Common Fractures Flashcards
6 signs of a fracture?
PAIN - ensure adequate pain relief and never suddenly move a limb with a suspected fracture
DEFORMITY - the position of the distal part of the fracture is determined by gravity. The position of the proximal part is determined by muscles. Sometimes the deformity is influenced by the direction of the force which caused the fracture
TENDERNESS
SWELLING - natural response to injury, but in excesss can be painful and make treatment & recovery more difficult. To reduce swelling the injured part can be elevated. This is the most important act in first aid treatment of fractures
DISCOLOURATION/BRUISING - loss of blood causes a dark bruising initially due to deoxygenated Hb in the soft tissues. Then as the Hb is phagocytksed, degraded, and carried to the liver by macrophages, the colour becomes gradually lighter to green, then yellow, then back to normal
LOSS OF FUNCTION
CREPITUS - grating feeling when broken ends of bone are scraped together, will elicit extreme pain
What 5 other general body tissues may be injured in bony fracture?
skin fat muscle blood vessels nerves
5 ways to investigate a suspected fracture?
XR - mainstay - pictures are taken in 2 planes, sagittal and coronal (to ensure it isn’t missed)
TOMOGRAMS - ‘slice’ through body
CT - modern tomograms
USS - can show accumulation of fluid, esp blood
RADIOISOTOPE SCAN - radioisotope injected into bloodstream, reacts with phosphate ions and it taken up by bone. An XR is taken which shows where there is high uptake of isotope, i.e. highly metabolically active site, i.e. fracture. This is more useful a couple of weeks post-injury if there is initial doubt about the fracture and the plain film is inconclusive. It is often used for scaphoid fractures. This doesn’t tell you anything about the fracture, apart from the fact it’s there
7 parts to describing a fracture?
- Which bone and which side
- Open/closed
- Where on bone is broken (intra-articular/mid-shaft/proximal third)
- Shape of fracture
- How many fragments
- Position of distal fragment
- Could it be pathological
3 common shapes of fracture?
Spiral - occurs in twisting injuries, common, usually low energy. Little soft tissue damage
Oblique - Straight through bone at an angle
Transverse - perpendicular line through bone
Oblique & transverse occur in high energy injuries and are caused by buckling or direct injury to bone. Can have major soft tissue damage and compromised blood supply to bone
3 ways to describe how many fragments?
Simple - clean break, 2 fragments
Butterfly - 3 fragments - 2 large ones at oblique angles, and a small triangular chunk of bone formed from this
Comminuted - several fragments
How is the distal fragment of the fracture described?
Displacement - ant, post, med, lat or mixture
Angulation - ant, post, varus, valgus
Rotation - internal, external
What is a pathological fracture?
The fracture seems out of proportion to the energy involved in the injury. This suggests the bone is weak as a result of a disease process e.g. osteoporosis or tumour deposits
2 main considerations in the immediate management of a fracture?
Pain relief
Neurovascular status
2 methods of pain relief in immediate management of a fracture?
Altenative to one of them?
Analgesic drugs - morphine or pethidine may be required
Splintage - holds fracture steady. This can be as simple as tying the legs together or putting arm in sling, but should encompass the joint and minimise movement.
An alternative to splintage is Traction - this can be used in early fracture management to relieve muscle spasm, which can greatly contribute to post-fracture pain. Useful for femoral neck fractures where splint is pretty much impossible to apply
Blood loss in limb fractures?
In upper limb and peripheral lower limb fractures there isn’t much blood loss and is generally well tolerated, even by the elderly.
In significant long bone fractures, esp the femur but also the tibia to an extent, blood loss is significant. A single femoral fracture can result in 2-3 units of blood lost into the soft tissues (1 unit is 450ml). A tibial fracture may result in 1 unit being lost
Blood loss in pelvic fractures?
Major pelvic fractures, esp if unstable, are assoc w major venous bleeding from the pelvic plexuses, which can be up to 6 units or so. If combined with another skeletal injury, this can be fatal, unless the fluid is promptly replaced, ideally with blood.
In terms of blood loss, what should be involved in the immediate management of long bone and pelvic fractures?
Long bone - X-match and a good-sized venous line for blood transfusion ASAP
Pelvic - X-match, 2 lines may be needed and a central venous line to ensure transfusion is keeping up with blood loss
What are open (compound) fractures and how occur?
