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Musculoskeletal > Fracture Assessment and Management > Flashcards

Fracture Assessment and Management Flashcards

1
Q

what is a fracture?

A

discontinuity of the bone

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2
Q

how do you describe fractures?

A

orientation
location
displacement
skin penetration

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3
Q

how to describe the orientation of fractures?

A

transverse
oblique
spiral
comminuted

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4
Q

how to describe the location of fractures?

A

epiphysis, metaphysis, diaphysis

proximal, middle, or distal 1/3

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5
Q

how to describe the displacement of fractures?

A

displaced

undisplaced

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6
Q

how to describe the skin penetration of fractures?

A

open

closed

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7
Q

why do we classify fractures?

A

improve communication

assists with prognosis or treatment

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8
Q

different fracture classification systems

A

descriptive: Garden, Schatzker, Neer, Wber
associated soft tissue injury: Tscherne, Gustilo-Anderson
universal: OTA

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9
Q

AO/OTA classification considers?

A 
bone
where the fracture is
type
group
subgroup
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10
Q

using the humerus an example, what are the types of fractures to proximal end segment according to AO/OTA?

A

extraarticular unifocal 2 part fracture
extraarticular bifocal 3 part fracture
articular or 4 part fracture

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11
Q

using the humerus an example, what are the groups of fractures to proximal end segment according to AO/OTA?

A

tuberosity

surgical neck

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12
Q

using the humerus an example, what are the subgroups of fractures to proximal end segment according to AO/OTA?

A

tuberosity: greater tuberosity, lesser tuberosity

surgical neck: simple, wedge, multifrgamentary

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13
Q

describe primary (direct) bone healing

A

intramembranous healing (via Haversian modelling)
little (<500mm) or no gap
slow process
cutter cone concept like bone remodelling

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14
Q

describe secondary (indirect) bone healing

A

endochondral healing, involves responses in the periosteum and external soft tissues
fast process resulting in callus formation (fibrocartilage)

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15
Q

outline the stages in secondary bone healing

A

haematoma formation
soft callus formation
hard callus formation
remodelling

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16
Q

what occurs in haematoma formation?

A

bleeding from damaged vessels > neutrophils release cytokines > macrophage recruitment

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17
Q

what occurs in soft callus formation?

A

collagen and fibrocartilage bridge fracture site and new blood vessels form

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18
Q

what occurs in hard callus formation?

A

osteoblasts, brought in by new blood vessels, mineralise fibrocartilage to produce woven bone

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19
Q

what occurs in remodelling?

A

months to years after injury osteoclasts remove woven bone and osteoblasts laid down as ordered lamellar bone

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20
Q

pre-requisites for healing

A

minimal fracture gap
no movement if primary healing
some movement if secondary
patient physiological state (nutrients, growth factor, age, diabetic, smoker)

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21
Q

Wolff’s law states?

A

bone adapts to forces placed upon it by remodelling and growing in response to these external stimuli

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22
Q

In a child, if the femur heals bent?

A

axial loading should be direct w/ remodelling occurring through axial loading

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23
Q

Periosteum on the ______ side will make more bone while on the _____ side , bone will be resorbed.

A

concave

convex

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24
Q

Fractures usually heal within what time frame?

A

6 months

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25
Q

what are exceptions to the usual healing timeline for fractures?

A

lower limb fractures take twice as long as upper limb fractures
paediatric fractures heal twice as fast as adults

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26
Q

list two groups of fractures healing complications

A

non-union

malunion

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27
Q

define non-union

A

failure of bone healing within an expected time frame

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28
Q

define mal union

A

bone healing occurs but outside of normal parameters of alignment

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29
Q

atrophic non-union

A

healing completely stopped w/ no x-ray changes, often physiological

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30
Q

hypertrophic non-union

A

too much movement, causing callus healing

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31
Q

causes of non-union

A

too much moving of fracture
poor blood supply
infection

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32
Q

outline fracture management

A

resuscitate
reduce (alignment)
rest (hold in position)
rehabilitate (get function back/avoid stiffness)

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33
Q

fracture management can be divided into what two routes?

A

conservative

surgical

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34
Q

examples of conservative fracture management

A

rest, ice, elevation
plaster/fiberglass cast or splint
traction - skin/bone

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35
Q

examples of surgical fracture management

A

external fixation
ORIF (open reduction internal fixation) [mono/biplanar, multiplanar]
arthroplasty [MUA +K wire] hemi or total
intramedullary nail insertion

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36
Q

how to diagnose a fracture?

