Fracture is a disruption of the continuity of a bone. All degrees of such trauma occur. The fracture is commonly thought of as a break in the bony supporting frame of the body, but it may be just a bruise or a crack of a bone.
Types of Fractures
Any bone in the body may be fractured to any degree. Various classifications of fractures are necessary for accurate description. The simple fracture is one in which the bone is not exposed to the surface, the compound fracture one in which there is an opening through the skin and intervening tissues so that the bone fragments are exposed.
- The incomplete fracture is one which does not pass completely through the bone so that its fragments are not separated; it is the so-called crack in a bone.
- The greenstick fracture is an incomplete fracture wherein the bone is merely bent, as the name implies, like bending a green twig; these fractures are more common in children.
- The transverse fracture is a relatively straight break across the bone.
- The oblique or spiral fracture is a long curved break in a bone. It may have any degree of displacement.
- The comminuted fracture is one in which there are more than two bone fragments; i.e., more than one fracture line.
- The impacted fracture is one where the bone fragments are driven together; part of the supporting strength of the bone is still present.
- Joint dislocation may be associated with fracture, called fracture-dislocation.
First aid, or immediate care of injured persons, has been well presented in many other volumes, to which the interested reader is referred. The primary concern in this book is the definitive treatment.
Diagnosis of fractures is in many cases quite obvious to the surgeon; in others, ascertaining the presence or the absence of a fracture is quite difficult. The mechanism of the injury may provide important insight to the diagnosis. Other diagnostic signs are pain and tenderness, swelling, crepitation (grating of the bone ends), deformities, discoloration, and impairment of use of the part. Any or all of these symptoms and signs may be present. The final and complete diagnosis, however, rests with x-ray photographs. In many instances this is the only means to definitely diagnose a fracture. In all cases of suspected fracture, x-rays must be taken, not only for diagnosis but also to learn the extent of fracture and the position of the fragments. After a fracture has been treated, x-ray pictures continue to be important in studying the progress. The corrected position of the fragments is determined, and the degree of healing is studied from time to time. In most instances the length of the treatment course is determined by repeated x-ray pictures which will show when healing of a fracture is complete. X-ray is the most important diagnostic tool in fracture management.
Healing of fractures takes place in a specific manner, although much of the process is not completely understood. At first fibrous tissue is formed between the bone ends from the blood and lymph which is always present at the site of fracture. Calcium is then deposited in the area, forming new bone. This regenerating bone is called callus. At first callus is overproduced, solidly bridging the gap between the fragments. As the repair process progresses, the bone assumes a normal appearance.
Time of healing is dependent on many factors. Fractures in children heal rapidly, while in the aged the process is considerably longer. The healing rate varies directly with age. Various bones have different rates of healing, the larger bones in general requiring a longer time. The general condition of the patient and the presence of concurrent disease may modify healing time. The weight-bearing bones require a longer time for healing before return to function than do non-weight-bearing bones. Healing time varies also with the accuracy of reduction and completeness of immobilization. For the most part, healing rate and treatment time are determined by serial x-ray photographs.
The re-establishment of the continuity of a fractured bone by healing is called union. Healing of a fracture in a deformed position is called malunion. Failure of a fracture to heal is known as nonunion. Healing of a fracture over a prolonged period of time is called delayed union.
Treatment of fractures
Principles of treatment of fractures are basic, but each must be given consideration as an individual case. As stated, any bone may be fractured to any degree. Seldom are any two cases exactly the same. Treatment must be directed not only to the injured bone but to injury of the surrounding soft parts as well. Occasionally nerves and blood vessels arc simultaneously injured, or they may be pinched or severed by the sharp bone fragments.
The basic principle of treatment of broken bones is to maintain the bone parts in normal position until healing has taken place. Many different methods and devices are used to maintain the fragments in normal alignment, dependent on the nature and the site of the fracture.
Fractures without displacement of the fragments require only such immobilization and rest as are needed to prevent displacement.
Fractures with displacement of their fragments require placement of the parts back into normal position and relationship, and then application of some device to maintain the position until healing takes place. Maneuver for replacement of the bone fragments to normal position is called reduction, or “setting” the bone. In most instances this can be done by traction and manipulation of the involved part without incision into the area, called closed reduction. For most reductions general or local anesthesia is required.
