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Fractures

I dared to argue with an Infection Control nurse. This was my punishment...

Fractures are defined as a discontinuity of bone so doesn't necessarily have to be a full-on snap in half. There is also a supposed colloquial difference between "fracture" and "break" of bone. In medicine, the term "break" is considered colloquial and doesn't have any strict meaning. "Fracture" is the correct, catch-all term for any discontinuity of bone. There are different types of fracture and you should know some of the different types.

The general principles of fracture management basically fall into reduction, fixation (or strictly, maintenance of reduction) and rehabilitation. These are true of all fractures. However, you'll also need to know about some common fractures as how to do these three things differs depending on whereabouts the fracture is. As such, the fractures can be broadly split into the following.

The final important complication to know about is compartment syndrome as this can prevent the need for amputation of a limb. That's pretty good if you can stop somebody having their forearm chopped off.

It is important to know how to classify fractures. It affects both treatment and prognosis, Basically, you should ask yourself a series of questions when describing a fracture. There may be further questions within each section but ultimately, these are ones you should ask about all fractures:

Types of Fractures:

Location

Which bone?

This heading should, hopefully, not be too difficult to understand. You need to know which bone is fractured. If you say that the femur is fractured when it is in fact the malleolus, this may result in somebody trying to fit a hip screw into your patients ear. This procedure would be highly dangerous and incredibly ineffective.

Where in the bone?

This is less obvious but it still fairly obvious. It's which bit of the bone has been broken, though this only really applies to long bones. It can be distal or proximal and can be further classified based on whether it is the diaphysis, metaphysis or epiphysis that is broken.

Severity

Open or Closed?

This concerns communication with the outside world. Hopefully from that you've figured out that: open - bone has penetrated the soft tissue to the outside world; and closed - bone has NOT penetrated the soft tissue to the outside world.

When it comes to open fractures, they are classified depending on how bad the damage to the soft tissue is. This is called the Gustilo classification:

  • I - low energy, wound <1cm
  • II - wound >1cm, moderate soft tissue damage
  • III - high energy, wound >1cm, extensive soft tissue damage

The final class is further split into: IIIA - adequate soft tissue cover, IIIB - inadequate soft tissue cover and IIIC - arterial injury.

Simple or Comminuted?

This is about how many fragments a bone has split into. The more fragments, the harder it is to treat and the worse the prognosis. Broadly speaking we talk about:

  • simple - where the bone has split into two fragments
  • comminuted - known elsewhere in the world as multi-fragmentary (actually, a more useful and self-explanatory term), where the bone has split into <2 fragments

Position

Linear, Transverse or Oblique?

This is to do with position of the fracture rather than position of the bone fragments. It is also only applicable to long bones: linear - along the axis of the bone; transverse - perpendicular to the axis of the bone; and oblique - diagonal to the axis of the bone.

Displacement

This is basically about whether the bone fragments are still in contact. Broadly speaking, you have:

  • Complete - means that there is no contact between separate bone fragments
  • Incomplete - means bone fragments are still partially joined

Severe displacement of fractures, particularly in adults requires more aggressive forms of reduction.

Angulation

This is about where the seperated bone fragments have rotated. This makes it less likely that bones will [reduction|reduce]] on their own (fortuitous reduction) and more likely that a deformity will form if left alone.

Associated factors

Adult or Child?

Children take half as long to heal as adults. Traction is also more effective and well-tolerated in children. Adults tend not to like to have their legs held in the air the whole time.

Neurovasculature

This should be fairly self-explanatory as well. Both need to be tested for. This means doing a peripheral neurological examination in the affected limbs and a full neurological examination where spinal injury is suspected. However, do NOT move a patient with a spinal injury. Just do what you can until appropriate help arrives.

Vascular injury is also important. If you can't feel peripheral pulses, it may be that a major artery in that limb has been lacerated and the patient is bleeding out. This is obviously bad as they may exsanguinate (lose all their blood). Losing all your blood makes oxygenation of tissues pretty much impossible which has the nasty sequela of death.

Compartment syndrome

You know what? This is so important I'm going to give it its own page. (Also, the disease template will make it easier to describe.)