Fractures

A fracture is a medical condition where the continuity of the bone is broken. When describing a fracture, it is essential to describe the type and severity of the fracture. Adequate description includes providing information about a number of different categories:

Open or closed?

Closed fracture = a broken bone with no open wound

Open fracture = a broken bone with a break in the skin

Simple or comminuted?

Simple = a fracture where the bone is broken into two fragments

Comminuted = bone is splintered or crushed into several pieces

Angle of break?

Transverse = this is when the break is perpendicular to the long axis of the bone

Oblique = bone is broken at an angle across the bone

Spiral = a fracture in which the bone has been twisted apart.

Level of displacement?

Displaced = a fracture where the ends no longer retain their normal alignment

Non-displaced fracture = bone fracture where the ends do retain their normal alignment.

Type of fracture

Hairline = a stress fracture which causes a very thin break – but bones retain the same shape

Compression = bone becomes fractures due to pressure from other bones, often in the vertebrae 

Distal Radius Fracture

This is a fracture of the radius which usually occurs due to a fall on an outstretched hand.

It can be divided into two main types of fractures

Colles’ Fracture

This is a fracture which occurs due to a fall on an outstretched hand.

It is an extra-articular fracture of the distal radius (within 2 centimeters of the joint) which involves dorsal angulation with radial tilt.

It causes a dinner fork deformity, due to dorsal angulation of the distal segment.

Smith’s fracture

This is a fracture which occurs with a fall onto flexed wrists.

It is an extra-articular fracture of the distal radius (within 2 cm of joint) which involves volar displacement of the distal segment and is less common than a Colles’ fracture.

These are inherently unstable and usually require surgical fixation.

Key tests

Plain film x-ray of the wrist

Management

If not displaced, immobilisation in cast

If displaced or neurovascular compromise, then operative fixation is often required

Supracondylar Fracture

This is a fracture which occurs at the distal end of the humerus, usually due to a fall on an outstretched hand

It can also be due to a direct blow to the lateral elbow (more common in children)

Symptoms

Pain and swelling

Key tests

Elbow X-ray

Complications

Vascular – acute ischaemia due to disruption of the brachial artery

Neurological – damage to the anterior interosseous nerve, median nerve

Scaphoid Fracture

This is a fracture which occurs across the scaphoid, one of the small hand bones.

It usually occurs due to a fall on an outstretched hand.

The blood supply to the scaphoid is from a nutrient branch of the radial artery which runs from distal to proximal.

Therefore, with a proximal pole scaphoid fracture, there is a high risk of avascular necrosis of the proximal segment.

Symptoms

Hand pain and swelling

Tenderness in the anatomical snuffbox

Pain on longitudinal compression of the thumb and on wrist movement

Key tests

Wrist X-ray. If unclear, MRI is gold standard

Management

Usually conservative in a plaster/splint for 6–8 weeks. If there is a delay in union, then it may require operative fixation.

Neck of femur

This is a hip fracture which is often seen in elderly women, usually secondary to a fall.

It can be categorised according to whether the capsule is affected.

Intracapsular fractures

These are divided into subcapital, transcervical and basicervical.

In these types, there is a high risk of damage to blood vessels causing avascular necrosis of the femoral head.

Therefore, in these types, the femoral head often requires replacement with a hemiarthroplasty or total hip replacement.

Extracapsular fractures

These are divided into intertrochanteric or subtrochanteric.

In these types, is less of a risk of avascular necrosis to the femoral head, which means that it does not have to be replaced as often.

Symptoms

Hip/groin pain

Inability to weight bear

Shortening of the leg due to iliopsoas pull with external rotation

Key tests

Hip X-ray shows disruption of Shenton’s line and discontinuity of the cortex

Management

Intracapsular

If non-displaced – consider internal fixation in situ with screws or a plate

If displaced and patient is unfit/elderly – hemiarthroplasty

If displaced and patient is younger/fit – total hip replacement

Extracapsular

If intertrochanteric – dynamic hip screw or intramedullary nail

 If subtrochanteric – intramedullary nail