Clinical skills - Fractures and Dislocations Flashcards
Fracture management
Reduce
Retain
Rehab
Fracture management - reduce
Closed reduction by applying a splint
Closed reduction by traction
Closed reduction by manipulation
Open reduction if closed reduction fails but not in all
Fracture management - retain
Maintain reduction until fracture heals Traction Plaster Splints Gravity in huumeral fractures Internal fixation - screws, plates, tension bands, intramedulllary devices
Fracture management - rehab
Restore to orig. status before the injury
Principles of DCO
Control of bleeding
Arterial repair, decompressing tension, pneumothorax and fasciotomy for compartment syndrome
Provisional fracture stability w/ external fixation
When is decompression fasciotomy considered
Taken more than 6 hrs to restore arterial supply to the limb
Extensive distal injury including burns
Significant venous damage
Pelvic binder
Emergency management
Pelvic binder over greater trochanters
Binding both legs together
Flexing hips by inserting a pillow under the knees
Pelvis packing
Double pelvic external fixators applied first to stabilise pelvis then a laparotomy is performed, and the pelvis is packed. External fixator may be left in situ for 3 months
Acute compartment syndrome
Rise in pressure within a closed space resulting in ischaemia of the components
Most common in lower limb, forearm, thigh
Ischaemia
Inadeqaute blood supply
Fasciotomy
Long cannula inserted into anterior compartment, under anaesthesia and once a certain pressure is made along w/ other clinical signs, patient is taken to operate - all compartments released
Early long bone stabilisation leads to reduced:
ARDS Pneumonia Ventilator days ITU days Hosp days Systemic infection
Treatment of open fractures
Photography
Cover w/ antiseptic dressing
Abx and splint the limbs - antitetanic when indicated
Theatre within 6 hrs for definitive survey
Debridement
Wound is vigorously irrigated w/ warm isotonic saline where appropriate
Stabilisation w/ external fixator
Debridement
Dead and damaged tissue excised
Signs of dead tissue
Doesn’t contract when pinched w/ forceps
Isn’t red and shiny
What happens few days after an open fracture is treated
Wound reinspected and covered w/ muscle and skin graft
Occasionally external factor is replaced w/ intrameduallary nail
Fracture definition
A soft tissue envelope in which there happens to be a break in cortex which exists from the opposite cortex
What kind of fracture does a twisting force produce
Spiral fracture w/ a long fracture line OR
Oblique fracture w/ short fracture line
What kind of fracture does a bending force produce
Transverse fracture w/ a third small fragment - bending wedge
What kind of fracture does a high energy force produce
Comminuted fracture w/ lots of fragments
Personality of fractures
Good
Bad
Ugly
Good fractures
Heal well
Bad fractures
Difficult to heal and have little chance of OA
Ugly fractures
Difficult to manage w/ a high chance of developing OA
All pelvic fractures are bad or ugly
Soft tissue
Skin Muscles Blood vessels Nerves Tendons and ligaments Fascia
Reading an x-ray
Read name of patient Confirm dob on patients wrist band Read hosp no. Find out date of X-ray Note part of region, right or left Look for whether standing or weight bearing X-rays
Angulation
Valgus
Parallel
Varus
Valgus angualtion
Apex medial
Distal limb away from midline
Parallel angulation
No angulation
Varus angulation
Apex lateral
Distal limb towards midline
Types of femoral neck or hip fractures
Sub trochanteric - reduce and fix w/ dynamic hip screw
Trochanteric - IM nail
Sub-capital/ intracapsular - requires replacement
Management depends on blood supply
Salter Harris
Classification of fractures in regards to epiphysis
Straight Above beLow Through - metaphysis and epiphysis cRushed
Dislocation
No articulation between joints when there is usually one
Neurovascular status is esp important
