Intro to fractures Flashcards
definition of a fracture
A fracture is described as a loss of continuity of the substance of bone
Can range from hairline to comminuted
is there a difference between break and fracture
no
How are fractures classified?
skin damage
displacement
pattern/shape
skin damage
open/compound
closed/simple
displacement
displaced
undisplaced
pattern/shape
oblique
transverse
spiral
open fracture
broken skin
risk of infection
blood loss
closed fracture
Skin intact
no communication to site of fracture
Less risk infection
Bleeding is internal
undisplaced fracture
Bone ends still in apposition
displaced fracture
Bone ends do not meet, reduction necessary
pattern of fracture i
Transverse Oblique Spiral Simple Comminuted Compression / crush
pattern of fracture ii
Greenstick Hairline Impacted Avulsion Articular Depressed
transverse fracture
Fracture at right angle
Obliquity < 30 degrees
Direct or indirect violence
oblique fracture
Angle of fracture > 30 degrees
Direct / indirect or torsional force
spiral fracture
Line of fracture curves around
Rapid union - large area in contact
comminuted fracture
More than 2 fragments
Unstable
Greater violence
+/- butterfly segment
compression/crush
on Cancellous bone
impacted fracture
One fragment driven into another
Stable, heals quickly
greenstick fracture
Bend in immature bone
children
hairline fracture
Trauma - fracture without displacement
Stress fracture
avulsion fracture
Sudden forceful muscle contraction - high force pulls off portion of bone
intra-articular fracture
Articular joint surfaces
May have associated haemarthrosis (bleeding within joint)
depressed fracture
Sharply localised blow depresses fragment of cortical bone
causes of fractures
Sudden injury Direct trauma indirect trauma Fatigue Repeated stresses No evidence of disease Pathological – Abnormal or diseased bone
2 types of trauma
direct violence
indirect violence
direct violence
Most common
Stresses exceed limit of strength of bone
Fall on ground
Hit by moving object
indirect violence
Twisting or bending stresses
Sports-related
Common in ankle fractures
fatigue/stress fracture
Repeated minor stresses rather than one specific incident
Pain increases with activity / decreases with rest
common sites of fatiure fracture
2nd MT, tibia
physical examination of fatigue fracture
localised bony tenderness / swelling / thickening/unable to WB
x ray findings of fatigue fracture
may need bone/CT scan
Nothing detectable initially / 2 - 4 weeks changes
+/- faint hairline crack / rarely displaced
Zone of callus formation
pathological fracture
Fracture occurs in bone weakened by disease
Fractures occurs with trivial trauma or spontaneously
causes of pathological fracture
Tumours: Bone is a common secondary site for cancer Bone disease (e.g. Osteoporosis)
stages of fracture healing
Haematoma Subperiosteal & endosteal cellular proliferation Callus Consolidation Remodelling
initial damage that occurs in fracutre
Periosteum - complete or partial tear
Disruption of Haversian systems
Death of adjacent bone cells
+/- Damage to muscle/nerve and blood vessels
haematoma
Tissue damage & bleeding
Haematoma between & around fracture segments
Haematoma clots
Subperiosteal & endosteal cellular proliferation
Inflammatory cells appear in haematoma
Proliferation of cells deep surface of periosteum
‘Collar’ of active tissue around fragments
Blood clot ‘pushed aside’
Cellular activity medullary canal
- Callus formation
Maturation cellular tissue Osteoblast & osteoclast activity Intracellular matrix laid down Removal of dead bone ‘Woven bone’ appears: Callus Palpable as hard mass Visible on X Rays
stage 4 consolidation
Woven bone replaced by lamellar (cortical) bone Solid union full bone repair no movement in fracture site full function can commence
remodelling
Newly formed bone remodelled to resemble normal bone
Bone strengthened along lines of stress
rate of union - how fast a bone heals in the young
Rapid callus formation 2 weeks
Consolidation 4 / 6 weeks
rate of union - how fast a bone heals in the adults
Callus 2 weeks Consolidation 3 months Occasionally 4 / 5 months long bones More rapid in slender bones UL vs LL Cancellous bone quicker
condition of bone during initial union
Partial repair of bone Initial callus around bone ends Minimal movement at fracture site May give way easily Visible fracture line on X- Ray Immature bone
malunion meaning and where is it most common
Bone has united soundly but in wrong position.
Common in clavicle fractures
non union and what is required to fix the problem
Bone ends do not unite and remain separate.
May require bone grafting and internal fixation
delayed union
Takes longer to unite than normal
But eventually does so
factors influencing healing
Type of bone Type of fracture Mobility at fracture site Blood supply Separation of bone ends
typical findings on clinical examinations
Visible / palpable deformity Localised swelling Visible bruising Marked bony tenderness Impaired function
principles of fracture management
Obtain sound bony union without deformity Restore function (work/social/ADLs etc) Without risk of complications
reduction aim
Adequate apposition and alignment of bone fragments
closed reduction
For minimally displaced fractures - no surgery required
get traction - disengage fragments
+/- Manipulation under anaesthesia (MUA) - reduce risk of infection
Usually immobilised in some form of splint/cast
open reduction
Requires Surgery for unstable/displaced fractures
+/- Internal or external fixation
conservative immobilisation
Non-rigid method of support e.g. collar / cuff / brace
Scotch-cast
Continuous traction (rarely used now)
Skin traction or Skeletal traction
external fixation
Bony fragments held with external device & pins
indications of external fixation
Severe soft tissue damage
Nerve or blood vessel damage
Pelvic fractures that cannot be internally fixated
Infected fractures
ORIF and examples
= Open Reduction Internal Fixation
E.g. Pins, plates, screws, wiring, IM - Inter Medullary nails
Indications of ORIF
Inherently unstable fracture Displaced fractures # cannot be otherwise controlled # of > 1 bone Pathological with bone disease Fractures that unite poorly
Advantages of ORIF
Likelihood of good reduction and union
Early mobilisation
Disadvantages of ORIF
Risk of infection
Additional trauma
Role of inpatient physio
Post fixation e.g. ORIF Early mobilisation Gentle exercise to maintain Gait education/aids education/advice
role of outpatient physio
At a later stage Once fracture healed or cast removed Exercise e.g. ROM Strengthening Pain Management
physiotherapy during immobilisation e.g. cast
reduce oedema Maintenance of circulation Maintain muscle function - active / static contractions Maintain joint range Maintain function
physiotherapy on removal of fixation/cast
Decrease swelling
Regain full ROM
Regain full muscle power
Restore full function e.g hand function (UL)/walking (LL)
complications of surgery
Pneumonia Blood loss -anaemia Shock Wound infection Delirium (Acute confusion)
complications of prolonged immobilisation
Respiratory tract infections
Urinary tract infections
Risk of pressure areas
Disuse muscle atrophy
immobilisation POP precautions
wound care
nerve compression
compression of blood vessel
hygience
