Fracture History, Examination, Management Flashcards
PC History
-key questions
Name, DOB, handedness, job/hobbies What - MOI, force When - time since injury Where - outside (tetanus risk?) Why - is injury secondary
Injury details Joint/bone/soft tissue -pain -stiff -swell -movement restriction -weight bearing
Mechanical symptoms
-locking <=> giving way
Neurological symptoms
-weakness, numbness, tingling
Systems review
PMHx, DHx
SHx
Systems review - explore possible causes of injury
Systemic - fever, fatigue, nightsweats, weight loss
CV - palpitations, SOB, cough,
GI/GU - bowels and bladder, abdo pain, N+V
Neuro - memory, speech, headaches, vision, hearing, dizzy, swallow
PMHx - AC/AP, IC, DM, tetanus status => affects healing
Increased falls risk - epilepsy, PD, dementia, alcohol
DHx - AC/AP, IC, NSAIDs allergies
SHx Living -who's at home? social network? -dependents? carers? -ability to do ADLs
Occupation
- work? hobbies?
- impact of injury
- getting to work? driving?
Substances
-alcohol, smoking, recdrugs => slow healing, infection risk
Travel
-exposures
Examination
Examination of bones
-top to toe if other injuries possible for swelling, tenderness, low ROI
Limb
- fracture - open vs closed
- limb NVS - temp, pulses, CRT, sensation, motor
Skin
- wound - open vs closed
- surrounding area - cellulitis, ulcer
Complications - compartment syndrome, infection
Imaging you would ask for and why
Xray - AP, lateral of injury, joint above and below WITH A FOCUS ON THE INJURY SITE
CT - complex fractures, polytrauma involving head, CS, CAP
CT angio - vascular involvement
MRI - soft tissue, SC
US - soft tissues, tendons, ligaments, foreign bodies, Doppler
Bloods - INR, G&S
- FBC, CRP - infection?
- INR, G&S - potential surgery?
- U&E, Ca, VitD, bone profile, PTH?
- glucose - DM?
Bedside
- urinedip
- swab open wounds - culture
Summarising findings
-mnemonic
SOD Site -bone -intraarticular/extraarticular -position - proximal/middle/distal
Obliquity
- complete vs incomplete
- direction - transverse, oblique, spiral
- skin penetration - open, closed
- condition - comminuted, segmental, impacted
Displacement
- translation
- angulation
- rotation
- length changes
Complications
- open wound
- neurovascular compromise => compartment syndrome
- infection
Management - 4Rs
-1st 2 Rs
when would you do what?
Resus
- ATLS in life threatening wounds
- CSpine restriction? Other injuries?
Reduce if displaced - when to do what
Open reduction - neurovascular damage, IA
Closed manipulation - EA
Management - 4Rs
-3rd R - methods and when to use?
Retain - maintain reduced position while callous forms in 6wks
Conservative - stabilise fractures if there is a delay before reduction/fixation
- cast - circumferential restrictor
- splint - noncircumferential restrictor with backslab
- brace - allows continued function
- sustained traction - collar and cuff, skin traction
Acute fracture - splint, backslab to accommodate swelling
1wk post injury - full circumferential for increased restriction
Management - 4Rs
-4th R - what may be done
Other aspects to management to consider
Rehabilitate - physio to regain function
Weight bearing status of lower limb
-non weight bearing => partial => full weight bearing
Swelling - rest, ice, elevation Smoking cessation - delays healing Analgesia - NO NSAIDs ABx prophylaxis for open fractures VTE prophylaxis IP OP if -not fully weightbearing/lower limb cast -TKR, THR Investigate cause of fracture
Complications
- immediate
- early
- later
- avascular necrosis risk
Immediate
- bleeds
- neurovascular damage
- fat emboli
Early
- wound infection
- loss of fixation
- compartment syndrome
Late
- malunion/nonunion/delayed union
- OA
Avascular necrosis risk
- head of femur
- waist of scaphoid
- neck of talus
Timings for healing
Callous - 6wks => temp fixation removed
Full healing - 12wks
LL heal 2x as slow as UL
When to
- externally fixate
- internally fixate
Ext fixation
- contaminated open wounds
- severe open fractures
- severe soft tissue injury
Internal fixation
- comminuted/displaced fractures
- IA fractures
Methods of IF
Intramedullary
-nails - long bones
-kwires - hold fragments together
Extramedullary
-plates, screws - bridge fractures, support sides
