Fractures Flashcards
What is the general approach to assessing fractures?
Hx & exam -mechanism & site -associated injuries -joint sx, neurovascular sx Radiology -two plain film orthogonal views -image joints above & below injury CT/MRI -if fracture poorly visualised on XR
How can long bone fractures be described radiologically?
Simple OR comminuted (3+ pieces) -if simple is it transverse, spiral or oblique? Which bone? Location on bone? -mid-shaft, base/head -intra-articular? Displaced/non-displaced -translation? -alignment? -rotation? -length? Open/compound
What does translation refer to?
Bones shifted sideways/back/forward in relation to each other
What does alignment refer to?
Fragments tilted/angulated in relation to each other
What are greenstick fractures?
Paediatric fractures occurring in children due to malleable bones
- bone fractures on one side
- buckles on the other
What is the prognosis of a greenstick fracture?
Reduction easy
Healing quick
What are the risk factors for fracture?
Osteoporosis/Osteomalacia/PDB
1o/metastatic neoplasia
Bone cysts
Congenital diseases
What are the four phases of fracture repair in unstable conditions?
Inflammation
Soft callus
Hard callus
Remodelling
Describe the inflammatory phase of fracture repair in unstable conditions
1-7 days
Fracture ends bleed
Haematoma formation around fracture site
Fibrin & capillary network forms
Describe the soft callus phase of fracture repair in unstable conditions
1-3 weeks
Vascular network expands
Fibrous tissue replaces haematoma
Subperiosteal new bone formation begins
Describe the hard callus phase of fracture repair in unstable conditions
1-4 months
Calcification of soft callus
Forms rigid, calcified tissue
Describe the remodelling phase of fracture repair in unstable conditions
Once fracture solidly united remodelling takes place (mo-yr)
New woven bone replaced by lamellar bone
Medullary canal restored
How does fracture repair take place in absolute stability?
Bone ends heal w/o callus formation
-cannot be visualised on XR
What are the two types of fracture repair?
Unstable (Plaster of Paris)
Stable (surgical intervention)
What are the possible acute complications of fractures?
Compartment syndrome Visceral injury Nerve injury Vascular injury Infection Rhabdomyolysis Bleeding
What is compartment syndrome?
Neurovascular compromise resulting from bleeding, oedema or inflammation causing increased pressure in an osteofascial compartment
-venous collapse further increases pressure
How long does it take for necrosis to occur in compartment syndrome?
6hrs
Which osteofascial compartments are most commonly affected in compartment syndrome?
Forearm
Lower leg flexor
How does compartment syndrome present?
Pain
-bursting, described as ‘worst ever’
-not relieved by strong opioids
Arterial system still intact
What compartmental pressure indicates a need for immediate decompression?
> 30mmHg above DBP
What is the management of compartment syndrome?
Remove casts, bandages, dressings etc. Elevate limb Immediate fasciotomy Debridement Aggressive IV fluids -risk of myoglobinuria & AKI Leave wound open
What are the potential late complications of compartment syndrome?
Infection DVT/PE Pressure sores Delayed/non/mal union Avascular necrosis Joint instability OA Complex regional pain syndrome Neurovascular compromise -limb loss
What is a delayed union fracture?
When a fracture takes longer than expected to heal for an injury of its type
What are the risk factors for a delayed union fracture?
Local - poor blood supply, infec, poor apposition of bone ends, presence of foreign bodies
Systemic - poor nutrition, smoking, corticosteroid therapy
What is the main clinical feature of a delayed union fracture?
Persisting fracture tenderness
What are the X-ray features of a delayed union fracture?
Fracture line remains visible
Little callous formation
What is the management of a delayed union fracture?
Eliminate any possible cause
Immobilise bone in plaster BUT promote muscular exercise w/i cast
What is a non-union fracture?
Fracture that will never unite w/o intervention
-diagnosed when not healed after 2x usual expected time
What are the clinical features of a non-union fracture?
Movement elicited at side
Pain diminishes as site gap becomes pseudoarthrosis
What are the X-ray features of a non-union fracture?
Hypertrophic non-union -enlarged fracture ends Atrophic non-union -tapered fracture ends -no suggestion of new bone formation
What is the management of a non-union fracture?
Conservative (splinting/bracing)
Surgical (rigid fixation +/- bone graft)
What is a mal-union fracture?
Bones unite in unsatisfactory position due to inadequate reduction/immobilisation
-usually an obvious deformity
What is the management of a mal-union fracture?
Remanipulation
Osteotomy
Internal fixation
Limb lengthening procedures
What is a Colles Fracture?
