Fractures Flashcards
What is a fracture?
- loss of continuity of the cortex of a bone
What is a pathological fracture?
- a fracture through bone weakened by a pre-existing pathological process
What is a simple fracture and what is a comminuted fracture?
- Simple: a bone fractured into two pieces
- Comminuted: a bone in three or more pieces
What is a segmental fracture?
- fractures at two levels of the same bone
What is a closed fracture and what is an open fracture?
- Closed: a fracture with intact skin overlying it
- Open: a fracture with a skin breach over it (formerly known as a compound fracture)
What is an extra-articular fracture and what is an intra-articular fracture?
- Extra-articular: a fracture that leaves the adjacent joint entirely undamaged
- Intra-articular: a fracture that involves a joint
What is an undisplaced fracture and what is a displaced fracture?
- Undisplaced: a fractured bone with its anatomy entirely unchanged
- Displaced: a fracture whose components are no longer in their original anatomical position
(displacement describes the position of the distal fragment in relation to the proximal fragment)
(a displaced fracture may involve translation, angulation, rotation or distraction/compression)
What are the 3 fracture patterns?
- transverse: straight across horizontally
- oblique: diagonal fracture
- spiral: diagonal and around the bone (from a twisting force)
Fracture patterns…
In children, the fracture may occur through the growth plate (physis) and they are graded using the Salter-Harris classification…
SALTR…
- S : Straight across physis
- A : Above physis
- L : Lower / beLow physis
- T : Through physis
- R : Ruined / cRushed physis
Another diagram of Salter-Harris classification…`
What are the clinical features of a fracture, and what should be checked?
- Clinical features: pain, swelling, tenderness and bruising
- Check: skin condition (open or closed), peripheral neurovascular status (weakness/numbness, pulse/capillary refill)
What investigations should be done for suspected fractures?
- X-ray: two view 90 grees to each other (usually AP and lateral)
- (CT scans also useful)
- (MRI useful to assess soft tissue damage)
Bone diagram showing metaphysis, epiphysis, diaphysis, physis…
Bone deformities associated with fractures…
What is the initial management for a fracture?
- ABCDE assessment
- give fluids / oxygen if needed
- control any external bleeding by direct pressure
- open fractures: cover any wounds with sterile dressings, ensure antibiotic cover and tetanus prophylaxis
- immobilise fractured bone: plaster, splint, brace, sling
- analgesia: usually IV opiates
- arrange imaging: x-ray / MRI
What is the definitive management for a fracture?
- Reduction: closed or open (surgical)
- Stabilisation: external splintage or intra-operative fixation (screws, nails, wires, plates, or intramedullary nail for long-bone fractures)
- Rehabilitation: if fracture is stable then mobilise early as possible
Methods of surgical stabilisation of fractures…
What are some immediate complications of fractures?
- Local: displacement of bone can cause skin to tear leading to an open fracture, nerves/blood vessels can be pressed on causing nerve palsies/ischaemia respectively
- General: haemorrhage can be excessive (especially from femoral, pelvis, open, or multiple fractures), hypovolaemic shock may result
What are some early complications of fractures?
- Local: compartment syndrome, infection, complex regional pain syndrome (aetiology not known)
- General: thromboembolism, fat embolism
What is compartment syndrome?
- Emergency in orthopaedics
- results from excessive pressure in a closed fascial muscle compartment (most commonly lower leg and forearm)
- Left untreated can be limb-threatening
- Muscle ischaemia occurs after a few hours, then necrosis can occur if prolonged hypoxia
- Viscous cycle of increased compartmental pressure, tissue hypoxia, tissue oedema, and cellular death
What is a serious complication of compartment syndrome?
- Rhabdomyolysis (muscles break down)
- proteins such as creatine kinase and myoglobin leak into bloodstream
- myoglobin is toxic for kidneys and can cause acute renal failure
What are the clinical features of compartment syndrome?
- Severe pain (increased on passive stretching)
- Late signs: no pulse, paraesthesia
What is the management for compartment syndrome?
- Fasciotomy (all 4 compartments of leg are opened up)
- relieves pressure and reestablishes blood flow
- fascia left open until swelling subsides
What is the prophylaxis for a thromboembolism (DVT)?
- Mechanical: anti-embolism stockings
- Pharmacological: low molecular weight subcutaneous heparin injection
What is a fat embolism and what is the treatment?
- may occur after long-bone fractures (eg. femur)
- occurs due to fat entering the circulation and embolising to the lungs
- (the medullary canal of long bones contains fat)
- can lead to acute adult respiratory distress syndrome (can be fatal)
- Treatment: oxygen and fluids, refer to HDU
What are some late complications of fractures?
- Delayed union/non-union
- Malunion: fracture heals in an abnormal position
- Osteoarthritis: more common after intra-articular fractures
- Stiffness
- Growth disturbance in children
What are the clinical features of a distal radial fracture?
