Disease Profiles: Fracture Management and Complications Flashcards
Which investigations would you perform in suspected fracture non-union?
X-ray, CT - bridging callus
What is chronic regional pain syndrome?
An exaggerated pain response after injury, can be caused by a peripheral nerve injury (type 2) but often is not (type 1)
Which patient group is most at risk of developing compartment syndrome following a tibial fracture?
Male 10-35 years
Name a fracture of the metatarsals which is prone to non union due to poor blood supply
Jone’s fracture of the fifth metatarsal
Why are older patients more likely to be treated non-operatively?
Increased risk of complications of surgery, failure of fixation and failure to rehabilitate satisfactorily
How does alcoholism, steroid abuse and hyperlipidaemia cause AVN?
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
2-15% of patients with a fracture of which bone will develop compartment syndrome?
Tibial shaft fracture
What is delayed union?
A fracture that is not healed within the expected time, can be caused by infection
What is fracture disease?
Term used to describe stiffness and weakness due to the fracture and subsequent splintage in cast
How are undisplaced, minimally displaced and minimally angulated fractures which are considered stable generally managed?
Usually treated non‐operatively with a period of splintage or immobilization and then rehabilitation
Name a fracture of the pectoral girdle which is prone to non union due to poor blood supply
Fracture of the distal clavicle
Describe the clinical presentation of fracture non-union
Ongoing pain, ongoing oedema, movement at the fracture site
Which type of blood disorder is a risk factor for idiopathic AVN?
Blood clotting disorders (hypercoaguable states)
Which investigations would you perform in suspected AVN?
MRI (early changes), x-ray (later changes)
Describe the definitive management of open fractures
Debridement, stabilisation with fixation, wound closure
Describe the prognosis of neuropraxia
Resolves over time with full recovery (can take up to 28 days)
What is de-gloving?
Avulsion of the skin from its underlying blood supply as a result of a shearing force on the skin
How can you predict the outcome of axonotmesis?
Nerve conduction studies from around a month from the time of injury
How would you manage ongoing haemorrhage from arterial injury in the pelvis?
Angiographic embolization
Describe the clinical presentation of a fracture causing excessive pressure on the skin
Tenting of the skin and ‘blanching’
Describe the management of irreversible AVN
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
Describe the management of vascular injury with distal ischaemia
Urgent vascular surgery review and emergency surgical management
Describe the non-pharmacological management of chronic regional pain syndrome
TENS machines, physiotherapy, lidocaine patches and sympathetic nerve blocking injections
Describe the general initial management of a fracture
Clinical assessment (especially neurovascular), analgesia, splintage +/- traction, imaging
What causes hypertrophic non-union?
Instability and excessive motion at the fracture site, infection
Which two forms of prophylaxis should be given in an open fracture?
Broad-spectrum antibiotics, tetanus vaccine/immunoglobin
What causes neurotmesis (3nd degree nerve injury)?
Complete transection of a nerve - rare in closed injuries but can occur in penetrating injuries
Describe the management of acute fixed fracture infection
Antibiotic therapy with or without surgical washout to suppress infection and enable healing
Paediatric supracondylar fracture of the elbow is associated which injury of which artery?
Brachial artery injury
Describe the management of displaced intra-articular fractures
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
Which type of fractures may require stabilisation?
Unstable injuries
Name a fracture of the carpals which is prone to non union due to poor blood supply
Scaphoid waist fractures
Describe the management of reversible AVN
Bisphosphates
Surgery - core decompression, curettage and bone grafting, vascularised fibular bone graft
Describe the management of chronic fixed fracture infection
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
What is malunion?
Fracture has healed in a non-anatomic position sufficient to cause pain, stiffness, loss of function and deformity
What is Volkmann’s ischaemic contracture?
Permanent contracture of forearm muscles resulting from missed compartment syndrome of the forearm
Which form of bone healing does ORIF encourage?
Primary
Describe the prognosis of neurotmesis
No recovery without surgical repair, recovery is variable
Describe the examination findings in AVN
Usually normal unless disease has advanced to collapse/OA
Name a fracture of the lower limb which is prone to non union due to poor blood supply
Subtrochanteric fracture of the femur
Describe the management of unstable extra-articular fractures
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
Knee dislocation is associated which injury of which artery?
Popliteal artery
Which form of bone healing does external fixation encourage?
