visible lucent line, 3 or more bridging cortices on ap and lateral view
Consolidation
- woven converts to lamellar
- non tender on attempt of angulation
x-ray: fracture line obliterated
Symptoms of fracture?
- Pain
- Loss of function
- Swelling
- Deformity
- Stiffness
- Crepitus
Signs of fracture?
Look
- Swelling
- Bruising (local and distal ~vascular cx)
- Wound
- Deformity
- Posture of distal extremity (nerve damage)
Feel
1. Tenderness
Move
- Abnormal movement
- Limited range of motion
- Pain with movement
- Crepitus
5 Rules of twos of X-Ray examination in fracture?
2VJLIO
- Two views
- anteroposterior
- lateral - Two joints
- joint above fracture
- joint below fracture - Two limbs
- so that not to be confused with epiphysis (in children)
- for comparison to normal - Two injury
- if severe force. look for indirect trauma fractures - Two occasion
- one or two weeks later
- hard to detect fracture:
i. distal end of clavicle
ii. scaphoid
iii. femoral neck
iv. lateral malleolus
v. stress fracture
vi. physeal injury
Four roles of X-Ray in fracture?
- Confirm clinical diagnosis
- Study displacement of fracture
- Plan treatment
- Post-reduction status
Systemic complication of fracture?
SCIFT
- Shock
- Crush Syndrome
- Infection
- Fat Embolism
- Thromboembolism
Local complication of fracture?
EARLY: VINCO BAMSEL
Urgent
- Vascular, Visceral
- Infection
- Nerve
- Compartment Syndrome
Less Urgent
- Blisters
- Algodystrophy
- Myositis Ossificans
- Sores (Pressure/Plaster)
- Entrapment nerve
- Ligament, tendon injury
LATE: COADUM
- Contracture
- Osteoarthritis
- Avascular necrosis
- Delayed Union
- Non-union
- Malunion
Classification of open wound fracture?
Gustillo’s Classification
- Type I: (<2% risk of infection)
- wound <1cm
- little soft tissue damage
- low energy (not crushing or comminuted)
- no periosteal stripping - Type II: (2-10% risk of infection)
- Wound >1cm
- minimal soft tissue damage
- low to moderate (crushing or comminuted fracture)
- no perisoteal stripping - Type III: (>10% risk of infection)
- Wound >10cm
- High energy
- A: fracture bone can be adequately covered by soft tissue, no periosteal stripping
- B: fracture cover by soft tissue is not possible (need to use flaps), periosteal stripping
- C: involve arterial injury, requires repair
Principles of treatment for open fracture?
- Antibiotic prophylaxis
- Wound debridement
- Fracture stabilization
- Early definitive wound closure
When and which antibiotics are given for prophylaxis?
- Within 3 hours of injury - Co-amoxiclav/Cefuroxime/Augmentin
* Both cover most Gram+ve and -ve - During debridement
- Co-amoxiclav/Cefuroxime/Augmentin
- Gentamicin - During definitive wound closure
- Gentamicin
- Vancomycin
* for delayed wound closure or grade III B/C
* both effective against MRSA, Pseudomonas - Continued prophylaxis
-co-amoxiclav/cefuroxime/Augmentin
(Grade I: max 24 hours) ~3 days
(Others: max 72 hours) ~3-5 days
What are the principles of wound debridement?
- Apply tourniquet to provide bloodless field
- Extend wound if needed (follow line of fasciotomy)
- Examine fracture surface (bend limb, do not use retractors) ‘deliver fracture’
- Remove devitalized tissue (4C)
- purplish colour (muscle?)
- mushy consistency
- fail to contract when stimulated (using forceps)
- fail to bleed when cut - Wound cleansing, irrigation with NS
- Leave nerve and tendon alone (unless expertise available)*expect for 2nd debridement
How to stabilize an open fracture?
- If wound cover delayed: External Fixation
* can be changed to internal during definitive wound cover if:
i. delay less than 7 days
ii. no signs of wound contamination
iii. Internal fixator can fx as well as external fixator - If wound cover can be achieved at debridement (+no contamination): Treat as closed fracture
Method of wound closure?
- Suture (if can be closed during debridement): usually Grade I or II
~ primary intention
~ delayed primary: suture again later - Split-skin grafts: severe
- Flaps (local or distant): severe
- Secondary intention: large wound
