Fractures
Describing a fracture
1. Which bone?
2. Which part of that bone? – eg distal third of diaphysis
3. Direction of fracture – transverse/oblique/spiral
4. Undisplaced or displaced? % of displacement?
5. Angulated?
6. Simple or comminuted?
7. Extra or intra-articular?
Important fractures:
- Greenstick fracture – kids
o The cortex bends rather than breaks
- Epiphyseal fracture
o Salter Harris classification – Type 2 most common
- Colles fracture
o Fracture of distal radius with dorsal displacement and angulation.
o Dinner fork appearance
o From falling on an oustretched hand – very common
- Smiths fracture = reverse Colles fracture
o From fall on dorsum of hand – uncommon
- Jones fracture
o Fracture at base of 5th metatarsal diaphysis
- Scaphoid fracture
o Caused by fall on the outstretched hand with forced dosrsiflexion. Get
snuffbox tenderness. Order a “scaphoid series” of films.
o Complication is avascular necrosis.
- Bennets fracture
o Fracture at base of 1st metacarpal
- Boxers fracture
o Fracture of metacarpal neck – classically of the little finger
- Night stick fracture
o Ulnar fracture
- Hangmans fracture
o Fracture of pedicles of C2
- Potts fracture
o Fracture of distal fibula
- Shaft of humerus fractures
o Always examine for radial nerve palsy
- Shoulder dislocation
Managing fractures
So what do you do?
- Full assessment
-
o Hx
o Exam
 Look – swollen? Bruised? Open/closed?
 Feel – tender? Loss of function? Crepitus?
 Move – active then passive
o Rule of 2s – 2 planes (AP + lat), 2 joints (get jts above and below
fracture), 2 occasions, 2 limbs, 2 opinions
Reduce (if necessary)
Immobilise
Maintain reduction
Rehabilitation
How do fractures unite?
- Secondary union with callus formation (natural)
o Fracture of bone causes haematoma formation. Tissue injury causes
inflammatory response. Haematoma gets organized into collagen and
granulation tissue. Osteoblasts activate and begin forming the callus.
(Callus is response to movement at a fracture site). New blood vessels
migrate into callus causing calcification and ossification. Remodelling –
see trabecullae crossing the fracture site on Xray.
o Disadvantage is that higher risk of malunion and the complications of that.
- Primary union (with rigid fixation)
o Bone ends are placed anatomically together and compressed tightly with
the use of screws/plates. Inflammatory response is much reduced. No
callus. Healing process takes much longer.
Problems:
- Malunion
- Delayed union
- Non-union – could be due to excess mobility or to poor blood supply.
Open fracture:
- The problem is infection
- Prophylactic antibiotics (IV – gram+ cover, +/- anaerobic cover)
- Anti-tetanus cover
- Irrigation
- Debridement
- Skin cover
- Open reduction of fracture and stabilization – eg use of external fixation
Ways of fixation of fractures:
- Plaster cast
- Internal fixation
o Indications: intraarticular fracture, neurovascular damage, poly-trauma…
o Extracortical – plates and screws
o Intramedullary
-
o Complications: infection, nerve and vessel injury, implant failure
External fixation
o Indications: usually as a temporary measure, open fractures
o Complications: pin site infection and possible ostemyelitis
Examining a joint – Look, Feel, Move
1. Inspection
2. Could I see the patient walk?
a. Gaits:
b. Antalgic – lean away from the pain side
c. Trendelenburg – hip abduction doesn’t work
d. Short-limbed
e. Spastic
3. Stand up straight
a. Look AP and from the side
4. Lie down
a. Inspect
b. Equal leg lengths?
i. True leg length = from ASIS to medial malleolus
ii. Apparent leg length = from xiphisternum to medial malleolus
iii. Why do you want to know leg lenth? To delineate from contracture
versus fracture (?)
5. Feel
a. Effusion?
b. Patellar tap – will only clunk if big effusion
c. Empty medial gutter of knee, then fill it, and feel for thrill.