Fractures in which the skin is broken - they occur in more violent injuries with high energy MOI
Potential consequences and management of an open fracture?
They result in the bone being contaminated with bacteria (e.g. from clothing, dirt, wood, metal etc) and there may be compromised blood supply so some of the tissue may die off.
It is a surgical emergency so the patient should be taken to theatre as soon as possible for debridement of dead tissue and sterilisation of the wound - this requires a wide incision to be made to explore for any potential small contaminants which could result in infection.
Wounds should be left open if there is any doubt that they couldn’t be closed without putting tension on the skin, leaving them to either heal spontaneously or be closed as a secondary procedure a few days later - all such patients require broad spec antibiotic cover (usually co-amoxiclav) and a form of tetanus protection
What is definitive fracture management?
A technique used (after bleeding and pain have been controlled) to restore normal function to the injured part of the body after a fracture
How might the management of a wrist fracture change between an elderly person and a young, fit craftsman?
Elderly person - manipulated under local anaesthesia in A&E dept and allowed to be discharged home to a comfortable environment. Will settle for less than perfect result so long as no interference with ADL’s
Young, fit craftsman - will undergo surgery and recovery to ensure perfect result for long-term health and job security
What is the basic rule of managing a fracture?
In order to achieve acceptable function, the anatomy of a fracture should be returned to as near normal as is safely and practically possible, especially if it passes through a joint - the margin of error is slightly greater if in the shaft of a long bone
This process is called Reduction, and it must be held in this position until the bone heals naturally
2 main ways in which reduction can be achieved?
Closed - putting traction on the distal fragment and relocating it back onto the proximal fragment by manipulation. This requires adequate analgesia, and general/local anaesthesia may be used. Manipulation normally involves reversing the direction of the deforming forces
Open - If closed is unsuccessful then open may be required - the fracture site is surgically opened and the fragments are relocated under direct vision
What does it mean when a bone is ‘united’ and ‘consolidated’?
United - it has been held in desired position and has become strong enough to support itself
Consolidated - after further reparation, it is strong enough to bear some load
4 ways in which a bone may be ‘held’?
Casting
External Fixation
Internal Fixation
Traction
What does casting involve?
Placing the limb in a Plaster of Paris cast until Union - it must be maintained at proper length (too short won’t protect, too long can result in delayed union) and it must span the joints both above and below the fracture to ensure complete control over it
How does a cast work?
It is moulded so that pressure is exerted at 3 points, holding the fracture in the correct position until the bone is healed
Disadvantages of casting?
They are heavy and immobilise joints - leads to muscle wasting and joint stiffness
Clinicians cannot examine or XR the bone without cutting open the cast
How do functional braces work?
Maintain 3D control over the fracture by casting above and below the joint and placing hinges between the casts, allowing movement in only one plane of motion (usually flexion-extension)
This relies on a very accurate fit so tend to be used after a few weeks, once the pain and swelling have settled
Materials of casts?
Plaster of Paris casts are heavy, messy (can take 3 days to dry) and very difficult to apply well.
Therefore, new stronger and lighter materials have been developed which are based on glass fibre and polyurethane resin combinations. They are not as versatile as plaster of paris so are usually used as secondary casts a week or 2 later, once the swelling has settled. They are ideal for cast braces (in functional braces)
What is an external fixator?
When are they used?
Benefits and drawbacks?
A device which is fixed to the bones by pins which stabilises they limb by means of an external scaffold
They are used in high energy fractures assoc with extensive soft tissue damage, because blood supply is damaged so it is important to have initial phase of soft-tissue healing. Casts are unsuitable because the wound becomes inaccessible, and internal fixation is hazardous because of ischaemia and risk of wound contamination
They can be used to treat the fracture definitively (without having to remove and put on cast) and can be adjusted at later stages to allow some movement at wound site. However, pin sites are easy route for infection, which is common and problematic
What is internal fixation and when is it used?
Why is it not used for all fractures?
4 methods of internal fixation?
It involves holding the fractured bone in place with screws, plates or nails - it is used when a high degree of accuracy is required, or all other methods fail
It is technically demanding and prevents natural healing of bone
Apposition
Interfragmentary compression
Interfragmentary compression plus onlay device
Inlay device
