Fracture Treatment John Ebnezar
Chapter Notes

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General Principles of FracturesChapter 1

Fracture: It is defined as a break in the surface of the bone, either across its cortex or through its articular surface.
Dislocation: It is a complete and persistent displacement of a joint in which at least part of the supporting joint capsule and some of its ligaments are disrupted.
Subluxation: It is a partial separation of a joint.
Sprain: It is a tear in the ligament.
Strain: It is a strain in the muscles.
Simple fractures: Here the bone breaks within the soft tissues and does not communicate to the exterior (Fig. 1.1A).
Compound fractures: Here the soft tissue envelope is broken and the fracture fragments communicate to the exterior (Fig. 1.1B).
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Figs 1.1A and B: Showing simple and compound fractures
Mechanism of fractures: Bone usually breaks when it is subjected to abnormal and sudden force in a normal individual and this could be due to:
  • Fall from heights
  • RTA: Road traffic accidents in its various forms
  • Assault.
In rare incidents fractures can also happen due to trivial trauma (pathological fractures) usually seen in a diseased bone or due to repetitive trauma as seen in stress or fatigue fractures.
Types of Fractures
  1. Based on the extent of the fracture line:
    • Incomplete fractures: It involves only one surface of the cortex or the bone.
    • Complete fractures: Here the fracture involves the entire bone. It could be un-displaced or displaced.
  2. Based on the pattern of fractures (Figs 1.2A to E)
    • Linear fractures: These could be transverse, oblique or spiral.
    • Comminuted fractures where in there are more than two fragments.
    • Segmental fractures: Here the fracture is in the form of segments and it could be a two level, three level, a longitudinal or a comminuted split.
    • Bone loss: This is seen in compound fractures and it could be less than or more than 50% loss
  3. Atypical fractures (Figs 1.3A to D):
    • Green stick fractures: It is seen exclusively in children. Here the bone is elastic and usually bends due to buckling or breaking of one cortex when a force is applied.
    • Impacted fractures: Here the fracture fragments are impacted into each other and are not separated and displaced.
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      Figs 1.2A to E: Types of fractures based on fracture patterns: (A) transverse, (B) spiral, (C) oblique, (D) comminuted, and (E) segmental fractures
    • Stress or fatigue fractures: It is usually an incomplete fracture commonly seen in athletes and in bones subjected to chronic and repetitive stress (E.g. Third metatarsal fractures, fracture tibia, etc)
    • Pathological fractures: It occurs in a diseased bone and is usually spontaneous. The force required to bring about a pathological fracture is trivial.
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      Figs 1.3A to D: Showing atypical fractures: (A) compression, (B) pathological, (C) greenstick, and (D) torus fractures
    • Hair line or crack fracture: It is a very fine break in the bone which is difficult to diagnose clinically. Radiology usually helps in the diagnosis
    • Torus fractures: This is just buckling of the outer cortex and is a variant of the green stick fractures that is usually seen in children.
Displacement of Fractures
A complete fracture usually gets displaced due to various factors depending on the direction of forces, mode of injury, pull of the muscles, a fracture can show any of the following displacements or angulation (Figs 1.4A to D).
  • Anterior angulation or displacement
  • Posterior angulation or displacement
  • Varus or medial angulation or displacement
  • Shortening
  • Translational.
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Figs 1.4A to D: Showing types of angulation in fractures: (A) Medial, (B) Lateral, (C) Anterior, and (D) Posterior
Clinical Features
  • Pain
  • Swelling
  • Deformity (Figs 1.5A to D)
  • Inability to use the affected part.
  • Tenderness
  • Loss of transmitted movements
  • Crepitus
  • Shortening.
Features due to neuro-vascular injuries like brachial vessel injury, radial nerve injury, median nerve injury could also be present.
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Figs 1.5A to D: Showing some important deformities in orthopedics: (A) dinner fork deformity, (B) swan neck deformity, (C) anterior dislocation of hip, and (D) posterior dislocation of hip
  • Plain X-ray: This is the gold standard in the diagnosis of fractures. Minimum two views, anterior and lateral and sometimes oblique views are required to make an accurate diagnosis of fractures.
