11aaa. Fracture

Question 1

history taking ?fracture

Answer 1

PC: pain? An
HoPC: trauma - describe in detail? Does the traumatic process explain the extent of the injury (?fragility fracture ?domestic abuse) any other injuries/symptoms? any contact with contaminated objects (esp if open fracture)
MHx: previous fracture? Cancer diagnosis?
DHx: medications? On any bone protection?
FHx: any fractures at a young age in family
SHx: consider NAI/domestic abuse

Question 2

examination ?fracture

Answer 2

MSK exam of affected area

Neurovascular status
- UL/LL neuro sensation and power mainly

Signs of acute limb ischaemia?
Look (1)
Pallor

Ask: (2)
Pain
Paraesthesia

Feel (2)
Temperature: perishingly cold
Pulseless
CRP

Move (1)
Paralysis

Question 3

how do you describe a fracture

Answer 3

Displaced or not displaced?
Open or closed?

Question 4

dispalced vs non-dispalced frcatures

Answer 4

Displaced Fracture: bone breaks into two or more pieces and moves out of alignment.

Non-Displaced Fracture: the bone breaks but does not move out of alignment.

Question 5

how do you describe a fracture where the broken piece of bone is at a right angle to the bone’s axis?

Answer 5

Transverse Fracture

Question 6

how do you describe a fracture where the break has a curved or sloped pattern.

Answer 6

Oblique Fracture

Question 7

How do you describe a fracture where one part of the bone has been twisted at break point

Answer 7

spiral fracture

Question 8

How do you describe a fracture where the bone breaks into several pieces

Answer 8

comminuted

Question 9

How do you describe a fracture where one of your bones is broken in at least two places, leaving a segment of your bone totally separated by the breaks?

Answer 9

segmental

Question 10

how do you describe a fracture when a fragment of bone is separated from the main mass.

Answer 10

avulsion

Question 11

how do describe a fracture where the ends are driven into each other; commonly seen in arm fractures in children.

Answer 11

buckled /impacted- often causes torus

Question 12

This fracture causes one side of the bone to bend, but does not actually break through the entire bone

Answer 12

torus fracture

Question 13

an incomplete fracture in which the bone is bent; occurs most often in children.

the disruption of one cortex occurs while the other is bent

Answer 13

greenstick

Question 14

the break is parallel to the bone’s long axis.

Answer 14

linear fractyre

Question 15

what is a stress fracture

Answer 15

a hairline crack.Stress fractures are tiny cracks in a bone. They’re caused by repetitive force, often from overuse — such as repeatedly jumping up and down or running long distances. Stress fractures can also develop from normal use of a bone that’s weakened by a condition such as osteoporosis.

Question 16

what is a pathological fractyre vs fragility

Answer 16

pathological - caused by weakness of the bone structure that leads to decrease mechanical resistance to normal mechanical loads. osteoporosis, cancer, infection (such as osteomyelitis), inherited bone disorders, or a bone cyst.

Fragility fracture is a type of pathologic fracture that occurs as a result of an injury that would be insufficient to cause fracture in a normal bone. often is osteoporosis

Question 17

compression/wedge fractrure

Answer 17

usually involves the bones in the back (vertebrae).

Question 18

3 principles of fracture management

Answer 18

Reduce

Hold

Rehabilitate

In the context of high-energy injuries, this is precluded by resuscitation following ATLS (Advanced Trauma Life Support)

Question 19

what is reduction of a fracture? why is it important to do asap

Answer 19

Reduction involves restoring the anatomical alignment of a fracture or dislocation of the deformed limb.

Reduction allows for:
- Tamponade of bleeding at the fracture site
- Reduction in the traction on the surrounding soft tissues, in turn reducing swelling*
- Reduction in the traction on the traversing nerves, therefore reducing the risk of neuropraxia
- Reduction of pressures on traversing blood vessels, restoring any affected blood supply

Question 20

different ways to reduce a fracture

Answer 20

Fracture reduction is typically performed closed in the Emergency Room.

open (by directly visualising the fracture and reducing it with instruments) intra-operatively.

