Trauma Education

Trauma Education

There are numerous joints in our body, it is where two bones meet. They make the skeleton - and body - flexible; some open like a hinge (eg. knees and elbows), while others allow more complex movements forward, backward, rotate (eg. shoulder and hip).

As we engage in our daily activities, go about our active lifestyle and as we grow older, it is unavoidable that we might encounter certain muscle injuries and joint disorders, in varying degrees of severity. Certain trauma may need immediate medical attention while others may not be life-threatening, yet could still be life-altering. Thus, it is very crucial to be educated on the types of trauma and medical assistance you would need.

What you need to know:
Adult Forearm Fractures

The forearm is made up of the radius and the ulna. Holding the hands at the side with palms facing up, the ulna is the bone closest to the body and larger eat the elbow, while the radius is closest to the thumb which is larger at the wrist. The primary motion of the forearm is rotation – the ability to turn our palms up or down; the ulna stays relatively still while the radius rotates around it.

A forearm fracture affects the ability to rotate the arm, as well as bend and straighten the wrist and elbow. In most cases of forearm fractures, both bones are broken. Forearm fractures that occur nearer the wrist are distal fractures, whereas fractures at the middle or near the elbow at the top are proximal fractures. Forearm bones can crack slightly, or it can break into multiple pieces and may line up straight, or be far out of place. In some cases, bone fragment can even stick out through the skin or a wound penetrates down to the broken bone – these open fractures require immediate medical attention due to the risk of infection.

Causes
The most common causes of forearm fractures include:

  • Direct blow
  • Fall on an outstretched arm, often during sports or from a height
  • Automobile/motorcycle accidents
  • If only one bone is broken, it is typically the ulna, it is usually caused by a direct blow to the outside of the arm when patient raised it in self defense.

Symptoms
A broken forearm usually causes immediate pain, and will often cause an obvious deformity – it may appear bent, or shorter than the other arm. The patient will most likely need to support the injured arm with the other hand.

Other symptoms include:

  • Swelling
  • Bruising
  • Inability to rotate arm
  • Numbness or weakness in the fingers or wrist (rare)

Diagnosis
A broken forearm calls for immediate attention at the urgent care centre or emergency room for initial treatment.

The doctor needs to know the specific circumstances of the injury; for example if the patient fell from a ladder, how far did he fall? It is also important to inform the doctor of any other injuries or if you have any existing medical problems such as diabetes, and if you are currently taking any medications.

The doctor will then examine the skin for any cuts or open injury, feel around the arm to determine if there is any other areas of injury, check patient’s pulse at the wrist to make sure that there is good blood flow from forearm to the hand. The patient may also be asked to move the fingers and wrists to determine if any nerves may be injured at the impact of injury. Lastly, the doctor will examine the shoulder, upper arm, elbow, wrist and hand to ensure that all else is fine.

X-rays will then be prescribed to show where the bone is broken at, how many pieces of broken bones there are, and whether there is any displacement in between the broken bones.

Treatments
As with treatment of broken bones, the basic rule is to put the broken bones back into position and prevent them from moving out of place until they are completely healed. Because the radius and ulna rely on each other for support, it is important that they are properly stabilised and accurately aligned during healing, so to avoid any future problems with wrist and elbow movement.

In the emergency room, the doctor may try to temporarily realign the bones, depending on how far out of place they are, while first controlling patient’s pain through medication. A splint and sling will then be applied and provided to keep the arm in position, as any further moving may cause worse harm and may cause additional damage to nearby blood vessels, nerves or tissues.

  • Non-surgical treatment
    If only one bone is broken and it is not out of place, it may be possible to treat it with a cast or brace. The doctor will closely monitor the healing of the fracture, make appointment for frequent x-ray follow ups. If the fracture shifts position, surgery may be required to put the bones back together.
  • Surgical treatment
    Open fractures or when both bones are broken usually results in surgical treatment, with open fractures requiring immediate surgery for fear of the risk of further infection. If there is no open injury, the doctor may recommend waiting until the swelling subsides before having surgery. Keeping the arm immobilised and elevated for several days will decrease the swelling, at the same time giving the stretched skin a chance to recover.During surgery, any cuts from the surgery will be thoroughly cleaned out, and broken bones fixed and put back together via internal or external fixation depending on the severity of fracture.