  • CT Scan: This is required in special situations like spine injuries, chest injuries, skull fractures, etc to make a cross sectional study of the affected area.
  • MRI Scan: It is useful to diagnose any fracture. In addition it helps to identify soft tissue injuries. Gold standard but high costs are prohibitive.
Fracture Management
The goal of fracture management is to restore the lost anatomy back to its normal or as near to normal as possible. The responsibility of an orthopedic surgeon is to ensure that there is no functional disability to the patient following the treatment of fractures.
Management of Simple Fractures
Simple fractures are managed by conservative or operative methods.
Conservative Methods
  1. For undisplaced fractures, incomplete fractures and impacted fractures the following methods could be employed:
    • Cuff and collar sling: For upper limb injuries like clavicle fractures, shoulder injuries, etc. (Fig. 1.6A)
    • Strapping: This is indicated for fracture clavicle, rib fractures, phalangeal injuries, etc. (Fig. 1.6B)
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      Figs 1.6A to C: Methods of conservative treatment of fractures clavicle: (A) collar and cuff sling, (B) strapping and sling suspension, (C) figure of 8 bandaging
    • Rest and NSAIDs: This is useful in impacted fractures like neck of femur, etc
    • Plaster slabs: This is used to support the injured limb in the initial stages to accommodate the swelling. It is also useful as a first aid measure.
  2. For displaced fractures: This consists of resuscitation, reduction, retention and rehabilitation. To illustrate further:
    • Resuscitation: This is the top most priority if the patient is in shock following a fracture or dislocation.
    • Reduction of the fracture fragments if it is displaced. Usually it is done under general anesthesia after adequate radiographic study. Reduction methods are
      1. Closed reduction: It is adapted usually for simple displaced fractures. The technique followed is traction and counter traction methods. It is a blind technique and needs considerable skill and expertise (Figs 1.7A and B). It commonly results in malunion.
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        Fig. 1.7A: Showing methods of closed reduction of a greenstick fracture in children: The opposite intact cortex is broken
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        Fig. 1.7B: The reduction is done
      2. Continuous traction: Certain examples of continuous traction as a form of fracture treatment are Gallow's traction for fracture shaft femur in children (Fig. 1.10), Dunlop's traction for supracondylar fracture of the humerus (Fig. 1.9), skeletal traction for trochanteric fractures of the femur (Fig. 1.11), Smith's straction (Fig. 1.8), etc.
    • Retention: This is by
      1. Plaster of paris, splints or casts. These are the most common mode of immobilization. Slab encircles half the limb while the cast encircles the entire limb.
      2. Continuous traction as explained earlier
      3. Functional braces: These are splints that are used once the fracture becomes sticky after 2–3 weeks. The advantage of this method is patient can use the affected limb thereby reducing the fracture immobilization complications (Fig. 1.12).
    • Rehabilitation: This is by way of physiotherapy and exercises.
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Fig. 1.8: Showing overhead skeletal traction (Smith's traction)
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Fig. 1.9: Showing Dunlop's traction
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Fig. 1.10: Showing Gallow's traction in children (< 2 years of age)
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Fig. 1.11: Böhler-Braun splint
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Fig. 1.12: Showing a functional cast brace
Operative Management of Fractures
This could be open reduction and internal fixation with implants as in DCP plating and screws in fracture humerus or tibia or Closed reduction and internal fixation as in interlocking nailing of the femur, tibia, humerus, etc.
It is indicated if the conservative treatment method fails or if there are specific indications as mentioned below.
Absolute Indications
  1. Failed closed reduction
  2. Displaced intra-articular fractures
  3. Type III and IV epiphyseal injuries
  4. Major avulsion fractures
  5. Nonunion
  6. Re-plantation of extremities
Relative Indications
  1. Multiple fractures
  2. Delayed union
  3. Loss of reduction
  4. Pathological fractures
  5. For better nursing care
  6. To avoid prolonged bed rest
  7. Certain fractures wherein conservative methods are ineffective. E.g. Galeazzi's fracture, Monteggia's fracture, fracture neck of femur, etc.
