Fractures Flashcards
presentation of a NOF
impact fall severe pain pain on internal and external rotation tender over hip joint shortened and externally rotated leg
risks during and post NOF repair op, how to minimise
infection - prophylactic AB DVT/PE - LMW heparin, TED socks, early mobilisation pressure sores - early mobilisation bleeding death chest infection - Spinal>GA and early mobilisation dislocation non/mal union avascular necrosis leg length discrepancy
Investigations for suspected NOF
first line AP X-ray
CT if unsure about fracture
management of NOF
ORIF - open reduction, internal fixation
analgesia
if suspecting osteoporosis DEXA scan - result determines if patient needs to be started on bisphosphonates
rivaroxaban etc stopped 48 hours pre-op
prognosis of NOF post treatment
30% die after one year
report deaths to coroner within 30 days post op
if not sure why patient died discuss with coroner
types of NOF fracture and what operation to do
external capsular:
1) inter-trochanteric - dynamic hip screw (DHS) whole of neck attached to head
2) sub-trochanteric - intramedullary nail
internal capsular:
semi arthroplasty or total hip replacement.
blood supply compromised, avascular necrosis. Head will die if not replaced.
true NOF
offer THR to those who were able to walk independently with no more than the use of a stick and aren’t cognitively impaired and are medically fit for the anaesthetic and procedure
investigations required before operation for fractured NOF
FBC - infection, anaemia U&Es - dehydration, renal baseline, electrolyte imbalances Clotting screen Cross match, group and save - 2-4 units ECG - baseline heart function Blood sugar - DM CXR echo if murmur
need to identify and correct: anaemia, volume depletion, anticoagulation, electrolyte imbalance, uncontrolled DM, HF, correct arrhythmia or ischaemia, acute chest infection, exacerbation of chronic chest conditions
when to perform surgery for NOF
day on or after admission
management of a trauma fracture
ATLS! -ABCDE
airway maintenance and cervical spine control
breathing and ventilation
circulation and haemorrhage control
disability - neurological statue (Examine neuromuscular status of limb)
Exposure and environment control - undress to check for hidden injuries but prevent hypothermia
if GCS <8 unable to maintain airway - intubate
if its an open wound: remove gross contamination
cover in a saline gauze, splint using back slab
IV AB ASAP
theatre - wash out and debridement and stabilise fracture within 24 hours
ORIF
stabilise and preserve blood supply
DVT prophylaxis
causes of compartment syndrome
high velocity fracture or overuse of muscle in athletes - chronic compartment syndrome
signs and when do you suspect compartment syndrome
SUSPECT IF PAIN NOT RESPONDING TO ANALGESIA - deep, constant, poorly localised pain which isn’t responding to analgesia
signs: bruising and swelling paraesthesia of nerves of affected compartment increased cap-refil paralysis, lack of pulse
management of compartment syndrome
release any dressings/casts causing external compression
position limb @ level of the heart
emergency fasciotomy to release pressure - hip op. open all involved compartments. Open for a few days and then re-close, may need skin graft for reclosure
what is delayed union and what affects it
failure to reach bony union at 6 months post injury
factors
local - stability, infection, pattern (segmental fractures increase risk), location (scaphoid, distal tibia, base 5th metatarsal increased risk due to blood supply)
systemic - diet, DM, smoking, HIV, meds - NSAIDs, steroids
which nerve may be injured in a fibula neck fracture
common peroneal
which nerve may be injured in a supracondylar of the humerus fracture
median
