Fractures
What is a fracture?
-
A fracture is description for a broken bone
​
What are the types of fracture?
-
Transverse - a straight horizontal break across a bone
-
Spiral - a twisting type fracture
-
Comminuted - a fracture with multiple bone fragments at the site of the break
-
Segmental - a fracture where there is more than one fracture in the same bone
-
Peri-articular - a fracture around or extending into a joint
-
Peri-prosthetic - a fracture typically around an artificial joint replacement
​
What are the principles of fracture management?
-
The aim of treating any fracture is to keep the bone stable so that the body's biology can heal the broken bone
​
How can fractures be stabilised?
-
Fractures can be stabilised with casts, splints, internal metalwork such as plates and screws or external metalwork such as an external fixator
​
How do you choose how to stabilise a fracture?
-
All management decisions are made in patient centred, shared manner. Some fractures are amenable to stabilisation with a cast or splint, whereas some are more amenable to surgical stabilisation
Deformity
What is a deformity?
A deformity is an atypical, structural deviation or distortion of the bone's shape from its normal alignment, length and/or size​
​
What causes deformity of bones
-
A bony deformity can either be present from birth (congenital) or develop in later life (acquired)​
​​
What causes acquired bony deformities?
-
Most acquired bony deformities are a result of trauma
-
Deformities from trauma can occur if the bone fails to heal (non-union) or heals in the wrong position (malunion), which can cause a limb to be shorter and have a bend.
​
What are the consequences of a bony deformity?
A disruption of the normal weightbearing axis may occur which can result in:​
-
A change in the way you normally walk, such as a limp
-
Referred pain - a change in the weight passes through a bone can cause pain in other areas such as the hip, knee or ankle
-
Joint stiffness - a deformity around a joint can affect the way a joint normally moves, resulting in become stiffer
-
Misalignment - a foot that points inwards or outwards may suggest a bone has a rotational or twisted deformity
​
How can a bony deformity be managed?
-
A symptomatic bony deformity can be correct with surgery
-
Breaking the bone in a controlled manner​
-
Realigning the bone - this may be performed acutely or gradually over time
-
Stabilising the bone until it heals - once the been realigned it must be kept stable to allow it to heal. This may be with internal metalwork or an external fixator
Non Union
What is a non-union?
-
Most broken bones heal without any problems, with new bone forming to connect the broken bone back together.
-
Unfortunately in some patients the broken bones do not heal.
-
A fracture is considered to have a non-union when a broken or fractured bone does not heal in the expected period of time.
-
The expected healing time for each bone can vary, with bones in the lower limb taking longer than those in the upper limb.
​
What are the causes of non-union?
There are several reasons why bones do not heal which may include:
-
Infection at the site of the fracture
-
Inadequate blood supply to the bone
-
A gap between the two ends of fractured. bone
-
Inadequate stabilisation of the bone which allows movement
​​
What is the difference between an atrophic and a hypertrophic non-union?|​
-
Atrophic - minimal evidence of bony healing or callus formation on x-ray
-
Hypertrophic - evidence of large amounts of callus or attempts at bony healing on x-ray​
​​
What are the symptoms of non-union
-
Ongoing pain
-
Swelling
-
Deformity
-
Instability
-
Inability to weight bear
​
What are the treatment options for non-union
-
The majority of symptomatic non-unions are treated with surgery and may include:
-
Re-fixation
-
Percutaneous screws
-
Infection debridement
-
External fixation - Ilizarov or taylor spatial frame
Limb Length Discrepancy
Limb length discrepancy is typically where an arm or leg is shorter than the other, but both arms or legs may be affected. The lower limbs are more commonly affected than the lower limbs.
​
What causes limb length discrepancies?
-
Congenital (from birth)
-
Post traumatic
-
Growth plate injury in childhood - trauma or infection
-
Non-union
-
Malunion
-
Bone tumours
-
Short stature
How can leg length discrepancy be managed?
-
Up to 2cm - this can be accommodated with a insert in a patients shoe
-
More than 2cm - surgical management
​
What are the surgical options for leg length discrepancy?
-
External fixation - an external fixator is attached to the outside of the leg with pins and wires. The external frame can adjusted to correct the leg length discrepancy. The frame remains onto the outside of the leg until the bone which has been made longer has fully healed.
-
Internal lengthening nails - an motorised nail is inserted inside the middle of the bone. The motor gradually lengthens the bone until the desired length is achieved. After the lengthened bone has fully healed the motorised nail must be removed.
Bone Defects
What is a bone defect?
-
A bone defect is when part of bone is lost, typically from trauma or infecton
What are the types of bone defect?
-
Partial - a bone defect where there is a portion of bone missing but there is still some contact between the remaining bone ends
-
Segmental - a bone defect where there is a portion of bone missing but there is no contact between the the remaining bone ends
​​
Are all partial bone defects the same?​
-
Partial bone defects can be considered critical or non-critical​
-
Critical - the remaining bone when healed support the function of the limb, even with the piece of bone missing
​
What are the techniques for managing bone defects
-
Grafting - synthetic materials or patients bone bone from elsewhere in the body - typically used for non-critical partial bone defects
-
Masquelet - the induced membrane technique - a two step surgical procedure:
-
​Creating a membrane around a cement spacer (induced membrane)
-
At a later date using that membrane to promote bone growth when the spacer is replaced with a bone graft.
-
-
Bone transport - distraction osteogenesis - a piece of bone from the affected bone is moved up or down to replace the missing piece, whilst new bone grows to replace where it came from​
-
Shortening with lengthening
-
Bringing two pieces of bone together to eliminate the defect and lengthening the same limb elsewhere to ensure it stays and equal length
-