Questionable Indications
  1. Neurovascular injuries
  2. Open fractures
  3. Cosmetic reasons
  4. Economic considerations
Contraindications for Operative Management
  1. Infection
  2. Small fragments
  3. Weak and porotic bones
  4. Soft tissue damage
  5. Undisplaced or impacted fractures
  6. Poor general and medical condition
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Fig. 1.13: Fracture shaft humerus fixed with DCP plate and screws
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Fig. 1.14: Showing fracture femur fixed with Küntscher's (IM) nail
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Fig. 1.15: Showing subtrochanteric fracture fixed by an interlocking nail
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Figs 1.16A and B: Showing tension band wiring (TBW) in fracture olecranon
Principles of Operative Management
Exposure: The fracture needs to be exposed thoroughly through proper approaches.
Reduction: After exposure, the fracture is reduced either closed or under direct vision.
Temporary stabilization: After reducing the fractures, temporary stabilization of the fracture is carried out with K-wires, etc
Definitive stabilization: This is done finally by using the following implants (Figs 1.17 to 1.20C):
  1. K-wire: For epiphyseal injuries, small bone fractures of the hand and feet, etc.
  2. Screws: For avulsion fractures and butterfly fragments, etc.
  3. Intra-medullary nails: For fracture through the narrow portion of the bone at the level of the isthmus in a long bone (Fig. 1.14).
  4. Plate and screws: DCP or AO plate and screws for diaphyseal fractures of the long bones (Fig. 1.13).
  5. Interlocking Nails: This is the gold standard in the current treatment of the fractures of the long bones.
  6. Steel wires No 18–20 gauge: This is useful for tension band wiring of fracture of the patella, olecranon (Figs 1.16A and B)
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Fig. 1.17: Showing self-tapping machine screws
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Fig. 1.18: Showing cortical screws—threaded wholelength and not self-tapping
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Fig. 1.19: Showing cancellous screw (above) and malleolar screw (below)
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Fig. 1.20A: Showing semitubular plate
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Fig. 1.20B: Showing AO plate
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Fig. 1.20C: Showing a dynamic compression plate (DCP)
Disadvantages of Operative Treatment
  1. Closed fracture is converted into an open fracture
  2. Presence of a scar
  3. Anesthetic problems
  4. Foreign body reaction
  5. Another surgery may be required in most cases to remove the implants
  6. Infection could be a dreaded problem
  7. More expensive
Complications of Fractures
Acute Complications
  1. Shock
  2. ARDS
  3. Vascular injuries (Fig. 1.21)
  4. Acute Volkman's ischemia (Figs 1.23A and B)
  5. Crush syndromes
  6. Deep vein thrombosis (Fig. 1.25)
  7. Injury to nerves (Fig. 1.22)
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Fig. 1.21: Injury to the brachial vessels can occur in displaced supracondylar fractures of humerus
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Fig. 1.22: Radial nerve injury can occur in fracture shaft of humerus
Chronic Complications
  1. Delayed union
  2. Malunion (Figs 1.24A and B)
  3. Nonunion
  4. Avascular necrosis due to damage to vascular supply to the bone
  5. Shortening due to malunion, bone loss, etc
  6. Growth disturbances in children due to injury to the epiphyseal plate
  7. Joint stiffness due to improper or prolonged immobilization following fractures or both
  8. Post-traumatic arthritis seen commonly in intra-articular fractures
  9. Volkman's ischemic contractures
  10. Myossitis ossificans
Complications Peculiar to Open Fractures
  1. Infection
  2. Chronic osteomyelitis
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    Figs 1.23A and B: (A) Volkmann's ischemic contracture (VIC) deformity, and (B) Volkmann's sign
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    Figs 1.24A and B: Malunion of a long bone like tibia will cause shortening and deformity
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    Fig. 1.25: Clinical photograph of deep vein thrombosis
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    Fig. 1.26: Sudeck's osteodystrophy
  3. Gas gangrene
  4. Tetanus
  5. Hypovolemic shock
  1. Implant failure like bending, breakage, migration, etc. This could be due to defective manufacturing or non-compliance by the patients.
  2. RSD (Reflex sympathetic dystrophy) seen commonly in Post Colles' fractures (Fig. 1.26).