Bones and fractures Flashcards
What is ultrasound useful to check for in RA?
Soft tissue swelling
Osteoporosis
Joint space narrowing
Marginal erosions
What find in initial phase of RA on USS?
Synovitis
What is seen on USS of RA in late stages of the disease?
Erosive arthropathy )periarticular eroisons and marginal)
Osteoporosis
Symmetrical
Concentric joint space narrowing
Preference for PIP + MCP (2nd +3rd)
Subluxation adn deformity (ulnar deviation)
Boutienniere and swan neck deformities
Carpal instability
What are synovitis signs?
Soft tissue swelling
Juxt-articular osteopaenia
General approach to large joint X-rays
Check patient demographic details (Name, DOB and hospital number)
Check type of joint image done (comment on projection of the image)
Check whether entire region has been covered
Is the XR adequate?
Bone density (normal/ increased or decreased/ lucency)
Look at joint spacing
Increased density in sclerotic processes or decreased in osteopaenia and lucency would be sign of what
Malignancy
What is an osteochondral defect?
Focal area of damage to cartliage and bone
Fracture Xrays approach
Describe the radiograph
Type of fracture?
Where is the fracture?
Is it displaced?
Is anything else going on?
What is angulation in fractures
Distal portion of bone in different direction
What is rotation of fracture on X ray
-Rotation of the distal fragment, distraction
What is impaction of a fracture?
Fracture resulting increased or decreased bone length
What is translation of bone in fractures?
Movement of fractured bones away from each other
What can cause a clavicle fracture
FOOSH
Direct trauma to shoulder
What is the most important thing to asses with a fracture
Neurovascular status
When is surgery ORIF used in clavicle fracture?
Lateral fractures, open fractures, NV compromise, bilateral, multiple trauma
What is general management for non complicated or severe breaks?
Immobilisation + analgesia + physio
What patients get a proximal humerus fracture?
Elderly, osteoporosis, FOOSH
What assess for in fractures
Deformity
Bruising
Muscular damage eg rotator cuff issues - proximal humerus
NV status
Dislocation
When is a radiograph used to investigate humeral shaft fracture?
Spiral fracture
What fractures do you get the fat pad sign with?
Radial head fracture, from a FOOSH
What is the terrible triad for elbow fracture?
Posterior elbow dislocation, radial head fracture and coronoid fracture
What motor symptoms does a radial head fracture cause?
Inability to fully extend elbow + reduced range of pronation and supination
What motor symptoms does a radial head fracture cause?
Inability to fully extend elbow + reduced range of pronation and supination
When do you not do an ORIF in children?
When danger of interrupting the growth plate - not in children
What is Monteggias fracture?
Ulnar (proximal) fracture and radial head dislocation
What is Galeazzis fracture?
Radial shaft fracture and ulnar dislocation
Why do some bones break in multiple places after force?
Ring structures - polo mint snaps in multiple places
Who is likely to get Colle’s fracture
Elderly, osteoporotic + postmenopausal women
Symptoms of a Colles fracture
Wrist pain + swelling + restrictred ROM + dinner fork deformity
Treatment for Colles fracture
Immediate reduction using anesthetic block + pre + post XRs to check, immobilisation and physio
Surgery if conservative measures not worked - K wired, bone grafting, ORIF
What causes a scaphoid?
Fall onto dorsiflexed hand - FOOSH
Not seen in extremes of age
Symptoms of scaphoid fracture
Wrist pain with restricted ROM
Tenderness on gripping and wrist extension
Tenderness aound anatomical snuffbox
Symptoms of scaphoid fracture
Wrist pain with restricted ROM
Tenderness on gripping and wrist extension
Tenderness aound anatomical snuffbox
Treatment for scaphoid fracture
Immobilisation in spica cast + PHYSIO
Surgical management with K wires
Boxers fracture symptoms
MCP pain + swell, deformity is displaced, may be bite marks or knuckle flattening
Treatment for Boxers fracture
Conservative - immobilisation - buddy strapp with reduction if needed + physio
When do you offer surgery for fractures?
Displacement, deformity, communition, angulation, instability
What is Bennetts fracture?
Thumb MCP base intra-articiular with displacement
Symptoms of Bennetts fracture
Thumb base pain + swelling + decreased ROM with instability
What is important with investigations for Bennetts fracture?
Repeat radiographies in 2 weeks
Bennetts fracture management
Conservative (Closed reduction with analgesia, immobilization in Bennet’s cast and physio), Surgery (If instability, ORIF and K wires)
Symptons/signs of pelvic fractures?
Pain and bruising in pelvic region, instability, flank/perianal/urogenital swelling, bruising, bleeding, high-riding prostate on PR
Investigations pelvic fracture
Pelvic radiograph - inlet and outlet views + oblique
CT - definitive
Treatment pelvic fracture
ALTS assess + resus, pelvic stabilisation using external fixator - prevent clot disruption
Radiological mebolisation
Surgery for unstable pelvic fractures and acetabular disruption
50% mortality
Mortality NOF 2 months after fixation
High mortality 30%
Signs of NOF
Trauma hostroy, hip pain with no weight bearing possible, external rotation and shortening of leg
Investigations for NOF
Hip nad pelvic radiographs - look at shentons line
Treat NOF
ALTS assess + resus
DVT prophylaxis
Surgery - extracapsular (reduction + dynamic hip screw), intracapsular (non-displaced would be internal screw fixation + displaced is hemi arthroplasty or total hip arthroplasty)
What is a dangerous complictaion of NOF fracture?
