FAQ

What is a fracture?

A fracture is defined as a disruption in the integrity of a living bone, involving injury to the bone marrow, periosteum, and adjacent soft tissues.

How does a fracture occur?

Fractures occur when the force applied to a bone exceeds the strength of the involved bone. Bones can fracture as a result of direct or indirect trauma. Direct trauma consists of direct force applied to the bone like tapping fractures (bumper trauma in road accidents), penetrating fractures (eg, gunshot wound) and crush fractures. Indirect trauma involves forces acting at a distance from the fracture site such as tension (traction), compressive, and rotational forces.

Fracture incidence is multifactorial and often complicated by such factors as the patient’s age, sex, co-morbidities, lifestyle, and occupation. Nearly 1.05 lakh people die in road accidents in India. Interestingly, there was a bimodal distribution of fractures in males, with a high incidence in young men and a second rise in men starting at the age of 60 years. In women, there was a unimodal distribution of fractures, with a rise around the time of menopause.

Restore the patient to optimal functional state, Prevent fracture and soft-tissue complications, Get the fracture to heal and in a position which will produce optimal functional recovery and Rehabilitate the patient as early as possible

How does an orthopaedic surgeon describe a fracture?

• Mechanism of injury (traumatic, pathological, stress)
• Anatomical site (bone and location in bone)
• Configuration Displacement : three planes of angulation, translation and shortening
• Articular involvement/epiphyseal injuries : fracture involving joint, dislocation and ligamentous avulsion
• Soft tissue injury

General Other injuries, Chest infection, Embolism, UTI, ARDS, Bed sores
Bone Infection, Non-union, Malunion, Avascular necrosis
Soft-tissues Plaster sores/Wound Infections, Tendon rupture, NeuroVascular injury, Nerve compression, Compartment syndrome, Volkmann contracture

• It depends on the energy transfer of the injury, the tissue response and the method of treatment.
• The patient factors include age, nutritional status, systemic diseases, hormonal factors and personal habits of smoking and alcoholism.

Fracture healing depends on many factors and varies considerably. In general, fracture healing, for adults, upper limb in 6-8 weeks and lower limb in 12-16 weeks and for child, upper limb in 3-4 weeks and lower limb in 6-8 weeks. Radiologically, on X-ray fracture healing is shown by Bridging callus formation and bone remodelling

Single-limb injury
This consists of patients where only either single long or small bone is fractured. Management depends on individual fracture considerations.

Multiple traumatic injuries (polytrauma)
These poly-trauma or multiply injured patients need much urgent attention. These patients could have life threatening associated injuries and need multi-disciplinary approach.

The initial assessment of a patient with polytrauma follows the advanced trauma life support (ATLS) protocol and includes the identification and treatment of life-threatening injuries. The first step is evaluation of the individual’s airway, breathing, and circulation. Once the patient is hemodynamically stable, the secondary survey, a complete systems-based physical examination, is performed.

These patients need higher tertiary care hospital management. Patients should be shifted to advanced trauma care units for intensive management where advanced infrastructure, equipments, facilities, specialist and super-specialists are available.

Management includes Life saving measures to Diagnose and treat life threatening injuries and Emergency orthopaedic involvement.

The initial management of fractures consists of realignment of the broken limb segment and then immobilizing the fractured extremity in a splint. The distal neurologic and vascular status must be clinically assessed. Splinting is critical in providing symptomatic relief for the patient. Patients should receive adequate analgesics.

An open fracture is a broken bone that penetrates the skin. Open fractures are typically caused by high-energy injuries such as car crashes, falls, or sports injuries. Furthermore, because of the risk of infection, there are more often problems associated with healing when a fracture is open to the skin.

Hemostasis should be obtained, followed by antibiotic administration and tetanus vaccination. Urgent irrigation and debridement (I&D) of the wound in the operating room is mandatory. The wound is subsequently stabilized either temporarily or definitively. If soft-tissue coverage over the injury is inadequate, soft-tissue transfers or free flaps are performed when the wound is clean and the fracture is definitively treated.

