FRACTURES

Question 1

WHAT IS A FRACTURE?

Answer 1

 Break or rupture in a continuity of a bone
 A fracture is a partial or complete break in the structural continuity of bone with soft tissue involvement.
-Bone is relatively brittle yet it has sufficient strength and resilience to withstand considerable stress

Question 2

OUTLINE THE MECHANISM OF INJURY INVOLVED IN FRACTURES

Answer 2

 Most fractures are due to a combination of forces (twisting, bending, compressing or tension)
 Twisting causes a spiral fracture;
 Compression causes a short oblique fracture.
 Bending results in fracture with a triangular ‘butterfly’ fragment;
 Tension tends to break the bone transversely; in some situations it may simply avulse a small fragment of bone at the points of ligament or tendon insertion
NB: Above description applies mainly to the long bones.

Question 3

WHAT DO FRACTURES RESULT FROM?

Answer 3

1. Single traumatic incident (direct or indirect force).
2. Repetitive stress (fatigue or stress fractures).
3. Abnormal weakening of bone (pathological fractures

Question 4

HOW ARE FRACTURES CLASSIFIED?

Answer 4

(a) Etiological classification
(b) Clinical classification
(c) Radiological classification
(d) Classification according to the Anatomical site

Question 5

HOW ARE FRACTURES ETIOLOGICALLY CLASSIFIED?

Answer 5

i. Traumatic #s- Direct/ indirect violence- With a direct force the bone breaks at the point of impact; the soft tissues also are damaged. With an indirect force the bone breaks at a distance from where the force is applied; soft-tissue damage at the fracture site is not inevitable.
ii. Pathological #s- Trivial violence/spontaneous
iii. Stress/ fatigue #s

Question 6

HOW ARE FRACTURED CLINICALLY CLASSIFIED?

Answer 6

i. Simple or closed - no communication betwn fracture site and skin surface.
ii. Compound or open- communication betwn # site & skin surface (e.g. Gustilo&Anderson’s classification)
iii. Complicated- Involving damage to nerves and major vessels

Question 7

OUTLINE THE RADIOLOGICAL CLASSIFICATION OF FRACTURES

Answer 7

 Transverse
 Oblique
 Spiral (bone is twisted apart)
 Comminuted (bone is splintered or crushed)
 Segmental
 Avulsion/ distraction (caused by traction, a bony fragment usually being torn off by a tendon or ligament)
 Butterfly
 Greenstick (occurs in children, whose bones are soft and yielding. The bone bends without fracturing across completely, the cortex on the concave side usually remaining intact)
 Impacted (one fragment is firmly driven into the other) Compression

Question 8

LIST THE CLASSIFICATION OF FRACTURES ACCORDING TO ANATOMICAL SITE

Answer 8

 Diaphysis
 Metaphysis
 Epiphysis

Question 9

DIFFERENTIATE BETWEEN COMPLETE AND INCOMPLETE FRACTURES

Answer 9

 Complete fractures- bone is split into two or more fragments e.g. transverse # radiologically
 Incomplete fractures- bone is incompletely divided and the periosteum remains in continuity e.g. greenstick fracture the bone is buckled or bent

Question 10

WHAT ARE THE GENERAL SIGNS OF A FRACTURE?

Answer 10

General signs (A broken bone is part of a pt!). Look for evidence of:
a) Shock or haemorrhage.
b) Associated damage to brain, spinal cord or viscera.
c) Predisposing cause- alcohol, drug abuse etc

Question 11

WHAT ARE THE LOCAL SIGNS OF A FRACTURE?

Answer 11

Local signs
1. Look - Swelling, bruising, deformity.
- Integrity of skin (intact or broken).
2. Feel -localized tenderness, warmth, distal pulses and sensation
3. Move - motor supply distal to # site, abnormal mvts - joints distal to injury

Question 12

WHAT IS FRACTURE DISPLACEMENT?

Answer 12

Displacement of fractures is defined in terms of the abnormal position of the distal fracture fragment in relation to
the proximal bone

Question 13

DESCRIBE THE TYPES OF FRACTURE DISPLACEMENT

Answer 13

a) Sideways shift/Translation- fragments may be shifted sideways, backward or forward in relation to each other, such that the fracture surfaces lose contact. It may be backwards, forwards, sideways, or longitudinally with impaction or overlap
b) Overlap. - Proximal and distal fracture segments overlap each other shortening the limb length.
c) Impaction. If there is shortening of bone without loss of alignment, the fracture is impacted. The bone substance of each component is driven into the other.
d) Length – Fragments may be distracted and separated, or they may overlap, due to muscle spasm, causing shortening of the bone. A fracture resulting in increased overall bone length, is due to distraction (widening) of the bone components.
e) Angulation (tilt). Fragments may be tilted or angulated in relation to each other. Medial angulation can be termed ‘varus’, and lateral angulation can be termed ‘valgus’. Can be Sideways, backwards or forwards
Anterior angulation’ means that the apex of the angle, points anteriorly or that the distal fragment is tilted anteriorly: while the opposite would be termed posterior angulation
f) Rotation (twist) - Rotation of a long bone fracture may be internal or external. One of the fragments may be twisted on its longitudinal axis; the bone looks straight but the limb ends up with a rotational deformity. Can be in any direction

