Fractures

last authored: April 2012, David LaPierre
last reviewed:

 

 

Introduction

Fractures, or traumatic injury to bone resulting in a break in the cortex, are common injuries. Typical fractures occur through force sufficient to overcome a bone's strength, and may be the result of a direct blow, axial loading, twisting, or bending. Pathologic fractures occur as the result of relatively little force in a bone with increased susceptibility.

 

Fractures can result in significant pain, crepitus, and/or abnormal motion. Soft tissue injury may also be evident.

 

Trauma is commonest cause of death ages 1-44, trauma ~25% of all ER visits. Each death from trauma leaves 3-8 people permanently disabled. Of fractures, 80% are from low energy (falls etc), while 20% are from high energy (collisions).

 

Energy imparted to limb is calculated by the formula KE = 1/2mv2 where m=mass and v= velocity. The worse the break, the more energy likely was absorbed.

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Types of Fracture

Open fractures occur when there is injury to the soft tissue as well, leading to communication between the skin surface and the fractured bone. Obvious protrusion of bone may be present, or may simply be a puncture wound extending down to the site of fracture. The greatest risk is osteomyleitis, a potentially disastrous bone infection.

 

type I: skin wound less than 1 cm - tetanus

type 2: greater than 1 but less than 10 cm - ( +aminoglycocides (ie gentamycin) )

type 3: open wound greater than 6 hours, farm yard (Clostridium), high energy with segmental # or bone loss (+ penicillins).

 

Pathologic fractures can occur for a variety of reasons, including

 

Stress fractures occurs with repeated force to a bone, before the bone and soft tissue has had time to adapt.

 

Salter-Harris Fractures

Fractures that include the cartilage epiphyseal plate of long bones in children are classified according to Salter and Harris, two physicians. Damage to the epiphyseal growth plate can permanentely disrupt the bone's ability to continue growing.

 

  • hand and wrist
  • distal radius
  • elbow
  • hip
  • femur
  • tibial
  • knee
  • ankle and foot

Hand and Wrist Fractures

 

shortening

dropped knuckle (bony prominence in palm)

extensor lap

 

Boxer's Fracture

The 5th metacarpal neck, and potentially the 4th; almost always angulated dorsally.

Swelling soreness

 

attempt reduction when:

  • angulation is greater than 30-45% on X-ray
  • scissoring (implies rotational fracture)

 

Reduction

The Jahss maneuver:

Second line: axial traction to digit to release soft tissues (5 minutes).

 

 

 

Bennett's fracture

intraarticular fracture across thumb CMC joint; fracture in

APL pulls base of metacarpal out extend, abduct, supinated

needs to be reduced to restore function and predispose to OA

 

reduction: pronate

 

 

Rolando's Fracture

Comminuted fracture at base of thumb.

Fixed surgically with K-wires

 

 

Scaphoid Fracture

 

Distal Radius

main article: pediatric forearm fracture

Distal radius fracture (DRF) describes number of different fractures. Some of these include Colles fracture, etc...

Anatomic descriptors are helpful.

Elbow Fractures

Swelling and ecchymosis

neurovascular exam

  • pulse
  • doppler exam
  • warmth
  • capillary refill

neuro exam

  • AIN: pure motor, flexion of distal tumb and first finger

Hip Fractures

 

The physical examination commonly reveals an abducted and externally rotated hip with leg-length discrepancy. The patient usually has localized tenderness over the hip and limited range of motion of the affected limb during attempts at passive and active rotation and flexion. Radiographs clearly demonstrate the fracture.

 

In some instances, however, patients with hip fracture have normal ambulation and complain only of vague pain in their buttocks, knees, thighs, groin, or back. These patients frequently report no antecedent trauma, particularly if cognitive impairment is present. Their physical examination, including assessments of active, passive, and resisted movements of the affected hip joint and limb, may be normal. They often have additional injuries (e.g., scalp lacerations, knee sprains, or other impairments) that mask the hip pathology and direct the physician's attention away from the diagnosis of hip fracture.

 

Osteoporosis is perhaps the most important disease associated with hip fractures, and its prevention is critical, especially in post-menopausal women.

Femur

Femoral fractures can be extremely painful and life-threatening, due to the amount of bleeding that can take place.

 

Splinting should take place, with a ring pushed upwards along the leg to rest alongside the buttocks, perineum, and groin. Care shold be taken to avoid damaging tissues at the ring site, or at the foot/ankle. Excessive traction can also result in neurovascular compromise through stretching of the peripheral nerves. This should be avoided if there is also fracture of the lower leg. (WHAT THEN?)

 

Hip fractures can temporarily be splinted by tying the two legs together.

Tibia Fractures

Tibial fractures can be immobilized with a long-leg plaster, metal gutter, or cardboard splint

Knee

Knee fractures can be immobilized using long-leg plaster splints or commercially available immobilizers. The knee should be in approx 10 degress of flexion to reduce excessive tension on the nerves and blood vessels.

Ankle and Foot Fractures

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Evaluating Possible Fractures

  • history
  • physical exam
  • radiological evaluations

History

 

If operative repair is deemed necessary, inquire into AMPLE:

  • allergies
  • medications
  • past medical history
  • last meal
  • events surrounding injury

 

Paresthesias can follow nerve laceration.

 

In the case of a suspected pathologic fracture, ask about history or symptoms of malignancy, especially related to lung, thyroid, renal, breast, prostate.

