Trauma & Fractures
Our surgeons have extensive experience with upper and lower extremity, pelvic and spinal trauma, including both soft tissue and bone injuries. Whilst most major trauma requires immediate attention within an Emergency Department, there are some instances that require operative intervention on a less urgent basis or which respond to non-operative management. We will work with you to develop the most appropriate management plan for an acute injury or long term issues associated with severe musculoskeletal trauma.
Given the unpredictable timing of trauma and fractures and the need to treat with some expediency, Orthopaedics ACT offer a Fast Track Trauma Clinic.
Appointments for the clinic can be made 7 days a week
by calling 0459 343 734 between 9am to 5pm.
Fractures: Types and Treatment
Fracture is the medical term for any break in the structure of a bone. In medical terms a fracture is a broken bone. These can range from low energy fractures such as green stick fractures or buckle fractures in children, to severe comminuted and compound fractures in high energy injuries such as motorbike accidents.
The treatment of a fracture depends on the type of fracture, where it occurs in the bone, how angulated or displaced the bone fragments are, the age of the patient, and other injuries that may have been sustained. Most bones will heal if left alone however they may heal short or in a bad position, and in the meantime the patient is left unable to mobilise.
As a result we now operate on many fractures, which may be simple manipulations and application of a plaster cast, to complicated fixation using plates and screws, rods or pins, or even external fixation frames. Certain fractures are emergencies and need treatment immediately such as many hip fractures or fractures associated with dislocations of joints.
Growth Plate Fractures
Children have growth plates at either end of most of their bones. The growth plate is usually about a centimetre away from the joint, and is made of cartilage and is therefore the weakest link in the chain. As a result paediatric fractures can break through the growth plate, and these require the growth plate to be pushed back into position. The majority of these fractures heal without incident, as children have an ability to remodel their bones straightening out any kinks themselves. Occasionally where the growth plate is severely damaged, disturbance of its growth can occur, and this can lead to shortening of the affected limb. Dealing with this is more complicated and may require surgery to either realign or even lengthen the limb. The majority of growth plate injuries heal up well after 3 to 6 weeks in a plaster but the patient must not play contact sport or fall onto the limb for a couple of months to prevent re-fracturing.
Non-Union is the medical term for a bone not fully healing. This can be related to various factors such as high energy injuries, bones broken into several pieces, severe soft tissue stripping, when the bone pierces the skin, infection or patient factors such as smoking or chronic steroid use. Non-unions can be treated with either bone stimulators which are placed on the skin and used every day for some months, as well as stopping predisposing problems such as smoking, but oftentimes require the bone to be operated on and bone graft or bone stimulating hormones to be added to the fracture site to promote healing.
Stress fractures refers to incomplete fractures through a bone which can be related to either normal stress on a weak bone (osteoporotic stress fractures), or excessive forces on a normal bone (foot fractures in army recruits who are marching long distances). The treatment for these is generally to reduce the amount of stress placed on the bone, either using a plaster or a walking boot, and will generally heal without surgery. Occasionally in some parts of the body fixation with plates and screws is necessary to prevent a sudden fracture of the bone. Investigations are necessary to diagnose possible causes for the non-union and to work out what treatment is appropriate.
Fractures: Foot and Ankle
Ankle fractures are one of the most common fractures seen in most emergency departments. They are usually related to patients slipping or twisting and rotating over there ankle. Damage can occur to the small bone on the outside (fibula) or the larger bone on the inside of the ankle (tibia) or to the ligaments which tie those bones together. Treatment depends on the stability of the ankle when it is weight-bearing, and can require x-rays, CAT scans or MRI scans. Treatment can range from fully weight bearing in a boot, to operations with plates and screws or rods. Dislocations of the ankle can happen at the same time that the bone breaks, and oftentimes this suggests a much worse injury with a more severe soft tissue stripping, and a chance of damage to the actual joint lining surfaces as well.
Heel fractures usually occur when people jump from a height and land awkwardly. The fractures can be displaced out of position or an displaced and treated on their merits oftentimes with non-weight bearing in a cast or boot for 6 to 12 weeks, or requiring operation to put the bones back into an anatomical position and hold them there with a plate and screws. Patients often develop stiffness after a calcaneal fracture, and can have pain for many years. Heel fractures are fortunately relatively uncommon, but may cause significant disability, such as stiffness, in the future.
Heel Fractures / Calcaneus Fractures
Midfoot fractures referred to the part of the foot between the toes and the ankle joint. They were first recognised in the Napoleonic wars by a surgeon called Lisfranc, who noticed them when soldiers fell from the horse and their foot caught in the stirrup in this area and the ligaments will bones were injured. These injuries need to be carefully assessed and often treated with plates or screws to realign them and prevent the arch of the foot collapsing and developing arthritis. These are severe injuries and can lead to long-term disability and pain. It is important that they are diagnosed and treated accurately.
