Fractures and their Classifications

Distraction Fractures

• Fracture fragments are separated by a space.

Valgus Fractures

• The distal segment moves away from the midline of the body.
• An example is genu valgum (knock-knees).

Impacted Fractures

• Fracture fragments are compressed into each other.

Angulated Fractures

• The direction of the fracture apex is either varus or valgus.

Open Fractures

• The bone protrudes through the skin.
• Main concern: infection
• Orthopedic emergency.
• Classified using the Gustilo-Anderson classification system.
  • Factors considered: Laceration size, tissue loss, devitalization, and major vascular injury.

Initial open fracture management

• Primary and secondary survey: ABCs (Airway, Breathing, Circulation).
• Pain control: Morphine, fentanyl.
• IV prophylactic antibiotics: Cefazolin, +/- gentamicin.
• Tetanus coverage: Td vaccine, TIG (tetanus immune globulin).
• Lavage the wound with sterile irrigation and dressing.
• Important investigations: X-ray, trauma labs, ECG, CXR, Consent.
• Surgical debridement.
• Open reduction and fixation (usually internal for the upper limb).

Pathological Fractures

• Fractures that occur in weakened bones due to underlying disease.
• Common causes:
  • Osteoporosis (most common).
  • Metastatic bone disease and primary bone cancers.
  • Multiple myeloma.
  • Osteomalacia and rickets.
  • Others: Osteogenesis imperfecta, scurvy, bone infections.
• Treatment: Focus on addressing the underlying disease.

Stress Fractures

• Fractures that occur in normal bones due to repetitive stress with inadequate healing time.
• Common in: Young adults during military training (March fracture), ballerinas, sports players, and individuals engaging in hard, repetitive physical activity.
• Common locations: Metatarsals, calcaneus, tibia.
• Pain: Usually during activity.
• Early X-rays: May not show the micro-fractures.
• X-rays after 2 weeks: May reveal callus formation.
• Management: Temporary limitation of weight bearing or reduction in physical activity.

Salter-Harris Fractures:

• Salter-Harris Classification:
  • Type I: Transverse fracture through the physis (separated).
  • Type II: Transverse fracture involving the physis, diverging to the metaphysis (above).
  • Type III: Transverse fracture through the physis and extending to the epiphysis (lower).
  • Type IV: Fracture across the physis from the metaphysis to the epiphysis (through).
  • Type V: Axial force crushing the physeal plate (ruined).

X-ray Principles (Rule of 2s):

• 2 Views: At least AP (anterior-posterior) and lateral.
• 2 Joints: The one above and one below the fracture site.
• 2 Sides: If unsure, assess both sides (essential for growth plate fractures in children).
• 2 Radiologist Opinions: If opinions differ, consult a third senior doctor.
• 2 Times: Obtain images before and after reduction.

Management of Fractures:

• Analgesia: Strong analgesics like morphine.

• Reduction:

  • Closed Reduction: IV sedation, apply traction, reverse the mechanism of injury.
  • Open Reduction:
    • Indications:
      • Non-union.
      • Open fracture.
      • Compromised blood flow or neurovascular tissue.
      • Mal-alignment of articular surfaces (intra-articular fractures).
      • Salter-Harris types 3, 4, and 5.
      • Trauma patients requiring early ambulation.
    • Post-reduction: Assess neuro-vascular status and obtain post-reduction X-rays.

• Fixation:

  • Internal: Screws, plates, pinning, nails, rods.
  • External: Splints, casts, traction, external fixation devices.

• Follow Up: After 2 weeks to evaluate bone healing.

• Stress fractures and scaphoid fractures: Diagnosis often made radiologically after 2 weeks.

• Rehabilitation: Necessary after fracture management.

Compartment Syndrome (HIGH-YEILD):

• Definition: Increased pressure within an extremity compartment compromising circulation and tissue function.
• Suspect in: Fractures or any damage to an extremity.