A

history and examination - tenderness/limb pain/swelling

obtain x-ray of affected region, ensure in at least two planes

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37
Q

how does shoulder dislocation usually present?

A

variable hx but often direct trauma
pain
restricted movement
loss of normal shoulder contour

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38
Q

clinical examination for dislocated shoulder

A

assess neurovascular status - axillary nerve

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39
Q

investigations for dislocated shoulder

A

x-ray prior any manipulation - identify fracture

scapular-Y view/modified axillary in addition to AP

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40
Q

types of shoulder dislocation from most to least common

A

anterior
posterior
inferior

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41
Q

anterior shoulder dislocation

A

bimodal distribution

humeral head not overlying glenoid

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42
Q

posterior shoulder dislocation

A

associated with seizures/shocks

‘lightbulb’ sign on x-ray

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43
Q

inferior shoulder dislocation

A

arm held abducted above head

humeral head not articular correctly

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44
Q

management of shoulder dislocation

A

safest: traction-countertraction +/- gentle internal rotation to disimpact humeral head
ensure adequate patient relaxation - Entonox, benzodiazepam

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45
Q

what should you avoid during shoulder dislocation management?

A

vigorous or twisting manipulation

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46
Q

if you were alone, what would you do to a dislocated shoulder?

A

use Stimson method

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47
Q

complications of shoulder dislocation

A

neurovascular: axillary nerve injury, iatrogenic, delayed onset
damage to labrum/glenoid/humeral head
recurrent dislocation

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48
Q

Bankart lesion

A

lesion of the anterior part of the glenoid labrum of the shoulder

49
Q

Hill Sachs defect

A

compression injury to the posterolateral aspect of the humeral head created by the glenoid rim during dislocation

50
Q

typical presentation of proximal humerus fracture

A

fall onto outstretched hand

typically elderly/those w/ osteoporosis

51
Q

investigation for proximal humerus fracture

A

plain x-rays

CT if concern over articular involvement or high degrees of comminution

52
Q

classification of proximal humerus fracture (described by Neer)

A 
surgical neck (2 parts)
avulsion fractures of GT (2 parts)
comminuted fractures (>3 parts)
53
Q

surgical management of proximal humerus fracture

A

collar and cuff
ORIF - plate and screws
arthroplasty
reverse arthroplasty

54
Q

when would a collar and cuff be appropriate? any risk?

A

2 part fracture, minimally displaced

high surgical risk/comorbidities

55
Q

when would ORIF - plate and screws be appropriate?

A

any fracture with displacement i.e 2 part+ but not highly comminuted

56
Q

when would arthroplasty be appropriate?

A

humeral head fracture with large displacement and thus high risk of non-union

57
Q

when would reverse arthroplasty be appropriate?

A

unrepairable rotator cuff
previous unsuccessful shoulder replacement
complex fracture/chronic shoulder dislocation

58
Q

how does distal radius fracture present?

A

bimodal distribution
often with clear mechanism of falling onto affected area, swelling and visible deformity
commonest presentation is dorsal displacement due to fall on outstretched hand

59
Q

how to investigate distal radius fracture?

A

plain radiographs - PA/lateral views to assess fracture type

thorough clinical examination to avoid concomitant injuries

60
Q

classification of distal radius fracture

A

extra articular or intra articular
dorsal angulation: colles fractures, dorsal barton
volar angulation: smith fracture, volar/reverse barton

61
Q

management of distal radius fracture

A

cast/splint
MUA & K wire
ORID

62
Q

when is cast/splint most appropriate for distal radius fracture?

A

temporary treatment for any distal radius fracture - reduction of the fracture and placement into cast until definitive fixation, definitive if minimally displaced, extra articular fractures

63
Q

when is MUA & K wire most appropriate for distal radius fracture?

A

fractures that are extra articular but have instability, particularly in children, wires can be removed in clinic post-op

64
Q

when is ORIF most appropriate for distal radius fracture?

