Fractures, clinical pictures and management

Question 1

What is a fracture?

Answer 1

• It is a break in the structural continuity of a bone
• It is associated with a variable degree of soft tissue envelop injury

Question 2

What is a Colle’s fracture?

Answer 2

• Occurs when you fall on a outstretched hand
• It can happen in the scaphoid, clavicle or olecranon (fracture or dislocation)

Question 2

What are the different mechanisms of injury?

Answer 2

1) Single traumatic event

2) Repetitive stress in a short period of time (stress fracture, when the bone cannot accommodate a stress “running” and breaks)

3) Abnormal weakening of the bone (osteoporosis (like breaking the neck of the femur or distal radius), pathological fracture)

Question 2

How does a fracture occur?

Answer 2

1) Twisting force = spiral fracture

2) Compression force = short oblique fracture

3) Bending force = Fracture with a butter-fly fragment

4) Tension force = breaks the bone transversely

Question 3

What are the clinical findings of fracture?

Answer 3

1) Pain (due to the periosteum being torn)

2) Loss of function (mainly because of mechanics and pain)

3) Deformity

4) Swelling (due to hemorrhage)

5) Hematoma/Ecchymosis “skin discoloration”

6) Wound

Question 4

What are the different types of bone fracture “structure”?

Answer 4

NON-Displaced:

1) Transverse

2) Linear

3) Oblique

4) Spiral (mainly due to a twisting injury)

5) Greenstick (like mountains on the cortex of the bone)

6) Comminuted

Displaced:
7) Displaced

Question 5

Healing after a spiral injury is better or worse than oblique?

Answer 5

Better as there is more surface area, thus more blood supply and a better healing

Question 6

What is the most stable type of fracture?

Answer 6

Transverse fracture

Question 7

What are the different classifications of bone fracture?

Answer 7

1) Open fracture:

• When the bone is exposed to the outside environment through the skin

2) Closed fracture:

• The fracture segments is not exposed to the outside

Question 8

What are the different bone fracture energy?

Answer 8

There is different energy, the more the energy the more the fragments, in high energy trauma there is a lot of comminution (small bone fragments) which indicates that it is unstable, and you expect the soft tissue to be affected, and the blood supply to be compromised and thus healing

Question 9

What is the Gustilo classification of compound (open) fractures?

Answer 9

1) Type-1:
- Low-energy
- Wound <1 cm

2) Type-2:
- Wound >1 cm
- Moderate soft tissue damage

3) Type-3:
- High energy
- Wound >1 cm
- Extensive soft tissue damage
- 3A (Adequate soft tissue cover), 3B (extensive soft tissue injury), 3C (open fracture associated with neuro-vascular injury)

Question 10

What are the complications of fracture?

Answer 10

Early:
1) Visceral injury
2) Vascular injury

3) Compartment syndrome (fracture is its most common cause, causes very extreme pain and swelling)

4) Nerve injury
5) Hemarthrosis (blood in the joint)
6) Infection

Late:
1) Delayed union (UL-6Weeks, LL-8/12Weeks)

2) Non-union
3) Mal-union
4) Tendon rupture
5) Osteonecrosis (usually to the lack of blood supply)

6) Algo-dystrophy
7) Osteoarthritis
8) Joint stiffness

Question 11

How to manage a fracture?

Answer 11

1) Life saving measures:
- A: airway and cervical spine immobilization
- B: Breathing
- C: Circulation
- D: Disability
- E: exposure

2) Orthopedic involvement

3) Monitoring the fracture

4) Rehabilitation

Question 12

How to diagnose a fracture?

Answer 12

1) Clinical picture

2) Diagnostic imaging
- X-ray’s (cheap)
- CT scan (3D image)
- MRI (soft tissue and used to detect micro-fractures to)

Question 13

How to treat a fracture?

Answer 13

1) Appropriate reduction

2) Early mobilization (start with early passive exercises followed by assisted active, ensures early and full recovery of function)

3) Prevent/treat the complications early

Question 14

How to manage a compound (open) fracture?

Answer 14

• While contacting orthopedic team for surgical treatment:

1) Irrigate the wound with N.saline, if not available then tap water, cover the wound with a sterile moist dressing

2) Immobilize the limb with a splint along with the joint above and below

3) Remove contaminations

4) IV antibiotics (cefuroxime with metronidazole or gentamicin)

5) Give a prophylaxis for tetanus

6) Check the distal neurovascular status

Question 15

What are the types of reduction?

Answer 15

1) Closed reduction (for minimally displaced fractures and most children fractures)

2) Open reduction

Question 16

How do we maintain a reduction?

Answer 16

1) External methods:
- Plaster of Paris (cast)
- Traction (Surface, skeletal)
- External fixator (Fractures associated with soft tissue injury, Fracture associated with N/V damage, Severely comminuted and, unstable fracture, Infected fracture)

2) Internal method:
- Wires
- Nails
- Screws
- Plates
- Pins

Question 17

Why should we maintain the reduction?

Answer 17

1) For pain relief (it is also due to the fact that the periosteum is stabilized)

2) Prevent mal-union

3) Minimizes non-union

Question 18

What are the complication of internal fixation?

Answer 18

1) Infection

2) Delayed union

3) Non-union

4) Implant failure

5) Re-fracture

Question 19

Wires and pins are used to treat fractures of which bones?

Answer 19

Small bones

Question 20

What are the factors that affects healing?

Answer 20

1) Energy of trauma

2) Degree of bone loss

3) Vascular injury

4) Infection

5) Type of bone fracture

6) Degree of immobilization

7) Pathological condition

Question 21

What are the complications of fractures?

Answer 21

1) Delayed union

2) Non-union

3) Mal-union

4) Post-traumatic arthritis

5) Growth abnormalities

6) Fracture diseases, joint stiffness, non-uses atrophy