Fracture/Dislocation/Sublaxation

Fracture:

It is the break in the continuity of bone.

Dislocation:

When the articular surfaces are no longer in contact with each other is called Dislocation.

Sublaxation:

When the articular surfaces are moved apart but there is still partial contact b/w them is called Sublaxation.

Classification of bone fracture by bone strength in relation to load:

A.     Traumatic fracture:

Fracture occurring due to any trauma is called traumatic fracture.

B.     Pathological fracture:

Fracture occurring due to pre-existing bone disease (osteoporosis, osteoarthritis) is called pathological fracture.

C.      Stress fracture:

When the bone is constantly exposed to increase stress due to military recusities etc it will lead to stress fracture.

D.     Green stick fracture:

This type of fracture occurs in young people, in this fracture the bone bends when exposed to excess pressure. 

Classification of fracture by direction of force:

1.      Transverse fracture:

The bone is broken in way that there is a horizontal line to the ling axis of bone i.e. plane of fracture is at right angle to the axis of bone. It occurs if a long bone is bent along its long axis.

2.      Spiral fracture:

It is a fracture in which a long bone is twisted along its axis.

3.      Compressed fracture:

When sudden excess pressure is applied, the long axis of bone can result in compressed fracture.

4.      Avulsion:

It is indirect fracture caused by avulsion or pull of a ligament or tendon. This is especially common where strong muscles insert in small bones like pisiform, patella (quadriceps), olecranon (triceps) etc

5.      Butterfly fracture:

When from the line of impact two lines move in opposite direction forming a wedge of bone.

6.      Comminuted fracture:

When the bone is broken into multiple pieces e.g. camel bite, crocodile bite, crush injuries etc.

Classification of fracture by anatomical sites:

        I.            Fracture of epiphysis (the ends of long bone beyond the epiphyseal plate)

      II.            Fracture of metaphysis (the flare each end between the diaphysis and the epiphyseal (growth) plate)

Metaphyseal Fracture

    III.            Fracture of diaphysis (shaft of long bone)

Diaphyseal Fracture

    IV.            Fracture of epiphyseal plate (in children and infants)

Classification of fracture by skin integrity:

A.     Closed fracture:

The skin is intact and the fracture site is not in contact with outside.

A-Closed Fracture, B-Open Fracture, C- Closed Fracture

B.     Open fracture:

The skin is not intact and the fracture site communicates with the external environment.

Classification of fracture by position:

1.      Undisplaced fracture:

The fracture in which the periosteum is largely intact is called undisplaced fracture.

2.      Displaced fracture:

The fracture in which the periosteum is not intact and the cortices are not in alignment is called displaced fracture.

Classification of fracture by management:

        I.            Stable fracture:

These are fractures which are unlikely to move further

     II.            Unstable fracture:

Unstable Fracture of distal Radioulnar

These fractures need prompt treatment because the fragment can easily move apart.

Factors affecting healing of fracture:

        i.            Initial injury:

·         Severe injury:

If the initial injury is severe it will result in compound fracture, soft tissue damage will be extensive. All these can delay the healing of fracture.

     ii.            Infection:

If at the site of fracture there is infection (damaged tissue, blood vessels, contamination), it can delay the healing of fracture.

   iii.            Interposition of soft tissue:

If there is fat or muscle in b/w fracture site it can hamper the healing of fracture.

    iv.            Poor blood supply:

If the supply to the fracture is poor due to any reason (trauma) blood vessel damaged it can delay the healing.

      v.            Pathological fracture:

The disease bone takes time to heal e.g. osteoporosis, osteomyletis, bone tumor, osteoarthritis etc

    vi.            Uremia:

It can affect healing of fracture, uremia basically affect the function of fibroblast (component for healing).

 vii.            Inadequate immobilization:

Fracture site usually given rest. Too much movement can affect the healing of fracture.

viii.            Distraction of fragments:

When excessive traction is applied to a fracture site, it can affect the healing of fracture.

Diagnosis of fracture:

History:

It is usually obvious for taking history.

Examination:

Proper examination can help in identifying fracture, associated injuries.

X – Rays:

They can tell you exactly about the fracture.

Management of fractures:

General management:

ABCD

Maintain Airway:

If there are tight clothing around the neck, any foreign body so remove it.

Breathing:

One should quickly assess the breathing by looking at the Alae Nasai (nostrils) chest movement.

Circulation:

Check the carotid pulse.

Disability:

Correct any disability.

If there is bleeding stop it, correct any obvious deformity, maintain I/V line, give fluids, if there is excess blood loss and blood transfusion arrangement, I/V antibiotics, analgesics, tetanus toxoids.

Specific management:

Reduction:

It is restoration of normal or near normal anatomy.

Types of reduction:

        I.            Closed reduction

      II.            Open reduction

        I.            Closed reduction:

By gravity:

This method is applied for upper limb fractures (humerus) e.g. collar and cuff

Closed manipulation:

Analgesics are given and joints are reduced.

Traction:

Skin traction:

Elastic bandage is applied to skin of lower limb and weight is attached to it.

Skeletal traction:

Nails passed in bone are connected to weight in overcome the force of muscle.

Open reduction:

Comminuted fractures and when closed reduction fails this method is applied.

Fixators:

These are devices applied to fracture site. They can be divided in external and internal fixators.

A.      Internal fixators:

Screws:

Use in repair of malleoli, epicondyle fracture.

Intramedullary nails:

Are passed in centre of bone

Plates:

These are metallic plates in fracture.

Wires:

K – Wire is used in uniting of small fragments of bone.

B.      External fixators:

Plaster of Paris (POP):

Bandage is impregnated in plaster and applied to fracture.

One bar & two bar fixators:



2 Bar Fixator



They are applied externally.

Complications of fracture:

Early complications:

                     i.            Skin laceration

                   ii.            Vascular injury

                  iii.            Muscle injury

                 iv.            Injury to nerves

                   v.            Acute compartment syndrome:

It is the condition in which pressure symptoms develop in tight fascial compartment like upper and lower limb. Usually there is accumulation of exudate blood which compresses the muscles, vessels and nerves. If urgent action isn’t taken it can lead to death of the tissues. When a patient develops acute compartment syndrome the splints should be removed and if needed fasciotomy is done to release the pressure. Once the inflammation subsides then wound can be repaired.

Late complications:

         i.            Malunion (abnormal union of fractured bone)

       ii.            Non union

      iii.            Delayed union

     iv.            Joint stiffness

       v.            Bone infection

     vi.            Septicemia

    vii.            Depression

  viii.            Myositis (any group of muscle diseases in which inflammation and degenerative changes occur).