Recovery
When treated properly, bones actually have a remarkable capacity to heal. Forearm bones typically take 3 to 6 months to fully heal, depending on the severity of the injury. The doctor will work with the patient on appropriate pain management solutions such as drugs or medications and rehabilitation programs such as casts or slings

Distal Humerus Fractures of the Elbow

The elbow is a joint that is made up of three bones – the humerus (upper arm bone), the radius (forearm bone on the thumb side) and the ulna (forearm bone on the pinky side), held together by ligaments, tendons and muscles, with three major nerves crossing the joint. The elbow joint bends and straightens like a hinge, it also rotates the forearm to allow the hand to face palm side up, or palm side down.

  • The distal humerus is the lower end of the humerus, forming the upper part of the elbow and is the spool around which the forearm bends and straightens.
  • The radial head is the knobby end of the radius where it meets the elbow. It glides up and down the front of the distal humerus when the arm is bent and rotates around the ulna when the wrist is turned up or down.
  • The olecranon is the part of the ulna that “cups” the lower end of the humerus, creating a hinge for elbow movement. The bony “point” of the olecranon can be easily felt beneath the skin because it is covered by just a thin layer of tissue.
  • Distal Humerus Fractures of the ElbowA distal humerus fracture occurs when there is a break anywhere within the lower end of the humerus, it can slightly crack or break into many pieces (comminuted fracture) that may line up straight or may be far out of place (displaced fracture). In some cases, bone fragments may stick out through the skin or wound penetrates down into the bone. Distal humerus fractures are uncommon, they account for only 2% of all adult fractures, and can occur on their own with no other injuries, but it can also be part of a more complex elbow injury.

Causes
Distal humerus fractures are most often caused by:

  • Falling directly on the elbow
  • A direct blow to the elbow from something hard, like a baseball bat, or car door during a vehicle collision
  • Falling on an outstretched arm with the elbow held tightly to brace against the fall. In this situation, the ulna (one of the forearm bones) is driven into the distal humerus, causing it to break.
  • Distal humerus fractures are also sometimes caused by weak or insufficient bone, this is most common in older patients whose bones have become weakened by osteoporosis. In these patients, a fracture may occur even after a minor fall.

Symptoms
A distal humerus fracture may be very painful and can prevent the patient from moving the elbow. Other signs and symptoms may include:

  • Swelling
  • Bruising
  • Tenderness to the touch
  • Stiffness
  • Feeling of instability in the joint, as if the elbow is going to “pop out”
  • In rare cases, the fractured bone may stick out of the skin, causing anopen fracture

Diagnosis
The doctor will examine the elbow after discussing the patient’s symptoms and medical history to determine the extent of the injury. He will check the skin for any cuts or lacerations, or open fractures that may require immediate intervention for fear of the risk of infection. The doctor will also feel around the elbow and other parts of the arm and shoulder to check if there are other areas of tenderness indicating other broken bones or injuries, check the pulse at the wrist and even ask the patient to move the fingers and wrists to ensure that there is good blood flow to the hand and fingers.

X-rays may also be warranted to help diagnose the fracture and its severity.

Treatments
In the emergency room, the doctor will apply a splint and sling will then be applied and provided to keep the elbow in position. Other immediate treatments may include applying ice to reduce pain and swelling as well as medications and drugs.

  • Non-surgical treatment
    Non-surgical treatment may be recommended for stable fractures in which the pieces of bone are not displaced, and are also recommended for patients who are at higher risk of surgical complications, such as patients with severe osteoporosis and other medical conditions.The doctor will apply a sling or splint to hold the elbow in place and closely monitor the healing of the fracture with frequent x-ray follow ups to make sure that the bone has not shifted out of place. The splints are typically worn for 6 weeks before supervised motion is allowed. If the fracture shifts position, surgery may be required to put the bones back together.
  • Surgical treatment
    Surgery is usually required for distal humerus fractures in which the bones have moved out of place or when there is open fractures. If there is an open fracture, surgery is scheduled as soon as possible for fear of the risk of further infection. Patients will be given intravenous antibiotics in the emergency room, and may receive a tetanus shot.During surgery, any cuts from the surgery and the surfaces of the bone will be thoroughly cleaned out, and broken bones fixed and put back together via internal or external fixation depending on the severity of fracture. In some cases, open fractures will require more than one surgery.

