First Aid and Emergency Management in Orthopedic Injuries MS Dhillon, Sarvdeep S Dhatt
INDEX
×
Chapter Notes

Save Clear


Introduction to Fractures and DislocationsChapter 1

MS Dhillon,
Sarvdeep S Dhatt
Fractures and dislocations are as old as mankind. Hippocrates, in his corpus Hippocratus (300 BC) has talked about the diagnosis and treatment of fractures and dislocations. Even then, first aid was a priority, and it was recognized that many complications could be averted with emergent primary management. Dislocations are slightly different from fractures, and despite us knowing about them for many millennia, (Kocher's method for reduction of dislocated shoulder is 3000 years old and still popular), these are often left unreduced too long. The problem often is a delay in diagnosis!
An understanding of the basics of orthopedic injuries is essential for appropriate first aid. By definition, a fracture is a structural break in the normal continuity of bone whereas dislocation is total disruption of a joint with no remaining contact between the articular surfaces. In the 21st century, advances in automation, better highways, faster cars and overcrowding, etc. have multiplied the incidence of trauma manifold. This is one of the most serious public health hazards of modern civilization, and newly developing economies, with poor infrastructure, but more and more automobiles and machines, are especially at risk.
Patients disabled with fractures or dislocations, or their complications are unable to earn a livelihood; we all know that the most effective management of orthopedic trauma starts when the medical personnel initially come in contact with the trauma victim. Early recognition of the extent, nature and potential problems of orthopedic injuries, as well as the early appropriate treatment of fractures or dislocations will not only stabilize the patient, but will make all subsequent management protocols easier.
Susruta, the father of surgery described 12 types of fractures and 6 types of dislocations, 2500 years ago, when he practiced and taught surgery in Varanasi, India. Etiology of fractures and dislocations as described by Susruta in his treatise ‘Susruta Samhita’ are falls, compression, blows and throwing. His book (written in Sanskrit) describes 12 types of fractures:
  1. Karkataka—Fracture with hematoma
  2. Asvakarna—Oblique fracture
  3. Curnita—Comminuted fracture
  4. Piccita—Compression fracture
  5. Asthichalita— Subperiosteal hematoma
  6. Kandabhagna—Transverse fracture
  7. Majjanugata—Impacted fracture
  8. Atipatita—Complete fracture
  9. Vakra—Greenstick fracture
  10. Chinna— Incomplete fracture
  11. Patita—Crack fracture
  12. Sphutita—Fissured fracture.
He also described six types of dislocations with direction of their displacements. In a broader sense, the pattern of fractures he described years ago remains the same, even today. However, now in addition to the above described types, we have the peri-implant and periprosthetic fractures.2
For the Emergency Medical Officer, a basic understanding of fractures is essential to be able to pick them up, to be able to understand their nature and potential expected problems during their course of treatment, as well as to be able to apply first aid measures.
Basically, fractures can be classified according to:
  1. Etiology
  2. Pattern of fracture
  3. Nature of fracture.
 
CLASSIFICATION BASED ON ETIOLOGY
Based on etiology, fractures may be of three types:
  1. Trauma or injury: A fracture sustained due to trauma is called a traumatic fracture. It can be caused by a direct injury as in a road traffic accident or a blow, etc. Indirect injury can cause fracture by a force transmitted along the bone, e.g. a fall on outstretched hand can cause fracture of head of the radius.
  2. Fatigue fracture: These fractures occur from repetitive stress. This is similar to the fatigue fractures that occur in metals. These fractures are mostly confined to the bones of lower limb and ascribed to prolonged walking, running or athletic activities. Some of the common fatigue fractures are fractures of 2nd metatarsal, fibula, tibia or of neck of femur. These occur mostly in sportsmen, but should be a diagnosis that comes to mind in elderly people also. Fracture of 2nd metatarsal is also known as ‘March fracture’ as it is found in fresh army recruits who march excessively without being properly trained.
  3. Pathological fracture: This term is applied to a fracture through a bone already weakened by disease. Often the bone gets fractured spontaneously or from a trivial trauma. In contrast to the traumatic fractures, these fractures are minimally displaced and often go into nonunion. The various pathological conditions responsible for pathological fractures may be osteoporosis, osteomalacia, osteopenia, Paget's disease, osteogenesis imperfecta, fibrous dysplasia, primary benign or malignant bone tumors or secondaries of a carcinoma.
 
CLASSIFICATION BASED ON THE PATTERN OF FRACTURE
Fracture can be classified according to the shape or pattern of the fractured fragments or surfaces. The fracture may have a combination of two or more of the patterns. This classification indicates the nature of the causative violence and also gives an indication of the likely stability of the fragments. This helps the surgeon in making decision about the various forms of fixation methods (Figs 1.1 to 1.9). These may be:
  1. Transverse fracture: It is caused by angulation or bending force. The fracture line is perpendicular to the long axis of the bone.
  2. Oblique fracture: The fracture is caused by a bending force, which in addition has a component along the long axis and as the name suggests, the fracture line is oblique or slanting.
  3. Spiral fracture: It is caused by a twisting or torsional force and the fracture line runs spirally in more than one plane.
  4. Comminuted fracture: It is caused by a severe direct force and the fractured bone has multiple fragments.
  5. Compression or crush fracture: Fracture occurs in spongy bones, which get compressed and cannot be restored fully to its original form, e.g. vertebra, calcaneum.
  6. Segmental fracture: In this type, there are two or more fractures in one bone, but at different levels.
  7. Greenstick fracture: In this type, the bones do not break completely; the inner cortex bends while the outer breaks. These fractures are peculiar to children as their bones are more resilient and springy and can withstand greater deformation without fracture. This can be likened to the pole used in pole vaulting. Also, the bone of this type can be crumpled like a concertina by a longitudinal compression force and such a fracture is termed as ‘Torus fracture’.
  8. Avulsion fracture: This can occur when a piece of bone detaches from the main bone usually because of being torn by the tendon attaching muscle to bone. For example, the avulsion of peroneus brevis tendon from the base of 5th metatarsal.
  9. Peri-implant or periprosthetic fracture: The fractures which occur at one end of an implant, whether an intramedullary nail or plate are known as peri-implant fractures. As the name implies, fractures that occur near the end of prosthesis, whether hip or knee prosthesis are known as periprosthetic fractures. With more number of joint replacements and implant surgeries taking place, periprosthetic fractures have thrown a new challenge to the orthopedic surgeon.
    3
zoom view
Fig. 1.1: Transverse fracture.
zoom view
Fig. 1.2: Oblique fracture.
zoom view
Fig. 1.3: Spiral fracture.
zoom view
Fig. 1.4: Comminuted distal femur fracture.
zoom view
Fig. 1.5: Compression—crush fracture.
zoom view
Fig. 1.6: Segmental humerus fracture.
4
zoom view
Fig. 1.7: Greenstick fracture.
zoom view
Fig. 1.8: Avulsion fracture tibial spine.
 
