Part 10: Fractures & Trauma

Fractures 101
1. How to classify fractures by etiology?
 Traumatic
 Non-traumatic (? =pathological)
o Structural alteration e.g. osteoporosis
o Lytic lesions e.g. cancer, infection
2. What are the fracture patterns?
 Transverse #: direct high energy force
 Oblique #: angular or rotational force
 Butterfly #
 Segmental #: high energy

Spiral #: rotational, low energy
 Comminuted #
 Avulsion #
 Compression / impacted #
3. Important points on open fracture
 Important factors determining outcomes (as in Gustilo-Anderson classification, which is also
related to energy of the injury)
o Fracture pattern
o Degree of soft tissue injury: wound size, soft tissues involved
(N.B. torn artery = grade IIIc, i.e. highest grade in classification)
o Degree of contamination
 Interventions
o Clean wound: remove foreign bodies, irrigation, dressing
o Infection: prophylactic antibiotics, debridement, (tetanus)
 Potential complications
o Early: neurovascular injury, compartment syndrome, multi-system injury
oLate: infection, periosteum stripping & non-union
4. Important points on intra-articular fracture
 Often leads to secondary arthritis due to poor repair ability of hyaline cartilage
 Principle of management
o Require perfect anatomical reduction: often needs open reduction
o Stable fixation
o Early mobilization: regain motions, decrease swelling

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5. How to describe a fracture on radiograph?
 Identify the main fracture
o Site
o Pattern
o Translation
o Angulation
o Rotation
o Shortening
 Associated fracture / joint dislocation or subluxation
 Soft tissue swelling
 ? hint of pathological fracture
6. “X-ray rule of 2s”
 2 sides: bilateral
 2 views: usually AP + lateral

2 joints: one joint above & below
 2 times: before & after reduction
7. General management principles of fracture
 Save life: ATLS protocol
 Save limb: assess neuro-vascular injuries & compartment syndrome
 Analgesics
 (For open fracture: debridement, antibiotics)
 RICE: rest, ice, compression, elevation
 Reduction
o Closed - under sedative & muscle relaxants
o Open
 Fixation
o External: splint, cast, traction, external fixator
o Internal: percutaneous pinning, extramedullary / intramedullary fixation
 Rehabilitation
 For pathological fracture: also treat underlying cause
o Osteopenia / osteoporosis: see p.6
o Osteomyelitis: antibiotics, drainage
o Bone metastasis: ? radiotherapy

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8. How do fractures heal?
 Secondary bone healing has four stages: hematoma, soft callus, hard callus & remodeling.
This occurs under relative stability, where micro-movements between fracture fragments
stimulate cells to become active and form callus (a heterogeneous tissue).
 In some situations bones heal by primary bone healing. In this circumstance bones heal
directly through remodeling, and there is no callus. This only happens under absolute
stability, i.e. bone ends in direct opposition with no gap, and no micro-movement. It is
achieved if the fracture is plated & compressed, e.g. in ORIF.
9. Why some fractures fail to heal?
 When the fracture has no sign of healing beyond 3-6 months (depends on site) it is termed
non-union. If there is attempt but not complete at expected time it is termed delayed union.
 Causes
o Local Cx: avascular necrosis, infection esp. osteomyelitis
o Anatomy: bone ends not apposed, inadequate stability
o Patient factors: advanced age, poor nutrition, DM, smoking, alcoholism
10. What are the possible complications of fracture?
 Early
o Local: neurovascular injury, compartment syndrome, infection...
o Systemic: hemorrhagic shock, sepsis, venous thrombo-embolism...
 Late
o Mal/non-union, AVN, osteomyelitis, secondary OA, joint stiffness, heterotopic
ossification...

