Fractures & Trauma

A bone fracture is a medical condition in which a bone is cracked or broken. It is a break in the continuity of the bone. While many fractures are the result of high force impact or stress, bone fracture can also occur as a result of certain medical conditions that weaken the bones, such as osteoporosis.

Fractures: Types and Treatment

The word "Fracture" implies to broken bone. A bone may get fractured completely or partially and it is caused commonly from trauma due to fall, motor vehicle accident or sports. Thinning of the bone due to osteoporosis in the elderly can cause the bone to break easily. Overuse injuries are common cause of stress fractures in athletes. Types of fractures include:

• Simple fractures in which the fractured pieces of bone are well aligned and stable.
• Unstable fractures are those in which fragments of the broken bone are misaligned and displaced.
• Open (compound) fractures are severe fractures in which the broken bones cut through the skin. This type of fracture is more prone to infection and requires immediate medical attention.
• Greenstick fractures: This is a unique fracture in children that involves bending of one side of the bone without any break in the bone.

Fracture Healing

Medical Therapy

Non-operative (closed) therapy comprises of casting and traction (skin and skeletal traction).

• Casting
  Casting closed reduction is done for any fracture that is displaced, shortened, or angulated. Splints and casts made up of fiberglass or plaster of Paris material are used to immobilize the limb.
• Traction
  Traction method is used for the management of fractures and dislocations that cannot be treated by casting. There are two methods of traction namely, skin traction and skeletal traction.

Skin traction involves attachment of traction tapes to the skin of the limb segment below the fracture. In skeletal traction, a pin is inserted through the bone distal to the fracture. Weights will be applied to this pin, and the patient is placed in an apparatus that facilitates traction. This method is most commonly used for fractures of the thighbone.

Surgical Therapy

• Open Reduction and Internal Fixation (ORIF) This is a surgical procedure in which the fracture site is adequately exposed and reduction of fracture is done. Internal fixation is done with devices such as Kirschner wires, plates and screws, and intramedullary nails.
• External fixation External fixation is a procedure in which the fracture stabilization is done at a distance from the site of fracture. It helps to maintain bone length and alignment without casting.

External fixation is performed in the following conditions:

• Open fractures with soft-tissue involvement
• Burns and soft tissue injuries
• Pelvic fractures
• Comminuted and unstable fractures
• Fractures having bony deficits
• Limb-lengthening procedures
• Fractures with infection or non-union

Rehabilitation

Fractures may take several weeks to months to heal completely. You should limit your activities even after the removal of cast or brace so that the bone become solid enough to bear the stress. Rehabilitation program involves exercises and gradual increase in activity levels until the process of healing is complete.

Hip Fractures

The hip joint is a "ball and socket" joint. The "ball" is the head of the femur or thigh bone and the "socket" is the cup shaped acetabulum. The joint surface is covered by a smooth articular surface that allows pain free movement in the joint.

Hip fracture is a break that occurs near the hip in the upper part of the femur or thigh bone. The thigh bone has two bony processes on the upper part – the greater and lesser trochanters. The lesser trochanter projects from the base of the femoral neck on the back of the thigh bone. Hip fractures can occur either due to a break in the femoral neck, in the area between the greater and lesser trochanter or below the lesser trochanter.
Hip fracture is most frequently caused after minor trauma in elderly patients with weak bones, and by a high-energy trauma or serious injuries in young people. Long term use of certain medicines, such as bisphosphonates to treat osteoporosis (a disease causing weak bones) and other bone diseases, increases the risk of hip fractures.

Signs and symptoms of hip fracture include

• Pain in the groin or outer upper thigh
• Swelling and tenderness
• Discomfort while rotating the hip
• Shortening of the injured leg
• Outward or inward turning of the foot and knee of the injured leg

Dr. Fischer may order an X-ray to diagnose your hip fracture. Other imaging tests, such as the magnetic resonance imaging or (MRI), may also be performed to detect the fracture.

Depending on the area of the upper femur involved, hip fractures are classified as

• Intracapsular Fracture
• Intertrochanteric Fracture
• Subtrochanteric Fracture

Hip fractures can be corrected and aligned with non-operative and operative methods:

Traction may be an option to treat your condition if you are not fit for surgery. Skeletal traction may be applied under local anesthesia, where screws, pins and wires inserted into the femur and a pulley system is set up at the end of the bed to bear heavy weights. These heavy weights help in correcting the misaligned bones until the injury heals.

Hip fractures can be surgically treated with external fixation, intramedullary fixation, or by using plates and screws.

