Understanding Fractures: Types, Diagnosis, and Management

1. Kingdom of BahrainArabian Gulf UniversityCollege of Medicine and Medical Sciences Surgery Subspecialty Orthopedics Ali Jassim Alhashli

2. Fractures • What is a fracture? • It is disruption of break in the continuity of the bone which can be partial or complete • Fracture is classified according to: • Anatomical location: proximal, middle or distal third of the shaft. • Direction of fracture line: transverse, spiral, oblique… etc. • Simple or comminuted. • Types of fractures (according to the pattern): • Transverse fracture: caused by a shear force (2 forces against each other). For example, elevator door closing from both sides on a bone. In addition, direct trauma (with a stick) can lead to transverse fracture. • Oblique fracture: the mechanism which is causing this type of fracture is bending. For example, when you are walking and suddenly your leg is trapped in a hole and you lean forward. • Spiral fracture: caused by twisting. • Avulsion: occurs due to a pulling force of a tendon or a ligament. Usually this happens at the end of bones where many strong tendons/ligaments are attached. These tendons/ligaments don’t rupture, instead they pull part of the bone to which they are attached. • Impaction: caused by compression. • Greenstick: one side breaks, the other doesn’t. This type of fracture is happening only in children (not found in adults!). • Simple fracture: closed – not penetrating the skin. • Compound fracture: open – penetrating the skin. • Comminuted fracture: the bone is broken into more than 2 fragments. • What are the signs and symptoms for a patients presenting with fracture? • Severe pain, swelling, deformity and loss of function. • Associated vascular or nerve injury (resulting in loss of sensation or paralysis). • If patients has an open fracture, he will present with a wound which can even be infected!

3. Fractures

4. What investigations are you going to request for a person presenting with a fracture? • X-ray of the involved bone. What is the rule of 2’s in radiology? • 2 views: anterior-posterior + lateral. • 2 joints: proximal and distal joints to the fracture. • 2 opinions. • 2 occasions. • You might also request and arteriography if you suspect injury to vasculature. • How to manage a person presenting with fracture? • Fracture reduction: • Definition: it is a procedure in which you restore a fracture or dislocation to its correct alignment. • There are 2 types: • Closed reduction: manipulation of bone fragments without surgical exposure of the fragments. • Open reduction (when there is open fracture or internal fixation is needed): fracture fragments are exposed surgically by dissecting the tissues. • Fracture stabilization: which can be • External fixation: • By a plaster, splint or cast. Notice that after stabilizing the fracture, the position of the bone must be checked again by a radiograph. • Traction: it is used to overcome the pull of muscles (such as Thomas splint that is used with femoral shaft fracture). • Internal fixation: • Types: K-wire, screws (stainless steel; attaching small bone fragments), nails (for long bone fractures or plates. • What are the indications for internal fixation? • Failure of external fixation. • Multiple injuries. • Damage to other structures such as vasculature or nerves. • Need to avoid long time of immobilization. • Rehabilitation. • How to manage and open fracture? • Clean the wound, keep it open, pack it with betadine gauze. • Give prophylactic antibiotics and tetanus immunization. Fractures

5. What are the complications of fractures? • Impairment of movement and function. • Soft tissue and muscle necrosis (especially if a vessel is injured or the fracture is compressing on a specific area). • Hemorrhage might also result and develop into hypovolemic shock (which is an emergency situation). • Bone & cartilage necrosis. Notice that avascular necrosis of the bone commonly occurs in the head of the femur or proximal part of scaphoid bone. Early diagnosis is done with MRI. • Nerve damage (example: damage to the axillary nerve when a fracture occurs in the surgical neck of the humerus). • Tears of tendons and ligament (example: a fracture in the clavicle can lead to a tear in coracoclavicular ligaments). • Fat embolism (especially if the fracture occurs in long bones). • Pelvic fractures: • Causes: • Fall from a significant height (especially in elderly). • Road traffic accidents in young patients. • Types: • Type-I: stable pelvic fracture. • Type-II: vertically stable; ROTATIONALLY UNSTABLE. • Type-III: vertically and rotationally unstable. • Signs and symptoms: pelvic pain, bruising, shock (mostly due to venous bleeding), inability to pass urine by urethra, rectal bleeding and highly mobile prostate gland felt by digital rectal examination. • Investigations: • X-ray of the pelvis. • CT-scan. • Urethrogram. • Treatment: • Resuscitation with IV fluids due to bleeding. • Reduction and fixation of the fracture. • Avoid inserting a Foley’s catheter if urethral injury is suspected. Instead, do a suprapubic catheterization. Fractures