6. Now want to show the range of motion. Always look at the face!
a. Active movement
i. Hip – Frog. Lift leg straight up into the air
ii. Knee – first check hips – frog (because obturator nerve can be
irritated causing pain in knee). Then bend knees so bring feet to
bum.
b. Passive movement
i. HIP
1. Roll leg - internal/external rotation
2. Flex hip (with flexed knee)
3. Now internal external rotation (using flexed knee as
fulcrum). Any crepitus?
4. Straighten the leg again on the bed
5. Now abduction and adduction. Place your forearm across
patient’s pelvis and move leg with other hand – in and out.
ii. Test for fixed flexion deformity – Thomas tests
1. Patient lies flat. Get them to pull good knee up to their
chest. This eliminates the lumbar lordosis.
2. In fixed flexion deformity, the other knee will be lifted up
off the bed.
3. Can also hang knee off side of bed – if problem in knee it
won’t hang properly
iii. KNEE
1. Are the quads firing?
2. Hyperextend the knee – 5 degrees is normal
3. Flex knees
4. Medial and lateral collateral ligaments
a. In full extension, lift leg up off bed a bit with one
arm. Use other arm to do varus and valgus thrusts.
5. Cruciates
a. Anterior/Posterior drawer tests – sit on foot, hold
top of tibia, and pull it forward and back. (Post
drawer test for PCL).
b. Lachman test (same effect)
c. Pivot shift – will clunk
6. Menisci
a. Palpate the knee joint line all around joint. With
damaged menisci will get pain.
Fracture of neck of femur
95% of hip fractures are a broken neck of femur. Break of head of femur is rare, but can
occur in young people, often in RTCs.
Is it intra or extra-capsular?
- Intracapsular fracture will compromise blood supply
- Extracapsular fracture doesn’t affect blood supply
Medial femoral circumflex artery is important.
Limb will be shortened and externally rotated.
In children have extra blood supply from ligamentum of Teres.
Garden classification 1-4
- important to distinguish undisplaced from displaced, because rate of healing
complications is different. Much higher risk of complications with displaced
fractures (about a third), versus undisplaced (<10%)
- 1 and 2 are undisplaced. So think that femoral head will survive. Just fixate.
- 3 and 4 are displaced. Will need surgical intervention.
On Xray – Shintan’s line will be broken if there is a fracture
Very high mortality with hip fractures – 30% mortality in 6 months if >80 years old
History:
- after a fall
- Can’t walk
- Leg is shorted and externally rotated
- SHx – if elderly patient, lives alone, could have been on the ground for days and
be severely dehydrated and hypothermic
Hip replacement
- Hemiarthroplasty (half hip replacement)
o So the femoral side is replaced but not the acetabulum
o Encourage patient to walk the day after surgery!
- Dynamic hip screw
o Screw moves along the line of the fracture
o Can walk the day after surgery
- Girdle procedure – excisional hip arthroplasty
Tibia fracture
In high velocity injuries. So be concerned about other injuries as well – investigate fully.
Often young patient. Can have common peroneal nerve involvement – foot drop. Can
have compartment syndrome!
Compartment syndrome
Increased pressure in a closed fascia compartment that can lead to ischaemic necrosis.
Most commonly in fractures of the tibia. Most commonly in anterior compartment.
Clinical features – 5 Ps
1. Pain out of proportion to the injury!
2. Pallor
3. Paralysis
4. Paraesthesia
5. Pulses present
Remember that can have normal pulses, normal neuro exam, normal looking and feeling
limb. The pain is out of proportion to the injury!
To test:
- Push toes down – get pain – means anterior compartment syndrome (ie pain on
passive stretching of muscle)
- dorsiflex the toe – get pain in the back of the leg – this means posterior
compartment syndrome
To treat:
- release all 4 compartments – fasciotomy ASAP
- Fasciotomy is clearly indicated if pressure in the compartment is >40mmHg
Osteoarthritis
Disbalance between wear and repair.
