69. Bones
From Primary Surgery
69.1 Examining an injured limb
The penalty of having a stiff skeleton is that it may break, especially the bones of the arms and legs. You can treat injuries to the soft tissues of the limbs in more or less the same way, wherever they occur, but each part of each limb bone is different-hence the space we devote to them. Treating them provides many opportunities for disaster, but none is more common or more serious than: (1) Primary closure of an open fracture (or a contaminated wound) (54.1). (2) Applying a cast over a recent injury without splitting it, especially in minor fractures with little initial swelling (70.4). More limbs are lost from these two causes than from anything else.
THE GENERAL METHOD FOR AN INJURED LIMB
HISTORY
Always take a careful history. Most fractures are the result of some characteristic injury, so enquire carefully about the force which caused an injured limb. For example:
If a patient landed on his heels from a height, he may have fractured his calcaneus, and also perhaps his spine.
If he fell on his outstretched hand, he may have any of the injuries to his upper limb listed in Section 74.1.
If a very small force was able to break his bone, it may have been weakened by some other disease so that the fracture is pathological.
If he is a child, he may have fallen because he is feeling ill.
CAUTION 1 Osteomyelitis and septic arthritis are the most important differential diagnoses. if you take a careful history you will not miss them.
EXAMINING AN INJURED LIMB
Many methods of examination are the same for an injured patient as for an orthopaedic one, so modify those in the list below appropriately.
The important signs of a fracture are: (1) tenderness and abnormal mobility at the fracture site, and (2) an abnormal X-ray. Sometimes you may be able to feel crepitus-the grating feeling as bone ends move over one another. It i s acutely painful so don't examine for it unless it is necessary. i f you expect to feel it and don't feel it, there may be soft tissue between the fragments.
LOOK Remove the patient's clothes and look for abnormal
attitudes, contour, and shortening. if displacement is gross,
one glance will tell you he has a fracture or a dislocationdeformity,
shortening, rotation, or overlap will be obvious. You
can diagnose most dislocations merely by looking at them.
Are both limbs the same? Compare one side carefully with
the other. One joint may look larger than the other, either
because it is swollen, or because the muscles round it are
wasted. if necessary, measure shortening with a tape measure
(77-3).
FEEL Ask the patient to point to exactly where the pain is.
Often, his whole joint is acutely tender; if it i s not, feel
carefully for the place of maximum tenderness, particularly
if you suspect a fracture of his wrist or ankle. You will then
know which bone to X-ray. Tenderness to gentle pressure is
a more useful sign than tenderness to deep pressure.
If a bone is tender, assume it is broken (or he has osteomyelitis) until an X-ray shows it is normal, or until you are quite sure he has not got osteomyelitis-see Section 7.3. if a ligament is acutely tender, it may be ruptured.
Feel the patient's bones carefully, for example, are the three bony points of his elbow (72-2) in their normal places?
If you suspect infection, test for warmth. Test for this first, because your other examinations may increase it. (1) Use the back of your hand to compare the abnormal side with the normal one. Or, (2) move the palm of your hand down the patient's limb. It usually gets progressively colder, if it gets warmer anywhere, the warm part may be abnormally vascular, usually because of infection.
MOVE Ask the patient to move his injured limb, as much as
he can himself. This is active movement.
If he can use his arm actively, or walk on his injured leg without a limp, he has no serious injury. Many important i njuries are missed, or unnecessarily overtreated, because nobody asks a patient to do this.
If he cannot move his limb actively, gently move it passively for him in all directions, as far as you can without hurting him.
Record the movement that is possible from the neutral position for each joint as shown in Fig. 69-1.
Most surgeons evolve their own particular routines, which they vary as necessary. Later we describe a detailed routine for the knee. Work out your own for the other joints.
Finally record your findings, and don't forget to include the soft tissue injuries. A patient's X-ray films are not a sufficient record of his injury.
15 GOLDEN RULES FOR FRACTURES
(1) If a patient is severely injured, save his life first; treat any airway obstruction (52.1), haemorrhage, or shock (53.2) before you treat his fractures.
(2) Splint him where he lies when you first see him (51.2); this will minimize soft tissue damage and avoid converting a closed fracture into an open one.
(3) Look for signs of nerve (55.8) and vessel injury (55.3) and record your findings.
(4) Handle his injured part as little as you can.
(5) if he has an obvious fracture, make sure that this is his only injury-it may be the least of his injuries. Don't let him die from a tension pneumothorax (65.5) while you are treating a fracture of his forearm!
(6) Don't be deceived by the absence of deformity and disability; sometimes he can continue to use his fractured limb.
(7) Take X-rays in 2 planes and examine them yourself.
(8) Reduce the fracture as soon as you can, don't wait for the swelling to go down, except sometimes in the ankle (82.4).
(9) if he has continuous severe pain, suspect circulatory impairment and treat it immediately (70.4).
