A fracture may be a complete break in the continuing of a bone or it may be incomplete break or crack.

Classification

·       Fracture:- Caused by injury.

·       Fatigue fracture:- Also known as stress fracture, because of repeated stress commonly occur in athletes or new military recruits. Commonly bones of lower limb is involved.

·       Pathological fracture:- Fracture though a some already weakened by disease often gives awayfrom trivial trauma fracture maybe

·       Simple

·       Compound fracture: when it is a open fracture

Grean-stick fracture are peculiar to children, bones before 10 year are springy and resilient like branches of a tree.

A statement that the patient is unable to stand or walk after an injury or to use injured part must always arouse suspicion of a fracture. Immediate appearance of deformity is clearly diagnostic.

Clinical Examination:

The objective signs of fracture are so well known that only a brief summary is required here followed signs may be present:

·       Visible or palpable deformity

·       Local swelling

·       Visible bruising (ecchymosis)

·       Marked tenderness over injury

·       Impairment of function

The following are cardinal signs in the fracture Abnormal mobility

·       Crepitus when injured part is moved.

·       Absence of transmitting movements clinical evidence; must always be confirmed by radiological examination

Additional Clinical Investigations

When fracture is diagnosed surgeon must see:

·       Is there a wound communcally with fracture with fracture?

·       Is there any impairment of circulation distal to fracture?

·       Is there any evidence of nerve injury?

·       Is there any evidence of visceral injury?

Skin Wound-The presence of a skin laceration does not necessarily mean that the fracture is an open one. It is very essential to know whether or not it communicate with bone at the site of fracture.

State of Circulation- The part of the limbs distal to the fracture must be examined for evidence of circulating impairment. Examination should be repeated frequently in the first 48 hours after fresh fracture that has been immobilized in plasters severe pain within the plaster or marked swelling of the digits should arouse swelling of the digits should arouse suspicion that all is not well. Observe the following things:

Colour- A pink colour is reassuring a blue, grey or white colour should arouse suspicion but in it say it does not necessarily by signify circulatory impairment.

Warmth- Warmth digits suggest a circulatory flow though it may be sluggish.

Arterial Pulses- The pulses if available for palpation are usually a reliable guide to the state of circulation, but when the limb is encased in plaster they are not readily accessible. If necessary plaster should be trimmed sufficiently to allow access to the pulses. It must be noted that is compartment syndromes (edema within faxial compartment) in leg or forearm builds up to such an extent that the viability of the contained tissue is unpaired. A very important feature is that impending muscle ischaemia causes severe pain when affected muscles are stretched passively.

Capillary Return- When the digital pulp or nail bed is compressed with a finger nail an area of blenching can be seen around the point of pressure. If on release of pressure the blood flows back briskly into the blanched area in a pink flush, the circulation in adequate of return is sluggish or absent obstruction to circulation should be suspected. Such cases should be referred to higher center immediately.

Nerve Conductivity- Ischaemic nerve quickly loses its ability to transmit impulses loss of sensibility in the digits, in absence of injury to nerves suggests ischemia. In ischaemic lesion of nerve all the nerve trunks are affected where as it is unusual for all trunks to be involved in a injury. Motor tests of nerve conductivity are less reliable.

Specific Test - If it should doubt about circulation give pin pick, if blood comes out it mean sluggish circulation is there otherwise send the patient to higher centre for Doppler study, ultrasonography. or anleviography.

State of spinal cord - There may be para or quadre plegia in spinal injury case. Bladder function must also be investigated in suspected injuries of spinal cord orcauda equina.

State of visera- In fracture of pelvis one must examine abdomen for bladder injury or urethral injury.

Radiological exam

Where facilities available suspected case or otherwise must be examine radiologically. It also tell the type of fracture.

Radiographic technique- The standard technique is to take two projections in plates at right angles to one another usually anterio prosterior and lateral views are taken. It must include the adjacent joint. In special situations additional oblique or tangential projection may be required especially in scophoid and head of radio fracture. If you are not satisfy with plain X-ray send the patient to higher centre for CT or MRI scan or ultrasound scanning. CT scan tells better about bones whereas MRI not only tells about bone but also give perfect image of soft tissues.

Clinical test of union

At a certain stage in the treatment of fracture it is necessary to ascertain whether or not sound union has occurred. The decision is made from clinical and radiological evidence.

There are three clinical test:

·                 Absence of mob.ility between the fragments.

·                 Absence of tenderness on firm palpation oversite of fracture.

·                 Absence of pain when angnlation stress is applied at the site of fracture.

Radiological criteria

There are two radiological features that indicate union

·                 Visible callus bridging the fracture.

·                 Continuity of bone trabecule across the fracture.

Principles of fracture treatment First aid

The doctor who chances to be at the scene of an accident should attempts more than to ensure that the airway is clear, to control any external hemorrhage, to cover any wound with a clean dressing, to provide some form of immobilization for a fractured limb, and to make the patient comfortable while awaiting the arrival of the ambulance.

