chapter 3 - general principles of fractures Flashcards
what is a fracture?
a fracture is an open or closed soft tissue injury of varying severity, accompanied by a break in the continuity of the adjacent or underlying bone
what is an open fracture
there is a break in the continuity of the skin overlying the fracture
what is a closed fracture
there is no communication between the fracture and the atmosphere
why do fractures occur?
interaction between the magnitude of the injuring load or force and the quality and resilience of the bone
what is a pathological fracture
fracture occuring through diseased bone which is weak ie metastatic tumours or an area of osteomyelitis
what is a stress or fatigue fracture
this occurs to normal bone that is subjected to repetitive loads of stress
what is the radiological appearance of a stress fracture
attempts at healing + new areas of fracture
what is a direct force and what type of fractures does it commonly cause?
direct trauma to the area of the fracture
transverse or complex fractures
what is an indirect force and what type of fractures does it commonly cause
the force was applied at a distance away from where the bone was fractured
oblique and spiral fractures in long bones
compression fractures in the spine
name 5 types of typical bone fractures
greenstick spiral comminuted trasnverse compound vertebral compression
define a simple fracture
single fracture line that may be transverse, oblique or spiral
define a segmental fracture and its clinical presentation
2 fracture lines
tubular segments of shaft which has cortex present on its entire circumference
no lateral stability but may be longitudinally stable
define a complex (comminuted) fracture and its clinical presentation
multiple fragments
cortex on parts of the circumference
no lateral and no longitudinal stability
what us the rule for taking X rays of fractures
hint: 2s
2 views, 2 joints, 2 sides, 2 opinions
what is the appropriate early immediate management of a fracture
- assess neurovascular status of the limb
- analgesia
- realign with gentle longitudinal traction
- sugar tongs splint
what could occur if a fracture is not splinted early?
severe oedema –> decreased blood supply –> more oedema
name the 6 modalities of displacement
shift distraction shortening impaction twist tilt
what is acceptable displacement in long bone shaft fractures? ie it does not have to be reduced
shift: 50% of diameter of shaft
shortening: 10mm
twist: 0 degrees
tilt: 10 degrees
impaction: 10mm
if the fracture involves the joint surface, which parameters are used and what do they mean?
ie simple split = undisplaced
split/gap: displaced laterally but not vertically
split/step: displaced vertically but not laterally
split/impaction: displaced vertically and compressed
acceptable displacement in articular surface fractures
gap up to: 5mm Large joint and 2mm small joint
step up to 2mm/ 1mm
impaction up to: 2mm/ 1mm
how is a closed fracture reduced?
direct manipulation
traction
how is an open fracture reduced?
surgically
4 reasons why fracture reduction may fail
- inexperience
2/ inadequate anaesthesia/muscle relaxation - inability to obtain a reduction - interposition of soft tissue or bony fragments
4.inability to maintain the reduction - unstable fracture configuration
2 indications for open reduction
failure of reduction
intra articular fractures which need to be reduced accurately
why must a fracture be immobilised
to maintain the reduction which has been obtained
two types of immobilisation
external fixation = no implant in the soft tissue
internal fixation = surgical implant within the soft tissue or bone
examples of external fixation methods
plaster of paris
traction
bracing or splinting
external fixator - transcutaneous fixation with pins anchored to the bone
examplesof internal fixation
intramedullary nail
plates and screws
interfragmentary wires and screws
3 indications for internal fixation
- inability to obtain or maintain fixation externally
- intraarticular fractures
- polytrauma
all fractures should be reduced and immobilised within X hours
72 hours
if the patiet has had a manipulation of a fracture and a plaster cast has been applied when should they be seen? and why
after 24 hours for a circulation check
when should the patient be seen immediately after manipulation and fixation of a fracture - 4 warning signs
- excessive or increasing pain
- pale, red or blue fingers or toes
- tingling or pins and needles in fingers and toes
- swelling in fingers and toes
after a fracture has been managed a POP circulation check is done 24 hours later - what is this
check neurovascular status in the limb
if concerned: plaster should be split down and loosened until perfusion occurs
if no improvement: remove plaster completely
if there is still pain, swelling or pins and needles - consider and exclude compartment syndrome
follow up visits following fracture management
2 weeks: check that plaster is not loose and do Xray in plaster
change plaster if loose to ensure that the correct position is maintained
2-4 week intervals: xray to check for fracture healing - out of plaster
assessment of union: clinical = if pain and movement on stressing is present - still requires immobilisation
radiological= look for callus
F/u after a fracture - what is the assessment of union?
clinical = if pain and movement on stressing is present - still requires immobilisation radiological= look for callus
what are the principles of management of open fractures?
- orthopedic emergencies
- basic evaluation as with closed fractures
- tetanus toxoid 0.5ml sc
- antibiotic cover
- cover the wound with a sterile dressing
- splintage of the fracture - padded kramer wire splint
- debridement of the wound ( remove foreign matter, excise dead tissue, start at the edge and work through the layers of fascia, muscle and bone)
- thorough washout with 5 L of warm normal saline
- test muscle viability - pinch skin with forceps and wait for contraction
- do not suture original wound closed at first debridement - if the wound was enlarged this extension may be loosely closed
- apply an external fixator
- after 48-72 hours the pt is reassessed in theatre and if the wound is clean it can be closed
- closure with split skin graft or suture
- if not clean - further debridement in theatre can be repeated until it can be closed
- once soft tissue has healed the external fixator can be removed and a plaster cast applied
