8.1 - Management of specific fractures Flashcards
1
Q
What is trauma?
A
Emergency broken bone support
2
Q
What is a fracture?
A
Break in the structure of bone associated with a soft tissue injury
3
Q
What is orthopaedics?
A
More longer-term conditions e.g. osteoarthritis
4
Q
How do we assess and manage trauma in hospitals?
A
- fracture usually the least important bit
- advanced trauma life support - keep patient alive first
- airway, breathing, circulation, disability
- occasionally treat as part of ‘C’
- reduce fracture
- hold fracture (plaster, external fixator, internal fixation)
- rehabilitate (normally 6 weeks later)
5
Q
What are the principles of orthopaedics?
A
- history and examination
- look –> feel –> move
- investigations e.g. X-ray
6
Q
What are the clinical signs of a fracture? (5)
A
- pain
- swelling
- crepitus
- deformity
- collateral damage - adjacent structural injury –> nerves/vessels/tendons/ligaments
7
Q
How do we investigate fractures? (3)
A
- X-ray (radiograph) - in most cases
- CT sometimes indicated (to make diagnosis, to assess pattern)
- MRI if unsure
8
Q
How do we describe fracture radiographs?
A
- demographics (ABC - adequacy, bones, cartilage)
- location - which bone, which part of bone? (proximal, distal, midshaft, intra-articular if extends into joint surface)
- pieces - simple/multifragmentary (comminuted)?
- pattern - transverse/oblique/spiral?
- displaced/undisplaced?
- translated/angulated?
- X/Y/Z plane?
- rotation
- impaction
- stable/unstable?
9
Q
What two types of bone movements can we have in a displaced fracture?
A
- translation
- angulation
10
Q
What direction is the movement of bone in translation?
A
Straight line movements where you can have:
- medial/lateral translation (X)
- proximal/distal translation (Y)
- anterior/posterior translation (Z)
11
Q
What direction is the movement of bone in angulation?
A
Rotation movements:
- varus/valgus movement (X) is in coronal plane towards/away from midline
- internal/external movement (Y) in axial plane
- dorsal/volar movement (Z) in sagittal plane
12
Q
What is direct fracture healing?
A
- anatomical reduction (ends of bone very close, often stable fracture)
- absolute stability/compression
- no callus
- (primary bone healing - intramembranous, mesenchymal SC–>osteoblast = direct formation of woven bone)
13
Q
What is indirect fracture healing?
A
- sufficient reduction
- micromovement (needed to heal)
- callus
- (secondary bone healing - endochondral, involves periosteum and external soft tissues, relatively stable fracture, mesenchymal SC–>chondral precursor–>bone cells produced)
14
Q
What is the process of indirect fracture healing?
A
- haematoma formation (bleeding between bone ends)
- inflammation –> cytokines released –> granulation tissue and blood vessel formation
- repair - chondroblasts/osteoblasts make soft callus (type II collagen - cartilage) which is converted to hard callus (type I collagen - bone)
- remodelling - callus responds to activity, external forces, functional demands and growth (osteoblasts); excess bone is removed
15
Q
What is Wolff’s law?
A
Bone grows and remodels in response to the forces that are placed on it
16
Q
How long does it take fractures in different bones to heal?
A
- 3-12 weeks depending on site and patient (usually 6 weeks)
- signs of healing visible on XR from 7-10 days
- general: upper limbs/hands quicker than lower limbs/feet
- phalanges: 3 weeks
- metacarpals: 4-6 weeks
- distal radius: 4-6 weeks
- forearm: 8-10 weeks
- tibia: 10 weeks
- femur: 12 weeks
17
Q
What are the main principles of fracture management? (3)
A
- reduce - bring fracture ends together
- hold - hold ends in right position with/without metal
- rehabilitate - once bone has healed, limb is still weak = needs rehabilitation
18
Q
What are the two types of reduction?
A
- closed - pull bones together without opening skin
- manipulation
- traction - skin / skeletal (pins in bone)
- open
- mini-incision
- full exposure
19
Q
What are the different ways of holding a fracture?
A
- plaster/splint (closed)
- fixation
- internal/external
- intramedullary/extramedullary
- monoplanar/multiplanar (external)
20
Q
What are the general complications of fractures (early/late)? (4)
A
- fat embolus
- DVT
- infection
- prolonged immobility (UTI, chest infections, sores)
21
Q
What are some specific complications of fractures? (6)
A
- neurovascular injury
- muscle/tendon injury
- non union/mal union
- local infection
- degenerative change (intra-articular)
- reflex sympathetic dystrophy
22
Q
What factors affect fracture healing? (2)
A
- mechanical environment - movement, forces
- biological environment - blood supply, immune function, infection, nutrition
23
Q
What are the causes of neck of femur (NOF) fractures in older vs younger patients?
A
- osteoporosis in older patients
- trauma in younger patients
- combination of both
24
Q
What do we want to know about patient’s history in NOF fracture? (4)
A
- age
- comorbidities - respiratory/cardiovascular/diabetes/cancer
- preinjury mobility - independent/shopping/walking/sports
- social history - relatives? stairs at home? alcohol?
25
What is the significance of the intertrochanteric line?
