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BASICS OF FRACTURE

What is a fracture?

A fracture is a partial or complete break in the structural continuity of bone. When a fracture
occurs, it is classified as either open or closed:

• Open fracture (Also called compound fracture.) - The bone exits and is visible through
the skin, or a deep wound that exposes the bone through the skin or one of the body
cavities breached.

• Closed fracture (Also called simple fracture.) - The bone is broken, but the skin is
intact.

Fractures have a variety of names. Below is a listing of the common types that may occur in
children:

• Greenstick - incomplete fracture. The broken bone is not completely separated.

• Transverse - the break is in a straight line across the bone.

• Spiral - the break spirals around the bone; common in a twisting injury.

• Oblique - diagonal break across the bone.

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• Compression - the bone is crushed, causing the broken bone to be wider or flatter in
appearance.

• Comminuted – there are more than two bony fragments.

Describing a Fracture:
A systematic approach is needed:

• Type of fracture

○ Transverse

○ Spiral

○ Oblique

○ Simple etc

• Anatomical location

○ Which bone is affected?

○ Which side - left or right?

○ Is the fracture proximal, middle or distal?

○ Is it intra-articular or extra-articular

• Displacement of the fracture fragments

○ Shift

○ Alignment
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○ Shortening

○ Rotation

• Associated fractures

○ Dislocation

○ Open or closed fracture etc.

Examples of describing a fracture

• "This is a oblique fracture of the mid-shaft of the right tibia with no displacement"

• "This is a transverse fracture of the distal radius with dorsal angulation"

Important Definitions

• Shift - loss of alignment in the cortices of the shaft of the bone resulting onto sideways
displacement

• Angulation - loss of normal longitudinal axial alignment of the shaft of the bone. This
may be anterior, posterior, medial or lateral

• Shortening - the bone appears shortened as a result of overlap of the fracture fragments
or due to impaction at the fracture site

• Rotation - this refers to the rotation of the distal fragment (relative to the proximal
fragment) along the long axis of the bone. This may be external or internal

• Undisplaced - the fracture fragments are almost in anatomical location

• Impacted fracture - a fracture that occurs as a result of compression of cancellous bone

in its long axis causing two bone ends to be forced tightly together.

What causes a fracture?

Fractures occur when there is more force applied to the bone than the bone can absorb. Bones are
weakest when they are twisted.
Breaks in bones can occur from falls, trauma, or as a result of a direct blow or kick to the body.

Fractures results from:

• A single traumatic incident. Breaks in bones can occur from falls, trauma, or as a result of
a direct blow or kick to the body.
• Repetitive stress
• Abnormal weakening of the bone (Pathological fracture).
Pathological fractures:
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Fractures occur in bones which have been weakened already due to a pathological process.
Causes of pathological fractures can be classified into generalised bone conditions or local
benign causes

General bone conditions

• Osteogenesis imperfecta
• Post-menopausal osteoporosis
• Metabolic bone disease
• Paget's disease
Local benign causes
• Chronic infection of bone
• Solitary bone cysts
• Aneurysmal bone cysts
• Chondromas
Primary bone tumours such as chondrosarcomas, osteosarcomas and Ewing's sarcoma are all
causes of pathological fractures and may metastasise to the breast, kidney, lung, prostate and
thyroid.

A child's bone differs from adult bone in a variety of ways:

• A child's bone heals much faster than an adult's bone. The younger the child, the
faster the healing occurs.
• Bones are softer in children and tend to buckle or bend rather than completely break.
• Children have open growth plates, also called epiphysis, located at the end of the long
bones. This is an area where the bone grows. Injury to the growth plate can lead to
limb length discrepancies or angular deformities.

What are the symptoms of a fracture?

The following are the most common symptoms of a fracture. However, each child may
experience symptoms differently. Symptoms may include:
• Pain and tenderness in the injured area
• swelling in the injured area
• obvious deformity in the injured area
• difficulty using or moving the injured area in a normal manner
• warmth, bruising, or redness in the injured area
The symptoms of a broken bone may resemble other conditions. Always consult your child's
physician for a diagnosis.

