Fracture management Flashcards
What is a fracture?
A break in the continuity of a bone
It should be thought of as a soft tissue injury around a broken bone since often more problems can arise from the soft tissue damage than from the fracture itself
What is an open fracture?
A fracture where the surface wound communicates with the fracture and there is thus potential for contamination through the wound
What is a transverse fracture?
A fracture in which the line of break forms a right angle with the axis of the bone. It is usually the result of a sharp, direct blow or may be a stress fracture caused, for example, by prolonged running.
What is an oblique fracture?
a fracture that is diagonal to a bone’s long axis.
What is a spiral fracture?
a fracture which occurs when a rotating force is applied along the axis of a bone. Spiral fractures often occur when the body is in motion while one extremity is planted.
What is a comminuted fracture fracture?
Also called multi fragmentary- bone injury that results in more than two separate bone fragments
What is a crush/compression fracture?
Occurs when cancellous/trabecular bone is crumpled such as in the calcaneum after a fall from a height or in the vertebral bodies, especially in the presence of osteoporosis
What is a stress fracture?
Also known as a hairline fracture, is a fatigue-induced fracture of the bone caused by repeated stress over time. Instead of resulting from a single severe impact, stress fractures are the result of accumulated trauma from repeated submaximal loading, such as running or jumping. Because of this mechanism, stress fractures are common overuse injuries in athletes
What is a greenstick fracture?
Seen in children whose bones are softer and more pliable and therefore tend to bend rather than break. Thus the cortex on one side breaks and there is a transverse fracture of the which extends into the mid portion of the bone but does not disrupt the opposite cortex. (imagine bending a young green twig).
What is an avulsion fracture?
An injury to the bone in a location where a tendon or ligament attaches to the bone. When an avulsion fracture occurs, the tendon or ligament pulls off a piece of the bone.
What is a butterfly fracture?
A specific type of comminuted fracture in which the centre fragment contained by two cracks forms a triangle.
What is a pathological fracture?
Fractures occurring in a bone that has already been weakened by disease and thus may occur under normal physiological stresses
What might cause pathological fractures?
Congenital Tumour Infection Endocrine Metabolic- osteoporosis
What is the most common cause of pathological fracture?
Osteoporosis
Where are the most common sites for an osteoporotic fracture?
Spine
Femoral neck
What is a Colles’ fracture?
A transverse fracture of the distal radius with dorsal displacement and shortening of the wrist. Often accompanied by fracture of the ulcer styloid
What causes displacement when a bone breaks?
The force of the injury
Gravity
The pull of muscles attached to the fragments
What are the different types of displacement?
Impaction
Angulation
Rotation
What is impaction?
The fragments of bone are driven towards one another causing shortening
What is angulation?
One fragment is angulated in relation to the other which, if left alone, may lead to deformity of the limb. It is described in degrees
How can you tell on an X-ray that there has been rotation?
There is a mismatch between the widths of the proximal and distal fragments
What is subluxation?
Partial loss of contact between joint surfaces i.e. partial dislocation
What are the 5 stages of fracture healing?
- There is bleeding into the fracture
- An inflammatory reaction is set up
- The cells proliferate and early bone and cartilage is formed (soft callus)
- This then consolidates as woven bone is transformed into stronger lamella bone
- The bone then remodels to the normal stresses it is placed under and over a period of months to years the bone returns to its normal shape
What factors promote fracture healing?
Good blood supply
Loading and micro motion (e.g. gentle weight baring exercises)
Nutritional status, Vit. D (absence of osteoporosis)
Local growth hormones (e.g. bone morphogenic protein- BMP)
What factors impair fracture healing?
DM
Corticosteroids
Smoking
Radiotherapy
Distraction of a fracture (bones either side of the fracture are pulled in opposite directions by muscles
NSAIDS (not necessarily avoided during fracture healing but monitored)
What are the two mechanisms of bone healing?
