Management of Fracture, Sprains and Dislocations

Fracture

Fracture refers to a condition where there is a complete or partial disruption in the continuity of the bone. Healthy bone is tough and resilient and can absorb powerful impacts. However, any abnormality of the bone or an external force beyond the stress level of the bone may result in a fracture. It is the one of the most common orthopaedic conditions affecting individuals of all age groups.

Classification of fracture

Fractures can be broadly classified into the following categories:

Open fracture: The fractured bone is exposed to the environment, through a deep wound in the skin.

Closed fracture: Although the bone is fractured, the skin remains intact.

Types of fracture

Depending on the nature of fracture, it can be classified into the following categories:

  • Greenstick fracture- It is an incomplete fracture of the bone without a separation of the bone. It is common in children, as their bones are softer and more elastic.
  • Transverse fracture- It is a complete break across the bone.
  • Oblique fracture- It is a fracture that is diagonal to the long axis of the bone.
  • Spiral fracture- It is a fracture that spirals around the bone and is common in twisting injuries.
  • Compression fracture- This is more common in the bones of the spine where the bone is crushed or collapses.
  • Comminuted fracture- In this type of fracture the bone is fragmented into several small pieces.
  • Impacted fracture- In this type of fracture one of the fragments of fractured bone is driven into the other.
  • Pathologic fracture- These refer to fractures due to weakened bone secondary to an underlying disease.

Causes of fracture

Application of force beyond the tensile strength of the bone causes a fracture. The majority of fractures are a result of a fall, trauma or a direct blow to the bone. Other factors such as aging or an underlying illness may also cause fractures due to weakened bone.

Symptoms of fracture

The most common symptom of a fracture is pain and swelling at the fracture site along with warmth and tenderness. The fracture may also result in a physical deformity and difficulty in movement.

Diagnosis of fracture

The diagnosis of fracture includes a medical history along with a physical examination of the site of fracture, by a physician, to determine the nature of the fracture. Diagnostic imaging studies such as X-ray help identify and locate the fracture.

Treatment of fracture

The objective of early fracture management is to control bleeding, prevent ischemic injury (bone death) and to remove sources of infection such as foreign bodies and dead tissue. The next step in fracture management is the reduction of the fracture and its maintenance. It is important to ensure that the involved part of the body returns to its function after the fracture heals. To achieve this, maintenance of fracture reduction with immobilization technique is done by either non-operative or surgical methods.

Non-operative (closed) therapy comprises of casting and traction (skin and skeletal traction).

Treatment of fracture

  • Casting- Closed reduction is done for any fracture that is displaced, shortened, or angulated. Splints and casts made up of fiberglass or plaster of Paris material are used to immobilize the limb.
  • Traction- Traction method is used for the management of fractures and dislocations that cannot be treated by casting. There are two methods of traction namely, skin traction and skeletal traction.

    Skin traction involves attachment of traction tapes to the skin of the limb segment below the fracture. In skeletal traction, a pin is inserted through the bone distal to the fracture. Weights will be applied to this pin, and the patient is placed in an apparatus that facilitates traction. This method is most commonly used for fractures of the thighbone.

Surgical Therapy

  • Open Reduction and Internal Fixation (ORIF) This is a surgical procedure in which the fracture site is adequately exposed, and reduction of the fracture is done. Internal fixation is performed with devices such as Kirschner wires, plates and screws, and intramedullary nails.
  • External fixation External fixation is a procedure in which the fracture stabilization is done at a distance from the site of fracture. It helps to maintain bone length and alignment without casting.

    External fixation is performed in the following conditions:

    • Open fractures with soft-tissue involvement
    • Burns and soft tissue injuries
    • Pelvic fractures
    • Comminuted and unstable fractures
    • Fractures having bony deficits
    • Limb-lengthening procedures
    • Fractures with infection or nonunion

Rehabilitation

Fractures may take several weeks to months to heal completely. You should limit your activities even after the removal of a cast or brace so that the bone become solid enough to bear the stress. Rehabilitation program involves exercises and gradual increase in activity levels until the process of healing is complete.

Sprains

Sprains and strains are injuries affecting the muscles and ligaments. A sprain is an injury or tear of one or more ligaments that commonly occurs at the wrists, knees, ankles and thumbs. A strain is an injury or tear to the muscle. Strains occur commonly in the back and legs. Sprains and strains occur due to overstretching of the joints during sports activities and accidents such as falls or collisions.

Symptoms of sprains include pain, swelling, tenderness, bruising and joint stiffness. Symptoms of strains include muscle spasm and weakness, pain in the affected area, swelling, redness and bruising.

Immediately following an injury and before being evaluated by a medical doctor, you should initiate the P.R.I.C.E. method of treatment.

  • Protection: Protect the injured area with the help of a support.
  • Rest: Give rest to the affected area as more damage could result from putting pressure on the injury.
  • Ice: Ice should be applied over a towel to the affected area for 15-20 minutes every two to three hours during the day. Never place ice directly over the skin.
  • Compression: Wrapping the knee with an elastic bandage or an elasticated tubular bandage can help to minimize the swelling and support to the injured area.
  • Elevation: Elevating the injured area above heart level will also help with swelling and pain.

Diagnosis involves a thorough physical examination. Your doctor will inspect the area of injury and joint mobility. X-rays or other tests may be ordered to rule out fractures or other pathology.

Your doctor may prescribe nonsteroidal anti-inflammatory drugs to reduce pain and inflammation. Physical therapy may be recommended for severe injuries. Surgery is rarely needed.

Dislocations

Dislocation refers to the disruption of a joint from the separation of two bones which articulate with each other at the joint. It may cause a temporary deformity and immobilization of the affected joint along with severe pain. Dislocation is more common in some of the major joints of the body such as shoulder, hip, knee, elbow and ankle. Sometimes it can also occur in the small joints of hand.

Causes

Dislocation may occur secondary to a sports injury especially in contact sports such as football, hockey, and basketball or may be caused by a fall or trauma due to motor vehicle accident.

Symptoms

Intense pain and swelling are the predominant symptoms of dislocation. There will be visible deformity along with a limitation of mobility of the joint. The injured joint may feel warm and tender. The patient may also experience numbness or tingling sensation near the site of the injury.

Diagnosis

The diagnosis of the dislocation is based on the medical history of the patient along with a physical examination and imaging studies such as X-ray and MRI scan.

Treatment

Any dislocation requires immediate medical attention. The management of dislocation depends on the location, severity or extent of the injury and also the age, health status or medical history of the patient. Both non-surgical and surgical treatment can be used for the management of dislocation.

  • Non-surgical treatment: The initial approach for the management of a dislocation is RICE (rest, ice, compression and elevation) therapy along with a splint or sling for immediate support and pain relief. Medication may be prescribed for reduction of pain and inflammation. Based on the nature of the dislocation your physician may try to realign the bone manually followed by immobilization of the joint by a cast or splint.
  • Surgical treatment: Surgery may be required if the nerves or blood vessels have been injured or a manual reduction of the dislocation is not feasible.

Rehabilitation

A rehabilitation program helps in complete recovery as well as to prevent a recurrence of the dislocation. Rehabilitation program involves exercises and gradual increase in activity levels until the process of healing is complete.