How is a fracture diagnosed?

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The physician makes the diagnosis with physical examination and diagnostic tests. During the
examination the physician obtains a complete medical history of the child and asks how the
injury occurred.
Diagnostic procedures may include:

• X-rays - a diagnostic test which uses invisible electromagnetic energy beams to

produce images of internal tissues, bones, and organs onto film.
• Magnetic resonance imaging (MRI) - a diagnostic procedure that uses a
combination of large magnets, radiofrequencies, and a computer to produce detailed
images of organs and structures within the body. This test is done to rule out any
associated abnormalities of the spinal cord and nerves.
• Computed tomography scan (Also called a CT or CAT scan.) - a diagnostic
imaging procedure that uses a combination of x-rays and computer technology to
produce cross-sectional images (often called slices), both horizontally and vertically,
of the body. A CT scan shows detailed images of any part of the body, including the
bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.

Treatment of Fractures:

When treating a fracture, it is important to remember you are treating not only the fracture but
the patient as a whole.

Aims of Fracture Treatment

Before considering how to treat a fracture, it is important to understand what the aims of fracture
treatment are:
• Restore optimum function of the injured limb
• Obtain and maintain reduction of the fracture
• Encourage union (restoration of normal bone structure) of the fracture
• Prevent complications
• Provide adequate pain relief
• Rehabilitation of the patient.

How do Fractures Heal?

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Bone healing occurs in four stages:

• Stage 1 – Tissue destruction & Haematoma formation.
○ After any fracture, bleeding occurs from the ends of the bone and from the
surrounding tissues
○ The vessels that are torn at the time of fracture lead to the formation of a fracture
haematoma.
• Stage 2 –Inflammation and Cellular proliferation and vascular ingrowths
○ Within 8 hours of the fracture occurring, an acute inflammation reaction occurs,
with proliferation of cells under the periosteum and within the breached
medullary canal
○ The bone fragment ends are surrounded by cellular tissues that bridge the fracture
○ The haematoma is reabsorbed and fine new capillaries grow in the area.
• Stage 3 - Callus formation
○ The proliferating cells are potentially chondrogenic and osteogenic in nature
○ Under the right circumstances, the cell population changes to osteoblasts and
osteoclasts
○ The dead bone is mopped up and woven bone appears in the fracture callus.
• Stage 4 - Consolidation and remodeling
○ The woven bone is replaced by lamellar bone and the fracture is solidly united
○ New bone is remodeled to resemble the original normal structure.

What affects Fracture Healing?

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Numerous factors can affect fracture healing:

• Patient - do they comply with the appropriate treatment?
• Energy of the injury
• Fracture site
○ Adequate compression?
○ Any movement?
• Infection
• Mode of treatment

Factors influencing bone healing:

Systemic factors Local factors

Age and Co- Degree of local trauma / soft
morbidity tissue
Hormones Degree of bone loss
Functional Vascular injury
activity
Nerve function Type of bone fractured
Nutrition Degree of immobilisation /
stability
Drugs (NSAID) Sterility / Infection
Growth Factors Local pathological condition
Cigarette Smoke Energy of Injury
Anatomic location

Fracture Treatment:

Treatment can only commence once a fracture has been diagnosed:

• Clinical assessment
• Radiological imaging
NB -
• Always need radiographs in two views
• In order for radiograph to be adequate, the joints above and below the injury should be
included.

General Principles
The following points should be taken into account:
• Average time taken for bones to unite is 8 weeks
• Lower limb fractures take approximately twice as long to unite as the upper limb
fractures
• Fractures in adults take an average twice as long to heal in comparison to those in
children
• Transverse fractures take longer to heal than oblique or spiral fractures
• Compound and comminuted fractures are particularly slow to unite
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• No fracture heals in less than 3 weeks.

Treatment of closed fracture:

• Reduction
1. Closed reduction
2. Open reduction
• Immobilization (hold reduction)
1. Cast splintage (Plaster of Paris or synthetic plaster)
2. Functional bracing
3. Continuous traction (Skeletal or skin traction)
4. Internal fixation
5. External fixation
• Rehabilitation and exercise

Which treatment is appropriate?

