Acute medicine - fractures Flashcards
Salter type 1
Straight across
Salter type 2
Above i.e. through the physis and metaphysis
Most common type (75%)
Salter type 3
Low i.e. through the physis and epiphysis
Salter type 4
Through i.e. through the physis, metaphysis and epiphysis
HIGH RISK FOR GROWTH PLATE INJURY
Salter type 5
ERasure of the growth plate - crush type
4 complications of shoulder dislocations
1) Bankart lesion = injury of anterior glenoid labrum
2) Hill-sachs lesion = cortical depression in postero-lateral head of humerus
3) Rotator cuff tear
4) Axillary nerve injury - runs inferiorly to humeral head, wraps around surgical neck of humerus, innervates deltoid and teres minor, needed for >15 degrees shoulder ABduction, sensory for skin over delotid/shoulder
NV assessment in a clavicle fracture
Nerve: brachial plexus injury, esp C5-6. Spurling test is specific for cervical root compression but is not sensitive (a negative test does not rule it out).
Vacular: subclavian artery runs closely opposed to the middle third of the clavicle (80% of fractures)
Middle third clavicular fracture management
- broad arm sling for 2 weeks
- if >12yo or shortened >2cm –> refer to ortho, and follow up with GP/fracture clinic
Lateral third clavicular fracture management
- broad arm sling fro 2 weeks +; if displaced refer to ortho
- fracture clinic in 5-7 days with xray
Medial third clavicular fracture management
Broad arm sling, ortho referral (both displaced and undisplaced) with ortho follow up
Proximal humeral fracture management
Immobilsation of shoulder in sling, body swathe or shoulder immobiliser
Follow up in fracture clinic or with GP in 7 days with x-rays to assess for further displacement
Degree of angulation/displacement to accept in prox humeral fractures
o 5-12 years - accept 60 degree angulation and 50% displacement
o >12 years - accept 30 degrees angulation and 30% displacement
* Isolated greater tuberosity fractures with displacement in the adolescent are an exception group in which surgical reduction and fixation is usually required.
Humeral fracture associations (transverse, short oblique, spiral)
Transvere/short oblique - direct trauma
Spiral - indirect twisting e.g. fall
Spiral in toddler or younger = NAI until proven otherwise
Humeral fracture management
reduction rarely required, use a collar and cuff; if mid-shaft, 1 week follow up in fracture clinic
Gartland type 1 location and management
Type I is a non displaced fracture. Immobilisation in an above-elbow backslab in 90 degrees elbow flexion with sling for 3 weeks. The backslab and sling should be worn under clothing (e.g. loose fitting shirt) and not through the sleeve
The backslab should extend as high above the elbow as possible (i.e. close to the axilla) and down to the metacarpophalangeal joints (MCP) joints. GP follow up in 3 weeks, no repeat xray required.
Gartland type 2 location and management
Type II supracondylar fracture describes a displaced fracture with an intact posterior periosteum. Refer to the nearest orthopaedic on call service for advice, A gentle reduction can be achieved by an anterior push on the distal fragment as the elbow is flexed to 90 degrees
Note the exception is type II injuries with coronal plane deformity (see radiological assessment). These must always be managed by orthopaedics.
Overnight observation and fracture clinic in 7 days post-injury, with xray of distal humerus in backslab
Gartland type 3 location and management
Type III supracondylar fracture describes a displaced fracture where both the anterior and posterior periosteum are disrupted. Refer to the nearest orthopaedic on call service, as requires urgent reduction and percutaneous pin fixation.
You are called by the midwife to assess a newborn baby who appears dysmorphic. On examination, there are multiple pterygium, joint contractures and talipes equinovarus.
- Meckel-Gruber syndrome
- Ellis Van Creveld syndrome
- Escobar syndrome
- Trisomy 18
- Larsen syndrome
- Trisomy 21
- Potter sequence
- Hecht syndrome
Correct answer:Escobar syndrome
Explanation:
This syndrome is also known as multiple pterygium syndrome. Pterygium describes webbed skin. There is also a lack of muscle movement in utero which leads to contractures and deformities such as talipes equinovarus (clubfoot).
You are called by the midwife to assess a newborn baby who appears dysmorphic. On examination, there is talipes equinovarus. You are unable to examine the palate because you cannot open the mouth wide enough to obtain a clear view.