Lisfranc (Midfoot) Fracture
Stress fractures of the foot are common particularly in military recruits who have normal bones but are subjected to walking long distances with heavy packs, thus overwhelming the bones ability to tolerate the forces being applied. These are called ‘March’ fractures as they are caused by marching. Stress fractures can also occur in relation to normal walking if people’s bones are. The intial treatment approach isy to reduce the amount of weight bearing done, and support this with either a boot or plaster for somewhere between six and 12 weeks. It is important to also look for any secondary causes such as osteoporosis. The majority of these fractures do not require anything further than non-operative treatment.
Stress Fractures of the Foot and Ankle
The talus is the ankle bone, which sits between the bottom of the shinbone (tibia) and the top of the heel bone (calcaneus). Talus fractures often occur from high energy injuries such as car accidents. The blood supply to the talus can be compromised when displacement of the bone can lead to tearing of the blood vessels, and ongoing damage to the bone from a lack of blood (osteonecrosis). The treatment is non-weight bearing for between six and 12 weeks, and anatomical realignment of the fracture which needs to be held with plates or screws or both. It is common for people to have long-standing stiffness after a fracture of the talus.
Toe fractures are common when people stub their toes. So long as the toe is not pointing sideways and will fit into a shoe, a non-operative pathway is recommended. It is uncommon to develop arthritis in the toes after a fracture. Forefoot fractures refers to the bones directly joining to the toes and these also also generally treated without surgery, depending on the severity and the number of bones broken. If one bone is broken, usually the bones on either side will help to hold it at length and splint it in the right position. Non-operative treatment usually requires treatment in a walking boot or in a cast.
Toe and Forefoot Fractures
Fractures: Hip & pelvis
Hip fractures can occur in elderly people after simple falls, or in younger people from higher energy injuries such as motor vehicle accidents. This type of fracture should be dealt with immediately and the Canberra Hospital currently deals with more than 300 incidents every year. In elderly patients, these are very serious fractures and patients can die as a result of the fracture and the treatment and the post-operative period.
Fractures of the hip are treated with plates and screws or intra-medullary rods which go down the inside of the bone. These allow people to get out of bed and weight bear immediately. Some fractures require treatment with an immediate hip replacement, either replacing the ball (hemi arthroplasty) or the socket and the ball (total hip replacement).
The decision is based on the type of fracture and also the age and physical health of the patient and the demands of their day-to-day life.
Fractures of the pelvis, like fractures the hip are seen in elderly people from simple falls, or in young people with high energy injuries such as motor vehicle accidents. They can be life-threatening because there are large blood vessels in the pelvis which can be torn. Emergency treatment may start with application of a brace and then immediate surgery with an external fixation frame, with pins placed in the bone which are joined to a frame outside the skin. This is specialised surgery, and requires significant experience particular for the more complex cases. People with pelvic fractures can have discomfort or pain in their pelvis for years after the injury but most people are able to return to good function.
Fractures: Knee & leg
Fractures of the Proximal Tibia
Fractures of the proximal tibia (tibial plateau fractures) are common after falls, twisting injuries or more high energy injuries. The treatment depends on the severity of the injury and the displacement of the fracture fragments. Minimally displaced fractures are treated via a range of motion brace with non-weight-bearing for a period of 6 to 8 weeks and then graduated weight-bearing. Displaced fractures require the bones to be put back into the correct alignment. Fractures within the bone caused by crushing of the honeycomb element of the bone, can require bone graft or graft with calcium phosphate or calcium sulphate material. A period of non-weight bearing of 6 to 8 weeks is required for fractures treated with any operation. Any fracture of the joint surface can lead to arthritis.
Paediatric femoral fractures are relatively uncommon. Treatment is predicated upon the age of the child, the size of the child, and the type of fracture. Very small children can be treated with an immediate cast called a spica which is put on in the operating theatre with the patient asleep. As patients get older flexible rods can be passed up the hollow part of the bone to hold the bone in position, or paediatric femoral rods can also be used. These are similar to ones used to treat adult fractures but have a smaller diameter. An non-operative alternative for some children is 6 weeks in traction, this depends on the child's age and type of fracture.
Pediatric Thighbone (Femur) Fracture
Fractures to the shaft of the tibia usually occur from high energy injuries such as sporting contact or motor vehicle accidents. Treatment is operative. Options include having an intra-medullary nail passed down the hollow inside of the bone with locking screws at either end to prevent rotation or shortening. Alternatively plates and screws may be used. Monitoring post-surgery is important to ensure that pressure in the compartment does not increase and threaten the blood supply to the calf muscle. The usual time for a shinbone fracture to heal in an adult is between 18 to 24 weeks, with weight-bearing allowed immediately or at 6 weeks. The risk of non-union of the tibia is higher than for most bones because a significant part of the bone is not surrounded by muscle which normally provides blood supply which helps to heal the fracture.
Shinbone (Tibia) Fractures
Femoral shaft fractures refer to fractures below the top of the hip bone and are usually the result of high-energy sporting or motor vehicle accidents. These require fixation with intra-medullary nails or rods which have locking screws at either end to prevent rotation or shortening. The healing rate is very good for these fractures. Femur fractures often occur in association with other injuries as people are often involved in car accidents. It takes between 18 and 24 weeks for the femur to heal but weight-bearing is generally allowed anywhere from immediately up to 6 weeks depending on the degree of common use and or fragmentation of the fracture. Unless there are issues, the medullary nail will be left in place.