A

any displaced, unstable fractures not suitable for K wires or with intra articular involvement may benefit from open reduction internal fixation with plate and screws

65
Q

goals of operative management of distal radius fracture

A

restore articular surface congruency
restore radial inclination
restore radial height
restore volar tilt

66
Q

list carpal bones in the wrist
1st row lateral to medial
2nd row lateral to medial

A

scaphoid, lunate, triquetrum, pisiform

trapezium, trapezoid, capitate, hamate

67
Q

presentation of scaphoid fracture

A

commonest carpal bone injury, usually young patients, typically fall backwards onto their hand

68
Q

clinical examination for scaphoid fracture

A

anyone w/ FOOSH, distal radius fracture should have a scaphoid exam
palpation of anatomical snuffbox, scaphoid tubercle or telescoping of thumb

69
Q

investigation of suspected scaphoid fracture

A

request scaphoid views of radiographs
delayed radiographs if normal but clinical suspicion
consider CT/MRI if still concerned

70
Q

management of scaphoid fracture

A

displaced > ORIF (retrograde blood supply, high risk of non-union/AVN of proximal pole)
undisplaced > conservatively w/ cast (length of time to heal is long)

71
Q

what is perilunate instability?

A

results from disruption to any of the ligament complexes that surround lunate

72
Q

perilunate dislocation

A

articulation with radius and surrounding carpal bones is maintained in lunate dislocation it is not

73
Q

stage 1 of perilunate instability

A

scapho-lunate dissociation > widening of scaphoid and lunate due to scapholunate ligament disruption

74
Q

stage 2 of perilunate instability

A

lunocapitate disruption > lunate remains normally aligned with distal radius, remaining carpal bones dislocated
capitate and lunate widening
high association with scaphoid fractures

75
Q

stage 3 of perilunate instability

A

lunotriquetral disruption
capitate and lunate not aligned w/ distal radius
lunate triquestral ligament is disrupted
high association with triquetral fractures

76
Q

stage 4 of perilunate instability

A

lunate dislocation with ‘tipped teacup’ sign

dorsal radiolunate ligament injury

77
Q

non-operative management of perilunate instability

A

closed reduction and casting has no indication and often poor outcomes compared to non-operative management, high risk of recurrent dislocation

78
Q

operative management of acute injury (perilunate instability)

A

open reduction, ligament repair and fixation

good functional outcomes

79
Q

operative management of non- acute injury (perilunate instability)

A

proximal row carpectomy

converts wrist into simple hinge type

80
Q

operative management of chronic injury (perilunate instability)

A

reduction of pain especially if degenerative changes

81
Q

presentation of pelvic fracture

A

usually a result of high energy trauma, patients can become very unstable - lot of visceral organs and vasculature are adherent to the pelvis

82
Q

examination for pelvic fracture

A

ABCDE approach - dont forget perineum/urethral opening

digitate - PV or PR exams, check for visceral damage or bleeding

83
Q

investigations for pelvic fracture

A

plain radiographs
urethrogram
CT +/- angiography

84
Q

classification of pelvic fracture

A

lateral compression
anterior-posterior compression
vertical shear

85
Q

management of pelvic fracture

A

ATLS/ABCDE principles
hypovolaemia common: IV access, think haemorrhage, pelvic binders over greater trochanters as tamponade device, ongoing instability suggests laparotomy or angiographic embolisation
definitive treatment via surgeons

86
Q

principle of of surgery on pelvic fracture

A

restore integrity of pelvic ring and alignment of sacroiliac joints
internal fixation w/ plate + screws
external fixation if unstable and not suitable for invasive surgery

87
Q

overview of proximal femur (NOF) fracture

A

common, rare in young, high energy major trauma, often result of osteoporosis and minimal trauma is elderly
marker of general frailty and higher mortality than breast cancer

88
Q

proximal femur fracture presents as?

A

often minor fall
may report groin, thigh or buttock pain
ask about preceding symptoms e.g. MI, TIA/stroke, seizure

89
Q

investigations for proximal femur fracture

A

plain radiographs

CT if not identified but high suspicion

90
Q

initial ED management of NOF fracture

A

rule out other injury/pathology causing fall
involve orthogeriatricians/med team
pain relief (consider fascia iliaca block in ED if necessary)
catheterise - limited mobility
bloods
ECG/chest x ray if >55
pre op optimisation - fluids

91
Q

proximal femur fracture classification

A

intracapsular: subcapital, transcervical, basicervical
extracapsular: intertrochanteric, subtrochanteric, reverse oblique

