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Case-Based Learning in Family Medicine+ ER

Musculoskeletal Medicine/Office Orthopedics

Wm. MacMillan Rodney, M.D.

April 28, 1994 (Updated 1994, 1996, 1998, 1999, 2008)

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Edited and Abridged from Schultz RJ. The Language of Fractures, 1st Edition. Williams and Wilkins, Baltimore, MD, 1972.

I. ESSENTIAL FRACTURE DEFINITIONS

A. A fracture is a complete or incomplete break in the continuity of bone or cartilage.

B. A complete fracture is one where both cortices of the bone have been broken as opposed to an incomplete fracture where only one cortex has been broken. See V.F. for examples of incomplete fractures (Greenstick and Torus).

If a fracture contains more than two fragments, it is classified as a comminuted fracture.

D. A comminuted fracture may have three or more pieces with various directional orientations. Simply refer to the entire collection of pieces as comminuted. A comminuted fracture is one that has more than two fracture fragments. This holds true whether the number is three or three thousand, regardless of location.

E. A closed or simple fracture is one in which the skin and soft tissues overlying the fracture are intact, and there is no communication with the outside environment.

F. An open or compound fracture exists anytime the fracture site communicates with the outside environment. This is true whether the wound or skin defect is a small pin hole, puncture wound, or massive disruption.

II. ESTABLISHING THE LOCATION OF FRACTURE

Reference Points and How to Use Them

A. New fractures of the shafts of long bones are said to be located in the proximal, middle, or distal thirds or at their junctions (p. 11 attached).

B. Fractures at these levels are referred to as fractures at the junction of the proximal and middle third (PM3) and junction of the middle and distal third (MD3).

C. A lesion occurring at about the midpoint of the bone, although located in the middle third, may be referred to as a midshaft fracture.

III. DIRECTION OF FRACTURE LINES

A. Transverse fracture. A transverse fracture is one that occurs when the fracture line is at right angles at the cortices or long axis of the bone. Transverse fractures may be complete or incomplete, open or closed, and may occur at any location.

B. Oblique fracture. An oblique fracture is one in which the fracture line runs obliquely to the long axis of the bone or the cortices.

C. Spiral fracture. A spiral fracture is caused by a torsional force and is somewhat like a long oblique fracture that spans a greater area and encircles the shaft of the bone, thus forming a spiral in relation to the long axis of the bone.

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Reference: Schultz RJ. The Language of Fractures, 2nd Edition. Williams and Wilkins, Baltimore, MD, 1990.

IV. POSITION: Alignment, Angulation, and Displacement

A. Alignment. Alignment is the relationship of the longitudinal axis of one fragment to another. Deviation of alignment or mal-alignment is the result of angulation of the fracture fragments.

B. Position. Position is the relationship of the fragments to their normal anatomical structure. Loss of position is called displacement and may result from the loss of apposition, over-riding, or rotation. In the shafts of long bones, various combinations can occur.

“Bayonet apposition” is a displaced fracture without angulation (see pp. 34, 35 attached).

C. Direction of angulation. The description of the direction of angulation is often the source of confusion. The direction of angulation can be described by the following:

1. By the direction of angular displacement of the distal fragment in relation to the proximal fragment;

2. By the direction of the apex of the angle formed by the fracture fragments.

Most often the direction of angulation is confused with the direction of angular displacement of the distal fragment. Too often, for example, a Colles’ fracture is said to have dorsal angulation when dorsal angular displacement of the distal fragment is meant. If the apex of the fractured radius is volar, this is called either volar angulation of the fracture or dorsal angular displacement of the distal fragment. Both methods are in common usage.

D. Displacement. Although usage has obscured a precise meaning for displacement, displacement generally signifies that the two fragments are no longer in contact.

V. OTHER DESCRIPTIVE TERMS

A. Distraction. Distraction occurs when the opposing ends of the fracture fragments are kept apart. This may be the result of excessive traction caused by the pull of tendons. This is different from displacement.

