Cortex - Adult trauma 3

Question 1

Who is hip fractures most common in ?

Answer 1

The majority of patients are >80 female and have osteoporosis

Also have co-morbidities e.g. cerebrovascular insufficiency, cardiac arrhythmias, postural hypotension etc. which contribute to falling over and the fracture occurring

Question 2

How can hip fractures be classified ?

Answer 2

As intra or extracapsular

Question 3

Why is it important to know if a hip fracture is intra or extracapsular ?

Answer 3

Because intracapsualr fractures are associated with AVN and non-union

Question 4

What is the treatment of hip fractures (hint intra and extracapsular fracture treatment differs)?

Answer 4

• Extracapsular fractures - Fixation using compression or dynamic hip screw (this is because no real risk fo AVN or non-union)
• Intracapsular fractures - arthroplasty (hemi-arthroplasty preferred for those with restricted mobility or if cognitivley impaired or THR which is reserved for the higher functioning hip fracture patient)

Question 5

What are the different ways in which femoral shaft fractures occur ?

Answer 5

• Usually trauma - high energy injuries
• Can occur due to osteoporotic bone, metatstatic disease, Paget’s disease and long term bisphosphonate use for osteoporosis

Question 6

What complications are you worried about following a femoral shaft fracture ?

Answer 6

• Major blood loss
• Fat embolism formation - can result in ARDS

Question 7

What is the management of femoral shaft fractures ?

Answer 7

Initial:

• Analgesia with femoral nerve block
• Put on thomas splint to stabalise it

Definite:

• Usually closed reduction and stabilization with an intramedullary nail

Question 8

What is a proximal tibial (plateau) fracture ?

Answer 8

It is an intra-articualr fracture with either a split in the bone, a depression of the articular surface or a combination of both

Question 9

How do most fractures occur ?

Answer 9

High energy injury or due to osteoporitic bone in low energy injuries

Question 10

What sort of injuries can proximal tibial (plateu) fractures occur with ?

Answer 10

Valgus stress to the knee can cause the fracture with failure of MCL and possibly ACL

Question 11

What is the treatment of Proximal tibia (plateau) fractures?

Answer 11

• ORIF
• Often end up requiring a TKR (total knee replacement)

Question 12

What are the different mechanisms for tibial shaft fractures ?

Answer 12

1. Indirect force and either bending (transverse fracture) or rotational energy (spiral fracture)
2. Compressive force from deceleration (oblique fracture)
3. A combination of these forces or from high energy injuries (comminuted fracture).

Question 13

What is the fractures are the commonest cause of compartment syndrome followinf trauma ?

Answer 13

Tibial shaft fractures

Question 14

What is the treatment options of tibial shaft fractures ?

Answer 14

• Minimally displaced - above knee cast
• Displaced or communted - ORIF

Question 15

What is the common mechanism of ankle injury ?

Answer 15

Inversion injury and/or rotational force on a planted foot (going over your ankle)

Question 16

In general what are the 2 main types of injury to the ankle ?

Answer 16

Sprains and fractures

Question 17

What are the common ligaments to sprain in your ankle ?

Answer 17

The lateral ankle ligaments (anterior & posterior talofibular ligaments and calcaneofibular ligament)

Question 18

What are the signs suggestive of an ankle sprain affecting the lateral ankle ligaments ?

Answer 18

Pain, bruising and mild to moderate tenderness over the involved ligaments

Question 19

When may an inversion injury and/or rotational force on a planted foot commonly causing ankle sprains result in a fracture ?

Answer 19

With higher force / energy or in osteoporotic bone

Question 20

In A&E what criteria is used to identify a suspected ankle fracture and give guidance as to which ankle injuries require an Xray?

Answer 20

Ottawa criteria - Any severe localized tenderness (known as bony tenderness) of the distal tibia or fibula or inability to weight bear for four steps merits an xray.

Question 21

What is the key to determining the treatment of an ankle fracture ?

Answer 21

Deciding if its stable or unstable

Question 22

Which ankle fractures are deemed stable and what is the subsequent treatment of them?

Answer 22

Isolated distal fibular fractures with no medial fracture or rupture of the deltoid ligament tx = walking cast or splint

Question 23

What suggests rupture of the deltoid ligament ?

Answer 23

• Bruising and tenderness medially on the ankle
• Or any talar shift or talar tilt without medial malleolar fracture (this is by definition a deltoid rupture)

Question 24

What are the unstable ankle fractures and what is the subsequent treatment of them ?

Answer 24

• These are Distal fibular fractures with rupture of the deltoid ligament (e.g. talar shift or tilt evident) - ORIF
• Bimalleolar (both medial and lateral malleoli) fractures - ORIF
  *

Question 25

Why must ankle fractures with talar shift be stabalised with ORIF ?

Answer 25

Because even 1mm of talar shift greatly increases ankle contact pressure & ==> subsequent risk of post-traumatic OA

Question 26

Why may ORIF for treating an ankle fracture be delayed by 1-2 weeks ?

Answer 26

Ankle fractures can be associated with substantial soft tissue swelling and fracture blisters. ==> to allow the soft tissues time to settle and reduce the risk of wound healing problems or infection