Pelvic Fractures

Pelvic fracture is a condition that arises due to breakage of the pelvis bones. It may damage internal organs, nerves, and blood vessels associated with the pelvis region.

The pelvis is a round structure of bones located at the base of the spine, connected to the sacrum of the spine with the help of strong ligaments. The pelvis is composed of three bones, namely ilium, ischium, and pubis that are fused together. The side of the pelvis is composed of a cup shape socket, known as acetabulum.

Various organs related to the digestive and reproductive systems lie within the pelvis ring. Also, several large nerves and blood vessels supplying the lower limbs pass through the pelvis. The pelvis ring also acts as point of attachment for muscles approaching from the upper and lower part of the body.

Based on the damage of the pelvis ring and associated structures, pelvic fractures can be categorized as:

• Stable pelvic fractures: Have single point breakage in the pelvis ring and broken bones remain in position; shows less bleeding
• Unstable pelvic fractures: Have breakage at two or more points, followed by severe bleeding. Unstable pelvic fractures may cause shock, extensive internal bleeding, and damage to the internal organs. It requires immediate medical care followed by long-term physical therapy and rehabilitation.

Causes

The common causes responsible for pelvic fractures include:

• Sports injuries or trauma
• Abrupt muscle contraction
• Conditions such as osteoporosis, especially in elderly people
• Accidental injury or fall from a great height

Symptoms

The common symptoms associated with pelvic fractures are:

• Pain and swelling in the groin or hip region that may worsen with ambulation
• Abdominal pain
• Bleeding through the urethra or vagina and the rectum
• Problems in urination
• Unable to stand or walk

Diagnosis

The diagnosis of pelvic fracture starts with physical examination including checking the functional activity of the various body organs present in the pelvic region. Imaging techniques such as X-rays, CT (Contrast Tomography) and MRI (Magnetic Resonance Imaging) scan may also be used to confirm the exact condition or breakage of the pelvic bones. In some cases, additional contrasting studies using radioactive dye may be recommended to evaluate the structural and functional activity of organs such as the urethra, bladder, and the pelvic blood vessels.

Treatment

Treatment of the pelvic fracture depends upon the severity of the injury and condition of the patient. Minor or stable fractures can be treated with conservative methods such as rest, medications, use of crutches, physical therapy, and if required minor surgery. These methods may take 8–12 months for complete healing.

The treatment of unstable fractures includes management of the bleeding and injuries of the internal organs, blood vessels, and nerves. Surgical intervention may be employed for fixation of the fractured pelvic bones using screws and plates. Pelvic bone fixation provides stability to the pelvic bone and promotes natural healing of the fracture.

Knee

Tibia Fractures

The tibia or shin bone is a major bone of the leg which connects the knee to the ankle. A tibial fracture is a break in the continuity of the shin bone (tibia).

Types

• Fractures of proximal tibia: A proximal tibial fracture is a break in the upper part of the shin bone or tibia. Proximal tibial fractures may or may not involve the knee joint. Fractures that enter the knee joint may cause joint imperfections, irregular joint surfaces, and improper alignment in the legs. This can lead to as joint instability, arthritis, and loss of motion. These fractures are caused by stress or trauma or in a bone already compromised by disease, such as cancer or infection. Proximal tibia fractures can result in injury to the surrounding soft tissues including skin, muscle, nerves, blood vessels, and ligaments.
• Tibial shaft fractures: A tibial shaft fracture is a break that occurs along the length of the tibia or shin bone (larger bone of the lower leg) between the knee and ankle joints. These fractures can occur while playing sports such as soccer and skiing.

The symptoms of tibia fracture include painful weight bearing movements, tenseness around the knee, limitation of movement and deformity around the knee. In some individuals, impairment of blood supply secondary to the fracture may result in a pale or cool foot. Patients may also experience numbness or feelings of ‘pins and needles’ in the foot as a result of associated nerve injury.

The diagnosis of tibial fracture is based on the medical history including history of any previous injuries, complete physical examination and imaging studies. The physician will evaluate a soft tissue around the joint to identify any signs of nerve or blood vessel injury. Multiple X-rays and other imaging studies such as CT and MRI scans may be used to identify the location and severity of the fracture.

The management of the fracture is based on the severity of the fracture, medical condition of the patient and the patient’s lifestyle.

Non-surgical treatment comprises of immobilizing the fractured site with the help of casts or braces to prevent weight bearing and to help the healing process. X-rays are taken at regular intervals to assess the healing process. Weight bearing and movement are initiated gradually, depending on the nature of the injury and the condition of the patient.

