1.1 Fractures and dislocations
A fracture is a break or loss of continuity in a bone. They are either open or closed, and may involve a joint surface (see below). The mechanism of injury (e.g. pathological, stress, periprosthetic) should be sought because it will give a clue as to the nature of the fracture. There is always a significant soft tissue component of fractures that requires consideration as part of the pattern of injury.
Types
Fractures are described by (Figure 1.1):
- Skin being intact (closed) or not (open)
- How many pieces of bone: two (simple) multiple (comminuted)
- Fracture pattern, e.g. oblique, tranverse, spiral, greenstick
- Anatomical location in the bone, i.e. diaphysis, metaphysis
- Joint involvement (articular) or not (nonarticular)
- Displacement. If displaced, the fracture will be any combination of: translation, angulation, rotation, shortening, distraction
Closed vs open fracture
An open (compound) fracture is one that communicates with an opening (break) in the skin. Any fracture that involves a body cavity which communicates with the skin, e.g. a pelvic fracture involving the rectum or vagina is also an open fracture.
Open fractures have more complications and are often caused by high-energy trauma. They can involve skin loss, injury to nerves and blood vessels, and be contaminated by 2debris (e.g. soil). All open fractures require prompt assessment and management to reduce the risks of complications.
Simple vs comminuted fracture
A simple fracture is a fracture consists of two parts of bone; fractures with more than two parts are comminuted.
Articular vs nonarticular fracture
Articular fractures involve the surface of a joint; nonarticular fractures do not. Articular fractures require careful management 3because of the risk of post-traumatic arthrosis, which can occur even after effective treatment.
Fracture displacement
Displacements are bone deformities caused by a fracture. They are described as the position of the distal fragment relative to the proximal and are usually categorised using radiographs.
Angulation Angulation describes the angle that the bone is left at after the fracture. It is given in degrees in either the coronal plane (varus v valgus) and/or the sagittal plane (anterior v posterior).
Rotation Rotation describes the angle a bone twists after fracture. It is difficult to determine accurately from a radiograph and is usually more obvious clinically.
Translation and shortening Translation is the displacement of the fracture parts away from each other. This distance is estimated and often described using the bone as a reference, e.g. ‘translated 50% of the width of the bone’. If the bones are also left overlapping, the length of this overlap is estimated and referred to as shortening.
Distraction and impaction Distraction and impaction refer to the distance or overlap, respectively, of two parts of bone after fracture if they are not displaced (i.e. still aligned).
Dislocations
Dislocations are described by:
- Direction of displacement
- Associated fractures
- Associated injuries, e.g. vascular, neurological
Any joint can be dislocated either by an indirect or direct force. Where there is no congruity between the joint surfaces the joint is dislocated; where there is partial congruity the joint is subluxed.
Neighbouring structures such as ligaments, nerves and blood vessels can all be injured by a dislocation. In some cases the blood vessels are kinked or stretched, compromising the 4blood supply distally. This is common in ankle fracture dislocations, but reducing the dislocation restores the blood supply promptly.
Healing and complications
Most fractures heal without complications or significant loss of function. However, complications, which can arise early or late, have the potential to cause both local and systemic problems.
The risk of complications is determined by many factors, both fracture-specific and patient-specific. Fracture-specific factors include open fractures, comminution, intra-articular involvement, soft tissue injury and dislocation. Patient-specific factors include age, weight and comorbidities.
Bone healing
Bone generally takes 6–8 weeks to heal. The process may take over a year for full fracture healing and remodelling, but clinically the patient will be asymptomatic. In general terms, most fractures heal well.
Fracture healing occurs in an environment that encourages the process. The more that environment is respected, the greater the likelihood of healing.
Stages of healing Fracture healing begins with development of a haematoma and then proceeds in three stages:
- Inflammation
- Repair
- Remodelling
To optimise healing, there needs to be good anatomical reduction (good bony contact and alignment), immobilisation and no infection. In other words, the environment for fracture healing has to be correct, taking into account all these factors. The amount of new bone formed, known as callus, is inversely proportional to the amount of movement across the fracture site.
The haematoma provides haemopoietic cells, which secrete the necessary growth factors and initiate the inflammatory stage. Within 2 weeks, primary callus is formed, which is then 5converted to hard callus. When the bone ends are not in contact, bridging callus is formed.
