Fracture Flashcards
Traumatic fractures
Direct: e.g. Assault/RTA
Indirect: fall on outstretched hand -> clavicle #
Avulsion
Stress fracture
Bone fatigue due to repetitive strain
E.g. In marathon runners
Pathological fractures
Normal forces in diseased bone -> #
Local: tumour
General: osteoporosis, Cushing’s, paget’s
Fracture patterns
Transverse Oblique Spiral Multifragmentary aka comminuted Crush Greenstick Avulsion
Fracture deformity
Translation
Angulation or tilt
Rotation
Impaction
Soft tissue issues to consider in fracture
Open or closed?
Compartment syndrome
Neuro vascular status
Primary survey
C-spine
Chest
Pelvis
Fracture assessment in secondary survey
Assess neurovascular status
Check for dislocations
? Reduction and splinting prior to imaging:
reduces bleeding, pain, risk of neurovasc injury
X-ray once stable
6 As of open fracture
Analgesia: M+M Assess: soft tissues, nv status Antisepsis: irrigate, swab, cover Alignment: reduce # + splint Anti-tetanus: check last tetanus jab Antibiotics: fluclox 500mg IV/IM + benpen 600mg IV/IM Or augmentin 1.2g IV Debride and fixate in theatre
Most dangerous complication of open #
Clostridium Perfringens
Wound infection + gas gangrene
+- shock + renal failure
Rx debride, benpen, clindamycin
Gustillo classification of open #s
- Wound <1cm
- Wound >1cm, minimal soft tissue damage
- Extensive soft tissue damage
reduction
If displaced -> reduce unless no effect on outcome e.g. Ribs
Aim = anatomical reduction
Alignment > opposition
Methods of reduction
Closed reduction: under local/regional/general anaesthetic
traction to disimpact, manipulation to align
Traction: only used to overcome contraction of large muscles e.g.femur mostly seen in paeds
Open reduction + internal fixation
Indications for internal fixation
Intra articular #
Open #
2 # in one limb
Failure of conservative management
Principles of restriction
Fixation: reduces strain -> bone formation reduces pain increases stability increases function
Methods of restriction
Non rigid: slings, elastic support
Plaster: first 24 hrs back slab/split cask, risk compartment synd
Functional brace: joint free to move, bone shaft supported in cast
Continuous traction: collar + cuff
External fixation: pins, wires + ext frame
Internal fixation: pins, plates, screws, nails
Rehab
Immobility -> reduced bone/muscle mass + joint stiffness
Maximise mobility of uninjured limb
Quick return to function reduces morbidity later
Physio
OT
Social services
General # complications
Tissue damage: haemorrhage, infection, rhabdomyolysis
Anaesthesia: anaphylaxis, teeth, aspiration
Prolonged bed rest: UTI/chest infection, pressure ulcer, muscle wasting, DVT/PE, reduced BMD
Specific # complications
Immed: NV damage, visceral damage
Early: compartment synd, infection, fat embolisation -> ARDS
Late: AVN, union issues, growth disturbance, post traumatic OA, complex regional pain synd, myositis ossificans
complications: neurological
Seddon classification
Neuropraxia: temporary interruption of conduction w/o loss of axon continuity
Axonotmesis: axon disruption-> distal Wallerian degeneration
connective tissue preserved, regeneration and recovery possible
Neurotmesis: entire nerve fibre disrupted, req surgery, recovery not complete
Common # associated palsies
Axillary N: numb chevron, weak abduction
ant shoulder dislocation/ humeral surgical neck #
Radial N: waiter’s tip, humeral shaft #
Ulnar N: claw hand, elbow dislocation
Sciatic N: foot drop, hip dislocation
Fibular N: foot drop, # neck of fibula, knee dislocation
Compartment syndrome
Fascia divide groups of muscles, nerves and vessels in limbs into discrete compartments Fascia do not stretch or expand easily # -> oedema -> incr compartment P -> decr venous drainage -> incr P Compartment P > capillary P = ischaemia Muscle infarction: rhabdo + ATN, fibrosis -> Volkman's isch.contracture
Compartment syndrome presentation
Pain in passive stretching of muscles
Warm erythematous swollen limb
^ CRT
Weak/ absent peripheral pulses
Management of compartment syndrome
Elevate limb
Remove bandages, split/remove cast
Fasciotomy
Causes of delayed/non Union
Ischaemia: poor supply / AVN
Infection
Incr inter-fragmentary strain
Interposition of tissue between fragments
Intercurrent disease: malignancy/malnutrition
Non-union
Hypertrophy: rounded, dense, sclerotic bone end
Atrophy: osteopenic bone
Management
optimise bio: infection, blood supply, graft, BMP
optimise mechanics: ORIF
Avascular necrosis
Sites: femoral head, scaphoid, talus
-> soft, deformed bone => pain, stiffness, OA
X-Ray: sclerosis + deformity
Myositis ossificans
Heterotrophic ossification of muscle at sites of haematoma formation
-> restricted painful movement