Recovery
Whether the treatment for distal humerus fractures are surgical or non-surgical, recovery take much work. The doctor will work with the patient on appropriate pain management solutions such as using ice to alleviate the pain, or drugs and medications for pain relief. Rehabilitation programmes such as casts or slings for long periods of time is required, but it may cause the elbow to become very stiff. Exercises with a physical therapist will also be arranged to help improve range of motion, decrease stiffness and strengthen the muscles within the elbow. During recovery, doctor will give very specific restrictions on what the patient can or cannot do with the injured arm over a period of time.

Distal Radius Fracture (Broken Wrist)

The radius is the larger of the two bones of the forearm, with the end toward the wrist called the distal end. A fracture of the distal radius occurs when the area of the radius near the wrist breaks, in fact the radius is the most commonly broken bone in the arm. A distal radius fracture almost always occur about 1 inch from the end of the bone, yet it can break in many different ways.

One of the most common distal radius fractures is a Colles fracture, in which the broken fragment of the radius tilt upward. The fracture may or may not extend into the wrist joint, and may occur together with a broken ulna. It is important to classify the type of fracture as some fractures are more difficult to treat than others, and thus treatment methods may vary.

Causes
The most common cause for a distal radius fracture is falling onto an outstretched arm. The wrist may break if the force of the trauma is severe enough. Osteoporosis may increase the risk of a broken wrist as well.

Symptoms
A broken wrist usually causes immediate pain, tenderness, bruising and swelling. In many cases, the wrist might become deformed and hang in an odd or bent way

Diagnosis
The doctor will examine the hand and wrist to see whether it is tender in any area or whether there is any deformity after discussing the patient’s symptoms and medical history. To confirm the diagnosis, an X-ray will be performed to show if the bone is broken or whether there is any displacement, and to also see how many pieces of broken bones there are.

Distal Radius Fracture

Treatments
If the injury is not extremely painful and the wrist is not deformed, it may be possible to wait until the next day to see a doctor. The wrist may be protected with a splint, an ice pack can be applied to the wrist and the wrist can be elevated until a doctor is able to examine it. However, if the injury is very painful and the wrist is deformed or numb, it is necessary to rush to the emergency room.

  • Non-surgical treatment
    If the broken bone is in good position, a plaster cast may be applied until the bone heals. If the position of the hone is out of place and likely to limit the future use of the arm, it may be necessary to realign the broken bone fragments via closed reduction. After the bones are properly aligned, a splint is usually used for the first few days to allow a small amount of normal swelling, and a cast added a few days to a week or so later after the swelling goes down. The cast will be changed 2-3 weeks later as the swelling subsides further.Depending on the nature of the fracture, the doctor may closely monitor the healing by taking regular X-rays; more stable conditions will warrant for X-rays that are less often as compared to unstable fractures. Physical therapy begins 6 weeks after the fracture, after the cast is removed, to improve the motion and function of the injured wrist.
  • Surgical treatment
    Severely displaced broken bones require surgery to correct the placement, such as open reduction. Depending on the type of fracture, there are a few options of holding the bone in the correct position to let it heal. Metal pins, plates and screws, external fixator, casts, or any combination of these techniques.

Recovery
Whether the treatment for distal radius fractures are surgical or non-surgical, recovery is different for every individual, so your doctor will arrange pain management and recovery or rehabilitation programmes that are specific to help you heal. Pain-relief medications such as ibuprofen and acetaminophen combined are effective to relieve pain and inflammation. Casts will be replaced as the swelling subsides and the original cast becomes loose, the last cast is usually removed after about 6 weeks. The full recovery period should be expected to take at least a year.

Acetabular Fractures

An acetabular fracture is a break in the ‘socket’ portion of the hip joint, which is not as common compared to the fractures that happen to the upper femoral head (‘ball’ portion of the joint’). A majority of acetabular fractures are caused by high-impact events such as a car collision, many times patients will have additional injuries that require immediate medical treatment. In a smaller number of cases where low-impact events occur such as a fall from a standing position, may cause an acetabular fracture in an older person with weaker bones.

In acetabular fractures, the bone can break straight across the socket, or it can shatter into many small pieces. With a fractured acetabulum, the femoral head may no longer fit firmly into the socket and the cartilage surface of both bones may be damaged. If the joint remains irregular or unstable, ongoing cartilage damage to the surfaces may lead to arthritis. In some cases where very high energy trauma occurs, the bone may stick out through the skin causing an open fracture, though open fractures of the acetebulum are rare becasue the hip joint is well-covered with soft tissues.

Causes
An acetabular fracture results when a force drives the head of the femur against the acetabulum. Depending upon the direction of the force, the femoral head is sometimes pushed out of the hip socket, causing a hip dislocation. With high-impact fractures, patients often experience extensive bleeding and have other serious injuries that require urgent attention.