AMPLE history
A - allergies M - medications P - past medical history L - last meal E - event
Bone healing
Fracture
Haemotoma
Cartilage
Replaced by lamellar woven immature bone
Remodelling bone - NSAIDs switch off infl process, so may delay bone healing
Growth and differentiation factors
Transforming Growth Factor (TGF-b) Bone Morphogenetic Proteins (BMPs) Fibroblast Growth Proteins (FGF-1,2) Insulin-Like Growth Factor (IGF-1) Platelet - Derived Growth Factor (PDGF)
Growth and differentiation factors process
Stem –> Proliferation, Migration –> Differentiation –> Matrix production, Vascularisation
Growth and differentiation factors in proliferation and migration
TGF - b
FGF
IGF
PDGF
Growth and differentiation factors in differentiation
BMP
Growth and differentiation factors in matrix production and vascularisation
TGF-b
BMP
FGF
Valid consent
Voluntary
Informed
Capacity
Valid consent - voluntary
Patient must be free to agree to refuse treatment
Consent should be obtained without coercion or duress
Valid consent - informed
The procedure must be explained in simple language
Complications and ‘material risks’ should be discussed - consequences
Valid consent - capacity
Must understand the relevant info provided
Be able to retain the info
Be able to weigh up the pros of cons of the treatment proposed
Be able to communicate
Types of consent
Implied
Oral
Written
Implied consent
The patient presenting to clinic to be examined
The arm offered for venepuncture
Oral consent
Verbal conversation gaining permission
Often formalised after the encounter w/ documentation in the notes
Written point
Pre-emptive
Involved
Best supported in law
Treatment without consent
Emergency situation to save life
Waiting for another professional would be detrimental to patient
Risk to public health
Severely ill and living in unhygienic conditions
FBC
Full blood count
Establishes total no. of RBC/s, WBC’s & platelets. These cells develop in active bone marrow - ends of long bones e.g. humerus
Characteristics of erythrocytes
Normocytic Macrocytic Microcytic Normochromic Hyperchromic Hypochromic
Normocytic
Normal cell size
Macrocytic
Larger than normal cell size
Microcytic
Smaller than normal cell size
Normochromic
Normal Hb content
Hyperchromic
Red cell saturated w/ Hb
Hypochromic
RBC w/ diminished Hb
Types of WBC
Neutrophils Lymphocyte Monocytes Eosinophils Basophils
Lymphocytes
Produce antibodies (B) or directly attack foreign cells (T) May be raised in viral infection, chronic bacterial illness e.g. TB Low in those w/ lupus
Function of monocytes
Phagocytosis
Function of eosinophils
Protect against irritants/ allergies
Basophils
Become mast cells in allergic reactions and release histamines
Bone marrow failure
Anaemia - lack of RBC's Leucopoenia - lack of WBC's Thrombocytopaemia - lack of platelets Pancytopenia - all 3 together Caused by drugs or disease
Liver function tests
Aminotransferases
Alanine aminotransferases (ALT)
Alkaline phosphatase
Aminotransferases
Enzymes present in liver cells which leak into blood when damaged
ALT
Raised in acute liver damage, injury to skeletal muscle
Alanine phosphatase
From bone or liver
In liver - often indicated mechanical blockage
Elevated in disease w/ osteoblastic activity
RhF
High in RhA, infections, malignancy, family history of RA, lung fibrosis, lupus
Prevalence increases w/ age
Found in 80% patients w/ RhA - predicts poor prognosis, radiological progression and extra-articular manifestation
Doesn’t correlate w/ disease activity
Anti-CCP antibodies
Anti-citrullated protein antigens found in inflamed synovium
Most spp antibody in RhA
Can be found early on
Predicts some patients w/ aggressive/ erosive disease
40% sero-ve patients are anti CCP+
Very early DMARD intervention in anti-CCP +ve infl arthritis delays progression to RA
ANA (Anti-Nuclear Antibodies)
Group of antibodies found in 5% of normal individuals
Only important in those w/ symptoms