(10) When you split a cast, divide the plaster and the padding right down to his skin.
(11) if you put him into traction, be sure to check this frequently (70.9).
(12) All joints that are not immobilized by the fracture must be kept moving (69.10).
(13) Remember that open fractures are contaminated wounds, so toilet them and use delayed primary closure (69.7).
(14) Aim to restore function. if a patient's arm is injured, try to restore the proper use of his hand; shortening and some misalignment are often acceptable. if his leg is injured, try to restore painless stable weight bearing; prevent misalignment; maintaining length is desirable, but a little shortening i s acceptable.
(15) Finally, remember to treat him as a whole person; don't only treat his injured limb.
69.2 X-rays for bony injuries
You are more likely to make a mistake because you don't examine a patient than because you don't x-ray him. Although all fractures should in theory be X-rayed, this may be unnecessary with some of them, and you may have no X-rays. If films are scarce, keep them for injuries which involve a patient's joints, especially his elbows, hips or ankles. Always X-ray him if his symptoms seem to be worse than your present diagnosis suggests. A fracture is a three dimensional lesion, so you will need X-rays in two planes at right angles in order to visualise it. For most fractures take an AP (anteroposterior) and a lateral view. Even if there is a radiologist's report, look at all films yourself, and you are in doubt, compare them with views of the other side, if possible on the same film. This is especially important in young children.
Make sure the films include enough of the patient. For example, a film of his forearm may fail to show an injury of his wrist, so in all long bone fractures, X-ray the joints above and below the fracture. Don't overlook a proximal injury, for example a fracture of the neck of the femur. It is a major error to treat a distal injury, and to fail to diagnose a proximal one.
If you are not sure if he has a fracture or not, ask him to come for another X-ray in 7 to 10 days time. If he does have a fracture you will see it more easily then. If his films are normal a week after the injury, the problem is not in his bones.
X-rays will not show you the position of his bones at the time of the accident. For example, an injury may have severely displaced the bones of the knee and torn its ligaments, after which they may have returned to their normal position. So a normal X-ray does not exclude a ligamentous injury.
Don't take 'X-rays for X-rays sake'. Many fractures can be diagnosed without them. Colles, Port, Smith, Bennett, Monteggia and Maisonneuve all described their fractures before X-rays were invented. If your X-ray machine does not work, or your stock of film is almost exhausted, here is some help.
IF YOU DON'T HAVE X-RAYS make your diagnosis of a fracture or a dislocation on: (1) the violence of the injury, (2) the classical deformities of particular injuries, (3) tenderness over a subcutaneous bone (if this is absent a fracture is unlikely), (4) loss of function (a patient who can walk and bear weight normally is unlikely to have a serious injury).
The injuries which least need an X-ray include: (1) extension fractures of the wrist, (2) clavicle fractures, (3) many tibial fractures (you can detect angulation and rotation clinically), (4) greenstick fractures of the forearm in children.
The injuries which most need an X-ray include: (1) doubtful hip injuries, which might be a slipped epiphysis, or frac. ture of the femoral neck, (2) possible penetrating wounds of the skull in children by hoes or garden forks, (3) ankle injuries, (4) elbow injuries, and (5) any long bone fracture where there might be a dislocation at the upper end, (6) severe foot injuries where the patient cannot walk.
COMPARE THE ABNORMAL SIDE WITH THE NORMAL ONE
69.3 Adequate function with minimum risk
There are two main meyhods of treating fractures,and t wo cor responding schools of fracture surgeons who emphasize one method of treatment rather than the other method: (1) Fixing fractures internally with metal screws, plates, and pins. (2) Treating them without operating, if an operation can be avoided- Some fractures, such as those of the clavicle, should never be treated by internal fixation. A few, such as those of the neck of the femur, can only be fixed internally. Many other fractures, such as those of the shaft of the femur, can be treated by either method.
Fixing fractures successfully by internal fixation needs: (1) Much training, experience, and skill, and is not to be leamt merely by reading a manual. (2) A complex and costly set of equipment. (3) Expensive screws and plates. (4) A theatre environment of the highest sterility. (5) Much time, which you probably will not have. If you attempt internal fixation without all these necessary conditions, too many of your patients will end up severely disabled by ununited or infected bones, which drip pus through multiple sinuses for many years.
Because internal fixation is such a disaster when it is badly done, we have collected together here a system of non-operative methods for most of the common fractures and for many of the rarer ones. You will find that these methods will give you a much lower rate of infection and non-union.
Of the fractures which have to be fixed internally, some of those of the olecranon and patella are not too difficult, so we have included methods of internal fixation for them. The only common fractures for which we have no adequate method are those of the neck of the femur. These have to be fixed internally, but they need more skill and equipment than you are likely to have.
