1b// Management of Specific Fractures Flashcards
What is the common nomenclature for orthopaedics? (4)
look
feel
move
x-ray
What is the nomenclature for trauma? (6)
- Reduce
- Hold
– Plaster
– External fixator
– Internal fixation - Rehabilitate
How do you assess and manage a trauma?
The fracture is usually the least important bit
Keep the patient alive first – ATLS
– Airway
– Breathing
– Circulation
– Disability (ie neurology)
Treat as part of ‘C’ occasionally or in secondary survey (ortho is sometimes blood)
How do you assess a fracture? (5)
Pain
Swelling
Crepitus
Deformity
“Collateral damage”
- Nerve
- Vessel
What are the investigations you do for fractures?
XR (in most cases)
CT sometimes indicated
- To make diagnosis
- To assess pattern
MRI if unsure
What would you see on a radiograph?
Name/ Date
Location: which bone and which part of bone?
Pieces: simple/multifragmentary?
Pattern: transverse/oblique/spiral
Displaced/undisplaced?
Translated/angulated?
X/Y/Z plane
Which ones out of transverse, oblique and spiral fractures are high or low energy?
transverse and oblique= high E
spiral= low E
What does the plane on a radiograph tell you?
type of displacement
What are the types of displacement?
translation (medial/ lateral/ dorsal/ volar)
angulation (valgus/ varus)
Rotation (internal/ external)
Impaction
What do the planes X/ Y/ Z show on a translation displacement?
x= medial/ lateral
y= proximal/ distal
z= anterior/ posterior
What do the planes X/ Y/ Z show on an angulation displacement?
x= varus/ vulgus
y= internal/ external rotation
z= dorsal/ volar
What are the 2 types of fracture healing?
indirect and direct fracture healing
What is direct fracture healing?
Anatomical reduction
Absolute stability/compression
No callus
What is indirect fracture healing?
Sufficient reduction
Micromovement
Callus
(without micromovement there is no indirect healing)
What are the steps of indirect fracture healing?
1) inflammation
2) repair
3) remodelling
Describe the inflammation stage (part 1) of indirect fracture healing.
- haematoma formation
- release of cytokines
- granulation tissue and blood vessel formation
Describe the repair stage of indirect fracture healing (part 2)
- soft callus formation (type II collagen- cartilage)
- converted to hard callus (type I collagen- bone)
- calcium and hydroxyapatite gets laid down
Describe the remodelling stage of indirect fracture healing (part 3)
- callus responds to activity, external forces, functional demands and growth
- excess bone is removed
What is the law of bone growth and remodelling?
Wolff’s Law: Bone Grows and Remodels in response to the forces that are placed on it
What is the normal time of bone healing? And what is the variation, and what does the variation depend on?
6 weeks
Actually 3-12 Weeks depending on site & patient
When are signs of healing visible on an x-ray?
from 7-10 dyas
How long does it take phalanges, metacarpals, and distal radius to heal?
Phalanges: 3 weeks
Metacarpals: 4-6 weeks
Distal radius: 4-6 weeks
How long does it take for the forearm, tibia, femur to heal?
Forearm: 8-10 weeks
Tibia: 10 weeks
Femur: 12 weeks
How do you manage a fracture?
Reduce
- open or closed
hold
-internal or external fixation
rehabilitate
- early/ late
- weight bearing
- physiotherapy
Describe the options for reduction.
What are the types of fixations?(5)
plaster
external monoplanar
internal extramedullary
internal intramedullary
external multiplanar
What are the 2 types of fracture complications?
general (early or late)
specific
What are the general fracture complications? (4)
Fat embolus
DVT
Infection
Prolonged immobility (UTI, chest infections, sores)
What are the specific fracture complications? (6)
Neurovascular injury
Muscle/tendon injury
Non union/mal union
Local infection
Degenerative change (intraarticular)
Reflex sympathetic dystrophy
What are the factors that affect fracture healing? (6)
mechanical environment:
- movement
- forces
biological environment:
- blood supply
- immune function
- infection
- nutrition
What are causes of fractured neck of femur?