Screening test for connective tissue diseases e.g. SLE, systemic sclerosis
ENA
ENA
Extracted nuclear antibodies
Spp antibodies formed against diff aspects of the cell
ANCA
Antibodies directed against cytoplasmic antigens in human neutrophils
C-ANCA (cytoplasmic, PR3)
P-ANCA (perinuclear, MPO)
Associated w/ some primary forms of vasculitis
Can change over time and associated w/ disease activity
Causes of physical disability
Congenital conditions
Acquired illness
Trauma
Classification of fractures
Closed fractures Open/ compound fractures Comminuted Displaced Angulated Impacted - pressure on 1 or 2 crushed together
Pathological fractures
Low impact
Bone cancer
Osteoporosis
Paget’s disease; osteoclasts function > osteoblasts
1’ bone cancer
Starts in the bone
2’ bone cancer
Starts in the breast, kidney, bladder etc and travels to bone
Green stick fractures
One side of the bone is broken and the other side is only bent
Only occurs in children
Systemic factors affecting healing
Age - decreased osteoblasts
Nutrition - vit D and Ca
Systemic diseases
Corticosteroids - asthma, RA, IBS
Cushing’s disease
Adrenal glands stop working due to corticosteroid therapy so no longer producing hormones —> brittle bones
FOOSH
Fall On Outstreched Hand
Non-traumatic dislocations are usually ..
Recurrent and follow initial trauma
Once you dislocate your shoulder, you become prone to again as the ligaments stretch
What suggests a compound fracture
Portruding bone or break in skin
Neurovascular assessment
Sensation
Capillary refill
Distal pulse (beyond fracture site)
Pre hospital treatment of fractures
Splint - immobilise
Sling
Elevation
DVT
Deep Vein Thrombosis
PE
Pulmonary Embolism
Increased risk due to being immobile
Fat embolism
Fat released from inside of bone into blood
Who needs an X-ray
Trauma hx Pain (severe) Loss of function e.g. inability to weight bear Deformity Crepitus, swelling and tenderness At risk group i.e. children and elderly
Why are children an at risk group concerning fractures
Poor historians
Difficult to examine
Cannot mentally isolate pain
Local variables affecting fracture healing
Type of bone Degree of trauma Vascular injury Degree of immobilisation Separation of bone ends Infection
How does type of bone affect fracture healing
Cancellous bone heals faster than cortical bone
How does degree of trauma affect fracture healing
Severely comminuted injuries w/ extensive soft tissue damage heal poorly
How does vascular injury affect fracture healing
Inadequate blood supply impairs healing
How does degree of immobilisation affect healing
The fracture site must be immobilised for vascular ingrowth and bone healing to occur
How does separation of bone ends affect fracture healing
Normal apposition of fracture fragments is needed for union to occur
Immediate complications of fractures
Pain, bleeding and shock, neuromuscular compromises
Acute compartment syndrome
Medium term complications of fractures
Infection Wound problems, cast problems e.g too tight Deformity, shortening Mal-union DVT/ PE/ chest infections, op related Fat embolism
Long term complications of fractures
Non-union, avascular necrosis, osteomyelitis
OA
Loss of function
Socioeconomic implications, psychological
Sublaxation
When the bones in a joint become partially displaced OR partial dislocation of a joint
Ottawa ankle rules
A series of ankle x-ray films is required only if there is any pain in malleolar zone and any of these findings
Bone tenderness at posterior edge or tip of lateral malleolus
Inability to weight bear - immediately and in emergency dept
Ottawa foot rules
A series of foot x-ray films is only required if there is any pain in mid-foot zone and any off these findings:
Bone tenderness at base of 5th metatarsal
Bone tenderness at Navicular
Inability to weight bear
Ottowa knee rules
