Fracture Assessment and Management Flashcards
what is a fracture?
discontinuity of the bone
how do you describe fractures?
orientation
location
displacement
skin penetration
how to describe the orientation of fractures?
transverse
oblique
spiral
comminuted
how to describe the location of fractures?
epiphysis, metaphysis, diaphysis
proximal, middle, or distal 1/3
how to describe the displacement of fractures?
displaced
undisplaced
how to describe the skin penetration of fractures?
open
closed
why do we classify fractures?
improve communication
assists with prognosis or treatment
different fracture classification systems
descriptive: Garden, Schatzker, Neer, Wber
associated soft tissue injury: Tscherne, Gustilo-Anderson
universal: OTA
AO/OTA classification considers?
bone where the fracture is type group subgroup
using the humerus an example, what are the types of fractures to proximal end segment according to AO/OTA?
extraarticular unifocal 2 part fracture
extraarticular bifocal 3 part fracture
articular or 4 part fracture
using the humerus an example, what are the groups of fractures to proximal end segment according to AO/OTA?
tuberosity
surgical neck
using the humerus an example, what are the subgroups of fractures to proximal end segment according to AO/OTA?
tuberosity: greater tuberosity, lesser tuberosity
surgical neck: simple, wedge, multifrgamentary
describe primary (direct) bone healing
intramembranous healing (via Haversian modelling)
little (<500mm) or no gap
slow process
cutter cone concept like bone remodelling
describe secondary (indirect) bone healing
endochondral healing, involves responses in the periosteum and external soft tissues
fast process resulting in callus formation (fibrocartilage)
outline the stages in secondary bone healing
haematoma formation
soft callus formation
hard callus formation
remodelling
what occurs in haematoma formation?
bleeding from damaged vessels > neutrophils release cytokines > macrophage recruitment
what occurs in soft callus formation?
collagen and fibrocartilage bridge fracture site and new blood vessels form
what occurs in hard callus formation?
osteoblasts, brought in by new blood vessels, mineralise fibrocartilage to produce woven bone
what occurs in remodelling?
months to years after injury osteoclasts remove woven bone and osteoblasts laid down as ordered lamellar bone
pre-requisites for healing
minimal fracture gap
no movement if primary healing
some movement if secondary
patient physiological state (nutrients, growth factor, age, diabetic, smoker)
Wolff’s law states?
bone adapts to forces placed upon it by remodelling and growing in response to these external stimuli
In a child, if the femur heals bent?
axial loading should be direct w/ remodelling occurring through axial loading
Periosteum on the ______ side will make more bone while on the _____ side , bone will be resorbed.
concave
convex
Fractures usually heal within what time frame?
6 months
what are exceptions to the usual healing timeline for fractures?
lower limb fractures take twice as long as upper limb fractures
paediatric fractures heal twice as fast as adults
list two groups of fractures healing complications
non-union
malunion
define non-union
failure of bone healing within an expected time frame
define mal union
bone healing occurs but outside of normal parameters of alignment
atrophic non-union
healing completely stopped w/ no x-ray changes, often physiological
hypertrophic non-union
too much movement, causing callus healing
causes of non-union
too much moving of fracture
poor blood supply
infection
outline fracture management
resuscitate
reduce (alignment)
rest (hold in position)
rehabilitate (get function back/avoid stiffness)
fracture management can be divided into what two routes?
conservative
surgical
examples of conservative fracture management
rest, ice, elevation
plaster/fiberglass cast or splint
traction - skin/bone
examples of surgical fracture management
external fixation
ORIF (open reduction internal fixation) [mono/biplanar, multiplanar]
arthroplasty [MUA +K wire] hemi or total
intramedullary nail insertion
how to diagnose a fracture?
history and examination - tenderness/limb pain/swelling
obtain x-ray of affected region, ensure in at least two planes
how does shoulder dislocation usually present?
