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Year 2 - BRS > 8.1 - Management of specific fractures > Flashcards

8.1 - Management of specific fractures Flashcards

1
Q

What is trauma?

A

Emergency broken bone support

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2
Q

What is a fracture?

A

Break in the structure of bone associated with a soft tissue injury

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3
Q

What is orthopaedics?

A

More longer-term conditions e.g. osteoarthritis

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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)
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5
Q

What are the principles of orthopaedics?

A
  • history and examination
  • look –> feel –> move
  • investigations e.g. X-ray
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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
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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
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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?
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9
Q

What two types of bone movements can we have in a displaced fracture?

A
  • translation
  • angulation
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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)
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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
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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)
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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)
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14
Q

What is the process of indirect fracture healing?

A
  1. haematoma formation (bleeding between bone ends)
  2. inflammation –> cytokines released –> granulation tissue and blood vessel formation
  3. repair - chondroblasts/osteoblasts make soft callus (type II collagen - cartilage) which is converted to hard callus (type I collagen - bone)
  4. remodelling - callus responds to activity, external forces, functional demands and growth (osteoblasts); excess bone is removed
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15
Q

What is Wolff’s law?

A

Bone grows and remodels in response to the forces that are placed on it

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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
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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
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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
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19
Q

What are the different ways of holding a fracture?

A
  • plaster/splint (closed)
  • fixation
    • internal/external
    • intramedullary/extramedullary
    • monoplanar/multiplanar (external)
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20
Q

What are the general complications of fractures (early/late)? (4)

A
  • fat embolus
  • DVT
  • infection
  • prolonged immobility (UTI, chest infections, sores)
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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
Q

What is the significance of the intertrochanteric line?

A
  • 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
Q

What are some examples of intracapsular and extracapsular fractures by location? (5)

A
  • subcapital (intracapsular)
  • transcervical (intracapsular)
  • basicervical (intracapsular)
  • subtrochanteric (extracapsular)
  • 3-part intertrochanteric (extracapsular)
27
Q

What kind of NoF fracture is more likely to have an interrupted blood supply?

A

Intracapsular = risk of avascular necrosis (death of bone due to lack of blood) is higher

28
Q

What feature is seen on XR that can help us identify a NoF fracture?

A

Shenton’s line (from medial edge of femoral neck to inferior edge of superior pubic ramus) - loss of contour can indicate NoF fracture

NB: not always abnormal in NoF fracture

29
Q

How do we determine whether to fix or replace a fracture? (3)

A
  • location of the fracture
  • degree of displacement
  • age
30
Q

Flowchart for treating NoF fractures.

A
  • 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
Q

How do shoulder dislocations present? (4)

A
  • variable history but often direct trauma
  • pain
  • restricted movement
  • loss of normal shoulder contour
32
Q

What is the clinical examination for shoulder dislocation?

A

Assess neurovascular status - axillary nerve

33
Q

How do we investigate shoulder dislocations?

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
34
Q

How do we manage shoulder dislocations?

A
  • 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
Q

What is a complication of shoulder dislocation?

A

Hill Sachs defect - as humerus comes out, bangs on glenoid and a fleck of bone comes off (Bankart lesion) –> recurrent shoulder dislocation

36
Q

What are the three ways of managing a distal radius fracture?

A
  • cast/splint
  • MUA and K-wire
  • ORIF
37
Q

When is cast/splint done for distal radius fracture?

A
  • 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
Q

When is MUA and K-wire done for distal radius fracture?

A
  • 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
Q

When is ORIF done for distal radius fracture?

A
  • Open Reduction and Internal Fixation
  • any displaced, unstable fractures not suitable for K-wires, or with intra-articular involvement
  • uses plates and screws
40
Q

What is another example of a fracture in the hand?

A

Scaphoid fracture

41
Q

What are some examples of wrist fractures? (3)

A
  • 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
Q

What causes a tibial plateau fracture?

A
  • 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
Q

What other injuries are associated with tibial plateau fractures?

A

Concomitant ligamentous or meniscal injury

44
Q

For which tibial plateau fracture patients do we do non-operative management?

A
  • only truly undisplaced fractures with good joint line congruency assessed on CT/high fidelity imaging
  • reduce, hold, rehabilitate
45
Q

What operative management is there for tibial plateau fractures?

A
  • 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
Q

What is the Gustillo-Anderson classification for open (tibial plateau) fractures? (Extra info?)

A
  • 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
Q

What is the most commonly fractured bone in ankle fractures?

A

Fibula

48
Q

What is a Weber A fracture?

A

Below ankle joint without damage to ligaments

49
Q

What is a Weber B fracture?

A

At the level of ankle joint and may extent to fibula

50
Q

What is a Weber C fracture?

A

Above ankle joint, unstable

51
Q

How do we manage ankle fractures non-operatively?
And for which patients is this suitable for?

A
  • 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
Q

How do we manage ankle fractures operatively?

A
  • 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)

Year 2 - BRS (84 decks)

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