Question 21

analgesia for reduction?

Answer 21

Regional or local blockade for - phalangeal/metacarpal/distal radius fractures

More commonly - conscious sedation in resus eg propofol with analgesia eg morphine

Question 22

What does the ‘hold’ principle of fracture management entail?

Answer 22

‘Hold’ is the generic term used to describe immobilising a fracture.

The most common ways to immobilise a fracture are via simple splints or plaster casts.

Initially, it is important to consider whether traction is needed, such as for subtrochanteric neck of femur fractures, femoral shaft fractures, displaced acetabular fractures, or certain pelvic fractures. Most commonly this is where the muscular pull across the fracture site is strong and the fracture is inherently unstable.

Question 23

principles of safe plaster casts

Answer 23

• For the first 2-weeks, plasters are not circumferential (not always the case in children) - this means They must have an area which is only covered by the overlying dressing, to allow the fracture to swell; if this principle is not adhered to, the cast will become tight (and subsequently painful) overnight, and if left the patient is at risk of compartment syndrome

If there is axial instability (whereby the fracture is able to rotate along its long axis), such as combined tibia-fibula metaphyseal fractures or combined radius-ulna metaphyseal fractures, the plaster should cross both the joint above and below
These are usually termed ‘above knee’ or ‘above elbow’ plasters, respectively, preventing the limb to rotate on its long axis; for most other fractures, the plaster need only cross the joint immediately distal to it

Question 24

what other things do you need to consider once the pt has had a successful ‘reduce’ and ‘hold’ of their fracture

Answer 24

Can the patient weight bear?
- This varies depending on fracture, however you should always inform the patient of this

Do they need thromboprophylaxis?
If the patient is immobilised in a cast and is non-weight bearing, it is common to provide thromboprophylaxis

Have you provided advice about the symptoms of compartment syndrome?

Question 25

what does the 'rehabilitate' portion of the reduce, hold, rehabilitate principles mean?

Answer 25

This refers to the need for most patients to undergo an intensive period of physiotherapy following fracture management. and mobilising asap

Question 26

what is an 'open' fracture

Answer 26

A fracture is ‘open’ when there is a direct communication between the fracture site and the external environment. This is most often through the skin – however, pelvic fractures may be internally open, having penetrated in to the vagina or rectum.

Question 27

open fracture - in-to-out vs out-to-in

Answer 27

Fracture may become open by either an “in-to-out” injury, whereby the sharp bone ends penetrate the skin from beneath, or an “out-to-in” injury, whereby a high energy injury (e.g. ballistic injury or a direct blow) penetrates the skin, traumatising the subtending soft tissues and bone.

Question 28

complications open fractures specifially

Answer 28

skin loss - may require plastics input for skin grafts soft tissue damage - muscle,tendon, ligament loss requireing reconstructive surgery neurovascualr injury INFECTION

Question 29

classification of open fracyures

Answer 29

The Gustilo-Anderson classification can be used to classify open fractures Type 1: <1cm wound and clean Type 2: 1-10cm wound and clean Type 3A: >10cm wound and high-energy, but with adequate soft tissue coverage Type 3B: >10cm wound and high-energy, but with inadequate soft tissue coverage Type 3C: All injuries with vascular injury 3A can be managed by orthopaedics alone, 3B requires plastics input, and 3C requires vascular input

Question 30

when an xray isnt enough for a complex fracture, what other imaging would you get?

