Fracture Management

Question 1

What is the definition of a fracture?

Answer 1

• A fracture is any loss in the continuity of bone and is most frequently the result of trauma.
• The term fracture encompasses all bony injuries, from simple undisplaced cracks in bone to major complex long-bone fractures with extensive soft-tissue injuries.
• Some additional terms in common use help describe the fracture.
• An open (compound) fracture is one in which there is a wound in communication with the fracture site.
• A comminuted fracture is one in which there are more than two main fragments.
• Inspection of radiographs allows description of the deformity.
• Angulation describes the relation of the long axis of the proximal and distal segments of bone.
• Displacement refers to the degree of separation between the bone ends.
• Rotation is best judged on clinical examination and refers to the degree of rotational malalignment at the fracture site.
• Angulation, displacement and rotation are described in relation to the major proximal fragment (even if this is quite short).

Question 2

Principles of treatment?

Answer 2

The fundamental aims are:

• Reduce the fracture under anaesthesia (if displaced)
• Maintain the reduction until the fracture heals
• Optimize the long-term functional outcome.

Fracture union is dependent mainly on the blood supply of the bone at the site of the injury. This is related to the intrinsic quality of the bone blood supply in a given location and the energy of the injury.

Question 3

Non-operative treatment

Answer 3

Relative indications for non-operative treatment:

• Low-energy undisplaced injuries
• Fractures in cancellous bone
• Phalangeal/metacarpal/metatarsal fractures
• Fractures that do not require anatomical reduction (e.g. clavicle, many humeral fractures)
• Some children’s fractures.

Question 4

Types of non-operative treatment

Answer 4

• Bed rest: some fractures can be treated with rest and analgesia alone, e.g. isolated pubic ramus fractures.
• Cast treatment: reduction and cast application is suitable for many common injuries in adults and children, particularly distal radial fractures.
• Splints: there is a variety of modern splints available that can be introduced at the outset or during the course of treatment to assist in immobilizing the fracture.
• Traction: this method of treatment confines the patient to bed, sometimes for long periods, and is seldom used now in adults.

Question 5

Operative treatment methods
External fixation

Answer 5

• External fixation devices are attached to bone by pins or wires and consist of an external frame
• The main advantages are minimally invasive surgery and versatility of application.
• Disadvantages are problems with pin-track infection, poor patient acceptance and a higher rate of mal-union
• Examples include distal metaphyseal fractures, bone where there has been previous osteomyelitis, multiple fractures, or extensive skin damage and swelling following high-energy trauma

Indications for external fixation:

• Closed fractures with extensive soft-tissue trauma
• Some open fractures
• Juxta-articular fractures where nailing and plating are technically difficult
• Temporary stabilization of long-bone fractures in multiple trauma
• Leg lengthening after post-traumatic shortening
• Correction of complex post-traumatic angular/rotational deformity.

Question 6

Operative treatment methods

Internal fixation - Intramedullary devices:

Answer 6

Internal fixation devices fall into two main categories:

• intramedullary devices
• plates.

intramedullary devices:

• Intramedullary nails are widely used in the treatment of lower-limb long-bone fractures in adults.
• They can be inserted with minimally invasive surgery and are excellent for restoring normal length, alignment and rotation.
• biomechanically very strong and are ideal for lower-limb diaphyseal fractures, where union times may be prolonged
• complications, such as infection, are also very low.
• cannot be applied so easily to the bones in the upper limb.
• The narrow medullary canals in forearm bones make nailing difficult to apply in the radius and ulna
• In children, flexible intramedullary nails can be used to stabilize long-bone fractures and the radius and ulna

Question 7

Operative treatment methods

Internal fixation - Plating

Answer 7

Plating:

• Plating is most commonly used for metaphyseal fractures, displaced intra-articular fractures and diaphyseal fractures in the upper limb in the adult
• main advantage is that a very precise reduction can be achieved
• more invasive technique and the complication rate associated with plating of diaphyseal fractures in the lower limb is higher than with intramedullary nailing.

Question 8

Operative treatment methods

Internal fixation - Indications

Answer 8

• Displaced intra-articular fractures – plates, wiring techniques
• Periarticular fractures – plates
• Lower-limb long-bone fractures – intramedullary nails
• Fractures with vascular or nerve injury
• Salter–Harris III and IV physeal fractures in children

Question 9

Dislocations

Answer 9

• A dislocation of a joint refers to complete loss of joint congruity
• A subluxation indicates a partial loss of joint congruity.
• Dislocations may be associated with neurovascular injury (e.g. hip dislocation is associated with sciatic nerve palsy in 10–15% of cases)
• Most dislocations can be treated by a prompt closed reduction under sedation or local anaesthesia
• Traumatic hip dislocations often require general anaesthesia to allow reduction.