B. Impaction. Impaction occurs when one fragment of the bone is forcibly driven or telescoped into the adjacent fragment or when the fracture fragments are allowed to press forcibly against each other.

1. Compression. A compression fracture of the vertebral body is a form of impaction. This is a common fracture scene in our nursing home population.

2. Impaction fractures are also commonly seen in trauma.

C. Avulsion fractures. Violent contraction of a muscle can cause rupture of the muscle belly or its tendon, or can pull away a fragment of bone at the insertion of the tendon. At ligamentous insertions, violent trauma applied in a direction, which places the ligament under great tension, may avulse a fragment of bone, rather than rupture the ligament. Thus, an avulsion fracture occurs when fragments of bone are pulled away from their original position. This is a form of “distraction.” (see V.A.)

D. Intraarticular fractures. An intraarticular fracture is a fracture which extends into and involves an articular surface of a joint. These fractures may or may not be displaced.

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Reference: Schultz RJ. The Language of Fractures, 1st Edition. Williams and Wilkins, Baltimore, MD, 1972.

E. Stress fracture. A fatigue or stress fracture is the result of repeated, relatively trivial, trauma to an otherwise normal bone. It occurs not as a sudden break, but as the result of alteration of the bone in the form of gradual, local dissolution, secondary to repeated minor and usually unaccustomed over use. This may or may not result in a complete fracture. Stress fractures occur most frequently in the lower extremities, especially in the metatarsals.

F. Incomplete fractures. Incomplete fractures occur when only one cortex of the bone has been broken. Incomplete fractures are relatively stable, and if protected, will tend maintain their position indefinitely. Incomplete fractures are common in the short bones, irregularly shaped bones, and flat bones. There are certain incomplete fractures which occur exclusively in children, probably because of the elasticity of their bones. These are greenstick fractures and torus fractures.

a. Greenstick fracture. This is an incomplete, angulated fracture producing bowing of the bone. It derives its name from its resemblance to a young branch which, when broken, breaks on its outer surface, but is maintained intact on its inner surface. It should be noted that the broken cortex is always on the convex aspect.

b. Torus fracture. In contrast to a greenstick fracture, a torus fracture is an incomplete fracture with a buckling of the cortex. Torus fractures are usually the result of compression forces and may be considered a type of compression fracture or, in fact, and impaction for x-ray.

VI. ADDITIONAL MISCELLANEOUS TERMS

A. Remodeling Remodeling of a complete oblique fracture of the midshaft of a femur in a 2-year-old child. See Figure 1.36 next page.

1. Plate A. Initial fracture.

2. Plate B. Periosteal new bone formation in a few weeks after injury.

3. Plate C. Union of the fracture with primary callus 2 months post injury.

4. Plate D. Early remodeling and resorption of the primary callus.

5. Plate E. Further remodeling

6. Plate F. At 13 months post fracture, note there is re-establishment of the canal and continued remodeling almost restoring the normal architecture (see p. 55 attached).

B. Dislocation. A dislocation is a complete disruption of the joint with loss of contact between the articulating surfaces of adjacent bones.

C. Subluxation. A subluxation is a partial loss of continuity between the two opposing articular surfaces with some part of the opposing articular surfaces remaining in contact. Subluxations may be very mild to very severe (see p. 7 attached).

D. Diastasis. A diastasis is a separation of normally joined parts, most commonly applied to slightly movable joints. Diastases occur in the region of the pubic symphysis or the distal tibiofibular syndesmosis (see p. 7 attached).

[pic] Reference: Schultz RJ. The Language of Fractures, 2nd Edition. Williams and Wilkins, Baltimore, MD, 1990.

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[pic] Reference: Schultz RJ. The Language of Fractures, 2nd Edition. Williams and Wilkins, Baltimore, MD, 1990.

VII. REDUCTION OF FRACTURES

A. Closed reductions. Closed reductions are reduction of fractures which do not require an operative incision to be made. This type of reduction is produced by traction or manipulation of the fractured fragments or a combination of both.

B. Open reduction. Open reduction is a restoration of the fracture fragments through surgical exposure of the fractured site.