Answer 30

CT

Question 31

plan ?open fracture

Answer 31

assess inc neuro-vasc : if either compromse URGENT bedside: Photograph the wound (Fig. 3) and remove any gross debris. However, an out-of-theatre washout is not indicated, instead the wound should then be dressed with a saline-soaked gauze. bloods: basic blood tests, including a clotting screen and a Group & Save. imaging: plain film radiograph 2 views initial: Broad-spectrum antibiotic cover should be administered, as per local guidelines, and a tetanus vaccination is required if the patient is not fully up-to-date with their vaccination. Definitive surgical management requires debridement of the wound and the fracture site, removing all devitalised tissue present. This should happen either immediately if contaminated with marine, agricultural, or sewage material, or <12-24 hours in all other cases

Question 32

early complatcions of fractures

Answer 32

Damage to local structures (e.g., tendons, muscles, arteries, nerves, skin and lung) Haemorrhage leading to shock and potentially death Compartment syndrome Fat embolism (see below) Venous thromboembolism (DVTs and PEs) due to immobility

Question 33

longer-term complications of fractures

Answer 33

Delayed union (slow healing) Malunion (misaligned healing) Non-union (failure to heal) Avascular necrosis (death of the bone) Infection (osteomyelitis) Joint instability Joint stiffness Contractures (tightening of the soft tissues) Arthritis Chronic pain Complex regional pain syndrome

Question 34

what is a fat embolism

Answer 34

Fat embolism can occur following the fracture of long bones (e.g., femur). Fat globules are released into the circulation following a fracture (possibly from the bone marrow). These globules may become lodged in blood vessels (e.g., pulmonary arteries) and cause blood flow obstruction.

Question 35

presentation fat embolism

Answer 35

Fat embolisation can cause a systemic inflammatory response, resulting in fat embolism syndrome. It typically presents around 24-72 hours after the fracture. Gurd’s criteria can be for the diagnosis. Gurd’s major criteria: Respiratory distress Petechial rash Cerebral involvement There is a long list of Gurd’s minor criteria, including: Jaundice Thrombocytopenia Fever Tachycardia

Question 36

what reduces the risk of fat embolism syndrome?

Answer 36

Operating early to fix the fracture reduces the risk of fat embolism syndrome

Question 37

management fat embolism

Answer 37

Management is supportive while the condition improves. The mortality rate is around 10%.

Question 38

what is compartment syndrome

Answer 38

Compartment syndrome is where the pressure within a fascial compartment is abnormally elevated, cutting off the blood flow to the contents of that compartment. Fascial compartments involve muscles, nerves and blood vessels surrounded by fascia.

Question 39

presentationa cute compartment syndrome

Answer 39

Acute compartment syndrome presents with the 5 P’s: P – Pain “disproportionate” to the underlying injury, worsened by passive stretching of the muscles P – Paresthesia P – Pale P – Pressure (high) P – Paralysis (a late and worrying feature)

Question 40

management compartment syndorme - initial and definitive

Answer 40

Initial management involves: Escalating to the orthopaedic registrar or consultant Removing any external dressings or bandages Elevating the leg to heart level Maintaining good blood pressure (avoiding hypotension) Emergency fasciotomy is the definitive management. Ideally, this should be as soon as possible after injury (e.g., within 6 hours). If it is delayed, irreversible damage may occur, and fasciotomy may not be beneficial.

Question 41

how to diagnose compartment syndrome

Answer 41

Acute compartment syndrome is primarily a clinical diagnosis based on clinical signs and symptoms. Needle manometry can be used to measure the compartment pressure. A device (manometer) measures the resistance to injecting saline through a needle into the compartment.

Question 42

What are the signs and symptoms of acute limb threatening ischaemia

Answer 42

1 or more of: Look (1) Pallor Ask: (2) Pain Paraesthesia Feel (2) Temperature: perishingly cold Pulseless Move (1) Paralysis

Question 43

what patterns of limb ischaemia may be seen in pts with peripheral arterial disease

Answer 43

intermittent claudication critical limb ischaemia acute limb-threatening ischaemia

Question 44

initial invetsigations ?acute limb ischaemia

Answer 44

- handheld arterial Doppler examination. - If Doppler signals are present, an ankle-brachial pressure index (ABI) should also be obtained.

