Fracture Management Flashcards
What fractures common in contact sports
Head and neck injuries
Fractures in C spine- can have bleed in brain
Vital signs and levels of consciousness for ATLS Prehospital assessment- Step 1
Glasgow Coma Scale score <13 (or equal)
Systolic BP <90mmHg
Resp Rate <10 or 29 breaths/min (<20 in infants <1 year)
any of these yes –> trauma centre
ATLS Prehosp assessment Step 2 if vitals okay
If any of these yes, take to trauma centre:
- penetrating injuries to head, neck, torso and extremities proximal to elbow + knee
- Chest wall instability or deformity e.g. flail chest
- Two or more proximal long bone fractures
- Crushed, degloved, mangled, or pulseless extremity
- Amputation proximal to wrist or ankle
- Pelvic fractures
- Open or depressed skull fracture
- Paralysis
Flail chest
Multiple ribs broken together and they can move independently of rest of torso- don’t ventilate effectively
ATLS Prehosp assessment if Step 2 okay
If any of these, trauma centre:
- Falls- adults >20 feet/6m, children >10 feet/3m
- High risk motor vehicle crash
- Auto vs pedestrian/bicyclist thrown, run over, or with significant impact
- motorcycle crash
ATLS Prehosp assessment special patient considerations
If any below, trauma centre:
- Older adults- risk injury/death increases after 55
- Children
- Anticoagulant use and bleeding disorders
- Burns
- Pregnancy >20 weeks
- EMS provider judgement
20% of patients that have calcaneal fracture have an associated…
Fracture in spine
Fall over 6 metres
Take to trauma centre regardless of anything
Likely to be damage you can’t see
ATLS Principles- Airway and C spine
Make sure C spine isn’t broken- if it is and you move can cause transection of spinal cord
–> immobilise C spine first
Is patient maintaining own airway?
Gumshield? Broken teeth?
ATLS- Breathing
Respiratory rate
Equal chest expansion
ATLS- Circulation
Signs for shock
Pulse
BP
ATLS- Disability
GCS
Pupils
ATLS- Exposure
Look for long bone deformity
Any obvious bleeding
Immobilisation of Upper limb
Broad arm Sling Collar and cuff Humeral brace Back slab Splints Vertura Splint Mallett Splint
Broad arm sling UL
offloads all upper limb so arm doesn’t pull down- good for any collar bone or AC joint injuries, or forearm if heavy if its in a cast
Collar and cuff UL
sling wrapped around neck and wrist- weight of arm pulls down and pulls fractures of humerus down and outs into place
Humeral brace UL
humeral shaft fractures- keeps everything lined up
Back slab UL
half of a plaster – supports joint- not full plaster as allows for inflammation and growth of injury so as to not cut off blood supply
Zimmer splint UL
Keeps finger in safe position o Posi (position of safe immobilisation) or Edinburgh position= wrist extended to 45 degrees, carpa-metacarpal joints at 90 degrees, interphalangeal joint neutral (0 degrees)- at this position collateral ligaments are under maximum tension, are taught- important as means doesn’t go stiff
Stiffness
One of most difficult things to treat
Apart from hand, elbow joint one of most notorious for getting stiff
Don’t want to keep someone with elbow at 90 degrees for more than you have to as otherwise will never straighten arm again
Vertura splint UL
Wrist comfy
Mallett splint UL
mallett injury is where FDP tendon can take small tuft of bone with it- so this keeps it back up in right position
Immobilisation Lower limb
Box splint Cricket pad splint Kendrick splint Backslab Boots/shoe Heal bearing shoe
Box splint LL
Stable lower limb splint
Keeps everything together in right position
Cricket pad splint LL
Keep knee in extension
Good for patella
Kendrick splint LL
Traction splint
Important if have fracture of long bones in leg and want to keep them under tense and traction
Helps stop bleeding
Can lose 4L of blood in femur
Greater trochanter
Insertion for gluteus medius
Weber A ankle injury
Fibular fracture below level of syndosmosis
Combination of ligaments and intra-osseus membrane that keeps tibia and fibula together
Heal bearing shoe
Keeps foot flat throughout gait cycle
During toe off foot will extend in the middle and puts pressure on metatarsals –> this will stop this from happening
Bone Healing pathways
