A fracture is defined as a break in the bone.
TYPES OF FRACTURES
Green stick fracture: It is
the fracture in the young bone of children where the break is
incomplete, leaving one cortex intact .
Closed fracture: A closed
fracture is one whre the fracture haematoma does not communicate
with the outside.
Open fracture: (Compound
fracture) This is one where the fracture haematoma communicates
with the outside through an open wound. A Compound fracture is a
serious injury as infection may gain entrance into the body through
the wound and thereby endanger the limb or even life.
Pathological fracture: It
is a fracture occurring after a trivial violence in a bone weakened
by some pathological lesion. This lesion may be a localised one,
like a secondary malignant deposit or a generalised disorder like
hyperparathyroidism or senile osteoporosis.
Stress fracture : It is a
fracture occurring at a site in the bone subject to repeated minor
stresses over a period of time.
Birth fracture: It is a
fracture in the new born children due to child due to injury during
ANATOMICAL TYPES OF FRACTURES
Various names are given to the fractures according to the
types of the fracture lines as transverse, oblique and spiral
Comminuted fracture : Here
the bone is broken into than two fragments.
Steallate fracture: This
occurs in flat bones of the skull and in patella, where the fracture
lines run in various directions from one point.
Avulsion fracture: This is
one, where a chip of bone is avulsed by the sudden and unexpected
contraction of a powerful muscle from its point of insertion, e.g.
the supraspinatus avulsing the greater tuberisuty of the humerus.
Impacted fracture: This is
one where a vertical force drives the distal fragment of the
fracture into the proximal fragment.
Depressed fracture: This
occurs in the skull where a segment of bone gets depressed into the
MECHANISM OF FRACTURE
A fracture can be caused by either by direct violence or
indirect violence. Direct violence causes a fracture at the site if
impact of the force. Indirect violence is one that is transmitted to
a bone away from the site of impact producing fracture there.
The nature of violence can be often inferred from the
radiological appearances of the fracture. Direct violence often
produces a comminuted fracture.
Torsion produces an oblique or spiral fracture. It is
important to understand the mechanism of fracture as it helps in
deciding the manoeuvres for reduction and the position for stable
immobilisation of the fracture.
When a man falls from a cocount tree or building top and
lands on his heels, he often sustains a fracture calcaneum and a
fracture of the spine. The fracture calcaneum is caused by the
direct violence is cased cased by cased by indirect violence.
From the clinical and treatment points of view, the
following types must be recognised.
(1) Closed fracture, (2) Open fracture, (3) Complicated
fracture when the fracture is associated with injuries to the
neighbouring vessels, nerves or joints.
Malunited fracture: The
patient comes with an old fracture united in a bad position.
Un-united fracture: The
patient presents with and old fracture where the fragments have
failed to unite.
Pathological fracture: This
must be suspected when an old person presents with a fracture
following minimal violence.
BIOLOGY OF FRACTURE HEALING
It is important to understand the biological process of
fracture healing and the factors influencing, as it helps one to
understand the principles of treatment. This process varies in
cortical and cancerous bone.
Fracture healing in cortical bone
The process of healing of a fracture is in many respects
similar to the process of healing of an incised wound. In the
healing of an incised wound, the gap is first filled with blood
which clots and later the haematoma is invaded and replaced by
granulation tissue. As the epithelium grows over the gap, the
granulation tissue becomes a fibrous scar. In the healing of a
fracture a similar staging can be seen in the earlier phases.
However, the end result in the healing of a bone is the formation of
mineralised mesenchymal tissue (callus) uniting the broken ends of
Fracture healing will be considered as a series of phases
which occur in sequence but also overlap to a certain extent.
(I) Inflammatory Phase.
a. Stage or haematoma formation.
b. Stage of granulation tissue.
(II) Reparative Phase.
a. Stage of fibrocartilaginous callus.
b. Stage of bony callus.
(III) Remodelling Phase.
Stage of Haematoma: When a
bone breaks, the gap is filled with blood from the ruptured
periosteal and endosteal vessels. This blood distends the soft
tissues and clots to form a haematoma. This process takes about 1-2
Stage of granulation tissue:
The soft tissues in the region undergo the usual changes of acute
aseptic inflammation with vasodilatation and exudation of plasma and
leucocytes. The clotted blood is invaded by fine capillaries and
young connective tissue cells and converted into granulation tissue
in about 2 weeks. The cellular element in this mass consists of
multipotent mesenchymal cells which are capable of differentiating
into fibroblasts, chondroblasts and osteoblasts.
Stage of callus: The
granulation tissue next matures into a fibrocartilaginous mass which
holds the fragments together.
Because of the peculiarities of microcirculation in
cortical bone there is some degree of cellular death in the ends of
the fracture bone. The fundamental healing response of bone to
injury is by the primary callus response.
Anchoring callus forms a little distance away from
fracture site to stabilise the fragments. In order to bridge gaps,
the bridging external callus forms to establish contact between
fracture ends and promote union. Medullary callus forms late from
the medullary cavity to unite with the callus from the opposite end.