Thighbone (Femur) Fracture
Fractures: Shoulder, Arm or Elbow
A broken arm can refer to a break in the humerus which is the bone between the shoulder and the elbow, or a break in the forearm bones (the radius and the ulna), or the elbow, or wrist.
Fractures of the humerus can often be treated in a hanging U-slab and then transferred to a brace which wraps around the arm to hold it in position and which can be tightened with a velcro strap.
Fractures which are more severe may need treatment with open surgery which may require plates and screws. The healing rate is high for these fractures.
Fractures of the radius and ulna are usually treated with plates and screws which allows the patient to move their arm with the restriction and discomfort of a cast. It usually takes between 6 to 12 weeks for bones of the upper limb to heal. Usually the plates and screws do not need to be removed unless they are symptomatic and bothering the person.
The collarbone often fractures from a fall onto an outstretched hand. Traditionally the majority of these fractures were treated without surgery but there is now evidence in journals to show that significant shortening of the bone may result and this can affect the function of the whole shoulder and so fixation with plates and screws is becoming more common. Fixation is necessary in fractures with shortening of more than 1.5 cm, or where the bone is broken in several places. It takes generally 6 to 12 weeks for the fracture to fully heal.
Broken Collarbone (Clavicle)
Elbow Fractures in Children
Paediatric elbow fractures can be very severe and frequently caused by fall from monkey bars with the elbow bending backwards (hyperextension). They can be associated with damage to nerves and blood vessels which get stretched at the time of the fracture, and usually require operative fixation to manipulate the bones back into good position, and then hold them with a combination of wires or screws. Children have an excellent ability to remodel or grow their bones straight, and paediatric elbow fractures almost always end up with a normal functional upper limb.
Forearm fractures in children are common and often result from fall from monkey bars onto an outstretched hand. If the alignment of the bones is good these can be treated non-operatively via placement in a cast. If the position of the bones is not ideal then manipulation of the bone into a better position and holding in either a cast or with wires or plates may be necessary. Growth plate fractures are common in the upper limb of the child, particularly at the wrist and generally do not cause any abnormality in the growth of the limb. Fractures in the middle of the bone need to be aligned properly and held for 6 weeks. Whilst healing the child needs to refrain from contact sport or falls for a couple of months.
Forearm Fractures in Children
Given the shoulder blade is encased in muscle, scapula fractures are usually high-energy impact.. Most of these fractures are treated non-operatively and heal well, but occasionally those around the socket of the shoulder joint itself may require fixation with screws and plates to hold their position. Patients with these fractures may feel a bit of crepitus or roughness of their scapula on their rib cage after the fracture but this is generally not severe.
Fracture of the Shoulder Blade (Scapula)
Olecranon fractures refer to the point of the elbow, where the triceps muscles, the main muscles on the back of the arm attach to straighten the arm out. To put the bone back into the correct position and hold treatment is usually a combination of wires, or a plate and screws. Sometimes these plates and screws can bother people and require removal 6 to 12 months after the surgery as they are prominent with very little soft tissue cover. The functional outcomes following an elbow fracture is generally excellent.
Olecranon (Elbow) Fractures
The radial head is the head of the radius bone of the forearm. It can be fractured if somebody falls directly onto their outstretched hand and the bone is pushed into the elbow and cracks. Non-displaced or minimally displaced fractures are generally treated non-surgically. Fractures which are broken into several pieces (comminuted) or those with unacceptable position are treated with plates and screws or even with replacement of the radial head itself. The outcomes for radial head fractures is generally excellent.
Radial Head Fractures
Shoulder trauma can occur from a fall in an elderly person, an awkward tackle in sport, or from high-energy injuries such as a motor vehicle accident. The shoulder is a complicated joint with several levels of muscles and tendons that move over each other and stiffness after shoulder injury is common. The treatment depends on the degree of displacement of the bone, whether it has angulated significantly, and the relationship of the tendons to the fracture fragments. Non-operative treatment consists of being placed in a sling and having a graduated range of motion program organised with help from the physiotherapist. Fixation of the fracture is usually performed through an incision to the front of the shoulder and fixed with either plates and screws or an intra-medullary rod down the inside of the bone. It is common for people to have significant stiffness after their shoulder fractures, and people may lose a significant amount of the range of motion of the shoulder particularly after more severe fractures.
Our specialist trauma surgeons:
All of our surgeons are experience in managing trauma and have or currently contribute to the rostering of the Emergency Department Trauma Unit at Canberra Hospital.
Dr Roberts graduated with Honours from the University of Sydney in 1982. He completed his advanced Orthopaedic training in Sydney.
Dr Al Burns graduated in medicine from the University of Sydney in 1995, and completed his advanced orthopaedic training in Sydney.
A graduate of the University of Sydney Dr Nicholas Tsai did his internship and residency in Westmead Hospital.
Dr Kulisiewicz graduated from the University of Sydney in 1998, then went on to work at The Canberra and Calvary Hospitals as an intern...
Professor Paul Smith graduated in medicine from The Flinders University of South Australia 1986, and completed orthopaedic surgical training in 1995.