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Orthopaedics > Fractures > Flashcards

Fractures Flashcards

1
Q

Definition of Fracture

A

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

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2
Q

Types of Fracture

A

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)

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3
Q

Deformity secondary to fractures

A

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

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4
Q

Fracture Healing (Primary)

A

Occurs when the edges are touching exactly - direct cortical re-establishment without a fracture callus developing

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5
Q

Fracture Healing (Secondary)

A

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

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6
Q

Diagnosing a Fracture - History - 3,3,1

A

When, where and how did the injury occur
Was there loss of consciousness?
Site and severity of pain
Neurovascular loss

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7
Q

Diagnosing a Fracture - Examination

A

ABC and primary survey to exclude life-threatening injury
General secondary survey —> Specific secondary survey
Look, feel and move

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8
Q

Diagnosing a Fracture - Investigations

A

Radiological –> X-rays (orthogonal), CTs, USSs, MRI
Bloods —> FBC, U+E, LFT, etc,
Poss – radioisotope bone scan

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9
Q

Treatments of fractures (3 ‘R’s)

A

Reduce, Retain reduction and Rehabilitation

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10
Q

When Reducing a Fracture you must consider?

A

Is it open or closed?

Does it require analgesia or anaesthesia?

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11
Q

In order to retain the reduction consider?

A

If Closed: traction or splintage
If open: Intramedullary or extramedullary fixation
Internal or external fixater (Ilizarov/taylor spatial frame)

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12
Q

When planning the rehabilitation consider?

A

Starts with reassurance of the patient
Require support from physiotherapists and occupational therapists
Requires hard work from the patient

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13
Q

How to classify complications of Fractures

A

Early and late

Local and general

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14
Q

Early local fracture complications

A

Fracture - loss of positioning and infection
Soft tissue - infection, wound breakdown & skin loss, peripheral nerve injuries (PNI) and vascular damage, damage to viscera,

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15
Q

Late local complications

A

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

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16
Q

General fracture Complications

A

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

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17
Q

Causes of Fractures

A

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

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18
Q

Greenstick Fractures

A

A break in young soft bone where there is a bend and partial break in the cortex. a type of incomplete fracture

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19
Q

Spiral Fractures

A

A fracture where the line of breakage is in a spiral. caused by a torque applied along the long axis of the bone

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20
Q

Avulsion Fractures

A

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

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21
Q

Burst Fractures

A

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

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22
Q

X rays to assess a fracture

A

Require images in two planes (orthogonal)

If in a limb can also require imaging of the joints above and below

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23
Q

A complicated Fracture

A

Where there is important soft tissue damage, particularly neurological or vascular

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24
Q

Open or compound fracture

A

Where there is some communication with the outside usually through a break in the skin - infection is a serious possiblity

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25
Q

Hangman’s Fracture

A

Fracture of the bilateral pedicle or lamina or the second vertebra - causes immediate death due to transection of the spinal cord

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26
Q

Impacted Fracture

A

When the bone fragments are forced together by the impact

Usually stable

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27
Q

Stability of Fractures

A

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

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28
Q

Salter-harris classification (Classification of injuries in children involving the growth plates)

A

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

29
Q

SALTER mnemonic (Imagine the bone as a long bone with a joint and growth plate at the bottom)

A 
S - Straight across 
A - Above the physis
L - Lower than the physis
TE - Through Everything  
R - Rammed
30
Q

Dislocation

A

Loss of joint integrity

Subluxation is the partial loss of joint surface integrity

31
Q

Healing time for a type II salter-harris #?

A

2-3 weeks

32
Q

Signs of a Fracture?