This is not the place to discuss the merits of the two schools, except to say that in the industrial world fracture treatment is dominated by internal fixation, and particularly by the Arbeitgemeinshaft fur Osteosynthesenfragen, the Association for Osteosynthesis, or AO for short. High technology methods of internal fixation, such as those of AO, are attractive, and give superb results with some difficult fractures. For example, they enable a patient to fall from his horse, break his radius, and yet be at work again the next week. But these ood results can only be obtained by master surgeons, when the risks of operating, and particularly the risk of infection, have been reduced to the lowest possible degree. This is essential, because infection is a ten times greater disaster in orthopaedics than it is in general surgery, where a wound infection is usually only a minor problem. If you have equipment for internal fixation, don't use it, except occasionally in its simplest forms, as described here. Unless you can meet AO criteria, your results will be disastrous. Refer the more difficult fractures, if you can-the place for AO is in a referral hospital.
The non-operative school is less preoccupied with mechanical elegance, less visible, less organized, and lacks an obvious label. The thinking behind its work is to follow the natural healing processes of the body, to use closed methods wherever possible, to encourage the patient to start using his limb as soon as he can, and to interfere surgically only if absolutely necessary, and then only in the simplest way possible. If it is not essential to restore the exact anatomy after a fracture, the non-operative school does not try to do so. It argues that the perfect immobilization which AO methods try so hard to achieve is seldom even desirable, and that in many fractures a little movement is a good thing in that it encourages callus formation and union, and prevents the absorption of bone. The members of this school point out that: (1) perfect radiological reduction does not always mean perfect function, and (2) function may be perfect, even though reduction is not. In the 1920s Boehler was the main exponent of these methods, and in the 1950s George Perkins. More recently these methods have been developed by Sarmiento. Because internal fixation is so dominant, no systematic collection of non-operative methods exists-hence the need for this one.
THE POSSESSION OF EQUIPMENT FOR INTERNAL FIXATION SHOULD NOT BE A LICENCE TO USE IT
With fractures of the shafts of long bones, non-operative methods give excellent results. With more difficult ones, particularly fractures into joints, your results, and those of most surgeons, are unlikely to be perfect. With difficult fractures try to:
(1) Get a patient's injured limb to unite in the position offunction. If it becomes fixed in this position it will be more useful to him than a limb which is septic, or has failed to unite, because you operated when the risks were too high. The measure of adequate function in a limb is its usefulness in relation to the patient's life and work. Adequate function is a state of his mind as much as of his joints; so, if he has a difficult fracture, warn him that function is unlikely to be perfect. Discuss the problems with him and let him prepare for them.
(2) Avoid unnecessary complications, especially infection and injuries to important structures. The patient may be in bed a little longer than if a master surgeon had treated him by internal fixation, he may perhaps be a little stiffer, and he will have less beautiful X-rays. But you will only get good results if you follow all the details carefully. How you apply a cast, when you should remove it, and exactly which exercises he should do are just as important as the mechanical niceties of internal fixation. There are some important general principles: (1) The maintenance of alignment (2) The avoidance of rotation of the fragments. (3) The avoidance of distraction. (4) The encouragment of joint movement. (5) The careful application of casts and traction. In addition, each fracture has its own rules. Remember that the size of a fracture has little relation to its seriousness. For example, you can easily treat a facture of the femur in a child, but a chip off the head of an adult's radius may have to be removed at an open operation.
THE DETAILS ARE CRITICAL
69.4 For the purposes of closed treatment there are three groups of fractures
They are: (1) Fractures of the shafts of long bones, including those of the mandible, the clavicle, and the ribs. (2) Fractures of the ends of long bones, often into joints, such as supracondylar fractures of the humerus, extension fractures of the wrist, and fractures of the tibial condyles. (3) Fractures with ischaemic or totally intracapsular fragments. Fortunately, there are only t wo fractures in this group-(a) intracapsular fractures of the neck of the femur, and (b) fractures of the neck of the scaphoid. These fractures can only be treated by replacing the fragments exactly and keeping them totally immobile, either in a cast (the scaphoid) or by internal fixation (the neck of the femur), until the ischaemic fragment has been vascularized from the more vascular one.
The first two groups of fractures need more discussion.
69.4a Fractures of the shafts of long bones
The shafts of long bones heal in four stages:
(1) Injury When a patient breaks one of his long bones, he injures the soft tissues round it, and tears the periosteum away from at least one of the fragments. This deprives the bone next to the fracture of its blood supply, and kills it.
(2) Callus formation During the next few weeks the
periosteum and endosteum near the fracture produce soft vascular
callus full of active spindle cells. Cancellous bone only forms
a significant amount of callus when the two bony fragments
are close together; cortical bone can form callus when they are
not so close. Gentle movement stimulates callus formation in
a fractured long bone; complete lack of movement depresses it.
The non-operative school welcomes callus, and encourages gentle
movements.