Weak or insufficient bone can cause acetabular fractures, this is most common in older patients whose bones have become weakened by osteoporosis. Although these patients do not often have other injuries, they may have complicating medical problems, such as heart disease or diabetes.

Symptoms
A fractured acetabulum is always painful, and the pain is worsened with movement. The patient may also feel numbness, weakness and a tingling sensation down the leg if a nerve damage has occurred.

Diagnosis
Patients with fractures caused by high-impact trauma will almost always be ushered to the emergency unit for initial treatment. If the fracture is indeed caused by high-energy impact, there may also be injuries to the head, chest, abdomen or legs. If there is significant blood loss, it may lead to shock, a life-threatening condition that can result in organ failure.

The doctor will perform a thorough examination of the pelvis, hips and legs, and he will check to see if the patient can move the ankles or toes and feel sensation on the soles. This is to ascertain if there are any nerve damage that occurred with the acetabular fracture. X-rays and CT scans will be warranted to show a more detailed image of the fracture and the severity of displacement, that will be very helpful in pre-operative planning.

Treatments
Treatment of acetabular fractures are dependent on the specific pattern of the fracture, how much the bones are displaced, and the overall health condition of the patient.

  • Non-surgical treatment
    Stable fractures with bones that are not displaced are good candidates for non-surgical treatment options. Patients who may be at higher risk of surgical complications are also recommended to be treated with non-surgical methods, such as those with severe osteoporosis, heart disease and other medical conditions that may not be able to tolerate surgery stress.Non-surgical treatments may include:

    • Walking aids such as crutches or a walker may be recommended for up to 3 months or until the bones are fully healed, to avoid bearing weight on the leg
    • Positioning aids such as an abduction pillow or knee immobiliser to limit the movement of the fractured hip may be used if the doctor is concerned about joint instability
    • The doctor may prescribe medications to relieve pain as well as an anti-coagulant (blood thinner) to reduce the risk of blood clots forming in the veins of the legs.
  • Surgical treatment
    Acetabular fractures damage the cartilage surface of the bone, thus an important goal of surgery is to restore a smooth, gliding hip surface. Most acetabular fractures are treated with surgery. During surgery, the doctor will reconstruct the normal anatomy of the hip joint by aligning bone fragments to restore the surface of the acetabulum, and fitting the femoral head into the hip socket. Yet, most acetabular fractures are not operated on immediately, instead the doctor may delay surgery after a few days to make sure the patient’s overall condition is stable. During this time, the leg may be placed in skeletal traction to immobilise movement to prevent additional injury to the hip socket.

Recovery
Pain is inevitable after surgery, but rest assured that the doctors and nurses will work to reduce your pain. Drugs and medications are often prescribed for short-term pain management post-surgery, including opioids, NSAIDs and local anaesthetics. Crutches and walkers are also prescribed for a period of time, with partial weight bearing allowed for some patients after 6 to 8 weeks. The doctor will recommend appropriate physical therapy and sports or fitness activities as the patient progresses from the fracture post surgery.

Fracture After Total Hip Replacement (Periprosthetic Hip Fracture)

A periprosthetic hip fracture is a broken bone that occurs around the implants of a total hip replacement, it is a serious complication that most often requires surgery. A fracture like this mostly occurs after a patient has spent years functioning well with a hip replacement. Fortunately, these fractures are rare.

periprosthetic hip fracture

Most periprosthetic fractures occur around the stem of the metal component placed in the femur, fractures of the acetabulum in these cases are less common. The severity of the fracture depends upon the quality and strength of the bone around the implant and the amount of force involved in the injury. The bone around the implant stem can break in many different ways

Causes
Periprosthetic femur fractures most often result from a fall or can also be caused by a high-impact occurrence, such as a direct blow to the side of the hip. A loosened femoral stem is also a major risk factor, typically occurring over a long period of time, and is most often due to everyday activity. It can also result from thinning of the bone (osteolysis).

 

Symptoms
The most common symptoms of periprosthetic hip fracture include:

  • Pain around the hip or thigh
  • Swelling and bruising around the hip or thigh
  • Inability to bear weight on the injured leg
  • Injured leg appears shorter or deformed

Diagnosis
Periprosthetic hip fractures are often very painful, so someone with this fracture will most likely go directly to the emergency unit where an emergency room physician and orthopaedic surgeon will be involved. They will closely examine the affected hip and the lower portion of the leg assessed for good blood flow to ensure that the main nerve (sciatic nerve) is functioning well.