Thus, according to the situation and function of callus distributed
around the fracture site the callus is described as follows. a)
Anchoring callus, b) Bridging callus, c) Uniting callus and d)
Sealing callus(Fig. 14. 5).
The fibrocartilaginous mass is converted first into
spongy immature bone and later into mature lamellar bone,
producing bony union between the fragments in about 8-12 weeks.
This conversion takes place in some areas by membranous ossification
and in other areas by endochondral ossification. By this time
clinical union of the fracture is complete.
Stage of Remodeling: Once
the fracture has been satisfactorily bridged, the newly formed bone
adapts to its new function. The site of fracture undergoes
remodeling by muscular and weight bearing stresses and any slight
deformity gets corrected by moulding. This remodeling process takes
up to a year and is seen better in children.
Primary bone healing:
Healing of fractures has also been achieved by artificial methods of
mechanical compression between the fracture fragments. In this,
external birdging callus is suppressed and healing is dependent one
of the activity of medullary callus and direct osteonal
penetration. Hence, there is no radiologically visible callus. This
has been called ‘Primary bone healing’ in the technique of
compression plating of fractures.
Fracture healing in Cancellous bone
In fractues at the metaphyseal ends of long bones and in
solid bones like vertebrae, the healing process is different. There
is no terminal bone death as in cortical fractures.
When there is direct contact of fragments, healing occurs
by the process of creeping substitution. New trabeculae
formed by intramembranous ossification are laid down on the original
trabeculae to produce bone between the two fragments. No bridging
callus is formed. Once union is estabilished remodelling occurs.
FACTORS WHICH INFLUENCE FRACTURE HEALING
Fracture treatment is not purely a question of effective
fracture reduction and fixation built a complex biological process.
The natural tendency for a fracture is to unite . When delay or
failure of union occurs, the causes are either local factors at the
site of fracture or defects in the methods employed in treatment.
Causes interfering with the healing of fractures are:
a) Imperfect immobilisation: (i) Too little extent of
immobilisation. and (ii) Too short a
period of immobilisation.
b) Distraction : Too heavy a pull of the distal fragment by
c) Surgical intervention : This empties the frcture haematoma
and strips the periosteum,
interfering with the blood supply and slowing the healing
a) Infection : This is the commonest cause for delayed union or
non-union in open fractures.
b) Inadequate blood supply to one fragment: Certain sites are
notorious for slow union or
non-union e.g. (i) Fracture neck of femur. The blood supply to
the head of the femur is
poor. (ii) Fracture scaphoid. The blood supply to the proximal
fragment is poor.
c) Interposition of soft tissues between the fragment prevents
bony apposition and interferes
d) Type of fracture: Transverse fractures unite slowly compared
to oblique or spiral
e) Type of bone: Fracture at the cancerous ends of bone unite
better than those in the mid
shaft of long bones where cancellous bone is minimal.
Fractures in children unite very rapidly whereas delayed
union is common in the aged. Other factors like protein and vitamin
deficiences, general diseases like syphilis and diabetes play only a
small part in influencing the rate of healing.
Bio-Compression at the
fracture site through protected weight bearing at the proper time
promotes healing of the fractures.
Fracture Clinics in Major Hospitals
Separate fracture clinics are very essential for better
care of patients with fractures in large hospitals. Ideally the
entire management must be in one department from the initial
treatment to the final medical rehabilitation.
Aim of Treatment
The aim of the treatment is the restoration of a limb to
be functionally and anatomically indistinguishable from the normal.
While anatomical restoration is certainly desirable it is far more
important to restore the function. It must be remembered that
treatment is of the injured limb and the person and not merely of
the fractures bone and the injured soft tissue must receive due
attention, if the ultimate functional result is to be satisfactory.
Principles of Management: The
general principles of management of fracture patients are:
1. Efficient first aid: This is down by a splitting. This
relieves the pain and prevents
2. Safe transport: This help to minimize complications in
injures to the spine, fracture of the
lower limbs, ribs etc.
3. Assessment of general condition of the patients for shock
and other injuries.
4. Assessment of local condition of the injured limb regarding
complications like vascular
injury, nerve involvement and injury to neighboring joints and
6. Radiography of the part.
7. Reduction of the fracture.
8. Immobilisation of the fragments.
9. Early physiotherapy for the preservation of function of the
10. Rehabilitation after union of the fracture to restore full
muscle power and joint movements
and to make the man fit for his original job.
DIAGNOSIS OF FRACTURE
The complete diagnosis of a fracture includes recognition
of (a) the presence of fracture and its site (b) the nature of the
fracture whether traumatic or pathological, recent or old and (c)
the presence of complications.
In cases of children the usual history
is that of a fall but the exact nature of the fall is not known. In
adults the mechanism of the fracture can be usually made out from
the nature of the violence, either a direct injury on the bone or
indirect injury by a twist, fall or muscular violence.
