FRACTURES

And other Orthopaedic Disorders

Jill Cavaiuolo

Fracture Definition

• Description: A fracture is a medical condition in which a bone is cracked or broken. While many fractures are the result of high force impact or stress, bone fracture can also occur as a result of certain medical conditions that weaken the bones.

CLASSIFICATION OF #

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.

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

Complete- the bone is completely broken in two or more pieces

Incomplete-the bone is not broken all the way through

Direction of Fracture LineTransverse

ObliqueSpiral

ComminutedCompression

Categories of Fractures• In a compound fracture, also called an

open fracture, the bone breaks through the skin; it may then recede back into the wound and not be visible through the skin.

Categories of Fractures• In a simple fracture, also called a closed

fracture, the bone breaks but there is no open wound in the skin.

Categories of Fractures• Complete fractures

refer to the way the bone breaks: In a complete fracture, the bone snaps into two or more parts..(i.e. # ulna)

• Incomplete fractures have a bone that breaks, but does not go all the way through.

Fracture Categories

http://www.hughston.com/hha/b_14_2_1a.jpg

Common Fractures

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

Common Fractures

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

Common Fractures

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

Common Fractures

• Oblique  -  diagonal break across the bone.

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Common Fractures

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

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Other types of Fractures

• An impacted fracture is one whose ends are driven into each other. This is commonly seen in arm fractures in children and is sometimes known as a buckle fracture.

• Other types of fractures are pathologic fracture, caused by a disease that weakens the bones, and stress fracture, a hairline crack.

Examples

Xray Example• This xray indicates a lateral view of an

oblique fracture to the mid humerus.

Closed Oblique Fracture

• This fracture is considered to be mildly displaced.

Types of Fractures• Mildly displaced spiral fractures of the

Tibia and Fibula.

Types of Fractures

• Comminuted and mildly displaced fractures of the distal Tibia and Fibula.

EXAMPLE: A 57 year old 350 lbs. man who puts

significant pressure on his ankle as he walks.

Diagnosis PILON FRACTURE

This is a comminuted fracture of the distal tibia due to axial compression

of the ankle joint. It is frequently associated with a fracture of the distal shaft of the fibula as well.

WARNING

GRAPHIC TRAUMA PICTURE

Open Fractures• A break in the skin

and underlying soft tissue leading into, or communicating with the fracture and its hematoma

WARNING

THE NEXT TRAUMA SLIDE IS VERY GRAPHIC

Open Fracture

REVISION

Define Fracture• Define Open and Closed #• Define Complete or Incomplete #• Give examples of classification based on

the direction of # line.• Define the following types of fractures.

Did you answer that it is a closed comminuted fracture of the femur?

Transverse complete # of Fibula

Compound(open) # of Tibia and Fibula. The tibial break looks oblique, and the fibula appears to be comminuted.

Fractures—Signs and Symptoms• Some clearly present (compound fracture)

or obvious deformity• Swelling, tenderness, altered sensation• Inability to move limb• Crepitus

– Grating sound heard if ends of bone fragments move over e/other

• Pain immediately after injury– Can be delayed if nerve damage in

area• Diagnostic Tests

– X-rays

Fractures- Complications• Muscle spasm

– Due to local pain and irritation– Pulls bone fragments further out of

position– Causes angulation (deformity) and

rotation of bone which can cause more soft tissue damage, bleeding, and inflammation.

• Infections – Tetanus, osteomyelitis– In Compound fractures or when

surgery needed precautions taken (antimicrobials, tetanus booster shot)

# Wrist: Note Swelling in top and bottom picture and deformity in the compound (open) fracture below.

Complications

• Ischaemia– Develops in limb following treatment– Occurs as oedema increases in 1st 48

hrs after trauma and casting.– Can be due to cast becoming too tight.

• The affected part becomes pale, pulseless, painful, paralysed, paraesthetic and 'perishing with cold' ('the 6 Ps').

• Fixed mottling of the skin implies irreversible changes.

• The limb may be red when dependent, leading to a misdiagnosis of inflammation, e.g. gout or cellulitis.

Complications Cont.

Compartment syndrome:

– Develops shortly after fracture when more extensive inflammation (crush fractures)

– Increased pressure of fluid w/in fascia causes severe pain and ischemia or necrosis of muscle

– Pressure effects can be aggravated by cast

Compartments of Lower Leg

Compartment Syndrome

Pressure Release

Compartment Syndrome

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Complications Cont.• Nerve damage

– w/ severe trauma or tearing of periosteum

• Failure to heal (nonunion) or healing of bone w/ deformity (malunion)– Results if bone is not stabilized with

ends closely approximated and aligned• Fractures at or near joint may have long-

term effects– Osteoarthritis or stunted growth

Complications Cont.

• Fat emboli– Risk when fatty marrow escapes from bone

marrow into vein w/in 1st week after injury– More common in fracture of pelvis or long bones,

especially if not well immobilized after injury– Can travel to lungs and cause obstruction,

extensive inflammation, and respiratory distress

Fat Embolism

• Fat Embolism Syndrome– Globules of fat, released from fractured

bone– Fat mixes with platelets

• Emboli travel to lungs, brain, or other areas.

