Fractures Flashcards
Describe primary bone healing
Minimal gap, bone able to fill gap. E.g. hairline fracture, fixation with plate & screws
Describe secondary bone healing
Fracture gap fills with granulation tissue, then cartilage (soft callus), then bone (endochondral ossification, hard callus), eg. colles fracture & POP, IM nail, ex-fix
What is the fracture healing process?
Haematoma-soft callus-hard callus-remodelling
What does communition mean in relation to fractures?
Bone breaks down into fragments- high energy impacts (watch soft tissus, compartment syndrome) or poor quality bone
What are some non operative holding management strategies?
Cast (POP, lightweight), functional bracing, traction
What are some internal fixations?
K-wires, cerclage wires, onlay devices-plates, screws, inlay devices- IM (intramedullary) nails
What are some external fixations?
Temporary, definitive. Can be lateral rod only, or ring shaped round limb
What is a possible management strategy for some intra or periarticular fractures?
Replacement
What is the general management if simple minimally displaced extra-articular fracture in acceptable alignment and stable?
Conservative management, splint
What is the general management if position unacceptable of fracture?
Reduction
What is the general management if fracture unstable and patient is fit?
Operative stabilisation
What is the general management if fracture caused by high energy, or substantial soft tissue swelling?
Avoid ORIF, wait until tissues settle, may opt for indirect techniques- nailing, ex-fix
What is the general management if undisplaced intra-articular fractures?
May be stable and treated non-operativey
What is the general management if displaced intra-articular fractures?
Reduction and rigid internal fixation to prevent post trauma OA
What is the general management of peri-articular fractures which risk non-union or AVN?
Joint replacement
What is the general management of open fractures?
ABx, tetanus, early debridement and operative stabilisation
What is the general management compartment syndrome in complicated fracture?
Fasciotomy & operative stabilisation
What is the general management if vascular injury has occurred in complicated fracture?
Reduction, stabilisation and reassess circulation. May need revascularisation procedure (stent etc)
What is the general management of nerve injury in a complicated fracture?
If open > explore, closed > reduce fracture & hold, recheck and observe
Describe a femoral shaft fracture
Usually high energy (unless pathological). Approx 1l blood loss, associated with other injuries, risk fat embolism, ARDS.
How are femoral shaft fractures commonly treated?
Resuscitation, analgesia- femoral nerve block, splintage- Thomas splint. If unstable- IM nailing
Describe the treatment of extra articular distal femur fractures?
Unstable- thomas splint. If not too distal can nail, if distal - plating.
Describe the treatment of intra-articular distal femur fractures?
Anatomical reduction, rigid fixation, plate & screws
Describe proximal tibial fractures
High energy young, low in old usually. Usually valgus stress- lateral tibial plateau fracture with disruption at articular surface.
What temporary treatment may a high energy proximal tibial fracture with substantial soft tissue damage need?
Temporary spanning with ex-fix
How is the personality of a proximal tibial fracture determined?
CT
What is the management of proximal tibial fractures?
Reduction, rigid fixation. Elevation-depressed articular fragments & bone grant. High proportion get post trauma arthritis
Describe fractures of the tibial shaft
Low or high energy. Risk of compartment syndrome. Open fracture common. Internal rotation poorly tolerated. 16 wks time to union, >1yr non-union. Conserative-plaster, operative-IM nailing, plating, ex fix
What is an intra articular distal tibial #?
Pilon #
What are some associated injuries of distal tibial #?
Spine, pelvis, calcaneus
What are the concerns in distal tibial #?
Significant soft tissue injury, surgical emergency > urgent bridging ex-fix.
What is the management of a distal tibial #?
Internal fixation once soft tissues settle
Are isolated distal fibular and minimally displaced medial malleolus # stable or unstable?
Stable- may be treated conservatively
What shift occurs in unstable bimalleolar fractures?
Talar shift
What is 1st degree nerve injury?
Neurapraxia- temporary conduction block/demyelination. Should resolve within 28d
What is 2nd degree nerve injury?
Axonotmesis- nerve cell axon dies distally from point of injury=wallerian degeneration. Structure of nerve (endoneurial tubes) intract, regenerates at 1mm per day
What is 3rd degree nerve injury?
Neurotmesis- nerve transected-rare with # or dislocation. Needs surgery
What are the indications for exploration of nerve injury?
Open #, penetrating injury, neuralgic pain> ongoing compression
What should be done if no function returns after #, indicating nerve injury?
NCS, nerve grafting, tendon transfers
What are some early systemic complications of #?
Hypovolaemia Fat embolism Acute Respiratory Distress Syndrome Systemic Inflammatory Response Syndrome Multi-Organ Dysfunction Syndrome
What are some late local complications of #?
Stiffness, loss of function, “fracture disease” Post-traumatic arthritis Non-union Atrophic non union Hypertrophic non-union Malunion Volkmann’s ischaemic contracture Chronic Regional Pain Syndrome Osteomyelitis Avascular necrosis DVT
What is malunion in fracture healing?
Fracture has healed in a non -anatomic position sufficient to cause symptoms-pain, stiffness, loss of function, deformity
What fractures require XR to confirm union?
Only diaphyseal fractures of major long bones
What are some signs of fracture healing?
Pain improvement, no tenderness, no movement at fracture site, no swelling or oedema
What are some causes of atrophic non-union?
Poor blood supply to fracture site, fracture gap too big and no movement, systemic disease, smoking, medicines e.g. steroinds, NSAIDs, bisphosphonates. Infetion