The newly formed callus forms a sheath round the broken bone, and is fixed to the fragments above and below the fracture, but not to the bone at the fracture site itself. The bone here is ischaemic and dead, and does not unite until it has been revascularized later.
After two weeks enough calcium has been deposited in the callus for you to see it on an X-ray. This calcified callus is slowly converted into loose open 'woven bone' which makes the bone ends 'sticky', and prevents them moving sideways on one another, although it still allows them to angulate.
(3) Clinical or bony union As time passes the woven bone
round the patient's fracture becomes harder, and so firmly fixed
to the fragments that they move as a single unit. This is clinical
union and is a critical milestone in the healing of a broken long
bone. It is the indication for a change in management, and is
more important than the appearance of his X-ray. It usually
occurs 4 to 8 weeks after the injury, but in the tibia it can take
much longer.
EXAMINING A LONG BONE FOR CLINICAL UNION
(1) Feel the fracture site for tenderness, looking at the patient's face as you do so- if it is not tender, his fracture has probably united.
(2) Feel the fracture site for warmth. if it feels warm, it has probably not united.
(3) Put one hand over the callus and grasp it firmly. Ask the patient to keep his limb muscles loose. With your other hand, move the lower end of his broken bone from side to side. if his fracture has united, the upper end of the bone should move in the opposite direction. Don't be too gentle, but don't move the bone so vigorously that you cause pain, or refracture it.
Pain, particularly pain at night, is a sign that a fracture has not united. Repeatedly examining a fracture in this way it useful, especially in the early days, because it promotes callus formation. if manipulation is painless and there is no move ment, the fracture has united.
When a patient's fracture has united clinically, you can reduce splinting, but you must continue to protect it from stress, and especially from stresses that are likely to break it. For example, a patient must protect a fracture of the shaft of his humerus from the angulation stresses that dangling it out of a sling will cause while his elbow is still stiff (71.17).
(4) Consolidation and remodelling Bone continues to heal during this stage, which lasts several months. The broken
fragments remain firmly held by callus, while the dead bone
the end of each fragment is slowly removed, and their ends joined
by more callus and finally by solid bone. The more a pa '
uses his limb, the stronger this new bone becomes. Excess
is slowly removed until his injured limb is as strong, or stronger, than it was before. Consolidation takes as long again as
clinical union, so if union took 8 weeks, consolidation will take 16 weeks. Don't allow him to do any violent sport until consolidation is complete.
69.4b How should you treat a broken long bone?
These guidelines follow from the above account of how long bones heal. They apply to fractures of the clavicle, the humerus, the ulna, and the shaft of the femur. The radius is for some reason an exception, perhaps because the healing processes described above are better adapted to angulation stresses than they are to those of rotation, and the radius is above all a bone that rotates. The tibia is also a bone which is best immobilized.
A little movement is a good thing in some long bone fractures because it promotes callus formation, especially in the early days, it increases the blood supply to a limb, and it improves muscle tone. Complete immobilization of a femur fracture is unnecessary, and by reducing callus formation, it delays union. So, allow the bone ends to move a little, and encourage the patient to keep exercising his muscles, even if they are inside a cast. Active movements in which he uses his own muscles, are better than passive ones.
A recent fracture is painful. This pain helps to limit excessive movement of the fragments. For the first three days after an injury pain prevents almost all movement. Thereafter a patient can move the fragments through a steadily increasing range of painless movement, but he must not move them so much that the flexible newly formed callus is broken. The limited range of movement increases the formation of callus and promotes union. So encourage him to use the joints on either side of his broken humerus or femur, within the range of painless movement. If he exceeds it, he may refracture his bone. Pain is subjective, so you will have to restrain some patients and encourage others. Exercise in the first few weeks after a fracture is the main factor in determining how much callus is formed, and it is callus which promotes union.
Cautious weight bearing speeds healing, so encourage a patient to walk on his broken leg-cautiously! He can only do this if you can prevent the fragments angulating. A plaster cast can prevent a patient's tibia doing this, but is much less satisfactory for his femur. So, if his tibia is broken, allow him to walk on it early, but if his femur is broken, keep him in bed on traction until it has united. His fracture will be so painful that he will seldom be able to bear weight until it is useful and safe for him to do so.
' Active movements' and 'weight bearing' are not the same. It is never too soon to start active movements, whereas bearing weight too soon may be disastrous. For example, if a patient tries to bear weight on a fractured femur too early, the fragments will gradually angulate, and may perhaps refracture.
GENTLE MOVEMENT INCREASES CALLUS EXERCISE IS NECESSARY, EVEN INSIDE A CAST AIM FOR ACTIVE PAIN-FREE MOVEMENTS
69.4c Fractures of the ends of long bones
If a fracture enters a joint, you will not be able or equipped to reduce the fragments precisely at an open operation, or to fix them internally. If you cannot refer a patient to have this done, the alternative is active movement, as early as pain will allow. This smooths the opposing joint surfaces, and lets them mould to one another as union proceeds.
