Classification and complications of fractures. Splint and tractions.
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fracture types classification diagram transverse oblique spiral comminuted
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Salter Harris epiphyseal fracture classification types children
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traction splint femur fracture application Thomas splint
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I now have comprehensive material from multiple authoritative sources. Here is the complete synthesis:
Fractures: Classification, Complications, Splints & Traction
1. CLASSIFICATION OF FRACTURES
Fractures are classified along several orthogonal axes.
A. By Aetiology / Formation Mechanism
| Type | Description |
|---|---|
| Traumatic | Direct force → transverse or comminuted fracture; indirect force (lever/rotation) → oblique or spiral fracture |
| Pathologic | Minor trauma to diseased bone (metastases, osteomyelitis, osteoporosis, Paget's, osteogenesis imperfecta, bone cysts) |
| Stress (Fatigue) | Repeated sub-maximal loading; classic example is the march fracture (2nd metatarsal in soldiers/runners). Radiographs often negative early; bone scan or MRI is more sensitive |
Pathologic fractures may occur without any significant trauma and must be suspected when the mechanism is inconsistent with the injury. — Tintinalli's Emergency Medicine, p. 1808
B. By Fracture Morphology (Pattern of the Fracture Line)
| Pattern | Description |
|---|---|
| Transverse | Fracture line ⊥ long axis; result of direct blow |
| Oblique | Diagonal fracture line; angulated force |
| Spiral | Winds around the shaft; rotational (torque) mechanism |
| Comminuted | >2 fragments (>6 fragments in some definitions); high-energy impact |
| Segmental | Two separate fracture lines create a free-floating segment |
| Avulsion | Fragment pulled off by ligament/tendon insertion |
| Bending/Wedge | Bending force creates a third triangular fragment |
| Greenstick | Cortex fractures on tension side, periosteal tube intact; children only |
| Torus (Buckle) | Cortex buckles on compression side without complete break; children only |
— General Anatomy and Musculoskeletal System, THIEME Atlas, p. 72
C. By Soft-Tissue Integrity (Open vs. Closed)
Closed fracture – skin intact over fracture site.
Open fracture – any wound communicating with the fracture (including small puncture wounds from protruding bone that recedes back). Major risk: osteomyelitis.
Gustilo-Anderson Open Fracture Classification
| Grade | Wound / Energy | Features |
|---|---|---|
| I | <1 cm; low energy | Minimal contamination |
| II | 1–10 cm; moderate | Some comminution, some contamination |
| IIIA | >10 cm; high energy | Gross contamination, adequate bone coverage |
| IIIB | >10 cm; high energy | Exposed bone, periosteal stripping |
| IIIC | Similar to IIIB | + Vascular involvement requiring repair |
— Tintinalli's Emergency Medicine, p. 1809
D. By Location Along the Bone
- Epiphyseal – involving the articular end
- Metaphyseal – flared region near the growth plate
- Diaphyseal – shaft
Also distinguished as proximal / mid-shaft / distal and intra-articular vs. extra-articular.
E. By Displacement
Fracture fragments may be:
- Translated – shifted sideways
- Angulated – angled relative to axis
- Shortened (overlapping) – due to muscle spasm/pull
- Rotated – twisted on the long axis
— Bailey & Love's Short Practice of Surgery, p. 442
F. Salter-Harris Classification (Paediatric Physeal Fractures)
Epiphyseal plate fractures cannot occur in fully-grown adults. Growth plate damage may disrupt future bone elongation.
| Type | Fracture Path | Mnemonic (SALTR) | Risk of Growth Disturbance |
|---|---|---|---|
| I | Through physis only (separation) | Slip | Low |
| II | Physis + metaphysis (Thurston-Holland fragment) | Above | Low–moderate; most common (~75%) |
| III | Physis + epiphysis (intra-articular) | Lower | Moderate |
| IV | Crosses metaphysis + physis + epiphysis | Through | High |
| V | Crush/compression of physis | Ram | High; often missed acutely |
— Tintinalli's Emergency Medicine, p. 1814–1815
G. AO/OTA Classification
The AO (Arbeitsgemeinschaft für Osteosynthesefragen) / OTA system classifies fractures alphanumerically by bone (number), segment (1=proximal, 2=diaphysis, 3=distal), and fracture type (A=simple, B=wedge, C=complex/comminuted). This is the internationally standard system used for research and surgical planning. — Rockwood & Green's Fractures in Adults, 10th ed.
