Fractures Flashcards
What is an oblique fracture?
One which occurs diagonally across the bone - in one plane
What is a spiral fracture?
Similar to oblique but occurs in more than one plane- not as simple as cutting a stick down the middle
What is angulation displacement fracture?
One in which the two parts of the bones point at different angles
What is a translation displacement fracture?
Bone parts are pointing in the same direction (same angulation) but one is moved off the exact line of the other - displaced to the side
What is rotation displacement fracture?
One bone segment is rotated away from the other one - same angle and line but two parts don’t line up
What is impaction fracture?
Shortening of the bone without loss of alignment
What is foreshortening fracture?
Shortening of the bone with loss of alignment
When giving a displacement description - which part of the bone is it referring to?
Is it referring to the distal fragment
What is the ‘rule-of-3’s’ for fracture healing?
Closed, paediatric, metaphyseal, upper limb fracture is simplest and will heal in 3 weeks
Any complicating factor doubles the healing time. Aka an adult femur diaphyseal fracture will take 24weeks. Adult (6weeks), diaphyseal (12weeks), lower limb(24 weeks).
What is difference between metaphyseal and diaphyseal?
Shaft of the long bone is the diaphysis
Ossified portion of bone in transitional zone between epiphysis (end of bone beyond the growth plate - physis) and diaphysis is the metaphysis
What is fracture disease?
Muscle atrophy, stiff joints and osteoporosis that follows immobilisation for treatment of a fracture
What is open reduction internal fixation?
Open surgery to realign the bone and then fix with screws etc on the inside and reconstruct joint surfaces - allows joint mobility
When is open reduction internal fixation indicated? x5
Intra-articular #s Failed conservative treatment 2 #'s in 1 limb Bilateral identical #s Open #s
What is external fixation and when is it useful?
Using wires into the bone, a bar and clamps to attach it all. Intervention is away from field of injury therefore good if burns, loss of skin or open fracture
How does lag screw fixation work and when is it useful?
Proximal hole is bigger than distal hole in bones and therefore when screw is tightened it pulls the distal segment into the proximal one - good for oblique fractures
What is the Gustilo classification of open fractures?
Type 1: low-energy, wounds 1cm causing moderate soft tissue damage
Type 2: greater than 1cm
Type 3: all high-energy fractures irrespective of wound size
Different subtypes of Type 3 Gustilo classification
IIIa - adequate local soft tissue coverage
IIIb - inadequate local soft tissue coverage
And periosteal stripping
IIIc - arterial injury needing repair
7a’s of emergency management of open fractures
ATLS (ABCDE)
Assessment - NV status, soft tissue injury and photographs of wound
Antisepsis - Take a swab from wound, copious irrigation - cover with large antiseptic dressing
Alignment: align and splint
Anti-tetanus
Antibiotics: 3rd gen cephalosporin eg. ceftrixone + metronidazole
Analgesia
Why is fracture reduction needed?
Return of function
Aids revascularisation
Frees any structures trapped between bone ends
Prevents later degeneration if joints involved
When is traction still used to fix fractures?
In children
In adults it has largely been replaced by fixation (internal and external)
What is traction?
Use of pulleys, weights and and ropes to apply force to a bone to aid mending in the early stages
What is skin traction?
Adhesive strapping to attach load to the limb - weight at end of bed
What is fixed traction?
Eg. using a Thomas splint
Does not require gravity, force is in the splint
What is skeletal traction?
Pin through bone allows bigger forces to be applied
What is balanced traction
Weight of limb is balanced against a load - can enable patient to lift leg out of bed
What is Gallows traction?
Suitable for children up to 2 years - buttocks rise just above bed
What is Salter and Harris classification of epiphyseal injury?
SALTR
I - Slipped - fracture through growth plate not affecting bone - seen in babies and pathological conditions
II - commonest injury with fracture line through growth plate and then up Above the growth plate into metaphysis
III - Lower - displaced fragment with fracture line through growth plate and down into epiphysis
IV - Through/Transverse - through metaphysis down through growth plate and into epiphysis
V - Ruined/Rammed - compression of growth plate
Prognosis with various epiphyseal injuries
Worst prognosis with type V
Good prognosis with 1 and 2
Poor prognosis with 3 and 4 - as proliferative and reserve zones are affected
When will fat embolism occur after a fracture?