It is often said that unless the fragments of all broken joint surfaces are replaced exactly, osteoarthritis always follows. Although this is true for the ankle, it is less true for such fractures as: (1) comminuted supracondylar fractures of the humerus in adults, (2) comminuted extension fractures of the wrist in elderly patients, (3) plateau fractures of the upper tibia, and (4) comminuted fractures of the calcaneus with injury to the subtalarjoint. With these fractures surprisingly good results follow from accepting the poor position of the fragments, and allowing early active movements to smooth out the irregular joint surfaces as union proceeds. These good results are in striking contrast to the poor results that average surgeons get when they try elaborate methods of internal fixation. Experts with the AO method may get excellent results with these fractures, but many of their followers do not.
69.5 Varieties of bony injury
When you see a fracture, think of it in terms of the variables in Fig. 69-5. Is it closed, or is there a tear in the skin over it, so that it is open (compound)? Spiral fractures have pointed tips, heal rapidly, and are caused by forces acting along the length of a limb, which remains fairly stable. Transverse and oblique fractures take longer to heal than spiral ones, and are caused by forces acting across a limb, which becomes unstable. Oblique fractures have rounded tips, heal particularly slowly, and have all the disadvantages of a transverse fracture, with the added one that you cannot easily get the fragments to hitch (73-13). Angulation can be anterior or posterior, the lower fragment can be in varus (directed towards the midline) or in valgus (directed away from it). Overlap is not always as undesirable as you might think 78.1), but always avoid distraction because, if the ends of two fragments do not touch, they may never unite.
Occasionally, the fragments are impacted into one another in a suitable position, so that you can preserve the impaction, as in some fractures of the necks of the humerus or the femur. Unfortunately, the fragments are usually in an unsatisfactory position, so that an important first step in reducing most fractures is to disimpact the fragments by pulling them apart.
A ligament can be sprained and only partly torn, or it can be completely ruptured. In a dislocation the joint surfaces are widely displaced, but in a subluxation they are still partly touching one another. Both subluxations and dislocations are often combined with fractures.
Fractures and dislocations differ greatly in the urgency with which you must treat them. Reduce all dislocations and fracture dislocations immediately, because the longer you leave them, the tighter the ligaments will become, and the more difficult or impossible your task. If a dislocation is likely to be difficult to reduce, use a relaxant. With most fractures you have more time, and the best time to reduce a fracture is either immediately after the injury, before the tissues have started to swell, or up to a week later (not more), after the swelling has gone. If you are referring a fracture for internal fixation, the sooner the patient reaches the referral hospital the better. He should at least be there within two weeks.
Which fractures are common? Some fractures and dislocations are much more common than others, but the rarer ones are no less important to the patients who have them, and are not necessarily any more difficult to treat. The common ones are extension fractures of the wrist, clavicle fractures, supracondylar fractures of the humerus in children, fractures of both forearm bones in children, fractures of the shaft of the humerus in adults, fractures of the tibia and fibula either alone or combined, fractures of the shaft of the femur, fractures of the radius and ulna, and fractures of the metatarsals and metacarpals. Most other fractures are rare.
DISTRACTION IS DANGEROUS REDUCE DISLOCATIONS EARLY
69.6 Fractures in children
A child's bones differ from those of an adult. Instead of fracturing completely, they often bend like a stick (incomplete or greenstick fractures), or there may only be a small swelling of the cortex (wrinkle fractures). Fractures in children always unite if you treat them properly; they need immobilizing for a shorter time, and you can almost always manage them by closed methods. Skin traction is much more satisfactory in children than it is in adults, and, because a child's joints do not become stiff permanently, he seldom needs physiotherapy.
Although some severe malpositions slowly disappear as a child grows, other apparently mild ones become steadily worse. So you must know which positions you can accept, and which you cannot. Here are some general principles-
(1) Try to get the fragments into line. They need not necessarily be end to end.
(2) Try to stop them rotating, because growth will not correct a rotation deformity.
(3) Be cautious about how much angulation you accept. This depends on: (a) The age of the child, and particularly on whether his epiphyses have united or not. In Caucasians they typically unite at 14 in a girl and 16 in a boy, but in an African they may remain open almost to the age of 20. (b) The distance of the fracture from the end of a long bone. The younger the child, and the nearer his fracture to the end of his bone, the greater the angulation you can accept. Uncorrected angulated fractures near the middle of a long bone cause severe deformity, especially in the forearm, and also in the femur and tibia. But angulation near the end of a bone in the plane of a hinge joint, such as the elbow, fingers, or knee, causes very little disability. Angulation in other directions is likely to be permanent.
(4) Overlap and moderate shortening are unimportant. In fractures of the femur and humerus in younger children, they are even desirable, because these bones readily regrow to their normal length- So you can leave a fractured long bone to unite with its fragments side to side up to the age of 10 in girls, and 12 in boys. The fragments unite rapidly, and the bone soon moulds.
