Case-Based Learning in Family Medicine

Musculoskeletal Medicine/Office Orthopedics

Wm. MacMillan Rodney, M.D.

April 28, 1994 (Updated 1994, 1996, 1998, 1999)

Edited and Abridged from Schultz RJ. The Language of Fractures, 1^st Edition. Williams and Wilkins, Baltimore, MD, 1972.

I. ESSENTIAL FRACTURE DEFINITIONS

A. A fracture is a complete or incomplete break in the continuity of bone or cartilage.

B. A complete fracture is one where both cortices of the bone have been broken as opposed to an incomplete fracture where only one cortex has been broken. See V.F. for examples of incomplete fractures (Greenstick and Torus).

If a fracture contains more than two fragments, it is classified as a comminuted fracture.

D. A comminuted fracture may have three or more pieces with various directional orientations. Simply refer to the entire collection of pieces as comminuted. A comminuted fracture is one that has more than two fracture fragments. This holds true whether the number is three or three thousand, regardless of location.

E. A closed or simple fracture is one in which the skin and soft tissues overlying the fracture are intact, and there is no communication with the outside environment.

F. An open or compound fracture exists anytime the fracture site communicates with the outside environment. This is true whether the wound or skin defect is a small pin hole, puncture wound, or massive disruption.

II. ESTABLISHING THE LOCATION OF FRACTURE

Reference Points and How to Use Them

A. New fractures of the shafts of long bones are said to be located in the proximal, middle, or distal thirds or at their junctions (p. 11 attached).

B. Fractures at these levels are referred to as fractures at the junction of the proximal and middle third (PM3) and junction of the middle and distal third (MD3).

C. A lesion occurring at about the midpoint of the bone, although located in the middle third, may be referred to as a midshaft fracture.

III. DIRECTION OF FRACTURE LINES

A. Transverse fracture. A transverse fracture is one that occurs when the fracture line is at right angles at the cortices or long axis of the bone. Transverse fractures may be complete or incomplete, open or closed, and may occur at any location.

B. Oblique fracture. An oblique fracture is one in which the fracture line runs obliquely to the long axis of the bone or the cortices.

C. Spiral fracture. A spiral fracture is caused by a torsional force and is somewhat like a long oblique fracture that spans a greater area and encircles the shaft of the bone, thus forming a spiral in relation to the long axis of the bone.

Reference: Schultz RJ. The Language of Fractures, 2nd Edition. Williams and Wilkins, Baltimore, MD, 1990.

IV. POSITION: Alignment, Angulation, and Displacement

A. Alignment. Alignment is the relationship of the longitudinal axis of one fragment to another. Deviation of alignment or mal-alignment is the result of angulation of the fracture fragments.

B. Position. Position is the relationship of the fragments to their normal anatomical structure. Loss of position is called displacement and may result from the loss of apposition, over-riding, or rotation. In the shafts of long bones, various combinations can occur.

“Bayonet apposition” is a displaced fracture without angulation (see pp. 34, 35 attached).

C. Direction of angulation. The description of the direction of angulation is often the source of confusion. The direction of angulation can be described by the following:

1. By the direction of angular displacement of the distal fragment in relation to the proximal fragment;

2. By the direction of the apex of the angle formed by the fracture fragments.

Most often the direction of angulation is confused with the direction of angular displacement of the distal fragment. Too often, for example, a Colles’ fracture is said to have dorsal angulation when dorsal angular displacement of the distal fragment is meant. If the apex of the fractured radius is volar, this is called either volar angulation of the fracture or dorsal angular displacement of the distal fragment. Both methods are in common usage.

D. Displacement. Although usage has obscured a precise meaning for displacement, displacement generally signifies that the two fragments are no longer in contact.

V. OTHER DESCRIPTIVE TERMS

A. Distraction. Distraction occurs when the opposing ends of the fracture fragments are kept apart. This may be the result of excessive traction caused by the pull of tendons. This is different from displacement.

B. Impaction. Impaction occurs when one fragment of the bone is forcibly driven or telescoped into the adjacent fragment or when the fracture fragments are allowed to press forcibly against each other.

1. Compression. A compression fracture of the vertebral body is a form of impaction. This is a common fracture scene in our nursing home population.

2. Impaction fractures are also commonly seen in trauma.

C. Avulsion fractures. Violent contraction of a muscle can cause rupture of the muscle belly or its tendon, or can pull away a fragment of bone at the insertion of the tendon. At ligamentous insertions, violent trauma applied in a direction, which places the ligament under great tension, may avulse a fragment of bone, rather than rupture the ligament. Thus, an avulsion fracture occurs when fragments of bone are pulled away from their original position. This is a form of “distraction.” (see V.A.)

D. Intraarticular fractures. An intraarticular fracture is a fracture which extends into and involves an articular surface of a joint. These fractures may or may not be displaced.