Pain: The patients complain
of pain and inability to use the limb.
Deformity: The presence of
deformity in along bones a after injury is a definite sign of
Local bony tenderness: This
is the most important clinical sign for the presence of a fracture.
The tenderness must be localised in a particular point in the course
of the bone.
Credits: Although creditus
felt during the examination of the part diagnostic of fracture, it
should not be purposely elicited as it causes severe pain and
it may produce further displacement and injury of soft tissues.
Abnormal mobility: Abnormal
movement in a segment of the limb denotes fracture.
Shortening of a segment of a limb after
injury indicates a fracture with over riding of the fragments.
The injured part, including the joint above and below, should be
radiographed in two views. The radiograph will confirm the presence
of the fracture and will also show the displacement of the
CONSERVATIVE MANAGEMENT OF FRACTURES
The principle of conservative management is 1) Closed
reduction of the fracture by manipulation, 2) Maintenance of
Reduction of Fracture
Reduction means the restoration of the normal anatomical
alignment of fragments in fractures. This procedure should be
painless and with relaxed muscles obtained by anesthesia.
Before reducing a fracture, one should understand the
mechanism of the violence that caused that fracture, the anatomical
importance of the fracture site and the displacement of the
The common types of displacement to be corrected are:
2. Rotation of one fragment
3. Over riding and shortening
4. Lateral displacement
Not all fractures need reduction. Crack fractures and
those with very minimal displacement need not be manipulated but
need only immobilization till union course.
Maintenance of reduction
In the majority of fractures, the maintenance of the
alignment of fragments is done by immobilisation with plaster of
Some fractures of the lower extremity like fracture of
the shaft of the femur need continuous traction to maintain
the reduction and to immobilise the fragments. The methods are (i)
Skin traction (ii) skeletal traction.
As a general rule, fractures must be immobilised till
the union is complete and this immobilisation is done by plaster
casts. The common types of plaster casts are:
1. Above Elbow plaster cast
2. Below Elbow plaster cast
3. U. plaster slab for humorous
4. Below knee plaster cast
5. Above knee plaster cast
Plaster casts should be applied with great care. Never
apply complete plaster casts a primary treatment after reduction of
fracture. Only a padded plaster slab should be applied.
The patient or the parent should be instructed to report immediately
if the fingers develop circulatory insufficiency like edema, pallor
or cyanosis with increasing pain. The nurse should be instructed to
slit the tight bandage down to the skin from end to end and then
report to the doctor. The cast should be completed only after 3 or 4
days when the reactionary swelling at their fracture site has
In some situations, complete and extensive immobilisation
of the part till the fracture units, does more harms than good by
producing joint stiffness and loss of function of the part. The
following are examples where plaster cast is not necessary is most
1) Fracture of the neck of the humors in elderly persons:
Rigid and prolonged immobilisation of the shoulder in elderly person
will lead to permanent stiffness of the shoulder. Movement of the
shoulder should be encouraged in 2 or 3 weeks’ times as soon as the
soft tissue swelling subsides.
2) Crack fractures of metacarpal bones. Here rigid
immobilisation of the hand in plaster leads to stiffness of all the
finger joints, simple strapping of the hand, allowing all fingers
free is sufficient.
3) Crack fractures of metatarsals: Immobilisation of the
leg in plaster casts for such fractures leads to stiffness of the
foot and pain on later weight bearing. If there is marked swelling
of the foot, a posterior plaster slab and rest in bed for a few days
will bring the swelling down. When the swelling has subsided
strapping the foot and gradual weight bearing should make the person
fit for normal walking in three to four weeks.
Post Reduction Management
A check radiograph must always be taken after the
reduction to confirm the satisfactory restoration of alignment. The
restoration of function of the limb must be the one main concern
immediately after the reduction and immobilisation of the fracture.
All joints, which are not immobilised, should be actively exercised
to prevent stiffness. This also keeps the muscles inside the plaster
in good tone and minimises wasting.
The plaster usually gets loose after two weeks, partly
due to the subsidence of swelling and partly due to the wasting of
muscles under the plaster. Such a plaster must be removed and
reapplied in a close fitting manner to prevent and Angulation
occurring inside the plaster. This is particularly important in
fractures of the forearm bones.
Duration of immobilisation
In children, the upper limb fractures unite in 3-4 weeks
and lower limb fractures unite in 6 - 8 weeks. In adults, the upper
limb fractures unite in 6-8 weeks and lower limb fractures unite in
12 - 16 weeks.
Diagnosis of Union of fracture
When the plaster is removed, the site of fracture is
tested for clinical union. The absence of localised bony
tenderness at the site is the surest evidence of union of the
fracture. The disappearance of the fracture lines in radiograph
occurs much later than clinical union. The presence of tenderness
and yielding at the fracture is not united. In such cases, if
radiographs shown good callus formation, the fracture will unite if
the immobilisation is continued for some more weeks. If no callus is
seen, it may lead to non union of the fracture requiring surgery.
