1B management of specific fractures Flashcards
1
Q
What is trauma?
A
Emergency broken bone support
2
Q
What are the main principles of dealing with trauma in hospitals?
A
- Advanced trauma life support
- Reduce fracture
- Hold fracture
- Rehabilitate (move) when fracture is healed
3
Q
What is orthopaedics?
A
More longer term conditions e.g. osteoarthritis
4
Q
What are the principles for orthopaedics?
A
- History and examination
- look → feel → move
- Investigations
5
Q
What are the clinical signs of a fracture?
A
- Pain
- Swelling
- Crepitus
- Deformity
- Adjacent structural injury: nerves/vessels/ligament/tendons
6
Q
How do we investigate fractures?
A
- Radiograph (Xray)- most popular
- CT scan
- MRI scan
- Bone scan
7
Q
How do we describe radiographs?
A
- Location- which bone and which part of bone?
- Pieces- simple/multifragmentary?
- Pattern- transverse/oblique/spiral
- Displaced/undisplaced
- Translated/angulated?
- X/Y/Z plane
8
Q
What are the two types of movements we can have of bones?
A
- Translation
- Angulation
9
Q
What direction is translation?
A
Straight line movements where you can have:
- medial and lateral translation
- proximal and distal translation
- anterior and posterior translation
10
Q
What direction is angulation movement?
A
Rotation movements:
- Varus/valgus movement is in coronal plane towards and away from midline
- Dorsal/volar movement is in sagittal plane
- Internal/external rotation is in axial plane
11
Q
What are general complications of fractures (early or late)?
A
- Fat embolus
- DVT
- Infection
- Prolonged immobility (UTI, chest infections, sores)
12
Q
What are some more specific complications of fractures?
A
- Neurovascular injury
- Muscle/tendon injury
- Non union/mal union
- Local infection
- Degenerative change (intraarticular)
- Reflex sympathetic dystrophy
13
Q
What are some causes of neck of femur (NOF) fractures?
A
- Osteoporosis in older patients
- Trauma in younger patients
- Combination of both
14
Q
What do we want to know about in the patient’s history when looking at NOF fractures?
A
- Age
- Comorbidities- cardiovascular/respiratory/diabetes/cancer
- Preinjury mobility- were they independent/shopping/walking/sports?
- Social Hx: relatives? do they have stairs at home? ETOH?
15
Q
What is the red dotted line?
A
- The attachment of the capsule along the intertrochanteric line on the front line
- On the back of the femur the capsule goes halfway up NOF
- Anything above dotted line is intracapsular and everything below it is extracapsular (there’s a half zone on the back where it’s extracapsular there but around the front it’s intracapsular)
16
Q
Identify the types of fractures for each image
A
- Subcapital (intracapsular)
- Transcervical (extracapsular)
- Intertrochanteric (extracapsular)
- Subtrochanteric (left) and 3 part intertrochanteric (right)
17
Q
What kind of fracture is in this pic? Is it likely to have interrupted blood supply and what does that mean?
A
Intracapsular left NOF fracture
Yes so risk of avascular necrosis (death of bone due to lack of blood) is higher
18
Q
How do we determine whether to either fix or replace a fracture?
A
- The location of the fracture
- The degree of displacement
19
Q
What treatment is given for extracapsular fractures?
A
- Blood supply to femur likely to be preserved so head of femur is likely to survive
- So we fix this fracture with plate and screws (dynamic hip screw)
20
Q
What treatment is given to intracapsular fractures?
A
- If the bone fragments haven’t moved apart and it’s likely the blood supply is still intact, we can fix the fracture with screws
- If the bone fragments have displaced, there’s a 25-30% chance of avascular necrosis so we think more about replacing the head of the femur as it might die
21
Q
When do we do a total hip replacement vs hemiarthroplasty?
A
- Total hip replacement if patient is:
- Walks >mile a day
- Independent
- Minimal comorbidities
- Hemiarthroplasty (leave acetabulum as bone but replace head and neck of femur) if patient has:
- Lower mobility
- Multiple comorbidities
22
Q
How do patients with shoulder dislocation present?
A
- Variable history but often direct trauma
- Pain
- Restricted movement
- Loss of normal shoulder contour
23
Q
What are clinical exam findings for shoulder fracture?
A
Assess neurovascular status- axillary nerve
24
Q
How do we investigate shoulder fractures?
