Fractures

Question 1

What are the two main classifications of fracture?

Answer 1

Closed - Skin intact

Open (also known as compound) - Skin broken around fracture

Question 2

What are the open fracture classifications described in Gustilo-Anderson classes?

Answer 2

Type I
Type II
Type III

Question 3

What are the characteristics of a Type I Gustilo-Anderson open fracture?

Answer 3

Low-energy clean wound

<1cm

Minimal soft tissue injury

Minimal fracture comminution

Question 4

What are the characteristics of a Type II Gustilo-Anderson open fracture?

Answer 4

Wound 1-10cm

Moderate soft tissue damage

Moderate fracture comminution

Question 5

What are the characteristics of a Type III Gustilo-Anderson open fracture?

Answer 5

High-energy wound

> 10cm

(IIIA No periosteal stripping, IIIB Periosteal stripping and IIIC Major vascular injury)

Question 6

Define COMMINUTION

Answer 6

A comminuted fracture is a break or splinter of the bone into more than two fragments.

AKA splintering

Question 7

What are the types of simple fracture?

Answer 7

Single fracture line producing two clear fracture fragments:

• Transverse
• Oblique
• Spiral

Question 8

What is an intra-articular fracture?

Answer 8

If the joint surface is affected.

If it isn’t, it’s considered extra-articular.

Question 9

What is a Unplaced / Displaced fracture?

Answer 9

unplaced - bone fragments stay in alignment

displaced - loss of alignment (more jigsawing to do)

Question 10

What things would you look for when classifying a fracture? (5)

Answer 10

Simple / Comminuted?

Intra/Extra Articular?

Unplaced / Displaced / None?

Pathological? (i.e. tumour)

Epiphysis involvement? Salter-Harris type?

Question 11

What are some immediate complications of fractures? (5)

Answer 11

(From minutes to hours)

Pain

Nerve / blood vessel / skin / muscle damage

Fat embolisms

Visceral damage (i.e. pneumothorax if rib fracture)

Disruption to overlying tissues

Question 12

What are some early complications of fractures? (4)

Answer 12

(From hours to days)

Compartment syndrome

Immobility

Wound Infection (if open wound)

DVT & PE

Question 13

What is compartment syndrome?

Answer 13

• Increased pressure in a closed fascial compartment.
• Osseofascial compartments have a fixed volume, so adding to this volume (with blood or traumatic exudate) will compartment pressure.

Question 14

What is the risk associated with untreated compartment syndrome?

Answer 14

If compartment pressure exceeds capillary pressure then this results in ischaemia.

Ischaemia will initiate a vicious cycle of more trauma exudate which increases pressure.

Untreated, this can lead to irreversible muscle necrosis.

Question 15

What is the treatment for compartment syndrome?

Answer 15

Emergency fasciotomy for pressure relief

Question 16

What are the symptoms of compartment syndrome? (4)

Answer 16

Post trauma:

Disproportionate pain
Pain on passive stretching of muscles

Palpable tense compartment and parasthesia

Terminal sign: pulselessness

Question 17

What are some late stage (weeks to months) complications of fractures? (6)

Answer 17

Stiffness

Sudek’s Atrophy

Malunion / Delayed union / Non Union

Pseudoarthrosis

Secondary Osteoarthritis

Chronic Osteomyelitis.

Question 18

What’s the inital treatment steps you give to someone presenting in A&E with a suspected fracture? (3)

Answer 18

1) Analgesia
2) Risk assessment - venous thromboembolisms and implement prophylactic heparin, anti-embolism stockings.
3) Identify and treat other injuries

MNEMONIC: A.R.I

Question 19

What are some fracture specific treatments? (5)

Answer 19

1) Reduction

2) Hold
a. Operative - Internal Fixation / External fixation
b. Non Operative - Simple spints, plaster of Paris, fibreglass casting.

3) Rehabilitaion (physio / OT)

Question 20

What can you consider for the treatment for open fracture? (4)

Answer 20

Dislocation reduction

Open fracture infection prevention (i.e. wound photo, Abx, tetanus)

Compartment syndrome emergency fasciotomy

Check for vascular compromise with angiograph