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BASICS OF FRACTURE

What is a fracture? A fracture is a partial or complete break in the structural continuity of bone. When a fracture occurs, it is classified as either open or closed:

Open fracture (Also called compound fracture.) - The bone exits and is visible through the skin, or a deep wound that exposes the bone through the skin or one of the body cavities breached. Closed fracture (Also called simple fracture.) - The bone is broken, but the skin is intact.

Fractures have a variety of names. Below is a listing of the common types that may occur in children:

Greenstick - incomplete fracture. The broken bone is not completely separated.

Transverse - the break is in a straight line across the bone. Spiral - the break spirals around the bone; common in a twisting injury. Oblique - diagonal break across the bone.

Compression - the bone is crushed, causing the broken bone to be wider or flatter in appearance.

Comminuted there are more than two bony fragments.

Describing a Fracture: A systematic approach is needed:

Type of fracture Transverse Spiral Oblique Simple etc

Anatomical location Which bone is affected? Which side - left or right? Is the fracture proximal, middle or distal? Is it intra-articular or extra-articular

Displacement of the fracture fragments Shift Alignment

Shortening Rotation Associated fractures Dislocation Open or closed fracture etc. Examples of describing a fracture "This is a oblique fracture of the mid-shaft of the right tibia with no displacement" "This is a transverse fracture of the distal radius with dorsal angulation" Important Definitions

Shift - loss of alignment in the cortices of the shaft of the bone resulting onto sideways displacement Angulation - loss of normal longitudinal axial alignment of the shaft of the bone. This may be anterior, posterior, medial or lateral Shortening - the bone appears shortened as a result of overlap of the fracture fragments or due to impaction at the fracture site Rotation - this refers to the rotation of the distal fragment (relative to the proximal fragment) along the long axis of the bone. This may be external or internal Undisplaced - the fracture fragments are almost in anatomical location Impacted fracture - a fracture that occurs as a result of compression of cancellous bone in its long axis causing two bone ends to be forced tightly together.

What causes a fracture? Fractures occur when there is more force applied to the bone than the bone can absorb. Bones are weakest when they are twisted. Breaks in bones can occur from falls, trauma, or as a result of a direct blow or kick to the body. Fractures results from: A single traumatic incident. Breaks in bones can occur from falls, trauma, or as a result of a direct blow or kick to the body. Repetitive stress Abnormal weakening of the bone (Pathological fracture). Pathological fractures:

Fractures occur in bones which have been weakened already due to a pathological process. Causes of pathological fractures can be classified into generalised bone conditions or local benign causes General bone conditions Osteogenesis imperfecta Post-menopausal osteoporosis Metabolic bone disease Paget's disease Local benign causes Chronic infection of bone Solitary bone cysts Aneurysmal bone cysts Chondromas Primary bone tumours such as chondrosarcomas, osteosarcomas and Ewing's sarcoma are all causes of pathological fractures and may metastasise to the breast, kidney, lung, prostate and thyroid. A child's bone differs from adult bone in a variety of ways: A child's bone heals much faster than an adult's bone. The younger the child, the faster the healing occurs. Bones are softer in children and tend to buckle or bend rather than completely break. Children have open growth plates, also called epiphysis, located at the end of the long bones. This is an area where the bone grows. Injury to the growth plate can lead to limb length discrepancies or angular deformities. What are the symptoms of a fracture? The following are the most common symptoms of a fracture. However, each child may experience symptoms differently. Symptoms may include: Pain and tenderness in the injured area swelling in the injured area obvious deformity in the injured area difficulty using or moving the injured area in a normal manner warmth, bruising, or redness in the injured area The symptoms of a broken bone may resemble other conditions. Always consult your child's physician for a diagnosis.

How is a fracture diagnosed?

The physician makes the diagnosis with physical examination and diagnostic tests. During the examination the physician obtains a complete medical history of the child and asks how the injury occurred. Diagnostic procedures may include:

X-rays - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. Magnetic resonance imaging (MRI) - a diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body. This test is done to rule out any associated abnormalities of the spinal cord and nerves. Computed tomography scan (Also called a CT or CAT scan.) - a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.

Treatment of Fractures: When treating a fracture, it is important to remember you are treating not only the fracture but the patient as a whole. Aims of Fracture Treatment Before considering how to treat a fracture, it is important to understand what the aims of fracture treatment are: Restore optimum function of the injured limb Obtain and maintain reduction of the fracture Encourage union (restoration of normal bone structure) of the fracture Prevent complications Provide adequate pain relief Rehabilitation of the patient.

How do Fractures Heal?

