Fractures Flashcards
Which sex is more prone to femoral fractures
Females - particularly elderly
Which age groups get femoral fractures
Vast majority are the elderly (over 60)
Young people occasionally with high energy trauma
List some risk factors for femoral fractures
Age over 50 Female Osteoporosis Smoking Malnutrition Excess alcohol Neurological impairment Impaired vision
What does a fracture require to heal
Adequate blood supply
List the blood supply to the femoral head
Intramedullary artery of the shaft of femur
Medial and lateral circumflex branches of profundal femoris artery
Artery of the ligamentum teres
Foveal branch of obturator artery
What are the types of proximal femoral fracture
Intracapsular - displaced or undisplaced
- subcapitlal and transcervical
Extracapsular - Basicervical, intertrochanteric, subtrochanteric
Which type of femoral fracture is more likely to heal
Extracapsular
Both sides of fracture have a blood supply - no disruption
What are the major risks with intracapsular fractures
Significant risk of not healing due to disruption of blood supply
AVN
How does a proximal femoral fracture present
History of a fall Pain Inability to weight bear Shortening of limb External rotation
What are some complications of immobility after surgery
UTI
Pressure sores
DVT
How do you treat an intracapsular fracture
Hip replacement
Either total or hemi-arthroplasty
Total replacement reserved for those who are young and fit - better ROM and longevity
How do you treat an extracapsular fracture
Pinning - variety of methods
Dynamic hip screw is popular
Why is incidence of hip fractures rising
Ageing population
What are the 11 standards of care for hip fractures
Transfer to ortho ward within 4 hours
Big 6 intervention in A and E
Receive inpatient bundle of care within 24hrs
Undergo surgery within 36hrs
No repeated fasting and fluids 2hr before op
Cemented arthroplasty (unless otherwise indicated
Geriatric assessment within 3 days
Early mobilisation and physio assessment w2 days post-op
Occupational therapy assessment by 3 days after admission
Bone health assessment prior to leaving ortho ward
Recovery optimised by MDT and discharge within 30 days
What are the big 6 interventions that should be carried out in A and E for a hip fracture
Analgesia NEWS Pressure area inspection Blood tests Fluid therapy Delirium screening
Give examples of pre-op analgesia
Strong opiates - morphine
Lots of side effects
Local nerve blocks
- avoids side effects
What makes pressure sores more likely
Delays to surgery
Frail or malnourished patients
Failure to mobilise early
Pressure sores take a long time to develop - true or false
False
Can start to develop within 30 mins of lying on hard surface
What are some key signs of dehydration
Low urine output
Concentrated urine
What are some key signs of fluid overload
Oedema
Crackles in the chest
Describe the WHO pain ladder
1- paracetamol or NSAID
2- codeine
3- strong opiate such as morphine
What is resuscitation
Process of correcting physiological disorders in an acutely unwell patient
List some clinical indicators of a deteriorating patient
Tachypnoea
Tachycardia
Hypotension
Reduced conscious level
All patients get high flow oxygen - true or false
TRUE
What is hypoxic drive
Long term pulmonary disease leads to CO2 retention
High CO2 means breathing switches and becomes driven by oxygen levels
What causes a torus fracture
Fall onto outstretched hand
Seen in kids
What is a plastic deformation fracture
Unique to children
Bone bends and becomes deformed rather than snapping
Needs manual correction which takes a lot of force
Children’s bones have remodelling potential - true or false
TRUE
What is Wollfs Law
Healthy bone will adapt to the load under which it is placed
What is Hueter-Volkman’s Law
Compression forces inhibit bone growth and tensile forces stimulate growth
List factors that would make you suspect NAI
History that doesn’t match nature/severity of injury
Vague or changing stories
Accusation of child hurting themselves deliberately
Delay in seeking help
Child dressed inappropriately for scenario
What are some key signs of NAI
Fractures in children under 2 - pre-walking
Injuries in various healing stages
More injuries than you’d expect
Injuries scattered across body
Increased intercranial pressure in infant
Intra-abdominal trauma in child
Injury that doesn’t fit story
What would you look for in a neurovascular exam
Colour Cap refill Skin temp O2 sats Pulse Sensation Sweating Skin wrinkling in water - if nerve damaged this wont happen
What hand movement would you do to test the median nerve
OK sign
What hand movement would you do to test the radial nerve
Thumb’s up or Hitchhiker’s thumb
What hand movement would you do to test the ulnar nerve
Star fish
Splay all fingers
What injury commonly affects the radial nerve
Humeral shaft fracture
What injury commonly affects the ulnar nerve
supracondylar, forearm and hand fractures
What injury commonly affects the median nerve
Elbow dislocation
What causes fractures to displace?