69.6a Epiphyseal injuries in children
Among the endpages of this book you will see charts showing the epiphyses, and stating both the time they appear and when they unite. These charts are for Caucasians-African epiphyses unite later.
Some epiphyses are much more often injured than others. E Epiphyses are of two kinds: (1) pressure epiphyses at the ends of long bones near joints, and (2) traction apophyses, to which muscles are attached. The cartilage joining epiphyses and apophyses to the shaft of a bone is weak, and is often the site of displacement. Except for an important injury to the medial epicondyle of the humerus, injuries to other apophyses are only a minor nuisance and are not discussed further here. Injuries to pressure epiphyses are much more important.
Suspect an epiphyseal injury whenever any patient under 20 has signs of an injury near the end of a long bone, even if it seems only to be a sprain. He may have displaced an epiphysis at the moment of injury after which it returned to its usual place, so a normal X-ray does not exclude a displaced epiphysis.
Fortunately, most epiphyseal injuries cause no growth disturbance. But if an epiphyseal plate is injured on one side only, or if it is one of a parallel pair, such as the radius and ulna, progressive angular deformity occurs slowly over several years, and can only be corrected by osteotomy. Salter and Harris have described the following five types of epiphyseal injury each of which needs managing differently, and has a different prognosis.
Type I The epiphysis slips completely off the end of the shaft, without a fracture. These injuries are common at birth and in early childhood. Reduction is usually not difficult, and the prognosis is good, except at the upper end of the femur (77.10).
Type II The line of separation runs through art of the epiphyseal plate and then out through the shaft, were it produces a characteristic triangular fragment (N, Fig. 69-7). This is a common epiphyseal injury, particularly at the distal end of the radius.
Type III The fracture extends from the joint surface into the epiphyseal line and then along it to the periphery. These are rare injuries, usually at the ends of the tibia. Accurate reduction is essential to restore a smooth joint surface and align the epiphyseal plates. An open operation may be necessary.
Type IV The epiphysis and part of the shaft split, particularly at the lateral condyle of the humerus (72.13). Perfect reduction is essential, and open reduction is often necessary.
Type V This is another rare injury, usually of the ankle or knee, with a poor prognosis. The epiphyseal plate is crushed and at least part of it subsequently closes early. The first x-ray may look almost normal, and you may think the child has only i sprain- Suspect an injury of this kind if he has a history of i crush injury, and don't let him bear weight for at least three weeks.
EPIPHYSEAL INJURIES IN CHILDREN
X-RAY Take two views of the child's injured limb at right angles; i f you find them difficult to interpret, compare them with exactly the same views of the other side. Failure to do this is responsiblefor most of the errors in treating children's fractures. Diagnosing an epiphyseal separation is difficult before the centres of ossification have appeared. Suspect epiphyseal separation if there is displacement of the shaft and soft tissue swelling.
REDUCTION An epiphyseal plate is easily damaged, so
reduce the displacement gently. if a Type I or II injury is more
than 10 days oId, leave it- The epiphysis will probably have
stuck in its displaced position, so that you will have to use
excessive force to replace it.
CAUTION I Reduce these injuries immediately, especially in the lower limbs. Any delay will make reduction more difficult-
IMMOBILIZATION injuries of the first three types need about
half the time required for a shaft fracture at the same agei
mmobilize Type IV injuries for the same time as for a shaft
fracture.
FOLLOW UP See the child regularly. Compare X-rays of his
injured and his normal sides- if there has been little growth
see him every 6 months.
THE PROGNOSIS is good for injuries of the first two types
and poor in the other three, particularly the fourth-
The younger the child the more growth he has ahead of him,
and the worse the deformity that may follow a given injury.
An injury in the last year of growth is likely to cause little
disability.
REDUCE EPIPHYSEAL INJURIES IMMEDIATELY
69.7 Open fractures
A fracture is 'open' when a break in the skin over it brings it into communication with the organisms of the outside world. The break in the skin can be the result of either a wound from outside, or a bony fragment piercing the skin from inside, in which case the tissues are less likely to be contaminated-
Traumatic osteomyelitis as the result of infection is always a possibility in an open fracture, but it is much less likely to occur if you do a careful wound toilet, and close the wound by delayed suture- So toilet all open fractures carefully and close them by delayed suture (54.4), even if the skin wound is a small one, and occurs from within outwards. This is especially important if the patient presents late. If you fail to do this and the wound becomes infected, traumatic osteomyelitis will probably follow. Failing to do an adequate toilet, and closing the wound by immediate primary suture are very common errors.
Although some open fractures can be fixed internally, don't try it. The wound is already contaminated, and the plates and screws will probably become infected. An occasional Kirschner wire is the maximum amount of internal fixation that is wise.