2. FRACTURE HEALING
Three overlapping phases:
- Inflammatory phase – haematoma, neutrophils/macrophages, cytokine release, revascularisation begins
- Reparative phase – granulation tissue, callus formation (collagen → cartilage → woven bone); necrotic bone ends resorbed by osteoclasts (creates the radiographic fracture line if initially invisible)
- Remodelling phase – longest phase (years); callus resorbed, trabecular bone laid along stress lines
Healing terms:
| Term | Definition |
|---|---|
| Union | Complete healing |
| Delayed union | Prolonged healing (typically >6 months) |
| Malunion | Healed with residual deformity |
| Nonunion | Failed healing, usually from poor vascularity or instability |
— Tintinalli's Emergency Medicine, p. 1809
3. COMPLICATIONS OF FRACTURES
Immediate (at time of injury)
- Haemorrhage – a closed femur fracture can lose 1–2 L into the thigh; open fractures carry higher risk
- Neurovascular injury – nerve or vessel damage at the fracture site or nearby joint (e.g., axillary nerve with shoulder fracture/dislocation, popliteal artery with knee dislocation, anterior interosseous nerve with supracondylar fractures)
- Skin/soft tissue damage – tenting of skin by bone fragment can convert a closed fracture to an open one
Early (hours to days)
- Compartment syndrome – rising pressure within a closed fascial compartment → ischaemia. Classic 6 P's: Pain (out of proportion, with passive stretch), Pressure, Paraesthesia, Paralysis, Pallor, Pulselessness. Orthopaedic emergency requiring fasciotomy
- Fat embolism syndrome – fat globules from marrow enter circulation; presents 24–72 h post-fracture with hypoxia, confusion, petechial rash (especially long-bone and pelvic fractures)
- Vascular thrombosis / DVT – immobility after fracture
- Infection / wound contamination (open fractures)
Late (weeks to months)
- Osteomyelitis – especially with open fractures; can be chronic and lead to amputation
- Avascular necrosis (AVN) – disruption of blood supply; classic sites: femoral head (neck of femur fracture, hip dislocation), scaphoid (proximal pole), lunate
- Nonunion / malunion – inadequate immobilisation, infection, poor blood supply, excessive distraction, smoking, diabetes, steroids
- Post-traumatic osteoarthritis – intra-articular fractures with residual incongruity
- Complex Regional Pain Syndrome (CRPS) / reflex sympathetic dystrophy – burning pain, allodynia, autonomic changes
- Growth disturbance – paediatric physeal injuries (Salter III–V)
- Contracture / stiffness – prolonged immobilisation (especially knee)
- Implant failure / refracture – after hardware removal
4. SPLINTS
Splinting is the first-line immobilisation in acute fractures. Unlike circumferential casts, splints allow for swelling without vascular compromise.
General Principles
- Immobilise the joint above and below the fracture
- Apply adequate padding (especially bony prominences)
- Maintain proper positioning while the material sets
- Assess neurovascular status before and after application
Common Splint Types
| Splint | Indication | Position |
|---|---|---|
| Shoulder immobiliser | Clavicle, proximal humerus, reduced shoulder dislocations | Arm adducted, internally rotated at side |
| Arm sling | Radial head fractures, supplementary support | Elbow ~90° flexion, forearm neutral |
| Long-arm gutter splint | Elbow and forearm injuries | Elbow ~90°, palm facing abdomen |
| Short-arm splint | Distal radius / wrist | Wrist in neutral or slight extension |
| Thumb spica | Scaphoid, 1st metacarpal (Bennett's), thumb fractures | Thumb abducted |
| Knee immobiliser | Tibial plateau, patellar fractures, ligamentous injuries | Knee in extension |
| Posterior ankle mold | Ankle fractures, severe sprains | Ankle at 90° (neutral dorsiflexion) |
| Prefabricated leg splint | Tibia/fibula fractures | Neutral alignment |
— Tintinalli's Emergency Medicine, p. 1818–1820
5. TRACTION SPLINTS
Historical Context
The traction splint was developed by Sir Hugh Owen Thomas in the late 1800s for femoral fractures. Modified to a half-ring design by Robert Jones, it reduced WWI femoral fracture mortality from 80% to 15%.
Purpose
Traction splints counteract the powerful thigh muscles that shorten a fractured femur, causing the thigh to lose its cylindrical shape and accumulate 1–2 L of blood. By restoring anatomical alignment, they:
- Reduce haemorrhage (increase tissue pressure, decrease dead space)
- Relieve pain
- Prevent neurovascular damage
- Reduce incidence of fat embolism
Indication
Isolated midshaft femur fracture (primary indication)
Contraindications
- Pelvic fractures
- Hip injuries with gross displacement
- Significant knee injuries
- Ankle/foot avulsion or amputation
- Associated distal tibia-fibula or ankle fracture in the same extremity (traction will distract that fracture)
- Open femur fracture — use with caution; consider only if definitive care is significantly delayed
Common Traction Splint Devices
| Device | Design |
|---|---|
| Hare Traction Splint | Half-ring; causes ~30° hip flexion |
| Kendrick Traction Device (KTD) | Compact half-ring |
| Ferno-Trac (Ferno-Washington) | Half-ring variant |
| Sager Emergency Traction Splint | No half-ring; no hip flexion; can be used bilaterally |
Application Principles (Ferno Traction Splint)
- Apply ankle hitch around posterior of heel; D-ring positioned inferiorly
- One rescuer maintains manual traction while lifting the leg
- Slide splint under patient with ischial pad seated firmly against ischial tuberosity
- Attach traction hook to D-ring; turn traction dial until leg resumes normal length (compare with uninjured side)
- Secure 4 Velcro straps (2 above, 2 below knee)
- Reassess neurovascular status
— Roberts & Hedges' Clinical Procedures in Emergency Medicine, p. 1078–1084
Site-Based Immobilisation Summary
| Site | Preferred Method |
|---|---|
| Hip | Leg-to-leg strapping + full body immobilisation |
| Midshaft femur | Traction splint (first choice); rigid splint if contraindicated |
| Knee | Cardboard or vacuum splint in position found |
| Tibia/fibula | Cardboard, air, or vacuum splint |
| Ankle | Pillow, cardboard, or air splint |
| Foot | Pillow or air splint |
| Toe | Buddy-taping to adjacent toe |
Sources:
- General Anatomy and Musculoskeletal System — THIEME Atlas of Anatomy, pp. 72–73
- Tintinalli's Emergency Medicine: A Comprehensive Study Guide, pp. 1808–1820
- Roberts & Hedges' Clinical Procedures in Emergency Medicine, pp. 1078–1086
- Rockwood & Green's Fractures in Adults, 10th ed., Chapter 2
- Bailey & Love's Short Practice of Surgery, 28th ed., pp. 442–444
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