Understanding different types of fractures and approach to fracture management

Injury to the bone leading to a fracture can be caused by a trauma where too much force has been applied to the bone to the point it breaks or it can be pathological , when the bone already has a diesease and it breaks during normal use after a minimal trauma .

A fracture can also be due to stress related injury , when a low velocity injury occurs repeatedly .

Before we talk about the management of fracture , it's really important to classify them.

When the fracture lies oblique to the long axis of bone , it is called as Oblique fracture while the fractures lying perpendicular to long axis of bone are called as Transverse fractures. When the oblique fracture is very severe, it leads to rotation along the long axis of the bone , this results in a fracture called as spiral fracture.

If the bone breaks into more than two fragments it is called as comminuted fracture while segmental fracture is more than one fracture along the bone.

A bone injury can be open or closed , open fracture has a break in the skin continuity which has chances of developing complications like infection , malunion or nonunion while when closed fracture occurs , the skin remains intact and only bone is broken . Understandably, open fractures are much more dangerous compared to the closed ones.

Open fractures have been classified further into 3 grades by Gustilo and Anderson classification system. 

.Grade 1 is given to the low energy wounds of size less than one centimetre

.Grade 2 are wounds of more than one centimetre size with moderate soft tissue injury 

.Grade 3 wounds are high energy wounds of size more than 10 centimeter having extensive soft tissue damage.

Grade 3 wounds are further subdivided into three subgroups , 

Grade 3A wounds have enough soft tissue coverage while grade 3B wounds have poor soft tissue coverage 

Grade 3C wounds are associated with an arterial injury 

Now that we have understood the different types of fractures , lets discuss about the diagnosis

Diagnosis involves evaluation of fracture to know the site and type of injury , associated injuries and neurovascular deficits.This will involve a thorough clinical examination and radiographs of proximal and distal joints.

When we try to assess the xray , few things to keep in mind are

-Changes in the length of the bone 

-Angulation of the distal bone and rotational effects

-Presence of foreign body aka materials such as glass

-Management of fractures

Clinical examination : Initial management must focus on careful clinical examination of the fracture site to look for associated injuries , haemorrhage and control of it , site and extent of injury 

Imaging : The fracture site must be carefully imaged , radiographs of distal and proximal joints must be taken.

Neurovascular status : Distal neurovascular status must be established 

Wound should be covered with a dressing and antibiotics should be given to prevent infections 

For open fractures, early debridement is main basis of management , debridement involves thoroughly cleaning the wound and getting rid of thickened skin or callus (hyperkeratosis) , infected or dead tissues , foregin material such as glass , dirt etc

In most of the cases the wound is left open , for irrigation of the wound six litres of saline is used which should be done within six hours of injury , stabilization of the fracture must be done and more often than not , an external fixator is applied in the first instance.