Principles of fractures and dislocations

Principles of fractures and dislocations

1. Stress fracture

   • normal bone
   • repetitive stress

2. Pathological fracture

   • abnormal bone
     • metastatic disease
     • benign lesion
   • vs
   • physiological stress

3. Force

   • Direct
     • break at point of impact (POI)
       • + soft tissue damage
   • Indirect
     • break away from POI
       • +/- soft tissue damage

4. Mechanism of Injury

   • Spiral
     • TORSION
       • rotational force applied to a lever
         • humerus
         • femur
   • Short Oblique
     • COMPRESSION
       • greenstick
         • children due to thickenss of periosteum
   • Butterfly
     • BENDING
       • Car accident
       • Comminution
         • e.g. vertebral comminution common when subject to
   • Transverse
     • TENSION

5. How to describe a fracture

   • open or closed?
     • open- antibiotics + cleaning of bone ends
   • bone(s)?
     • location?
   • simple or comminuted?
   • complete or incomplete?
   • involvement of joint?
   • displaced or non displaced?
     • displacement
       • translation
         • describe with reference to distal fragment (50%, 100%, or complete (off ended
       • alignment
         • angulation
       • rotation
         • twist
       • length
         • distraction
         • separation
         • overlap
   • traumatic, stress or pathological?

6. HEALING

   • INDIRECT
     • In tubular bone in the absence of rigid fixaiton
       • 1. Haemotoma formation
       • 2. Inflammation and Cellular proliferation
       • 3.Callus
         • response to movement at the fracture site
         • stabilise
       • 4. Consolidation
       • 5. Remodelling
   • DIRECT
     • fracture immobilised
       • example
         • Fixed with metal plate
         • impacted cancellous bone fracture
       • fracture healing occurs directly between fragments WITHOUT CALLUS
   • HOW LONG?
     • dependant on age, nutrition, general health, blood supply, type of fracture, fracture stability
   • promoted by physiological loading of bone (DONT IMMOBILISE)

7. CLINICAL FEATURES

   • LOOK
     • swelling
     • bruising
     • deformity
     • skin intact?
   • FEEL
     • bony tenderness
     • crepitus
       • grating bone against bone
     • pulses
     • associated injuries
       • tense compartment= compartment syndrome
   • MOVE
     • maybe not if patient awake and conscious
       • x-ray might be more appropriate
   • NEUROVASCULAR EXAM
     • all nerves and vessels traversing the compartment
       • at presentaiton AND after any intervention

8. IMAGING

   • X-RAY
     • rule of 2's
       • views, joints, limbs, injuries, occassions
   • ADVANCED IMAGING
     • Technitium Bone Scan
       • may be "cold" if performed within 48-72 hours of injury
     • CT
       • complex or interarticular fractures
       • used to define bony anatomy
     • MRI
       • assessment of associate structures
         • spinal cord, nerve root, ligament injuries
       • soft tissue anatomy definition

9. TREATMENT

   • REDUCTION
     • aim for adequate apposition and normal alignment
     • closed
       • + anasthesia
       • distal limb pulled in line with bone
       • fragments disengage and are repositioned
       • alignment adjusted in each plane
       • use
         • most fractures in children
         • for fractures that are stable after reduction
           • can be fixated
         • Unstable fractures can be reduced prior to internal fixation
     • open
       • operative reduction under direct vision
   • FRACTURE IMMOBILISATION
     • casting/ FIXATION
     • continuous traction
       • typically children
     • cast splintage
     • funcitonal bracing
     • internal fixation
       • wires
       • plates and screws
       • intermedullary nails
     • external fixation
     • internal vs External
   • REHAB

10. COMPLICATIONS

    • EARLY
      • vascular injury
      • nerve injury
        • shoulder- axillary
        • humerus- radial
        • humerus supracondylar- radial or median
        • hip- sciatic
        • knee- fibular
      • compartment syndrome
        • 5 P's
          • pain out of proportion to injury and pain on passive stretch most important
      • fracture blisters
      • infection
    • LATE
      • delayed union/ nonunion
        • Injury factors
        • treatment factors
        • Pt factors e.g. smoking, NSAIDs, drinking
        • Hypertrophic non-union: florid periosteal new bone formation, wants to heal- biology of healing okay just needs stability
        • Atrophic non-union- no signs of healing, needs improved biology
      • malunion
      • avascular necrosis
        • Femoral head, scaphoid, talus
      • growth disturbance
      • joint impairment
      • pain syndromes

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