Shamails

FRACTURE
Definition
A break in structural continuity of bone
Aetiology/ Causes

1. Traumatic fracture Types of fracture

1. Direct force – bone
breaks at point of
impact
2. Indirect force –
bone breaks at a
distance from
where force is
applied
2. Pathological fracture
1. Normal stress in
weakened bone
2. Eg: osteoporosis,
osteogenesis
imperfecta, Paget’s
disease Mechanism of injury:
3. Stress fracture 1. Spiral – twisting
1. Repetitive stress in 2. oblique – compression/bending force
normal bone 3. Transverse – tension /bending force
2. Eg: athletes, 4. Impacted – axial loading
dancers, military 5. Comminuted – high energy
personnel

Classification

OPEN FRACTURES CLOSED FRACTURE

Fracture with break in skin and there is exposure between Broken bone that does not penetrate
underlying soft tissues, fractured bone, hematoma and the skin
external environment

Clinical features

History

History of 1. Age: elderly- high risk for fracture, paediatrics-incomplete fracture

trauma 2. Mechanism of injury
1. Type of trauma (eg fall, falls onto the outstretched hand or MVA)-
suggestive of the type of fracture (eg, compression, twisting)

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3. Nature of incidents: high velocity/low velocity
4. Magnitude of applied force: high impact of low
Symptoms 1. Pain:
1. Ask about SOCRATES. Pain due to fracture normally severe, exacerbated by
movement or unable to move after fracture
2. Differentiate with compartment syndrome- the pain is rapid in onset, very
severe and not relieved by analgesic or after immobilization
2. Swelling
3. Bruising
4. Deformity
5. Open fracture or closed fracture-(luka samapai Nampak tulang, tissue kat dalam?)
6. Numbness- due to nerve injury
1. Spinal injury- follow dermatomal distribution
2. Fracture: follow peripheral nerve injury
7. Associated symptoms
1. Skin pallor- due to vessel injury or blood loss or sign of compartmental
syndrome
2. Blood in the urine- due to pelvic fracture (in the case of polytrauma)
3. Abdominal pain- polytrauma
4. Difficulty with breathing- lung injury in polytrauma
5. Loss of consciousness- head injury in polytrauma
Past medical 1. Previous injury
and surgical 2. Any other Musculoskeletal abnormality- to differentiate the current abnormality
history with preexisting abnormalities
3. Drug history- preoperative assessment
Family and
social history 1. Detail of work
2. Smoking status
Physical examinations

General 1. Airway obstruction and

examinations 2. Breathing problems
3. Circulatory problems (bleeding control) and cervical spine injury

Systematic 1. Obviously injured part

approach 2. Artery and nerve damage
3. Associated injuries in the region
4. Associated injuries in distant parts

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Standard sequence Look
Feel
1. Look 1. Shape- thin/ obese
2. Feel 2. Skin (intact? Open 1. Temperature
3. Move fracture?) 2. Localized tenderness.
3. Posture: spine, shoulder 3. Bone or joint (synovium) outline.
4. Deformity: compare with 4. Fracture crepitus
both limbs. Is it shortening
5. Vascular and peripheral nerve
or lengthening? Internal abnormalities
rotation or external 1. Pulse
rotation?
2. Sensation
5. Wound
6. Swelling
7. Bruising
8. Gait
9. Look at other part as well
Move
1. Active movement
1. Look for Degree of mobility, pain, muscle power, instability
2. For example, if patient have radius ulnar fracture, we ask patient to
flex and extend the wrist and elbow. Normally, it is limited movement
or unable to move.
3. How to confirm that unable to move is not due to neurological deficit?
Ask the patient to move the distal limb, for example, in radioulnar
fracture- ask to move the finger. If it is due to the fracture at
radioulnar, patient still can move
2. Passive movement
1. Examiner move the joint in anatomical plane
2. Look for restriction of movement (use goniometer) and feel for
crepitus
3. Be precise (e.g. Knee flexion 20-90 degrees)

Special test (if Apprehension test

patient develop 1. For shoulder instability.
chronic
complication such Tinel sign
as mal union or non 1. To test for Median nerve in carpal tunnel syndrome
union) 2. Positive if feel tingling or paresthesia along the distribution of median
nerve
Thomas test
1. if the hip cannot be straightened out ompletely, this is referred as “fixed
flexion deformity”
neurological examination
1. Muscle tone --> Power --> Tendon reflex --> Sensory function
2. If it is spine injury-follow dermatomal distributim. If farcture- peripheral
nerve distribution

Special features of Swelling, Redness, Lump (callus), Warm, Tenderness, Flexion caused pain
stress fracture

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Special features of 1. Local signs of bone disease
pathological 2. Congenital dysplasia, fibrous dysplasia, Cushing’s syndrome and Paget’s
fractures disease characteristic appearances.
3. Wasting
4. Lymph nodes and liver enlargement.
5. Mass
6. Rectal and vaginal examination.