In some cases satisfactory reduction can be obtained only by an open operation, known as open reduction. With this method incision is made through the soft parts; the bone is exposed, its fragments replaced, and a device installed to maintain the position. This is called internal fixation, as opposed to external fixation by application of devices on the outside of the involved part. Another means of fracture reduction is by the use of continuous traction appliances, called traction reduction. This is often used in conjunction with suspension apparatus, wherein the involved part is supported and continuously pulled.
Treatment of open or compound fractures almost invariably requires immediate open operation. The wound is treated by debridement (operation for removal of dead and infected tissue), and the bone fragments are reduced. Internal fixation devices may be used. The wound is repaired and most often external immobilization applied. All measures to combat infection are utilized.
Methods of immobilization
Methods of immobilization of a fracture without displacement or of those which have been reduced are many:
Plaster of paris casts are commonly used. The part is wrapped in several layers of soft materials for protection against pressure, and the plaster is applied over this. Most commonly it is applied by the use of rolls of coarse bandage which have been impregnated with plaster of paris; these are wetted and as they dry the hard plaster forms. Several types of casts are employed. The affected part is held in the “position of function”; i.e., the part’s most useful position. The circular cast completely envelops the part with the hard shell on all sides. The plaster splint is a cast on one surface of the affected part only; it is a sort of half shell held in place by bandage about it. Casts are also described by the regions of the body they immobilize, such as the fori.arm cast, leg cast, etc. The cast which incorporates the upper trunk and an upper extremity is called the shoulder spica; similarly, that encasing the lower trunk and thigh is known as a hip spica. The cast applied to the entire trunk is called a body cast. The foot cast which allows weight-bearing on an included heel piece is the walking cast. In general, casts have to be designed so as to immobilize at least the joint above and the joint below the fracture site. Close observation and care must be afforded the circulation whenever a part is casted.
Splints of various sizes, shapes, and materials are also employed for maintaining fractures in normal position for healing. These are rigid appliances which are padded and held in place by bandages or straps. Some are flat but others, such as the aluminum splints, are molded to fit the part. Splints vary greatly in their complexity and size from the small simple finger splint to the long back brace. Splints may be used to temporarily maintain fixation until a cast or other permanent device may be applied; or, they may be used to immobilize the fracture throughout its healing course. They may also be used after casts have been removed.
Rest of the part may be all that is necessary for immobilization of a fracture so that healing may ensue. Bed rest for treatment of fractures of the spine or pelvis often is all that is required. Sometimes a specific position, such as the arched back, is necessary. Rest of the upper extremity may be achieved adequately by the simple arm sling. Other bandages and straps may provide adequate rest.
Traction and traction-suspension methods for reduction of fractures and maintaining them in reduced position often make use of complicated devices. These methods have greatest usefulness in fractures of the limbs, but they may be used occasionally for neck and pelvic fractures. Most commonly the traction is acquired by weights on a rope over a pulley attached to the part. In some cases, however, elastic bands may afford the traction by tension, such as with jaw fractures. Attachment of the traction rope to the involved limb may be by adhesive or bandage about it; this is called skin traction. In other instances where this is not feasible and traction is required for long periods, skeletal traction may be necessary. This entails a minor operation wherein a bone pin or wire is inserted directly through the bone. A caliper device is attached to the ends of the pin to which the pull is applied.
This minor procedure, usually performed under local anesthesia, more often provides greater comfort in traction.
Fractures are held out of position by the muscular attachments to the bone fragments. The principle of traction for reduction is to overcome this muscular pull by tension on the bone in the line of the normal alignment. In some cases, traction has to be exerted on both ends of the broken bone so that a second traction device, called counter traction, is employed.
In traction-suspension methods of reduction and immobilization, the traction is maintained while the extremity is suspended free in a slinglike contrivance. Usually freer movement is allowed with these seemingly complex forms of traction.
Internal fixation methods used in conjunction with open reduction of fractures are of several different kinds. The bone fragments are replaced to normal position and relationship and then a device is installed to accurately hold them. Such devices are made of inert metals which cause little or no reaction of the tissue. Many are left permanently in place; others are removable.
Wiring of fracture fragments is done by drilling holes through the adjacent ends of the broken bone and inserting a wire through the holes. As the wire is twisted taut, the fragments are held snugly together.
Screws are frequently used across fracture lines uniting and holding the fragments. This is especially useful in oblique fractures.
Bone plates are used to secure many type fractures. These are metal bars with screw holes in them which are placed on the surface of a bone across a fracture line. Screws placed in the ends of both fragments hold the bone ends firmly together against the plate.