X-rays of the pelvis, hip and femur bones will show the quality of the bone, how many pieces of broken bones there are, as well as the extent of the displacement. Some cases also calls for CT scans to provide a more detailed 3D images of the bone structures. The doctor may place a small traction device on the foot to help keep the leg straight to prevent any further damage.

Treatments
Most periprosthetic hip fractures require surgery. To determine the right treatment for the specific case, the doctor will consider the type and location of the fracture, the quality of the remaining bones, whether the implant in the femur is loose and the patient’s overall medical health status.

  • Surgical treatment
    Usually patients who require surgery may be in the hospital for several days before the surgery is performed, to medically stabilise the patient to reduce any inherent risks of the surgery. The general approaches to treat periprosthetic hip fractures include open reduction and internal fixation, or a revision of the joint implants, or a combination of both.

Recovery
Post surgery, the doctors and nurses will work to reduce your pain, drugs and medications are often prescribed for short-term pain management, including opioids, NSAIDs and local anaesthetics. Physical therapy begins soon after operation, and the surgeon will determine how much weight can be placed on the healing leg. A hip brace may also be required several weeks after surgery to further protect the hip while the fracture heals. Post surgery, patients may spend several weeks in a skilled rehabilitation center to improve strength and general health. The process of regaining strength and the ability to walk normally may take several months of work.

Femur Shaft Fractures (Broken Thighbone)

The femur (thighbone) is the longest and strongest bone in the body, thus it usually takes a lot of force to break it. The long, straight part of the femur is called the femoral shaft and any breakage along this length of bone is called a femoral shaft fracture.

Femur Shaft Fractures

The femoral shaft runs below the hip to where the bone begins to widen at the knee.

Types of femoral shaft fractures
Depending on the force that causes the fracture, femoral fractures vary greatly; the pieces of bone may line up correctly (stable fracture) or be out of alignment (displaced fracture), the skin around the fracture may be intact (closed fracture) or the bone may puncture the skin (open fracture). Femoral fractures are classified depending on the location of fracture (distal, middle or proximal), the pattern of fracture (crosswise fractures, lengthwise, or middle), and whether the skin and muscle over the bone is torn by the injury.

Causes
Femoral shaft fractures in young people occur frequently due to high-impact collision such as motor vehicle crash, falls from great heights or gunshot wounds. A lower-force incident such as falling from standing, may cause a femoral shaft fracture in an older person who has weaker bones.

Symptoms
A femoral shaft fracture usually causes immediate, severe pain and the patient will not be able to put any weight on the injured leg. It may look deformed, with one leg shorter then the other leg, and no longer straight.

Diagnosis
After discussing about your injury and medical history, the doctor may also ask about how the fracture happened and do a thorough examination of your overall condition as well as the leg specifically. The doctor will keep a look out for an obvious deformity of the thigh or leg, breaks in the skin or bony pieces that may be pushing on the skin, as well as bruises. The doctor will also feel along the thigh, leg and foot, check the tightness of the skin and muscles around the thigh, as well as check for pulses.

X-rays will then be ordered to evaluate the type of fracture the actual location within the femur. CT scans can also provide doctors with valuable information about the severity of the fracture in more detailed, such as very thin and hard to see fracture lines.

Treatments
Most femoral shaft fractures require surgery to heal, though very young children are sometimes treated with a cast.

  • Surgical treatment
    Most surgery to treat femoral shaft fractures are scheduled within 24 to 48 hours until other life-threatening injuries or unstable medical conditions are stabilised. External fixation with metal pins or screws placed into the bone above and below the fracture site provide temporary treatment for femoral shaft fractures. Procedures like intramedullary nailing will be performed when the overall condition of the patient is stabilised.

Recovery
Most femoral shaft fractures take 3 to 6 months to completely heal, if it is an open fracture or the bone was broken into several pieces, or if the patient uses tobacco products, healing process may be prolonged. Doctors will prescribe drugs and medications as pain management options. Doctors will also encourage leg motion early on in the recovery period, thus it is very important to follow doctor’s instructions strictly to avoid further problems and injuries.

Fractures of the Proximal Tibia (Shinbone)

The knee is the largest weight-bearing joint of the body where three bones meet to from the knee joint – the femur (thighbone), tibia (shinbone) and the patella (kneecap). Ligaments and tendons act like strong ropes to hold the bones together, working also as restraints, allowing some types of knee movement, and not others.