Fracture of distal radius (w/i 4cm radio-carpal joint)
-w/ dorsal displacement of distal fragment
What causes a Colles Fracture?
Fall onto outstretched hand (FOOSH) in extension
- marked visible deformity
- associated w/ osteoporosis in elderly women
What are the X-ray signs of a Colles Fracture?
Dorsal displacement of radius
Radial impaction & angulation
-shortened radius compared to ulna (dinner fork deformity)
How should a Colles Fracture be managed initially?
Manipulation w/ traction & application of moulder plaster
-anaesthetised w/ haematoma/Bier’s block
If good position achieved manage conservatively
-X-rays at wk 1 & 2
What is the definitive management of a Colles Fracture?
Open reduction & internal fixation (w/ locking plate)
-req in unstable/commuted fractures
What are the potential complications of a Colles Fracture?
Median nerve damage
Post-traumatic Carpal Tunnel Syndrome
What is a Smith’s Fracture?
Fracture of distal radius (w/i 4cm of radio-carpal joint)
-w/ volar displacement of the distal segment
What is the cause of a Smith’s Fracture?
Fall on flexed wrist
What is the management of a Smith’s Fracture?
Less common & more unstable
Always require open reduction & internal fixation
What is the most commonly fractured carpal bone?
Scaphoid
What is the cause of a Scaphoid Fracture?
Occur w/ violent hyperextension of wrist
How does a Scaphoid Fracture present?
Pain maximal in anatomical snuff box
Pinch grip weak
Undisplaced
What X-rays does a Scaphoid series consist of?
AP
Lat
2 oblique views
What is the management of an undisplaced Scaphoid Fracture?
Conservative - immobilisation in thumb spica for 6-8wks
-10% risk of non-union, may require surgery
What is the main complication of a Scaphoid Fracture?
Avascular necrosis
What are the common types of Forearm Fracture?
Monteggia (most common)
Galeazzi
What are the features of a Monteggia Fracture?
Proximal ulna fracture
Radial head dislocation
What are the features of a Galeazzi Fracture?
Fracture of radius
Dislocation of distal radio-ulnar joint
-often associated w/ radial nerve injury or extensor tendon injury
-ant interosseous nerve injury often missed
What are the clinical features of an anterior interosseous nerve injury?
FPL & FDP paralysis
-lack of pinch mechanism b/w thumb & index finger
What are the common causes of a Femoral Neck Fracture?
Fragility fracture in elderly
Pathological fracture at site of bony mets
What are the signs on examination of a Femoral Neck Fracture?
Hip pain on passive movements
If fracture displaced
-pt lies w/ limb shortened & externally rotated
What are the three main vessels supply blood to the femoral head?
Intramedullary vessels (run inside medullary canal) Medial/Lat Circumflex artery anastomoses -from profunda femoris -run proximally through joint capsule -medial circumflex is main source Artery of ligamentum teres -<10% of normal blood supply
What are the three types of femoral head fracture?
Intracapsular
Intertrochanter
Subtrochanteric
What is an intracapsular fracture?
Fractured NOF
-occurs proximal to capsular insertion on femoral neck
What is the Garden Criteria?
Used to grade NOF fractures based on degree of displacement
- Garden 1 = incomplete, impacted
- Garden 2 = complete, not displaced
- Garden 3 = complete, continuity b/w fracture heads
- Garden 4 = Complete, no continuity
What are the management options for intercapsular fractures?
Garden 1/2 -open reduction & internal fixation Garden 3/4 -hemiarthroplasty -high risk of AVN
How should young pts w/ intercapsular fractures be managed?
Should have any fracture screwed
-hemiarthroplasty may require multiple revisions
How should fit pts w/ intercapsular fractures be managed?
If mobilising well & good w/ ADLs then total hip replacement rather than hemiarthroplasty
-better outcomes
What is an intertrochanteric fracture?
Fracture lies b/w trochanters
- extracapsular
- no threat to blood supply of femoral head
What are the management options for intertrochanteric fractures?
Dynamic hip screw
- fracture reduced on traction table
- guide-wire positioned under fluoroscopy
- DHS then fixed
What is a subtrochanteric fracture?
Fracture below trochanters
- extracapsular
- no threat to blood supply of femoral head
- occur in high energy trauma/lytic lesions
What are the management options for subtrochanteric fractures?
Intramedullary nail & hip screw
What is the general approach to assessing hip fracture patients?
Take full falls hx
?prev fractures/bone pain before fall
?length of lie (rhabdomyolysis)
What investigations are appropriate in hip fracture patients?
