Chapter V - Fractures

Physical Assessment & Fractures

Physical Examination

Usually a patient visits an orthopedist for some kind of fracture or pain. The orthopedist checks for the posture and movements of the patient along the joint of complaint and inquires about history of pain, accident, trauma, or injury. He will then perform an examination for full range of motion and strength of the particular joint involved in the complaint. The physician also looks for any kind of asymmetry or atrophy of the muscles along with any developmental and traumatic deformities and examines for any signs of muscle wasting, stiffness, tenderness or tremors. The orthopedist makes a proper check for any curvature deformity with the vertebrae like kyphosis or scoliosis. Depending on the muscle involved or the fracture, the orthopedist checks the gait of the patient along with the deep tendon reflexes, which gives important clue as to the type of muscle and nerve involved. The physician then performs various diagnostic procedures to diagnose the problem and prepares the plan of action for treatment.

Fractures

Classification

In medicine, fractures are classified as closed or open (compound) and simple or multi-fragmentary (formerly comminuted).

Closed fractures

Simple fractures

Special considerations for children

In children, whose bones are still developing, there are risks of either a growth plate injury or a greenstick fracture.

A greenstick fracture occurs because the bone is not as brittle as it would be in an adult, and thus does not completely fracture, but rather exhibits bowing without complete disruption of the bone's cortex.

Growth plate injuries require careful treatment and accurate reduction to make sure that the bone continues to grow normally.

Plastic deformation of the bone, in which the bone permanently bends but does not break, is also possible in children. These injuries may require an osteotomy (bone cut) to realign the bone if it is fixed and cannot be realigned by closed methods.

Though fracture of the bone itself is obvious, an x-ray is ordered to confirm the type and extent of the fracture. A CT scan or MRI can be ordered to diagnose the fracture involving the skull or the vertebrae. An orthopedist performs a procedure called fracture reduction in order to treat such cases.

Simple manipulation is called closed reduction. If an operation is required, then the procedure performed is called open reduction. Sometimes, the dislocation of the bone (especially in cases of joints) takes place along with the fracture. In such cases, the bone is relocated with the help of a plate, pin, or screw. The bone is also immobilized with a cast to precipitate the healing process. The cast is applied in such a way that it does not hamper the blood circulation.

Bone healing

Phases of fracture healing

There are five phases of healing:

• Fracture and inflammatory phase
• Granulation tissue formation
• Callus formation
• Lamellar bone deposition
• Remodeling

Inadequate bone healing
Inadequate bone healing may predispose to further fractures at the same site, as well pseudarthrosis, undesired mobility in what appears to have become a new joint.

Stress fracture
A stress fracture is a very small sliver or crack in the bone that is accompanied by intense pain.

There are many types of stress fractures. One of the most commonly known is tibial stress fracture. The tibia is a weight-bearing bone; therefore, when a stress fracture occurs on it, it takes much longer to heal than one on a non-weight-bearing bone. Another common type occurs in the metatarsals of the feet. These also take quite a while to heal because the feet are constantly facing weight. A third type of stress fracture is known as the fibula stress fracture. The fibula is non-weight-bearing bone; therefore, when a stress fracture occurs on it, it takes less time to heal than one on a weight-bearing bone are fractures that occur along one line, splitting the bone into two pieces, while multi-fragmentary fractures involve the bone splitting into multiple pieces. A simple, closed fracture is much easier to treat and has a much better prognosis than an open, comminuted fracture. are those in which the skin is intact, while open (compound) fractures involve wounds that communicate with the fracture and may expose bone to contamination. Open injuries carry an elevated risk of infection; they require antibiotic treatment and usually urgent surgical treatment (debridement). This involves removal of all dirt, contamination, and dead tissue.