Bone bands are pliable metal strips used to encircle a bone at its fracture site to hold the fragments in position. They are useful in oblique and comminuted fractures, but are not used commonly since the blood supply may be impaired.
Intramedullary pins and nails are metal rods which are placed in the bone marrow cavity (medulla) to hold fracture fragments in position. These are inserted in the cavity of one fragment to extend past the fracture site into the cavity of the other fragment. In recent years these have proved most useful for many type fractures. In- tramedullary pins vary greatly in size from the small slender wire used in finger fractures to the long solid bar used in femur shaft fractures. Most of these are removed after healing is complete. With some a curved tip is left protruding to facilitate removal (pull-out pins).
Special internal fixation devices have been designed for specific type fractures. For fracture of the neck of the femur various hip pins and screws have been devised. These are inserted from the side of the femur up through the fractured neck into the head. They secure the fracture and allow much earlier ambulation than other forms of treatment. They are usually left in place permanently.
Bone grafts may be indicated in the course of treatment of some fractures. These are especially useful in cases of nonunion or delayed union. There are several techniques used for the transfer and implantation of a piece of bone to another site. Bone graft for spinal fusion has been mentioned. The on-lay bone graft is placement of a strip of bone across the surface of the fracture line. It is commonly taken from the shaft of the tibia and is sutured in place. The sliding bone graft is one where a strip of bone is loosened across a fracture line and slid down over the line. One section of the excised bone is made longer than the other and they are moved to replace each other end-for-end. Bone chips may be useful in promoting healing in “stubborn fractures.” These chips are placed in and about the fracture line and incite healing. Cancellous bone is particularly useful for this, and frequently the donor site is the upper end of the tibia.
Specific fractures cannot be discussed in detail in a book such as this. Scientific volumes have been written about each individual fracture, as well as collectively. Suffice it to say, any type fracture may occur in any bone and each has its individual aspects. The general considerations of the more common fractures are all that can be presented here.
Skull fractures are often associated with brain injury.
Rib fractures result from direct blows on the chest. One or several ribs may be broken.
The major symptom of a fractured rib is pain. A local anesthetic agent injected into the fracture site or the nerve leading from the area may be used to help control the pain. With each respiration there is movement of the rib cage and the fracture fragments. The cage may be splinted and held at a minimum of movement by the application of a tight band around the chest. Such is applied during full expiration. For this purpose adhesive tape or the rib belt may be used. Breathing is then accomplished all by diaphragm movement and the ribs are immobilized for healing. Ambulation is allowed. In the case of multiple fractures and those where the rib cage is depressed against underlying vital structures, open operation and wiring of the rib fragments may be necessary.
Fractures of bones of the upper extremity must be treated with the object of restoration of a useful and painless motion range. The upper extremity serves only for placing the hand in the best position for useful function; this is dependent on its ability to move in all directions and its flexibility. Re-establishment of optimal function as soon as possible is the aim in treatment of fractures of the upper limb.
Fracture of the clavicle (collarbone) is relatively common, especially in children. With a complete break the fragments are most often out of position. Treatment is by holding the shoulder up and back. This places traction on the bone in its line of alignment; direct manipulation of the fragments may be required. This position must be maintained until healing is complete. Various devices are used to hold the shoulder up and back; both shoulders must be held to secure the position adequately. A figure- of-eight bandage around the front of the shoulders and crossed at the back is often used. Shoulder braces and straps are also commonly employed, and occasionally casts. For the first few days a sling supporting the forearm on the injured side may add to comfort, but gradually full use of the limb is allowed within pain limits. Healing time is approximately 3 weeks in children and 4 weeks in adults. Sound healing and good functional results are the rule. Occasionally operation for placing of intramedullary wires is indicated whenever the fragments cannot be secured otherwise. These usually are of the pull-out type.
Fracture of the scapula (shoulder blade) is not common, but may occur from direct blows. Complete healing with normal return of function usually results. Treatment is conservative by placing the limb on the involved side at rest, by bed rest, and/or by arm sling.
Fracture of the humerus (upper arm bone) may occur at any level. Impacted fractures of the upper portion may be treated by simply binding the arm to the chest. Others with displacement of fragments may require casting. The hanging cast utilizes the principle of traction on the bone simply by the weight of the cast. The shoulder spica incorporates the upper limb and chest so that neither the shoulder nor the elbow can move, with the fragments reduced to normal position. Frequently traction – suspension apparatus is employed. Fractures of the lower end of the humerus are frequently of the comminuted type and associated with other fractures about the elbow. After reduction these are often held in fully flexed position, since rehabilitation to complete range of motion from a flexed position is more easily obtained than from an extended position.