Reference: Schultz RJ. The Language of Fractures, 1^st Edition. Williams and Wilkins, Baltimore, MD, 1972.

E. Stress fracture. A fatigue or stress fracture is the result of repeated, relatively trivial, trauma to an otherwise normal bone. It occurs not as a sudden break, but as the result of alteration of the bone in the form of gradual, local dissolution, secondary to repeated minor and usually unaccustomed over use. This may or may not result in a complete fracture. Stress fractures occur most frequently in the lower extremities, especially in the metatarsals.

F. Incomplete fractures. Incomplete fractures occur when only one cortex of the bone has been broken. Incomplete fractures are relatively stable, and if protected, will tend maintain their position indefinitely. Incomplete fractures are common in the short bones, irregularly shaped bones, and flat bones. There are certain incomplete fractures which occur exclusively in children, probably because of the elasticity of their bones. These are greenstick fractures and torus fractures.

a. Greenstick fracture. This is an incomplete, angulated fracture producing bowing of the bone. It derives its name from its resemblance to a young branch which, when broken, breaks on its outer surface, but is maintained intact on its inner surface. It should be noted that the broken cortex is always on the convex aspect.

b. Torus fracture. In contrast to a greenstick fracture, a torus fracture is an incomplete fracture with a buckling of the cortex. Torus fractures are usually the result of compression forces and may be considered a type of compression fracture or, in fact, and impaction for x-ray.

VI. ADDITIONAL MISCELLANEOUS TERMS

A. Remodeling Remodeling of a complete oblique fracture of the midshaft of a femur in a 2-year-old child. See Figure 1.36 next page.

1. Plate A. Initial fracture.

2. Plate B. Periosteal new bone formation in a few weeks after injury.

3. Plate C. Union of the fracture with primary callus 2 months post injury.

4. Plate D. Early remodeling and resorption of the primary callus.

5. Plate E. Further remodeling

6. Plate F. At 13 months post fracture, note there is re-establishment of the canal and continued remodeling almost restoring the normal architecture (see p. 55 attached).

B. Dislocation. A dislocation is a complete disruption of the joint with loss of contact between the articulating surfaces of adjacent bones.

C. Subluxation. A subluxation is a partial loss of continuity between the two opposing articular surfaces with some part of the opposing articular surfaces remaining in contact. Subluxations may be very mild to very severe (see p. 7 attached).

D. Diastasis. A diastasis is a separation of normally joined parts, most commonly applied to slightly movable joints. Diastases occur in the region of the pubic symphysis or the distal tibiofibular syndesmosis (see p. 7 attached).

Reference: Schultz RJ. The Language of Fractures, 2nd Edition. Williams and Wilkins, Baltimore, MD, 1990.

Reference: Schultz RJ. The Language of Fractures, 2nd Edition. Williams and Wilkins, Baltimore, MD, 1990.

VII. REDUCTION OF FRACTURES

A. Closed reductions. Closed reductions are reduction of fractures which do not require an operative incision to be made. This type of reduction is produced by traction or manipulation of the fractured fragments or a combination of both.

B. Open reduction. Open reduction is a restoration of the fracture fragments through surgical exposure of the fractured site.

C. Fixation. Fixation is a method of holding the fractured fragments into position following reduction. Fixation may be performed by external means such as cast immobilization or by internal means. (Casts are also placed in cases which do not require reduction if one wants to be a purist--DPL.)

VIII. TERMS RELATED TO FRACTURE UNION

A. In delayed union, fracture repair, although retarded, is proceeding and will eventually produce firm union just so long as additional adverse stresses are not added.

B. Non-union exists when there is failure of union of the fracture fragments and the processes of bone repair have ceased completely. With non-union, the opposing ends of the fracture fragments become atrophic and the medullary canals have become covered over by sclerotic, eburnated bone.

C. Slow union--there are many fractures that even under ideal conditions are known to heal slowly. Most importantly, slow union is not to be confused with delayed union, which is retarded healing beyond the normal rate for a given fracture.

D. Mal-union. Mal-union occurs when there is union of the fracture with angulatory for rotary deformity.

General Guidelines for Fractures that are Managed Operatively

(for more specifics, see pp.12-14)

Edited and Abridged from Anderson BC. Office Orthopedics for Primary Care Diagnosis and Treatment,

2^nd Edition, 1999, ISBN 0-7216-7089-x

Fracture/Dislocation	Reason for Orthopedic Referral
Fractures that require referral to orthopedic surgery
Multifragment intra-articular	Risk of arthritis and malunion
Fracture dislocations	Difficulty of reduction, risk of arthritis
Metastatic lesion of bone	Risk of pathologic fracture
Comminuted fractures	Risk of nonunion and angulation
Compound fractures	Risk of infectious complication
Fractures associated with neurovascular compromise	Soft-tissue injury