- Callus formation- occurs if there is movement at the fracture site e.g. in a cast
- Primary bone healing: if the fracture is held rigidly stiff as in rigid internal fixation, there is primary bone healing without callus formation
How long does a lower limb fracture in an adult take to heal?
Approx. 12 weeks
How long does an upper limb fracture in a child take to heal?
Approx. 3 weeks
How long does an ankle fracture in an adult take to heal?
Approx 6 weeks
How long does a lower limb high energy fracture take to heal?
Approx 24 weeks
What are the 2 main rules to remember when taking an X-ray of a suspected fracture?
- X-rays must be orthogonal i.e. there should always be two views taken at 90° to each other (usually an AP and a lateral X-ray)
- X-rays should include the joint above and the joint below the fracture as involvement of either joint will affect severity and management
What is indicated by the words ‘red-dot’ on the film?
An informal way of a radiographer indicating that they think there is an abnormality
What are the 5 steps in describing an X-ray?
- Date, patient details, angle
- Anatomy of the fracture (name the bone; name the part of the bone e.g. upper third, epiphysis etc; intra-articular or extra-articular; immature vs immature skeleton)
- Pattern of the fracture (transverse, oblique, spiral)
- Displacement
- Specialist terms e.g. comminuted, greenstick, butterfly, fracture dislocation
Where is the epiphysis?
Bone distal to the growth plate
What is the physis?
The growth plate
What is the diaphysis?
The shaft of the bone
What is the metaphysis?
The bone directly proximal to the growth plate
What are the 4 key principles of fracture management?
- Resusitation (ATLS)
- Reduction
- Stabilisation
- Rehabilitation
What three X-rays are performed in any major trauma as part of the ATLS primary series?
C-spine
Chest X-ray
Pelvic X-ray
How is an open fracture dealt with?
- Urgent booking for theatre (within 6 hours)
- Examine- size of wound; is bone exposed; evidence of degloving; neurovascular status
- Pain killers
- Remove any gross contamination from the wound
- Broad spectrum antibiotics
- Tetanus status- if the patient has not had a booster in the last 10 years give anti-tetanus antibodies
- Photograph the fracture
- Cover the wound with a betadine soaked dressing
What are the different types of reduction?
Closed: gentle manipulation of the fracture without opening the skin
Open: surgically expose the fracture to allow manipulation of fragments
Traction: use of skin/skeletal traction to pull the limb via a pulley system in the direction of a weight applied at the end of the bed
What are the different methods of stabilisation?
- Non-rigid methods of support e.g. sling/brace
- Plaster fixation
- Functional bracing
- Continuous traction
- External fixation
- Internal fixation
What is the most common method of plaster fixation?
Use of plaster of Paris
Why is a back-slab often used?
Due to risk of compartment syndrome, during the first 24-48 hours after a fracture a back slab (half a cast) is usually applied, This allows for accommodation of any early swelling and can be completed by application of a further few layers of plaster after a few days.
What is functional bracing?
joints are left free to move but The shafts of the bone are supported in cast segments usually joined by hinges to allow movement only in one plane. This is most widely used for femoral or tibial fractures. Usually, wait for the fracture to being to unite before functional bracing is used e.g. in lower limb fractures a plaster cast is used for 6 weeks and then converted to a functional brace
What is the major risk of external fixation?
Pin site infection (can lead to deep infection e.g. osteomyelitis)
What is ORIF?
Open reduction internal fixation
What factors might influence how a fracture should be managed?
The nature of the accident Complexity of the fracture Associated injuries Age, general health and personal preference of patient Facilities available Skill of the surgeon
What presentations might raise suspicion about non-accidental injury in children?
- Multiple fractures of different ages (i.e. has sustained fractures on multiple occasions but only just presented)
- Fractures in non-ambulatory children
- Inconsistent history
- Delayed presentation
- Recurrent presentation (esp. at different hospitals)