A

Pain and tenderness (increased temp)
Swelling and deformity (haematoma or haemoarthrosis)
Abnormal movement and creptitus, loss of function

33
Q

Orthopaedic Emergencies (9)

A

Amputations, Open fractures, Pentrating injures, Major bleeding or vascular injury, pelvic fractures/open book, Major joint dislocations, Compartment sydrome, spinal injury, multiply injured patient

34
Q

Vascular injury

A

Clock starts at time of injury –> after 6hrs there is irreversible damage (blood loss–> ischaemia–> compartment syndrome–>tissue necrosis)

35
Q

Classification of Open fractures

A

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

36
Q

Gustilo type I

A

skin wound is <1cm, minimal contamination with a simple fracture Infection risk - 0-4%

37
Q

Gustilo type II

A

Skin wound is >1cm with moderate crush damage or moderate comminution or moderate contamination Infection risk - 2-6%

38
Q

Gustilo type IIIA

A

Laceration of >5cm with comminution and contamination

Consider delayed primary closure (DPC) or Split thickness skin grafting (STSG) Infection risk - 5-12%

39
Q

Gustilo type IIIB

A

Bone is Exposed after debridement and requires local or free flap for coverage - Massive contamination
Infection risk - 16-45%

40
Q

Gustilo type IIIC

A

Vascular injury - must repair or amputate the limb

41
Q

Management of major open fractures

A

Examine and sterilise –> may have to extend wound and remove dead muscle/bone and foreign material/bacteria
Stabilise and give antibiotics/Tobramycin beads

42
Q

Signs of compartment syndrome (six ‘P’s)

A

Pain, Pallor, Paresthesia, Pulselessness, Paralysis, pretty damn cold
Particularly pain which is out of proportion with injury
Most common in arms and legs

43
Q

Treatment of Compartment syndrome

A

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

44
Q

General Management of Fractures

A

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

45
Q

How long does it take for fractures to heal?

A

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

46
Q

Sudek’s Atrophy (Reflex sympathetic Dystrophy or Complex regional pain syndrome)

A

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

47
Q

Nerve damage during fractures

A

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

48
Q

Neuropraxia

A

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

49
Q

Vascular Injury during fractures

A

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

50
Q

Volkmann contracture of the forearm

A

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

51
Q

Myositis ossificans

A

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

52
Q

Delayed Union

A

The bone takes longer to heal than normal but it will occur eventually with or without augmentation

53
Q

Non union

A

There is a complete cessation of bone healing which will not improve without an augmentation procedure such as bone grafting

54
Q

Mal Union

A

The fracture unites but with the fragments in unacceptable positions leading to deformity

55
Q

Plaster Sores

A

A constant diffuse pain under a cast - should not be ignored and any complaint of unrelenting pain or a digging sensation should be examined.

56
Q

Colle’s Fracture

A

Fracture of the distal radius with dorsal augulation - fall on the outstretched hand

57
Q

Smith’s Fracture

A

Fracture of the distal radius with palmar augulation - fall on the flexed hand

58
Q

Jones’ Fracture

A

Fracture of the base of the 5th metatarsal - can be an avulsion fracture due to the pull of the peroneus brevis tendon

59
Q

Boxer’s Fracture

A

Fracture of the head of the 5th metacarpal with palmar augulation - most commonly after someone punches a wall or person

60
Q

Easily missed fractures in children

A

Buckle # of radius/ulna - heal quickly
Supracondylar # - common
Radial head # - common

61
Q

Easily missed fractures in adults

A

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

62
Q

Osteomyelitis

A

infection of the bone, once infected always infected, horrible infection - treat with antibiotics and debridement and may require bone grafting

63
Q

Bone sites at risk of AVN

A

Head of femur
Proximal scaphoid
Body of the talus

64
Q

Grades of Ligament injury

A

I - few torn fibres but structurally intact
II - Incomplete tear without pathological laxity
III - complete tear causing pathological laxity

65
Q

Indication for Austin-Moore hemiarthroplasty

A

High chance of avascular necrosis of femur head, eg intracapsular fracture of NoF

66
Q

Indication for dynamic hip screw

A

Intertrochanteric fractures

67
Q

Indication for cannulated screws

A

Intracapsular fracture where there is a chance to save the femoral head

68
Q

Initial management of hip and thigh injuries

A

Thomas splint

69
Q

Indication for intramedullary nails

A

Infratrochanteric femoral fractures (load bearing devices)

Orthopaedics (9 decks)

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