If clinical union is present, the plaster is discarded.
In the case of upper limb fractures, cuff and collar is kept for a
week or two and gradual active movements started. In lower limb
fractures, the limb will sweel up when the plaster is removed. This
edema is prevented by the application of an elastic crepe bendage
and active movements of joints and graduated weight bearing is
allowed under the supervison of a physiotherapist.
Physiotherapy and Rehabilitation
A good physiotherapy department is essential for any
hospital dealing with a large number of fracture patients. Here,
therapaeutic exercise and other treatment is carried out by
physiotherapists under the supervision of the orthopaedic surgeon.
In the treatment of fractures, it is very important to
restore the full function of the limb as well as that of person, in
the shortest possible time. The common disabilities at the end of
the fractrures treatment are muscle wasting and joints stiffness and
this has been aptly named Fracture Disease. Even when the
plaster is on, the patients are made to attend the physiotheraphy
department and are taught exercises for the joints which are free.
When the plaster is removed, the muscle strength is built up by
graduated exercises, and joints are mobilised by active and assisted
FUNCTIONAL CAST BRACING (FCB)
Functional cast bracing is a method of conservative
management of fractures which permits functioning of the joints and
muscles of the limb, while immobilising the fracture.
Controlled motion physiologically induced is the single
most important factor in osteogenesis (Sarmiento). This is the basic
principle of all functional bracing .
The main disadvantage of the plaster cast immobilisation
of limb fractures is the stiffness of joints and circulatory
stagnation due to prolonged immobilisation and disuse of the limb.
This is avioded in functional cast bracing.
It is generally used in the management of disphyseal
fractures of long bones like tibia, humerus. In this method the
primary management of the fracture is reduction and immobilisation
in a plaster cast. At the end of 3 to 4 weeks when the soft tissue
reaction has subsided and the fracture is stickly, the plaster cast
is removed and the functional cast bracing is done as a second
stag. The extent of the plaster is reduced, joint movements are
permitted, and the muscle function is encouraged. Early weight
bearing with the cast brace is allowed in the case of lower limb
In the treatment of fracture tibia, the initial treatment
is by reduction and immobilisation in an above knee plaster slab and
cast. After about 3 weeks a Pateller tendon bearing type of below
knee cast with an ankle hinge is applied and patient allowed weight
bearing. A similar brace with the knee joint is used for fracture
femur where the brace extends to the groin.
This concept of functional cast bracing is a revival of
the earlier methods of the 19th century French school of
Championere who practised minimal immobilisation of joints. It also
resembles the still earlier splinting of fractures by Hippocrates.
The Indian system of bone setting practised by Asans and usthads
consists of manipulation and splinting with flat bamboo strips and
local application of herbal leaves surrounding the limb and allowing
gradual movements of neighbouring joints. This is seen to promote
union of fractures in many cases. This is a form of functional cast
bracing. Functional cast bracing has a place in selected cases of
long bone fractures.
OPEN (SURGICAL) REDUCTION AND INTERNAL
The majority of the fractures could be satisfactorily
treated by closed methods. However, some fractures where there is an
inherent instability of the fragments or a tendency for delayed
union or non-union are better treated by open reduction of the
fracture by surgical method and internal fixation.
Open reduction should be undertaken unless all facilities
are available to deal with such cases and perfect aspectic
techniques can be assured.
Principles of Open reduction
1. Anatomically accurate realignment of fragments.
2. Rigid fixation with metalic implants.
1. Cases where closed methods of treatment have failed to
reduce and maintain the reduction.
E.g. fracture of both bones of the forearm.
2. Fractures where one fragment is retracted by muscle
pull e.g. fracture patella, olecranon.
3. Fractures where there is difficulty in holding the
fragments rigidly in reduced position.
e.g. Fracture neck of femur, Monteggia fracture
dislocation of the forearm.
4. Fractures involving articular surface of joints e.g.
Condylar fractures of the tibia femnur.
5. Fractures near a joint where a small fragment is
displaced and is inaccessible for manual
re-positioning e.g. fracture of the medial epicondyle
of the humerus with displacement.
6. Multiple limb fractures where conservative treatment
is difficult in practise and cumbersome
to the patient e.g. Bilateral fracture femur or tibia.
Fracture femur and tibia in the same leg.
7. Pathological fracture.
8. Fracture of distal femur or proximal tibia with vasular
impairment in the leg.
9. Open reduction is also done in the treatment of
Methods of Internal Fixation of fractures
After open reduction of fractures, the fragments are
maintained in position by internal fixation by the following
methods. 1) Screws only, 2) Plates and screws, 3) Wires and 4) Intra
Screw: Screws alone are used
to stabilise small fragments like medial malleolus of the ankle,
lateral condyle of humerus. The types of screws available are
cortical screws, cancellous screws, malleolar screws.
Plates and Screws: These are
widely used in the fixation of disphyseal fractures like fracture
both bones forearm, fracture shaft of humerus and tibia. The earlier
plates used like the Sherman and Eggers have been replaced by
dynamic compression plates and semitubular plates.
