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MBChB YR2 MSK > Disease Profiles: Fracture Management and Complications > Flashcards

Disease Profiles: Fracture Management and Complications Flashcards

1
Q

Which investigations would you perform in suspected fracture non-union?

A

X-ray, CT - bridging callus

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2
Q

What is chronic regional pain syndrome?

A

An exaggerated pain response after injury, can be caused by a peripheral nerve injury (type 2) but often is not (type 1)

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3
Q

Which patient group is most at risk of developing compartment syndrome following a tibial fracture?

A

Male 10-35 years

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4
Q

Name a fracture of the metatarsals which is prone to non union due to poor blood supply

A

Jone’s fracture of the fifth metatarsal

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5
Q

Why are older patients more likely to be treated non-operatively?

A

Increased risk of complications of surgery, failure of fixation and failure to rehabilitate satisfactorily

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6
Q

How does alcoholism, steroid abuse and hyperlipidaemia cause AVN?

A

Increased fat in circulation sludges up the capillary system which promotes coagulation within prone areas of bone

Increased fat in the marrow can compress venous outflow

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7
Q

2-15% of patients with a fracture of which bone will develop compartment syndrome?

A

Tibial shaft fracture

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8
Q

What is delayed union?

A

A fracture that is not healed within the expected time, can be caused by infection

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9
Q

What is fracture disease?

A

Term used to describe stiffness and weakness due to the fracture and subsequent splintage in cast

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10
Q

How are undisplaced, minimally displaced and minimally angulated fractures which are considered stable generally managed?

A

Usually treated non‐operatively with a period of splintage or immobilization and then rehabilitation

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11
Q

Name a fracture of the pectoral girdle which is prone to non union due to poor blood supply

A

Fracture of the distal clavicle

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12
Q

Describe the clinical presentation of fracture non-union

A

Ongoing pain, ongoing oedema, movement at the fracture site

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13
Q

Which type of blood disorder is a risk factor for idiopathic AVN?

A

Blood clotting disorders (hypercoaguable states)

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14
Q

Which investigations would you perform in suspected AVN?

A

MRI (early changes), x-ray (later changes)

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15
Q

Describe the definitive management of open fractures

A

Debridement, stabilisation with fixation, wound closure

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16
Q

Describe the prognosis of neuropraxia

A

Resolves over time with full recovery (can take up to 28 days)

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17
Q

What is de-gloving?

A

Avulsion of the skin from its underlying blood supply as a result of a shearing force on the skin

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18
Q

How can you predict the outcome of axonotmesis?

A

Nerve conduction studies from around a month from the time of injury

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19
Q

How would you manage ongoing haemorrhage from arterial injury in the pelvis?

A

Angiographic embolization

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20
Q

Describe the clinical presentation of a fracture causing excessive pressure on the skin

A

Tenting of the skin and ‘blanching’

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21
Q

Describe the management of irreversible AVN

A

Generally joint replacement is usually required in the hip, knee or shoulder to control symptoms

Rotational osteotomy can be considered if less than 15% of femoral head damaged (rare)

Fusion can be considered in the wrist or foot/ankle

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22
Q

Describe the management of vascular injury with distal ischaemia

A

Urgent vascular surgery review and emergency surgical management

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23
Q

Describe the non-pharmacological management of chronic regional pain syndrome

A

TENS machines, physiotherapy, lidocaine patches and sympathetic nerve blocking injections

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24
Q

Describe the general initial management of a fracture

A

Clinical assessment (especially neurovascular), analgesia, splintage +/- traction, imaging

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25
Q

What causes hypertrophic non-union?

A

Instability and excessive motion at the fracture site, infection

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26
Q

Which two forms of prophylaxis should be given in an open fracture?

A

Broad-spectrum antibiotics, tetanus vaccine/immunoglobin

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27
Q

What causes neurotmesis (3nd degree nerve injury)?

A

Complete transection of a nerve - rare in closed injuries but can occur in penetrating injuries

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28
Q

Describe the management of acute fixed fracture infection

A

Antibiotic therapy with or without surgical washout to suppress infection and enable healing

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29
Q

Paediatric supracondylar fracture of the elbow is associated which injury of which artery?