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Fragility Fractures
 Fracture resulted from fall from standing height or less
 Often the first presentation of osteoporosis
o Distal radial fracture is usually first fracture in relatively younger & active pt
o If left untreated vertebral fracture or even hip fracture will occur
- hip fracture brings profound disability, or even death
 As part of frailty in geriatric patients
o Sarcopenia & muscle weakness => increased risk of fall

Femoral Neck Fracture

 “Geriatric fracture” – often marker of fragility, poor prognosis (6X 2-year mortality)
 Classified by intra- or extra-capsular (the former has risk of disrupting blood supply to
femoral head, esp with displacement => non-union, AVN)
o Garden classification: predict risk of vessel damaged for intra-capsular fracture

 P/E
o Limb shortening
o Externally rotated
o Tenderness & resistance when internally rotated
 X-ray crucial in rule out pathological lesions (malignancy, infection)
 Management principles
o Fix as soon as possible (after co-morbidities settled)
 Hemi-arthroplasty vs fixation
 Former preferred if intra-capsular & Garden grade III/IV
o Prevent peri-operative complications e.g. DVT, bed sores, posterior dislocation
o Early mobilization & weight-bearing
o Measures to prevent further fall
o Treat osteoporosis

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Vertebral Compression Fracture
 Only involve anterior column, hence stable
 But leads to kyphotic deformity
 Can be silent / back pain
 Rule out metastasis esp. if red flags e.g. no fall, cancer history
 Mx: conservative vs surgery

Distal Radial Fracture

 Fall on outstretched hand, classically in peri-menopausal women / elderly
 Eponymous names largely abandoned in real practice now
o They have very well-defined (hence narrow) description
o Replaced by description of fracture site +/- extension into DRUJ / CMCJ

Colles’ Fracture
 Most common
 Simple transverse fracture 1 inch from joint line +/- ulnar styloid fracture
 Pain & swelling with or without displacement
 “Dinner-fork deformity”
o Dorsal & radial displacement + angulation of distal radial segment
o Radial shortening
o Loss of radial inclination
o Loss of volar tilt

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  Management
o Not displaced: splint followed by cast
o Displaced: closed reduction, cast
o Comminuted or unstable: surgery

Smith’s Fracture
 Also known as “reverse Colles’ fracture”
 Fall on dorsum of hand => palmar displacement & angulation

Other Common Fractures & Associated Dislocations

Clavicle #  Most commonly middle third – mostly conservative management
 Less commonly lateral third – prone to non-union or extend to AC joint,
often need surgical intervention e.g. ORIF
Humerus #  Proximal #: usually after fall in osteoporotic pt, possible injury to axillary n.
or brachial plexus; may associate with shoulder dislocation
 Mid-shaft #: can be transverse, oblique, spiral, comminuted...; may cause
injury to radial n.
 Distal #
o Supracondylar #: rare in adult
o Condylar #: seen in high energy impact if non-osteoporotic, must
check neurovascular involvement (median & ulnar n., brachial a.)
Elbow disl.  In most cases forearm bones dislocate posteriorly
 If no #, reduction usually stable and rarely recur
 Look for associated #, neurovascular involvement (median & ulnar n.,
brachial a.); long-term may be complicated with secondary OA
Ulna # *Ulnar & radial # often do not occur alone (as it is ring structure)
Radius # – look for # of partner bone / disruption of either radio-ulnar joint

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  Olecranon #: comminuted (direct blow) or transverse (avulsion #)
 Radial head # (c.f. more commonly neck # in children)
 Nightstick #: ulnar # named from naturally defend against weapon of police
in the US; high risk of non-union, need ORIF with plate & screw
 Monteggia #: proximal third ulnar # with PRUJ disruption (radial head
dislocation); fall on hand with forced pronation; usually require surgery
 Galeazzi #: distal third ulnar # with DRUJ disruption; much more common
than Monteggia; usually require surgery
 Distal radial #: see previous section
Scaphoid #  Mechanism: fall with wrist extended
 Difficult to visualize on X-ray – request “scaphoid view” / MRI
 Watson test
 Displaced # may disrupt retrograde blood supply to proximal pole
=> screw fixation to prevent non-union, AVN & secondary OA
Femur #  Neck / intertrochanteric #: most commonly fragility #, see above
 Subtrochanteric #: can be high energy but still more probably fragility #
 Shaft #: high energy injury or pathological #; can cause systemic
complication (e.g. blood loss) and vascular compromise
 Supracondylar #
 Condylar #
Tibia #
Fibula #
Calcaneus #  Fall from height – check associated spine compression #
 If intra-articular & displaced need ORIF

Cervical Spine Injuries

Trauma

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