Traumatology - sprains, dislocations and fractures
Fractures
When a fracture occurs significant soft tissue damage also occurs, something important to consider given that the radiograph will only show the bone. The severity of the injury will vary greatly depending on if the injury is high or low energy, a question that should be asked in all cases.
High energy injuries are likely to cause significant damage to blood vessels, muscles and nerves, often with crushing and devitalization of the bone. Lower energy injuries are less likely to cause such significant and wide ranging damage.
There are three stages of fracture management:
- Deal with any open wounds
- Attend to fracture until it is united
- Mobilize the joints and rehabilitate the limb
There are a number of physical signs of a fracture, see the list below.
Some fractures are notoriously hard to diagnose, these are shown in the skeleton above.
Untreated fractures will unite without any intervention, in a perfect case, the fracture will unite soundly in a good position, however, we may see delayed union, non-union or union in the wrong position, malunion. We discuss this in further detail in question 2.
We should now consider some basic classifications of fractures:
- Simple and compound
- Compound fractures have an open wound, simple fractures do not (is there contamination or not
- This terminology is generally not used now and instead we use the terms closed and open.
- In an open fracture we use the Gustilo open fracture classification
- I - open clean wound <1cm in length
- II - open >1cm but <10cm in length
- IIIA - open with adequate soft tissue coverage of fractured bone despite extensive soft tissue laceration (e.g. gunshot)
- IIIB - open fracture with extensive soft tissue loss and periosteal stripping - massive contamination
- IIIC - open fracture with an arterial injury irrespective of soft tissue injury
- In a closed fracture we use the Tscherne classification system to sort soft tissue damage
- 0 - minor or no soft tissue injury
- I - superficial contusion or abrasion to skin
- II - deep contaminated abrasions with skin or muscle contusion
- III - extensive skin contusion with muscle and tissue destruction
- Shape
- Transverse fractures - the result of a direct blow or pure angular force applied to the bone.
- Oblique/spiral fractures - This is most long bone fractures, it is the result of a violent twisting movement about the long axis of the bone.