If you apply the above principles rigidly, infection is unlikely, and antibiotics will make little difference (54.1). So give them only if an infection occurs which needs treating.
Gustillo, Ramon, and Anderson J.T. ' Prevention of infection in the treatment of 1025 open fractures of the long bones. Journal of Bone and Joint Surgery 1976;58A 454
OPEN FRACTURES
This extends Section 51.3 on caring for a severely injured patient and Section 54.1 on caring for wounds. Open fractures of particular bones such as the tibia (81.12), the radius and ulna (73.6), and the femur (78.6), are discussed elsewhere.
All open fractures need urgent treatment, so don't leave them until the following day. Take the patient to the theatre and give him a general anaesthetic. Toilet his wound to remove all foreign material (54.1). Syringe out the whole of the inside of his wound with saline under pressure every 10 minutes all through the operation. Remove all dead tissue until you reach a healthy bleeding surface. Then LEAVE THE WOUND OPEN! But make sure you cover any arteries and nerves.
CAUTION ! (1) Don't close the wound by primary suture. (2) if the skin edges gape, don't try to bring them even partly together with stitches. (3) When you finally close the wound some days later, don't close it under tension.
If bone fragments have no attachments, remove them. But if they have any attached periosteum, leave them; they may live. if you remove them unnecessarily, you will leave a gap which can only be replaced by grafting. Try to bring the fragments together end to end. if possible, keep them in place with traction rather than in a cast. if this is difficult, at least try to maintain the alignment of the limb by applying traction. if convenient, you can combine traction with plaster slabs or a plaster gutter.
If you are going to apply a cast, don't do so until all risk of infection is past. if necessary, graft the patient's skin
wound, and apply a cast on the same day.
Raise the patient's injured limb.
DIFFICULTIES WITH OPEN FRACTURES
If the SKIN iS BRUISED over the fracture,watch it carefully. It may break down so that a fracture which was closed initially becomes open.
If FRACTURE BLISTERS develop, they do not make the fracture into an open one. Prick them with a sterile needle, and cover them with vaseline gauze.
If a PIECE OF BONE iS MISSING, bringing the fragments into contact with one another is more important than maintaining length.
CLOSE ALL OPEN FRACTURES BY DELAYED PRIMARY SUTURE TRAUMATIC OSTEOMYELITIS IS PREVENTABLE
69.8 Open joint wounds
Immediate primary suture is usually advised for joint wounds, but in knee wounds in particular, it can be disastrous. Although it is unwise to leave a joint widely open, it is equally unwise to close it tightly. An effective compromise is to do a thorough wound toilet, as for any other wound, and to close it immediately, leaving a corner of the joint open to improve drainage and the chance of healing. Some joints will be destroyed and need an arthrodesis, but this will happen anyway. Don't let the presence of an opening into a joint influence your decision as to whether to close the rest of a wound immediately, or by delayed primary suture.
Antibiotics have the same rather uncertain role that they do in other contaminated wounds (54.1).
OPEN JOINT WOUNDS
Excise the edges of all layers of the patient's wound, remove dirt and wash out the joint cavity forcibly with saline from a syringe.
If necessary, open his wound wider by the standard incIsion
for the joint (7.17), and feel around inside it- You mayfeel
a piece of the patient's trousers inside his knee!
Even if his injury is a recent one, don't sew up the joint capsule
completely. instead, leave the joint and the wound at
least partly open, so that pus can discharge. Don't insert&
rubber drain.
If the bones in a joint wound are dislocated and the wound is open, reduce it urgently. Every hour's delay makes the loss of the joint more certain. Leave the skin wound partly open and pack
it with gauze.
If a patient's wound is already badly infected, i t maybe
helpful to leave a plastic tube with side holes cut in it td
irrigate it.
Don't try to immobilize a wounded joint, or it may never move again. Instead, encourage early gentle movements. Make these more and more vigorous as the joint heals. Close the wound as soon as the danger of infection has passed usually after about 3 days. The superficial tissues may ' n a skin graft.
If the knee is involved, apply skin or skeletal traction (79.
to take tension away from it. CAUTION ! Don't forget tetanus
toxoid.
69.9 Pathological fractures
Two kinds of fracture can occur without major trauma: (1) Fractures m which normal bone is subjected to unaccustomed, frequently repeated normal movements, as in fatigue fractures of the tibia (81.8), and march fractures of the metatarsals (83.11). (2) Fractures in which the bone is abnormal. Under the age of 20 the common causes are a chondroma (in a finger or toe) or a bone cyst at the end of a long bone, and osteomyelitis (7.2). Over the age of 40 the common causes are a secondary carcinoma (in the spine, pelvis, humerus, or femur), or osteoporosis (in the spine or femoral neck).
PATHOLOGICAL FRACTURES
X-RAYS Benign lesions typically have a smooth margin, and malignant ones a ragged gnawed appearance.