variable hx but often direct trauma
pain
restricted movement
loss of normal shoulder contour
clinical examination for dislocated shoulder
assess neurovascular status - axillary nerve
investigations for dislocated shoulder
x-ray prior any manipulation - identify fracture
scapular-Y view/modified axillary in addition to AP
types of shoulder dislocation from most to least common
anterior
posterior
inferior
anterior shoulder dislocation
bimodal distribution
humeral head not overlying glenoid
posterior shoulder dislocation
associated with seizures/shocks
‘lightbulb’ sign on x-ray
inferior shoulder dislocation
arm held abducted above head
humeral head not articular correctly
management of shoulder dislocation
safest: traction-countertraction +/- gentle internal rotation to disimpact humeral head
ensure adequate patient relaxation - Entonox, benzodiazepam
what should you avoid during shoulder dislocation management?
vigorous or twisting manipulation
if you were alone, what would you do to a dislocated shoulder?
use Stimson method
complications of shoulder dislocation
neurovascular: axillary nerve injury, iatrogenic, delayed onset
damage to labrum/glenoid/humeral head
recurrent dislocation
Bankart lesion
lesion of the anterior part of the glenoid labrum of the shoulder
Hill Sachs defect
compression injury to the posterolateral aspect of the humeral head created by the glenoid rim during dislocation
typical presentation of proximal humerus fracture
fall onto outstretched hand
typically elderly/those w/ osteoporosis
investigation for proximal humerus fracture
plain x-rays
CT if concern over articular involvement or high degrees of comminution
classification of proximal humerus fracture (described by Neer)
surgical neck (2 parts) avulsion fractures of GT (2 parts) comminuted fractures (>3 parts)
surgical management of proximal humerus fracture
collar and cuff
ORIF - plate and screws
arthroplasty
reverse arthroplasty
when would a collar and cuff be appropriate? any risk?
2 part fracture, minimally displaced
high surgical risk/comorbidities
when would ORIF - plate and screws be appropriate?
any fracture with displacement i.e 2 part+ but not highly comminuted
when would arthroplasty be appropriate?
humeral head fracture with large displacement and thus high risk of non-union
when would reverse arthroplasty be appropriate?
unrepairable rotator cuff
previous unsuccessful shoulder replacement
complex fracture/chronic shoulder dislocation
how does distal radius fracture present?
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
how to investigate distal radius fracture?
plain radiographs - PA/lateral views to assess fracture type
thorough clinical examination to avoid concomitant injuries
classification of distal radius fracture
extra articular or intra articular
dorsal angulation: colles fractures, dorsal barton
volar angulation: smith fracture, volar/reverse barton
management of distal radius fracture
cast/splint
MUA & K wire
ORID
when is cast/splint most appropriate for distal radius fracture?
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
when is MUA & K wire most appropriate for distal radius fracture?
fractures that are extra articular but have instability, particularly in children, wires can be removed in clinic post-op
when is ORIF most appropriate for distal radius fracture?
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
goals of operative management of distal radius fracture
restore articular surface congruency
restore radial inclination
restore radial height
restore volar tilt
list carpal bones in the wrist
1st row lateral to medial
2nd row lateral to medial
scaphoid, lunate, triquetrum, pisiform
trapezium, trapezoid, capitate, hamate
presentation of scaphoid fracture
commonest carpal bone injury, usually young patients, typically fall backwards onto their hand
clinical examination for scaphoid fracture
anyone w/ FOOSH, distal radius fracture should have a scaphoid exam
palpation of anatomical snuffbox, scaphoid tubercle or telescoping of thumb
investigation of suspected scaphoid fracture
request scaphoid views of radiographs
delayed radiographs if normal but clinical suspicion
consider CT/MRI if still concerned
management of scaphoid fracture
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)
what is perilunate instability?
