Fractures - General Principles

Fractures - General Principles

Fracture Description

1. Integrity of Skin/Soft Tissue

·                 closed: skin/soft tissue over and near fracture is intact

·                 open: akin/soft tissue over and near fracture is lacerated or abraded, fracture exposed to outside environment. continuous bleeding from puncture sl1e or fat droplets in blood suggest communication with fracture

2. Location (Figure 4)

·                 epiphyseal: end of bone, forming part of the adjacent joint

·                 metaphyseal: the flared portion of the bone at the ends of the shaft.

·                 diaphyseal: the shaft of a long bone (proximal, middle, distal)

·                 physis: growth plate

3. Orientation/Fracture Pattern (Figure 5)

·                 transverse: perpendicular fracture line, direct force, high energy

·                 oblique: angular fracture line, angular or rotational force

·                 butterfly: slight comminution at the fracture site which looks like a butterfly

·                 segmental: a separate segment of bone bordered by fracture lines, high energy

·                 spiral: complex, multi-planar fracture line, rotational force, low energy

·                 comminuted/multl-fragmenary: more than 2 fracture fragments

·                 intra-articular: fracture line crosses artlcu1ar cartilage and enters joint

·                 compression/Impacted: impaction of bone, e.g. vertebrae, proximal. tibia

·                 torus: a buckle fracture of one cortex. often in children (Figure 49)

·                 green-stick: an incomplete fracture of one cortex, often in children (Figure 49)

·                 pathologic: fracture through bone wakened by disease/tumour

4. Displacement (Figure 5)

·                 nondisplaced: fracture fragments are in anatomic alignment

·                 displaced: fracture fragments are not in anatomic alignment

·                 distracted: fracture fragments are separated by a gap

·                 angulated: direction of fracture apex. e.g. varus/valgus

·                 translated: percentage of overlapping bone at fracture site

·                 rotated: fracture fragment rotated about long axis of bone

Management of Fractures

·                 ABCs, primary survey and secondary survey (ATLS protocol)

o       rule out other fractures/injuries

o       rule out open fracture

·                 AMPLE history - Allergies, Medications, Past medical history, Last meal, Events surrounding injury

o       consider pathologic fracture with history of only minor trauma

·                 additional history/physical:

o       baseline functional status -handedness (upper extremity) vs. ambulatory ability (lower ertremity- note distances, stairs, and use of assistive devices such as canes, walkers, wheelchairs, etc.)

o       occupation and smoking status

o       mechanism of injury

o       past medical history (note any contraindications to or general anesthetic)

o       neurovascular status

·                 analgesia

·                 imaging

·                 splint extremity

1. obtain the .reduction (refer to Table 22 for appropriate IV sedation)

·                 closed reduction

•                  apply traction in the long am of the limb

•                  reverse the mechanism that produced the fracture

•                  reduce with IV sedation and muscle relaxation (fluoroscopy can be used if available)

·                 indications for open reduction - NO CAST

·                 other indications include

•                  failed closed reduction

•                  cannot cast or apply traction due to site (e.g. hip fracture)

•                  pathologic fractures

•                  potential fur improved function with open reduction and Internal fiDtion (ORIF)

·                 potential complications of open reductions

•                  infection

•                  mal-union

•                  non-union

•                  implant failure

•                  new fracture

·                 re-check. neurovascular status after .reduction and obtain post-reduction x-ray

2. maintain the reduction

·                 external stabilization - splints, casts, traction, external fixator

·                 internal stabilization -percutaneous pinning, extra rnedullary fixation (screws, plates, wires), intramedullary fixation (rods)

·                 follow-up- evaluate bone healing

3. rehabilitate to regain  function and avoid joint stiffness

Fracture Healing

Evaluation of Healing: Testa of Union

·                 clinical.: No longer tender to palpation or stressing on physical exam

·                 x-ray: trabeculae cross fracture site. visible callus bridging site on at least 3 of 4 cortices

General Fracture Complications

Table 2. General Fracture Complications