Clinical approach to fractures Flashcards
What aspects of a history may suggest a fracture?
- History of injury
- Tenderness of bone
- Deformity of bone
- Pain with remote force
- Abnormal mobility
- Patient will protect and support limb/part of body
- Fracture from fall from standing height suggests pathological fracture
What rule is used when ordering a radiograph?
- Rule of 2
- 2 joints: affected joint and one above/one above and one below
- 2 angles: AP and lateral
- 2 separate occasions
How do you describe a fracture/radiograph?
1) Demographics of patient details
2) Date of radiograph
3) Orientation of image
4) Mechanism of injury as described by patient
5) Talk about fracture
What do you include when talking about a fracture on a radiograph?
- Anatomical location
- Compound of closed (and GA class if relevant)
- Type of fracture
- Intra- or extra-articular
- Deformities (displacement, angulation, rotation)
- Soft tissue and neurovascular status
- Other medical conditions
What are the 4 R’s of fracture management?
Resus, reduction, restriction (stabilisation), rehab
What part of ATLS contains fracture resus and why?
- Secondary survey
- Fractures not immediately life threatening, so assess primary survey first
What is the initial management of fractures?
- Give analgesia
- Assess NV status and document
What is the definitive management of fractures?
- Wound debridement (if any)
- Fixation in theatre
- Internal fixation avoided in open fractures
What are the 6A’s of open fracture management?
- Analgesia
- Assess NV status and document
- Anti-sepsis
- Anti-tetanus
- Alignment and splinting
- Antibiotics (broad spectrum)
What is the cornerstone of open fracture fixation?
- Early debridement of foreign material and devitalised tissue
- Irrigate wounds with 6L saline
- Cover wounds with dressing
- External fixation
When should fractures be reduced?
- All displaced fractures should be reduced unless no proven benefit (e.g. clavicular fractures)
- Anatomical reduction particularly important on articular surfaces
What must be done to check success of fracture reduction?
Check alignment of fracture with pre- and post-reduction X-ray
What are the 2 possible methods for fracture reduction?
- Closed-manipulation
- Open/surgical
Closed reduction/manipulation?
- Done under LA, regional, or GA
- Aims to realign fractur and may involve traction
What are the indications for closed reduction/ manipulation?
- Low energy undisplaced fractures
- Fractures in cancellous bone (kids)
- Phalangeal or metacarpal fractures
- Fractures that don’t require anatomical reduction (e.g. clavicular and most humeral fractures)
What is restriction of a fracture?
- Fixation of fracture site that reduces strain on bone
- This allows easier healing and greater chance bone remains aligned
Where should fixation be done?
- At a site that allows movement once restriction is removed
- E.g. where ligaments aren’t too tight
What are the methods for restriction?
- Non-rigid (e.g. slings or elastic support)
- Crutches
- Splints
- Plaster
- Functional brace
- Continuous traction
- External fixation
- Internal fixation
What are some complications of PoP casting?
- Compartment syndrome
- Pressure sores (particularly malleolus, dorsum of foot, distal ulna at wrist)
- Skin blistering
- Hair follicle/sweat gland dermatitis from staph infection
When is external fixation most useful?
- Open fractures
- Fractures with burns
- Fractures with tissue loss
Rehabilitation (4 R’s of fracture management)?
- Immobility causes reduced muscle mass and joint stiffness
- Therefore earlier mobilization reduces morbidity later
- Methods include physiotherapy, occupational therapy and social services
What are the pros and cons of external fixation?
- Pro’s: minimally invasive, and versatile
- Con’s: risk of pin tract infection, and has higher rates of mal-alignment
When are external fixations used?
- Open fractures
- Closed fractures with extensive soft tissue damage
- Fractures with burns
What are the2 types of internal fixation?
Intramedullary and extramedullary
Intramedullary internal fixation?
- Nails and wires inserted into the bone and held in place with pins
- Used in LL diaphyseal fractures and UL fractures
- Very good union rate and low complication rate
Extramedullary internal fixation?
- Main form is plating
- Used in metaphyseal, articular, and UL diaphyseal fractures
- Achieve high degree of fixation but has higher complication rate