A

Brachial artery injury

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30
Q

Describe the management of displaced intra-articular fractures

A

Require anatomic reduction and rigid fixation by way of ORIF using wires, screws and plates

In situations with predictable poor outcome consider joint replacement/arthrodesis

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31
Q

Which type of fractures may require stabilisation?

A

Unstable injuries

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32
Q

Name a fracture of the carpals which is prone to non union due to poor blood supply

A

Scaphoid waist fractures

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33
Q

Describe the management of reversible AVN

A

Bisphosphates

Surgery - core decompression, curettage and bone grafting, vascularised fibular bone graft

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34
Q

Describe the management of chronic fixed fracture infection

A

For infections present for longer than a few weeks, fracture healing may still be accomplished with antibiotic suppression but the metalwork will need later removal

If the infection cannot be suppressed and becomes too problematic surgical removal of all implants and debridement of infected bone is required

35
Q

What is malunion?

A

Fracture has healed in a non-anatomic position sufficient to cause pain, stiffness, loss of function and deformity

36
Q

What is Volkmann’s ischaemic contracture?

A

Permanent contracture of forearm muscles resulting from missed compartment syndrome of the forearm

37
Q

Which form of bone healing does ORIF encourage?

A

Primary

38
Q

Describe the prognosis of neurotmesis

A

No recovery without surgical repair, recovery is variable

39
Q

Describe the examination findings in AVN

A

Usually normal unless disease has advanced to collapse/OA

40
Q

Name a fracture of the lower limb which is prone to non union due to poor blood supply

A

Subtrochanteric fracture of the femur

41
Q

Describe the management of unstable extra-articular fractures

A

Usually ORIF

IM nail fixation indicated in some situations - very swollen soft tissues, tenuous blood supply to fracture, where ORIF may cause extensive blood loss (e.g. femoral shaft), or where plate fixation may be prominent (e.g. tibia)

Another option where ORIF is not suitable is external fixation - risk of infection and loosening

42
Q

Knee dislocation is associated which injury of which artery?

A

Popliteal artery

43
Q

Which form of bone healing does external fixation encourage?

A

Secondary

44
Q

Name 3 early systemic complications of a fracture

A

Fat embolism, ARDS, SIRS

45
Q

Describe the clinical presentation of femoral head AVN

A

Insidious onset of groint pain exacerbated by stairs or impact

Bilateral disease in 80% of cases

Can be asymptomatic

46
Q

Which investigation can be used in vascular injury with distal ischaemia to localise the site of occlusion in theatre?

A

Urgent angiography

47
Q

What is the ‘hanging rope sign’ on x-ray?

A

Later sign of femoral head AVN - patchy sclerosis of the weight bearing area of the femoral head with a lytic zone underneath formed by granulation tissue from attempted repair

48
Q

Describe the clinical presentation of chronic regional pain syndrome

A

Charcteristics are variable but include constant burning or throbbing, sensitivity to stimuli not normally painful (allodynia) including cold or light touch, chronic swelling, stiffness, painful movement and skin colour changes

49
Q

How would you investigate a potential nerve injury?

A

Nerve conduction studies

50
Q

Describe the management of compartment syndrome

A

Release all dressings/cast to skin and do not elevate

Emergency fasciotomy to relieve pressure, wound left open for a few days then closed

51
Q

Describe the prognosis of axonotmesis

A

Axons regenerate along the endoneurial tubes at a rate of 1mm per day

Recovery is variable, full power or sensation may not be achieved

52
Q

Describe the two mechanisms of open fractures

A

Spike of fractured bone puncturing the skin or laceration of the skin from tearing or penetrating injury

53
Q

Which type of fractures may require open/closed reduction?

A

Displaced or angulated fractures

54
Q

What might cause post-traumatic arthritis?

A

Can occur due to intra-articular fracture, ligamentous instability or fracture malunion

55
Q

What is irreversible AVN?

A

AVN after the articular surface has collapsed

56
Q

Which form of bone healing does IM nail fixation encourage?

