Fractures

• Types of Fracture

  • Compound fracture
  • Stable fracture
  • Pathological fracture
  • Transverse
  • Oblique
  • Spiral
  • Segmental
  • Comminuted
  • Compression fractures
  • Greenstick
  • Buckle (torus)
  • Salter-Harris
• Compression fractures


  • Affecting the vertebrae in the spine
• Greenstick and buckle fractures

  • Typically occur in children rather than adults
• Salter-Harris fractures


  • Only occur in children (adults do not have growth plates)
• Wrist Fractures

  • Colle’s fracture
  • Scaphoid fracture
• Colle’s fracture refers to a transverse fracture of the distal radius near the wrist, causing the distal portion to displace posteriorly (upwards), causing a “dinner fork deformity”. This is usually the result of a fall onto an outstretched hand (FOOSH)
• Scaphoid fracture is often caused by a FOOSH. The scaphoid is one of the carpal bones and is located below the base of the thumb. A key sign of a scaphoid fracture is tenderness in the anatomical snuffbox (the groove between the tendons when extending the thumb). The scaphoid has a retrograde blood supply, with blood vessels supplying the bone from only one direction. This means a fracture can cut off the blood supply, resulting in avascular necrosis and non-union
• Some key bones have vulnerable blood supplies, where a fracture can lead to avascular necrosis, impaired healing, and non-union. These are the scaphoid bone, the femoral head, the humeral head, and the talus, navicular, and fifth metatarsal in the foot
• Ankle fractures involve the lateral malleolus (distal fibula) or the medial malleolus (distal tibia). The Weber classification can be used to describe fractures of the lateral malleolus (distal fibula). The fracture is described in relation to the distal
• Ankle fractures


  Involves the lateral malleolus (distal fibula) or the medial malleolus (distal tibia)
• Weber classification

  Used to describe fractures of the lateral malleolus (distal fibula) in relation to the distal syndesmosis between the tibia and fibula
• Tibiofibular syndesmosis


  Very important for the stability and function of the ankle joint
• If the fracture disrupts the syndesmosis

  Surgery is more likely to be required in order to regain good stability and function of the joint
• Weber classification types for fractures of the lateral malleolus

  • Type A – below the ankle joint – will leave the syndesmosis intact
  • Type B – at the level of the ankle joint – the syndesmosis will be intact or partially torn
  • Type C – above the ankle joint – the syndesmosis will be disrupted
• Pelvic Ring Fractures

  The pelvis forms a ring. When one part of the pelvic ring fractures, another part will also fracture
• Pelvic fractures often lead to significant intra-abdominal bleeding, either due to vascular injury or from the cancellous bone of the pelvis. This can lead to shock and death, so needs emergency resuscitation and trauma management
• Pathological Fractures

  Occur due to an underlying disease of the bone, such as a tumour, osteoporosis or Paget’s disease of the bone
• Common sites of pathological fractures

  • Femur
  • Vertebral bodies
• Main cancers that metastasise to the bones

  • Prostate
  • Renal
  • Thyroid
  • Breast
  • Lung
• Fragility Fractures


  Occur due to weakness in the bone, usually due to osteoporosis. They often occur without the appropriate trauma that is typically required to break a bone
• Risk of a fragility fracture over the next 10 years can be predicted using the FRAX tool
• Bone mineral density measurement


  Can be done using a DEXA scan
• WHO criteria for osteopenia and osteoporosis

  • T Score at the Hip Bone Mineral Density More than -1 Normal -1 to -2.5 Osteopenia Less than -2.5 Osteoporosis Less than -2.5 plus a fracture Severe Osteoporosis
• NOGG guidelines


  Can be used to guide the medical treatments appropriate for an individual based on their FRAX score
• First-line medical treatments for reducing the risk of fragility fractures

  • Calcium and vitamin D
  • Bisphosphonates (e.g., alendronic acid)
• Bisphosphonates


  • Interfere with osteoclasts and reduce their activity, preventing the reabsorption of bone
• Key side effects of Bisphosphonates

  • Reflux and oesophageal erosions
• Denosumab

  • Monoclonal antibody that works by blocking the activity of osteoclasts. It is an alternative to bisphosphonates
• Imaging

  1. rays are the initial imaging investigation when a bone fracture is suspected. CT scans give a more detailed view of the bones when the x-rays are inconclusive or further information is needed
• Principles of Fracture Management

  The first principle is to achieve mechanical alignment of the fracture by: Closed reduction via manipulation of the limb, Open reduction via surgery. The second principle is to provide relative stability for some time to allow healing to occur by fixing the bone in the correct position while it heals
• Fracture management

  1. Closed reduction via manipulation of the limb

  2. Open reduction via surgery

  3. Provide relative stability for some time to allow healing to occur
• Ways to fix the bone in position

  • External casts (e.g., plaster cast)
  • K wires
  • Intramedullary wires
  • Intramedullary nails
  • Screws
  • Plate and screws
• Management of patients with fractures

  1. Patients presenting to A&E will be investigated with x-rays to establish the diagnosis

  2. Patients with fractures require appropriate pain management

  3. Straightforward fractures may be managed in A&E (e.g., a Colle’s fracture in a young adult) with closed reduction if bones are out of alignment

  4. Complex fractures and those requiring surgery (e.g., hip fractures) are referred to the on-call trauma and orthopaedics team
• Possible early complications of fractures

  • Damage to local structures (e.g., tendons, muscles, arteries, nerves, skin, and lung)
  • Haemorrhage leading to shock and potentially death
  • Compartment syndrome
  • Fat embolism
  • Venous thromboembolism (DVTs and PEs) due to immobility
• Possible longer-term complications of fractures

  • Delayed union (slow healing)
  • Malunion (misaligned healing)
  • Non-union (failure to heal)
  • Avascular necrosis (death of the bone)
  • Infection (osteomyelitis)
  • Joint instability
  • Joint stiffness
  • Contractures (tightening of the soft tissues)
  • Arthritis
  • Chronic pain
  • Complex regional pain syndrome
• Fat embolism can occur following the fracture of long bones (e.g., femur)
• Fat embolism process

  1. Fat globules are released into the circulation following a fracture (possibly from the bone marrow)

  2. Fat globules may become lodged in blood vessels (e.g., pulmonary arteries) and cause blood flow obstruction
• Fat embolisation can cause a systemic inflammatory response, resulting in fat embolism syndrome
• Fat embolism syndrome typically presents around 24-72 hours after the fracture
• Gurd’s major criteria for fat embolism syndrome diagnosis

  • Respiratory distress
  • Petechial rash
  • Cerebral involvement