Basics of Fracture Management Flashcards
how is a fracture classified?
VARYING DEGREES OF STABILITY TO A TELESCOPING FORCE (longitudinal force) APPLIED AFTER REDUCTION (normal alignment) (is it stable?)
what does treatment of a fracture depend on?
Stability of fracture
Patient Factors (fitness, other injuries etc.)
Closed vs Open
Types of Fracture and Stability to shortening:
what types of stability do different kinds of fractures cause?
COMPLETE STABILITY - transverse
NO STABILITY TO SHORTENING:
- oblique
- spiral
- Comminuted
POTENTIAL STABILITY:
- oblique fractures
- < 45 degrees
As you apply a longitudinal force down in a fracture that isn’t transverse then you would find the proximal and distal segments would slide past each other
what is an open fracture?
There is a direct communication between the external environment and the fracture
usually through a break in the skin, but not always, e.g. fragments of bone from a fractured pelvis penetrating the rectum
a graze on the skin that does not penetrate the dermis over a fracture does NOT make it an open fracture
open fractures differ form closed fractures in what 2 main ways?
Higher risk of infection
Higher energy of injury
how are open fractures graded?
Gustilo grading:
Type I - low energy, wound <1cm
Type II - moderate soft tissue damage, wound 1-10cm
Type III - high energy, wound >10cm; any gunshot, farm accident:
- IIIA - soft tissue damage +++ but not grossly contaminated
- IIIB - periosteal stripping (soft tissue over bone been stripped off)
- IIIC - assoc. neurovascular complication
what is the management of open fractures?
tetanus and antibiotic prophylaxis (slows bacterial growth)
Photograph (don’t have to keep uncovering it), cover and stabilise limb (splintage)
surgical emergency:
- Some operation within 6h
- All operation within 24 hrs
early and thorough wound excision and toilet - By senior experienced surgeons (Take out everything that is dead)
do not close wound – leave skin open
repeat wound review and toilet
early definitive skin cover (5-7 days)
stabilise # definitively
? bone grafting
fasciotomies
treatment of a fracutre - what is initially done?
Immobilisation (best thing to do)
Pain relief
treatment of a fracutre - what assessment is carried out?
Clinical:
- Fracture
- Circulation (distal to fracture)
- Neurological (distal to fracture)
- Open vs Closed
Radiological
treamtent of a fracture - what definitive treatment is done?
No reduction required
Reduction required (if there is displacement - Reduce bone back to its anatomical position) - LA,GA,other
Maintenance of position:
- Conservative
- Operative
whata re the 2 types of fracture treamtent?
Conservative and operative
what is the conservative treatment of a fracture?
No Immobilisation:
- Strapping
- Brace
Immobilisation:
- Cast
- Functional Bracing
- Traction
what is the operative treatment of a fracture?
Pins
External fixators
Intramedullary rods
Screws and Plates
Conservative Fracture Treatment:
if there is No Initial Immobilisation or reduction required, then what may be done?
No support
Support:
- Strapping
- Elastic Bandage
- Brace
Conservative Fracture Treatment:
if there is Initial Immobilisation +/- Reduction, what may be done?
Cast
Functional Brace
Traction (In the medical field, traction refers to the practice of slowly and gently pulling on a fractured or dislocated body part. It’s often done using ropes, pulleys, and weights. These tools help apply force to the tissues surrounding the damaged area)
what are the cast principles?
THREE POINT LOADING
HYDRAULICS
ROTATIONAL CONTROL - By including joint above and below
what is soft tissue hinge?
Always present
Dependent on magnitude of injury
Periosteum, interosseous membrane, septum
Muscles
what do hydraulics do?
Soft tissue can burst out with out constraint
what is functional bracing?
For long bones - Femur, tibia, humerus
Joints left free - To mobilise
Once bone “Sticky” - No longer shorten
Stops bending
Stops angulation
Allows joints to move
what is the process of traction?
AXIAL FORCE
SOFT TISSUE SLEEVE
ALIGNMENT RESTORATION
CLOSED REDUCTION
INDIRECT REDUCTION
MAINTENANCE REDUCTION
Pulls along line of limb and aligns bone
how is skin traciton done?
Applied via adhesive or non adhesive tape
CHILDREN - Gallows <12kg (child weight)
ADULT < 6LB
BLISTERING / SLOUGHING
COMPARTMENT SYNDROME
how is skeletal traction done?
Traction via bone (pin or wire)
Allows greater force/weight
Common sites:
- Femur
- Tibia
what are the different types of operative treatment?
External Fixation
Internal Fixation:
- Intramedullary Nailing
- Screw
- Plate
what are external fixators?
Fixation from outside
Pins or wires passed through skin and bone
Fixed to an external frame
what are some common indications for external fixation?
Fractures with poor soft tissue conditions (inc. open fractures)
Where distraction through the fixator may help with fragment reduction
Emergency pelvic stabilisation for haemorrhage control
Limb reconstruction
what are the different external fixator types?
what are some complications in external fixation?
Neurovascular injury
Pin tract infection (infection in the tract through which the pin runs)
Loss of fracture alignment
(Joint contractures)
(Tardy union)
how may additional wires be used in external fixation?
Wires not attached to frames
May be used to “pin” fragments together
Combined with casts or ex-fix
what is Intramedullary Nailing?
Pass a nail done the centre of the long bone form top to bottom
what is the indication for Intramedullary Nailing?
Long Bone Diaphyseal Fracture:
Tibial
Femoral
Humeral
Paediatric
what is the IM Nailing Technique?
Patient positioned
Fracture reduced
Entry point - Small incision, X-ray guided entry/wire
Canal reamed
Nail Passed
Bone locked onto nail - Proximally and distally
Only done in long bones, not done in short bones or at the top or bottom of long bones
what are the IM nailing Advantages?
Incisions remote (far away) from fracture - Proximal or distal bone
Minimal fracture exposure:
- Preserve periosteum
- avoid necrosis/damage soft tissues + bone
Joints free to move - Don’t get joint stiffness like you are worried about with some of the external fixators
how is internal fixation using screws and plates done?
Usually incision over and exposure of fracture
Accurate reduction fracture - articular
Access for bone grafting
Allows early joint mobilisation
what is the risk associated with internal fixation using screws and plates?
Devascularisation (cut blood supply so slower to heal)
Wound problems
Infection
what are the different types of screws used?
Different Types:
- Depending type bone
- Cortical vs cancellous
Different sizes - Depending size bone
how can screws fit 2 pieces of bone together?
a) Compress (Compression tend to heal quicker than if left open a bit)
b) Fix in position
what is plate fixation and how is it done?
Fixed to outside of bone with screws
Load sharing - Plate and bone take weight, Initially more on plate (as bone heals it takes more weight)
No of Types
Bone needs to heal before plate fails - Due to repeated bending
what are the different types of plates?
Compression - Squeeze bone together
Neutralisation - Resist rotating forces (spiral fractures)
Buttress - Stop collapse
Strut/Bridging - No opening fracture, more like external nail
Strut done is very damaged bone that has significant soft tissue damage. Incision at top and bottom and the plates are slide in, like an intramedullary nail, locked at top or bottom but it is outside the medulla, so like an external nail
