How do you describe a fracture to a colleague?

Give the bone and location (including whether it is intra-articular), whether it is open or closed, the pattern, the displacement, angulation, rotation and shortening, and whether it is stable. Add the neurovascular status.

What should happen immediately with an open fracture?

Give intravenous antibiotics as soon as possible, ideally within 1 hour of injury. Handle the wound only to remove gross contamination and photograph it, cover it with saline-soaked gauze and an occlusive film, splint the limb and refer urgently. Debridement takes place in theatre.

What are the early signs of compartment syndrome?

Pain out of proportion to the injury and pain on passive stretch of the compartment's muscles. Paralysis, pallor and pulselessness are late signs, and a palpable pulse does not exclude it. Release casts and dressings to skin and refer as an emergency.

Does a normal X-ray rule out a fracture?

No. Scaphoid, femoral neck and stress fractures can be invisible on early radiographs. If suspicion persists, MRI is the usual next test, and current NICE guidance says to consider it first-line for a suspected scaphoid fracture.

Fracture Principles

General MSK Principles

Lens

Overview

A fracture is a complete or incomplete break in the continuity of bone, from a hairline crack to a comminuted open injury with neurovascular compromise.

The steps are the same at every site: identify the fracture, describe it systematically, check the skin, neurovascular status and adjacent joints, then reduce, hold and rehabilitate. Open fractures and compartment syndrome are emergencies. Treat the patient, not the X-ray.

Anatomy & Pathophysiology

Cancellous bone (metaphysis, epiphysis, vertebral bodies) has a better blood supply and heals faster than cortical bone. The periosteum supplies the cells and vessels for callus; it is thicker in children, who heal and remodel faster. The scaphoid, femoral head, talus and navicular have a fragile blood supply and are prone to non-union or avascular necrosis (AVN).

Force predicts pattern: bending gives transverse fractures, torsion spiral, compression impaction, tension avulsion, and high energy comminuted (more than 2 fragments) or segmental fractures. Children's bone also fails as a greenstick (one cortex breaks, the other bends) or buckle (torus) fracture.

Describing and classifying

Assume any wound near a fracture communicates with it until proven otherwise. Oblique, spiral and comminuted patterns tend to displace; transverse and impacted patterns resist it.

Gustilo-Anderson grading of open fractures, assigned at debridement: I clean wound under 1 cm; II over 1 cm without extensive soft-tissue damage; IIIA extensive damage, bone still covered; IIIB needs a flap; IIIC arterial injury needing repair.

Salter-Harris grading of growth plate injuries: I through the physis, II exits the metaphysis (the commonest), III exits the epiphysis, IV crosses all 3, V is a crush. Types III to V carry the greatest risk of growth arrest.

Healing

Healing passes through inflammation (haematoma), repair (soft then hard callus) and remodelling along lines of load (Wolff's law). Relative stability (a cast or a nail) heals with callus; absolute stability heals without it. As a rough guide, upper limb fractures unite in around 6 weeks and lower limb in around 12.

Slowed by smoking (a major modifiable risk for non-union), diabetes, poor nutrition, vitamin D deficiency, corticosteroids, alcohol, infection and too little stability
Hypertrophic non-union: abundant callus, good biology, too little stability; treated by stabilising
Atrophic non-union: little callus and sclerotic ends from poor biology; needs biological stimulation as well

Clinical Pearl

Describe every fracture in the same order:

•Bone and location, intra- or extra-articular
•Open or closed
•Pattern
•Displacement, angulation, rotation and shortening
•Stability

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