Question 45

management acute limb threatening ischaemia

Answer 45

Initial management ABC approach analgesia: IV opioids are often used intravenous unfractionated heparin is usually given to prevent thrombus propagation, particularly if the patient is not suitable for immediate surgery vascular review Definitive management: intra-arterial thrombolysis surgical embolectomy angioplasty bypass surgery amputation: for patients with irreversible ischaemia

Question 46

in what way are childrens bones different to adults

Answer 46

growth plates more flexible but less strong (prone to greenstick fractures) good blood supply (heal more quickly and with less deformity compared to adults

Question 47

what is the risk with growth plate fractures?

Answer 47

can disturb the growth of the childs bones - very bad

Question 48

classifictaion for growth plate fractures

Answer 48

Growth plate fractures are graded using the Salter-Harris classification. The higher the Salter-Harris grade, the more likely the fracture is to disturb growth. Use the SALTR mnemonic to remember the types: Type 1: Straight across Type 2: Above Type 3: BeLow Type 4: Through Type 5: CRush

Question 49

pain ladder in children

Answer 49

Step 1: Paracetamol or ibuprofen Step 2: Morphine

Question 50

what pain medictaions are not used in children? why?

Answer 50

Codeine and tramadol are not used in children as there is unpredictability in their metabolism, so the effects vary too greatly to make them safe and effective options. Aspirin is contraindicated in children under 16 due to the risk of Reye’s syndrome (except in certain circumstances such as Kawasaki disease).

Question 51

what is osteogenesis imperfecta

Answer 51

Osteogenesis imperfecta is a genetic condition that results in brittle bones that are prone to fractures. Defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine.

Question 52

subtypes of osteogeneisis imperfecta? most common type

Answer 52

The most common, and milder, form of osteogenesis imperfecta is type 1 Type I - The collagen is normal quality but insufficient quantity. Type II - Poor collagen quantity and quality. Type III - Collagen poorly formed. Normal quantity. Type IV - Sufficient collagen quantity but poor quality.

Question 53

inheritance osteogenesis imperfecta

Answer 53

autosomal dominant abnormality in type 1 collagen due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides

Question 54

presentation osteogenesis imperfecta

Answer 54

presents in childhood fractures following minor trauma blue sclera deafness secondary to otosclerosis dental imperfections are common

Question 55

bloods osteogeneiss imperfecta

Answer 55

adjusted calcium, phosphate, parathyroid hormone and ALP results are usually normal in osteogenesis imperfecta

Question 56

radiology osteogenesis imperfecta

Answer 56

Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.

Question 57

management osteogenesis imperfecta?

Answer 57

MDT approach medical: - bisphosphonates - vitamin D supplementation Physiotherapy and occupational therapy to maximise strength and function

Question 58

what are the main cancers that metastasise to bone which may contribute to pathoplogical fractures

Answer 58

The main cancers that metastasise to the bones are (mnemonic: PoRTaBLe): Po – Prostate R – Renal Ta – Thyroid B – Breast Le – Lung

Question 59

what are pathological fractures

Answer 59

Pathological fractures occur due to an underlying disease of the bone, such as a tumour, osteoporosis or Paget’s disease of the bone. They may occur with minor trauma or even spontaneously without any history of trauma. Common sites are the femur and the vertebral bodies.

Question 60

what are fragility fractures

Answer 60

Fragility fractures occur due to weakness in the bone, usually due to osteoporosis. They often occur without the appropriate trauma that is typically required to break a bone. For example, a patient may present with a fractured femur after a minor fall.

Question 61

key SE of bisphosphonates

Answer 61

Reflux and oesophageal erosions (oral bisphosphonates are taken on an empty stomach sitting upright for 30 minutes before moving or eating to prevent this) Atypical fractures (e.g. atypical femoral fractures) Osteonecrosis of the jaw Osteonecrosis of the external auditory canal