Osteoporosis (older)
Trauma (younger)
Combination
What is the history of someone with a fractured neck of femur fracture?
Age
Comorbidity:respiratory/cardiovascular/diabetes/cancer
Preinjury mobility:independent/ shopping/ walking/ sports
Social hx: relatives, stairs, ethanol
Do you know the anatomy of the neck of femur fracture?
What are the names of these neck of femur fractures?
What is most likely to happen in an intracapsular NoF fracture?
blood supply is more likely to be compromised
- Avascular necrosis
- non-union
How do you manage NoF fractures?
extracapsular fractures= fix
intracapsular fracture= a bit more complex
What does the decision of fix or replace depend on for NoF fractures?
depends on location/ displacement and age
Describe the decision making process for NoF management.
What is this meant to look like, and what is this?
dislocated shoulder
What is the presentation normally like for shoulder dislocation?
variable hx but often direct trauma
pain
restricted movement
loss of normal shoulder contour
What is the most common shoulder dislocation?
anterior
What do you do for a shoulder dislocation, and what can you find?
assess neurovascular status- axillary nerve
Anterior shoulder dislocation is the most common occurring dislocation at the shoulder, which can cause direct trauma (compression or traction) to the axillary nerve
What investigations do you do for a dislocated shoulder?
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
What is the management of shoulde rdislocation?
Numerous techniques to reduce a dislocated shoulder…
Vigorous manipulation or twisting manipulation should be avoided to avoid fractures
Safest method is to use traction-counter traction +/- gentle internal rotation to disimpact humeral head
Ensure adequate patient relaxation-
Entonox; benzodiazepines
If alone could use Stimson method
Undertake in safe environment, especially in elderly e.g., resus, ask for senior/ anesthetic support early on if necessary
What does AP stand for in x-rays?
anterior-posterior
What are shoulder dislocation complications?
Hill-Sachs defect
Bankart lesion
What are the 2 wrist fractures you should know?
distal radius fracture
scaphoid fracture
Distal radius fracture anatomy.
What are the possible managements of distal radius fractures?
cast/ splint
MUA and K-wire
ORIF
What is a cast/ splint for distal radius fracture?
Temporary treatment for any distal radius fracture- reduction of fracture and placement into cast until definitive
fixation
Definitive if minimally displaced,extra articular fracture
What is a MUA and k-wire for distal radius fracture?
For fractures that are extra- articular but have instability, particularly in children, manipulation under anaesthetics (MUA) in theatre with K-wire fixation can be used. Wires can then be removed in clinic post-op
What is ORIF for distal radius fracture?
any displaced, unstable fractures not suitable for K-wires or with intra-articular involvement may benefit from open reduction internal fixation with plate and screws
Anatomy of scaphoid fracture.
tibia plateau fracture
What does the proximal tibia comprise of?
The proximal tibia comprises a key weight bearing surface as part of your knee joint, articulating with the distal femur
Describe the tibial joint surface.
it is relatively flat and comprises of both medial and lateral plateaus with a central tibial spine acting as an insertion point for ligaments
What can cause a tibial plateau fracture?
Any extreme valgus/ varus force or axial loading across the knee can cause a tibial plateau fracture, with impaction of the femoral condyles causing the
comparatively soft bone of the tibial plateau to depress or split
What type of injury is not uncommon from tibial plateau fractures?
concomitant ligamentous or meniscal injury is not uncommon
What is the management for tibial plateau fractures?
non-operative: only truly undisplaced fractures with good joint like congruency assessed on CT or high fidelity imaging
operative:
- predominance of treatment will be operative
- restoration of articular surface using combination of plate and screws
- bone graft or cement may be necessary to prevent further depression after fixation
trimalleolar fracture
What is the management of ankle fractures?
Describe Weber A, B, C.