Typically arises on day 3-10
How does fat embolism present?
Confusion, dyspnoea, tachycardia, decreased PaO2, fits, coma, petechial rash
What will you see on CXR/CT in fat embolism
Small subpleural nodular opacities - snow storm appearance
Mortality with fat embolism
10-20%
What is crush injury/compartment syndrome?
Dead weight of limb when immobile or in coma may cause crush/compartment - pressure leads to vascular occlusion, leads to hypoxia, necrosis and then increased pressure etc etc
Signs of crush injury/compartment syndrome x5
Redness, mottling, blisters, swelling and pain on passive muscle stretching
Management of crush injury/compartment syndrome
Prompt fasciotomy is limb/life saving
When is non-union said to have occurred?
If no evidence of progression towards healing, clinically or radiologically
What is delayed union?
When fracture does not heal within the time reasonably expected for that fracture
Causes of delayed union?
Fracture in bone that has finished growing
Poor blood supply (lower tibia) or avascular fragment (scaphoid)
Communited/infected fractures
Generalised disease - eg. malignancy, infection
Distraction of bone ends by muscle
What is Complex Regional Pain Syndrome type 1?
Occurs in limb trauma without nerve injury. Its a “complex disorder or pain, sensory abnormalities, abnormal blood flow, sweating and trophic changes in superficial or deep tissues”
Another name for CRPS type 1?
Reflex sympathetic dystrophy/ Sudecks atrophy
What is CRPS type 2?
When nerve lesions are present - causalgia
Presentation of CRPS?
Initial trauma (may be trivial or severe) - followed weeks or months later by pain, allodynia/hyperalgesia, vasomotor instability, abnormal sweating Often burning pain and can affect whole limb
What makes symptoms worse in CRPS?
Exercise
Treatment of CRPS
Encourage optimism
Avoid bad habits leading to immobility
Amitriptyline +/- NSAIDs
What causes clavicle fracture? Most commonly and also historically
Historically - fall onto outstretched hand
Most after a direct blow to the shoulder
Which part of the clavicle is most commonly fractured?
Middle 1/3
Management of clavicle fractures normally?
Broad arm sling with follow up x-rays at 6 weeks to ensure union
What is broad arm sling?
Sling over whole arm and then going around the neck
When might clavicle fractures need more than conservative management
Lateral end fractures if non-union occurs - may need internal fixation
Complications of clavicle fracture x3
Brachial plexus injury
Subclavian vessel injury
Pneumothorax
When do scapula or acromion fractures occur?
They are high energy transfer injuries - therefore usually present with other fractures
Signs of acromioclavicular joint dislocation
Tender prominence over the AC joint
Adduction of arm across the body will increase pain
Management of AC joint dislocation
Sling support and early mobilisation
When do proximal humerus fractures occur?
Typically stable osteoporotic fractures in the elderly
What can proximal humerus fractures result in
May result in 2-4 fragments eg. tuberosities coming off
What typically causes fractures of the humeral shaft?
Fall onto outstretched arm
Management of humeral shaft fracture
90% conservative management - splinting with a humeral brace and gravity traction with ‘collar and cuff’
Immobilise for 8-12 weeks
What is a complication of humeral shaft fracture or surgery to treat it
Radial nerve injury causing wrist drop
What can cause anterior shoulder dislocation
Fall on arm or shoulder
Signs of anterior shoulder dislocation
Loss of shoulder contour (flattening of deltoid) and an anterior bulge from head of humerus
What can be damaged in anterior shoulder dislocation
Axillary nerve (check deltoid patch sensation) and check pulses Can also be damaged during reduction
Treatment of anterior shoulder dislocation x2
1) Simple reduction - longitudinal traction to arm in abduction - gentle pressure to replace head
2) Kocher’s method - Flex elbow to 90 - abduct shoulder, externally rotate shoulder/humerus and adduct arm back across front of body before internally rotating shoulder
Post treatment of shoulder dislocation
Support arm in internal rotation with broad arm sling
How does posterior shoulder dislocation present
Rare and presents with limitation of external rotation
Details of inferior shoulder dislocation x3
Rare
From hyperabduction
High incidence of complication: NV injury, tuberosity avulsion, rotator cuff tear
What is a supracondylar fracture and in whom is it common?
