What are the Signs and Symptoms of a Fracture?
Loss of function
What to consider when describing fractures?
Configuration e.g. spiral
Articular (joint surface)
Displacement (of distal fragment)
~Angulation (the younger the child is the more angulation you can accept because bones grow so fast)
How would you describe the Mechanism of a Fracture?
Soft tissue envelope
What is meant by a Pathological Fracture?
Fracture occurring through abnormal bone under physiological load
E.g. osteoporosis ‘normal bone but less of it’, osteomalacia ‘abnormal bone’ , tumour
What does Fracture Healing depend on, and name the 3 phases
Fracture Healing is a balance between stability and biology
Inflammatory 1-5 days
Reparative 4-40 days
Remodelling 25-200 days (can go for more much longer)
Healing by Callus
What are the Local Factors influencing Fracture Healing?
Injury – configuration/soft tissue injury
Bone – cancellous v cortical
Treatment – reduction (restore anatomy)/ stability (e.g. plaster, frame, screws, rod) / infection
What are the Regional and Systemic Fractures influencing Fracture Healing?
Blood supply / muscle cover
Age/co-morbidity (e.g. renal failure)/ bone pathology / head injury (healing speeds up due to the response to the head injury)
What is Pearson's Rule?
What happens when fracture healing goes wrong?
Malunion (healed in the wrong position) --> deformity, late arthrosis (degeneration of articular cartilage with a subsequent change in the bony articular surfaces, development of osteophyte, deformation of the joint and the development of moderate synovitis)
Non-Union: hypertrophic (extra callus has been laid due to lots of movement causing instability – hypertrophy is body’s response to try to achieve stability), atrophic (no healing potential)
What are Early Local Fracture Complications?
What are Early Systemic Fracture Complications?
Hypovolaemia (due to blood loss) / shock
Fat embolism --> due to fat being released from bone fracture (yellow marrow) --> same effect as pulmonary embolism
Acute respiratory distress syndrome
Disseminated intravascular coagulation (all clotting factors have been used up --> continuous bleeding)
What are Late Local Fracture Complications?
Re-fracture (muscle doesn’t heal properly – becomes calcified --> joint stiffens)
What are Late Regional Fracture Complications?
Chronic regional pain syndrome
What is Compartment Syndrome?
raised pressure within an enclosed fascial space leading to localised tissue ischaemia
Pain – excessive/progressive/not relieved by analgesia / ‘passive stretch pain’
Neurovascular changes are late – by the time the pulses have disappeared an amputation is required
If in doubt, perform surgical decompression
Check for puncture wounds when looking at Open v Closed Fractures. How do you assess Open Injuries?
(After surgical removal of dead tissue)
Gustillo and Anderson
I: <1cm, clean
II: >1cm, mod contamination (most common)
III: high velocity, farmyard (including neurovascular damage)
A: adequate skin cover
B: bone exposed
C: circulatory compromise
What do you consider when looking at Children's Fractures?
- Buckle (Torus) fractures – compression (the topmost layer of bone on side of the bone is compressed causing the other side to bend away from the growth plate)
- Greenstick fractures - Tension
Growth plate (Epiphyseal) fractures
What do you need to consider when looking at Epiphyseal Fractures?
What are Stress Fractures?
Repetitive, non-violent ‘subtle’ stresses
‘Fatigue’ v ‘Insufficiency’ – bone hasn’t had time to develop e.g. suddenly running a marathon
Female > men
Predispositions: osteoporosis, sports, eating disorders
Discuss Osteoporotic Fractures
Osteoporosis is characterised by low bone mineral content, enhanced bone fragility and consequent increased fracture risk/
Sensitivity to osteogrens
Prevention: weight-bearing exercise pre 35 years, vitamin D + calcium
Diagnosis: DEXA Scan wrist / hip / spine (compare against normal bone)
Discuss Non-Operative Treatment
Wool and crepe
Sling / collar and cuff
Cast – POP / fibreglass
Traction – skin / skeletal
Discuss Operative Treatment
Protect soft tissues / avoid infection
Open or closed reduction (break put in right space)
Implants – biologically inert
Anatomical reduction *intra-articular*
Early joint / muscle rehabilitation