fractures Flashcards
bones with vulnerable blood supplies where a fracture can lead to AVN, non-union..
scaphoid
femoral head
humeral head
certain foot bones - talus, navicular, 5th metatarsal in foot
main cancers that metastasise to the bone
(PoRTaBLe)
Prostate Renal Thyroid Breast Lung
treatment to reduce fragility fractures
calcium + vit D
biphosphonates (alendronic acid)
- denosumab where bisphosphonates contraindicated/not tolerated
bisphosphonates side effects
- reflux, oesophageal erosion - need to be taken on an empty stomach + sit upright for 30mins
- osteonecrosis of jaw
- osteonecrosis of external auditory canal
- atypical fractures
bisphosphonates MoA
reduce osteoclast activity - preventing reabsorption of bone
methods of stabilising fractures
(stability to allow to heal)
external cast - plaster cast
K wires
intramedullary
early fracture complications
>damage to local tendons, muscles, nerves etc >haemorrhage leading to shock + death >compartment syndrome >fat embolism >venous thromboembolism
fat embolism post fracture
can cause systemic inflammatory response - fat embolism syndrome
presents ysyally 24-72hrs post fracture
pres = stress, petechial rash, cerebral involvement
longer-term fracture complications
>delayed union > malunion - pain,stiffness, loss of function, deformity >non-union >AVN > infection (osteomyelitis) >joint instability/stiffness >contractures (tightening of soft tissue) >arthritis >complex regional pain syndrome
reasons why non-union may occur post fracture
poor bloody supply to fracture gap too big systemic disease **smoking** steroids NSAIDs bisphosphonates
neurapraxia
occurs when the nerve has a temporary conduction defect from compression or stretch + resolve over time with full recovery
(can take up to 28days)
axonotmesis
nerve injury sustained due to compression or stretch from a higher degree of force with death of the long nerve cell axons distal to the point of injury
neurotmesis
complete transection of a nerve requiring surgical repair for any chance of recovery of function
prognosis in Salter-Harris fractures
fracture prognosis is poorer as the classification progresses
(children’s fractures around the physis aka growth plate)
chronic regional pain syndrome presentation
constant burning or throbbing sensitivity to stimuli not normally painful swelling, stiffness painful/restricted movement skin colour changes
metatarsal stress fractures
commonest - 2nd or 3rd metatarsal
runners, soldiers on prolonged marches, dancers, long walks in people not used to them
xrays may not demonstrate until 3 weeks
when is surgery offered for hallux valgus?
for pain + restriction of function
- cosmetic reasons won’t be happy
This 50 year old lady complains of left 1st MTPJ pain on walking, particularly when wearing thin, non-supportive shoes. She cannot wear high heels because of the pain and stiffness in the joint. On examination, active and passive range of movement of the joint is reduced (and quite tender at the end range of movement) and grind test is positive.
hallux rigidus
classification used in ankle fractures
Weber classification
Type A - below ankle joint, syndesmosis intact
Type B - at level of joint, syndesmosis intact or partially torn
Type C - above joint, syndesmosis disrupted
management of ankle fractures
assessmnet of stability determines posible management - if fracture disrupts syndesmosis, surgery is more likely
conservative = cast or moon boot surgical = open reduction internal fixation (ORIF)
what are people with tibial shaft fractures more at risk of?
compartment syndrome - particularly anterior compartment
–> open fractures common, v slow healing
management of tibial shaft fractures
conservative (up to 50% displacement + 5degrees angulation)
= above knee cast
surgical = IM nail, ORIF
associated risk in tibial plateau fractures
neurovascular injury - popliteal structures, common peroneal nerve
compartment syndrome
often associated soft tissue injuries eg ACL
management of tibial plateau fractures
conservative = above knee cast
surgical (more common, high energy injury)
- ORIF
- external fixator
- delayed total knee replacement
causes of femoral shaft fractures
high energy injury - major trauma, pobs with other injuries
metastatic disease, Paget’s, long term bisphophonate use for osteoporsis
substantial blood loss can occur in displaced fractures - up to 1.5L
management of femoral shaft fractures
initially = Thomas splint - temp stabilisation, minimises blood loss + fat embolism
definitive = IM nail, plate fixation or ORIF
most common pelvic fragility fracture in elderly?