In the final stage, the newly formed bone is remodelled to restore the bone's prefracture ability to bear physiological load.
Local complications
General complications to the site of the fracture occur immediately, early in the healing process (within days) or late (after 6 weeks). Early complications are:
- vascular injury
- soft tissue injury
- compartment syndrome
- infections
- nerve injury
Late complications are:
- delayed union
- non-union
- malunion
- implant complications: infection, prominence, breakage
- joint stiffness
- avascular necrosis
- osteomyelitis
- growth disturbance or arrest
- osteoarthritis
- contractures
- complex regional pain syndrome
- heterotopic ossification
Systemic complications
General systemic complications affect the body more widely and, like local complications, occur either early or late in the healing process. Early complications are:
- thromboembolism
- pneumonia
- acute respiratory distress syndrome
- acute renal failure
- shock
- multiorgan failure
Late complications are:
- sepsis
- pressure sores
- muscle wasting
- reduced mobility
1.2 Consent
Consent is the permission granted by a patient for a medical procedure, including surgery, to be performed. A surgeon is liable if a patient's consent is not obtained correctly before a procedure is carried out.
Consent must also be obtained for any adjunctive procedures. The patient must be advised of alternate treatment options and the consequences of not undergoing treatment. The complications of, and recovery from, the procedure must be explained and documented. Ideally, consent for the procedure should be taken at the time of admission.
Types of consent
There are different types of consent.
- Implied consent is presumed for minor procedures, such as radiography and phlebotomy
- Expressed verbal consent is normally adequate for simple procedures with minimal risk of harm, for example insertion of a nasogastric tube
- Expressed written consent is required for all surgical procedures; written consent is not legal proof that adequate consent has been obtained, but rather proof that a discussion has taken place outlining the specifics of the procedure, risks and benefits, along with the other aspects discussed below7
For any consent to be valid, it must be voluntary and informed, and the patient giving it must have capacity.
Voluntary
The decision to give consent should be the patient's alone; there should be no coercion or pressure from family, friends or medical staff.
Informed
The patient should be given all the information about the procedure:
- the reason for carrying out the procedure
- what it involves
- the benefits of the procedure
- the risks of the procedure in terms of possible complications
- other treatment options
- the possible consequences if the procedure is not carried out
The patient needs to be fully informed, i.e. no information should be withheld from them.
Capacity
To give consent, a patient must have capacity, i.e. the ability to make decisions regarding their care. They must be able to:
- understand the information they are given about the procedure
- retain the information
- weigh the risks and benefits of the procedure in order to make a decision whether to agree to it
- communicate their decision
All adults are assumed to have capacity unless there is significant evidence against this. Factors that reduce capacity are:
- dementia
- acute confusion
- intellectual disability
- drug or alcohol intoxication
- use of certain medications
- fatigue
Capacity assessment
Capacity can change, so it is assessed at the time that consent is required. This is usually at admission for an emergency and at outpatient listing for an elective case. Capacity can be rechecked at any time during the patient's stay. Consent is usually checked verbally at multiple times prior to the patient's procedure.
A patient may have capacity to consent to one procedure but not another. For example, a patient with intellectual disability may be able to give consent for a blood test but may lack the capacity to consent to a procedure with longer term consequences, such as an operation.
If a patient makes a decision that you consider irrational, their decision will stand as long as they have capacity.
Lack of capacity
If a patient lacks capacity, decisions about their treatment depend on whether:
- they have made an advance statement or an advance decision to refuse treatment
- they have conferred a lasting power of attorney on another person, giving that person the authority to make decisions on their behalf, should they lose capacity
- an independent mental capacity advocate has been assigned to represent and support the patient
If none of these conditions apply, decisions must be made on behalf of the patient by the doctor responsible for their care.
Any decision made on a patient's behalf must be in their best interests, considering their preferences, wishes, beliefs and 9values. Whenever possible, the views of the family and friends of the patient should be sought when making such decisions.
Capacity in children
In most countries, as in the UK, over 16s are regarded as adults and have capacity by default. Under 16s can give consent on their own behalf if they are judged to understand what a treatment involves and its possible consequences (termed Gillick competence).