When deciding which treatment is appropriate, the following point should be noted:
• Does the fracture need reducing?
• If reduction is required, how should this be carried out? Is the fracture stable or unstable?
○ Open / closed?
○ Is precise reduction necessary?
• How to hold the fracture in reduction? It is important to prevent loss of alignment while
the bone ends are uniting:
○ No support needed
○ Traction
 Thomas' splint
○ External splints
 Non-rigid supports - sling, bandaging etc.
 Plaster of Paris
○ External fixators
 IIazarov frame
○ Internal fixation
 Plates
 Screws
 intramedullary nails
○ Joint replacement
• Treatment plan
○ How long does the fracture need to be immobilised for?
○ When can they start mobilising again?
NB: -
• If the articular surface is damaged, a perfect anatomical reduction (< 2mm) is required
• It is of up most importance to start early mobilisation to prevent joint stiffness.

General Management of Fractures

• Pain control with analgesics
• Assessment of blood loss
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• Management of associated injuries

• Judicious use of antibiotics if the injury is an open one.

Treatment Options
Taking all the factors into consideration, there are five possible methods of fracture treatment:
• No treatment is necessary except possible comfort and protection
• Immobilize with an external splint without the need for reduction
• Closed reduction with manipulation or traction followed by immobilization with an
external splint or further traction
• Open reduction and internal fixation (ORIF)
• Excision of fracture fragment and prosthetic replacement.
Aims of Immobilisation
• Pain relief
• Limit movement at the fracture site
• Prevent angulation and / or displacement.

Indication for Operative treatment

• Compound fractures
• If closed manipulation is unsuccessful in reducing the fracture
• If the fracture is unstable
• Soft tissue management
• Management of complications e.g. vascular or head injuries.

Comparison of Conservative vs Operative treatment

• Joint stiffness
○ Risk lower in operative treatment
• Infection
○ Risk higher in operative treatment
• Speed of Healing
○ Quicker in conservative treatment
• Non-union
○ Present in both.

Important Definitions

• Reduction - placing the bone fragments into their original or acceptable position
• Manipulation - the technique of reducing a fracture. In many situations it is the
correction of residual angulation by pressing the distal fragment in the correct direction
while a hand is held under the fracture to provide a fulcrum
• Traction - the disimpaction of the fragments. It serves to align the proximal and distal
parts of the limb
• Stable - position of the fragments that can be safely held in position in a plaster while the
fracture is healing
• Unstable - position of the fragments that cannot be safely held in position in a plaster
while the fracture is healing.

Fracture complications:
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These can be of a general nature, local - involving structures around the fracture site or those that
are applicable to all fractures.

General complications
• Association with internal haemorrhage
• Shock
• Metabolic responses to trauma
• External haemorrhage and infection - open fractures only
• Hypostatic pneumonia
• Urinary tract infections
• Deep vein thrombosis leading to pulmonary embolism
• Pressure sores
• Muscle wasting
• Demineralisation of the bone.

Local complications

• Skin damage - includes stretching of the skin by the underlying fracture fragments,
lacerations, fracture blisters, necrosis and skin loss
• Vascular injuries - these may arise at the time of injury e.g. disruption of the vessel by the
fracture fragments or may arise post manipulation of the fracture or post operatively
• Neurological injuries - damage during the fracture mechanism to the spinal cord, brachial
plexus, nerve root or peripheal branch
• Tendon injury - the tendon may become bound down, compressed or even rupture
• Visceral injuries - especially in the chest and pelvis.
Examples of local complications occurring as a result of certain pathology
• Fractured face - can cause airway obstruction
• Broken rib - perforation of the lungs, ruptured liver
• Fractures and dislocations of the knee - popliteal artery damage
• 4/5th thoracic vertebra - damage to the aorta.