Muscle action and gravity
Initial force on impact
What type of splint is used for femoral fractures
Thomas splint
What is Gallows traction
Legs are suspended to apply traction to legs
Used in femoral shaft fractures
What are the pros and cons of pinning long bones
Gives predictable position for rapid healing and early mobilization
Comes with surgical risks - infection and anaesthetics
When would you operate on a child fracture
Displaced intra-articular fractures
Displaced growth plate injuries
Open fractures
List common fixation techniques and when they are used
Flexible nails - diaphysis
K wires - metaphysis
Wires and screws - epiphysis
Why can you not put a screw across the physis when fixing a fracture
It will cause premature stop in growth
Describe the 5 types of Salter-Harris fractures
Grade 1 - Straight across physis - separates epiphysis and metaphyis
Grade 2 -Transversely through physis but exits through metaphysis forming triangular fragment
Grade 3 - Crosses physis and exits through epiphysis
at joint space
Grade 4 - Through everything! Extends upwards from the joint line,
through the physis and out the metaphysis
Grade 5 - Crush injury to growth plate
What is the most common type of shoulder dislocation
Anterior
What injury typically causes anterior shoulder dislocation
Fall onto outstretched hand with an externally rotated shoulder
What injury typically causes posterior shoulder dislocation
Direct blow to front of shoulder
Associated with seizures
What injury shows up with the light bulb sign
Posterior shoulder dislocation
Looks like light bulb on x-ray
How do you manage a dislocated shoulder
Closed reduction under sedation
Open reduction - severe/complex cases
Stabilisation and rehab
Risk of re-dislocation increases as you age - true or false
False
Decreases with age
What injury typically causes an elbow dislocation
Fall onto outstretched hand
What directions can an elbow dislocate in
Posterior
Anterior
Medial/lateral
How do you manage an elbow dislocation
Closed reduction under sedation
Open reduction - rarely needed
2 weeks in sling and rehab
What injuries can cause an interphalangeal joint dislocation
Hyperextension
Direct axial blow
What directions do IPJ’s dislocate in
almost always pos
How do you manage an IPJ dislocation
Closed reduction under local nerve block
Open reduction - rare
2 weeks in buddy strapping
If unstable strap into Edinburgh position
What injury typically causes a patellar dislocation
Sudden quads contraction with a flexing knee
Which direction does the patella dislocate in
Lateral
Who commonly gets patellar dislocations
Teenagers
More common in girls
What increases your risk of a patellar dislocation
Hypermobility Under-developed lateral femoral condyle Increased Q angle Lateral quads insertions Weak vastus medialis
What forms the Q angle
Line from ASIS to midpoint of patella
2nd line from tibial tuberosity through midline of patella
The angle the 2 lines form is the Q angle
How does a patellar dislocation present
Clear history
Pain medially
Effusion
Positive patella apprehension test
How do you manage a patellar dislocation
Reduce with knee extension Radiographs Aspirate Brace Physio Surgery if repeat dislocations
Who is most commonly affected by knee dislocations
Teenagers
More common in girls
What surrounding structures can be injured in a knee dislocation
Popliteal artery or vein
Peroneal nerve
Ligaments
How do you manage a knee dislocation
Reduction under sedation
Surgical reduction if needed
Stabilise in splint or by external fixation
Which injuries can cause a hip dislocation
High velocity injury - RTA
Fall from height
Which direction does a hip normally dislocate in
Posterior
which fractures are often associated with a hip dislocation
Posterior acetabular wall
Femur
How does a dislocated hip present
Flexed, internally rotated and adducted knee
what urgent management is needed for a dislocated hip
neurovascular assessment
radiographs and CT
urgent reduction
stabilise in tractions if required
What are the definitive managements for hip dislocations
Fixation of associated fractures
Fixation of other injuries in poly-trauma
What are some potential complications of a hip dislocation
Sciatic nerve palsy
Avascular necrosis of the femoral head
Secondary osteoarthritis of hip
What is an open fracture
Bone disruption where there is an overlying break in the skin and tissue
High energy injury
The break in sin communicates directly with the fracture and its haematoma
What is the other name for an open fracture
Compound fracture
What is a comminited fracture
One with 3 or more pieces
What is an avulsion fracture
Where a small piece of the bone is pulled off by a muscle or tendon which is attached to it
What is meant by the translation of a fracture
The extent to which the fracture fragments are not axially aligned - e.g. shifted to the left/right
Typically you describe the displacement of the distal fragment relative to the proximal one
Express as a % of bone width and the direction
What is meant by the angulation of a fracture
Extent to which fracture
fragments are not
anatomically aligned in a
angular fashion - what is the angle between fragments
Typically you describe the angle that the distal fragment is pointing relative to where it should be
Describe in degrees or as valgus, parallel or varus
What is meant by the rotation of a fracture
Extent to which fracture fragments are rotated relative to each other
Typically you describe which direction the distal fragment is rotated relative to the proximal portion of the bone
Aside from an obvious break in the bone, which other x-ray signs may suggest fracture
Periosteal reaction - whiter area on bone
Callus
Visible fat pad in elbow- means there is an effusion in the joint, typically a intraarticular elbow fracture
Lipohaemarthrosis - blood and flat leak out. less dense fat floats on top creating a line
What is a segmental fracture
A fracture with at least 2 fracture lines which together isolate a segment of bone - have a piece basically floating in the middle, unattached to anything
What is ORIF
Open reduction and internal fixation
What are some of the risks of hemiarthroplasty
Dislocation risk
Infection risk
Risk of loosening
What is the difference between unipolar and bipolar hemiarthroplasty
Unipolar - only the femoral head is replaced and it connects to the natural socket
Bipolar - femoral head is replaced but you also place artificial liners in the socket - better ROM and less likely to erode the acetabulum
The higher the grade of salter harris fracture, the more likely they are to cause growth disturbance - true or false
True