Physical Exam

Examine the site of injury for the following:

  • tenderness
  • swelling
  • deformity
  • crepitation
  • abnormal motion

As the latter two maneuvers can be very painful and result in further injury, they should be done carefully and only as necessary for diagnosis.

 

Periodically reassess the neurovascular status of the affected area.

 

Fractures should be described according to the following rubric:

location (epiphysis, metaphysis, diaphysis, physis)

open/closed

orientation or pattern: transverse, oblique, butterfly, segmental, spiral, comminuted, intra-articular, compression, torus, green-stock, pathologic)

angulation (degrees or percentage; describe direction of apex pointing)

displacement

communted?

articulation involved

rotation

 

 

pain, swelling, deformity, loss of function, crepitus

gait disturbance

soft tissue: open vs closed

The greater the soft tissue injury, the higher the risk of infection. This is due to disruption of vascularity, increased amounts of pathogen, and direct access for the pathogen.

 

examine bones and joints above and below

Radiological Evaluations

X-ray has clear benefit in evaulating fractures, but is not perfect. This reasons for this are many. Pain may be referred from another area, some fractures are not seen on standard series, some injuries may take up to 10 days to be revealed, and classical radiological signs may not be present. Common injuries which may not be obvious include the scaphoid, nondisplaced radial head fracture, and metatarsal stress fracture.

get orthogonal (taken at right angles to each other) views, such as AP and lateral. Include the joint above and below the site of injury to fully evaluate the situation.

 

soft tissue air, foreign body, swelling

location of fracture

fracture pattern: transverse, spiral, oblique, segmental

simple vs comminuted (multiple pieces)

angulation, displacement, or rotation

 

CT, bone scans, and MRI can be used.

 

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Fracture Management

Fracture emergencies include open fractures (with increased risk of osteomyelitis), dislocation/subluxation (with risk of neurovascular damage and difficulty reducing the joint), and neurovascular damage (with obvious consequences).

 

As with any potentially life-threatening injury, ensure the ABCs - airway, breathing, and circulation - are assessed and managed first. Fractures are often recognized as a component of the secondary survey during trauma care.

 

Splinting is critical to reduce pain, preventing neurovascular damage, reducing the chances of open fracture, and improving transport and movement.

 

 

Closed Reduction

casts, slings, splints

 

 

Open fractures

Provide analgesia as required. Control bleeding with pressure; do not clamp unless absoultely necessary. Gross debris should be removed.

 

Debridement should be carried out by qualified personnel, often in the operating room. This is required for adequate pain control during exploration. The goal is to create a clean surgical site. Remove non-viable tissue and reduce the infectious load. Extend the wound as far as is necessary. Be systematic in removing skin, muscle, and bone. Limit touriquet time.

 

Swabs should be taken, and antibiotics should be started. This is often a first generation cephalosporin for gram positive coverage and an aminoglycoside for gram negatives.

 

Tetanus should be given.

 

Operative treatment

Surgical repair should be considered with (peri) articular fracture (risk of OA), vascular injury, floating joints, open fracture, failed closed reduction, and with multiple trauma. Multiple long bone fractures from traumas need to be operatively repaired in order for stabilization and allow patients to be cared for effectively. Compound tissues need to be debrided.

 

Different approaches to operative management are beyond the scope of this topic, but include plates, screws, IM nail device, joint replacement, or amputation.

 

 

Post-fracture care

Appropriate follow-up, with both clinical and radiological assessment, is necessary to ensure effective healing.

 

The goals of rehabilitation are to restore strength, motion, and proprioreception.

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Complications from Fractures

Life-threatening fractures include pelvic fractures.

 

early

compartment syndrome

blood loss (up to 1.5L from a long bone)

soft tissue infection (inc gass gangrene), osteomyelitis, septic arthritis

deep vein thrombosis/PE

neurovascular injury

fat embolism syndrome (ARDS) - pulmonary, cerebral dysfunction/petichiae, especially from long bone fractures

late

post-traumatic arthritis

complex regional pain syndrome (reflex sympathetic dystrophy)

delayed union/nonunion/malunion

 

 

 

 

 

 

 

 

 

 

 

 

About 15-20% of patients die within one year of a hip fracture, and up to 50% of patients previously independent will require long term institutionalization.

in hospital mortality - 5%.

predictors of mortality

chances of walking independently: 70-80% who could

50% of people become dependent in some IADL, and almost all need some form of help getting around

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Fracture healing

There are four stages of fracture healing, each which overlaps with the other.

A fractured bone usually experiences disruption of blood supply.

inflammation: hematoma, bone necrosis, leads to inflammation, angiogenesis, and infiltration of neutrophils.

soft callus: fibroblasts and other cells invade the area, leading to cartilage formation: (clinical union: no pain or movement at # site). Necrotic edges are resorbed by osteoclasts, revealing 'hairline' fractures a few days after injury.

hard callus: cartilage model to woven (immature) bone

remodelling: woven to lamellar (mature) bone - 6-12 months, up to years later. Extra callus is resorbed, and bone is laid down along natural lines of stress in trabeculae.

Improved remodeling is related to:

the more unstable the joint, the more callus is formed.

 

compund fractures are usually stripped of all tissues, making them dysvascular. Infections thus will be combated slowly.

bone only receives 5% of cardiac output, and so has a difficult time fighting infection.

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Resources and References

Hip Fractures in Adults (American Family Physician, 2003)

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