A series of knee x-ray films is only required for knee injury patients w/ any of these findings: Age 55+ Isolated tenderness of patella Tenderness at head of fibula Inability to flex to 90 degrees Inability to weight bear
Bony injury non suspected - Ottawa -ve
Advice to patient on duration of healing
Advice on keeping gently mobile
Analgesia
RICE
RICE
Rest - rest for 48 hrs
Ice - 20 mins at a time, 4-8x daily
Compression - helps reduce swelling
Elevate - 6-10 inches above heart
Services offered to fracture and non-fracture patients
Physio
Occupational Therapy
Social support
Psychological support
Common MSK injuries seen in primary care
Back and ankle strains and sprains
Meniscal tear of knee –> may require MRI to diagnose
Rotator cuff tear of shoulder
Overuse injuries
Overuse injuries
Bursitis - foot, hip, elbow
Tendonitis - shoulder, Achilles’ tendon
Plantar fasciitis - under the foot
Diazepam
Used to treat back and ankle strain and sprains
WHO analgesic ladder
Step 1 - simple analgesia
Step 2 - moderate analgesia
Step 3 - strong analgesia
Step 1 of WHO analgesic ladder
Non -opioid, mild pain, plus minus adjuvants
Step 2 of WHO analgesic ladder
Weak opioid, moderate pain plus minus non-opioids and adjuvants
Step 3 of WHO analgesic ladder
Strong opioid, severe pain plus minus non-opioid
Non-opioids (OTC)
Ibuprofen or another NSAIDs
Paracetomol (acetominophen)
Aspirin
Weak opioids
Codeine
Tramadol –> synergy w/ paracetamol
Low dose or morphine
Strong opioids
Morphine Fentanyl Oxycodone Hydromorphone Buphenophine
Consider prophylactic laxatives to avoid constipation
Adjuvants
Antidepressants Anticonvulsants Antispasmodic Muscle relaxant Biphosphonate Corticostroids
Can you combine drugs of the same class
No but combing an opioid and a non-opioid is effective
Time doses of drug half-life, not when pain recurs
Ibuprofen dosage
400mg TDS
Ibuprofen side effects
GI ulceration
Cardiac arrhythmias
Renal toxicity
Cocodamol dosage
500 mg paracetamol and 8 mg codeine (15-30mg when prescribed)
1 or 2 tablets QDS
Cocodamol side effects
Constipation Nausea Drowsiness Dependence/ addiction Confusion
Naproxen dosage
500 mg BDS
Stronger than ibuprofen, replacement (NSAID)
Opioid based
Side effects of morphine
Constipation
Nausea and vomiting
Drowsiness
Ways to administer med
Orally Patch Nasally Suppository Rectally IV Buccally Intra-articular Intramuscularly Sub lingual Via a pessary (intravaginal) Topically
Common ENA
antiRo: Sjogren’s and cutaneous lupus antiLa: Sjogren’s and cutaneous lupus Ds DNA: SLE Scl 70: limited systemic sclerosis Anti-centromere: CREST JO-1: polymyositis
Colles’ fracture
Fracture of distal radius with dorsal angulation
Smith’s fracture
Fracture of distal radius with palmar angulation
Caused by a FOOSH
Jones’ fracture
Fracture at base of 5th metatarsal
Boxer’s fracture
Fracture at head of 5th MCP with palmar angulation
Result of ruching person or wall
Scaphoid fractures
Quite common but easily missed
Pain in anatomical snuffbox
Can be caused by FOOSH
Can lead to AVN
Buckle fracture of radius/ulna
Look for angulation of cortex
Radial head fracture
Easily missed as may require several views to identify
What is Garden classification used for
Femoral neck fractures
Garden classification - Stage I
Incomplete fracture of the neck (so-called abducted or impacted)
Garden classification - Stage II
Complete without displacements
Garden classification - Stage III
Complete with partial displacement. Fragments are still connected by posterior retinacular attachment and there is malalignment of the femoral trabeculae
Garden classification - Stage IV
A complete femoral neck fracture with full displacement, the proximal fragment is free and lies correctly in the acetabulum so that the trabeculae appear normally aligned.
Immediate post-op complication after hip replacement surgery
Pulmonary embolism
Complications of shoulder dislocation and fractures
OA
Capsulitis
Chronic instability
Axillary nerve palsy
Complication of fractures involving growth plates
Growth arrest