A

Secondary

57
Q

Describe the clinical presentation of a fracture

A

Localised bony (marked) tenderness, swelling, deformity, crepitus

58
Q

Describe AVN associated with trauma

A

AVN which occurs secondary to fractures - the fracture disrupts the blood supply to an entire portion of bone

59
Q

Describe the clinical presentation of compartment syndrome

A

Disproportionate pain, paraethesia, pallor, pulselessness (late sign)

Tensely swollen limb, usually tender to touch

Pain on passive stretch of muscles in involved compartment

60
Q

Describe the management of a fracture causing excessive pressure on the skin

A

Fracture should be reduced as an emergency (under analgesia +/‐ sedation) to avoid subsequent necrosis

61
Q

What is avascular necrosis?

A

Failure of the blood supply to the end of a bone, resulting in ischaemic necrosis of bone and marrow

62
Q

When would you give a patient with an open fracture just a tetanus vaccine (no immunoglobin)?

A

If history unknown and uncontaminated, vaccinated >10 years ago (clean injury) or vaccinated >5 years ago (contaminated injury)

63
Q

Why is a surgical wound through swollen and contused skin and soft tissues not advisable?

A

The wound may not be able to be closed which would leave a route for infection, or excessive tension on the wound may lead to necrosis and wound breakdown

64
Q

What causes axonotmesis (2nd degree nerve injury)?

A

Occurs from either a sustained compression or stretch or from a higher degree of force

Nerve remains continuous and internal structure is intact but the long nerve cell axons distal to the point of injury die (Wallerian degeneration)

65
Q

What causes atrophic non-union?

A

Can occur due to rigid fixation with a fracture gap, lack of blood supply to the fracture site, chronic disease, soft tissue interposition, or infection

66
Q

Why might an intracapsular hip fracture or other synovial intra-articular fracture not unite if there is a fracture gap?

A

Synovial fluid can inhibit healing if a fracture gap exists

67
Q

Which patient group is most at risk of developing avascular necrosis?

A

Greater incidence in males, typical age 35-50 years

68
Q

What causes neuropraxia (1st degree nerve injury)?

A

Occurs when the nerve has a temporary conduction defect from compression or stretch

69
Q

What causes idiopathic AVN?

A

Coagulation of the intraosseous microcirculation → thrombosis occludes artery → blood flow decreases

70
Q

When would IV metronidazole be used in open fracture prophylaxis?

A

To cover anaerobes if there is soil contamination

71
Q

What is compartment syndrome?

A

Increased pressure in the enclosed space of the compartments of the limbs, caused by swelling of tissue or increase in fluid, will affect the functions of the muscles and nerves in the compartment

72
Q

Which injuries are particularly at risk of developing a DVT?

A

Pelvic or major lower limb fractures within a period of immobility

73
Q

What is reversible AVN?

A

AVN detected before the articular surface has collapsed

74
Q

Shoulder trauma is associated which injury of which artery?

A

Axillary artery injury

75
Q

Describe the management of fracture disease

A

Most cases resolve with time and may be helped with physiotherapy

76
Q

Describe the pharmacological management of chronic regional pain syndrome

A

Analgesics, antidepressants (amitriptyline), anticonvulsants (gabapentin) and steroids may help

77
Q

Describe the clinical presentation of vascular injury with distal ischaemia

A

Signs of reduced distal circulation - reduced or absent pulses, pallor, delayed capillary refill, cold to touch

78
Q

Describe the appearance on x-ray of AVN following the collapse of the articular surface

A

Articular surface will be irregular and as secondary OA develops the associated signs will be visible (LOSS)

79
Q

Name 2 late systemic complication of a fracture

A

DVT, PE

80
Q

How does decompression sickness cause AVN?

A

Nitrogen gas bubbles form in the circulation after too rapid a depressurization after deep sea diving

81
Q

Describe the management of post-traumatic arthritis

A

Treatment may involve analgesia, bracing/splinting, arthrodesis or joint replacement

82
Q

When would you give a patient with an open fracture a tetanus vaccine and immunoglobin?

A

If contaminated injury and history unknown or < 3 prior doses

83
Q

When would exploration of a possible nerve injury be indicated?

A

Open fracture, penetrating injury, neuralgic pain

84
Q

Describe the immediate management of an open fracture

A

Direct pressure, reduce dislocation with NV exam before and after, remove debris, photograph, cover, stabilise

MBChB YR2 MSK (36 decks)

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