Fractures Flashcards
Definition of Fracture
A break in the structural integrity of a bone because it is unable to support the energy placed on it. Average citizen of a developed country will experience 2 in their lifetime
Types of Fracture
Open, if skin is broken, or Closed if skin is not. Complete - transverse( perpendicular forces), oblique(parrallel forces), spiral, longitudinal, comminuted/ segmental (more than 2 pieces), impacted. Incomplete - greenstick, torus (buckling of the cortex), bow, hairline (common in children)
Deformity secondary to fractures
Displacement/apposition, Angulation, Rotation or Shortening
–> consider the direction and degree of change from normal
Fractures are usually described by the relationship of the distal fragment to the proximal
Fracture Healing (Primary)
Occurs when the edges are touching exactly - direct cortical re-establishment without a fracture callus developing
Fracture Healing (Secondary)
i) Haematoma: tissue damage causing bone end death. ii) Inflammation: inflammatory cells invade. iii) Callus(cartilage+osteoid): Form osteoblasts/clasts, (6-12wks). iv) Consolidation: lammellar bone replaces woven bone, v) Remodelling: normal structure restored
Clinical union 3-4 months, remodeling 6-12 months
Diagnosing a Fracture - History - 3,3,1
When, where and how did the injury occur
Was there loss of consciousness?
Site and severity of pain
Neurovascular loss
Diagnosing a Fracture - Examination
ABC and primary survey to exclude life-threatening injury
General secondary survey —> Specific secondary survey
Look, feel and move
Diagnosing a Fracture - Investigations
Radiological –> X-rays (orthogonal), CTs, USSs, MRI
Bloods —> FBC, U+E, LFT, etc,
Poss – radioisotope bone scan
Treatments of fractures (3 ‘R’s)
Reduce, Retain reduction and Rehabilitation
When Reducing a Fracture you must consider?
Is it open or closed?
Does it require analgesia or anaesthesia?
In order to retain the reduction consider?
If Closed: traction or splintage
If open: Intramedullary or extramedullary fixation
Internal or external fixater (Ilizarov/taylor spatial frame)
When planning the rehabilitation consider?
Starts with reassurance of the patient
Require support from physiotherapists and occupational therapists
Requires hard work from the patient
How to classify complications of Fractures
Early and late
Local and general
Early local fracture complications
Fracture - loss of positioning and infection
Soft tissue - infection, wound breakdown & skin loss, peripheral nerve injuries (PNI) and vascular damage, damage to viscera,
Late local complications
Fracture - loss of reduction, delayed union/mal-union/non-union, osteoarthritis, joint stiffness and contracture,
Soft tissues - wound infection or breakdown, PNI and vascular damage
General fracture Complications
CNS:Confusion, CVA or fat embolism (1-2days post injury)
CVS:MI, DVT or PE, hypovolemic shock, RS:Pneumonia
GI:Haemorrhage, ileus, UGS:UTI or retention, Endo:unstable diabetes
Causes of Fractures
Depends on the energy of the event and the strength of the bone (normal or pathological eg osteoporosis)
High energy events - car crashes, or low energy - stress fractures
Greenstick Fractures
A break in young soft bone where there is a bend and partial break in the cortex. a type of incomplete fracture
Spiral Fractures
A fracture where the line of breakage is in a spiral. caused by a torque applied along the long axis of the bone
Avulsion Fractures
Occurs when a piece of bone is pulled away from the main mass of the bone due to physical trauma. This can occur with a ligament due to external force or at the site of a tendon insertion due to powerful muscular contraction
Burst Fractures
A type of traumatic fracture of the vertebra when placed under high energy axial load - this causes its to fracture and burst outwards and this can cause significant damage to surrounding structures
X rays to assess a fracture
Require images in two planes (orthogonal)
If in a limb can also require imaging of the joints above and below
A complicated Fracture
Where there is important soft tissue damage, particularly neurological or vascular
Open or compound fracture
Where there is some communication with the outside usually through a break in the skin - infection is a serious possiblity
Hangman’s Fracture
Fracture of the bilateral pedicle or lamina or the second vertebra - causes immediate death due to transection of the spinal cord
Impacted Fracture
When the bone fragments are forced together by the impact
Usually stable
Stability of Fractures
How likely the fracture is to move and become displaced
Particularly important in the spinal column
Stable ‘#’s: transverse, short oblique
Unstable ‘#’s: spiral, long oblique
Salter-harris classification (Classification of injuries in children involving the growth plates)
I - transverse # through the physis (5%) II - a # through the physis with a piece of proximal bone (metaphysis) (75%). III - as type II but with a piece of distal bone (epiphysis) (8%) IV - a # through all three elements (10%) V - compaction of the physis (~1%) The last 2 as associated with growth deformity
SALTER mnemonic (Imagine the bone as a long bone with a joint and growth plate at the bottom)
S - Straight across A - Above the physis L - Lower than the physis TE - Through Everything R - Rammed
Dislocation
Loss of joint integrity
Subluxation is the partial loss of joint surface integrity
Healing time for a type II salter-harris #?
2-3 weeks
Signs of a Fracture?