Question 14

DESCRIBE THE STAGES OF FRACTURE HEALING

Answer 14

i) Hematoma formation (immediate response)- Vessels are torn and a haematoma forms around and within the fracture
ii) Subperiosteal and endosteal cellular proliferation (inflammatory response) esp. osteoblasts- Within 8 hours of the fracture there is an acute inflammatory reaction with migration of inflammatory cells and the initiation of proliferation and differentiation of mesenchymal stem cells from the periosteum, the breached medullary canal and the surrounding muscle
iii) Callus formation (chord material i.e. calcium and iron) 2-4 weeks (repair response) - thick cellular mass, with its islands of immature bone and cartilage, forms the callus or splint on the periosteal and endosteal surfaces. As the immature fibre bone (or ‘woven’ bone) becomes more densely mineralized, movement at fracture site decreases progressively
iv) Consolidation- With continuing osteoclastic and osteoblastic activity the woven bone is transformed into lamellar bone.
v) Remodeling- Reshaped by a continuous process of alternating bone resorption and formation

Question 15

WHAT ARE THE IMMEDIATE COMPLICATIONS OF FRACTURES?

Answer 15

i) Hemorrhage – may lead to shock
a) Internal or external e.g. # femur 2L
# Tibia = ½L
# Pelvis 3- 5L
ii) Nerve or vascular injury
iii) Soft tissue injury e.g. visceral organs, urethra etc.
iv) Tendon injury

Question 16

WHAT RE THE INTERMEDIATE COMPLICATIONS OF FRACTURES?

Answer 16

Intermediate Complications
i) Avascular necrosis- it’s the necrotic death of the tissues due to blood supply disruption
ii) Amputation
iii) Compartment syndrome- presents with 6Ps: pain, paraesthesia, pressure (feels woody), pallor, paralysis & pulseless Joint stiffness. It due to critical pressure increase within defined muscular compartment causing a decline in perfusion pressure in that area.
iv) Volkmann Ischemic contractures
v) Osteomyelitis
vi) Fat embolism
vii) Thromboembolism
viii) Septic wound/ septicemia in compound #s

Question 17

WHAT ARE THE LATE COMPLICATIONS OF FRACTURES?

Answer 17

Late complications
i) Malunion (may lead to late neuropathies e.g. valgus deformity at elbow –an ulcer)
ii) Nonunion delayed union
iii) Osteathrosis- common & particular #s esp. displaced
iv) Joint instability/ deformity
v) Post traumatic atrophy
vi) Ostechiorosis- harden brittle
vii) Osteoarthritis
viii) Shortening of bone
ix) Intra- articular and peri- articular adhesion
x) Hypostatic pneumonia
xi) DVT
xii) Pressure sores

Question 18

WHAT ARE THE LOCAL CAUSES OF A FRACTURE NON-UNION?

Answer 18

A. Local causes
i. Local (infection) sepsis
ii. Interposition of soft tissue
iii. Inadequate or poor local blood supply e.g. fracture neck of femur (Ischemia)
iv. Inadequate immobilization
v. Intact fellow bone
vi. Bone loss or crushing
vii. Over traction – loss of apposition in-between
viii. Iatrogenic- wrong open reduction and internal fixation
ix. Local malignancy- bone destruction
x. Severe communication
xi. Extensive opening
xii. Dissolution of fracture hematoma by synovial fluid bathing the joint

Question 19

WHAT ARE THE GENERAL SYSTEMIC CAUSES OF A FRACTURE NON-UNION?

Answer 19

General systemic causes of non union
i. Anemia
ii. Poor general health
iii. Mineral and vitamin deficiency especially calcium and vitamin D
iv. Metabolic disease e.g. uncontrolled DM
v. Hyperparathyroidism acidosis help destroy the bone
vi. Lack of androgen, estrogen hormones

Question 20

HOW DO YOU TREAT CLOSED FRACTURES?

Answer 20

 Generally treat the patient, not only the fracture.
 Manipulation to improve the position of the fragments, followed by splintage with POP to hold them
together until they unite; meanwhile joint movement and function must be preserved.
 Management objectives are covered by three simple injunctions: * Reduce. * Hold. * Exercise
 Treatment & resuscitation must always take precedence, but don’t unduly delay attending to #

Question 21

IN WHICH CASES IS FRACTURE REDUCTION UNNECCESSARY?

