Adult Fractures (Part 1 of 5) - Myles Clough, MD

Dr. Sechrest: Hello, I’m Dr. Randale Sechrest, your host for EOrthopod.TV. Today I have as my guest Dr. Myles Clough. Dr. Clough did his medical school training at Oxford University in Oxford, England. From there he completed an orthopaedic residency at the University of British Columbia. Dr. Clough is also a clinical instructor in orthopaedics at the University of British Columbia. Welcome, Dr. Clough.

Dr. Clough: Thank you, Randy.

Dr. Sechrest: Today I thought we would have a general discussion on a very common topic in orthopedics and, in some ways, it’s what orthopedics is all about, and that’s the treatment of fractures.

Dr. Clough: Well, I think it is a problem that all orthopaedic surgeons look at and have to be very aware of the best treatment and I think it’s also a subject that people in the world don’t get a lot of information about. I think we get focused quite a small part of the fracture, and leave almost to nature a lot of the healing and that results in people being very puzzled about why certain things are happening after they’ve had a major bone injury.

Dr. Sechrest: Well, let’s talk a little bit about a fracture, and first let’s just define some terms. I think everybody’s always coming in and saying, “Well, is it fractured or is it broken?” So explain to me the common terms that we use to describe fractures and what they mean.

Dr. Clough: Well, people use the words ‘break’, ‘crack’, and ‘fracture’ as if they actually mean something different. But really, in real terms, they don’t mean anything different at all. They’re the same, and orthopaedic surgeons use the term ‘fracture’ as a technical term and it means that there’s a discontinuity between two parts of the bone and a ‘break’ is probably the common term that’s exactly equivalent. When people use the word ‘crack’, which many patients do, what they mean is a fracture that hasn’t moved very much or, if it has moved, it’s come back together again so that the displacement between the two parts of the bone is very small; and when you look on the x-ray there’s only a little tiny line between the two fragments. That kind of looks like a crack and it makes people think that it’s an injury that’s of less significance than a ‘real fracture’ but it isn’t. It’s exactly the same. In order for that crack to have occurred, the two parts of the bone must have been totally separated and very often what’s actually happened is the two things have come right apart and then come back together again, and it looks like there has been no. . it’s like a small thing. It can sometimes be quite a big thing, and it can always develop into a big thing if it’s not treated properly.

Dr. Sechrest: Well now, I think a lot of orthopaedic surgeons, you included, have this fondness of saying, “A fracture is nothing more than a soft tissue injury, a large soft tissue injury, that happens to involve a broken bone.” Explain that concept.

Dr. Clough: Well, that’s very important I think because you consider a leg as a structure that is mainly muscle and skin – we call that soft tissue – but the muscle and skin surround the bone. The bone is like a rigid tube inside an envelop of muscle and soft tissue. When the bone breaks, you have the situation where it starts off rigid, it’s deformed by a force like this, and that force gets bigger and bigger, and then suddenly it breaks. As it breaks it’s like this, and the ends of the bone tear through the muscle that surrounds that tube of bone so that we see, and really focus on the bone, but there’s that big area of torn muscle, stretched skin, sometimes even torn nerves and arteries, that surround the broken bone. We see the broken on the x-ray and, in fact, in terms of the long-term disability, the way that the broken bone heals is very important. But in terms of the symptoms and in terms of what the patient is going through, the torn muscle and the damage to the skin and the purple coloration and the swelling and everything else that goes along with the soft tissue injury is often paramount.

Dr. Sechrest: Yeah, and I think the other thing that we ought to point out is people, we get swelling from two different reasons. One is the swelling of the tissue and the leakage of edema and that sort of fluid, but we also get a lot of bleeding both from the ends of the fracture and, as you said, the torn muscle, the torn soft tissue that’s around it; and, of course, if you’ve torn an artery or something like that, which is a much more serious injury, you can get massive bleeding and life-threatening bleeding in some fractures.

Dr. Clough: Well, I don’t disagree with you but actually would disagree with saying a torn artery is a more serious injury, because you always tear arteries. You know, there are always small arteries that are torn by this soft tissue injury and they bleed extensively and that’s where much of the bleeding comes from. I think what you’re referring to is a torn major artery where, because it’s torn, the blood supply to the rest of the limb is compromised, and that’s certainly, I agree with you, is a much more serious problem.

Dr. Sechrest: Yes, agreed. Well, let’s talk a little bit about the different types of fractures because, again, we’re still defining terms and we have all of these terms that patients are going to hear like ‘comminuted’, ‘compound fractures’, ‘simple fracture’, all of these terms that mean something to us as orthopaedists. Can you give us a simple way of understanding the different types of fractures and what they mean?

