Definitions
- Dislocation = total loss of congruity between articular surfaces
- Subluxation = partial loss of congruity between articular surfaces
- Fracture = a break in continuity of a bone
Fracture healing
- Fractures heal by restoration of bone continuity
- Rate of healing varies with age and is quicker in children
- Cancellous bone heals more quickly than cortical bone
- Some movement at fractures site is required for healing to occur
- Also requires an uninterrupted blood supply
- Bone healing can arbitrarily be divided in to five stages
Stage one
- Haematoma formation
- Bone ends bleed
- Periosteum is stripped for variable length
- Surrounding soft tissues may be damaged
Stage two
- Acute inflammation
- Cell division begins within 8 hours
- Cell proliferation seen within periosteum
Stage three
- Callus formation
- Dead bone is resorbed
- Immature woven bone is laid down
Stage four
- Woven bone is replaced by lamellar bone
- Fracture becomes united
Stage five
- Phase of remodelling
- Medullary cavity is restored
- Bone returns to normal shape
Principles of fracture management
- Some general principles need to be applied to fracture management
- Need to consider
- Reduction of the fracture
- Immobilisation of the fracture
- Rehabilitation
- Need for reduction varies from fracture to fracture
- Usually need to correct rotational or valgus or varus deformity
- Intra-articular fractures need anatomical reduction
- Reduction can be performed as either an open or closed procedure
- Immobilisation is required until fracture union
- Can be performed by external or internal methods
- External methods include
- Plaster casts
- Traction
- External fixation
- Internal methods include
- Plates
- Intramedullary nails
- K-wires
Indications for internal fixation
- Intra-articular fractures - to stabilise anatomical reduction
- Repair of blood vessels and nerves - to protect vascular and nerve repair
- Multiple injuries
- Elderly patients - to allow early mobilisation
- Long bone fractures - tibia, femur and humerus
- Failure of conservative management
- Pathological fractures
- Fractures that require open reduction
- Unstable fractures
Complications of internal fixation
- Infection
- Non-union
- Implant failure
- Refracture
Indications for external fixation
- Acute trauma - open and unstable fractures
- Non union of fractures
- Arthrodesis
- Correction of joint contracture
- Filling of segmental limb defects - trauma, tumour and osteomyelitis
- Limb lengthening
Complications of external fixation
- Overdistraction
- Pin-tract infection
Complications of fractures
- Early
- Infection
- Muscle and tendon injuries
- Nerve injuries
- Vascular injuries
- Visceral injuries
- Late
- Delayed union
- Non-union
- Malunion
- Avascular necrosis
- Myositis ossificans
- Volkmann's contracture
- Stiffness and instability
- Algodystrophy
- Reflex sympathetic dystrophy
Compound fractures
- All open fractures must be assumed to be contaminated
- Object of treatment is to prevent them becoming infected
- First aid treatment is the same as for a closed fracture
- Peripheral neurovascular status should be assessed
- In addition the wound should be covered with a sterile dressing
- Wound should be photographed so that repeated uncovering is avoided repeated exposure
- Antibiotic prophylaxis should be given
- Tetanus immunisation status should be evaluated
Picture provided by Matteo Bianchi, Trauma Centre San Paolo, Milan, Italy
Management
- Open fractures require early operation
- Ideally this should be performed within 6 hours of injury
- Aims of surgery are to:
- Clean the wound
- Remove devitalised tissue
- Stabilise the fracture
- Small clean wounds can be sutures
- Large dirty wounds should be debrided and left open
- Debrided wounds can be closed by delayed primary suture ar 5 days
Pathological fractures
- Generalised bone disease
- Osteoporosis
- Metabolic bone disease - osteomalacia, hyperparathyroidism
- Paget's disease
- Myelomatosis
- Localised benign bone disorder
- Chronic infection
- Solitary bone cyst
- Fibrous cortical defect
- Chondroma
- Primary malignant bone tumours
- Osteosarcoma
- Chondrosarcoma
- Ewing's tumour
Bibliography
Forward D, Morgan C G. Diagnosis and immediate care of open fractures. Hosp Med 2002;
63: 298-299. |