CLASSIFICATION BASED ON THE NATURE OF FRACTURE
They can be of two types:
  1. Simple or closed fractures: Fracture is simple or closed when there is no communication between the site of fracture and the exterior of the body, i.e. the overlying skin and soft tissues are intact. Importantly, a badly comminuted fracture without any break in the skin will still be called a simple fracture. For most closed fractures, treatment with casts or surgery can be delayed till the patient is fit for anesthesia.
    zoom view
    Fig. 1.9: Periprosthetic fracture.
  2. Open (compound) fracture: A fracture is open or compound when there is a wound communicating to the fracture. It is not merely the presence of the wound but direct communication between the wound and fracture that is important for it to be termed as open fracture. If the sharp fracture-end pierces the skin from within, resulting in an open fracture, then it is termed as internal compounding (Fig. 1.10). If the object causing the fracture lacerates the skin and soft tissues over the bone as it breaks the bone, resulting in an open fracture, it is termed as external compounding. The risk of infection (Fig. 1.11) is more in the external compound fractures. Open fractures need to be treated immediately with surgery to carefully clean and close the wound. Massive open fractures with great losses of the skin, muscle, and blood supply to the bone are the most serious and difficult to treat. Nowadays, the term “compound” fractures has been largely replaced by “open” fractures.
 
JOINT DISLOCATIONS
A joint is dislocated when its articular surfaces are wholly displaced, one from the other so that all apposition in between them is lost. A joint is subluxated when its articular surfaces are partly displaced but retain some contact between them.
5
zoom view
Fig. 1.10: Grade I open wound. (For color version, see Plate 1)
zoom view
Fig. 1.11: Grade 3 open femur fracture. (For color version, see Plate 1)
Dislocations and subluxations may be classified on the basis of etiology into following types:
  1. Congenital dislocation: It is a condition where a joint is dislocated from birth, e.g. congenital dislocations of hip or knee.
  2. Traumatic dislocation: Injury is by far the most common cause of dislocation and subluxation of the joints. Common joint dislocations involve the shoulder, hip, elbow, ankle and interphalangeal joints. In many cases, dislocation or subluxation is associated with a fracture. When this occurs, the injury is termed as fracture-dislocation or fracture-subluxation. In some joints, the supporting structures like the capsule and ligaments do not heal properly after the primary dislocation if there is inadequate initial care, leading to subsequent instability; this causes repeated subluxations or instability, or even a recurrence of dislocation, many times after trivial trauma or even after certain movements within the normal range. This is termed as recurrent dislocation, and the shoulder joint is the most common site for the development of this problem (Fig. 1.12).
    zoom view
    Fig. 1.12: Shoulder dislocation.
    zoom view
    Fig. 1.13: Pathological dislocation hip with resorption of head and neck.
  3. Pathological dislocation: The articulating surfaces forming a joint may be destroyed by an infective or a neoplastic process, or the ligaments may be damaged due to some disease. This results in dislocation or subluxation of the joint without any trauma. In underdeveloped countries, tuberculosis is the leading cause of such pathological dislocations, e.g. dislocation of the hip joint (Fig. 1.13).
    6
  4. Voluntary dislocation: Some individuals have hyperlax joints by birth or some may have connective tissue disorders such as Ehlers-Danlos syndrome, and they can subluxate or dislocate some of their joints at will. Such individuals are labeled as voluntary dislocators. However, these individuals may be thought to be psychic cases, and hence the term used nowadays for such a dislocation is “demonstrable dislocation”.
This generalized and rather simplistic overview gives us a fair idea about the diversity, severity, and nature of fractures and dislocations. Management concepts are based on this, and emergency treatment starts when the doctor first evaluates the patient. We must realize that fractures can range from a small, easily missed crack as a greenstick fracture to a massive, life-threatening break of the pelvis. Emergency Medical personnel should understand that serious injuries, including injuries to the skin, nerves, blood vessels, muscles, and organs, may occur at the same time as the fracture; these injuries in addition to being life threatening can complicate fracture treatment. All breaks in bone are associated with internal bleeding, as blood vessels and tissues are damaged internally. The bigger the bone, more the blood loss, and the saying in most emergency rooms is that when we see a fracture of the femoral shaft with displacement, give 2 liters of fluid and a minimum of one pint of blood! Fracture associated blood loss often leads to shock, and pelvic fracture cases could bleed to death.
A suspected fracture should never be ignored since it may lead to permanent disfigurement. Details will be discussed in the following chapters. We end this chapter by saying, “If you are not sure whether a bone is fractured, treat the injury as a fracture”.