A basic guide to fractures

1. Orthopaedics 101
Brooke Sachs 2015

2. Things you need to know
• Describing a fracture over the phone
– Revise basic bony anatomy, tendons, ligaments
• Orthopaedic emergencies
– Vascular +/- neurological compromise
– Unstable pelvic fractures
– Hip dislocations – avascular necrosis of femoral head
– Compartment syndrome
– Septic joints/osteomyelitis
• Basic fracture patterns
– Colles fracture
– Scaphoid fracture
– NOF fracture
– Ankle fractures
– Paediatric fractures
• Managing dislocations

3. Describing a fracture
• Hello, orthopaedic registrar, I’m [name] in ED. I have a
67 year old patient presenting following…
• Mechanism: high or low impact, pathological
• Haemodynamically (un)stable
• Open/compound
• Bone(s) involved, intraarticular, involving physis
– Where on the bone (proximal, mid-shaft, distal etc)
• Type -
Spiral/oblique/triangular/transverse/comminuted/gree
nstick/compression
• Displacement – distracted/impacted, angulated,
translated, rotated
• Neurovascular status (dermatomes, myotomes, nerve
dist), functional status

4. Mechanism
• It matters! • speed
• height (and how high!)
• Crush (and by what)

5. What’s a pathological fracture?
• Minimal or no trauma, or fracture larger than expected
given impact
• Related pathologies:
– Osteoporosis (resorption of bone mass)
– Osteomalacia, osteonecrosis (reduced bone quality)
– Osteogenisis imperfecta, fibrous dysplasia (insufficient
bone production)
– Giant cell granuloma, aneurysmal bone cyst (augmented
bone resorption)
– Paget’s disease of bone (pathological bone remodelling)
– Malignancy – primary or secondary tumours
– Infection
http://www.ncbi.nlm.nih.gov/pubmed/2577585

6. How to describe a fracture
• Think about:
• Displacement
• Angulation
• Shortening
• Rotation

7. Describe that fracture…
• Demographics
– (age, gender, living
conditions)
• Cause of fracture
– traumatic vs minimal
trauma vs pathological
• Bone(s) involved +
location
• Type of fracture
– open/closed
– complete/incomplete
– Displaced (rotated, distracted, angulated)
– Comminuted/Spiral/Transverse/Avulsion/G
reenstick...
• Distal radius and ulnar
fracture image

8. Describe that fracture…
• Demographics
– (age, gender, living
conditions)
• Cause of fracture
– traumatic vs minimal
trauma vs pathological
• Bone(s) involved +
location
• Type of fracture
– open/closed
– complete/incomplete
– Displaced (rotated, distracted, angulated)
– Comminuted/Spiral/Transverse/Avulsion/G
reenstick...
• Midshaft femoral
fracture image

9. If you’re keen…
Fracture grading systems:
• Garden’s (NOF #)
• Salter-Harris (paediatric)
• Gustilo-Anderson – open
• Scaphoid
• Weber (ankle)

10. Describing a fracture
• Hello, orthopaedic registrar, I’m [name] in ED. I have a
67 year old patient presenting following…
• Mechanism: high or low impact, pathological
• Haemodynamically (un)stable
• Open/compound
• Bone(s) involved, intraarticular, involving physis
– Where on the bone (proximal, mid-shaft, distal etc)
• Type -
Spiral/oblique/triangular/transverse/comminuted/gree
nstick/compression
• Displacement – distracted/impacted, angulated,
translated, rotated
• Neurovascular status (dermatomes, myotomes, nerve
dist), functional status

11. Initial Management
The exam:
• Look-Feel-Move-Special tests
• The injured site
• Vascular/neurological injuries
• Local injuries
• Distal injuries – examine the
thorax, spinal column/cord,
pelvis and abdomen, pectoral
girdle, head
• DRSABC
• Reassure, comfort
• Pain management
• History and Exam (and
secondary survey)
• X-Ray (x2, 90⁰ apart), CT
and/or MRI
• If hip fracture – chemical
thromboprophylaxis
(enoxaparin)
• If need surgery, fast for at least
6/24 (can do rapid induction if
urgent)
• Splint

12. Closed reduction or surgical
management?
Non-operative:
• Reduction
– Muscle
relaxant/anaesthesia
– Adequate apposition
– Normal alignment
– X-ray once aligned and in
cast/splint
– Generally used for
fractures that will be stable
post-reduction
– Can do closed reduction
prior to I/E fixation if
neurovascular compromise
Operative:
• When closed reduction
fails
• Articular surfaces
involved
• If fixation is necessary for
stabilisation

13. Think surgical management when:
• Non-union
• Open fracture
• Compromised neurovasculature
• Intra-Articular involvement
• Salter-Harris III, IV, V
• polyTrauma
• (NO CAST)

14. Complications
Early Late
Local Neurovascular Injury
Infection
Compartment Syndrome
Implant Failure
Fracture Blisters
Malunion
Non-union
Osteonecrosis
Osteomyelitis
Heterotopic Ossification
Post-traumatic arthritis
Reflex sympathetic dystrophy
Growth Disturbances
Systemic Sepsis
DVT / PE
Fat Embolus
ARDS
Haemorrhagic Shock

15. Open Fractures
• Gustilo-Anderson Classification
• Type I - Small wound (<1cm), usually clean, no soft
tissue damage and no skin crushing (i.e. a low energy
fracture)
• Type II - Moderate wound (>1cm), minimal soft
tissue damage or loss, may have comminution of
fracture (i.e. a low-moderate energy fracture)
• Type III - Severe skin wound, extensive soft tissue
damage (i.e. high energy fracture)
• Three grades: A – adequate soft tissue coverage, B – fracture
cover not possible without local/distant flaps, C – arterial injury
that needs to be repaired.

16. Compartment syndrome
• Pain
• Pallor
• Paraesthesia
• Paralysis
• Pulselessness
• Perishingly cold
• “Pressure”

17. Unhappy triad
• ACL tear
• MCL tear or strain
• Medial meniscal tear
• Caused by medial force
on the knee while the
foot is fixed.
• Also known as
O’Donoghue’s triad after
a US orthopaedic surgeon
who described it in 1950
• Image of an unhappy
triad
http://radiopaedia.org/articles/odonoghues-unhappy-triad-1
http://www.epainassist.com/images/Unhappy-Triad.jpg

18. More to think about:
• Canadian C spine rules
• Ottawa ankle and knee rules
• Rotator cuff injuries
• Shoulder dislocations
• Stable vs unstable vertebral fractures
• Osteomyelitis

19. Excellent resources:
• http://radiologymasterclass.co.uk/tutorials/m
usculoskeletal/
• Orthobullets.com
• Wheeless online textbook
• Apley’s System of Orthopaedics and Fractures
• BoneSchool.com