Fractures

Question 1

Wrist fractures to know

Answer 1

Colle’s fracture

Scaphoid fracture

Question 2

What is Colle’s fracture?

Answer 2

Fracture of the distal radius causing posterior displacement of the distal portion

Dinner fork deformity

Usually a result of fall onto outstretched hand

Question 3

What are signs of a scaphoid fracture? What is the possible complication of a fracture here?

Answer 3

Tenderness in the anatomical snuffbox

Fracture can lead to avascular necrosis due to the retrograde blood supply to the scaphoid

Question 4

What are some fracture sites at risk of avascular necrosis?

Answer 4

Femoral head

Scaphoid

Humeral head

talus, navicular and fifth metatarsal in the foot

Question 5

What can be used to classify ankle fractures?

Answer 5

Weber classification can be used to describe fractures of the lateral malleolus (distal fibula).

Question 6

What is the importance of the tibiofibular syndesmosis in the ankle?

Answer 6

It is between the distal tibia and fibula

It is very important for ankle stability and function

If a fracture disrupts this syndesmosis then surgery is more likely to be required to regain stability/function of the joint

Question 7

Weber classification for ankle fractures

Answer 7

The Weber classification defines fractures of the lateral malleolus as:

Type A – below the ankle joint – will leave the syndesmosis intact
Type B – at the level of the ankle joint – the syndesmosis will be intact or partially torn
Type C – above the ankle joint – the syndesmosis will be disrupted

Question 8

What are the common cancers that metastasise to bone?

Answer 8

Prostate
Renal
Thyroid
Breast
Lung

Question 9

How can risk of fragility fracture be assessed?

Answer 9

Using FRAX tool

Also DEXA scan to measure bone density

Question 10

What do DEXA results mean?

Answer 10

More than -1 = normal bone mineral density

-1 to -2.5 = osteopenia

Less than -2.5 = osteoporosis

Question 11

How do bisphosphonates work?

Answer 11

Bisphosphonates work by interfering with osteoclasts and reducing their activity, preventing the reabsorption of bone.

Question 12

What are some key side effects to remember of bisphosphonates?

Answer 12

Reflux and oesophageal erosions (oral bisphosphonates are taken on an empty stomach sitting upright for 30 minutes before moving or eating to prevent this)

Atypical fractures (e.g. atypical femoral fractures)

Osteonecrosis of the jaw

Osteonecrosis of the external auditory canal

Question 13

What is an alternative to bisphosphonates where these are contraindicated, not tolerated or not effective?

Answer 13

Denosumab is a monoclonal antibody that works by blocking the activity of osteoclasts

Question 14

What is the investigation of choice in suspected fracture?

Answer 14

X-ray in two planes

Question 15

Principles of management of fractures

Answer 15

Reduction of the fracture (closed or open) - to realign fracture

Casts or intramedullary nails/screws to provide stability and facilitate healing

Analgesia

Follow up appointment in fracture clinic if sent home

Complex fractures and those requiring surgery - review by orthopaedics team
- NBM if operation needed

Question 16

Complications of fractures

Answer 16

Early:

• Damage to local structures e.g. tendons/nerves
• Haemorrhage
• Compartment syndrome
• Fat embolism
• VTE due to immobility

Later (long-term):

• Delayed union or non-union
• Malunion (misaligned)
• Avascular necrosis
• Infection (osteomyelitis)
• Joint instability/stiffness
• Chronic pain

Question 17

What is fat embolism?

Answer 17

Can occur following the fracture of long bones (e.g., femur)

Fat globules released into circulation after a fracture

These become lodged in blood vessels e.g. pulmonary arteries and cause blood flow obstruction

Typically 24-72h after fracture

Mortality is high and it can lead to multi organ failure

Question 18

What criteria can be used for the diagnosis of fat embolism?

Answer 18

Gurd’s criteria

Major criteria:
Respiratory distress
Petechial rash
Cerebral involvement

Minor criteria include:
Jaundice
Thrombocytopenia
Fever
Tachycardia

Question 19

What can help prevent fat embolism? How is it treated?

Answer 19

Operating early to fix the fracture reduces the risk of fat embolism syndrome.

Management is supportive while the condition improves.