Fracture in shaft of humerus just above the condyles - most common fracture of childhood
Complications of supracondylar fractures? x4
May compromise brachial artery, median, radial or ulnar nerve function
What should you do after supracondylar fracture to prevent further injury
Keep elbow in extension - prevent exacerbating brachial artery damage
What is Gartland classification of supracondylar fractures?
Type I - non-displaced
Type II - angulated with intact posterior cortex - posterior hinge is intact but there is a gap anteriorly
Type III - posterior displacement - unstable fracture
Details of Gartland type III classification
IIIa - posteromedial displacement threatens the radial nerve
IIIb - posterolateral displacement threatens the median nerve
Management of supracondylar fractures
Type I - above elbow backslab and sling
Type II - reduction usually required
Type III - ORIF
Complication if fracture of medial condyle
Ulnar nerve compression
Complication if fracture of lateral condyle
Cubitus valgus and ulnar nerve palsy
What is an intercondylar humerus fracture
T shaped supracondylar fracture with a line going down for a break between the condyles
Most common cause of elbow joint effusion in children
Supracondylar fracture
Most common cause of elbow joint effusion in adults
Radial head or neck fracture
Signs of elbow joint effusion on lateral xray
Sail sign (displacement of anterior fat pad by joint effusion - pushing it out so it is no longer aligned with the humerus) Posterior fat pad sign (displacement of posterior fat pad making it visible - normally not visible)
Signs of radial head fracture
Elbow is swollen and tender over the radial head
Flexion and extension may be possible
Pronation and supination hurt
May see joint effusion on xray but fractures often missed
Treatment of radial head fracture
Undisplaced = collar and cuff
Displaced limiting supination/pronation - may need internal fixation
Complications of radial head fracture x2
1) 3-14% are associated with terrible triad of radial head fracture, elbow dislocation and coronoid process fracture - leading to joint instability and complications
2) Radial nerve injury may occur with severe ant.displacement - but is rare
Typical patient for pulled elbow - what happens
Child 1-4 year old who has been lifted by the arms - radial head slips out of annular ligament
Presentation of pulled elbow
Arm held slightly flexed and twisted inwards
Management of pulled elbow
Reduction by cradling elbow, thumb and forefingers over radial head - either Hyperpronate or supinate and flex the elbow
Caution with pulled elbow
25% recur therefore warn parents not to pull arm of child
What causes elbow dislocation?
Fall on not yet fully outstretched hand with elbow flexed - causes posterior ulna displacement on humerus
Signs of elbow dislocation
Swelling and arm held in flexion
Reduction of elbow dislocation
Stand behind patient
With fingers on epicondyles - push forwards on olecranon and down on forearm
What is needed after elbow dislocation reduction
X-ray to exclude any fractures
Immobilise in backslab for 10 days
Complications of elbow dislocation
Stiffness
Instability
Ectopic ossification
Radio-ulnar joint disruption
What to do if olecranon fracture?
ORIF
When is elbow arthroplasty indicated?
Comminuted distal humerus fractures where ORIF may be difficult
What forearm fracture do falling children often get?
Buckle forearm fracture - dorsal Cortex crumples on pressure but volar cortex remains intact therefore distal fragment is angled dorsally
Signs of buckle forearm fracture
Local tenderness and swelling
Also called torus fracture which means mound
Management of buckle forearm fracture
They are stable fractures therefore a splint or short-arm cast for 3 weeks may be sufficient
What are greenstick fractures?
One cortex (volar or dorsal) is compressed and the other bends/rotates Deformation can continue to angulate with growth
What is Colles fracture?
Fracture of distal radius causing dorsal angulation and displacement producing ‘dinner-fork’ wrist deformity
What is usual history for Colles fracture?
Fall into outstretched hand. - common in osteoporotic post menopausal women
What is the wrist deformity in Colles fracture?
Dinner-fork wrist deformity - due to dorsal angulation of distal radius
Reduction of Colles fracture
Biers block - tourniquet around arm, empty arm of blood, inflate tourniquet, inject local anaesthetic, manipulate fracture, 30mins after anaesthetic release tourniquet
What is Smiths fracture?