- Meckel-Gruber syndrome
- Ellis Van Creveld syndrome
- Escobar syndrome
- Trisomy 18
- Larsen syndrome
- Trisomy 21
- Potter sequence
- Hecht syndrome
Correct answer:Hecht syndrome
Explanation:
Also known as trismus-pseudocamptodactyly syndrome. Mutations in the MYH8 gene lead to short muscles and tendons and subsequent limited range of movement. The mouth is particularly affected.
You are called by the midwife to assess a newborn baby who appears dysmorphic. On examination, there is a cardiac murmur and congenital vertical talus.
- Meckel-Gruber syndrome
- Ellis Van Creveld syndrome
- Escobar syndrome
- Trisomy 18
- Larsen syndrome
- Trisomy 21
- Potter sequence
- Hecht syndrome
Correct answer:Trisomy 18
Explanation:
Also known as Edwards syndrome. Both Edwards syndrome and Ellis Van Creveld syndrome can present with cardiac abnormalities but congenital vertical talus (commonly known as “rocker-bottom feet”) is associated with Trisomy 18.
An 11-month-old boy presents with a limp. His mum tells you that there has been no history of trauma. He has had a runny nose for the past three days, but no fever. He is usually well. On examination, there are no obvious abnormalities. The boy limps but doesn’t seem to be in pain. You request bloods for FBC and CRP and an x-ray. The FBC shows lymphopaenia with a CRP of 30. There is a hairline spiral tibia fracture on x-ray. When you discuss the results with his father, he tells you that his son tripped down two steps yesterday, but that he hadn’t mentioned it because he didn’t think he had hurt himself at the time and it didn’t seem significant at the time. Which of the following is the most likely diagnosis?
* a)Malignancy.
* b)Osteomyelitis.
* c)Toddler’s fracture.
* d)Non-accidental injury.
A: Incorrect. You should always consider malignancy in your differential diagnosis for limp, but this child is otherwise well, with no red flags and reassuring bloods, and the x-ray does not support the diagnosis.
B: Incorrect. Not all cases of osteomyelitis will present with fever but most are painful and/or will cause the child to be unwell. It can present with vague symptoms so it should be considered. The x-ray does not support the diagnosis.
C: Correct. Commonly occurs in children who are just starting to walk or become active. The mechanism of injury may be very minor and not noticed by the parents. The initial x-ray may be normal or the fracture may be mistaken for a nutrient vessel. The blood results can be explained by the viral URTI.
D: Incorrect. You should always consider NAI in any child with a fracture – especially if the history is not clear. However, toddler’s fracture often presents without any obvious mechanism of injury.
The correct answer is C.
Ossification centres of the elbow
CRITOE (1,3,5,7,9,11)
Capitellum at 1 year
Radial head at 3 years
Internal (medial) epicondyle at 5 years
Trochlear at 7 years
Olecranon at 9 years
External (lateral) epicondyle at 11 years
Investigations and management of a SUFE
A slipped upper femoral epiphysis (SUFE)is the commonest cause of hip pain in the adolescent age group (10-15 years).
* Males are more frequently affected than females by 2:1
* It may be bilateral in 30% of cases
* Positivefamily history,obesityandhormonalabnormalitiessuchas hypogonadism,hypothyroidismandhypopituitarism are well known associations
The pathology is a stress fracture through the upper femoral growth plate resulting in a progressive slip of the femoral head over the femoral neck. The affected limb shortens and externally rotates as the deformity increases with time.
If this condition is left untreated it may result in severe limb shortening, fixed external rotation and stiffness of the hip. This may then be followed by early onset of osteoarthritis in adulthood. Needs surgical management.
In a small number of cases sudden catastrophic failure of the growth plate may occur, resulting in severe deformity and loss of blood supply to the femoral head (avascular necrosis) with serious long-term sequelae.
A frog-leg lateral x-ray will confirm.
Associations with heel spurs
Heel spurs,when located on the inferior aspect of the calcaneus, is often associated with plantar fasciitis and ankylosing spondylitis.Enthesitis (inflammation where joint capsules, ligaments, tendons attach to bone) is the hallmark of ankylosing spondylitis. The two areas in the foot involved are the Achilles tendon at the back of calcaneus and the plantar fascia at the base of heel.