On Xray – say you want a lateral view and 2 orthognal views. Would also like to see the
joint above and below.
1. Decreased joint space
2. Osteophytes
3. Subchondral sclerosis (whitish – white bone is dead bone)
4. Subchondral cysts
Clinical features:
- Large joints
- Hands – typically the first MCP joint, distal IP joints
- Heberden’s nodes (distal), Bouchard’s nodes (proximal)
Complications of OA:
- Subluxation – partial loss of congruity between bones
- Ankylosis – stiffness
- Deformities
- Loose bone formation
Osteoporosis = brittle bone disease
Characterised by low bone mass and deterioration of the microarchitecture of bone tissue
with consequent increase in bone fragility and susceptibility to low trauma fractures.
Bone is essentially normal but there is too little of it.
-
DEXA scan – to assess bone mineral density
T-scan
Calcium
Vitamin D
Management:
- Bisphosphonates (fosomax) – inhibit osteoclasts
o SEs – GI upset, TMJ osteonecrosis
- PTH analogues (new)
o Possible slight increase in risk of osteosarcoma
- Exercise!!
ATLS – Advanced Trauma Life Support
This is the gold standard for managing multi-trauma patients.
The “golden hour” after trauma.
1. AIRWAY and C-SPINE
a. Hold airway in position until can apply collar/sand bags/tape
b. Important to get patient off spinal board ASAP – very uncomfortable and
risk of pressure sores
c. What obstructs airway? Tongue – jaw thrust. Look inside. Suction. Risk of
airway oedema, especially if burns, smoke etc.
d. Definitive airway is a cuffed ET tube in the larynx. Need definitive airway
in unconscious patient, GCS <10, severe facial injury, burns (oedema)
e. Always 100% O2
2. BREATHING and VENTILATION
a. 100% O2 going into both lungs
b. flail chest?
c.
d.
e.
f.
g.
h.
PTX? Open and closed PTX
Haemothorax?
Pulmonary contusion?
ARDS?
Diaphragmatic rupture? (bowel loops in chest)
Types of ventilation:
I. Spontaneous
II. Assisted – face mask and ambu nag with 100% O2
3. CIRCULATION
a. Where do you bleed into? – One to the floor and three above – external,
pelvis, abdomen, thorax.
b. Shock – definition and 5 types (cardiogenic, neurogenic, anaphylactic,
septic, hypovolaemic)
c. Grades of shock
I. lose <750mls of blood – no one notices
II. lose 750-1500mls – get tachycardia
III. lose 1500-2000mls - ie 30-40% of blood volume – get tachycardia,
falling BP, falling UO
IV. lose >2litres – tachypnoea, tachycardia, pale, sweaty, decreased
UO, etc
d. Management: stop the bleeding! – pressure!
e. If pelvic fracture – massive venous plexus in pelvis – can be torn when the
pelvis is traumatized. If patient is stable – they’re OK. If unstable – go
straight to theatre! (so no CT)
f. Hartman’s – 2litres of warm Hartman’s in the first hour – via 2 large bore
IV catheters, one in each antecubital fossa (orange and grey are largest)
g. Group and crossmatch 6 units. Give O neg blood if urgent.
h. Coagulability is decreased in a cold environment – so keep the room
warm.
i. Urine output should be 0.5ml/kg/hour
j. Insert catheter
k. How do you know if urethra is traumatized? – See blood at urethral
meatus, high riding prostate on DRE, haematurea, bruising of labia etc.
l. Suprapubic catheter goes in 2 finger breadths above the pubic symphysis.
4. DISABILITY
a. AVPU scale
b. Pupils
c. GCS – 6 motor, 5 verbal, 4 eyes
i.
If <8 – will be unable to maintain airway and require intubation
5. EXPOSURE and ENVIRONMENT
a. Do the secondary survey
Spine