C. Fixation. Fixation is a method of holding the fractured fragments into position following reduction. Fixation may be performed by external means such as cast immobilization or by internal means. (Casts are also placed in cases which do not require reduction if one wants to be a purist--DPL.)

VIII. TERMS RELATED TO FRACTURE UNION

A. In delayed union, fracture repair, although retarded, is proceeding and will eventually produce firm union just so long as additional adverse stresses are not added.

B. Non-union exists when there is failure of union of the fracture fragments and the processes of bone repair have ceased completely. With non-union, the opposing ends of the fracture fragments become atrophic and the medullary canals have become covered over by sclerotic, eburnated bone.

C. Slow union--there are many fractures that even under ideal conditions are known to heal slowly. Most importantly, slow union is not to be confused with delayed union, which is retarded healing beyond the normal rate for a given fracture.

D. Mal-union. Mal-union occurs when there is union of the fracture with angulatory for rotary deformity.

General Guidelines for Fractures that are Managed Operatively

(for more specifics, see pp.12-14)

Edited and Abridged from Anderson BC. Office Orthopedics for Primary Care Diagnosis and Treatment,

2nd Edition, 1999, ISBN 0-7216-7089-x

|Fracture/Dislocation |Reason for Orthopedic Referral |

| Fractures that require referral to orthopedic surgery |

|Multifragment intra-articular |Risk of arthritis and malunion |

|Fracture dislocations |Difficulty of reduction, risk of arthritis |

|Metastatic lesion of bone |Risk of pathologic fracture |

|Comminuted fractures |Risk of nonunion and angulation |

|Compound fractures |Risk of infectious complication |

|Fractures associated with neurovascular compromise |Soft-tissue injury |

General Guidelines for Fractures that are Managed Nonoperatively

|Fracture/Dislocation |Nonoperative immobilization or Treatment |

| General Categories of Fractures Managed Nonoperatively |

|All stress fractures |Reduced running, standing, repetitious use |

|All nondisplaced extra-articular fractures |Casting for 3-6 weeks (WMR: or splinting equivalent) |

|Most small (flecks) avulsion fractures |Casting for 2-4 weeks (WMR: or splinting equivalent) |

|Some nondisplaced, single-fragment intra-articular fractures |Casting for 4-6 weeks (WMR: or splinting equivalent) |

|HUMERUS | |

|Fragment displacement 6-8mm |Unstable; risk of arthritis; internal fixation |

|Rim fracture >10o |Internal fixation |

|Bicondylar fracture |Skeletal traction; cast brace; internal fixation |

|KNEE | |

|Tibial spines |Molded long-leg cast for 4-6 weeks |

|Subcondylar fracture |Molded long-leg cast for 4-6 weeks |

|Patellar, displaced or comminuted |Cerclage or patellectomy[wmr beware bipartite] |

|Osteochondritis dissecans, symptomatic with locking |Arthroscopy |

|Tibial and fibular fracture |Unstable; internal fixation |

|ANKLE | |

|Unstable bimalleolar fracture |Risk of arthritis; internal fixation |

|Trimalleolar fracture |Risk of arthritis; internal fixation |

|Fracture at or above the syndesmosis |Unstable; risk of arthritis |

|Displaced ankle fragments |Unstable; risk of arthritis |

|CALCANEUS | |

|Intra-articular fracture |Risk of arthritis |

|Displaced posterior process fracture |Restore the integrity of the Achilles tendon |

|Nonunion of the anterior process |Internal fixation |

|Fracture/Dislocation |Reason for Orthopedic Referral |

| |

|TALUS | |

|Displaced neck fracture |Risk of Avascular necrosis |

|NAVICULAR | |

|All displaced fractures |Unstable |

|FOOT | |

|Neuropathic fracture |Risk of nonunion or malunion |

|Transverse fifth metatarsal fracture |Risk of nonunion or malunion |

|Displaced or comminuted proximal phalangeal fracture |Risk of nonunion or malunion |

workshop\fracture.doc\4-12-99

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