Fractures Flashcards
polytrauma
more than one major long bone is injured/major fracture is associated with significant chest or abdominal trauma
what does polytrauma often cause
usually high energy fractures, with major blood loss (hypovolaemia)
pain, increased sympathetic response, fat embolism
ARDS, SIRS, MODS
SIRS
amplification of inflammatory cascades in response to trauma with pyrexia, tachycardia, tachypnoea and leukocytosis (high WCC)
ARDS
may occur due to hypoperfusion,SIRS, aspiration or fat embolism
inflammation of lung parenchyma leading to inflammatory exudates forming in alveoli and impairment of gas exchange
what is required in polytrauma
rapid skeletal stabilisation - limit biological trauma and blood loss and fat embolism
external fixators can be used because they can be rapidly applied with minimal blood loss
IM nails can also be applied - however risk of fat embolism
only unstable pelvic, femoral and tibial fractures treated, and injuries with vascular compromise, open fractures and (impending) compartment syndrome. minor fractures left till later
general fracture management
- Resuscitation – ABCDE
- Analgesia – IV morphine
-
Assessment
- Open vs closed
-
Neurovascular status
- Pulse
- Capillary refill
- Temperature
- Colour
- Sensation
- Motor power
- Soft tissue injury
- Compartment syndrome
- Splintage
- Investigations
- Reduction
-
Holding
- Operative and non-operative
primary bone healing
minimal fracture gap (<1mm) and new bone is able to fill the gap from osteoblasts
eg in hairline fractures and when bones are fixed with compression screws and plates
secondary bone healing
gap at site of fracture that must be temporarily filled to act as a scaffold for new bone to be laid down (inflammatory response)
2y bone healing process
- Fracture occurs
- Haematoma occurs with inflammation from damaged tissues
- Macrophages and osteoclasts remove debris and resorb the bone ends
- Granulation tissue forms from fibroblasts and new blood vessels
- Chondroblasts form cartilage (soft callus)
- Osteoblasts lay down bone matrix (collagen type 1)– Enchondral ossification
- Calcium mineralisation produces immature woven bone (hard callus)
- Remodelling occurs with organization along lines of stress into lamellar bone
how do oblique fractures occur
sudden deceleration force
more likely to shorten
how do transverse fractures occur
bending of bone
how do spiral fractures occur
twisting
how do comminution fractures occur
high energy force/poor quality bone (osteoperosis in elderly)
how is location of a fracture in a long bone described
in thirds and type of bone involved (eg metaphyseal)
intra-articular and extra-articular
intra = extending into joint
what greater risks do intra-articular fractures have
stiffness, pain, post-traumatic OA (especially if uneven surface)
how is displacement described
direction of translation of distal fragment
volar (palmar) and dorsal in forearm. and radial and ulnar
angulation of bone
describes the direction in which the distal fragment points towards and the degree of deformity
measured in degrees from longitudinal axis of diaphysis
what is used to diagnose mandibular fractures
tomogram
what is used to assess fracture of complex bones
CT
what is used to detect stress fracture that may fail to show up on x ray (until hard callus appears)
technetium bone scan
initial management of long bone fracture
Clinical assessment, analgesia, splintage/immobilisation and investigation (usually X rays)
splintage: temporary plaster slab, sling, orthosis, Thomas splint (femoral shaft in children)
if the fracture is grossly displaced or obviously dislocated, or risk of skin damage - reduction of fracture should be performed without waiting for X ray
in general, how are undisplaced, minimally displaced and minimally angulated fractures which are considered to be stable treated
non-operatively
period of splintage/immobilisation then rehabilitation
how are displaced/angulated fractures where the position is deemed unacceptable treated
reduction
cast application may be performed, serial x rays to ensure no loss of position
how are unstable injuries treated
surgical stabilisation
(K wires, external fixation,IM nails, screws, plates etc)
when is ORIF avoided
soft tissues too swollen
tenous blood supply to fracture
risk of extensive blood loss
what is the aim of ORIF
anatomic reduction and rigid internal fixation leading to 1y bone healing
management of open fractures
expediently to prevent infection which may result in non-union (atrophic or hypertrophic)
Gustilo classification
used to describe the degree of contamination, size of wound, whether it will be able to be closed or require plastic surgery and the presence of an associated vascular injury (for open fractures)
management of open fracture
initally:
- IV broad spectrum antibiotics
- sterile/antiseptic soaked dressing applied to wound to prevent further contamination before fracture is splinted
- ensure tetanus immunisation
- prompt surgery - debridement
what does wound tension cause
skin necrosis and wound breakdown
If there is any doubt over the viability of soft tissues or if the wound is heavily contaminated, it is usually safer to leave the wound open and allow ongoing infection to drain out and return to theatre for debridement in 48 hours.
what type of non union can infection cause
atrophic and hypertrophic