Gustilo Anderson Classification

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Sepsis Sepsis
rate rate

Type i 0% Type iiia 5%

Type ii 2.5% Type iiib 28%

Type iii 13.7% Type iiic 8%

TYPE I TYPE II
1. The wound is less than one centimeter 1. The laceration is more than one centimeter
long. long (1cm<x<10cm)
2. It is usually a clean puncture, through 2. There is no extensive soft-tissue damage,
which a spike of bone has pierced the skin. flap, or avulsion.
3. There is little soft-tissue damage and no 3. There is a slight or moderate crushing
sign of crushing injury. injury, moderate comminution of the
4. The fracture is usually simple, transverse, fracture, and moderate contamination.
or short oblique, with little comminution.

TYPE III TYPE III A

1. Extensive damage to soft tissue, including 1. Soft-tissue coverage of the fractured bone
muscles, skin, and neurovascular is adequate, despite extensive laceration,
structures. flaps, or high-energy trauma.
2. A high degree of contamination. The 2. This subtype includes segmental or severely
fracture is often caused by high-velocity comminuted fractures from high-energy
trauma trauma, regardless of the size of the
3. Fracture with high degree of comminution wound.

TYPE III B TYPE III C

1. Periosteal stripping and exposure of bone, 1. Associated with an neurovascular injury
massive contamination, and severe that must be repaired, regardless of the
comminution of the fracture from high- degree of soft-tissue injury.
velocity trauma.
2. After debridement and irrigation is
completed, a segment of bone is exposed
and a local or free flap is needed for
coverage.

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Investigation

X-ray CT scan
Terms: • A general view is obtained -> then region of interest is
1. Radiopaque: white (x ray cannot selected -> series of cross-sectional images is
pass through. Eg, bone) produced
2. Radiolucent: black (x ray can pass
through. Eg air) Type of plane
Limitation 1. Coronal
1. Risk to developing fetus especially in 2. Sagittal
first pregnancy 3. Axial
2. Poor soft tissue contrast 4. 3D view reconstruction
Advantage
• Modification (using contrast media) 1. Fast compared to MRI
• Sonography: sinus track 2. Excellent contrast resolution, able to display bone
• Arthrography: inject die in the joint. and soft tissue
Usually done intraoperative Application
1. Acute trauma: head (intracranial bleed),
intraabdominal (in cases of polytrauma that might
involve abdomen), chest, spine (lumbar fracture),
pelvis
2. Preoperative planning for fracture fixation
1. For complex fracture: pelvic fracture (hard
to visualise on x ray), acetabulum, tibial
plateau fracture(maily), foot and ankle
3. Percutaneous ct guided biopsy (eg, spine infection)
Limitation
1. Relatively poor soft tissue contrast compared to
MRI
2. High radiation
MRI Ultrasound
1. Superb soft tissue images of any body 1. Use high frequency sound wave
part of any plane 2. Hypoechoic/hyperechoeic
2. Using strong magnetic field, no
radiation Application
3. Hypointense/hyperintense 1. Identifying cystic lesion

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4. T1: Water black, fat bright 1. Abscess, hematoma, arterial aneurysm,
5. T2(H20): Water bright popliteal cyst
2. Assessing tendons (if patient develop complication not
Intravenous contrast during acute setting)
1. Relies on active blood supply 1. Tendinitis, partial or complete tear
2. Areas of active inflammation will be 3. Screening for newborn babies where bony part still
highlighted cartilaginous (eg DDH)
3. MR arthrography: contrast injected
into the joint Limitation
Application 1. Operator dependant
1. Detect changes in marrow
1. Osteonecrosis (eg, in previous hip Other modalities
dislocation), extend of infection
(chronic osteomyelitis), tumour Radionuclide imaging: Isotope bone scan (using
extension, extend of infection technetium 99)
2. As accurate as arthroscopy to diagnose 1. Bony metastasis
intraarticular pathology: meniscus tear, 2. Diagnosing stress fracture
chondral defect, ligament tear 3. Detecting small bone abscess or osteoid osteoma
3. Bone and soft tissue tumour 4. Loosening or infection around a prosthesis
5. Femoral head ischaemia
Limitation
1. Cannot give good contrast on bone, Bone mineral density test: DEXA
ossification or calcification- sometimes 1. For diagnosis osteoporosis
need combination of CT and MRI 2. Use X-ray beam with very low energy

Rule of 2 of x ray

2 views 1. Must be 90 degrees to each other (eg, AP and lateral)

2. AP and obliques for Hand and foot x ray because in lateral the metacarpal bone tend to
be overlap
3. AP and scapula Y view for shoulder
2 joints 1. Eg, if we visualise radioulnar joint, the x ray must include the elbow and wrist
2. In the forearm or leg, one bone may be fractured and angulated.
3. Angulation, however, is impossible unless the other bone is also broken, or a joint
dislocated.
2 limbs 1. To compare injuries with the normal side especially for paediatric patient because the
immature epiphyses may confuse diagnosis of a fracture
2 injuries 1. Severe force often causes injuries at more than one level.
2. In fracture of the calcaneus or femur, it is also important to do X-ray of the pelvis and
spine (e.g.: falls from a height to one or both heels and calcaneum is crushed, over 20%
suffer from associated injuries of spine, pelvis or hip)
2 1. In paediaric patient or in subtle cases
occasions 2. Eg, in the case of scaphoid fracture, at first no fracture seen, but in a week later after
inflammatory process has taken place, the osteoclast will eat the dead bone and
produced callus formation. Then we can see the line of fracture

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