Fractures

Discontinuity of bone

1. Pathological (bone weakened by pre-existing disease)

2. Stress fracture (repeated loading on normal bone)

3. Traumatic (low- or high-energy)

1. Metabolic disease

2. Infections (most commonly bacterial, never viral)

3. Malignancy (1ry or 2ry)

Breast in females

Prostate in males

Lung, kidneys, and thyroid in both

1. Epiphyseal (causes joint stiffness, difficult reduction, intra- or extra-capsular)

2. Diaphyseal (need stabilization/fixation

3. Metaphyseal (causes mal-union>non-union)

4. Growth plate fractures (Salter-Harris Classification)

1. Shearing force parallel to growth plate, hypertrophic layer is affected, usually due to directtrauma

2. Shearing force with bending but the fracture only involves the metaphysis and maybe thegrowth plate

3. Shearing force with bending but the fracture only involves the epiphysis and maybe thegrowth plate

4. Shearing force with bending but the fracture involves the metaphysis, goes through thegrowth plate, and to the epiphysis

5. Perpendicular axial force, leads to crushing of growth plate and germinal layer, mostly due tofalling down will still standing

1. Closed fractures

2. Open fractures (communication through traumatic wound to surrounding environment)

ATLS,

Analgesia,

Anti-tetanus,

Antibiotics (upon arrival, 1st gen cephalosporines and penicillins), Adequate irrigation,

Debridement (within 4-8 hrs)

1. Direct (Tapping, Crush, Penetrating)

2. Indirect (Traction, Angulation, Rotational, Compression, and Axial compression)

Small force on small area

transverse fracture on long bones of legs and arms

Large force on large area

Extensive soft tissue damage

Transverse fracture or comminuted

Large force on small area

Velocity is more important than mass

Low- vs high-velocity

Transverse fracture

Most common in patella, olecranon, and medial maleolus

Transverse fracture or with triangular fragment

Convexity under tension

Concavity under compression

T or Y shaped fracture

Common in femur and humerus

*pain, loss of function, deformity

*abnormal mobility and crepitations

*neurovascular injury

*X-ray findings

1. Life: ATLS

2. Limb: decompression if tgere is compartment syndrome

3. Wound: if open (tetanus, antibiotics, irrigation)

4. Fracture

*always prevent further soft tissue damage, analgesia, decrease incidence of fat embolism and shock

1. Reduction (open, or closed)

2. Immobilization (traction, cast, externral/internal fixation)

3. Rehabilitation

Metapheseal bone can accept more deformity (~20°) than diaphyseal bone (~10°), has better remodeling

Screws: absolute stability/must not cross growth plate (in pediatrics)

K-wires: no absolute stability/can cross growth plate

Child + Upper Limb (standard) = 3weeks

Lower limb x2

Adult x2

Greenstick fracture x2

Smoker x2

Consolidation (more callus formation) x2

Remodeling (translucent canal) x2

Transverse fracture x1.5 (oblique fracture has better healing)

1. Bone healing abnormalities (non-, mal-, and delayed union, AVN)

2. Infections

3. Pulmonary problems (PE, ARDS)

4. Soft tissue injury (arterial and nerve injuries, compartment syndrome)

5. Bleeding disorder

6. Other: complex regional pain syndrome (CRPS) , osteoarthritis, and myositis ossificans

1. Presence of growth plate (londitudinal growth) and perichondral plate (bone thickness)

2. Thick periosteum (prevents dislocatiom of fracture)

3. More cancellous bone (less propagation of fracture)

4. More radiolucent on X-ray (cartilagenous>ossified bone) (may underestimate fracture)

5. Tensile strength of ligaments>bone (bone is injured more)

1. Germinal: most important, 1st near epiphysis

2. Proliferative

3. Hypertrophic: weakest due to increased size of cells so less cell numbers, and more fluid and less connections between cells

4. Zone of provisional calcification

1. Severity of fracture (Salter-Harris Classification)(higher class has worse prognosis)

2. Age (younger is worse prognosis)

3. Physis injured (contribution to growth potential)

4. Anatomic type of fracture

5. Treatment

6. Displacement in same plane of motion (better prognosis)

The higher the growth potential the better prognosis

Lower limb: around the knee (distal femur and proximal tibia)

Upper limb: away from the elbow (proximal humerus and distal radius)

Hyaline cartilage plate in metaphysis at each end of a long bone, it is the part where new bone growth takes place

Found in children and adolescents, and is replaced by epiphyseal line in adults

INFANTS: diaphysis (1st ossification)

TODDLERS: metaphysis

ADOLESCENTS: epiphysis

Falling on outstretched hand

1. Extent of soft tissue injury (which affects bone healing)

2. Displacement of fracture

1. Mechanism of injury

2. Muscle pulling

1. If there is a visible deformity: most likely the fracture is displaced

2. Assess distal neurovascular bundles (radial, ulnar, and median nerves, and radial and ulnar vessels)

3. Stiffness occurs in fractures near joints

Always distal piece in relation to proximal piece

1. Translation: medially/laterally

2. Angulation: vulgus/varus or anterior/posterior

3. Rotation: assessed by x-ray including joints above and below, or by assessing thickness of cortex