– Clotting cascade activated = petechiae

Fat Embolism Syndrome

• Signs and Symptoms– Dyspnoea– Confusion– Pulmonary complications

– Pulmonary Oedema– ARDS(Acute Respiratory distress

syndrome)– Petechiae-small spots on the skin

Complications-DVT

Closed Fracture Considerations• The energy of the

injury• Degree of

contamination• Patient factors• Additional injuries

Fractures—Treatment • Management of Pain,nausea etc.• Cleaning the wound if open-may be done in

theatre• Immediate splinting and immobilization• Reduction of bones to restore normal

positionClosed reduction: exerting pressure and tractionOpen reduction: requires surgery

• Pins, rods, plates, screws

Splinting and Immobilization

– Casting with plaster or fiberglass, and splints .

Closed Reduction Traction

Application of force or weight pulling on limb that is opposed

by body weightForce maintains alignment of

bones, prevents muscle spasms, and immobilizes the

limb

Open Reduction

• Internal fixation of Radius

External Fixation

• This is a patient treated with an external fixator, which is used to treat fractures that are too unstable for a cast. You can shower and use your hand gently with the external fixator in place.

Internal FixationFractured Pelvis

Internal Fixation

Trans articular pin fixation

Fractures—Pathophysiology: Factors Affecting Healing Process

• Amount of local damage to bone and soft tissue– Major determining factor– Prolonged inflammation or extensive

damage to bv or periosteum impairs healing

• Amount of realignment and approximation– Closer the ends of the bones are, the

smaller the gap to fill, the faster the healing process

• Secondary problem – Foreign material or infection delays

healing

Factors Affecting the Healing Process

• Numerous systemic factors– Delayed healing in elderly pts w/

circulatory problems, diabetes mellitus, anaemia, nutritional deficits, steroid therapy.

Bone Healing• As soon as a fracture occurs, the body

acts to protect the injured area, forming a protective blood clot and callus or fibrous tissue.

• New "threads" of bone cells start to grow on both sides of the fracture line. These threads grow toward each other.

• The fracture closes and the callus is absorbed.

Fractures—Pathophysiology of Bone Repair

Nursing Management

General Observations for pins, traction and casts include:

• Skin inspection hourly• Neurovascular observations ½ -1 hourly• Limb alignment• Limb exercises• Signs of infection –warmth, swelling, pain,

odour, discharge

Nursing Management

• Elevation• Monitor Pt. pain and comfort• Remind Pt. of injured limb and positioning

etc.• Check bed positioning of Pt to ensure

traction is functioning.• Check equipment i.e. pulleys, pins etc.• Pts. with traction must never have weight

bags lifted randomly.

Plaster Management

• Maintain cast integrity• Turn Pt. 1-2 hrly• Use palms when handling wet plaster• Do not cover wet cast-allow to dry• Check cast ooze and outline• Educate Pt. to not shove anything inside of

cast e.g. knitting needles

Plaster Management

• Do not use blow dryer to dry cast• Cast will heat when drying• Cast is heavy• Observe skin around cast edge, skin

breaks can lead to infection

A Case History

A 24 year old right hand dominant man sustained a compound fracture of his right forearm as a teenager. He had a deep infection that required part of the bone to be removed. His right wrist was severely deformed and x rays showed bone loss and a non-union of the fracture.He had surgery that reconstructed his bone, rehab. and he returned to work as a full time construction worker.

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A Case History

Other Disorders

Sprains and StrainsSprain. A sprain is a stretching or

tearing of ligaments. Ligaments are tough bands of fibrous tissue that

connect one bone to another. Common locations for sprains are

your ankles and knees. Strain. A strain is a stretching or

tearing of muscle or tendon. People commonly call strains "pulled" muscles. Hamstring and back injuries are among the most

common strains

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Sprains and Strains• Both easily torn when excessive force exerted

on a joint• Avulsion

– Ligaments or tendons completely separated • Painful, tenderness, discoloration (due to

haematoma formation)• Strength and range of movement of the joint are

limited• Diagnosis: X-ray,scans etc. to rule out fracture

and to note extent of damage

Sprains and Strains Healing

• Tear, then inflammation, then granulation tissue

• Collage fibers form to create links w/ existing tissue

• Eventually healing mass bound together w/ fibrous tissue

• Healing 6 weeks• Severe damage requires surgery

Dislocation• Separation of 2 bones at a joint

– Loss of contact between articulating bone surfaces

– Usually one bone out of position, other normal– Eg. humerus displaced from scapula

• Subluxation– Bone only partially displaced w/ partial loss of

contact between surfaces• Causes considerable soft tissue damage

– Also damage to ligaments, nerves, bv as bone pulled away from joint

– Inflammation and bleeding– Severe pain, swelling, tenderness

Dislocation

• Diagnosis confirmed by X-ray• Treatment

– Reduction to dislocated bone, immobilization, therapy to maintain joint mobility

– Healing is slow if ligaments and soft tissue extensively damaged

History After breaking a hip, a 70 year old

woman undergoes hip replacement surgery. After 5 days she comes back

with severe hip pain. Diagnosis

TOTAL HIP PROSTHESIS SUPERIOR DISLOCATION

References

Fracture classification/sprains and strains• www.mayoclinic.com• Radiology Web Site - McGill University

http://sprojects.mmi.mcgill.ca/icmcradiology/index.aspx• Brigham and Women’s Hospital Types of Fractures

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