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 delivery.

ANATOMICAL TYPES OF FRACTURES

        Various names are given to the fractures according to the types of the fracture lines as transverse, oblique and spiral fractures.

        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 cranium.

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.

CLINICAL TYPES

        From the clinical and treatment points of view, the following types must be recognised.

        Fresh fracture: (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 bone.

        Fracture healing will be considered as a series of phases which occur in sequence but also overlap to a certain extent.

        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 days.

        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:

Local causes

General Causes

        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.

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:

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.

        History: 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 fracture.

        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.

        Measurements:  Shortening of a segment of a limb after injury indicates a fracture with over riding of the fragments.

        Radiological examination: 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 fragments.

CONSERVATIVE MANAGEMENT OF FRACTURES

        The principle of conservative management is 1) Closed reduction of the fracture by manipulation, 2) Maintenance of reduction.

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 fragments.

        The common types of displacement to be corrected are:

        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 Paris casts.

        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.

Immobilisation

        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 subsided.

        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 cases.

        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 exercises.

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 fractures.

        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 19^th 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 FIXATION

        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.

Indications

        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 non-union.
 
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 medullary nails.

        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.

        Disadvantages: Internal 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 

        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.

Delayed complications

        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.

Late Complications

        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.

Clinical features

        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 severe pain.

        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.

MYOSITIS OSSIFICANS

Definition

        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 generalised.

Etiopathology

        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.

Clinnical features

        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.

Radiological features

        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 opaque mass.

Treatment

        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 encouraged.

        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

        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.

Pathogenesis

        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.

Clinical features 

        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 fatally.

Investigations

        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.

Treatment

        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

        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 fracture.

Etiology

        The causes of delayed and non-unionn are as follows.

                1. Soft tissue interposition between the fragments.
                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 non-union.

        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.

Clinical features

        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 atrophic type.

Treatment

        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 osteogenesis.

        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.

MALUNION

        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.

Clinical features

        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 internal fixation.

CROSS UNION

        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 significance.

SUDECK'S OSTEODYSTROPHY

        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.

Radiological features

        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.

Treatment

        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.

BIRTH FRACTURES

        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 birth fractures.

        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 delivries.

        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.

EPIPHYSEAL INJURIES
 
        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.

        Definition: It is a fracture occurring in a bone weakened by a pathological lesion following a trival injury.

Clinical features

        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.

Radiological features

        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.

Causative Pathology

        The lesions which weaken a bone and make it susceptible to fracture could be classified as follows:

                I.  Generalised disorders

                      Children:
                            1.  Osteogenesis imperfecta
                            2.  Rickets

            Adults:
                3.  Osteomalacia
                4.  Osteosclerosis
                5.  Hyperparathyroidism

            Old Age:
                6.  Generalised Osteoporosis of bone. (Senile or Postmenopausal.)
                7.  Paget's disease of bone.
                8.  Carcinomatosis
                9.  Multiple Myelomatosis.

                II. Local Lessions

                    Benign :

                        a.  Solitary bone cyst in children and adolescents.
                        b.  Parathyroid lesion (localised), Fibrous dysplasia.
                        c.  Enchondroma of bone in hand and feet.
                        d.  Osteomyelitis.

        Malignant:

            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 tumour.

Management

        A)  Confirm the diagnosis of pathological fracture. This is done by establishing the nature of the causative pathology by,

                a) Thorough clinical examination.
                b) Blood Biochemistry including Serum Calcium, Inorganic Phosphates, Serum Proteins,
                    Electrophoretic pattern.
                c) Imaging techniques: Plain X ray, Tomography, Computerised Tomography (CT Scan)
                    and Isotope bone scan, Magnetic Resonance Imaging (MRI).
                d) Biopsy at the site of fracture or any other accessible lesion.

        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 FRACTURE

        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.