Fracture description
- Name of injured bone
- Integrity of skin/soft tissue
Closed, open - Location
epiphyseal, metaphyseal, diaphyseal (proximal, middle, distal), physis (growth plate) - Orientation/fracture pattern
• transverse: fracture line perpendicular (<30° of angulation) to long axis of bone; result of direct high energy force
• oblique: angular fracture line (30°- 60° of angulation); result of angulation and compressive force, high energy
• butterfly: fracture site fragment which looks like a butterfly
• segmental: a separate segment of bone bordered by fracture lines; result of high energy force
• spiral: complex, multi-planar fracture line; result of rotational force, low energy
• comminuted/multi-fragmentary: >2 fracture fragments
• intra-articular: fracture line crosses articular cartilage and enters joint
• avulsion: tendon or ligament tears/pulls off bone fragment; often in children, high energy
• compression/impacted: impaction of bone; typical sites are vertebrae or proximal tibia
• torus: a buckle fracture of one cortex, often in children
• greenstick: an incomplete fracture of one cortex, often in children
• pathologic: fracture through bone weakened by disease/tumour - Alignment of fracture fragments
• non-displaced: fracture fragments are in anatomic alignment
• displaced: fracture fragments are not in anatomic alignment
• distracted: fracture fragments are separated by a gap (opposite of impacted)
• impacted: fracture fragments are compressed, resulting in shortened bone
• angulated: direction of fracture apex (e.g. varus/valgus)
• translated/shifted: percentage of overlapping bone at fracture site
• rotated: fracture fragment rotated about long axis of bone
Signs of open fracture
continuous bleeding from puncture site or fat droplets in blood are suggestive of an open fracture
How to describe displacement
Refers to position of the distal fragment relative to the proximal fragment
Varus angulation
Apex away from midline
Valgus angulation
Apex toward midline
Xray rule of 2s
2 sides - bilateral
2 views - AP and lat
2 joints - joint above and below
2 times - before and after reduction
Reasons for spinting
Pain control
Reduces further damage to vessels, nerves and skin and may improve vascular status
Decreases risk of inadvertently converting closed to open fracture
Facilitates patient transport
Approach to fractures
- Clinical assessment
- ABCs
- R/o other fractures/injuries
- rule out open fracture
- SAMPLE
- Physical exam (deformity, soft tissue integrity, maximal tenderness, NVS, avoid ROM/moving injured area to prevent exacerbation) - Analgesia
- Imaging
- Splint extremity
- Management: Closed vs. Open Reduction
- obtain the reduction (see appropriate IV sedation)
■ closed reduction
◆ apply traction in the long axis 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 – not able to cast or apply traction due to site (e.g. hip fracture) – pathologic fractures – potential for improved function with ORIF
■ ALWAYS re-check and document NVS after reduction and obtain post-reduction x-ray - maintain the reduction
■ external stabilization: splints, casts, traction, external fixator
■ internal stabilization: percutaneous pinning, extramedullary fixation (screws, plates, wires), IM fixation (rods)
■ follow-up: evaluate bone healing - rehabilitate to regain function and avoid joint stiffness
Indications for open reduction
NO CAST
Non-union Open fracture Neurovascular Compromise Displaced intra-Articular fracture Salter-Harris 3,4,5 PolyTrauma
What is Buck’s Traction
system of weights, pulleys, and ropes that are attached to the end of a patient’s bed exerting a longitudinal force on the distal end of a fracture, improving its length, alignment, and rotation
Normal progression of fracture healing
Weeks 0-3
Hematoma, macrophages surround fracture site
Weeks 3-6
Osteoclasts remove sharp edges, callus forms within hematoma
Weeks 6-12
Bone forms within the callus, bridging fragments
Months 6-12
Coritcal gap is brdiged by bone
Years 1-2
Normal architecture is achieved through remodelling
Evaluation of fracture healing
Tests 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
Local early fracture complications
Compartment syndrome
Neurological injury
Vascular injury
Infection
Implant failure
Fracture blisters
Local late fracture complications
Mal/non-union
AVN
Osteomyelitis
Heterotopic ossification
Post traumatic OA
Joint stiffness/adhesive capsulitis
CRPS type I/RSD
Systemic early fracture complications
sepsis
DVT
PE
ARDS secondary to fat embolism
Hemorrhagic shock
What is heterotopic ossification
The formation of bone in abnormal locations (e.g. in muscle), secondary to patho
What is Wolff’s Law
Bone remodels itself to over time in response to mechanical load to better withstand loading stressors placed upon it
Articular cartilage properties
- 2-4 mm layer covering ends of articulating bones, provides nearly frictionless surface
- avascular (nutrition from synovial fluid), aneural, alymphatic
Avascular necrosis definition and commonly affected areas
Avascular Necrosis Ischemia of bone due to disrupted blood supply; most commonly affecting the femoral neck, talus neck, or proximal scaphoid
Fracture blister definition
Formation of vesicles or bullae that occur on edematous skin overlying a fractured bone
Osteochondritis dissecans
Osteonecrosis of subchondral bone most often occurring in children and adolescents and causing pain and potentially hindering joint motion
Articular cartilage defects etiology
- overt trauma, repetitive minor trauma (such as repetitive ankle sprains or patellar maltracking); common sports injury
- degenerative conditions such as early stage OA or osteochondritis dissecans
Articular cartilage defects clinical features
- similar to symptoms of OA (joint line pain with possible effusion, etc.)
- often have predisposing factors, such as ligament injury, malalignment of the joint (varus/valgus), obesity, bone deficiency (AVN, osteochondritis dissecans, ganglion bone cysts), inflammatory arthropathy, and familial osteoarthropathy
- may have symptoms of locking or catching related to the torn/displaced cartilage
Articular cartilage defects investigations
- x-ray (to rule out bony defects and check alignment)
- MRI
- diagnostic arthroscopy (treatment is often guided by what is seen during arthroscopy)