Primary and Secondary pathways
Which pathway used depends on stability of fracture site and location
Strain
The percentage of change in length of the material in relation to original length
Change in length/original length
Stress
Force per unit area
Sheer stress
On joint surfaces, opposing directions to each other
Tensile stress
Pull stuff away
Compressive stress
Push
Yield strength
The lowest stress that produces a permanent deformation in a material
Stability
Ability to maintain its original configuration
Bone Healing strain
<2% change in bone length= Primary
2-10%= Secondary
>10%= Won’t heal
Osteoclasts
Bone cells that break down bone tissue
Osteoblasts
Bone cells that create new bone tissue
Cutting cone
Bone remodelling unit
At the front is osteoclasts, behind it is osteoblasts laying down layers of bone
In middle, Haversian canal
Cortical bone
On outside
Thick and compact
Up and down stress
Travecular bone
Centre
Withstands stress in different irections
Osteonal Remodelling
Primary bone healing
Gap at fracture site must be less than 1mm
Process of fully formed osteons bridging a fracture gap may take months
<2% strain- has to be absolutely stable with almost no movement at fracture site
Secondary bone healing
- Haematoma formation
- Fibrocartilaginous callus formation
- Bony callus formation
- Bone remodelling
2dary bone healing- Step 1
Fracture leads to haematoma formation at fracture site
Up to 1 week from injury
2dary bone healing- Step 2
1 week to 1 month after injury
Strain/movement at the fracture site stimulates multipotent cells in the periosteum to differentiate into osteoprogenitor cells which produce bone without first forming cartilage (external callus)
Bridging callus forms fibrocartilage which become calcified and is then replaced by bone
2dary bone healing- Step 3
1-4 months
Soft calcified chondral callus becomes hard mineralized osteoid callus
At this point, fracture is united, solid and pain free
Primary bone healing overall
No callus Absolute stability No movement Biological process- osteoid cutting cone/haversion Gap <1mm Strain <2%
Secondary bone healing overall
Inflammation phase --> soft callus --> hard callus --> bone remodelling Biological process- callus formation Gap >1mm Strain 2-10% Relative stability required
Fracture fixation Aim
Restoring function
Normal function- normal ROM, pain free, stable
Restoring anatomy
Reduction (length, rotation, angulation)
What happens if don’t fix fracture
Malunion/deformity
Post traumatic arthritis
Intra-articular fractures
Requires absolute stability
Aim is to restore joint anatomy to restore function
Do not want callus formation/post traumatic arthritis (pain free)
Usually fixed with plates and screws
Extra-articular fractures
Requires relative stability
Callus formation will not affect functional outcome
Any modality that will maintain reduction
Plate fixation
Can use plate to bridge fracture, to stop rotation
Intramedullary nailing
Don’t need to open all up- just top
Important to respect soft tissue envelope- e.g. don’t disrupt blood supply
Screw fixation
Use screw to get absolute stability as can compress fracture
Screw converts rotation force into longitudinal force
External fixator
When soft tissue too inflamed to operate yet
K wire fixation
Wire stays until bone heals
Absolute stability methods
Aim- primary bone healing
Plate and screw fixation
Screw fixation alone
Relative stability methods
Aim- secondary bone healing Intramedullary nail K wire fixation Plaster Sling External fixator Plate fixation
Risk of treating a fracture
Pain Infection Bleeding Damage to nerves, tendons, blood vessels, fracture of bones Non-union Mal union Failure of metalwork Stiffness
Non-union
An arrest in the fracture repair process
Non-union types
Septic (secondary to infection)
Hypertrophic (callus but not bridging)
Pseudoarthritis (new joint)
Atrophic (disruption to blood supply)
Collar bones and non-union
o 15% of collar bone fractions go into non-union if conservative treatment done, if do surgery only 5% go into no-union
Failure of metalwork
Whole point is to hope biological process finishes and is done before the metalwork fails
If non-union, metal ends up taking all of force and eventually fails