Bone healing occurs in four stages: Stage 1 Tissue destruction & Haematoma formation. After any fracture, bleeding occurs from the ends of the bone and from the surrounding tissues The vessels that are torn at the time of fracture lead to the formation of a fracture haematoma. Stage 2 Inflammation and Cellular proliferation and vascular ingrowths Within 8 hours of the fracture occurring, an acute inflammation reaction occurs, with proliferation of cells under the periosteum and within the breached medullary canal The bone fragment ends are surrounded by cellular tissues that bridge the fracture The haematoma is reabsorbed and fine new capillaries grow in the area. Stage 3 - Callus formation The proliferating cells are potentially chondrogenic and osteogenic in nature Under the right circumstances, the cell population changes to osteoblasts and osteoclasts The dead bone is mopped up and woven bone appears in the fracture callus. Stage 4 - Consolidation and remodeling The woven bone is replaced by lamellar bone and the fracture is solidly united New bone is remodeled to resemble the original normal structure.

What affects Fracture Healing?

Numerous factors can affect fracture healing: Patient - do they comply with the appropriate treatment? Energy of the injury Fracture site Adequate compression? Any movement? Infection Mode of treatment Factors influencing bone healing: Systemic factors Local factors Age and Co- Degree of local trauma / soft morbidity tissue Hormones Degree of bone loss Functional Vascular injury activity Nerve function Type of bone fractured Nutrition Degree of immobilisation / stability Drugs (NSAID) Sterility / Infection Growth Factors Local pathological condition Cigarette Smoke Energy of Injury Anatomic location Fracture Treatment: Treatment can only commence once a fracture has been diagnosed: Clinical assessment Radiological imaging NB Always need radiographs in two views In order for radiograph to be adequate, the joints above and below the injury should be included. General Principles The following points should be taken into account: Average time taken for bones to unite is 8 weeks Lower limb fractures take approximately twice as long to unite as the upper limb fractures Fractures in adults take an average twice as long to heal in comparison to those in children Transverse fractures take longer to heal than oblique or spiral fractures Compound and comminuted fractures are particularly slow to unite

No fracture heals in less than 3 weeks.

Treatment of closed fracture: Reduction 1. Closed reduction 2. Open reduction Immobilization (hold reduction) 1. Cast splintage (Plaster of Paris or synthetic plaster) 2. Functional bracing 3. Continuous traction (Skeletal or skin traction) 4. Internal fixation 5. External fixation Rehabilitation and exercise

Which treatment is appropriate? When deciding which treatment is appropriate, the following point should be noted: Does the fracture need reducing? If reduction is required, how should this be carried out? Is the fracture stable or unstable? Open / closed? Is precise reduction necessary? How to hold the fracture in reduction? It is important to prevent loss of alignment while the bone ends are uniting: No support needed Traction Thomas' splint External splints Non-rigid supports - sling, bandaging etc. Plaster of Paris External fixators IIazarov frame Internal fixation Plates Screws intramedullary nails Joint replacement Treatment plan How long does the fracture need to be immobilised for? When can they start mobilising again? NB: If the articular surface is damaged, a perfect anatomical reduction (< 2mm) is required It is of up most importance to start early mobilisation to prevent joint stiffness. General Management of Fractures Pain control with analgesics Assessment of blood loss

Management of associated injuries Judicious use of antibiotics if the injury is an open one.

Treatment Options Taking all the factors into consideration, there are five possible methods of fracture treatment: No treatment is necessary except possible comfort and protection Immobilize with an external splint without the need for reduction Closed reduction with manipulation or traction followed by immobilization with an external splint or further traction Open reduction and internal fixation (ORIF) Excision of fracture fragment and prosthetic replacement. Aims of Immobilisation Pain relief Limit movement at the fracture site Prevent angulation and / or displacement. Indication for Operative treatment Compound fractures If closed manipulation is unsuccessful in reducing the fracture If the fracture is unstable Soft tissue management Management of complications e.g. vascular or head injuries. Comparison of Conservative vs Operative treatment Joint stiffness Risk lower in operative treatment Infection Risk higher in operative treatment Speed of Healing Quicker in conservative treatment Non-union Present in both. Important Definitions

Reduction - placing the bone fragments into their original or acceptable position Manipulation - the technique of reducing a fracture. In many situations it is the correction of residual angulation by pressing the distal fragment in the correct direction while a hand is held under the fracture to provide a fulcrum Traction - the disimpaction of the fragments. It serves to align the proximal and distal parts of the limb Stable - position of the fragments that can be safely held in position in a plaster while the fracture is healing Unstable - position of the fragments that cannot be safely held in position in a plaster while the fracture is healing.