Fractures of the forearm bones (radius and/or ulna) are most common, particularly in children. More often the break occurs in the wrist end of the bones. Frequently these two bones are fractured concurrently, but more often the radius alone is involved. A common injury is Colles’ fracture, in which the lower end of the radius is broken with the lower fragment displaced toward the back side of the wrist. This occurs from forceful falls on the hand. Fractures of the lower end of the forearm bones are treated by reduction of displaced fragments and immobilization, most commonly by application of forearm cast. Anesthesia, local or general, is frequently necessary. The cast may be replaced by splints in 3 or 4 weeks, but 5 to 6 weeks are required for complete healing.
Fractures of the upper end of the forearm bones can sometimes be treated by closed reduction and casting, but many times open operation is indicated to assure maximal function. The elbow end of the ulna may require open reduction and internal fixation, commonly intrame- dullary wire, for complete reduction and healing. In adults a fracture of the upper end of the radius (radial head and/or neck) may provide maximal functional result by excision (removal) of the fragments.
Fractures of the shafts of the forearm bones may require open reduction and fixation, but most often closed reduction with casting yields normal anatomy and function. In children, shaft fractures may heal with slight although obvious angulation, but such residual deformity is corrected gradually by growth processes. Rarely is re-fracture with casting indicated. The varieties of fracture of the forearm bones are numerous, and again it must be emphasized that generalities are not applicable to all cases; individual considerations must be afforded each case.
Fracture of the carpals (wrist bones) is not common, except for that of the navicular bone (also called the scaphoid bone). This fracture is sustained by fall on the outstretched hand. It may be associated with other fractures and dislocations; compound fracture is rare; the so- called wrist sprain is frequently a navicular fracture. Diagnosis is confirmed only by x-ray picture. Treatment consists of immobilization in a cast of the wrist including the thumb and the hand in the “grasp” position. Union of the fracture is slow, and nonunion occurs in delayed or inadequate application of immobilizing device to the wrist. Casts may be required for periods of 8 to 12 weeks. Healing is determined by repeated x-ray pictures, and re-application of casts for even longer periods is sometimes required. Casting is used until healing is complete, as evidenced by x-ray picture. Other fractures of the carpals are indeed rare.
Fractures of the metacarpals (hand bones) may occur at any level in any of the five. These can occur by blows on the knuckles or on the outstretched finger, or by direct strikes over the back of the hand. Most often they are transverse or oblique fractures with displacement or angulation. Treatment is most often with reduction by manipulation and position maintenance by casting. Healing usually takes 3 to 4 weeks. In some cases, however, traction on the finger to maintain the corrected position is necessary; more often, skeletal-type traction is used, with a wire through a finger bone attached by elastic band to a loop of sturdy wire extending from wrist cast about the hand (the so-called banjo cast). In the case of multiple fractures of the metacarpals, skeletal traction of all involved digits may be attached to the same “banjo” loop.
Fractures of the phalanges of the fingers (finger bones) may require very simple or very extensive consideration. These may be sustained from a multitude of injuries. Not uncommonly they are compounded by an associated laceration or “smash” of a finger. Diagnosis of extent and degree of displacement is dependent on x-ray pictures. In many cases merely application of splint will assure adequate immobilization for healing. In other instances, the application of casts or traction devices is necessary; open reduction with internal fixation is occasionally required. The relationship of the tendons and the finger phalanges is intimate, and accurate restoration is imperative for normal function of the hand as a whole—man’s most intricate manipulative natural device. Often adequate lost time for finger fractures is a well-spent investment for good functional healing and rehabilitation. Healing of finger fractures, as determined by serial x-ray pictures, usually takes 3 weeks or longer. Rehabilitation may include finger exercises.