Reverse Colles - distal radius fractures with fragment angled palmarly (volar displacement) - usually extra-articular
Fixation commonly needed
What is Bennetts fracture?
Carpometacarpal fracture/dislocation of the thumb
Need percutaneous wire fixation
Signs of scaphoid fracture
Tender in anatomical snuff box
Pain on axial compression of the thumb
Pain on ulnar deviation of pronated wrist or supination against resistance
Imaging of suspected scaphoid fracture
Need scaphoid series X-ray
What is paronychia?
Infection under the eponychial fold - antibiotics may help in early stages but if collection forms then drainage is required
What is a felon?
Infection of the pulp of a distal finger
Which is the most common metacarpal to be fractured?
5th metacarpal - punching injuries
Management of stable closed metacarpal fractures?
Splint/cast for two weeks - wrist in partial extension, MCPs in flexion and fingers in extension
Management of unstable wrist fractures
May require k wires or ORIF
What is risk with punching Metacarpal fractures
May be wounds eg, from victims teeth - can get infected and can be communicating with joint
What is gamekeepers thumb
Partial or complete tears of ulnar collateral ligament at MCP joint - due to forced thumb abduction - also called Skiiers thumb
Treatment of gamekeepers thumb
Partial - can be managed with thumb casting
Complete - needs surgical management
What is the main concern with pelvic fractures?
Concern for the contents rather than the bones itself - like a suit of armour
When do pelvic fractures usually become worrying
When 2 or more fractures with one above the level of the hip because then it is unstable - 25% have internal injuries
Sign of pelvic fracture
Leg length discrepancy
Signs of serious complications of pelvic fracture
Haemorrhage - abdominal distension Bladder rupture Urethral rupture - drop of blood at end of urethra - unable to pass urine - prostate high riding on PR Sciatic nerve trapping - persistent pain Perineal or scrotal haematoma
What is Malgaignes fracture?
Pelvic fracture / Usually a fracture anterior and posterior to the acetabulum which causes displacement of a fragment involving the hip joint
Leg shortening is sign
- 60% of all unstable fractures and 20% of all fractures
Management of acetabulum fractures
Open reduction and reconstruction of the articular surface to delay onset on OA
How do you examine a patient with suspected pelvic fracture?
Gentle palpation of iliac crests, pubic symphysis, sacrum/coccyx, and posterior SI joints
Can gently compress pelvis but no rocking as will cause pain and can exacerbate bleeding
What are the signs of an intracapsular hip fracture?
External rotation, adduction and shortening
Where does an intracapsular hip fracture occur? 3 types
Just below the head of femur
Can be subcapital, transcervical or basicervical (just before trochanters)
Risk with intracapsular hip fractures
Medial femoral circumflex artery supplies the head via the neck therefore ischaemic necrosis of the head may occur
Treatment of intracapsular hip fracture
If non-displaced then screw fixation is okay as risk of avascular necrosis is much less
If displaced then hemiarthoplasty (hip replacement)
Details of intertrochanteric-extracapsular fractures x3
Occurs in older age group
Blood supply adequate therefore non-union not usually a problem
Screw fixation
What causes femoral shaft fracture?
Usually considerable force therefore look for fractures/damage elsewhere
Problem with femoral shaft fracture? x2
Lots of blood can be lost even in a simple fracture
Sciatic nerve injury can also occur
What happens to two fragments in femoral shaft fracture?
Lower fragment pulled up by hamstrings and adducted by adducters
Proximal fragment is flexed by iliopsoas, abducted by gluteus medius and laterally rotated by gluteus maximus
Treatment of femoral shaft fracture?
Stabilise in ED
Locked intramedullary nail introduced over a guide wire
Consequences of condylar fractures and tibial plateau fractures
Intra-articular therefore demand accurate joint reconstruction to minimise later OA
What causes posterior hip dislocation
Eg. car crash with front seat passengers when knee strikes dashboard
Where do you feel for femoral head in posterior hip dislocation
In the buttock
What happens to the leg in posterior hip dislocation
Leg is flexed, internally rotated, adducted and shortened
What can happen in posterior hip dislocation
Sciatic nerve may be lacerated, stretched or compressed
Treatment of posterior hip dislocation
Reduce under GA and traction for 3 weeks to promote capsule healing
How does the patella typically dislocate?