Wires : Wires are used in
the fixation of fractures of the pattella and olecranon.
Intra Medullary Nails :
Diaphyseal fractures in the lower limbs are stabilised with intra
medullary nail fixation. Example is fracture shaft of femur treated
by Kuntscher Intra-medullary nailing.
Advantages of Internal Fixation:
The main advantage fixation is rigid immobilisation of the
fragments which helps in earlier mobilisation and quicker
restoration of function.
fixation involves surgical opening of the fracture site which
exposes the site top infection. The stripping of the
periosteum during surgey causes interference with the blood supply
to the fragments and delays the healing process. Trauma to the soft
tissue also contributes to joint stiffness.
Infection after an operation on bones is a disaster which
could lead to chronic osteomyehtis and prolonged misery. Such an
iatrogenic complication should be prevented at any cost.
COMPLICATIONS OF FRACTURE
These complications can be immediate delayed or late.
Many of these are preventable and hence great care should be taken
to minimise their incidence.
Immediate complications are usually caused by the
violence producing the fracture and these occur at the time of
fracture or immediately after. These can be general complications
like shock or local complications like injury to vessels, injury to
nerves or viscera in the vicinity.
These are complications, setting in after a few days upto
a few weeks. Infection in open fractues causing non-specific wound
infection or specific infections like tetanus and gas gengrene occur
in the first few days. The other complications are Fat embolism,
Volkmann's ischaemia, delayed nerve injury and Myositis ossificans.
These occur as late results of the injury or of its
mismanagement. These include (1) Malunion, (b) Nonunion, (c) Cross
union, (d) Stiffness and contracture of joints, (e) Post traumatic
osteoarthrosis, (f) Late nerve palsy (Tardy paralysis).
Sometimes the injuries to the nerves and vessles are
caused by the lack of efficient splinting and injudicious handling
of the fractured limb during transport. The most serious
complications is an open fracture is infection. Some of the
important complications are discribed below.
VOLKMANN'S ISCHAEMIC CONTRACTURE
Definition : Volmann's
ischamic contracture (VIC) is a contracture developing in a group os
muscles caused by ischemia due to compression or spasm of arteries.
Etiology : It is seen in the
forearm and hand and less commonly in the leg and foot. Ischemia
contracture of the forearm and hand is a tragic complication still
common in India. This crippling deformity is mostly due to tight
bandaging with crude splints applied by traditional bone setters in
the treatment of elbow and forearm injuries. It is also seen in
hospital practice due to the careless application of tight plaster
bandages. It can occur in grossly displaced supracondylar fractures,
where the sharp anterior edge of the upper fragment irritates or
demages the brachial artery.
Pathology : The condition is
due to contusion, spasm or thrombosis of the brachial artery at the
elbow, or the radial and ulnar arteries in the upper half of the
forearm. It is also due to edema and increased pressure in
ther anterior osteofascial compartment of the forearm. There is an
area of ischemic necrosis of the pronator and flexor muscles
in the forearm, followed by fibrosis and later
contractures of these muscles. These may also be associated
ischaemic paralysis of the median and ulnar nerves. In the later
stages there are secondary capsular contractures of the wrist and
the finger joints.
Clinically this can be described in two stages.
1. Acute Volkmann's Ischaemia
2. Chronic Volkmanns's Ischaemic Contracture.
Acute Volkmann's Ischaemia
The patient who has been manipulated and plastered for
supracondylar fracture elbow may present the next day with acute
unbearable pain and swelling in the fingers and hand. Thee
will be pallor of the skin and edema and inability to move
the fingers. Capillary filling in the nail bed and redial pulse are
absent. There may also be paraesthesia and paresis due to ischemia
of median and ulnar nerve. Passive extension of the fingers causes
Treatment : This is an
emergency, threatening the life of the limb and must be tackled with
speed and vigour to prevent permanent damage.
At this stage of all constricting bandages and plaster
should be removed immediately and fixion at the elbow lessened. If
the fracture at the elbow has not been reduced, immediate
manipulation must be done to reduce the fracture and relieve the
pressure on the blood vessels.
If the pulse does not reappear after this, the artery is
surgically explored and decompressed. Incision of the skin and deep
fascia (fasciotomy) releases the tension in the cubital fossa and
forearm and restores the pulse in the vessel. If the vessel is found
damaged it should be repaired.
Chronic Volkman's Ischaemic Contracture
This is the established contractures of the forearm
muscle in varying grades of severity. The deformity is typical. The
forearm is wasted , the wrist is fixed, the metacarpophalageal
joints remain extended, interphalangeal joints are flexed. On
passively extending the wrist, the finger flexion gets worse but on
full flexion of the wrist, fingers can be fully extended passively.
This is the Volkmann's sign. There will also be varying
degrees of paresis of the median and ulnar nerves.