Fracture of the pelvis (the innominate bone composed of the pubis, the ilium, and the ischium on each side) is most often a closed fracture. It may be associated with injury’ to the bladder or other lower abdominal organs. Such associated injury is the primary situation, usually of more concern than the break in the bones. Since the pelvis is essentially a ring of bone, it is usually broken in more than one place. Depending on the location and the amount of displacement of the fragments, the treatment and healing time vary. In most instances, bed confinement from 2 to 4 weeks is necessary. During this period, close attention must be afforded the veins of the legs to avoid blood stagnation and clot formation; care of the skin to prevent bedsores is important. The period of bed rest is followed by weight-bearing on crutches for 2 to 6 weeks. In only a few cases is a swathe or sling around the pelvis suspending it to an overhead frame on the bed. necessary; such is used only when compression is needed for fragments which have been pulled apart with widening of the pelvis. In the more severe fracture of the pelvis where the femur has been driven upward through the pelvic bone with its protrusion into the abdomen, heavy traction on the lower extremity may be needed. Complete rehabilitation with normal gait is usual after pelvic fractures.
Fractures of the bones of the lower extremity demand treatment with the object of restoring painless normal weight-bearing. With standing, the weight is divided between the two lower limbs; while walking, the entire body weight is shifted from one to the other. Both states depend essentially on the bones. Therefore, longer recovery periods may be necessary in these fractures. Treatment is directed toward maintenance of length and normal weight-bearing lines and toward restoration of normal range of joint motion and muscle power. Replacement of fragments and securing them until healed is necessary. As with all fractures of the limbs, they are maintained in the position of most useful function.
Fractures of the femur (thigh bone) are of several types and any level, each with its particular considerations. The most common fracture of this bone is that of the neck, the so-called “broken hip.” More often it occurs in the older age groups, commonly by simple falls. The fracture is usually a complete break, but often it is impacted. In almost all instances reduction and fixation are best accomplished by open operation. These are inserted by hip incision down to the bone from the side of the upper end of the femur, through the neck and fracture line and up into the head; x-ray pictures are taken during operation. Other methods of immobilizing this fracture have been utilized with success, such as casts and traction, but open operation with “hip pinning” allows much earlier ambulation with subsequently fewer complications.
Fractures of the shaft of the femur may be of any type at any level. Again individual consideration dictates the treatment method of choice. Almost all of the basic methods of immobilization are used. Casts, such as the hip spica are practical for many, either initially or after healing has begun with other methods. Traction of one sort or another is always applied as soon as practicable, preferably as a first-aid measure. Regardless of the specific fracture and the choice of definitive immobilization, traction is applied until all preparations have been made and all equipment is in readiness. This may be by a portable splint or temporary bed traction. In many cases of shaft fractures, traction-suspen- sion apparatus is used to hold the bone in position for healing. In children less than 5 years of age, overhead traction with the legs pulled upward is most practical; after healing has begun, a hip spica may be applied.
In some cases where satisfactory position cannot be maintained and/or to expedite ambulation on crutches, open operation may be indicated. This may be accomplished by installing bone plates across the fracture line. In other cases, a long sturdy intramedullary bar is inserted down through the narrow cavity.
Fractures of the lower end of the femur about the knee vary greatly in type. Some may be immobilized adequately by traction devices, but others will require open operation with internal fixation by screws, wires, or plates.
Fractures of the patella (kneecap) may be a single break or severely comminuted. The method of treatment depends mainly on the degree of separation of the fragments. When there is little separation, nonoperative treatment by bandage or cast may suffice. When the fragments are widely separated, operation to wire the fragments together is usually necessary. In cases of severely comminuted fracture of the patella, the bone may have to be removed.
Fractures of the tibia and fibula (leg bones) are quite common. They may occur at any level and may be greenstick, transverse, spiral, or comminuted. They may be simple or compound. Treatment varies with the particular features of each individual fracture. For most closed fractures, reduction of the break and immobilization by a cast will suffice. Others may require traction apparatus or even open operation. Almost all cases of compound fractures of the leg necessitate operation with internal fixation devices. Screws, wires, and bone plates are used. A cast is required after operation. Fractures involving the malleoli demand special care to assure a sound ankle joint.
Fracture of the tarsals may be multiple or singular; dislocation may be associated. Treatment rests with molding of the fragments into normal position and application of a cast. Open operation is rarely necessary.
Fractures of the metatarsals usually occur by direct blows to the foot. One or more of these foot bones may be fractured. Treatment rests with the application of a cast which molds the bones into normal relationship. Preservation of the arch of the foot is important.
Fractures of the phalanges of the foot may be extremely painful, but, except for the great toe, they are seldom serious. Severe fracture of the great toe may require a cast. Often the walking cast is used for this and other foot fractures. Other fractures of the toe bones require simply measures to alleviate pain. Footwear may temporarily have to be modified or omitted.