Commoner in elbow + quadriceps
Can be surgically excised
Pellegrini-stieda disease
A form of myositis ossificans
Calcification of the superior attachment of the MCL at the knee following trauma
Complex regional pain syndrome type 1
Complex disorder of pain, sensory abnormalities, abnormal blood flow, sweating and trophic changes in superficial or deep tissues with no evidence of nerve injury
Assoc with: #s, carpal tunnel release, ops on dupuytron’s contracture, HZV, MI, idiopathic
Symptoms of complex regional pain syndrome type 1
Wks/maths following injury, area neighbouring traumatised area
Lancing pain, hyperalgesia or allodynia
Weakness hyper-reflexia, dystonia, contractures
Swollen, shiny skin
Usually self limiting, can try gabapentin, amitryptiline
Refer to pain team
Growth disturbance due to fracture
Salter-Harris classification of growth plate injuries
- Straight across 5% e.g. SUFE
- Above 75%
- Lower 10%
- Through 10% union across physis interferes with growth
- Crush uncommon physis injury -> growth arrest
Osteoporosis RF
Age + shattered Steroids Hyper para/thyroidism Alcohol + cigarettes Thin BMI<22 Testosterone low Early menopause Renal/liver failure Erosive/inflammatory bone disease: RA / myeloma Dietary Ca low/ malabsorption
NOF presentation
O/E shortened + externally rotated mechanism RF premorbid mobility premorbid independence comorbidities MMSE
NOF management
Resus: dehydration, hypothermia Analgesia: M + M Assess NV status of limb Imaging: AP + lateral films Prep for theatre
Prep for theatre
Anaesthetist: inform of pt, book theatre Bloods: FBC, U=E, clotting, X-match (2U) CXR DVT prophylaxis: LMWH + TEDS ECG Films: orthogonal X-Rays Get consent
Imaging
AP + lateral films Check Shenton's lines Intra or extra capsular? Displaced or non-displaced? Osteopaenic?
Classification
Intracapsular: subcapital, transcervical, basicervical
Extracapsular: intertrochanteric, sub trochanteric
Intracapsular #s - Garden classification
- incomplete, undisplaced #
- complete, undisplaced #
- complete, partially displaced #
- complete, completely displaced #
NOF anatomy
Capsule attaches: proximally to acetabular margin, distally to intertrochanteric line
Blood supply to femoral head: retinacular vessels in capsule running distal -> prox (damage = risk of AVN), intramedullary vessels, artery of ligamentum teres
Surgical management of intracapsular NOF #
Garden 1/2: ORIF with cancellous screws 3/4: <55yrs = ORIF with screws, f/u in OP with arthroplasty if AVN develops (30%) 55-75 yrs = total hip replacement >75 yrs = hemiarthroplasty mobile: cemented Thompson's immobile: uncemented Austin Moore
Surgical management of extracapsular NOF #
ORIF with DHS - dynamic hip screw
Complications specific to NOF #
AVN of femoral head in 30% displaced #
non/mal-union 10-30%
infection
OA
Prognosis of NOF #
mortality at 1 yr = 30%
50% never regain pre-morbid function
>10% unable to return to permorbid residence
Colles #
FOOSH
female elderly pop with osteoporosis
‘dinner fork’ deformity
X-ray features of Colles’ fracture
distal radius: extra-articular #
dorsal displacement + angulation (11 degree volar tilt) of distal fragment
decreased radial height + inclination
+- ulna styloid avulsion or impaction
Management of Colles’ fracture
NV injury: median nerve + radial artery reduction -> imaging manipulation under anaesthesia # clinic f/u for cast in 48hrs 6wks cast + physio
Complications specific to Colles’ #
Medican N injury Frozen shoulder Tendon rupture (EPL) Carpal tunnel syndrome Mal/non-union Sudek's atrophy/CRPS
Smith’s # (aka reverse Colles’)
Fall onto back of flexed wrist
# of distal radius
Volar displacement + angulation of distal fragment
Reduction + cast for 6 wks
Barton’s #
oblique intra-articular # of dorsal distal radius
dislocation of radio-carpal joint
reverse Barton’s = volar aspect of radius
Presentation of scaphoid #
FOOSH
Tenderness in anatomical snuffbox
Tender on telescoping of thumb
Specific management of scaphoid #
Request scaphoid x-ray view
Treat with suggestive clinical hx even if X-ray normal (scaphoid plaster)
+ve X-ray after 10 days (localised decalcification) -> 6 wks plaster
-ve but clinically tender -> 2wks plaster
Complications specific to scaphoid #
AVN of scaphoid (blood supply distal-> proximal)
= stiffness + pain at wrist
Monteggia #
proximal 1/3 of ulna shaft
ant dislocation of radial head at capitulum
(palsy of deep branch radial N)
Galleazzi #
# of radial shaft between mid and distal 1/3s dislocation of radio-ulna joint
Specific management of radial + ulna shaft #s
unstable: adults = ORIF, kids = MUA + above elbow plaster plaster in most stable position proximal # = supination distal # = pronation mid-shaft # = neutral
