• Trauma: single incidence, repeated minor trauma (stress # - eg. Metatarsals - walking too much)
• # occur both in normal and abnormal bones (if abn = pathological # - eg. Ca, osteoporosis)
• Pathological #: (1) Generalised bone disease (2) Benign (3) Malignant: primary, secondary
• Trauma: most frequent cause of #

• Clue to cause
• Mx
• Associated injuries to neighbouring structures (eg. overlying skin, BV, n)
• Complications + prognosis

Transverse, oblique/spiral, compression, segmental

• Transverse # (eg. From direct blow) is a dirty compound # (from outside to in)
• Spiral #: from rotation (eg. Skiing), unstable (reduced by rotation, but once released, will return to spiral position), seldom has direct injury to skin but sharp edges can develop into compound # (clean: from inside to out)
• Compression: eg. Calcaneal # - also likely to have compression # of T12 or L1 vertebra (can see associated pattern of damage)
• Avulsion # of lesser trochanter of femur due to iliopsoas (eg. Kicking action), will only avulse if bone already abnormal (this site common for secondary metastases deposit)

Displacement (type & amt)

Angulation, shortening, rotation, sideways

• Side shifting: overlap = shortening; jam against each other = impaction (eg. Colles #; stable but deformed)
• Side tilting: anterior, lateral, medial, lateral tilting
• Twist/ Rotational deformity

1. Haematoma: immediately after, under periosteum
2. Inflammation: bring in inflammatory cells, repair cells (remove injured + dead tissue)
3. Callus: depends on age of Pt + location of #, in 2-3w new bone formation. Cartilage -> replaced by bone (spongy) -> becomes cortical bone
4. Consolidation: of cortical bone (strength) - see bone threads on X-ray (healed); bone must be protected until consolidation
5. Remodelling: complete when original medullary cavity present

SIGNS

• Due to blood loss: eg. # femur - lose 800-1000 cc

Swelling, bruising, blisters, tenderness, deformity, crepitus, abnormal movement, loss of function

• Blister: skin damage, blood gradually oozes from bone to surface forming bloody blisters
• Crepitus: # ends rubbing on each other
• Tenderness: tenderness localises # site
• Not all # exhibit these signs
• Assoc.: skin, BV, nerves (therefore need to exam peripheral pulses, BP, surrounding areas, etc.)

Eg. Colles #: deformity

Eg. Spine #: plegia, affect resp

Eg. Pelvis #: urethra, bladder rupture

INVESTIGATIONS

2 views, 2 occasions, 2 joints, 2 sides

• 2 views at right-angles to each other (AP may hide # that shows up on lateral view)
• 2 occasions/ intervals/ times: eg. 2 weeks later not so painful, better positioning of hand for X-ray (eg. To see scaphoid, put wrist in dorsiflexed position)
• 2 joints: eg. Not just # of ulna, but also radius dislocated anteriorly (Monteggia's #: # of proximal half of the shaft of the ulna, with dislocation of the head of the radius)
• 2 sides: L + R, esp. in children (epiphyseal growth plates)

Tomogram, CT, MRI, bone scan

1. 1st aid and resuscitation: A, B, C, D, E

2. Reduction if necessary

• If # is displaced and displacement results in cosmetic abnormality or dysfunction in movt
• If displaced and no effect (eg. # rib), no need to reduce
• Most do not need reduction (> 50%)
• Closed reduction: manipulation (TCM bonesetters very skilful)
• Open reduction: surgery (esp. for # involving jts)

3. Immobilisation if necessary

• If # already stable, no need to immobilise (eg. # spine in osteoporosis, b/c they are impacted, one reason why ht decreases with age)
• Ribs: impossible to immobilise
• Jt #: immobilisation needed
• However, most cases do not require immobilisation
• Methods: traction, cast, bracing, internal fixation, external fixation
• Traction: separate impacted bones, maintain original length, heals if 50% of bone in contact
• Plaster: easy to use, very popular, if too tight can cause ulcer (burning pain, no relief with analgesic, skin dead in 6 hr - no more pain)
• Bracing: plastic, allows some movt, protects #
• Open reduction and internal fixation: plate, rod inside bone
• External fixation: eg. Compound comminuted #, drive nails through top and bottom segments of #, expose skin surface for further Tx

4. Rehabilitation always

• Rehab starts from # site and spreads out whole body (eg. Colles # -> complication = frozen shoulder due to decreased movt of whole limb)
• Upper body strength important in LL injury (may have to use crutches)

1. Prevent oedema -> fibrosis (elevate limb)
2. Exercise: active, assisted, functional activity
3. Psychological
4. Social

• Shock
• Crush syndrome: of muscle -> releases Mb -> renal shut-down
• DVT
• Fat embolism: from marrow to bloodstream -> pulmonary emboli / brain
• Tetanus
• Gas gangrene

May involve bone, soft tissue, joints