Overview

• Stages of fracture healing:

  1. Haematoma
  2. Organisation
  3. Callus formation
  4. Modelling
  5. Remodelling or completion
• Definition of fracture:

  • Any loss in the continuity of bone
  • Most commonly the result of trauma
• Principles of fracture treatment:

  • Reduce the fracture under anaesthesia (if displaced) - closed or open reduction (surgical)
  • hold - maintain the reduction until the fracture heals - non-operative or operative methods
  • Optimise the long-term functional outcome
• Non operative treatment indications:

  • Low energy undisplaced injuries
  • Fractures in cancellous bone (spongy bone)
  • Phalangeal/metacarpal/metatarsal fractures
  • Fractures that do not require anatomical reduction e.g. clavicle, many humeral fractures
  • Some children's fractures
• Types of non-operative treatment:

  • Bed rest and analgesia - isolated pubic ramus fracture
  • Cast treatment - particularly distal radial fractures
  • Splits
  • Traction - confines patient to bed so rarely used clinically
• Operative treatment methods:

  • External fixation
  • Internal fixation - intramedullary device or plates
  • Arthroplasty
• External fixation:

  • External fixation devices attached to bone by pins and wires and have an external frame
  • Advantages - minimally invasive surgery
  • Disadvantages - pin track infection, poor patient acceptance and higher rate of mal-union
  • External fixation particularly useful where application of internal fixation would be difficult or risky - previous osteomyelitis, multiple fractures, excessive skin damage and swelling
  • May be used temporarily until internal fixation is deemed safe
• Internal fixation:

  • Treatment of choice for displaced unstable fractures where poor reduction would compromise healing or functional outcome
  • Intramedullary devices - e.g. intramedullary devices for lower limb long bone fractures in adults
  • Plates and screws
• Arthroplasty:

  • Joint replacement
  • Management of intracapsular hip fractures in elderly patients
• Shoulder dislocation nerve injury:

  • Axillary nerve
  • Provides innervation to the deltoid and teres minor muscles
  • Unable to abduct the affected limb beyond 15 degrees
  • Loss of sensation over the inferior deltoid - regimental badge area
• Humeral shaft fracture nerve injury:

  • Radial nerve - within spinal groove of humerus
  • Weakness in wrist extension - wrist drop
  • Diminished sensation back of thumb, index, middle, and 1/2 of ring finger
• Supracondylar humeral fracture nerve injury:

  • Almost always seen in children
  • Anterior interosseous nerve most commonly involved - weakness of the index and thumb pincer movement - weak OK sign
  • Ulnar nerve - claw hand deformity, weak thumb adduction
  • Median nerve - forearm constantly supinated and flexion is weak
• Distal radial fracture nerve injury:

  • Median nerve
  • Enters hand under the flexor retinaculum at the wrist
  • Opposition of the thumb and flexion of the index and middle fingers affected
  • Sensory deficits over palmer surface of lateral three and a half digits
• Posterior hip dislocation nerve injury:

  • Sciatic nerve
  • Foot drop
  • Motor and sensory deficit such as paraesthesia and numbness
• Knee dislocation nerve injury:

  • Common peroneal nerve
  • Decreased sensation in the top of the foot or lateral leg
  • Foot drop
• Initial treatment of compound (open) fracture:

  • Cover wound with sterile dressing
  • Reduction and splinting
  • Antibiotics
  • Theatre
• Early local complications:

  • Compartment syndrome
  • Nerve injury
  • Vascular injury
  • Infection
• Late local complications:

  • Non-union: fracture fails to heal
  • Mal-union: heals in an abnormal position
  • Post traumatic osteoarthritis
  • Avascular necrosis e.g. intracapsular NOF fracture
  • Complex regional pain syndrome
• General complications of fractures:

  • Fat embolism
  • VTE due to immobility
• Patient risk factors for delayed non-union:

  • Smoking
  • Alcohol abuse
  • Increased age
  • Steroid use
  • Diabetes mellitus
  • Chronic renal failure
• Fat embolism:

  • Occurs following the fracture of long bones - fat globules are released into the circulation
  • Fat globules can get lodged in blood vessels
  • Can cause a systemic inflammatory response resulting in fat embolism syndrome
  • Gurd's major criteria - respiratory distress, petechial rash, cerebral involvement
  • Other criteria - jaundice, thrombocytopenia, fever, tachycardia
  • Can lead to multiple organ failure - management is supportive while the condition improves
• Vascular injury:

  • Sacroiliac joint - iliolumbar artery
  • Sacrum - Lateral sacral artery
  • Iliac bone - Superior and inferior gluteal artery
  • Acetabulum - inferior gluteal artery and obturator artery
  • Pubic rami - pudendal artery
• Grades of open fracture:

  • I - wound >1cm long, usually low energy compound from within
  • II - wound between 1 - 10ch without extensive tissue damage
  • IIIA - extensive tissue damage but soft tissue coverage still possible
  • IIIB - extensive soft tissue loss including periosteal stripping and bone damage
  • IIIC - open fracture with arterial injury requiring repair
• X-rays are the initial imaging investigation when a bone fracture is suspected. Two views (two x-rays taken from different angles) are always required, as a single view may miss a fraction.

  CT scans give a more detailed view of the bones when the x-rays are inconclusive or further information is needed.
• Compartment syndrome:

  • When muscle swells within a restrained fascial compartment and eventually occludes its blood supply - resulting in infarction and late ischaemic contracture
  • Most commonly occurs in the calf and forearm
  • Symptoms - severe pain - 5Ps
  • Pulseless is not a feature
  • Needle manometry to measure pressure
  • Management with emergency fasciotomy
  • Debride any necrotic tissue - left open to heal via secondary intention
• Main cancers that metastasise to the bones:

  • Prostate
  • Renal
  • Thyroid
  • Breast
  • Lung
• Fractures that are vulnerable to avascular necrosis:

  • Scaphoid
  • Femoral head
  • Humeral head
  • Talus (ankle)
  • Fifth metatarsal in the foot