11aaa. Fracture Flashcards
history taking ?fracture
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
examination ?fracture
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
how do you describe a fracture
Displaced or not displaced?
Open or closed?
dispalced vs non-dispalced frcatures
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.
how do you describe a fracture where the broken piece of bone is at a right angle to the bone’s axis?
Transverse Fracture
how do you describe a fracture where the break has a curved or sloped pattern.
Oblique Fracture
How do you describe a fracture where one part of the bone has been twisted at break point
spiral fracture
How do you describe a fracture where the bone breaks into several pieces
comminuted
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?
segmental
how do you describe a fracture when a fragment of bone is separated from the main mass.
avulsion
how do describe a fracture where the ends are driven into each other; commonly seen in arm fractures in children.
buckled /impacted- often causes torus
This fracture causes one side of the bone to bend, but does not actually break through the entire bone
torus fracture
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
greenstick
the break is parallel to the bone’s long axis.
linear fractyre
what is a stress fracture
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.
what is a pathological fractyre vs fragility
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
compression/wedge fractrure
usually involves the bones in the back (vertebrae).
3 principles of fracture management
Reduce
Hold
Rehabilitate
In the context of high-energy injuries, this is precluded by resuscitation following ATLS (Advanced Trauma Life Support)
what is reduction of a fracture? why is it important to do asap
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
different ways to reduce a fracture
Fracture reduction is typically performed closed in the Emergency Room.
open (by directly visualising the fracture and reducing it with instruments) intra-operatively.
analgesia for reduction?
Regional or local blockade for - phalangeal/metacarpal/distal radius fractures
More commonly - conscious sedation in resus eg propofol with analgesia eg morphine
What does the ‘hold’ principle of fracture management entail?
‘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.
principles of safe plaster casts
- 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
what other things do you need to consider once the pt has had a successful ‘reduce’ and ‘hold’ of their fracture
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?
what does the ‘rehabilitate’ portion of the reduce, hold, rehabilitate principles mean?
This refers to the need for most patients to undergo an intensive period of physiotherapy following fracture management.
and mobilising asap
what is an ‘open’ fracture
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.
open fracture - in-to-out vs out-to-in
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.
complications open fractures specifially
skin loss - may require plastics input for skin grafts
soft tissue damage - muscle,tendon, ligament loss requireing reconstructive surgery
neurovascualr injury
INFECTION
classification of open fracyures
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
when an xray isnt enough for a complex fracture, what other imaging would you get?
CT
plan ?open fracture
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
early complatcions of fractures
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
longer-term complications of fractures
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
what is a fat embolism
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.
presentation fat embolism
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
what reduces the risk of fat embolism syndrome?
Operating early to fix the fracture reduces the risk of fat embolism syndrome
management fat embolism
Management is supportive while the condition improves. The mortality rate is around 10%.
what is compartment syndrome
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.
presentationa cute compartment syndrome
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)
management compartment syndorme - initial and definitive
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.
how to diagnose compartment syndrome
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.
What are the signs and symptoms of acute limb threatening ischaemia
1 or more of:
Look (1)
Pallor
Ask: (2)
Pain
Paraesthesia
Feel (2)
Temperature: perishingly cold
Pulseless
Move (1)
Paralysis
what patterns of limb ischaemia may be seen in pts with peripheral arterial disease
intermittent claudication
critical limb ischaemia
acute limb-threatening ischaemia
initial invetsigations ?acute limb ischaemia
- handheld arterial Doppler examination.
- If Doppler signals are present, an ankle-brachial pressure index (ABI) should also be obtained.
management acute limb threatening ischaemia
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
in what way are childrens bones different to adults
growth plates
more flexible but less strong (prone to greenstick fractures)
good blood supply (heal more quickly and with less deformity compared to adults
what is the risk with growth plate fractures?
can disturb the growth of the childs bones - very bad
classifictaion for growth plate fractures
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
pain ladder in children
Step 1: Paracetamol or ibuprofen
Step 2: Morphine
what pain medictaions are not used in children? why?
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).
what is osteogenesis imperfecta
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.
subtypes of osteogeneisis imperfecta? most common type
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.
inheritance osteogenesis imperfecta
autosomal dominant
abnormality in type 1 collagen due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides
presentation osteogenesis imperfecta
presents in childhood
fractures following minor trauma
blue sclera
deafness secondary to otosclerosis
dental imperfections are common
bloods osteogeneiss imperfecta
adjusted calcium, phosphate, parathyroid hormone and ALP results are usually normal in osteogenesis imperfecta
radiology osteogenesis imperfecta
Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.
management osteogenesis imperfecta?
MDT approach
medical:
- bisphosphonates
- vitamin D supplementation
Physiotherapy and occupational therapy to maximise strength and function
what are the main cancers that metastasise to bone which may contribute to pathoplogical fractures
The main cancers that metastasise to the bones are (mnemonic: PoRTaBLe):
Po – Prostate
R – Renal
Ta – Thyroid
B – Breast
Le – Lung
what are pathological fractures
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.
what are fragility fractures
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.
key SE of bisphosphonates
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