- intertrochanteric line runs between greater trochanter and lesser trochanter
- capsule sits on intertrochanteric line
- above intertrochanteric line = intracapsular fracture (worry about blood supply)
- below intertrochanteric line = extracapsular fracture (blood supply likely preserved so head of femur likely to survive)
26
What are some examples of intracapsular and extracapsular fractures by location? (5)
- subcapital (intracapsular)
- transcervical (intracapsular)
- basicervical (intracapsular)
- subtrochanteric (extracapsular)
- 3-part intertrochanteric (extracapsular)
27
What kind of NoF fracture is more likely to have an interrupted blood supply?
Intracapsular = risk of avascular necrosis (death of bone due to lack of blood) is higher
28
What feature is seen on XR that can help us identify a NoF fracture?
Shenton's line (from medial edge of femoral neck to inferior edge of superior pubic ramus) - loss of contour can indicate NoF fracture
## Footnote
NB: not always abnormal in NoF fracture
29
How do we determine whether to fix or replace a fracture? (3)
- location of the fracture
- degree of displacement
- age
30
Flowchart for treating NoF fractures.
- extracapsular --> internal fixation (plate and screws - dynamic hip screw or nail)
- intracapsular?
- displaced - <55y/o = reduce and fixation with screws, >65y/o = replace (total hip replacement if fit and mobile, hemiarthroplasty if less fit)
- undisplaced --> fixation with screws
31
How do shoulder dislocations present? (4)
- variable history but often direct trauma
- pain
- restricted movement
- loss of normal shoulder contour
32
What is the clinical examination for shoulder dislocation?
Assess neurovascular status - axillary nerve
33
How do we investigate shoulder dislocations?
- 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
34
How do we manage shoulder dislocations?
- numerous techniques to reduce a dislocated shoulder
- vigorous/twisting manipulation 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 BZs
- if alone could use Stimson method (using hanging weights)
- undertake in safe environment, especially in elderly e.g. resus, ask for senior/anaesthetic support early on if necessary
35
What is a complication of shoulder dislocation?
Hill Sachs defect - as humerus comes out, bangs on glenoid and a fleck of bone comes off (Bankart lesion) --> recurrent shoulder dislocation
36
What are the three ways of managing a distal radius fracture?
- cast/splint
- MUA and K-wire
- ORIF
37
When is cast/splint done 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
38
When is MUA and K-wire done for distal radius fracture?
- for fractures that are extra-articular but have instability, particularly in children
- MUA (manipulation under anaesthesia) in theatre with K-wire (Kershner wire - pin in wrist) fixation can be used
- wires can be removed in clinic post-op
39
When is ORIF done for distal radius fracture?
- Open Reduction and Internal Fixation
- any displaced, unstable fractures not suitable for K-wires, or with intra-articular involvement
- uses plates and screws
40
What is another example of a fracture in the hand?
Scaphoid fracture
41
What are some examples of wrist fractures? (3)
- Colle's fracture - from fall on an outstretched hand
- Smith fracture - from fall on a flexed wrist/direct blow to the back of the wrist
- Barton's fracture - intra-articular fracture
42
What causes a tibial plateau fracture?
- proximal tibia comprises a key weightbearing surface as part of the knee joint, articulating with distal femur
- tibial joint surface is relatively flat and comprises both medial and lateral plateaus with a 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 **impaction of the femoral condyles causing the comparatively soft bone of tibial plateau to depress or split**
43
What other injuries are associated with tibial plateau fractures?
Concomitant ligamentous or meniscal injury
44
For which tibial plateau fracture patients do we do non-operative management?
- only truly undisplaced fractures with good joint line congruency assessed on CT/high fidelity imaging
- reduce, hold, rehabilitate
45
What operative management is there for tibial plateau fractures?
- 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
46
What is the Gustillo-Anderson classification for open (tibial plateau) fractures? (Extra info?)
- type I - puncture wound <1cm, minimal contamination and soft tissue damage
- type II - laceration 1-10cm, moderate soft tissue damage, adequate bone coverage, minimal comminution
- type IIIA - laceration >10cm, extensive soft tissue damage, adequate bone coverage, segmental/severely comminuted fractures, heavily contaminated wounds
- type IIIB - as IIIA but with periosteal stripping and bone exposure
- type IIIC - any open fracture with vascular injury requiring repair
47
What is the most commonly fractured bone in ankle fractures?
Fibula
48
What is a Weber A fracture?
Below ankle joint without damage to ligaments
49
What is a Weber B fracture?
At the level of ankle joint and may extent to fibula
50
What is a Weber C fracture?
Above ankle joint, unstable
51
How do we manage ankle fractures non-operatively?
And for which patients is this suitable for?
- non-weightbearing below knee cast for 6-8 weeks, can transfer into walking boot and then physiotherapy to improve range of motion/stiffness from joint isolation
- Weber A i.e. below syndesmosis and therefore thought to be stable
- Weber B if no evidence of instability (no medial/posterior malleolus fractures and no talar shift)
52
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
- Weber B (if unstable fracture - talar shift/medial or posterior malleoli fractures)
- Weber C (i.e. fibular fracture above the level of the syndesmosis therefore unstable)