Laterally as a result of a twisting motion of the lower leg, combined with the contraction of the quadriceps
How does the knee appear after patella dislocation?
Flexed with a lateral deformity
Management of patella dislocation
Reduction with gentle medial pressure combined with extension of the knee - followed by period of immobilisation in cast/posterior splint or brace - rehab with quadriceps strengthening exercises
What usually causes patella fracture? x2
Fall onto a flexed knee or due to dashboard injury in motor vehicle accident
Management of patella fracture
Non-displaced with intact extensor mechanism - just manage conservatively
Displaced may need surgical fixation
Management of isolated collateral ligament injuries
Medial rarely needs surgery
Lateral surgery is required if there is instability - look for associated common peroneal nerve injury
Cause of medial meniscus tear
Twists to a flexed knee eg. football
Cause of lateral meniscus tear
Adduction and internal rotation
Signs of meniscus tear
Extension is limited (knee locking) - as displaced segment lodges between femoral and tibial condyles
Can only walk on tiptoes
Tender joint line
Knee can suddenly give way if tear becomes free at one end
Management of meniscus tear
Conservative when possible - arthroscopy is usually needed for locked knees, cysts or persisting symptoms
What tibia fracture is commonly associated with anterior cruciate injury
Avulsion fractures of the intercondylar region
What sort of tibial fractures are common?
Open shaft fractures because little anterior covering tissue
Management of pretibial lacerations
Better to use adhesive strips (steristrips) than to suture because these can be loosened if skin swells and if flap stretched too tightly then skin will necrose
What is a Toddler’s fracture?
Spiral fracture of the distal tibial shaft seen in toddlers - supportive treatment - should only occur in a toddler who is walking
What is a common ankle ligament strain and how does it occur?
Strain to anterior talofibular part of the lateral ligament - caused by twisted inversion
Signs of ant. talofibular ligament strain
Stiffness and tenderness over the lateral ligament - pain on inversion
Sign of more serious problem than lateral ankle ligament strain
Tenderness over medial malleolus
Treatment of lateral ligament strain
RICE
Rest, Ice, Compression, Elevation
What causes medial deltoid ligament strain
Rare - due to eversion
What can occur with ankle ligament strains
Malleolar and metatarsal fractures
What is Maisonneuve’s fracture?
Proximal fibular fracture + syndesmosis rupture - and medial malleolus fracture or deltoid ligament rupture
Therefore always examine proximal fibula with ‘ankle sprains’
What is Lisfranc fracture-dislocation
At 1st tarsometatarsal joint - can cause compartment syndrome of the medial foot
What are Os Calcis fractures
Fractures of the calcaeneus - often bilateral after a serious fall
Will have swelling, bruising and inability to weight bear
What is AO Weber classification of malleolar fractures?
a1 - transverse fibula fracture at or below joint line with no medial injury
a2/3 - with medial injury
b1-3 - fibula fracture at joint line + medial injury (b2) and posterior injury (b3)
c1/2 - oblique fibular fracture above ruptured tibiofibular ligament with medial injury (c2)
c3 - maisonneuves fracture - proximal fibula injury
What are the most common injuries with facial trauma?x2
Facial laceration and mandible fracture
What should always be considered with facial trauma?
C-spine injury
Management of rugby players “cauliflower” ear
Drain haematoma repeat every few days and strap pressure dressing against head
Signs of mandible injury
Local tenderness and swelling
Jaw malocclusion
A mobile fragment and may have bone protruding into mouth
If communited fracture then tongue can make it very difficult to manage airway
Diagnosis of mandible injury
Orthopantogram radiograph
Treatment of mandible fracture
ORIF with miniplates is better than wiring the teeth together
Signs of zygomatic arch fractures
Before swelling there will be a depression in front of the ear
Lateral jaw excursions of jaw opening may be painful
Investigation of zygomatic arch fractures
Submentovertex view
Good treatment for swollen eye
Rubber glove filled with ice
What is likely to be the result of trauma to face/eye?
