Fracture management

Question 1

What are the fracture types of long bones?

Answer 1

Oblique fracture Fracture lies obliquely to long axis of bone
Comminuted fracture >2 fragments
Segmental fracture More than one fracture along a bone
Transverse fracture Perpendicular to long axis of bone
Spiral fracture Severe oblique fracture with rotation along long axis of bone

Question 2

Describe the Gustilo and Anderson grading system for open and closed injuries

Answer 2

1 Low energy wound <1cm
2 Greater than 1cm wound with moderate soft tissue damage
3 High energy wound > 1cm with extensive soft tissue damage
3 A (sub group of 3) Adequate soft tissue coverage
3 B (sub group of 3) Inadequate soft tissue coverage
3 C (sub group of 3) Associated arterial injury

Question 3

How should an open fracture be managed

Answer 3

Immobilise the fracture and monitor neurovascular status. Manage infection including tetanus prophylaxis and iv broad spectrum antibiotics. Debridement and lavage within 6 hours ideally. External fixation to enable soft tissue healing before further internal fixation considered. Unless internal fixation is necessary for sufficient stability.

Question 4

What are the ottawa ankle rules?

Answer 4

Examination criteria that would warrant an xray in ankle pain: Pain in malleolar zone and unable to weight bear for 4 steps, tenderness over the Medial malleolar zone (tip of the medial malleolus to the lower 6cm of posterior border of distal tibia) and lateral malleolar zone (tip of the lateral malleolus to lower 6 cm of the posterior border of the fibular) .

Question 5

For fibula injuries what is the Weber classification?

Answer 5

Typa A below the syndesmosis
Type B at the level of the tibial plafond and may extend proximally to involve the syndesmosis and Type c is above the syndesmosis which may itself be damaged.
Note also the Maisonneuve fracture - spiral fibular fracture that leads to disruption of the syndesmossi and widening of the ankle joint in which surgery is required.

Question 6

How are ankle fractures managed?

Answer 6

Management
Depends upon stability of ankle joint and patient co-morbidities.
All ankle fractures should be promptly reduced to remove pressure on the overlying skin and subsequent necrosis.
Young patients, with unstable, high velocity or proximal injuries will usually require surgical repair. Often using a compression plate.
Elderly patients, even with potentially unstable injuries usually fare better with attempts at conservative management as their thin bone does not hold metalwork well. Typically a below knee cast including the mid foot.

Question 7

Describe a Galeazzi fracture

Answer 7

Distal radial fracture with an associated dislocation of the distal radioulnar

Question 8

Describe a Monteggia Fracture

Answer 8

Fracture of the proximal ulna with dislocation of the proximal radioulnar joint

Question 9

Describe a Colles fracture

Answer 9

Distal radius with dorsal displacement

Question 10

Describe a Smith’s fracture

Answer 10

distal radius fracture with volar (anterior) displacement

Question 11

Describe a boxer’s fracture

Answer 11

A fracture of the neck of the fourth or fifth metacarpal with volar displacement of the metacarpal head,

Question 12

how would a Galeazzi fracture present?

Answer 12

blow to the wrist with immediate swelling. tender distal radius, difficulty pronating and supinating the wrist. Unable to mae the OK sign. Sensation and pulses in tact with no involvement of elbow and upper limb

Question 13

Proximal humerus fractures

Answer 13

Very common. Usually through the surgical neck. Number of classification systems though for practical purposes describing the number of fracture fragments is probably easier. Some key points:
It is rare to have fractures through the anatomical neck.
Anatomical neck fractures which are displaced by >1cm carry a risk of avascular necrosis to the humeral head.
In children the commonest injury pattern is a greenstick fracture through the surgical neck.
Impacted fractures of the surgical neck are usually managed with a collar and cuff for 3 weeks followed by physiotherapy.
More significant displaced fractures may require open reduction and fixation or use of an intramedullary device.

Question 14

How would a fracture of the radial head present?

Answer 14

FOOSH, swelling over elbow with tenderness over forearm especially lateral side of the elbow and restricted supination/pronation

Question 15

Bartons fracture

Answer 15

both distal radius fracture and radiocarpal dislocation fall onto extended pronated wrist

Question 16

Scaphoid Fracture

Answer 16

Scaphoid fractures are the commonest carpal fractures.
Surface of scaphoid is covered by articular cartilage with small area available for blood vessels (fracture risks blood supply)
Forms floor of anatomical snuffbox
Risk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal 1/3)
The main physical signs are swelling and tenderness in the anatomical snuff box, and pain on wrist movements and on longitudinal compression of the thumb.
Ulnar deviation AP needed for visualization of scaphoid
Immobilization of scaphoid fractures difficult

Question 17

What system is used to classify growth plate fractures in children?

Answer 17

Salter-harris
I Fracture through the physis only (x-ray often normal)
II Fracture through the physis and metaphysis
III Fracture through the physis and epiphyisis to include the joint
IV Fracture involving the physis, metaphysis and epiphysis
V Crush injury involving the physis (x-ray may resemble type I, and appear normal)

Question 18

What system is used to classify supracondylar fractures in children?

Answer 18

Gartland

Question 19

What is a Pott’s fracture?

Answer 19

bimalleolar fracture caused by a combined abduction, external rotation from an eversion force

Question 20

What is a Bennett’s fracture

Answer 20

fracture of the base of the first metacarpal (when punching) usually with dislocation or subluxation of the carpometacarpel joint

Question 21

What is a greenstick fracture?

Answer 21

fracture in children with bend and crack

Question 22

What is a buckle fracture?

Answer 22

fracture in children without complete break compression fracture, stable

Question 23

What is Freibergs disease?

Answer 23

Anterior metatarsalgia affecting the head of the second metarsal - usually pubertal growth spurt due to stress microfractures at the growth plate. Different from a stress fracture in that on x-ray joint space widening, formation of bony spurs, sclerosis and flattening of the metatarsal head