Temporary immobilization for the long bones of the lower limb is conveniently arranged by bandaging the two limbs together so that the sound limb forms a splint for the injured one. In the upper limb, support may be provided by bandaging the arm to the chest or, in the case of the forearm, by improvising a sling.

Treatment of uncomplicated closed fractures

The three fundamental principles of fracture treatment- reduction, immobilization and preservation of function-are well known, and there is still no better way of discussing the treatment of a fracture than under-these three headings.

Methods of reduction: When reduction is decided upon it may be carried out in three ways.

·                 by closed manipulation

·                 by mechanical traction with or without manipulation

·                 by open operation

Manipulative reduction: The technique is simply to grasp the fragments through the soft tissues to disimpact them if necessary them, and then to adjust them as nearly as possible to their correct position.  -

Reduction by mechanical traction Indication for immobilization

There are onlythree reasons for immobilizing a fracture.

1.                to prevent displacement orangulation of the fragments

2.                to prevent movement that might interfere with union.

3.                to relieve pain Methods of immobilization

When immobilization is deemed necessary there are four methods by which it may be affected:

•                          by a plaster of Paris cast or other external splint

•                          by continuous traction

•                          by external fixation

•                          by internal fixation

•                          Immobilisation by plaster, splint or brace

For most fractures the standard method of immobilization is by plaster of Paris cast. Also available are various proprietary substitutes for plaster, which offer the advantages of lighter weight, radiolucency and imperviousness to water, though at much greater cost. Most such products are also more difficult to apply: nevertheless they are being used on an increasing scale. For some fractures a splint made from metal, wood or plastic is more appropriate-for example, the Thomas's splint for fractures of the shaft of the femur, or a plastic collar for certain injuries of the cervical spine.

The plaster bandages are applied in two forms: round and round bandages and longitudinal strips or slabs to reinforce a particular area. Round and round bandages must be applied smoothly without tension, the material being drawn out to its full width at each turn. Slabs are prepared by unrolling a bandages to and fro upon a table : an average slab consist of about 12 thicknesses. The slabs are placed at point of weakness or stress and are held in place by further turns of plaster bandage.

·                 Immobilisation by external fixation

By convention, however, the term external fixation is used to imply ridge anchorage of the bone fragments to an external device such as metal bar through the medium of pins inserted into the proximal and distal fragments of a long bone fracture.

Fixation is now by means of rigid bars of a frame-the fixator-to whichthe pins are attached by clamps with multiaxial joints. Two or three pins are inserted into each fragment and the producting ends of the pins surface parallel with the fractured bone.

·                 Immobilisation by internal fixation for internal fixation we refer the patient to higher centre

Rehabilitation

Active exercise - While a limb is immobilized in a plaster or splint; exercises must be directed mainly to the preservation of muscle function by static contractions. The ability to contract a muscle without moving a joint is soon acquired under proper supervision.

Continuous passive motion - When restrictive splints are no longer required, exercise should be directed to mobilizing the joints and building up the power of the muscles. Finally, when the fracture is soundly united, treatment may be intensified, movements being carried out against gradually increased resistance until normal power is regained. Engineers have designed machines that provide continuous to and fro movements at a joint without any effort on the part of the patient. The range of movement can be varied as required, being increased gradually as the joint becomes more mobile. This techniques of exercising joints passively has many applications.

Complications of fractures

Infection

Wound infection occasionally remains superficial and the bone escapes, but more often the infection extends to the bone, giving rise to osteomyelitis This is a serious complication, because once a bone is infected with pyogenic organism the infection tends to become chronic.

Delayed Union

Union is deemed to be delayed if the fracture is still freely mobile 3 or 4 months after the injury.

Causes - Any of the following eight factors mayfavour non union.

1.                Infection of the bone.

2.                Inadequate blood supply to one or both fragments.

3.                Excessive shearing movement between the fragments.

4.                Interposition of soft tissue between the fragments.

5.                Loss of apposition between the fragments (including over distraction by traction           apparatus)

6.                Dissolution of the fracture haematoma by synovial fluid (in fractures within joints).

7.                The presence of corroding metal in the immediate vicinity of the fracture.

8.                Destruction of bone, as by a tumour (in pathological fractures)

Shortening

Shortening of a bone after fracture may arise from three causes

1.                Mal-union, the fragments being united with overlap or with marked angulation.

2.                Crushing or actual loss of bone, as in severely comminuted compression fractures or in gunshot wounds when a piece of bone is shot away.

3.                In children, interference with the growing epiphysial cartilage (growth plate)

Special features of fractures in children

Injuries involving the growth plate

The most obvious difference between the bones of children and those of adults is the presence in childhood of cartilaginous growth plates at each end of the major long bones but usually at only one end of the 'short' long bones (metacarpals and metatarsals). Here it may be recalled that the greater proportion of the growth of the bone, and later closure of the growth plate, occurs in the humerus at the proximal end, in the radius end, in the radius and ulna at the distal end, in the femur at the distal end, and in the tibia and fibula at the proximal end. In other words, the most growth occurs awayfrom the elbow and towards the knee.

Complications - Injury to brachial artery complicating supracondlylar fracture of the humerus is common especially tight bandage.