Pain and tenderness (increased temp)
Swelling and deformity (haematoma or haemoarthrosis)
Abnormal movement and creptitus, loss of function
Orthopaedic Emergencies (9)
Amputations, Open fractures, Pentrating injures, Major bleeding or vascular injury, pelvic fractures/open book, Major joint dislocations, Compartment sydrome, spinal injury, multiply injured patient
Vascular injury
Clock starts at time of injury –> after 6hrs there is irreversible damage (blood loss–> ischaemia–> compartment syndrome–>tissue necrosis)
Classification of Open fractures
Gustilo classification - 1976 - based on mechanism of injury, severity of bone and soft tissue damage and level of contamination
Type I, II, IIIA/IIIB/IIIC
Gustilo type I
skin wound is <1cm, minimal contamination with a simple fracture Infection risk - 0-4%
Gustilo type II
Skin wound is >1cm with moderate crush damage or moderate comminution or moderate contamination Infection risk - 2-6%
Gustilo type IIIA
Laceration of >5cm with comminution and contamination
Consider delayed primary closure (DPC) or Split thickness skin grafting (STSG) Infection risk - 5-12%
Gustilo type IIIB
Bone is Exposed after debridement and requires local or free flap for coverage - Massive contamination
Infection risk - 16-45%
Gustilo type IIIC
Vascular injury - must repair or amputate the limb
Management of major open fractures
Examine and sterilise –> may have to extend wound and remove dead muscle/bone and foreign material/bacteria
Stabilise and give antibiotics/Tobramycin beads
Signs of compartment syndrome (six ‘P’s)
Pain, Pallor, Paresthesia, Pulselessness, Paralysis, pretty damn cold
Particularly pain which is out of proportion with injury
Most common in arms and legs
Treatment of Compartment syndrome
Fasciotomy when –> worsening clinical picture, when tissue pressure approaches 20-30mmHg below diastolic, signs of significant tissue injury, if there was significant ischaemia (>6hrs) when perfusion was restored
General Management of Fractures
In open #s minimise infection risk
In closed #s reduction (may need manipulation, traction or an open reduction) - depending on site and articular involvement may not want to reduce - Must maintain reduction with fixation
How long does it take for fractures to heal?
Depends on the method of fixation
Long bones - 12wks
Cancellous ends of long bones/short bones 6-8wks
Children 2-3wks
Will heal to the point of being painless in 2-3wks
Sudek’s Atrophy (Reflex sympathetic Dystrophy or Complex regional pain syndrome)
A condition which can occur post traumatic injury in up to 5% of cases where there is sympathetic damage resulting in burning pain, skin changes, excessive perspiration –> this can lead to immbolisation and general atrophy of the body part
Nerve damage during fractures
Distal neurovascular assessment is a crucial part of 2ary survey
In closed fractures nerve injury is usually grade 1 or neuropraxia which will recover on its own - in open fractures nerves may be transected - should always explore and if poss repair
Neuropraxia
Loss of function in peripheral nerves lasting 6-8wks usually due to blockage of nerve conduction for a variety of reasons
Can occur in closed bone fractures
Vascular Injury during fractures
If tissue is still pink with good capillary refill even if pulses are weak or lost they will likely return once fracture is reduced
If tissue is white and do not have good capillary refill then good chance will need vascular repair even once fracture is reduced
Volkmann contracture of the forearm
Occurs when the brachial artery is blocked by supracondylar # or compartment syndrome causing ischaemic necrosis of the flexor muscles with ulnar and median damage and an absent radial pulse — most common in children
Myositis ossificans
The calcification of muscle post traumatic injury - there is a rare autosomal dominant hereditary form
Treatment is usually conservative but surgical intervention may be required
Delayed Union
The bone takes longer to heal than normal but it will occur eventually with or without augmentation
Non union
There is a complete cessation of bone healing which will not improve without an augmentation procedure such as bone grafting
Mal Union
The fracture unites but with the fragments in unacceptable positions leading to deformity
Plaster Sores
A constant diffuse pain under a cast - should not be ignored and any complaint of unrelenting pain or a digging sensation should be examined.
Colle’s Fracture
Fracture of the distal radius with dorsal augulation - fall on the outstretched hand
Smith’s Fracture
Fracture of the distal radius with palmar augulation - fall on the flexed hand
Jones’ Fracture
Fracture of the base of the 5th metatarsal - can be an avulsion fracture due to the pull of the peroneus brevis tendon
Boxer’s Fracture
Fracture of the head of the 5th metacarpal with palmar augulation - most commonly after someone punches a wall or person
Easily missed fractures in children
Buckle # of radius/ulna - heal quickly
Supracondylar # - common
Radial head # - common
Easily missed fractures in adults
Scaphoid # cause pain in anatomical snuffbox - can cause AVN
Posterior dislocation of the shoulder - requires multiple plan view to exclude
Hip #’s –> Can be very subtle and require bone scans to detect, particularly in people with weak bones
Osteomyelitis
infection of the bone, once infected always infected, horrible infection - treat with antibiotics and debridement and may require bone grafting
Bone sites at risk of AVN
Head of femur
Proximal scaphoid
Body of the talus
Grades of Ligament injury
I - few torn fibres but structurally intact
II - Incomplete tear without pathological laxity
III - complete tear causing pathological laxity
Indication for Austin-Moore hemiarthroplasty
High chance of avascular necrosis of femur head, eg intracapsular fracture of NoF
Indication for dynamic hip screw
Intertrochanteric fractures
Indication for cannulated screws
Intracapsular fracture where there is a chance to save the femoral head
Initial management of hip and thigh injuries
Thomas splint
Indication for intramedullary nails
Infratrochanteric femoral fractures (load bearing devices)