Fracture management can be divided into non-operative and operative techniques. The non-operative technique consists of a closed reduction if required, followed by a period of immobilization with casting or splinting. Closed reduction is needed if the fracture is significantly displaced or angulated.

General trend toward operative treatment last 30 yrs with improved implants and antibiotic prophylaxis and use of closed and minimally invasive methods

Current absolute indications:-
Polytrauma, Displaced intra-articular fractures, Open fractures, Fractures with vascular injury or compartment syndrome, Pathological fractures, Malunion and Non-unions

Current relative indications:-
Loss of position with closed method, Poor functional result with non-anatomical reduction, Displaced fractures with poor blood supply, Economic and medical indications

Restoring the patient as close to pre-injury functional level as possible.
Approach needs to be pragmatic with realistic targets. Multidisciplinary involvement of Physiotherapist, Occupational therapist, nurse, General Practitioner and Social worker is needed.

The bones of the body form the human frame, or skeleton, which supports and protects the softer parts of the body. They grow rapidly during one’s early years, and renew themselves when they are broken.
Bones have a center called the marrow, which is softer than the outer part of the bone. Bones contain the minerals calcium and phosphorus, which are combined in a crystal-like or latticework structure. Because of their unique structure, bones can bear large amounts of weight.

Bones are rigid, but they do bend, or “give” somewhat when an outside force is applied to them. When this force stops, bone returns to its original shape. If the force is too great, however, bones will break, just as a plastic ruler breaks after being bent too far.

Fractures can happen in a variety of ways, but there are three common causes:

• Trauma accounts for most fractures.
• Osteoporosis also can contribute to fractures.
• Overuse sometimes results in stress fractures.

Usually, you will know immediately if you have broken a bone. You may hear a snap or cracking sound. The area around the fracture will be tender and swollen. A limb may be deformed, or a part of the bone may puncture through the skin.

If you think a bone may be broken, medical examination and x-rays are usually necessary. The orthopaedician usually applies a splint to prevent further damage, to lessen the pain and to help stop any bleeding. Elevation helps to reduce bleeding and swelling.

All forms of treatment of broken bones follow one basic rule: the broken pieces must be put back into position and prevented from moving out of place until they are healed..

All tissues, bone included, will heal spontaneously.

For most orthopedic diseases and injuries there is more than one form of treatment. The orthopedist will discuss the treatment options with the patient and help select the best treatment plan that will enable the patient to live an active and functional life.

The first techniques of operative fracture treatment were developed in the 19th century.
This method gave rise to the combination of the disadvantages of the conservative and the operative fracture treatment. The fracture had to be opened with a real risk for infection, the bone healing was disturbed, and there was muscular atrophy and joint stiffness.

“Biological osteosynthesis” : a terminology introduced to indicate a new type of osteosynthesis leading to a sufficiently stable fixation of the bone fragments allowing early mobilisation, but without major disturbance of the vascularisation. Advanced Orthopedics believes that quality care starts by spending time with each patient to properly diagnose and manage the condition

Availability of improved quality implants, higher antibiotics, and technological advances in infection control to keep sterility in operation theatre, multi-disciplinary approach and surgical critical care has expanded horizons of orthopaedic surgeons.

It has changed in most of the things

• Management of poly-trauma or multiply injured
• Critical and / or Geriatric orthopedics
• Bone non-union and deformity correction
• Bone infections
• Complicated or complex intra-articular fractures
• Arthroscopy and arthroplasty
• Minimally invasive orthopedics

Arthroscopic surgery is one of the most common orthopedic procedures performed today. Through stab incisions over joints, with the use of small instruments and cameras, an orthopaedic surgeon can visualize, diagnose, and treat problems within the joints.

Sports medicine is a branch of orthopedics that specializes in the treatment of injuries suffered due to athletic activity. Joints commonly affected by sports injuries include the knee (ACL/MCL tears, meniscal tears) and the shoulder (rotator cuff tears, dislocation). Depending on severity, some sports injuries, particularly ligament tears, will require surgical treatment.