Treatment : This disabling
condition is difficult to treat and only salvaging procedures are
often possible. In minimal deormities, prologed physiotherphy and
splinting with elastic traction to the fingers will correct the
deformity and improve function.
In cases where conservative treatment has failed, the
deformity can be improved by surgery. The soft tissue procedures
used are the sliding of the origin of the common flexor muscles or
lengthening the flexor tendons. The bony procedures used are
shortening the forearm bones or excisionn of the carpal bones
improving the appearance and function of the hand.
Ischemic contracture to leg
Volkmann's inchemic contracture also occurs in the
muscles of the leg and foot. In closed fractures of the proximal end
of the tibial shafts, the haematoma confined under the tense
osteofascial compartment compresses the tibial arteries, causing
progressive ischemia and later contracture. If untreated it leads to
equins contracture and clawing of the toes.
Mysositis ossificans is a condition wherein there is new
bone formation in soft tissues around joints following trauma.
The name is a misnomer as it is not an inflammation of
the muscles. It is better referred to as post traumatic
ossification. This condition is quite different from the
Myositis ossificans progressiva (described elsewhere) which is
This complication is very common following injuries
around the elbow. Myositis ossificans can occur after reduction of
the dislocation of the elbow or supracondylar fracture. Sometimes,
it occurs even after minim al injuries like crack supracondylar
fracture or crack fracture of the neck of the radius. In all these
cases, the invariable cause is massage to the elbow and vigorous
passive stretching to resore movements of the elbow, given by the
bone setters or by well meaning relations of the patient.
It also occurs around hip joints following head injuries
and traumatic paraplegia.
The exact mechanism of this type of new bone formation is
unclear. Following trauma, there is hemorrhage around the periosteum,
capsular ligaments as well as muscles surrounding the joint. In
some cases, in the reactionary stage, there is formation of new bone
around these tissues. This is called myositis ossiicans.
In the early active stage, there is slight warmth
with limitation of movements due to muscle spasm In the later
consolidating stage a firm lumb is palpable is front of the
elbow. In the final stages a bony hard lumb is flt surrounding the
elbow with total loss of movement.
In the early active stage a fussy ill defined radio
opacity (cotton wool appearance) is seen in front of the elbow. In
the later mature stage the radiograph shows a dense irregular radio
The best treatment is preventive. In all cases of elbow
injuries, strict instructions must be given not to give massage or
passive stretching to the joint after removal of the plaster. Even
in crack fractures of the lower end of the humerus or neck of the
radius, it is a wise precaution to apply a plaster slab for a short
time to prevent the elbow being massaged.
In the active stage, the range or movement is recorded
and the elbow is rested in a plaster slab for about 4 weeks. When
the plaster is removed it will be found that movement has improved
and that the shadow is smaller but denser. Immobilisation may be
continued for another 3 weeks for maximum increase of range of
movements. The radiograph may then show a dense well defined
homogenous calcified mass. Thereafter, active exercise are
When the condition is well established and non
progressive, surgical excision of the myositic mass may be done to
restore mobility. Some cases may benefit by arthroplasty (excision
or replacement ) of the elbow joint.
Fat embolism syndrome is a serious post traumatic
complication causing sudden respiratory distress. It occurs within
the first few days after major polytrauma or fracture of the pelvis
or femur. It can also occur after fracture manipulation or
intramedullary fixation operation.
Free fat globules of microscopic sizes from the bone
marrow, excape into the blood stream and cause embolic phenomena in
the lungs, brain and skin.
The condition occurs usually in young adults and is of
sudden onset, presenting with acute pulmonary or cerebral symptoms.
The early symptoms are shortness of breath, followed by restlessness
and confusion. The clinical signs are pyrexia, tachycardia and
tachypnoea with dyspnoea and cyanosis. Characteristic petechial
rashes develop in the chest, axillae, foot, neck and conjunctiva.
Disorientation and coma follow in more severe case which may end
There is arterial hypoxemia due to pulmonary
insufficiency and PA 02 values fall below
60 mm Hg. Thrombocytopenia also occurs. Urine may show sudanophilic
granules. Fundoscopy reveals fat emboli in retinal vessels. Chest X
ray shows snow storm appearance.
The only specific treatment off fat embolism is directed
at improving the hypoxemia due to respiratory distress. Oxygen is
administered by nasal tubing or face mask ventilator. Accurate
monitoring of blood gases, fluid and electrolyte balance is
essential. The use of massive steriod therapy has been found to be
helpful. Mild or moderate cases recover in a week or ten days.
Massive fat embolism is most often fatal.
Non-union is defined as failure of the fracture to unite
by bony continuity. It is a difficult and challenging morbidity and
needs surgical intervention active rehabilitation.
Delayed union of a fracture is one where healing has not
occurred at the expected time of union for the type and site of the
The causes of delayed and non-unionn are as follows.
1. Soft tissue interposition between the
2. Segmental fractures with impaired blood supply to
the middle fragment.