6. Hip dislocation: • Definition: it is when femoral head is not properly located in the acetabulum. • Cause: • It is uncommon because this joint is strong but may occur with car accidents. • The position of the person which causes dislocation: hip flexed, adducted and internally rotated. • Posterior dislocations are more common. • Presentation: affected limb appears shorter and medially rotated. • Diagnosis: x-ray of the hip • Treatment: reduction under general anesthesia (± open reduction and/or internal fixation). • Complications: • Avascular necrosis of femoral head. • Injury to sciatic nerve. • Developmental Dysplasia of the Hip (DDH): • Epidemiology: 1/1000 births. • Risk factors (remember the 5 f’s): • First born. • Female. • Family history. • Feet (breech presentation). • Fluid (oligohydramnios). • Special tests: • Age > 6 months: Ortolani and Barlow. • Age < 6 months: Galeazzi. • Investigations: • Age > 5 months: ultrasound. • Age < 5 months: x-ray. • Treatment: • First 5 months: Pavlik harness. • 6 – 18 months: hip spica. • < 18 months: osteotomy. Fractures

7. Fractures

8. Proximal femur fracture: • Epidemiology: commonly occurring in elderly females because the neck of their femur is brittle (due to osteoporosis). • Types: • Intracapsular: subcapital, cervical or basal. High risk for injury of blood vaessels. • Extracapsular: greater trochanter, lesser trochanter, intertrochanteric or subtrochanteric. Extracapsular fractures will not injure blood vessels. • Diagnosis: x-ray. • Treatment: • Intracapsulat fractures: joint replacement (which can be total arthroplasty or hemiarthroplasty). • Extracapsular fractures: fixation. • Calcaneus fracture: It is associated with lumbar spine fracture due to fall from a significant height. Fractures

9. Fractures

10. Shoulder dislocations: Fractures

11. Fractures

12. The knee: • Dislocation of knee joint: • Types: it can be anterior or posterior. • Anterior and posterior cruciate ligaments: • Anterior cruciate ligament: prevents posterior displacement of femur on the tibia. • Posterior cruciate ligament: prevents anterior displacement of femur on the tibia. • Diagnosis/treatment: • Immediate closed reduction (DON’T WAIT FOR X-RAY!). • Complications: • Injury to popliteal artery/vein. • Injury to fibular nerve (which results in foot drop). • Unhappy triad: • The firm attachment of the tibial collateral ligament to the medial meniscus is of clinical significance because tearing of this ligament frequently results in concomitant tearing of the medial meniscus. • The injury is frequently caused by a blow to the lateral side of the extended knee or excessive lateral twisting of the flexed knee. • This injury is common in athletes who twist their flexed knees while running (in football and soccer). • The anterior cruciate ligament may also tear subsequent to the rupture of tibial collateral ligament. • Achilles tendon rupture: • Achilles tendon connects calf muscles to the heel bone and is needed for plantarflexion of the foot (aids in walking). • Signs and symptoms: • A popping sound when injury occurs. • Severe calf pain and swelling near the heel. • Inability to stand or walk on the affected foot (no plantarflexion). • Check by: Thompson’s test. • Treatment: • Young patient: surgical repair. • Elderly: splint. Fractures

13. Fractures

14. Fractures

15. Rotator cuff injury: • What are rotator cuff muscles? “remember SITS” • S: Supraspinatous. • I: Infraspinatous. • T: Teres minor. • S: Subscapularis. • Causes: • Injury to the shoulder. • Progressive degeneration or wear-and-tear of tendon tissue. • Repetitive overhead activity and heavy lifting over a prolonged period of time. • Diagnosis: • X-ray: usually NO findings. • Ultrasound. • MRI. • Treatment: • Conservative: rest, ice, steroid injections and physical therapy. • Severe symptoms/injury to muscles or tendons: surgery! • Some important fractures: • Colle’s fracture: distal radial fracture resulting from fall on an extended wrist. It results in dinner-fork deformity. • Smith’s fracture: distal radial fracture resulting from fall on a flexed wrist. • Proximal fracture of humerus: injury to axillary nerve (which is innervating deltoid muscle). • Fracture of humerus shaft: injury to radial nerve (innervating extensor of forearm). • Suprachondylar fracture: injury to median nerve (innervating flexors of forearm). • Anatomical snuff box fracture: avascular necrosis of scaphoid bone. • Callus formation in healing of a fracture: • Soft callus: it is a fibrocatilage bridge between the two fracture ends. • Hard callus: forms after 2-4 days; it is mineralized soft callus; it is stable to bear weight after 6-8 weeks. Fractures

16. Definition: increased pressure within a closed space (compartment) which results in compromise of circulation. • Causes: • Fractures. • Blunt trauma. • Very tight dressings or casts. • Vascular injuries (such as acute arterial occlusion). • Burn injuries. • Signs and symptoms: • Hallmark finding is PAIN OUT OF PROPORTION especially with passive stretching of the involved muscle. • Parasthesia: of cutaneous distribution supplied by the compressed nerve is an early sign. • Paralysis: often after ischemia is well-established. • Pallor: may not be present. • Pulselesness: pulse may be present. • Compartment is tense on palpation. • Diagnosis and treatment: • CLINICAL DIAGNOSIS. • Measure pressure of the compartment: • > 30 mmHg: usually will not produce a compartment syndrome. • < 30 mmHg: indication for fasciotomy. Notice that pressure < 30 mmHg for < 8 hours will produce irreversible tissue death. Compartment Syndrome