General Guidelines for Fractures that are Managed Nonoperatively

Fracture/Dislocation	Nonoperative immobilization or Treatment
General Categories of Fractures Managed Nonoperatively
All stress fractures	Reduced running, standing, repetitious use
All nondisplaced extra-articular fractures	Casting for 3-6 weeks (WMR: or splinting equivalent)
Most small (flecks) avulsion fractures	Casting for 2-4 weeks (WMR: or splinting equivalent)
Some nondisplaced, single-fragment intra-articular fractures	Casting for 4-6 weeks (WMR: or splinting equivalent)
HUMERUS
Fragment displacement <1cm or angulation <45^0	Hanging cast plus pendulum stretching exercises
CLAVICLE
Nonarticular proximal third	Figure-of-eight splint or simple sling
Middle third	Figure-of-eight splint or simple sling
Nondisplaced distal third	Figure-of-eight splint or simple sling
ELBOW
Dislocation without fracture	Closed reduction with distal distraction
Nondisplaced radial head fracture	Simple sling and range-of-motion (ROM) exercises
Nondisplaced fracture of the radius or ulna	Long-arm cast with collar and cuff
WRIST
Most distal radius fractures without foreshortening of the radius or with less than 20^0 of angulation	Chinese finger-trap traction plus sugar-tong splint plus short-arm cast

HAND
Boxer fracture of the fifth metacarpal with less than 40^0of angulation	Removable volar splint
Volar dislocation of the MTP with avulsion fracture <2-3mm	Radial or ulnar gutter splinting
Extra-articular metacarpal fracture of the thumb without displacement in any plane	Thumb spica cast plus ROM exercises of the thumb
Dorsal dislocation of the MP joint of the thumb if a single reduction succeeds	Dorsal hood splint
Gamekeeper’s thumb, incompletely ruptured	Dorsal hood splint
Extra-articular fractures of the proximal and middle phalanges (nondisplaced and without rotation or angulation)	Buddy-tape plus ROM exercises
The acute boutonniere injury without avulsion fracture	Splinting of the PIP joint in extension plus ROM exercises of the finger joints
Dislocation of the PIP joint without volar lip fracture	Radial or ulnar gutter splinting for 2 weeks, then buddy-taping
All distal phalanx fractures	Stack splint
Most mallet fingers	Stack splint or dorsal aluminum splint in full extension
Mallet fractures, displacement <2-3mm	Stack splint
CHEST
Rib fracture, without pulmonary injury	Wide bra, Ace wrap, or chest binder
PELVIS
Nondisplaced, nonarticular, with minimal pain	Touch-down-weightbearing crutches
HIP
Hip fracture in a debilitated patient	Prolonged bedrest
Impacted fractures that are weeks old	Non-weightbearing crutches followed by touch-down-weightbearing crutches
Stress fractures	Bedrest vs. crutches vs. reduced running
Avascular necrosis	Crutches
KNEE
Patellar, nondisplaced and intact quads	Long-leg case, well molded at the patella
Avulsion fracture at the joint line	Velcro straight-leg brace
Osteochondritis dissecans without mechanical locking or effusion	Straight-leg raises and observation
Tibial plateau rim, if <10^0	Long-leg cast
TIBIA
All tibial stress fractures	No running vs. decreased running schedule

Most minimally displaced tibial fractures, if <1cm leg shortening or <5-10^0 of angulation	Long-leg casting with suprapatellar and medial tibial molding; neutral ankle position; knee flexed to 5^0
FIBULA, ALL FRACTURES	Short-leg walking cast for pain control vs. reduced standing and walking
GASTROCNEMIUS TEAR	No running, reduced standing and walking, tape
ANKLE
Isolated small avulsion fractures	Short-leg walking cast for 2-4 weeks
Nondisplaced single malleolar fractures	Jones dressing followed by a short-leg walking cast for 4-6 weeks
Stable bimalleolar fractures	Jones dressing followed by a short-leg walking cast for 4-6 weeks.
Posterior process of the talus	Short-leg walking cast for 4-6 weeks
Lateral process of the talus, nondisplaced	Short-leg walking cast for 4-6 weeks
CALCANEUS
Most extra-articular fractures (except the displaced posterior process fracture)	Bedrest for 5 days, Jones dressing, short-leg walking cast with crutches and non-weightbearing, then gradual weightbearing
TALUS
Chips, avulsions, nondisplaced neck fractures	Short-leg walking cast for 8-12 weeks
NAVICULAR
All avulsion, stress, and tuberosity fractures (except with large fragments)	Short-leg walking cast for 4-6 weeks
FOOT
Heel-pad syndrome	Heel cups or padded insoles
All fifth MTP avulsion fractures	Short-leg walking cast for 2-4 weeks
Jones fracture of the fifth metatarsal, nondisplaced	Jones dressing followed by a short-leg walking cast for 3-4 weeks
Nondisplaced metatarsal fractures	Short-leg walking cast with crutches and non-weightbearing for 2-3 weeks plus casting and weightbearing for an additional 2 weeks
All stress fractures of the metatarsals	Well-supported shoe plus limited standing and walking
Nearly all great toe fractures without comminution or soft-tissue injury	Taping plus a well-supported shoe vs. short-leg walking cast for 2 weeks
Nearly all sesamoid fractures without comminution or soft-tissue injury	Short-leg walking cast for 3-4 weeks, then a well-supported shoe
Lesser toe fractures	Cotton ball between the toes plus taping