Dr. Clough: Well, I think in terms of the way that things are treated and the severity of the problem, the biggest classification difference is ‘open’ and ‘closed’. So an open fracture means that there is an opening from the skin through to the broken part of the bone and that means that there’s potential for contaminants, bacteria, dirt, and stuff from the outside world to come into the fracture and contaminate it causing infection. A closed fracture is one in which the body’s defenses – the skin – are still intact and there’s much less likelihood that the bone will become infected. So I think, you probably agree, that the difference between open and closed is one of the most paramount ways to classify a fracture.

Dr. Sechrest: Yes, absolutely, and I think you put it right. In one case you assume that the bed, blood, all of the swelling, that fluid under the skin is still sterile and if there’s any nick in the skin, any nick whatsoever you can’t assume that and you have to assume that all of that fluid is potentially contaminated, potentially infected.

Dr. Clough: See, the bone ends can come out through a very small opening. If you have the bone like this, and then, during the middle of the deforming force it’s gone like that, this little piece up here could have come through the skin and stabbed through – it could even have pistoned through – and come all the way out, and then after the deforming force is over, the accident is over, everything will come almost back to good alignment; but because there’s this little small puncture in the skin, you know that that bone came through and is contaminated and then it’s brought back probably a piece of clothing or some dirty skin or some mud from the outside world right into the middle of the fracture where it has a great potential for causing a problem.

Dr. Sechrest: I think we ought to explain not only does that mean that the risk of infection is higher but it changes dramatically how we initially deal with that fracture.

Dr. Clough: Yes. Anybody who has an open fracture, it’s a surgical emergency. You want to be able to clean out the material that’s potentially contaminating that area, clean out any dead muscle, which is a real set-up for extension of the infection, so that anybody who has an open fracture almost automatically in modern medicine needs an operation; and the operation extends the wound, makes everything look worse, but the object is to get to the fracture site and clean everything out. You can’t do that through a little tiny hole. You can’t do that by irrigating out the puncture wound. You have to do it by exposing everything and getting rid of all of the potential contamination.

Dr. Sechrest: Yeah, I think we’ve all had the experience of just what you described and that is going in on one of these small open fractures where you have maybe a half-inch incision, and you think, “I’m just going to go wash some blood out. I’m going to run some water through this. I’m going to clean it up. Once we open it up and get in there, there’s dirt, there’s grass, there’s rocks. It’s amazing what can be sucked back in through one of those little small holes.

Dr. Clough: I absolutely agree with you.
Dr. Sechrest: Well, let’s move on a little bit. I think that the risk of infection and the need for surgery is clear. Now, when we’re talking about other things like comminuted, displaced, angulated, these are terms that patients are going to hear about describing their fracture beyond open and closed. Go through the different ways that we, as orthopaedists, describe fractures and what they might mean in terms of treatment.

Dr. Clough: Okay. I’ll step one step back from that and say that the key question is stable and unstable. If you have a fracture that’s stable what that means in terms of orthopaedic surgeons is in the judgment of the surgeon, those bones are going to stay in reasonably good position even if you don’t do anything terribly elaborate. So a stable fracture might be one in which things are interlocked and inter-digitated and things are going to stay more or less well lined up. Most cracks are stable fractures. An unstable fracture is a fracture which is very likely to shift out of position with time. So although it may be lined up to begin with, eventually if you don’t do things to prevent it, that fracture will angulate or shorten or rotate, and the limb will not function as well as it should be. Now the ways in which you look at a fracture and say, “this is going to stable and this is going to be unstable” come back to what you were talking about – the difference between a displaced fracture or an angulated fracture or a comminuted fracture. A displaced fracture means that the two or more parts of the fracture are not lined up. They’re not still in their original position and they can be shifted out of position like that or they can be rotated or they can be translated and shortened. An angulated fracture means that they may still kind of point to each other but they aren’t lined up and often that involves rotation as well. A ‘comminuted’ fracture, I think that word should probably be replaced by ‘splintered’ because that’s what it means. It means instead of being two pieces in which you have a high chance of a stable fracture, there are many more pieces or pieces in which the bone is more or less and all of those little pieces are not really contributing to making the fracture stable. And importance of the concept of stable versus unstable is: If you have an unstable fracture you nearly always have to do something to make sure, in operative way, you have to do some operation to make sure that that bone will stay lined up properly out to length, rotated properly, and you can move it early on so that you have the best chance of healing.

Dr. Sechrest: There’s one other distinction that fractures sometimes take on and that is whether it involves a joint or not. So describe for me what’s the importance of a fracture that involves the joint versus one that does not.