pubic ramus
Low energy pubic rami fractures in elderly tend to be minimally displaced lateral compression injuries + settle with conservative management over time
risk in pelvic fractures
often leads to significant intra-abdominal bleeding
- emboli
- shock + death
3 main patterns of pelvic fractures
- Lateral compression - side impact (RTA)
- Anteroposterior compression - torn pubic symphysis, open book pelvic fracture
- Vertical shear force - fall from height + rapid deceleration, sacral + lumbosacral roots at high risk of injury
mandatory investigation in pelvic fractures
PR exam
assess sacral nerve root function + look for blood
blood = open fracture
pelvic fracture management
initial = pelvic binder
conservative = rest, physio, analgesia, occu
surgical = open reduction internal fixation (ORIF)
cause + presentation of scaphoid fractures
caused by FOOSH
tenderness in anatomical snuffbox
pain on compressing thumb metacarpal
treatment + complication of scaphoid fractures
plaster cast 6-12weeks
avascular necrosis*
non-union
types of distal radius fractures
Colles fracture - FOOSH, dinner fork deformity
Smith fracture - fall onto back of flexed wrist, ORIF
Barton fracture - intra-articular involvinf dorsal or volar rim, ORIF
Colles fractures
FOOSH, dinner fork deformity
distal radius - causes distal portion to displace posteriorly (upwards)
complications of Colles fractures
ulnar styloid fracture
median nerve compression from stretch of nerve
bleed into carpal tunnel
long term = rupture of extensor pollicis longus tendon - requires tendon transfer
management of Colles fracture
(distal radius)
cast, splint
ORIF, manipulation under anesthesia (MUA), K wires
external fixation if in lots of bits (comminuted)
why is the forearm prone to multiple injuries?
radius + ulnar connected with proximal + distal radioulnar joints = forms ring
fracture of one bone - usually injury in another
cause + treatment of isolated ulnar fractures (nightstick)
result from direct blow - classic defensive fracture (nightstick)
conservative or ORIF
*make sure no dislocation of radial head at elbow (Monteggia)
what is a Monteggia injury?
fracture of ulnar shaft + dislocation of radial head at elbow
management = ORIF
what is a Galeazzi injury?
fracture of distal part of radius + dislocation of distal radioulnar joint
(ulnar intact)
management = ORIF
cause + presentation of olecranon fracture
fall onto elbow
insertion of triceps tendon - extension of elbow
management of olecranon fracture
conservative = cast
surgical = tension band wiring, ORIF, plate fixation
causes of humeral shaft fracture
fall resulting in transverse or comminuted
direct trauma resulting in oblique or spiral
biggest risk in humeral shaft fractures
neurovascular injury - esp RADIAL nerve (sits in humeral groove)
presentation = wrist drop + loss of sensation in first dorsal web space
management of humeral shaft fractures
high union rate (90%) - most conservative
conserv = humeral brace / U-slab cast
surgical = IM nail, ORIF plate fixation
what nerves are at risk of damage in shaft vs proximal humeral fractures?
shaft = radial (humeral groove) - wrist drop
proximal = axillary - regimental patch test
cause + management of proximal humeral head fractures
common
low energy or osteoporotic bone
conservative = collar + cuff surgical = ORIF, replacement
**damage to axillary nerve - regimental patch test
malunion of a fracture of the distal radius may result in impaired grip strength, is this impairment associated with loss of extension or flexion at the wrist joint post injury?
wrist extension is associated with poor grip strength ost distal radial fracture
which types of salter-harris fractures are intra-articular?
III + IV - fracture splits the physis
which nerve is most at risk in a Colles fracture?
median nerve
Fractures have the potential to remodel over time. That is that they change shape with ‘bone laid down along areas of stress’.
What is the eponymous name given the the physics principle being described and applied here?
Wolff’s law