Bloods (incl coag/group & save)
ECG & CXR
AP pelvis/lat hip X-ray
What is the prognosis of a hip fracture?
10-20% require a change to more dependent residential status
-mobilise w/i 24hrs for best outcome
What is the mechanism of injury resulting in a wedge compression fracture of the thoracolumbar spine?
Excessive spinal flexion w/ intact post ligaments
- anterior fractures
- occur w/ minimal trauma in osteoporosis
How do wedge compression fractures of the thoracolumbar spine present?
Marked pain
-worse on movement/wt bearing
-slowly improves over months
Multiple fractures cause kyphotic deformity of lumbar spine
What investigations are appropriate in wedge compression fractures of the thoracolumbar spine
AP/lat X-rays of spine
What are the management options for wedge compression fractures of the thoracolumbar spine?
Bed rest for 1-2wks
Conservative
-mobilisation/muscle strengthening
-thoraco-lumbar brace for 3mo (if marked wedging)
Surgical
-kyphoplasty (if ongoing pain at level of fracture)
What are the common cervical vertebral fractures?
Jefferson’s fracture
Hangman’s fracture
Odontoid fracture
What is a Jefferson’s fracture and how is it diagnosed?
C1 fracture due to axial compressive force on vertex of skull transmitted to spine
-open mouth XR to dx
What is a Hangman’s fracture and how is it diagnosed?
C2 fracture due to hyperextension of the neck
-lat XR to dx
What is an Odontoid fracture and how is it diagnosed?
Fracture of odontoid peg associated w/ spinal cord injuries
-peg view XR to dx
Describe tibial fractures
Most common fracture in adult
Open fracture common due to s.c. position
What are the management options for a tibial fracture?
Minimally displaced/undisplaced
-full length cast (mid-thigh to metatarsal neck, knee flexed, ankle 90o)
Displaced
-reduction under GA w/ XR guidance before full length cast application
How should a tibial fracture be monitored?
Limb elevated/observed for 48hrs (compartment syndrome)
Position checked w/ XR at 2wks
Changes to below knee cast at 4wks
In which groups are ankle fractures common?
Young athletes
Osteoporotic older women
What malleoli can be fractured in the ankle?
Medial malleolus
Lateral malleolus
Posterior malleolus (formed by post tibia)
What is the most common mechanism of injury causing an ankle fracture?
Abduction & lat rotation of joint
-leads to lat malleolus shearing off
What are the signs on examination of an ankle fracture?
Intense pain
Inability to stand
What X-rays should be ordered when investigating an ankle fracture?
AP
Lat
Mortise
What is the Weber classification?
Used to classify lat malleolus fractures based on relationship to syndesmosis (tibulofibular joint)
- Weber A = fracture below syndesmosis (intact)
- Weber B = fracture at syndesmosis (partially intact)
- Weber C = fracture above syndesmosis (non-intact)
What is Talar Shift?
Important indicator of instability in ankle
-talus no longer exhibits equal joint space around articulation w/ fibula & tibia
What are the management options for an ankle fracture?
Weber A
-stable, rarely require surg management
-6wks plaster of paris
Weber B
-conservative management tried (repeat X-rays wkly)
-if fails try ORIF
Weber C
-never stable, requires open reduction & internal fixation
Multiple malleoli
-always unstable, operative management
What are the Ottowa rules?
X-ray of ankle required only if -pt unable to wt bear -has pain -bony tenderness at lat/med malleolus X-ray of foot required only if -pt unable to wt bear -bony tenderness over navicular/base of 5th metatarsal
What is the Salter Harris Critera?
Classifies physeal (growth plate) fractures (SALTER)
- Type 1 = Straight across (rare)
- Type 2 = Above (most common)
- Type 3 = Lower
- Type 4 = Through
- Type 5 = ERasure of growth plate
What is the general management of closed long bone fractures?
A-E resus
Analgesia
Image length of bone + joint above/below
Manipulation & stabilisation in plaster of Paris
-ensure ankle at 90o
Re-image & check for complications
Conservative/surgical management long term
What is the general management of open long bone fractures?
A-E resus
Analgesia
Check distal neurovascular status/soft tissue injury
IV a/b +/- tetanus prophylaxis
Leg imaged & taken to theatre w/i 6hrs
-definitive management & irrigation
-plastics input may be required
What is the Gustilo & Anderson criteria?
Classification system for assessing open fractures
- 1 = simple fracture, wound <1cm
- 2 = simple fracture, wound >2cm
- 3 = multi-fragmented fracture
- 3A = w/ adequate soft tissue cover
- 3B = requires plastics input
- 3C = associated w/ vascular injury