Complications applicable to all fractures

Bone healing abnormalities

• Delayed union - union is delayed. There is abnormal movement, pain on stressing the
fracture and tenderness over the fracture site at a time at when union is expected. Causes
include the nature of the initial injury, with compound and comminuted fractures more
likely to develop non-union; other causes include infection of the fracture haematoma,
interposition of soft tissue between the fracture fragments, poor blood supply to the
fracture site, inadequate immobilisation and pathological fractures
• Non-union - can be atrophic or hypertrophic. The former is when there has been deficient
bone formation at the fracture site and a hypertrophic non-union is where there has been
excessive callus formation
• Malunion - the bone ends heal in a clinically imperfect position. It most commonly
causes shortening with an overlap of the bone fragments
• Avascular necrosis - bone death most commonly occurs with intra-articular fractures of
the hip joint, proximal scaphoid and proximal humerus.
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Other complications
• Infection - most commonly occurs with open fractures. Major disorders include tetanus,
gas gangrene, toxic shock syndrome, necrotizing fasciitis (an aggressive, life threatening
fascial infection), acute osetomyelitis (bone infection). Chronic infection of the bone can
occur
• Joint stiffness
• Secondary osteoarthritis
• Growth disturbance if the epiphyseal growth plate has been damaged
• Tendon ruptures or tendonitis.Sudeck's atrophy (reflex sympathetic dystrophy) - an
abnormal peripheral autonomic response to injury characterised by severe pain, stiffness,
discolourisation and oedema
• Myositis ossificans - an extensive calcified mass in the soft tissues proximal to the joint
that leads to a severe mechanical block to movement
• Muscular atrophy
• Fat embolism - microparticles of fat escape the fracture site and lodge in the glomeruli of
the kidney and lung
• Tardy nerve palsy - late onset nerve palsy
• Renal calculi
• Accident neurosis - psychiatric problem.

Injuries other than fractures

In addition to bony injuries, other anatomical structures can also be damaged in a injury:

Joints
Joints can be damaged in three ways:
1. Subluxation - this is the partial dislocation of a joint, in which there is still partial contact
between the joint surfaces
2. Dislocation - there is no contact between the joint surfaces
3. Fracture dislocation - there a fracture around the joint in addtion to the joint dislocation.

Ligaments
Ligament injuries can be grouped into three different types:
1. Sprain - this is a partial tear in the ligament or joint capsule but the joint however is still
stable
2. Partial rupture - this is the partial rupture of the ligament. There is some loss of joint
stability
3. Complete rupture - this is the complete rupture of the ligament and is associated with
joint instability.

Soft tissues:

• Blood vessels
• Nerves
Likewise, nerve injury can be grouped into three different types:
1. Neuropraxia - there is transient loss of function as a result of the impulse being
interrupted as it passes down the nerve fiber. It occurs as a result of a gentle blow or
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compression. The motor system is more frequently damaged than sensory function.
Recovery takes hours to months
2. Axonotmesis - there is loss of function as a result of the relative loss of continuity of
the axon and its covering of myelin. It occurs as a result of severe compression. There
is loss of both motor and sensory systems. Recovery takes longer than neurapraxia
3. Neurotmesis - this is the most severe lesion affecting the nerve. There is complete
loss of motor, sensory and autonomic function and occurs as a result of severe
bruising or cuts. There is no neural continuity. There is no recovery.
• Muscles
Muscle injuries can be classified according to the degree of clinical impairment:
1. Mild strain/contusion (1st degree) - a small number of muscle fibers are torn. This is
associated with minor swelling and discomfort with little or no loss of strength or
limitation of movement
2. Moderate strain/contusion (2nd degree) - a greater number of muscle fibers are torn
than in the 1st degree. This is associated with a clear loss of function
3. Severe strain/contusion (3rd degree) - there is a tear across the whole cross sectional
area of the muscle. There is a total loss of muscle function.
• Skin- abrasion, bruise, lacerations.

Edited by
Dr. Chowdhury Iqbal Mahmud
MBBS, FRCS (UK), MCh Orth (UK)
Fellow in Orthopaedics (Singapore)