Basic fracture principles

by Michael Held, Maritz Laubscher, Graham McCollum, Phinda Njisane & Vela Njisanee

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What is a fracture?

A fracture is an ‘incomplete or complete break in the continuity of a bone’. However, this definition does not account for accompanying soft tissue injury. The degree of soft tissue injury dictates fracture management and the degree of fracture healing. Therefore, a better definition would be that a fracture is ‘an open or closed soft tissue injury of varying severity, accompanied by a break in the continuity of the adjacent underlying bone’.

Basic fracture classification

Fractures may either be ‘open’ or ‘closed’. In open fractures, there is a break in the continuity of the skin overlying the fracture. In closed fractures, there is no communication between the fracture and the atmosphere.

Other definitions

• Pathological fracture: Fracture which occurs in diseased bone. The disease weakens the bone e.g. metastatic cancer or osteomyelitis.
• Stress fracture: Fracture in normal bone that is subjected to repetitive loads or stress.

Fracture patterns

Complete fractures

1. Simple: A single fracture line. The fracture line may be transverse, oblique, saggital or spiral.
2. Segmental: ≥ 2 fracture lines, creating a tubular segment of the shaft.
3. Complex/comminuted: Multiple fracture fragments with no lateral or longitudinal stability.

Incomplete fractures

1. Greenstick: On bending this leads to an incomplete break of the bone.
2. Buckle: A stable compression fracture.

Describing fractures

When describing a fracture, one should comment on the following:

1. Soft tissue involvement: open (grading) vs closed
2. Position: metaphysis vs diaphysis; proximal vs distal
3. The injury/fracture itself: the extent (complete vs incomplete) and the fracture pattern itself
4. Location: the bone involved
5. Displacement: length, angulation, rotation, apposition
6. Is there growth plate (Salter-Harris) or aurticular involvement?
7. Neurovascular status: sensation and distal pulses

Diagnosis of fractures

The primary survey of the patient should always take precedence to the examination of a fractured bone, unless torrential bleeding from the fracture site is suspected.

As with all clinical examinations you must start with history (how, when and what), followed by examination (look, feel, and move) and then special investigations.

1. History: How did the injury happen? When did it happen? What has been done so far in terms of management/ treatment? Note the pain, patient’s activities of daily living and relevant history (medical, surgical or social).
2. Examination:
   • Note vital signs
   • Look: skin – wounds, bleeding, colour; soft tissue swelling, bone – deformity/alignment
   • Feel: deformity, swelling, tenderness and distal pulses
   • Move: active movement, passive movement, abnormal range of motion/location
3. Special investigations: X-rays apply the Rule of Twos: 2 views, 2 joints, 2 limbs, 2 opinions, 2 occasions (see ‘Approach to orthopaedic X-rays’).
4. Severity

Fracture management

Basic principles for management priority is life > limb > fracture.

Generally, a fracture may require surgical intervention or non-surgical intervention. Non-surgical management involves closed reduction with immobilisation (cast or splint). Management is dependent on the fracture’s stability and displacement. Surgical management can include:

• Open reduction which remains the gold standard for most intra-articular fractures.
• External fixation with pins and bars which is often used in fractures with high infection risk (open fractures) or in staged management of multiple injured patients to avoid long operating times.

Examples:

1. Percutaneous pin fixation (e.g. elbow fractures in children)
2. Intramedullary (i.e. femoral nail) or extramedullary devices (e.g. plate fixation in forearm fractures)

Indications for surgical management:

• Failed nonoperative management (malunions or nonunions)
• Unstable open fractures (II–III)
• Displaced intra-articular fractures
• Salter-Harris III–V
• Multiple fratures involving pelvis femur or spine

Contra-indications for surgical management:

• Poor soft tissue quality affecting fracture or surgical approach, e.g. infection, excessive swelling, burns.
• Amputation is considered to be better for the patient and limb.
• Surgery or anaesthesia is contrainidcated due to patient’s medical history.