Avascular necrosis + blood supply to femoral neck compromise
Especially in intracapsular as leaves ligamentum teres as only source
Where is concerning for considerable blood loss?
Pelvic, femoral shaft fractures
On the floor and 4 more -
Long bones/limbs
Abdomen
Pelvic
Chest
Heaad
Signs femoral shaft fractures
Pain, deformity and bruising to thigh
Assess soft tissues of leg (sciatic nerve + peripheral circulation)
Treatment femoral shaft fracture
Resus then fracture splinting
Surgery indicated
What causes tibial plateau
Direct compression injury - femoral condyle impacting on tibial plateua
Often fall from height
Signs tibial plateua injury
Knee pain, swelling )haemarthrosis) + deformity with ass ligament injury
Where are Weber fractures?
Ankle joint
Causes of Weber fractrue
Indirect - inversion of ankle ass with ligmaent damage and dislocation. Lateral malleolar
A,B or C
What causes talus fractures?
Forced dorsiflexion, high energy trauma - RTA or fall from heigh tor low energy eg sprain -> avulsion. Below the knee plaster or ORIF
What causes calcaneum fracture
Fall onto heel, common bilaterally
High energy such as fall from height
Ass spine, pelvis and tibial plateau injury
What is RICE
Rest Ice compression Elevation
What causes a metatarsal fracture
Inversion injury (avulsion)
Direct injury causes complete fracture, can get shaft, stress and neck fractures
Common fractures in children
Greenstick
Buckle fracture
Supracondylar fracture
Pulled elbow
Distal forearm - MUA
What criteria is used to classify fractures in children?
Salter Harris criteria
What does Salter Harris criteria stand for?
Straight across
Above
Lower or beLow
Two or Through
ERosure of growth plate
When to suspect NAI in children
Fully dependent child/non ambulatory with fracture
Injury and history inconsistent
Delay in seeking medical attention
Multiple fractures
Senior - seek help if any suspicions
Injuries to: both sides of the body, soft tissue, with particualr patterns, untreated
What can cause pathological fractures
Tumour
Bone cysts
Metabolic disorders
How do you assess a closed frature?
Assess NV status
Assess soft tissues
Splint
Back slab
What extra do you need to do when treating an open fracture?
Open: Photograph before dress
Tetanus booster
IV antibiotics
Patient assessment in emergency fracture
Masive haemorrhage
AW + C spine
Breathing
Disability - GCS, neurology + abdo exam
Exposure - avoidance of hypothermia
Approach to fractures
Anatomy - which part, side of which bone?
Fracture type - open/closed, transverse, obliwue, spiral comminuted
Number of fragments
Displacemet - translation, angulation, rotation, shortening, distraction
Joint involvement - intra or extrarticular
Ass dislocation
NV assessment
Initial management of fracture patients
IV access
Analgesia
Bloods - prepare for theatre
Resus
Analgesia for fractures
Stepwise:
-Paracetemol
-NSAIDs
-Codeine
-Tramadol
-Morphine
What bloods do you do to prepare a patient for theatre
FBC
U+Es
Group and save
Cross match
Resus for fracture patients
Fluids
Blood components
Major trauma
Transufion pack
Why are postmenopausal women more at risk of fractures?
Decreased bone mineral density + increased fracture risl
What can reduce the risk of osteoporisis and fracture in postmenopausal women
HRT
Calcium/vit D supplementation
How does number of pregnancies affect fracture risk?
Reduces risk of hip and lower spinal fracture (NOT wrist)
Increased oestrogen and load on lower skeleton
Increases per preganancy
Factors htat influence bone density
Menopause
Parity
Age
Sex
Genes
Nutrition
Exercise
Race - caucasian or south east asian particuarly at risk, smoking
What is the opposite of a Colle fracture?
Smiths fracture
Early complications of fractures
Bleeding - internal and extermal
Injury to nerves, vessels, internal organs
Compartment syndrome
Infection
Fracture blisters
Pressure sores
Late complications of fractures
Infection - osteomyelitis
Mal-union/non-union
Growth disturbance
Joint stiffness
Complex Regional Pain Syndrome (CRPS)
Avascular necrosis
Myositis ossificans
Late complications of fractures
Infection - osteomyelitis
Mal-union/non-union
Growth disturbance
Joint stiffness
Complex Regional Pain Syndrome (CRPS)
Avascular necrosis
Myositis ossificans
What is Compartment syndrome
Pressure inside a comparmtent increases due to accumulation of blood or fluid trapped in this compartment, restricts blood flow to area and potentially damages nerves and muiscles nearby
What does excruciating pain on passive stretching of muscle compartment signify?
Early sign of compartment syndrome
What does excruciating pain on passive stretching of muscle compartment signify?
Early sign of compartment syndrome
What does excruciating pain on passive stretching of muscle compartment signify?
Early sign of compartment syndrome
What does excruciating pain on passive stretching of muscle compartment signify?
Early sign of compartment syndrome
What does excruciating pain on passive stretching of muscle compartment signify?
Early sign of compartment syndrome
How do you treat compartment syndrome
Immediate surgical decompression - fasciotomy. Otherwise can lead to ischaemia and necrosis of tissue.
What is myositis ossificans?
When bone tissue grows where its not supposed to eg soft tissue, ligaments, muscle, after trauma -> restricted ROM, hard lump
Signs of basal skull fracture
Battles sig n
CSF leaking out of ears and nose
Haemotympanum
How quickly does a NOF need surgery and why?
24 hours - 50% mortality, retrun to optimum asap