3. Comminuted fractures.
4. Open fractures.
5. Infected fractures.
6. Pathological fractures.
7. Inadequate immobilisation and
8. Insecure fixation and premature weight bearing.
Pathology : There are two types of
The hypertrophic type where the fracture ends are
hypertrophic, sclerosed and vascular. There is a fibrous union and
this has a biological capacity to unite. The second is the
atrophic type where the fragments are inert and a avascular. The
ends of the fragments are tapering, osteoporotic and very mobile
with sometimes a false joint with even a synovial lining.
It occurs in long bones like humerus, forearm or tibia.
It occurs in intra capsular fracture of neck of femur and in
fracture scaphoid. The characteristic sign is abnormal mobility or
yielding at the fracture site without pain.
Radiologically there is sclerosis of fracture
surfaced and closure of the medullary canal in the hypertrophic
type. There is osteoporosis and tapering of fracture ends in the
Established non-union is long bones has to be treated by
operation. The fracture site freshened by excision of the
scar tissue and the bones ends fixed by rigid internal fixation
and supplemented by cancellous bone grafts to promote
Bone tissue has been shown to have natural Bioelectrical
properties. Application of electrical current, constant or
pulsed has been shown to stimulate osteogensis at the negative
electrode. In recent years this technique has been used in cases of
non-union, in conjunction with good reduction and immobilisation to
promote union of the fracture.
This means that the fracture has anatomically malunited
with angulation, rotation or overriding of the fragments. This is
due to failure to reduce the fragments into proper alignment or
failure to hold them in position till union.
The patient presents with a deformity at the fracture
site. It commonly occurs at the shaft of long bones e.g. forearm,
femur, tibia or at the end of bones e.g. supra conbdylar fracture
humerus, Colles' fracture. Radiology will show the degree of
angulation, rotation or overriding of the fragments.
If the deformity is minimal and the function of the limb
is satisfactory the malunion can be accepted. In young children,
malunion tends to correct itself by the remodelling at the fracture
site. If the deformity is gross or functional disability is marked,
malunion is surgically treated by osteotomy, realignment and
This complication can occur in fractures of the shafts of
the radius and ulna and in fractures of the tibia and fibula. The
proximal fragment of one bone unites with the distal fragment of the
other bone. When it occurs in the forearm, supination and pronation
movements are lost. In the leg bones cross union is not of much
Sudeck's osteodystrophy is a post traumatic painful
stiffness of the hand and fingers. It commonly occurs as a
complication of Colles's fractures or even minor trauma to the hand.
It also occurs in the foot after injuries. Its exact etology is
unclear. It is considered to be a post traumatic, reflex sympathetic
dystrophy, producing vasomotor disturbances.
Clinically the hand is swollen, extremely painful, smooth
and glossy. Skin creases are obliterated. Nails and hair are
atroptic. It is associated with capillary and venous dilatation. The
joints of the hands are stiff and painful. In the early stage, the
affected part is warm but later it becomes colder than normal.
In early stages, there are generalised speckled areas of
osteoporosis. Later, the cortex also gets demineralised with a
glassy appearance of all bones of the forearm and hand.
Management is difficult and recovery is slow. Treatment
is by vigorous physiopherapy using active exercises, assisted
movements, splinting and keeping the part elevated. In very severe
cases, relief may be obtain by a cervical sympathetic block or
FRACTURES IN CHILDREN
Fractures in children are important as the presence of
the epiphysis in the long bones makes them vulneravle to damage to
the growth plate, resulting in growth disorder and
deformities. There are several difference between children's and
adult bones. Children's bones are liable and withstand greater
bending force than the rigit adult bone. As the periosteum is thick,
it remains intact on one side cortex in moderate violence resulting
in green stick fractures. Children's fractures unite much faster
than those in adults. In accurate in reduction with angulation can
still heal in good shape due to remodelling. Shortening due
to overlapping in long bone fractures as in femur, gets corrected
upto 1/2 inch due to the stimulation of growth in the epiphysis.
Injuries in children occurs as domestic injuries at home
and at play, mostly due to fall. The types of injures are :
i. Birth fractures.
ii. Battered Baby fractures
iii. Epiphyseal fracture separation.
These are seen in new born babies and are more common
deliveries in breech presentation, particularly when there is
difficulty in the labour. Immobilisation by simple strapping for a
weeks is sufficient for these fractures. The following are common
Fracture shaft of femur:
This occurs when the obstetrician tries to bring the leg down in the
breech delivery by hooking his finger around the groin of the body.
Fracture shaft of humerus:
This also occurs during extraction of the upper limb in breech
Fracture chavicle: This
occurs during difficult extraction of the after coming head in
breech presentation. This is often associated with birth injuries to
the brachial plexus. A crack fracture clavicle may be missed at
birth and the baby may by brought two or three weeks later with the
lumb in the clavicle due to callus formation.
BATTERED BABY SYNDROME
This is a condition where children are brought with one
or more fractures with a suspicious history of fall. The history
does not correlate with the type of fracture. There may be multiple
generalised contusions along with a single fracture. There may be
fractures of long bones along with rib and skull fractures.