Fracture complications:

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These can be of a general nature, local - involving structures around the fracture site or those that are applicable to all fractures. General complications Association with internal haemorrhage Shock Metabolic responses to trauma External haemorrhage and infection - open fractures only Hypostatic pneumonia Urinary tract infections Deep vein thrombosis leading to pulmonary embolism Pressure sores Muscle wasting Demineralisation of the bone. Local complications Skin damage - includes stretching of the skin by the underlying fracture fragments, lacerations, fracture blisters, necrosis and skin loss Vascular injuries - these may arise at the time of injury e.g. disruption of the vessel by the fracture fragments or may arise post manipulation of the fracture or post operatively Neurological injuries - damage during the fracture mechanism to the spinal cord, brachial plexus, nerve root or peripheal branch Tendon injury - the tendon may become bound down, compressed or even rupture Visceral injuries - especially in the chest and pelvis. Examples of local complications occurring as a result of certain pathology Fractured face - can cause airway obstruction Broken rib - perforation of the lungs, ruptured liver Fractures and dislocations of the knee - popliteal artery damage 4/5th thoracic vertebra - damage to the aorta.

Complications applicable to all fractures Bone healing abnormalities Delayed union - union is delayed. There is abnormal movement, pain on stressing the fracture and tenderness over the fracture site at a time at when union is expected. Causes include the nature of the initial injury, with compound and comminuted fractures more likely to develop non-union; other causes include infection of the fracture haematoma, interposition of soft tissue between the fracture fragments, poor blood supply to the fracture site, inadequate immobilisation and pathological fractures Non-union - can be atrophic or hypertrophic. The former is when there has been deficient bone formation at the fracture site and a hypertrophic non-union is where there has been excessive callus formation Malunion - the bone ends heal in a clinically imperfect position. It most commonly causes shortening with an overlap of the bone fragments Avascular necrosis - bone death most commonly occurs with intra-articular fractures of the hip joint, proximal scaphoid and proximal humerus.

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Other complications Infection - most commonly occurs with open fractures. Major disorders include tetanus, gas gangrene, toxic shock syndrome, necrotizing fasciitis (an aggressive, life threatening fascial infection), acute osetomyelitis (bone infection). Chronic infection of the bone can occur Joint stiffness Secondary osteoarthritis Growth disturbance if the epiphyseal growth plate has been damaged Tendon ruptures or tendonitis.Sudeck's atrophy (reflex sympathetic dystrophy) - an abnormal peripheral autonomic response to injury characterised by severe pain, stiffness, discolourisation and oedema Myositis ossificans - an extensive calcified mass in the soft tissues proximal to the joint that leads to a severe mechanical block to movement Muscular atrophy Fat embolism - microparticles of fat escape the fracture site and lodge in the glomeruli of the kidney and lung Tardy nerve palsy - late onset nerve palsy Renal calculi Accident neurosis - psychiatric problem. Injuries other than fractures In addition to bony injuries, other anatomical structures can also be damaged in a injury: Joints Joints can be damaged in three ways: 1. Subluxation - this is the partial dislocation of a joint, in which there is still partial contact between the joint surfaces 2. Dislocation - there is no contact between the joint surfaces 3. Fracture dislocation - there a fracture around the joint in addtion to the joint dislocation. Ligaments Ligament injuries can be grouped into three different types: 1. Sprain - this is a partial tear in the ligament or joint capsule but the joint however is still stable 2. Partial rupture - this is the partial rupture of the ligament. There is some loss of joint stability 3. Complete rupture - this is the complete rupture of the ligament and is associated with joint instability. Soft tissues: Blood vessels Nerves Likewise, nerve injury can be grouped into three different types: 1. Neuropraxia - there is transient loss of function as a result of the impulse being interrupted as it passes down the nerve fiber. It occurs as a result of a gentle blow or

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compression. The motor system is more frequently damaged than sensory function. Recovery takes hours to months 2. Axonotmesis - there is loss of function as a result of the relative loss of continuity of the axon and its covering of myelin. It occurs as a result of severe compression. There is loss of both motor and sensory systems. Recovery takes longer than neurapraxia 3. Neurotmesis - this is the most severe lesion affecting the nerve. There is complete loss of motor, sensory and autonomic function and occurs as a result of severe bruising or cuts. There is no neural continuity. There is no recovery. Muscles Muscle injuries can be classified according to the degree of clinical impairment: 1. Mild strain/contusion (1st degree) - a small number of muscle fibers are torn. This is associated with minor swelling and discomfort with little or no loss of strength or limitation of movement 2. Moderate strain/contusion (2nd degree) - a greater number of muscle fibers are torn than in the 1st degree. This is associated with a clear loss of function 3. Severe strain/contusion (3rd degree) - there is a tear across the whole cross sectional area of the muscle. There is a total loss of muscle function. Skin- abrasion, bruise, lacerations.

Edited by Dr. Chowdhury Iqbal Mahmud MBBS, FRCS (UK), MCh Orth (UK) Fellow in Orthopaedics (Singapore)