17. Compartment Syndrome

18. Definition: Acute Respiratory Distress Syndrome (ARDS) which occurs due to release of fat droplets following a fracture of a long bone (usually the femur in a road traffic accident). • Causes: • Most common: fracture of a long bone or intramedullary nails (used for treatment of long bone fractures). • Burns. • Severe infections. • Signs and symptoms: • They usually appear immediately or 2-3 days following injury. • Fat embolism syndrome is characterized by a triad: • Dyspnea: with a respiratory rate < 30 breaths/minute. • Confusion. • Petechial rash on the chest. • Diagnosis: • ABG: PO2 > 60 mmHg. • CXR: snowstorm-like appearance. • Cryostat: a frozen section of clotted blood reveals presence of fat. • Treatment: • Oxygen and maintain PO2 < 90 mmHg. • Severe hypoxemia: mechanical ventilation. • Heparin (?) • Prognosis: mortality reaching up to 50% with multiple fractures. Fat Embolism Syndrome

19. Acute osteomyelitis: • Pathophysiology: • Bacteria lodge in an end artery at the metaphysis of a bone and proliferate there → local increase in WBCs → decreased blood flow and pressure necrosis → pus moves to Haversian and medullary canals → it also extends beneath the periosteum. • Causes: • Hematogenous: most commonly S.aureus. • Rarely trauma. • Signs and symptoms: • Patient will have a history of infection (e.g. throat or skin) or trauma. • Fever. • Pain at the affected area. In addition, it will be swollen with limited joint motion. • Diagnosis: • Labs: CBC (leukocytosis), ↑ESR and CRP. • Imaging: • X-ray: features will appear 2 weeks after onset of symptoms. • Early disease can be detected by MRI or bone scan. • Sequestrum vs. involucrum: • Sequestrum is a necrotic dead bone while involucrum is reactive bone surrounding the sequestrum. • Treatment: • Medical: obtain a specimen for culture. Then, start IV antibiotics (anti-staphylococcal). • Surgical: • Indications: presence of abscess or failure of medical treatment. • Drainage of the abscess, wound kept open to heal by secondary intention, antibiotics. Osteomyelitis

20. Osteomyelitis

21. Chronic osteomyelitis: • Epidemiology: often seen in lower extremities of a diabetic patient. • Cause: • Untreated or failed treatment of acute osteomyelitis resulting in sequestrum surrounded by involucrum and drainage of pus to the surrounding skin via a sinus tract. • Occasionally can be caused by: surgery or trauma. • Organism(s): polymicrobial. • Signs and symptoms: • Most common: persistent drainage following an episode of acute osteomyelitis or onset of inflammation/cellulitis around an open fracture. • Fever (not always present). • Pain. • Diagnosis: • X-ray: irregular areas of destruction + periosteal thickening. • Bone scan might be useful if x-rays are not diagnostic. • Treatment: • EXTENSIVE DEBRIDEMENT of all necrotic and granulation tissue. • Reconstruction of bone and soft tissue. • Antibiotics. Osteomyelitis

22. Definition: it is a chronic, non-inflammatory disease affecting the joints. It results in destruction of cartilage of the joint with secondary remodeling and hypertrophy of the bone. • Epidemiology: • OA affecting knee joint is the most common cause of chronic disability among elderly population. • Risk factors for OA: advanced age, female sex, genetic factors, major trauma to the joint, repetitive stress to the joint and obesity. • Classification: • Idiopathic (most common). • Secondary to other underlying conditions such as: • Gout. • Diabetes and acromegaly. • Valgus or varus deformity • Clinical presentation: • Most commonly involved joint is the knee joint. • Monoarticular, asymmetric joint involvement. • Joint pain increases with exercise and relieved with rest. • Joint involvement is slow, progressive and irreversible. • Physical examination of the joint: no signs of inflammation but there will be crepitations with the movement of the joint. • Diagnosis: clinical + x-ray findings (osteophytes, narrowing of joint space, hypertrophy of subchondral bone with formation of a cyst). • Treatment: • Start patient on acetaminohpen (to relieve his pain). • If it doesn’t work, move to NSAIDs (e.g. ibuprofen). • If still pain cannot be controlled, try intra-articular injections of hyaluronic acid. • If medical therapy fails and patient’s quality of life is decreased → knee replacement surgery. Osteoarthritis

23. Etiology: • Young female (age > 40 years) → most common cause of septic arthritis is gonorrhea. This is especially seen during: menses and pregnancy. • Older patients with pre-existing destruction of the joint (e.g. patient has RA) → S.aureus is the most common cause. • Clinical presentation: • Patient might present with fever and monoarthritis with signs of inflammation of the joint involved (warm, red, swollen and painful with decreased range of motion). • Diagnosis: • Synovial fluid analysis: <50,000 WBCs/mm3. Culture and Gram-stain is usually NEGATIVE in gonococcal arthritis (thus you rely on cell count). Culture is positive for septic arthritis caused by other organisms: Staph, Strept, and other Gram-negatives. • Treatment: • Gonococcal arthritis: ceftriaxone. • S. aureus arthritis: nafcillin or vancomycin. Septic Arthritis