Radiograph reveal multiple fractures with subperiosteal new bone at
different stages of healing. All this suggest repeated
violence by the parent or attendant.
These children should be admitted in the hospital for
management and also to prevent further violence. The management
includes the social worker's assistance by tractful enquiries to
determine the family background and to provide counselling. Family
background may reveal poverty, parental separation, alchoholism and
drug addiction, unwanted babies and unwed mothers. A psychologist
will also be needed for parental counselling.
Fracture separation of the epiphyses are common in children
and occur in the age group 5-10 years. It is common in the elbow
region. The normal elbow also must be radiographed to identify the
normal epiphyses. The following are three common types of epiphyseal
injuries out of the 5 types described by Salter.
Type I Simple separation of the epiphysis. e.g epiphysis
of the medial epicondyle at the elbow.
Type II : Fracture separation with a metaphyseal segment.
e.g Lower radial epiphysis. The fragment often includes a
small triangular metaphyseal segment
and hence it is not a pure separation of epiphysis.
Type III : Compression injuries of the epiphysis. e.g.
At the lower end of tibia.
Epiphyseal separation near the elbow often reqauires open
reduction and internal fixation. Compression or crush injury of the
epiphysis results in premature fusion and arrest of growth at the
epiphysis causing or deformity.
Other common fractures in children mostly due to fall on
the outstretched hand are (1) fracture calvicle, (2) Supracondylar
fracture, (3) Fracture radius and ulna. These are dealt with in
detail in other chapters.
Definition: It is a fracture
occurring in a bone weakened by a pathological lesion following a
When a patient presents with a fracture, with a history
of a minimal or trival violence, one should suspect pathological
fracture. On careful questioning, the patient may admit of having
had some local pain or discomfort even before the occurrence of the
fracture. The pain at the site of fracture is usually less than that
in a traumatic fracture. The causative pathology may be very obvious
as in the case of advanced primary malignancy but sometimes the
pathological fracture may be the first sign of an occult primary.
The common causes of pathological fracture in the elderly is a
secondary deposit from a primary malignancy elsewhere or multiple
myeloma of bone. Secondaries in bone indicate advanced stage of the
disease. Pathological fracture in the vertebrae often presents as an
exacerbation of backache and the primary could be diagnosed only it
one keeps the suspicion index high.
The fracture line is often transverse and clean cut. The
fracture line runs across a localised osteolytic area in the shaft
of the bone. Sometimes the whole bone may show evidence of
generalised rarefaction or osteosclerosis.
The lesions which weaken a bone and make it susceptible
to fracture could be classified as follows:
I. Generalised disorders
1. Osteogenesis imperfecta
6. Generalised Osteoporosis of bone. (Senile or
7. Paget's disease of bone.
9. Multiple Myelomatosis.
II. Local Lessions
a. Solitary bone cyst in children and
b. Parathyroid lesion (localised), Fibrous
c. Enchondroma of bone in hand and feet.
a. Secondary deposit in bone from primary lesion in
Thyroid, Breast, Bronchus,
Kidney or Prostate.
b. Primary malignant tumor in bone, e.g. Ewing's
A) Confirm the diagnosis of pathological
fracture. This is done by establishing the nature of the causative
a) Thorough clinical examination.
b) Blood Biochemistry including Serum Calcium,
Inorganic Phosphates, Serum Proteins,
c) Imaging techniques: Plain X ray, Tomography,
Computerised Tomography (CT Scan)
and Isotope bone scan, Magnetic Resonance
d) Biopsy at the site of fracture or any other
B) Treatment : This should include, (i) Treatment
for the fracture (by reduction and retention of the fragment by
immobilisation) (ii) Treatment for the disease. An operative
curetting followed by internal fixation will help in establishing
diagnosis, removal of the pathology and also treatment for the
fracture. Most pathological fracture through a benign lesion like
simple bone cyst or enchondroma is treated by surgical curettage and
bone grafting with excellent results.
Most often, the fracture through a maligment secondary
deposit occurs in a geriatric patient, who is already debiliated by
the primary disease. The management of such a patient needs the team
work of the Orthopaedic surgeon, the Geriatric physician, the
Oncologist and Radiotherapist so that the elderly person may spend
the remaining months of his life free from the miseries of pain. The
senior citizen is entitled to enjoy a pleasant quality of life as
long as he lives and meet his with dignity.
Stress fractures are fractures usually occuring in weight
bearing bones, caused by repeated minimal stresses. It is seen
following unaccustomed strenuous exercise in military recruits under
training. It commonly occurs in the metatarsals of the foot (March
fracture) upper tibia and fibula and neck of femur.
The patient presents with diffuse pain of a few weeks
duration with no history of specific injury to the site. Clinically,
there is localised tenderness at the bone. Radiography shows a
hairline crack in the bone and there may even be some callus around
the site. Rest for a few weeks and symptomatic treatment is usually