ACL reconstruction is a surgical procedure that repairs a torn anterior cruciate ligament (ACL), one of the four ligaments that help stabilize the knee. The ligament is reconstructed using a tendon that is passed through the inside of the knee joint and secured to the upper leg bone (femur) and one of the two lower leg bones (tibia).

Nonunion is failure of the bone healing process to go to completion. A recipe for non-union would be an injury to a vulnerable area which damages the blood supply, treated by open surgery which doesn’t manage to stabilize the fracture and the patient starts walking too early! Together these factors would create a serious risk of nonunion.

The treatment of nonunion is to reverse the conditions which may predispose; freshen up the area to allow a new blood supply to grow in, immobilise the fracture and use bone graft to give the process of ossification a good start. Most often this means surgery with bone grafting and exchange of hardware or the Ilizarov method being popular surgical choices.

Osteomyelitis is the medical term for an infection in a bone. Once considered incurable, osteomyelitis can be successfully treated today. Still, osteomyelitis is a serious condition, requiring aggressive treatment to prevent spread of your infection and to save the affected bone.

The treatment for chronic osteomyelitis consists of surgery and antibiotics. Surgery includes draining the infected area, removing diseased bone and tissue and restoring blood flow to the bone.

Providing rotation and precise dexterity, the hand and wrist are complex joints with several components that work in coordination. Common causes for surgery to the hand and wrist include: carpal tunnel syndrome; traumatic injury, such as a fall, severe cut, or sports injury; and severe arthritis.

Instead of opening fractures completely for fixation, indirect reduction is sought and smaller incisions are taken to put the implants. Special instruments are available to fix fractures in MIS/ MIPPO method.

When compared to traditional open surgery, the capability to perform a surgical procedure through a small incision provides several potential benefits, including reduced tissue damage, blood loss, and scarring. Likewise, the less invasive surgical technique often leads to a shorter recovery period.

Fractures take several weeks to several months to heal, depending on the extent and location of the injury. Rehabilitation is to promote a return to function and independent living. Exercise restores motion and strength while functional training facilitates a return to daily activities, work, or sport.

Fractures of the hip are relatively common in adults and often lead to devastating consequences. Disability frequently results from persistent pain and limited physical mobility. Hip fractures are associated with substantial morbidity and mortality. Most hip fractures occur in elderly individuals as a result of minimal trauma, such as a fall from standing height. 50% of post hip fracture patients require permanent use of assistive devices or aids for walking

Surgery is needed in almost all cases of fracture neck femur, except few undisplaced fractures. The treatment of femoral neck fractures primarily depends on a careful assessment of patient’s age, co-morbidities and activity level, bone quality and fracture pattern. All patients must be evaluated thoroughly and their condition stabilized prior to proceeding with internal fixation of the femoral neck fracture.

Early surgery (within 24-48 hr) is associated with a reduction in 1-year mortality and lower incidence of pressure sores, confusion, and fatal pulmonary embolism

This technique has many advantages such as; minimal trauma, no need to open the fracture site, optimal biomechanical stability (eliminates rotational and binding forces, allows pure compressive forces), possibility to reconstruct large bone defects, correction of deformities, providing early joint motion, keeping the blood supply of the bone, and minimal blood loss during the operation.

It involves one or more of the bones in a limb being broken, and then the two separate parts of that bone being slowly pulled apart (distracted). Normally this involves small adjustments done several times a day. Bone regenerates in this situation, and new bone cells will be produced and will fill the space in the break. The new bone will not be fully hardened (consolidate) for over a year, but should be strong enough to support walking within a few months of surgery.

Most surgeons recommend a maximum of 5cm per limb, but up to 12cm is possible with some techniques. For an increase of 5cm (50mm) a normal, healthy adult should expect the whole process to take about 6 months from operation, to being able to walk again. There are no long term effects on the lengthened bone, as bone is under constant remodeling; hence the newly formed bone is as strong as the intact original bone.