A fracture in the shinbone just below the knee is called a proximal tibia fracture. In addition to broken bone, soft tissues may be injured at the same time and must be treated together. In most cases, surgery is required to restore strength, motion and stability to the leg, and reduce the risk for arthritis.

Fractures of the Proximal Tibia

The proximal tibia is the upper portion of the bone, closest to the knee. (Right) Ligaments connect the femur to the tibia and fibula (kneecap not shown).

Types of proximal tibia fractures
There are several types of proximal tibia fractures. The bone can break straight across (transverse fracture) or into many pieces (comminuted fracture). Sometimes these fractures extend into the knee joint and separate the surface of the bone into a few (or many) parts – intra-articular fractures or tibial plateau fractures. This type of fractures can contribute to arthritis, instability and loss of motion over time. Fractures can be closed or open, depending on the way the bone breaks upon impact.

Causes
A fracture of the upper tibia can occur from stress (minor breaks from unusual excessive activity), or from already compromised bone (as cancer or infection). In young people, these fractures are often resulted from high-energy impacts while in older persons, lower-energy impact on weakened bone is sufficient to cause these fractures

Symptoms
A fracture of the proximal tibia may cause:

  • Pain that is worse when weight is placed on the affected leg
  • Swelling around the knee and limited bending of the joint
  • Deformity, the knee may look “out of place”
  • A pale and cool feeling of the foot may suggest that the blood supply is impaired in some ways
  • Numbness around the foot may be due to nerve injury or excessive swelling within the leg

Diagnosis
After discussing about your injury and medical history, the doctor may also ask about how the fracture happened and examine the soft tissue surrounding the knee joint. The doctor will keep a look out for any obvious deformity of the thigh or leg, bruising, swelling, open wounds, and will access the nerve and blood supply to the injured leg and foot.

X-rays will then be ordered to evaluate the type of fracture the actual location within the femur. CT scans can also provide doctors with valuable information about the severity of the fracture in more detailed, such as very thin and hard to see fracture lines. MRI scans may also be used to provide clear images of soft tissues, although it is not a routine test. Other tests to check other parts of the body are also done to make sure no other body parts are injured during the impact.

Treatments
A proximal tibia fracture can be treated non-surgically or surgically, depending on the type of the injury and the general needs of the patient.

  • Non-surgical treatment
    Non-surgical methods to treat proximal tibia fractures include casting and bracing, in addition to restrictions on motion and weight bearing.
  • Surgical treatment
    Few surgical methods are available to be considered to obtain alignment of the broken bone fragments and keep them in place while they heal, such as internal fixation with special rods, plates and screws, and external fixation when the soft tissues around the fracture is too badly damaged.

Recovery
Post surgery, drugs and medications are often prescribed for short-term pain management, including opioids, NSAIDs and local anaesthetics. The doctor will recommend physical therapy at an appropriate time after surgery to prevent stiffness, and also determine how much weight can be placed on the healing leg. Customised rehabilitation plans will be scheduled to help regain strength, together with recommended lifestyle habit changes.

Tibia Shaft Fracture

The lower leg is maked up of the tibia and fibula; the tibia is the larger of the two bones that supports most of our body weight and is an important part of both the knee joint and ankle joint. The tibia is the most commonly fractured long bone in the body, a tibial shaft fracture occurs along the length of the tibia, below the knee and above the ankle. In many cases, the fibula may be fractured as well.

Types of tibia shaft fractures
There are several types of tibial shaft fractures, depending on the force that caused the break. The pieces of bone may line up correctly (stable fracture) or they may be out of alignment (displaced fracture), the skin around it may be intact (closed fracture) or punctured (open fracture).

Tibial fractures are classified depending on the location of the fracture (distal, middle or proximal), the pattern of fracture (lengthwise, crosswise or in the middle) and whether the skin or muscle over the bone is torn by the injury (open or closed fracture).

Causes
Tibial shaft fractures are often caused by high-energy collisions, such as a motor vehicle or motorcycle crash that can break the bone into several pieces (comminuted fracture). Lower-energy impacts such as sports injuries can also cause tibial shaft fractures. These fractures are typically caused by a twisting force and result in an oblique or spiral fractures.