Answer 21

Reduction is unnecessary:
i. when there is little or no displacement;
ii. when displacement does not matter initially (e.g. in #s of the clavicle) and
iii. When reduction is unlikely to succeed (e.g. with compression #s of the vertebrae).
 Reduction should aim for adequate apposition and normal alignment of the bone fragments

Question 22

WHAT ARE THE MAIN METHODS OF FRACTURE REDUCTION?

Answer 22

Two methods of reduction: closed and open

Question 23

WHAT IS OPEN REDUCTION?

Answer 23

Operative reduction under direct vision
As a rule, however, open reduction is merely the first step to internal fixation

Question 24

WHAT ARE THE INDICATIONS FOR OPEN REDUCTION?

Answer 24

Indications
i. Failure of closed reduction
ii. when there is a large articular fragment that needs accurate positioning or
iii. For traction (avulsion) fractures in which the fragments are held apart

Question 25

WHAT IS HOLD REDUCTION?

Answer 25

Restrict movement of fractured bone fragments to promote soft-tissue healing and to allow free movement of the unaffected parts

Question 26

DESCRIBE THE METHODS OF HOLDING REDUCTION

Answer 26

Available methods of holding reduction are:
i. Continuous traction- includes: Traction by gravity, Skin traction and Skeletal traction
ii. Cast splintage- use of POP.
iii.Functional bracing- using either POP or one of the lighter thermoplastic materials
iv. Internal fixation- Bone fragments are fixed with screws, a metal plate held by screws, a long intramedullary rod or nail (with or without locking screws), circumferential bands or a combination of these methods
v. External fixation- transfixing screws or tensioned wires that pass through the bone above and below the fracture and are attached to an external frame

Question 27

WHAT ARE THE INDICATIONS FOR INTERNAL FIXATION OF FRACTURES?

Answer 27

1. Fractures that cannot be reduced except by operation.
2. # s that are inherently unstable and prone to re-displace after reduction (e.g. mid-shaft #s of forearm and some displaced ankle fractures). Also #s liable to be pulled apart by muscle action (e.g. transverse fracture of the patella or olecranon).
3. # s that unite poorly and slowly, principally #s of femoral neck.
4. Pathological #s in which bone disease may prevent healing.
5. Multiple fractures where early fixation (by either internal or external fixation) reduces the risk of general complications and late multisystem organ failure.
6. # s in pts. who present nursing difficulties (paraplegics, those with multiple injuries and very elderly)

Question 28

WHAT ARE THE INDICATIONS FOR EXTERNAL FIXATION OF FRACTURES?

Answer 28

a) #s associated with severe soft-tissue damage (incl open #s) or those that are contaminated, where internal fixation is risky& repeated access is needed for wound inspection, dressing or plastic surgery.
b) #s around joints that are potentially suitable for internal fixation but soft tissues are too swollen to allow safe surgery; use spanning external fixator for stability until soft-tissue conditions improve.
c) Pts with severe multiple injuries, especially if there are bilateral femoral fractures, pelvic #s with severe bleeding, and those with limb and associated chest or head injuries.
d) Ununited #s, which can be excised and compressed; sometimes this is combined with bone lengthening to replace the excised segment.
e) Infected fractures, for which internal fixation might not be suitable

Question 29

WHAT ARE THE OBJECTIVES OF EXERCISE IN THE TREATMENT OF FRACTURES?

Answer 29

objectives are to:
i. Reduce oedema,
ii. preserve joint movement,
iii. restore muscle power and
iv. guide the patient back to normal activitY

Question 30

HOW DO YOU TREAT OPEN FRACTURES?

Answer 30

 Rapid general assessment is the first step to r/o any life threatening conditions
 Any gross contamination is removed and are then covered with a saline-soaked dressing under an impervious seal to prevent desiccation.
 Given antibiotics, usually co-amoxiclav or cefuroxime, but clindamycin if the pt is allergic to penicillin
 Tetanus prophylaxis is administered: toxoid for those previously immunized, human antiserum if not.
 Splint limb, until surgery is undertaken.
 Checking repeatedly limb circulation and distal neurological status, particularly after any fracture reduction manoeuvres.
 Observe for compartment syndrome
 All open fractures, no matter how trivial, must be assumed to be contaminated
Early definitive wound cover- Grade I or II # may be sutured, after debridement

Question 31

WHAT ARE THE IMPORTANT PRINCIPLES OF FRACTURE TREATMENT?

Answer 31

Essential principles of treatment are
i. Antibiotic prophylaxis.
ii. Urgent wound and fracture debridement.
iii. Stabilization of the fracture- internal or external fixation