results from disruption to any of the ligament complexes that surround lunate
perilunate dislocation
articulation with radius and surrounding carpal bones is maintained in lunate dislocation it is not
stage 1 of perilunate instability
scapho-lunate dissociation > widening of scaphoid and lunate due to scapholunate ligament disruption
stage 2 of perilunate instability
lunocapitate disruption > lunate remains normally aligned with distal radius, remaining carpal bones dislocated
capitate and lunate widening
high association with scaphoid fractures
stage 3 of perilunate instability
lunotriquetral disruption
capitate and lunate not aligned w/ distal radius
lunate triquestral ligament is disrupted
high association with triquetral fractures
stage 4 of perilunate instability
lunate dislocation with ‘tipped teacup’ sign
dorsal radiolunate ligament injury
non-operative management of perilunate instability
closed reduction and casting has no indication and often poor outcomes compared to non-operative management, high risk of recurrent dislocation
operative management of acute injury (perilunate instability)
open reduction, ligament repair and fixation
good functional outcomes
operative management of non- acute injury (perilunate instability)
proximal row carpectomy
converts wrist into simple hinge type
operative management of chronic injury (perilunate instability)
reduction of pain especially if degenerative changes
presentation of pelvic fracture
usually a result of high energy trauma, patients can become very unstable - lot of visceral organs and vasculature are adherent to the pelvis
examination for pelvic fracture
ABCDE approach - dont forget perineum/urethral opening
digitate - PV or PR exams, check for visceral damage or bleeding
investigations for pelvic fracture
plain radiographs
urethrogram
CT +/- angiography
classification of pelvic fracture
lateral compression
anterior-posterior compression
vertical shear
management of pelvic fracture
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
principle of of surgery on pelvic fracture
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
overview of proximal femur (NOF) fracture
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
proximal femur fracture presents as?
often minor fall
may report groin, thigh or buttock pain
ask about preceding symptoms e.g. MI, TIA/stroke, seizure
investigations for proximal femur fracture
plain radiographs
CT if not identified but high suspicion
initial ED management of NOF fracture
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
proximal femur fracture classification
intracapsular: subcapital, transcervical, basicervical
extracapsular: intertrochanteric, subtrochanteric, reverse oblique
proximal femur fracture management (intracapsular)
total hip arthroplasty
hemiarthroplasty
cannulated screws
proximal femur fracture management (extracapsular)
DHS
IM nail
total hip replacement for NOF fracture
mobile with <1 walking stick outdoors
no cognitive impairment
medically suitable for procedure and anaesthetic
hemiarthroplasty for NOF fracture
mobile with >1 walking stick outdoors
reduced AMTS
comorbidities or reduced baseline not benefiting from THR
cannulated screws for NOF fracture
undisplaced fractures where vessels unlikely to be disrupted
young patients
compliant w/ non-weightbearing while fracture heals
DHS for NOF fracture
for 2/3/4 part intertrochanteric fractures
provides compression as prosthesis is perpendicular to fracture line
IM nail for NOF fracture
subtrochanteric fracture unstable due to pull of hip girdle
reverse oblique pattern not amenable to DHS as fracture line not perpendicular
post-operative management of proximal femur fracture
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
overview of femoral shaft fracture
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
femoral shaft fracture management
resus as necessary, hypovolemia not uncommon, traction useful to temporarily reduce pain + bleeding
operative management for femoral shaft fracture
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
insertion point on tibia for ligament
central tibial spine
what can cause tibial plateau fracture?
extreme valgus/varus force or axial loading across the knee
impaction of femoral condyles causing the tibial plateau to depress or split
concomitant ________ or ________ injury is not uncommon
ligamentous or meniscal injury
classification of tibial plateau fracture
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)
non operative management of tibial plateau fracture
only truly undisplaced fractures w/ good joint line congruency assessed on CT or high fidelity imaging
operative management of tibial plateau fracture
restoration of articular surface using plate + screws
bone graft or cement may be necessary to prevent further depression after fixation
ankle joint comprised of?
talus articulating with tibia and fibula
joint stability of the ankle is necessary for function and provided by?
ligaments
bone projections
list ligaments in the ankle
medially: talofibular, calcaneofibular
laterally: deltoid
list bone projections in the ankle
medially: medial malleolus of tibia
laterally: lateral malleolus of fibula
posteriorly: posterior malleolus of tibia
presentation of ankle fracture
extensive soft tissue swelling
inability to bear weight
clinical examination of ankle fracture
identify tenderness over ligament complexes
x ray to ascertain ____ are important to assess stability in ankle fracture
talar shift
ankle fracture classification
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
non-operative management of ankle fracture
non-weightbearing below knee cast for 6-8 weeks > walking boot > PT
weber A
weber B is no evidence of instability)
operative management of ankle fracture
soft tissue dependent, ORIF +/- syndesmosis repair either screw/tightrope technique
weber B unstable
weber C
maisonneuve fracture
spiral fracture of the proximal third of the fibula associated with a tear of the distal tibiofibular syndesmosis