92
Q

proximal femur fracture management (intracapsular)

A

total hip arthroplasty
hemiarthroplasty
cannulated screws

93
Q

proximal femur fracture management (extracapsular)

A

DHS

IM nail

94
Q

total hip replacement for NOF fracture

A

mobile with <1 walking stick outdoors
no cognitive impairment
medically suitable for procedure and anaesthetic

95
Q

hemiarthroplasty for NOF fracture

A

mobile with >1 walking stick outdoors
reduced AMTS
comorbidities or reduced baseline not benefiting from THR

96
Q

cannulated screws for NOF fracture

A

undisplaced fractures where vessels unlikely to be disrupted
young patients
compliant w/ non-weightbearing while fracture heals

97
Q

DHS for NOF fracture

A

for 2/3/4 part intertrochanteric fractures

provides compression as prosthesis is perpendicular to fracture line

98
Q

IM nail for NOF fracture

A

subtrochanteric fracture unstable due to pull of hip girdle

reverse oblique pattern not amenable to DHS as fracture line not perpendicular

99
Q

post-operative management of proximal femur fracture

A

geriatrician input from admission: bone health, medical optimisation, secondary fall prevention
PT: prevent HAI, DVT/PE by early mobilisation
OT: package of care and assistance or aids at home

100
Q

overview of femoral shaft fracture

A

significant force required, high incidence of concomitant life threatening injuries - asses ABCDE/ATLS
clin/exam include neurovascular status of limb
xrays above/below for fracture/dislocation

101
Q

femoral shaft fracture management

A

resus as necessary, hypovolemia not uncommon, traction useful to temporarily reduce pain + bleeding

102
Q

operative management for femoral shaft fracture

A

IM nail antegrade from the hip or retrograde from the knee as surgeon preference, injury pattern, existing prostheses dictates
open reduction and internal fixation if nailing unsuitable e.g. segmental fracture, knee or hip replacements

103
Q

insertion point on tibia for ligament

A

central tibial spine

104
Q

what can cause tibial plateau fracture?

A

extreme valgus/varus force or axial loading across the knee

impaction of femoral condyles causing the tibial plateau to depress or split

105
Q

concomitant ________ or ________ injury is not uncommon

A

ligamentous or meniscal injury

106
Q

classification of tibial plateau fracture

A

lateral: type 1 (split), type 2(split +depression), type 3 (depression)
medial: type 4 (medial plateau)
medial + lateral: type 5 (bicondylar), type 6 (metaphyseal-diaphyseal dissociation)

107
Q

non operative management of tibial plateau fracture

A

only truly undisplaced fractures w/ good joint line congruency assessed on CT or high fidelity imaging

108
Q

operative management of tibial plateau fracture

A

restoration of articular surface using plate + screws

bone graft or cement may be necessary to prevent further depression after fixation

109
Q

ankle joint comprised of?

A

talus articulating with tibia and fibula

110
Q

joint stability of the ankle is necessary for function and provided by?

A

ligaments

bone projections

111
Q

list ligaments in the ankle

A

medially: talofibular, calcaneofibular
laterally: deltoid

112
Q

list bone projections in the ankle

A

medially: medial malleolus of tibia
laterally: lateral malleolus of fibula
posteriorly: posterior malleolus of tibia

113
Q

presentation of ankle fracture

A

extensive soft tissue swelling

inability to bear weight

114
Q

clinical examination of ankle fracture

A

identify tenderness over ligament complexes

115
Q

x ray to ascertain ____ are important to assess stability in ankle fracture

A

talar shift

116
Q

ankle fracture classification

A

weber A: below syndesmosis > ligament disruption and joint stability unlikely
weber B: at level of syndesmosis > ligament disruption, joint stability possible assessment for talar shift necessary
weber C: above syndesmosis, ligament disruption, joint instability likely

117
Q

non-operative management of ankle fracture

A

non-weightbearing below knee cast for 6-8 weeks > walking boot > PT
weber A
weber B is no evidence of instability)

118
Q

operative management of ankle fracture

A

soft tissue dependent, ORIF +/- syndesmosis repair either screw/tightrope technique
weber B unstable
weber C

119
Q

maisonneuve fracture

A

spiral fracture of the proximal third of the fibula associated with a tear of the distal tibiofibular syndesmosis

Musculoskeletal (7 decks)

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