Question 10

Early local complications of fractures

Compartment Syndrome

Answer 10

• Compartment syndrome occurs when muscle swells within a restrained fascial compartment and eventually occludes its blood supply, resulting in an infarction and a late ischaemic contracture (Volkmann’s ischaemic contracture)
• Trauma is the most common cause, although the condition is often seen in patients with alcohol and drug abuse problems who lie for prolonged periods on a limb
• Clinical diagnosis is based on a high index of suspicion, and the presence of increasing pain despite adequate analgesia and fracture immobilization
• The most useful physical sign is the presence of increased pain on passive flexion and extension of the fingers or toes of the affected limb
• measurement of the compartment pressure is advisable. A pressure of less than 30 mmHg can be considered normal and a pressure of more than 40 mmHg is high
• prompt fasciotomy of the muscle compartments

Question 11

Early local complications of fractures

Nerve Injury

Answer 11

Fracture or Dislocation Associated Nerve Injury

Shoulder dislocation Axillary nerve

Humeral shaft Radial nerve

Supracondylar humeral fracture Anterior interosseous or median nerve

Monteggia fracture dislocation Posterior interosseous or radial nerve

Distal radial fracture Median nerve

Posterior hip dislocation Sciatic nerve

Knee dislocation Common peroneal nerve

Question 12

Early local complications of fractures

Vascular Injury

Answer 12

• commonly associated with high-energy fractures, many of which are open.
• Some closed injuries, eg complete knee dislocation and supracondylar fracture of the humerus in children, carry the risk of this complication
• diagnosis is often obvious on clinical examination with the classical signs of acute ischaemia – pallor, pulselessness, paralysis, paraesthesia and a cold limb
• Angiography is required to confirm the diagnosis, followed by surgery to revascularize the limb

Question 13

Late local complications

Non Union

Answer 13

• non-union occurs when a fracture fails to heal
• Non-union is uncommon, but overall, affects about 5% of fractures.
• more common in high-energy or open fractures with extensive damage to the bone blood supply
• Some patient risk factors have also been shown to increase the risk of non-union.
  
  • Smoking
  • Alcohol abuse
  • Increasing age
  • Steroid use
  • Diabetes mellitus
  • Chronic renal failure

Question 14

Late local complications

Post-traumatic osteoarthritis

Avascular necrosis

Complex regional pain syndrome

Answer 14

Post-traumatic osteoarthritis:

• The risk of osteoarthritis developing is proportional to the degree of residual joint incongruity
• In older patients the complication is often treated by arthroplasty. In younger patients consideration may have to be given to arthrodesis (fusion)

Avascular necrosis;

• It tends to occur in bones where the blood supply to one major fragment crosses the plane of the fracture and is disrupted, especially if the fracture is displaced
• complication affects displaced fractures of the femoral neck, scaphoid and talus in adults

Complex regional pain syndrome:

• Complex regional pain syndrome is an occasional late local complication of an upper or lower limb fracture, (Reflex sympathetic dystrophy)

Question 15

General complications of fractures

Fat Embolism syndrome

Answer 15

Risk factors for development of FES

• Lower-limb diaphyseal fractures, especially the femur
• Multiple fractures
• Closed fractures
• Young patients (<35 years).

Clinical features are related to the underlying pathophysiology and include:

• Tachypnoea
• Dyspnoea
• Confusion/agitation
• Petechial rash (usually on the trunk, head and neck area)
• Tachycardia
• Other occasional features are fat in the urine (lipuria), retinal emboli on fundoscopy and fat in the sputum.

Investigations:

• demonstrate a low pO2 and a low pCO2, and thrombocytopenia
• More severe cases with progressive lung involvement eventually exhibit increased pCO2
• chest radiograph demonstrates diffuse bilateral infiltrates.
• Deposition of emboli in the kidneys and liver may be associated with altered urea, electrolytes and liver enzymes.

Question 16

General complications of fractures

Deep venous thrombosisand pulmonary embolism

Answer 16

• Lower-limb DVT and PE are occasional complications of fractures.
• The overall incidence of both complications in all fractures is low (<1%).
• However, the risk of DVT is considerably higher in patients with multiple trauma, lower-limb trauma or concomitant head injury, and in patients aged over 40 years
• In patients with multiple trauma there may be contraindications to the use of these methods owing to coagulopathy, and in high-risk patients inferior vena cava filters may have to be used.

Question 17

General complications of fractures

Complications of immobility

Answer 17

• Respiratory tract infection is a common occurrence in the early postoperative period in the elderly.
• Basal atelectasis contributes to development of this complication, which is also a higher risk in patients with pre-existing lung disease.
• Urinary tract infection in the elderly is another consequence of immobility and poor bladder drainage.
• Use of catheters and pre-existing bladder drainage problems increase the risk.
• Pressure sores are a significant risk after fractures, particularly in elderly patients.
• The incidence of this problem is related to the level of immobility, the fracture and the quality of nursing care
• Disuse osteoporosis and joint stiffness may occur in patients who have prolonged periods of immobility after fractures