Fracture Guidelines for Referral to a Surgical Orthopedist

Fracture/Dislocation	Reason for Orthopedic Referral
All compound fractures	Risk of infection and soft-tissue injury
Nearly all comminuted fractures	Unstable; risk of nonunion
Most intra-articular fractures	Risk of arthritis and poor joint function
Most spiral shaft fractures	Unstable; risk of shortening
Most displaced fractures	Unstable; risk of nonunion
SHOULDER AND UPPER ARM Clavicle
Associated with rib fracture	Risk of lung or great vessel damage
Distal third associated with displacement	Risk of nonunion
Humerus
Transverse shaft fusion	Risk of nonunion
Neck fracture with shoulder dislocation	Unstable; risk of arthritis
Fragment displacement >1cm or angulation >45^0	Unstable
Supracondylar fracture with displacement	Risk of arthritis, brachial artery or median nerve injury
ELBOW AND FOREARM
Displaced radial head fracture	Unstable
Displaced fracture of the radius or ulna	Unstable; risk of compartment syndrome
WRIST
Displaced or intra-articular distal radius fracture	Unstable; risk of arthritis
Radius foreshortened by 5mm or angulation >20^0	Risk of arthritis
Navicular fracture	Risk of Avascular necrosis or nonunion
Perilunate dislocation	Referral for primary repair or fusion
THUMB
Gamekeeper’s thumb, complete tear	Risk of poor function
Intra-articular metacarpal fracture of the thumb—Bennett fracture and Rolando fracture	Unstable; risk of arthritis
Dorsal dislocation of the MP joint of the thumb	Single attempt at closed reduction; Sx referral if unsuccessful
Transverse fracture at the base or neck, spiral oblique, comminuted, and condylar fracture (intra-articular)	Unstable; risk of poor function and abnormal alignment

Fracture/Dislocation	Reason for Orthopedic Referral
HAND
Metacarpal fracture (except the fifth)	Unstable
Boxer’s fracture of the fifth MC with angulation >60^o	Unstable; referral for pin fixation
Volar dislocation of the MCP joints with avulsion fragment >2-3mm	Unstable; risk of arthritis
Volar subluxation of the DIP greater than 2-3mm displacement, or involvement of >30% of the articular surface	Referral for primary repair
Rupture of the flexor digitorum profundus tendon	Referral for primary repair
PELVIS AND HIP JOINT
Pelvic/acetabular fracture	Multiple injuries; unstable; traction
Hip fracture	Unstable; internal fixation
Fracture of the femur	Unstable; traction; internal fixation (x infants)
KNEE
Supracondylar fracture	Unstable; internal fixation
Tibial plateau depressed >6-8mm	Unstable; risk of arthritis; internal fixation
Rim fracture >10^o	Internal fixation
Bicondylar fracture	Skeletal traction; cast brace; internal fixation
KNEE
Tibial spines	Molded long-leg cast for 4-6 weeks
Subcondylar fracture	Molded long-leg cast for 4-6 weeks
Patellar, displaced or comminuted	Cerclage or patellectomy
Osteochondritis dissecans, symptomatic with locking	Arthroscopy
Tibial and fibular fracture	Unstable; internal fixation
ANKLE
Unstable bimalleolar fracture	Risk of arthritis; internal fixation
Trimalleolar fracture	Risk of arthritis; internal fixation
Fracture at or above the syndesmosis	Unstable; risk of arthritis
Displaced ankle fragments	Unstable; risk of arthritis
CALCANEUS
Intra-articular fracture	Risk of arthritis
Displaced posterior process fracture	Restore the integrity of the Achilles tendon
Nonunion of the anterior process	Internal fixation

Fracture/Dislocation	Reason for Orthopedic Referral
TALUS
Displaced neck fracture	Risk of Avascular necrosis
NAVICULAR
All displaced fractures	Unstable
FOOT
Neuropathic fracture	Risk of nonunion or malunion
Transverse fifth metatarsal fracture	Risk of nonunion or malunion
Displaced or comminuted proximal phalangeal fracture	Risk of nonunion or malunion

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