- Colles’: fall on outstretched hand, distal radial fracture with dorsal displacement of the distal fragment
- Smith’s: volar displacement of distal fragment
Colles VS and Smith fracture diagram…
Colles fracture…
What is the management for a distal radial fracture and potential complications of Colles’?
- immobilise with splint and analgesia, physio
- surgical: open reduction and internal fixation with plates / screws
- Colles’: median nerve injury
Garden classification for neck of femur fractures…
- type I and type II are not too bad
- type III and type IV are bad
What are hip fractures broadly divided into?
- intracapsular fractures (or subcapital)
- extracapsular fractures (or intertrochanteric)
Which type of hip fracture is worse and why? (intracapsular vs extracapsular)
- intracapsular is worse
- the fracture line is between the blood supply (femoral artery) and the femoral head, potentially severing the blood supply to the head (retinocular vessels are severed)
- risk of avascular necrosis and nonunion
What is the mortality rate of elderly people with NOFs?
- 30% of elderly people die within a year after a hip fracture
What are the clinical features of a hip fracture (NOF)?
- severe pain around hip/groin, worse with movement
- unable to weight-bear
- leg is shortened and externally rotated
- (all elderly patients with hip pain should be assumed to have a hip fracture until proven otherwise)
What is the management for hip fractures?
- Undisplaced intracapsular (or subcapital) fracture: internal fixation (low chance of disruption to blood supply)
- Displaced intracapsular (or subcapital) fracture: hemiarthroplasty for elderly, total hip replacement in younger/mobile patients
- Extracapsular fractures (or intertrochanteric): internal fixation with dynamic hip screw
What is a hemiarthroplasty?
- femoral head is replaced
- artificial head articulates with the normal acetabulum
What are the clinical features of an ankle fracture and what should be checked?
- pain and swelling around ankle, may be unable to weight-bear, tenderness
- neurovascular status of the foot should be checked
What is a Maisonneuve fracture?
- a high fibular fracture that results in an unstable ankle
Talar shift (ankle fractures)…
- talar shift is suggestive of disruption to the medial ligaments and indicates that fracture is likely to be unstable
What is the management for ankle fractures?
- Stable: external splintage and analgesia
- Unstable: surgical stabilisation
What are the systemic complications that can be associated with bone fractures or damage to associated soft tissues?
- Shock syndrome
- Myoglobinuria (myoglobin in the urine): can occur if there has been significant muscle injury (or rhabdomyolysis)
- Bone marrow embolisms: can travel to lungs
- Fat embolisms: seen in severe multiple fractures, can cause cerebral ischaemia and/or pulmonary insufficiency
What is a Bennett fracture?
- fracture of the base of the thumb (caused by forced abduction injuries)
What is a Boxer’s fracture?
- fracture of the 5th metacarpal
Calcaneal fractures…
- most frequently fractured tarsal bone
- typically occurs after falling form height and landing on heels
- symptoms: heel pain and inability to weight bear
Lisfranc injury of the foot…
- dislocation of the tarsometatarsal joint between the medial cuneiform bone and base of the second metatarsal in the midfoot
What are most foot fractures a result of?
- crush injury
What is a Monteggia fracture?
- involves the proximal third of the ulnar shaft and anterior dislocation of the radial head at the capitellum
What is a Galeazzi fracture?
- involves the distal third of the radial shaft and dislocation at the radioulnar joint
What are the Ottawa ankle rules and why might the rules not be accurate?
Ottawa ankle rules…
- ankle x-ray if: tenderness of lateral or medial malleoli, inability to weight bear more than 4 steps
- foot x-ray if: bone tenderness at 5th metatarsal, bone tenderness at navicular bone, inability to weight bear more than 4 steps
Reasons why might not be accurate…
- if patient is intoxicated or has reduced consciousness
- if patient has other distracting painful injuries
- if patient has reduced sensation in lower limb
Greenstick fractures…
Buckle fracture…
How should most uncomplicated paediatric fractures be managed?
- usually a simple cast and immobilisation
- children’s bones are very good at healing themselves
What are some causes of pathological fractures?
- tumours: primary, secondary (metastatic)
- metabolic: osteoporosis, Paget’s disease
- hyperparathyroidism
Supracondylar fracture…
Tibial plateu fracture…
- commonly occur as a result of high-energy impact
Weber classification of ankle fractures…
- Type A: lateral malleolar fracture below level of syndesmosis, stable fracture, deltoid ligament intact
- Type B: lateral malleolar fracture at level of syndesmosis, may be stable or unstable, deltoid ligament may be torn
- Type C: lateral malleolar fracture above syndesmosis, unstable injury, deltoid ligament injury present, open reduction and internal fixation needed
Patient presents with pain on palpation of the anatomical snuffbox, what is the diagnosis and what is the management?
- scaphoid fracture
- x-ray: repeat x-rays after 10 days
- high risk of avascular necrosis (due to blood supply distally)