Symptoms
A tibial shaft fracture usually causes immediate severe pain. Other symptoms may include:

  • Inability to walk or bear weight on the leg
  • Deformity or instability of the leg
  • Bone “tenting” over the skin at the fracture site or bone protruding through a break in the skin
  • Occasional loss of feeling in the foot

Diagnosis
After discussing about your injury and medical history, the doctor may also ask about how the fracture happened and do a thorough examination of your overall condition as well as the leg specifically. The doctor will keep a look out for any obvious deformity of the thigh or leg, breaks in the skin or bony pieces that may be pushing on the skin, as well as bruises. The doctor will also feel along the thigh, leg and foot, check the tightness of the skin and muscles around the thigh, as well as check for pulses.

X-rays will then be ordered to evaluate the type of fracture the actual location within the tibia. CT scans can also provide doctors with valuable information about the severity of the fracture in more detailed, such as very thin and hard to see fracture lines.

Treatments
In planning treatment for tibial shaft fracture, the doctor will consider the patient’s overall health, the cause and severity of the injury, as well as the extent of soft tissue damage.

  • Non-surgical treatment
    Non-surgical treatment may be recommended for patients who are poor candidates for surgery due to their overall health problems, or those who are less active and are able to tolerate small degrees of angulation or differences in leg length. Patients with closed fractures with minimal movement of the fracture ends are also considered for non-surgical treatment.Initially a splint is used to provide comfort and support, once the swelling subsides, a cast and brace will be replaced to immobilise for initial healing and provide protection and support until healing is complete. Lastly, physical therapy will be arranged appropriately.
  • Surgical treatment
    Surgery may be recommended for open fractures with wounds that need monitoring, fractures that have not healed with non-surgical interventions, and fractures with many bone fragments and a large degree of displacement. Intramedullary nailing is the most used surgical method for treating tibial fractures, though they are not ideal for fractures in young children and adolescents who are still growing, to avoid crossing the bone’s growth plates.

Recovery
Most tibial shaft fractures take 4 to 6 months to completely heal, if it is an open fracture or the bone was broken into several pieces, or if the patient uses tobacco products, healing process may be prolonged. Doctors will prescribe drugs and medications as pain management options. Doctors will also encourage leg motion early on in the recovery period, thus it is very important to follow doctor’s instructions strictly to avoid further problems and injuries.

Distal Femur Fractures of the Knee

The knee is the largest weight-bearing joint in the body, with the distal femur making up the top part of the knee joint and the tibia (shinbone) supporting the bottom part. The distal femur is where the bone flares out like an upside-down funnel, and fractures that occur on the femur just above the knee joint are distal femur fractures.

Distal femur fractures mostly occur in either older people whose bones are weakened, or in young people who have experienced high-impact injuries. The bone that breaks may extend into the knee joint and may shatter the bone into many pieces.

Types of distal femur fractures
There are several types of distal femur fractures, depending on the force that caused the break. The bone can break straight across (transverse fracture) or into many pieces (comminuted fracture), fractures may extend into the knee joint and separate the surface of the bone into a few (or many) parts (intra-articular). Because they damage the cartilage surface of the bone, intra-articular fractures can be more difficult to treat. The bone may break the skin (open fracture), and often involve much more damage to the surrounding muscles, tendons, and ligaments. These fractures have a higher risk for complications and take a longer time to heal.

When the distal femur breaks, both the hamstrings and quadriceps muscles tend to contract and shorten, causing bone fragments to change position and become difficult to line up with a cast.

Causes
Distal femur fractures most commonly occur in younger people (under age 50) and the elderly.

  • In younger patients, these fractures are usually caused by high energy impacts, such as falls from significant heights or motor vehicle collisions. Because of the nature of these fractures, many patients may also have other injuries, of the head, chest, abdomen, pelvis, spine, and other limbs.
  • In elderly people, distal femur fractures are typically caused by poor bone quality. A lower-force event, such as a fall from standing, can cause a distal femur fracture. Although these patients do not often have other injuries, they may have other medical problems, such as conditions of the heart, lungs, and kidneys, and diabetes.

Symptoms
The most common symptoms of distal femur fracture include:

  • Pain with weightbearing
  • Swelling and bruising
  • Tenderness to touch
  • Deformity, the knee may look “out of place” and the leg may appear shorter and crooked

In most cases, these symptoms occur around the knee, but patients may also have symptoms in the thigh area.

Diagnosis
After discussing about your injury and medical history, the doctor may also ask about how the fracture happened and do a thorough examination of your overall condition as well as the leg specifically. The doctor will assess the overall condition to make sure no other body parts have been injured, and make sure it is not an open fracture. The doctor will also check the blood and nerve supply to the injured leg.