BIOPSY if you decide to biopsy the lesion, take tissue from
the border of the lesion and try to get normal and abnormal
bone in the same specimen.
TREATMENT Most pathological fractures unite, many of them
at the normal speed, so that you can treat most of them in
the same way as fractures through normal bone. Even fractures
through secondary metastases may unite-
If a fracture takes place through a bone cyst, it may unite. if it does not, refer the patient.
If a fracture takes place through a sarcoma, this may be an indication for amputation.
69.10 Active movements means active movements!
All fractures need some exercises from the first week onwards, if not before. Fractures must thus be firmly associated with exercises in the minds of everyone-including the patient. The decision to treat fractures by non-operative methods is thus not a decision to do nothing! Enthusiasm for exercises is a critical part of this method. Exercises are usually necessary for the injured joint itself, and are always important for the normal joints on either side of it. If these joints are not used, even for a few days, they soon become stiff. Encouraging, cajoling, and even bribing and bullying all have their place.
DEMONSTRATE THE EXERCISES YOURSELF
Who is to encourage the patient to move his joints? Few
district hospitals have a physiotherapist, and even the elements
of physiotherapy are not yet part of any nursing curriculum.
So the responsibility is yours, as you go round the ward, to make
sure that the patients do their exercises. Your staff must see the
patients doing their exercises, and really care that they are done.
Exercises are no less important with out-patients. Teach the
exercises using examples of each kind of injury, and let your staff
see you demonstrating them. Merely telling your nurses and
medical assistants to get the patients exercising is not enough.
Show them just how much trouble you are prepared to go to
yourself.
Here are some exercises which all ward staff should know and teach patients. Carefully supervised walking is an important leg exercise and is discussed in Section 8.1. Active movements may be painful, especially to begin with, so ease the patient's pain with plenty of aspirin and persist in your persuasion.
ACTIVE MOVEMENTS ARE SAFER THAN PASSIVE ONES
SOME EXERCISES
You will need some exercises when a patient is in bed, and others later when he is able to walk.
JAW EXERCISES
Chewing Ask the patient to chew gum or sugar cane.
CLAVICLE EXERCISES
Shoulder bracing Encourage the patient to keep bracing his shoulders backwards; this will help to draw the fragments of his fractured clavicle out to length. Make sure he keeps his shoulder, elbow, and hand moving.
BACK EXERCISES
Arching exercises Ask the patient to lie on his back and arch it so as to make a tunnel that you can put your hand through. This is a good exercise for a stable fracture of his thoracic or lumbar spine.
Extension from the prone position Ask him to lie on his front. With someone holding his legs, ask him to arch his back so as to raise his shoulders from the bed without using his arms- This is a useful extension exercise later in spinal i njuries.
SHOULDER EXERCISES
Arm dangling i s useful for all arm fractures, especially those of the humerus when the patient's arm is in a sling. Ask him to stoop forwards and let his injured shoulder swing l oosely in all directions. Let it swing under the influence of gravity, like a pendulum, as in Fig. 69-11. Don't let him tighten his shoulder with his arm to his side, because this may angulate a broken humerus. More shoulder exercises are shown in Fig. 71-7.
ELBOW EXERCISES
Flexion and extension Ask the patient to repeat flexion and extension movements gently many times within the limits of pain. Forceful exercises are particularly undesirable in elbow injuries (72.10).
FOREARM EXERCISES
Pronation and supination Ask the patient to do this repeatedly with his elbow at 90°- This is the movement of turning the knob of a door.
WRIST EXERCISES
Flexion and extension Ask him to flex and extend his wrist as freely as he can.
FINGER EXERCISES
Squeezing a ball Ask the patient to keep squeezing a rubber ball, or a ball of cotton wool, inside a tight gauze bag.
HIP EXERCISES
Abduction Ask him to lie on his side and abduct his hip against gravity.
Flexion When he is lying on his back in bed, ask him to raise his leg from his hip with his knee straight.
KNEE EXERCISES
Quadriceps exercises While the patient is lying on his back, ask him to keep his leg straight and lift his knee off the bed. When he can do these exercises satisfactorily, let him do them with sand bags of increasing weight on his ankle.
Knee swinging If his knee is stiff, ask him to let it hang over the side of his bed, and swing until it is at least 90°. As the range of movement in his knee improves, he can get the l ast few degrees of flexion by grasping his lower leg in his arms and flexing his knee.
Cycling is superb knee exercise. Knee bending with his foot raised on a step i s useful in patellar fractures and is shown in Fig. 79-7.
ANKLE EXERCiSES
Cycling is also one of the best ankle exercises. Make sure the patient flexes and extends his ankle as he rides.
ALL PATIENTS WITH FRACTURES NEED SOME EXERCISES, AND THEY MUST BE SUPERVISED BY SOMEONE WHO CARES
