Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Fractures

Fractures

A fracture is a potentially serious injury, damaging not only bone but also the soft tissues in the surrounding area—tendons, ligaments, muscles, nerves, blood vessels, and skin. Fractures may be the result of direct trauma, e.g. an impact to the leg, or indirect trauma, e.g. when the foot is trapped, causing the athlete to fall awkwardly and break the leg.

Types of injury

Skeletal fractures may be transverse, oblique, spiral, or comminuted. When the fractured ends of the bone pierce the skin the injury is an open or compound fracture ; when the skin remains undamaged, it is a closed or simple fracture. With compound fractures there is a great risk of infection to the bone, and special treatment is required. If the fracture involves an  adjacent articular joint surface it is called an articular surface fracture. An avulsion fracture means that a bone attached to a muscle or ligament has been torn away. The different types of fracture displacement are angulation, rotation, and shortening. The aim of any treatment should be to return the fractured ends as precisely as possible into their correct position, that is, to reduce displacement and return the bone to its normal alignment by manipulation. For fractures in children and adolescents.

Associated soft tissue injuries

The soft tissues around the fracture are often damaged by sharp fragments of bone, and the more violent the impact the greater the risk of extensive soft tissue injury. Such injuries can increase hemorrhage and delay healing, and may even cause more problems than the fracture itself. It is rare for major blood vessels and nerves to be damaged when a fracture occurs, but this may be a complication of fractures of the humerus just above the elbow, and fractures of the wrist .

Location

Certain sports lead to characteristic injuries: fractures of the lower leg predominate among soccer players; fractures of the forearm are common in gymnasts; and fractures of the clavicle in horseback riders.

Symptoms and diagnosis

The following features suggest that a fracture has occurred:
– swelling and progressive bruising in the injured area;
– tenderness and pain around the site of injury caused by both movement and loading of the limb;
– deformity and abnormal mobility of the fractured bone.
Sometimes fractures may cause few or none of these signs and symptoms. This can be true of fractures of the neck of the femur or of the humerus when the fractured surfaces of the bone are driven into each other, becoming firmly impacted and giving the fracture stability.fractures and may allow an early return to training and competition. This can be achieved by use of
fracture bracing, orthotics and, in some cases, by external fixation (using a frame system).
– In cases of fracture with displacement, the fractured ends are realigned by manipulation (reduced) either without surgery (a closed procedure), or with surgery (an open procedure). In the latter case, internal fixation of the fracture is achieved by the use of cerclage (steel wire), plates, screws, rods, pins, or nails. Internal fixation usually also requires the application of a cast or brace, which can be removed after a short time; some cases allow early immobilization without a cast. External fixation may be used for open fractures.

Aftercare

Active muscular exercises such as flexing and lifting must involve all parts of the body not in a cast to maintain general cardiovascular fitness and avoid muscle hypotrophy. Muscles inside the cast can be exercised isometrically; where movement is possible dynamic exercises can be included. The length of time spent in a cast or brace depends on the location of the fracture, its severity, and the rate of progression through the healing process. A fracture of the wrist may be immobilized for 4–6 weeks, whereas a fracture of the lower leg is likely to be in a cast or brace for at least 3 months, and an equal period needs to be spent undergoing rehabilitation following removal of the cast.

Stress fractures

Stress fractures (also called fatigue or insufficiency fractures) occur most frequently as a result of repeated loading of the skeleton over a long period and are probably preceded by periostitis.

Causes

Stress fractures can appear following the application of a normal load at high frequency (e.g. long-distance running); of a heavy load at normal frequency (e.g. repeatedly running 100 m (or 100 yards) carrying a second person); or of a heavy load at high frequency (e.g. intensive weight training). The last is the most dangerous, as it is likely not only to cause stress fractures but also to overload other tissues. There is an increased incidence of stress fractures in athletes because of an increase in bone width and hip rotation. Athletes with leg-length discrepancy, or excessively high or low foot arches, also have increased incidence of stress fractures. Running more than 100 km (60 miles) per week and playing basketball are associated with stress fractures, and these injuries are more common in young people and in women. There is also a greater incidence in women with menstrual disturbances and eating disorders, and in women taking oral contraceptive medication.
There are two theories about the origin of stress fractures. The fatigue theory states that during repeated protracted effort, such as running, the muscles pass their peak of endurance and are no longer able to support the skeleton during impact as the foot strikes the ground. The load is therefore transferred directly to the skeleton; its tolerance is eventually exceeded and a fracture occurs (in the same way that a paperclip breaks after repeated bending).,
The overload theory is based on the fact that certain muscle groups contract in such a way that they cause the bones to which they are attached to bend. The contraction of the calf muscles, for example, causes the tibia to bend forward like a drawn bow. After repeated contractions the innate strength of the tibia is exceeded and it breaks.

Treatment

When a stress fracture occurs, the athlete should:
– rest the injured area for 2–8 weeks depending on the type of injury until the pain has resolved and healing can be seen on X-ray;
– keep up conditioning in the swimming pool or by cycling;
– gradually return to activity when activities of daily living are pain-free, and when there is no local tenderness.
The doctor may:
– prescribe crutches to relieve the injured part, especially in a femoral neck fracture;
– apply a walking boot or a plaster cast for 2–6 weeks if the pain is severe, or if the fracture is located on the tibia, navicular bone or the proximal fifth metatarsal;
– check the progress of healing with X-ray examinations;
– pay particular attention to stress fractures in the femoral neck, the anterior aspect of the medial tibia, proximal fifth metatarsal, and navicular bone.
These fractures often need surgery in order to heal and in order to allow the athlete to return to activities within reasonable time without risking complications.

Prevention

Stress fractures are to be avoided, and risk factors must be analyzed and eliminated. Athletes should assess their training methods with the coach, trainer, physical therapist, and physician, and pay particular attention
to footwear and equipment. The time it takes tissue to adapt is important. Other risk factors include the ‘female triad’ of menstrual disturbances, low bone density, and dietary problems . Bone geometry and biomechanical abnormalities should also be analyzed.

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