Fractures and their Classifications

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Questions and Answers

What describes a directed fracture?

Fracture apex is directed inward.

The distal segment moves towards the midline.

Fracture fragments are compressed into each other.

Fracture fragments are separated by a gap. (correct)

What is the major concern in an open fracture?

Risk of infection. (correct)

Bone weakening.

Delayed healing.

Peripheral nerve damage.

In which classification is the grading of open fractures based on laceration size?

AO classification.

Richter classification.

Elder classification.

Gustilo-Anderson classification. (correct)

What characterizes a pathological fracture?

It occurs in weak bones due to underlying disease. Signup and view all the answers

Which is a common cause of stress fractures?

Repetitive stress without adequate healing. Signup and view all the answers

When are micro-fractures typically visible on an X-ray?

By two weeks due to callus formation. Signup and view all the answers

What is commonly associated with stress fractures in younger individuals?

Repetitive physical activity. Signup and view all the answers

What type of fracture occurs when bone protrudes through the skin?

Open fracture. Signup and view all the answers

What characterizes a Type II fracture in the Salter-Harris classification?

Transverse involving the physis, diverting away Signup and view all the answers

Which imaging technique is essential for assessing growth plate fractures in pediatrics?

At least two views (AP & lateral) Signup and view all the answers

Which situation indicates the need for open reduction?

Non-union of fracture Signup and view all the answers

What is a defining characteristic of a Type IV Salter-Harris fracture?

Crosses the physis from metaphysis to epiphysis Signup and view all the answers

What is a common indication for internal fixation in fracture management?

Compromised neurovascular tissue Signup and view all the answers

What defines compartment syndrome?

Increase pressure within the extremity compartment Signup and view all the answers

How long after fracture reduction should follow-up occur to evaluate healing?

2 weeks Signup and view all the answers

Which of the following analgesics is considered strong for managing fracture pain?

Morphine Signup and view all the answers

What is the most common mechanism leading to anterior dislocation of the shoulder?

External rotation and abduction Signup and view all the answers

Which clinical feature is typically observed in a patient with an anterior shoulder dislocation?

Asymmetric shoulder appearance Signup and view all the answers

What complication has the highest incidence following an anterior shoulder dislocation?

Recurrent dislocations Signup and view all the answers

What should be checked when assessing neuro-vascular structures in a patient with shoulder dislocation?

Radial and brachial pulses Signup and view all the answers

During a shoulder X-ray evaluation for dislocation, which condition might be observed?

Hill-Sachs deformity Signup and view all the answers

What is the first step in the management of an anterior shoulder dislocation?

Closed reduction with IV sedation Signup and view all the answers

In what position is the upper limb typically held after an anterior shoulder dislocation?

Abducted and slightly externally rotated Signup and view all the answers

What is the purpose of post-reduction X-rays after managing a shoulder dislocation?

To evaluate the success of reduction and check for complications Signup and view all the answers

What is the appropriate management for a nondisplaced lower arm fracture?

Long arm cast for 4-6 weeks Signup and view all the answers

Which clinical assessment would indicate a brachial artery injury?

Cold and pale extremity Signup and view all the answers

What complication can arise from reduced perfusion following a forearm injury?

Volkmann contracture Signup and view all the answers

Which nerve injury is associated with a fracture at the medial epicondyle?

Ulnar nerve injury Signup and view all the answers

What would a patient with ulnar nerve injury likely present with?

Difficulty in abduction and adduction of fingers Signup and view all the answers

What is a common cause of surgical neck fractures in adults?

Direct trauma Signup and view all the answers

Which of the following presentations is NOT associated with surgical neck fractures?

Wrist drop Signup and view all the answers

Which assessment is most critical to evaluate after a humeral surgical neck fracture?

Radial pulse Signup and view all the answers

What is the typical management for 80-90% of mid-shaft humeral fractures?

Closed reduction and splinting Signup and view all the answers

What is a common characteristic of supracondylar fractures of the humerus?

It typically occurs in pediatric cases Signup and view all the answers

Which mechanism of injury is most likely to result in a supracondylar humeral fracture?

A fall onto the outstretched hand Signup and view all the answers

What condition should be suspected in children presenting with a spiral fracture in the mid-shaft of the humerus?

Child abuse Signup and view all the answers

Which of the following is NOT part of the assessment for mid-shaft humeral fractures?

Axillary nerve assessment Signup and view all the answers

Study Notes

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.

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Test your knowledge about different types of fractures, including directed, open, and pathological fractures. This quiz will challenge you on the concerns and classifications associated with fractures, as well as causes like stress fractures. Perfect for students in medicine or sports science.