Secondary
Name 3 early systemic complications of a fracture
Fat embolism, ARDS, SIRS
Describe the clinical presentation of femoral head AVN
Insidious onset of groint pain exacerbated by stairs or impact
Bilateral disease in 80% of cases
Can be asymptomatic
Which investigation can be used in vascular injury with distal ischaemia to localise the site of occlusion in theatre?
Urgent angiography
What is the ‘hanging rope sign’ on x-ray?
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
Describe the clinical presentation of chronic regional pain syndrome
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
How would you investigate a potential nerve injury?
Nerve conduction studies
Describe the management of compartment syndrome
Release all dressings/cast to skin and do not elevate
Emergency fasciotomy to relieve pressure, wound left open for a few days then closed
Describe the prognosis of axonotmesis
Axons regenerate along the endoneurial tubes at a rate of 1mm per day
Recovery is variable, full power or sensation may not be achieved
Describe the two mechanisms of open fractures
Spike of fractured bone puncturing the skin or laceration of the skin from tearing or penetrating injury
Which type of fractures may require open/closed reduction?
Displaced or angulated fractures
What might cause post-traumatic arthritis?
Can occur due to intra-articular fracture, ligamentous instability or fracture malunion
What is irreversible AVN?
AVN after the articular surface has collapsed
Which form of bone healing does IM nail fixation encourage?
Secondary
Describe the clinical presentation of a fracture
Localised bony (marked) tenderness, swelling, deformity, crepitus
Describe AVN associated with trauma
AVN which occurs secondary to fractures - the fracture disrupts the blood supply to an entire portion of bone
Describe the clinical presentation of compartment syndrome
Disproportionate pain, paraethesia, pallor, pulselessness (late sign)
Tensely swollen limb, usually tender to touch
Pain on passive stretch of muscles in involved compartment
Describe the management of a fracture causing excessive pressure on the skin
Fracture should be reduced as an emergency (under analgesia +/‐ sedation) to avoid subsequent necrosis
What is avascular necrosis?
Failure of the blood supply to the end of a bone, resulting in ischaemic necrosis of bone and marrow
When would you give a patient with an open fracture just a tetanus vaccine (no immunoglobin)?
If history unknown and uncontaminated, vaccinated >10 years ago (clean injury) or vaccinated >5 years ago (contaminated injury)
Why is a surgical wound through swollen and contused skin and soft tissues not advisable?
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
What causes axonotmesis (2nd degree nerve injury)?
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)
What causes atrophic non-union?
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
Why might an intracapsular hip fracture or other synovial intra-articular fracture not unite if there is a fracture gap?
Synovial fluid can inhibit healing if a fracture gap exists
Which patient group is most at risk of developing avascular necrosis?
Greater incidence in males, typical age 35-50 years
What causes neuropraxia (1st degree nerve injury)?
Occurs when the nerve has a temporary conduction defect from compression or stretch
What causes idiopathic AVN?
Coagulation of the intraosseous microcirculation → thrombosis occludes artery → blood flow decreases
When would IV metronidazole be used in open fracture prophylaxis?
To cover anaerobes if there is soil contamination
What is compartment syndrome?
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
Which injuries are particularly at risk of developing a DVT?
Pelvic or major lower limb fractures within a period of immobility
What is reversible AVN?
AVN detected before the articular surface has collapsed
Shoulder trauma is associated which injury of which artery?
Axillary artery injury
Describe the management of fracture disease
Most cases resolve with time and may be helped with physiotherapy
Describe the pharmacological management of chronic regional pain syndrome
Analgesics, antidepressants (amitriptyline), anticonvulsants (gabapentin) and steroids may help
Describe the clinical presentation of vascular injury with distal ischaemia
Signs of reduced distal circulation - reduced or absent pulses, pallor, delayed capillary refill, cold to touch
Describe the appearance on x-ray of AVN following the collapse of the articular surface
Articular surface will be irregular and as secondary OA develops the associated signs will be visible (LOSS)
Name 2 late systemic complication of a fracture
DVT, PE
How does decompression sickness cause AVN?
Nitrogen gas bubbles form in the circulation after too rapid a depressurization after deep sea diving
Describe the management of post-traumatic arthritis
Treatment may involve analgesia, bracing/splinting, arthrodesis or joint replacement
When would you give a patient with an open fracture a tetanus vaccine and immunoglobin?
If contaminated injury and history unknown or < 3 prior doses
When would exploration of a possible nerve injury be indicated?
Open fracture, penetrating injury, neuralgic pain
Describe the immediate management of an open fracture
Direct pressure, reduce dislocation with NV exam before and after, remove debris, photograph, cover, stabilise