Dr. Clough: Well, the joint is defined as the gap between two bones and the important part about a joint is that the bones have to move on one another. So that when you move your arm around or when you move your fingers or pretty well any part of your limb, two or more bones are moving on one another. They have to have a special surface which is called joint surface or articular cartilage. The terms are synonymous, they mean the same thing, and the articular cartilage is a fairly thin layer of slippery gristly substance which has some unique good things and one bad thing. The good things are that it’s self-lubricating, it doesn’t need a blood supply, and it’s very hard wearing. If you’ve got a good area of joint surface it’ll probably stay a lifetime. The bad thing is it doesn’t grow again. So, if you damage joint surface the damage is permanent and it won’t replace itself, unlike bone, which has a mechanism for replacing bone, causing scar tissue to turn into bone. If you get scar tissue in a joint, it stays scar tissue and that joint will no longer function as a smooth surface. So the result is that a fracture that goes into a joint has to be treated with the joint surface in mind, and that really nearly always means that you want to prevent there being any stick, irregularity, or hole, in the joint surface. If the joint surface started off out of alignment, you need to make that alignment back as close to perfect as you can.

Dr. Sechrest: Yeah, I sometimes describe it to patients that it’s a bearing surface and it’s like any other bearing. If you think of a machine that you have a very smooth bearing surface that fits together, it will last a lifetime as you said. If it gets the least bit out of whack, so to speak, it’s going to wear out very rapidly and our joints are the same. They are bearings that essentially have to move against one another.

Dr. Clough: Yeah, I agree, and also with a bearing it could kind of grind itself down and end up looking not so bad. But with a joint surface, if it grinds itself down, that’s the end of that joint.

Dr. Sechrest: Yeah, you end up with bone rubbing against bone which is not a good thing.

Dr. Clough: No, and that’s what arthritis is. That’s what long-term posttraumatic osteoarthritis is. It’s bone rubbing against bone.

Dr. Sechrest: Give me a little bit more detail about the ways that bones actually break. What type of forces act on bones that cause them to eventually break?

Dr. Clough: Well, really in summary, the bone is loaded above its capability, and there are a number of ways that that can happen, but really it all comes down to the mechanical force that’s put on the bone is greater than that bone can sustain and it can be bending. That’s a very common way. You don’t always think about that but if you were standing and something pushes against you, the bone is actually being bent and that’s why it breaks. Another way that bones break is a twist. You trap your foot and your upper body moves. The bone which is rigid is now having a torqueing force and that results in a break. There are some fractures that are caused by compression where the load on the bone is too great, and it’s more or less in the line of the bone. There’s another form of fracture in which the muscle that attaches to the bone pulls so hard that it pulls a piece of bone off and that’s called an avulsion fracture and it’s actually an interesting fracture because it means that the force is still there. The force of that muscle pulling on that dislodged piece of bone is still there and it’s very difficult to get that to heal because the thing that caused the problem in the first place is still happening unlike most fractures where the force that caused the injury is usually over and gone with. And then, finally, I would say that violence is a problem that causes some fractures and we see gunshot wounds and blast injuries and high energy trauma is another extremely and dangerous cause of fractures and people sort of expect that. They expect that if they’re in a motor vehicle accident, they’ve fallen off a building, something like that, bones are going to be broken, that’s sort of almost easy to understand. What’s perhaps less easy to understand is that there are fractures that can occur from low energy situations where the mechanics or the forces that are applied to the bone are too great for the tolerance of the bone.

Dr. Sechrest: Yeah, I think the other thing we ought to cover as well, is the notion that, as you said, everyone expects when they’re in a car wreck or if they fall off a two-story building, that they are going to break a bone. Some conditions that weaken the bone result in fractures that occur with normal activities, and that’s what we would term as a pathologic fracture. Give me a little information about pathologic fractures, what causes those, and how they may differ from the typical fracture that we see in healthy bone.

Dr. Clough: So there are a number of fractures that occur in abnormal bone. We call them pathological fractures but really it’s easiest to think of them as abnormal, and they’re very common because there’s a pathological process called osteoporosis that occurs in everybody as they grow older, and bones gradually get weaker. The result is that elderly people are at a great risk of having a fracture and these are very dangerous fractures sometimes that cause extreme disability and indeed mortality for some of the elderly people who fall over and break their hip. Osteoporosis is a rather mysterious process that gradually, over a number of years, cause bone to be reabsorbed. Normal bone has a balance between reabsorption and re-growth so that all the time bone cells are being turned over. Some bone cells are being absorbed and others are new bone cells and are being formed and forming new bone, and with osteoporosis that balance is tipped in the direction of reabsorption so more bone gets reabsorbed than gets laid down. This weakens the bone and causes larger and larger areas of space inside the bone that isn’t actually occupied by bone cells. It’s occupied by blood or marrow or something that isn’t very strong, and that occurs typically in women who are in the second half of their life, but it also occurs in men and it does occur in some young people as well.

Dr. Sechrest: Now what does that mean in terms of the strength of the bone?

Dr. Clough: Well, the bone has essentially less bone. There isn’t the same volume of strong material so it takes less to break it, and it’s as simple as that.