A
- X-ray prior to any manipulation- identify fracture e.g. humeral neck, greater tuberosity avulsion or glenoid
- Scapular-Y view/modified axillary in addition to AP
25
How do we manage shoulder fractures?
There are numerous techniques to reduce shoulder dislocation.
- Vigorous manipulation or twisting should be avoided to avoid fractures
- Safest method is **traction-counter traction +/- gentle internal rotation** to disimpact humeral head
- Ensure adequate patient relaxation e.g. entonox or benzodiazepines
- If alone could use **Stimson method** (using hanging weights)
- Undertake in safe environment esp in elderly e.g. resus, ask for senior/anaesthetic support early on if necessary
26
What is a complication of shoulder dislocation?
**Hill-Sachs defect**:
As humerus comes out, it bangs on **glenoid** and a fleck of bone comes off (called a **Bankart lesion**).
This can lead to **recurrent shoulder dislocation**.
27
What does this image show?
Distal radial fracture
28
What are the 3 ways of managing distal radial fracture?
- Cast/splint
- MUA and K-wire
- ORIF (open reduction internal fixation)
29
When is a cast/split used for distal radius fracture?
- **Temporary treatment** for any distal radial fracture- reduction of fracture and placement into cast until definitive fixation
- Definitive if minimally displaced, extraarticular fracture
30
When is MUA and K-wire used in distal radius fractures?
- For fractures that are **extra-articular** but have **instability**, particularly in children
- MUA (manipulation under anaesthesia) in theatre with K-wire (Kershner wire- a pin in the wrist) fixation can be used
- Wires can be removed in clinic post op
31
What is ORIF and when is it done for distal radial fractures?
- Open reduction and internal fixation
- For any **displaced, unstable fractures** not suitable for K-wires or with intraarticular involvement
- Uses plates and screws
32
What does this show?
Scaphoid bone fracture
33
What is this an example of?
Tibial plateau fracture
34
What is a lipohaemarthrosis?
Lipohaemarthrosis results from an intra-articular fracture with escape of fat and blood from the bone marrow into the joint.
Fat floating to surface when patient is lying down (this Xray was taken with patient lying down)
This is pathognomonic of a fracture within a joint- tells us not where a fracture is, but that there’s one there that we need to spot
35
How can a tibial plateau fracture be caused?
- Proximal tibia has a key weightbearing surface as part of knee joint, articulating with distal femur
- Tibial joint surface is relatively flat and comprises of medial and lateral plateaus with central tibial spine acting as insertion point for ligaments
- Any extreme valgus/varus force or axial loading across knee can cause tibial plateau fracture, with impact of the femoral condyles causing the comparatively soft bone of tibial plateau to depress or split
**Concomitant ligamentous** or **meniscal injury** can also be associated with this.
36
For which tibial plateau patients do we do non-operative management?
- Only **truly undisplaced fractures** with **good joint line congruency** assessed on CT
- We reduce, hold and rehabilitate
37
What operative management is there for tibial plateau fracture?
- Predominance of treatment will be operative
- Restoration of articular surface using combo of **plate and screws**
- **Bone graft or cement** may be necessary to prevent further depression after fixation
38
What are the different fractures in this pic?
39
What is the most commonly fractured bone in ankle fractures?
Fibula
40
How do we manage ankle fractures non-operatively?
**Non-weightbearing below knee cast** for **6-8 weeks**, can transfer into **walking boot** and then **physio** to improve range of motion/stiffness from joint isolation
41
What is a Weber A fracture?
Below ankle joint (syndesmosis) without damage to ligaments
42
When are Weber A fractures treated non-operatively?
If they’re below syndesmosis and therefore thought to be stable
43
What is a Weber B fracture?
At the level of ankle joint and may extend to fibula
44
When are Weber B fractures managed non-operatively?
If no evidence of instability (no medial/posterior malleolus fractures and no talar shift)
45
How do we manage ankle fractures **operatively**?
- Soft-tissue dependent- patients need strict elevation as injuries often swell considerably
- **ORIF +/- syndesmosis repair** using either screw or tightrope technique
- Syndesmosis screws can be left in situ but may break after some time so therefore can be removed at a later date if needed
- Done to Weber B fractures
46
What is a Weber C fracture and why is it operated on every time?
- Above ankle joint
- i.e. fibular fracture above level of syndesmosis so will be unstable