Inferior orbital plate fracture because it is very fragile and pressure is transmitted here from resilient eye ball
What do you see on X-ray with orbital fracture? X3
Eyebrows sign - air leaking into orbit
Tear drop sign- herniation of fat and fluid through orbital floor
Fluid level in maxillary Antrum/sinus (underneath)
What sort of xray should be done to investigate orbital fracture?
Occipital mental view at 45degrees because otherwise with front on the thick Petrous bone obscures view of upper facial bones
What physical signs may occur with orbital floor fracture?
Damage to inferior rectus muscle therefore eye cannot look up
Intraorbital Nerve damage - loss of sensation on cheek, nose and upper lip
Feel a step when run finger along maxillary margin
What is elephants trunk on xray
Zygomatic arch - the head is the zygomatic bone body
What is the tripod fracture?
Occurs with front on facial trauma
Zygomatic arch and infraorbital plate fracture and zygomatico-frontal suture separation
Patient face - cheekbone will look depressed
What is an OM 30degree facial xray good for viewing
Lateral wall of maxillary antrum(sinus) - can sometimes rupture with orbital fracture
And zygomatic arch
How does mastoid appear on xray?
Aero-type appearance because of patchy black from air
How does mandible usually dislocate?
Anteriorly
Can be from laughing, yawning or trauma
Signs of mandible dislocation
Patient can’t move jaw
Management of mandible dislocation
Reduce it - wrap gauze around thumb and push mandible from inside the mouth down and posteriorly
What is key blood-wise in fracture?
The haematoma that forms as a result - it is the only blood supply to the fracture
What occurs in repair of fracture
Inflammatory response with cytokines - promote angiogenesis - therefore new vessels form and then new bone gets put down (woven bone)
What is the mature type of bone
Lamellar bone
What is new bone
Woven bone
How do fractures heal?
Bones being close together so that osteoblasts and osteoclasts can work for remodelling - if bones move then won’t heal - hence casts
What is wolfs law?
Bone remodels according to the load that is put on it - remodelling occurs in the direction of loading and resumes normal shape
What drug shouldn’t be given to people with fractures
NSAIDs and steroids - slow down healing
Greenstick fracture?
Elastic and dense bone - therefore deforms instead of fractures - defect in one bit but cortex still in continuation
What is avulsion fracture
Bit of bone pulled off by the muscle
What do you get in a fracture under tension
Transverse fracture
What do you get in compression fracture? (Eg. Dashboard crush in accident)
Oblique fracture at 30 degrees
What do you get with torsion injury
Spiral
What do you get with direct high energy injury
Communited
Initial management of any open fracture
IV augmentin 1.2grams with gentamicin (unless penicillin allergy - clindamycin)
Give tetanus
What is important thing you need to know for hip fracture?
Intracapsular or extracapsular - because intracapuslar - blood supply to the head of femur will be interrupted and head will be dead and need replacing
Blood supply to femoral head
Medial circumflex artery
What is garden classification of hip fracture?
1 and 2 are not displaced
Therefore in theory blood supply is not affected
Garden 1 - incomplete fracture
Garden 2 - complete fracture
Garden grade 3 - partially displaced - trabecular are still aligned
Grade 4 - fully displaced and trabecular not aligned
Management of garden grade 1 and 2 hip fracture
Grade 1 and 2 - screw
Also screw for young patients displaced #
What is dynamic hip screw?
Sliding screw that allows fracture to slide and compress - therefore walk on it straight away after surgery
When do you use dynamic hip screw
Displaced extracapsular NOF #
How do you treat intracapuslar displaced feature (garden 3 and 4)
Hemi or total arthroplasty
Management of distal forearm fractures in children?
They have very thick periosteum that you can manipulate with a wire OR leave to heal (will heal completely without doing anything)
Intracapuslar hip fracture - when do you do total hip replacement and when do you do hemiarthroplasty
Hemiarthroplasty if old and frail etc - if young and can manage it then do THR
What do you need to do in hip dislocation
Urgent reduction to avoid AVN - occurs within 24-48hrs
What is Galeazzi fracture
Distal 1/3 fracture of radius with dislocation of the radioulnar joint
What is Bartons fracture
Intraarticular distal fracture (unlike Colles or Smiths)
Position of leg in hip fracture
Shortened, adducted and externally rotated