Surgical treatment is considered to maintain alignment of the fractured bone. External or internal fixators may be used to align the fractured bone segments. If the fracture does not involve the knee joint, rods and plates can be used to stabilize the fracture. For a fracture involving the knee joint, a bone graft may be required to prevent the knee joint from collapsing. An external fixator is used when the surrounding soft tissue is severely damaged, as the use of plate and screw may be harmful.

As the tibial fracture usually involves the weight bearing joint it may cause long term problems such as loss of knee motion or instability and long term arthritis. Hence a rehabilitation program is initiated along with the treatment comprising of instructions on weight bearing, knee movements, and the use of external devices such as braces.

Femur Fracture

The femur or thigh bone is the longest and strongest bone in the body, connecting the hip to the knee. A femur fracture is a break in the femur. The distal femur is the lower part of the thigh bone which flares out like an upside-down funnel and its lower end is covered by a smooth, slippery articular cartilage that protects and cushions the bone during movement. Fracture of the distal femur may involve the cartilaginous surface of the knee as well and result in arthritis.

Types

• Distal femurfracture: The distal femur ispart of the femur bone that flares out like the mouth of the funnel.A distal femur (top part of knee joint) fracture is a break inthighbone that occurs just above your knee joint.
• Femoralshaft fracture: A femoral shaftfracture is a break that occurs anywhere along the femoral shaft,long, straight part of the femur.
• Proximalfemur fracture: A hip fracture orproximal femur fracture is a break in the proximal end of the thighbone near the hip.

Femur fractures may be caused by high energy injuries such as a fall from height or a motor vehicle accident. Patients with osteoporosis, bone tumor or infections, or a history of knee replacement are more prone to femur fractures. In the elderly, even a simple fall from a standing position may result in a fracture as the bones tend to become weak and fragile with advancing age.

Sudden, severe pain along with swelling and bruising are the predominant symptoms of femur fracture. The site is tender to touch with a visible physical deformity and shortening of the leg.

The diagnosis of femur fracture is based on the patient’s medical history including history of any previous injuries, complete physical examination and imaging studies. The physician will evaluate the soft tissue around the joint to identify any signs of nerve or blood vessel injury. Multiple X-rays and other imaging studies such as CT and MRI scans may be used to identify the location and severity of the fracture.

The management of the fracture is based on the severity of the fracture, medical condition of the patient and the patient’s lifestyle.

Non-surgical treatment comprises of immobilizing the fractured site with the help of casts or braces to prevent weight bearing and to help the healing process. X-rays are taken at regular intervals to assess the healing process. Weight bearing and movement are initiated gradually, depending on the nature of the injury and the condition of the patient.

Surgical treatment is considered to realign the fractured bone. The use of advanced technology and special materials has improved the surgical outcome even in older patients. External or internal fixation or a knee replacement may be required depending on the extent of the fracture. Timing of the surgery is an important factor in improving the surgical outcome.

Timing of surgery

In most cases, the surgery is delayed for a few days to develop an effective treatment plan and for preparation of the patient. With most distal femur fractures the surgery can be delayed unless the fracture is open to the environment.

External fixator

An external fixator is used when the surrounding soft tissue is severely damaged, as the use of plates and screws may be harmful. The external fixator maintains the alignment of the bone till surgery.

Once the patient is prepared for surgery, the surgeon removes the external fixator and places internal fixation devices into the bone during surgery.

Internal fixator

The internal fixation may be performed using intramedullary nailing or plates and screws. In intramedullary nailing a metal rod is inserted into the marrow canal of the femur to keep the fractured fragment in position. In the plate and screw method the bone fragments are realigned and held together with screws and plates, attached to the outer surface of the bone. If the fracture is of the comminuted type or the bone has broken into many pieces, plates or rods may be used at the ends of the fracture without disturbing the smaller pieces. The plate or rod will maintain the shape or strength of the bone till it heals. In elderly patients and those with poor bone quality, bone grafting may be used to improve the healing. Knee replacement may also be considered in complicated fractures or those with poor bone quality.

Knee replacement

Artificial implants may be used to replace the fractured segments of the bone and joint.

Rehabilitation

Rehabilitation of the femur fracture depends upon several factors such as age, general health of the patient and the type of fracture. As the femur fracture usually involves the weight bearing joint it may cause long term problems such as loss of knee motion or instability and long term arthritis. Hence a rehabilitation program is initiated along with the treatment comprising of instructions on weight bearing, knee movements, and the use of external devices such as braces.