X-rays will then be ordered to evaluate the type of fracture the actual location within the femur. To make sure that no other breaks are missed, the hip and ankle joints will also be X-rayed. CT scans can also provide doctors with valuable information about the severity of the fracture in more detail.

Distal Femur Fractures

The cross-sectional image has been placed above the corresponding 3-D image. The distal femur fracture on the left has not broken the weightbearing part of the bone. The fracture on the right, however, has broken the joint surface into two pieces.

Treatments

  • Non-surgical treatment
    • Skeletal traction is a pulley system of weights and counterweights that holds the broken pieces of bone together. A pin is placed in a bone to position the leg.
    • Casts and braces hold the bones in place while they heal. In many cases of distal femur fracture, however, a cast or brace cannot correctly line up the bone pieces because shortened muscles pull the pieces out of place. Only fractures that are limited to two parts and are stable and well aligned can be treated with a brace. Casts and braces can also be uncomfortable.

These treatments do not allow for early knee movement, thus they are used less often than surgical treatments.

  • Surgical treatment
    Newer medical techniques and advances of special materials and tools have resulted in effective surgical treatments for distal femur fractures, even in older patients with poor bone quality. Most distal femur fractures are not operated on immediately, and is delayed 1 to 3 days for a proper treatment plan to be developed and to prepare the patient for surgery. External fixation and internal fixation may be considered depending on the severity and level of damage of bone and soft tissue surrounding the fracture.

Recovery
Distal femur fracture is a sever injury and may take a year or more of rehabilitation before the patient is able to return to all everyday activities, depending on several factors like patient age, general health and the type of fracture. Doctors will arrange pain management strategies such as the use of drugs or medication to alleviate pain and suitable physical therapy with suitable walking aids such as crutches or knee brace. X-rays will also be done regularly to follow up on the recovery condition of the fracture.

Ankle Fractures (Broken Ankle)

Three bones make up the ankle joint – the tibia (shinbone), fibula (smaller bone of the lower leg) and talus (smaller bone between the heel bone and the tibia and fibula). The tibia and fibula each have specific parts that make up the ankle – media malleolus (inside part of tibia), posterior malleolus (back part of the tibia) and the lateral malleolus (end of the fibula). Multiple ligaments help make the ankle joint stable.

Ankle Fractures

An ankle fracture can range from a simple break in one bone, to several fractures which may force your ankle out of place and stop you from putting weight on it for a few months. Doctors classify ankle fractures according to the area of bone that is broken; a lateral malleolus fracture involves a fracture at the end of the fibula, whereas if both the tibia and fibula are broken, it is called a bimalleolar fracture.

Two joints are involved in an ankle fracture – ankle joint where the tibia, fibula and talus meet, and the syndemosis joint which is the joint between tibia and fibula, that is held together by ligaments.

Causes
The most common causes of ankle fractures include:

  • Twisting or rotating, and rolling the ankle
  • Tripping or falling
  • Impact during a car accident

Symptoms
A severe ankle sprain can feel the same as a broken ankle, thus every ankle injury should be evaluated by a physician.

Common symptoms for a broken ankle include:

  • Immediate and severe pain
  • Swelling, bruising and tenderness to touch
  • Cannot put any weight on the injured foot
  • Deformity, particularly if the ankle joint is dislocated as well

Diagnosis
After discussing the patient’s medical history, symptoms and how the injury occurred, the doctor will do careful examination of the ankle, foot or lower leg. X-rays will then be prescribed to show where the bone is broken at, how many pieces of broken bones there are, and whether there is any displacement in between the broken bones. CT scan and MRI scan may also be ordered to further evaluate the ankle injury and the surrounding ankle ligaments.

Treatments
The doctor will strategise treatment options for ankle fractures depending on which type of ankle fracture that is diagnosed. Usually if the ankle is stable, meaning that the broken bone is not out of place or just barely out of place, non-surgical treatments may be ordered, whereas surgery will be recommended for ankles are unstable.

Recovery
Post surgery, drugs and medications are often prescribed for short-term pain management, including opioids, NSAIDs and local anaesthetics to help alleviate the pain, and to help the patient to recover faster. The doctor will recommend physical therapy, home exercise programmes and strengthening exercises to progressively strengthen the ankle. Doctor will also prescribe supports such as splints, casts or removable braces for several months.