Fractures

Question 1

A child (or adult) presents with a displaced clavicle fracture in the medial third. What is your management?

Answer 1

immediate referral to orthopaedic services

Question 2

A child (or adult) presents with a displaced clavicle fracture in the lateral third. What is your management?

Answer 2

immediate referral to orthopaedic services

Question 3

What is the management of undisplaced clavicle fractures?

Answer 3

broad arm sling

• 2-3 weeks for middle third fractures or until comfortable
• 4 weeks for lateral third fracture or until comfortable

Question 4

Generally, middle third clavicle fractures can be managed conservatively, especially in young children. List three criteria for referring to orthopaedic services (out of a possible 6)

Answer 4

• completedly displaced
• shortening >2cm
• comminution
• open fracture
• pathological fracture
• neurovascular injury

Question 5

What treatment should be given for an undisplaced and non-impacted surgical neck of humerus fracture?

Answer 5

Triangular sling and pendulum exercises in sling when pain subsides

Question 6

What are 3 features of proximal humerus fracture that warrant prompt referral to orthopaedic services? (5 listed)

Answer 6

• Displacement (amount depends on age)
• Impaction
• Shoulder dislocation
• Neurovascular complications
• involving anatomical neck (not surgical neck) - see link
  https: //en.wikipedia.org/wiki/Surgical_neck_of_the_humerus

Question 7

Which type of humeral shaft fracture is suspicious for non-accidental injury in children?

Answer 7

spiral fracture

Question 8

What is the management of humeral shaft fractures?

Answer 8

Collar and cuff sling and non-urgent ortho review unless any red flags for fractures in general present. Traction from the weight of the arm tends to repair angulation and displacement without the need for manipulation. May need reduction in ED if very displaced/angulated.

Question 9

What is the management of an undisplaced supracondylar fracture?

Answer 9

above-elbow backslab in 90 degrees elbow flexion with sling for 3 weeks

Question 10

What is the management of a displaced supracondylar fracture?

Answer 10

Refer for urgent orthopaedic input - especially if fully displaced

Question 11

List two possible major complications of a supracondylar fracture

Answer 11

• vascular injury - check for radial pulse

- nerve damage - check median, ulnar and radial nerve function

Question 12

Do all lateral and medial epicondylar fractures of the elbow need to be referred to orthopaedic services (either urgently or non-urgently)?

Answer 12

Yes, due to high rates of poor outcomes

Question 13

What other injury is commonly associated with medial epicondyle fracture?

Answer 13

elbow dislocation - in 50% of cases

Question 14

What is a Monteggia fracture and how is it managed?

Answer 14

• A fracture of ulnar associated with radial head dislocation
• requires urgent orthopaedic review for reduction

Question 15

Galeazzi fracture-dislocation is a distal radial fracture associated with disruption of which joint (which should always be assessed on imaging if a radial fracture is found)?

Answer 15

distal radio-ulnar joint

Question 16

What is the first-line investigation of a suspected scaphoid fracture?

Answer 16

wrist xray

Question 17

If there is a high clinical suspicion for a scaphoid fracture despite a normal initial xray, what is the preferred second line option for further investigation

Answer 17

MRI of the wrist. CT can be used if MRI unavailable/contraindicated. If neither are available, repeat x-ray in 7-10 days

Question 18

What is the management of a scaphoid fracture?

Answer 18

Spica cast and orthopaedic review within 2 weeks. Urgent review not needed unless open fracture of trans-scaphoid peri-lunate fracture-dislocation

Question 19

What is the management of SUFE?

Answer 19

Non-weight bear and urgent ortho review

Question 20

What is the management of femoral shaft fractures?

Answer 20

Urgent orthopaedic review

Question 21

Which bone is involved in a Toddler’s fracture?

Answer 21

Tibia. It’s an oblique or spiral fracture where the periosteum stays intact

Question 22

Which toe is mostly likely to effect gait if fractured and therefore requires referral to orthopaedic services if fractured?

Answer 22

The big toe

Question 23

Fractures of toes 2 to 5 can require reduction if significantly displaced. Other than this scenario, what is one other situation where fracture requires urgent orthopaedic input?

Answer 23

Open fracture including when nailbed is involved (Seymour fracture)

Question 24

Which type of 5th metatarsal fracture is associated with poorer outcomes and therefore required orthopaedic input?

Answer 24

Jones fracture (distal to avulsion fracture)

Question 25

For the management of a Mallet finger (at the distal phalange), what position should the DIP joint be splinted in?

Answer 25

full extension

Question 26

How long does a Mallet finger need to be splinted for?

Answer 26

6-8 weeks

Question 27

If a mallet finger is diagnosed, what percentage of the joint space can be involved before referral to orthopaedic services is required?

Answer 27

30%

Question 28

What type of splint is required for a displaced/angulated 5th metacarpal fracture?

Answer 28

Ulnar gutter splint

Question 29

What distance between the scaphoid and the lunate is suggestive of a scapholunate injury and therefore warrents hand surgeon review?

Answer 29

> 3mm