Shoulder Disorders (HIGH-YEILD):

Anterior Shoulder Dislocation (Most Common)

• Occurs mainly in younger sports-active individuals and after trauma due to joint laxity.
• Recurrence risk: High due to weaker joint ligaments.
• Mechanism: External rotation and abduction.
• Clinical Features:
  • Presentation: Pain and difficulty moving the arm.
  • Examinations:
    • Look:
      • Asymmetrical shoulder appearance.
      • Box-shaped shoulder with loss of contour.
      • Prominent humeral head.
      • Typical position: Upper limb abducted and slightly externally rotated (locked in the position caused by the dislocation).
    • Feel: Assess neuro-vascular structures:
      • Radial and brachial pulses.
      • Axillary nerve (sensations over the deltoid area and abduction of the arm by the deltoid muscle).
    • Move: Reduced Range of Motion (ROM) and assess movements beyond the deformity (passive and active).
• Complications:
  • Recurrent dislocations (65-95%).
  • Injury to axillary nerve and artery.
  • Rotator cuff tear.
  • Post-traumatic arthritis.
• Investigations:
  • Shoulder X-ray (Rule of 2s): Shows the dislocation and may reveal the Hill-Sachs deformity (compression fracture of the posterolateral humeral head).
• Management:
  • Closed Reduction: IV sedation and muscle relaxation:
    • Longitudinal traction downwards by weight, spontaneous reduction within 15 minutes.
    • Manually by the Hennipen technique.
    • Lift arm to 90 degrees, then externally rotate and adduct until reduced.
  • Post-reduction: X-rays and neuro-vascular assessment.

Humeral Fractures (HIGH-YEILD):

• Common Locations:
  • Surgical neck fracture.
  • Mid-shaft fracture.
  • Supracondylar fracture.
  • Medial epicondyle fracture.
• For all humeral fractures:
  • Diagnosis: X-ray (Rule of 2s).
  • Assess:
    • Fracture site.
    • Closed or open.
    • Fracture pattern.
    • Alignment.

Surgical Neck Fracture:

• Typically occurs in adults (young adults and elderly).
• Cause: Usually direct trauma.
• Presentation: Pain, swelling, reduced ROM, ecchymoses over the upper arm and chest (related to damage to surrounding vasculature).
• Assessment:
  • Radial pulse.
  • Axillary nerve injury (arm abduction and loss of sensations over the shoulder).
  • Posterior humeral circumflex artery injury (bleeding).
• Diagnosis: X-ray of the upper arm (AP, Lateral).
• Management: Depends on fracture severity and displacement.
  • Closed reduction (if necessary), splinting, or ORIF (open reduction and internal fixation).

Mid-Shaft Fracture:

• Fracture of the diaphysis of the humerus.
• Cause: Direct trauma.
• Presentation: Pain, swelling, reduced ROM.
• Assessment:
  • Radial nerve injury (runs in the radial groove posteriorly): Wrist drop, loss of sensation over the dorsum of the hand (1st, 2nd, 3rd fingers).
  • Injury to the deep brachial artery: Assess ulnar and radial pulses, and perfusion status (warm and pink, pale and cold).
• Diagnosis: X-ray of the upper arm.
• Management:
  • 80-90%: Closed reduction and splinting.
  • Complicated cases (e.g., comminuted): Open reduction and internal fixation.

Supracondylar Fracture of the Humerus:

• Typically occurs in pediatric cases, rare in adults.
• Causes: Fall with hyperextended arm at the elbow, FOOSH (fall onto outstretched hand).
• Presentation: Pain, arm held close to the body.
• Assessment:
  • Brachial artery injury: Assess ulnar and radial pulses and perfusion status (warm and pink, pale and cold).
  • Median nerve injury.
  • Compartment syndrome assessment.
• Diagnosis: Lower arm X-ray, consider surgical exploration if diminished distal pulse.
• Management:
  • Non-displaced: Long arm cast for 4-6 weeks. Follow up with X-ray after 1 week to confirm good fracture position.
  • Vascular compromise or displaced: Open reduction and internal fixation (may require vascular surgery).
• Complications:
  • Median nerve palsy.
  • Tear or entrapment of the brachial artery or compression.
  • Compartment syndrome.
  • Volkmann contracture (due to reduced perfusion leading to necrosis of flexor muscles).

Medial Epicondyle Fracture:

• Avulsion fracture of the medial epicondyle (origin of the anterior forearm flexor muscles).
• Causes: Pitching activities, FOOSH.
• Presentation: Pain on the medial elbow.
• Assessment:
  • Ulnar nerve injury: Loss of finger abduction and adduction, ulnar deviation of the wrist, loss of sensation over the medial 1.5 digits and medial palm.
• Management:
  • Depends on severity and displacement.
  • Closed reduction and splinting or ORIF.

Nerve Injuries in the Humerus:

• Surgical Neck: Axillary nerve.
• Radial Groove: Radial nerve.
• Distal Humerus: Median nerve.
• Medial Epicondyle: Ulnar nerve.