Fractures Flashcards
What is a dislocation?
Complete joint disruption
What is a subluxation?
Partial dislocation
How can dislocations be diagnosed?
Clinical exam and radiology
Which injuries are associated with dislocations?
- Fractures
- Neurovascular damage
What are the long term effects of a dislocation?
- Recurrent instability
- Stiffness
Why are open fractures important?
- Higher energy injury
- Increased infection rate
- Soft tissue complications
- Long term morbidity
Describe the Gustilo classification of open fractures
- Type 1: wound < 1 cm, clean and simple
- Type 2: wound > 1 cm, moderate tissue damage but simple and adequate skin coverage
- Type 3: extensive soft tissue damage and complex
- 3A: adequate periosteal coverage
- 3B: requires soft tissue covering procedure
- 3C: vascular injury requiring repair
How should open fractures be managed?
- Full ATLS assessment and treatment
- Tetanus and antibiotic prophylaxis
- Cefuroxime/ augmentin/ clindamycin - Gent at the time of fixation
- Repeated examination of n/v status
- Wound only handled to remove gross contamination
- Photograph, cover and stabilise limb
- No provisional irrigation/exploration
- Radiographs
When is emergency urgent surgery required for an open fracture?
- Polytraumatised patient
- Marine or farmyard environment
- Gross contamination
- Neurovascular compromise
- Compartment syndrome
What are the four Cs of surgical debridement and fixation?
- Colour
- Contraction
- Consistency
- Capacity to bleed
When should an amputation be considered?
- Insensate limb/foot
- Irretrievable soft tissue or bony tissue
- Other life threatening injuries
Describe the features of cortical bone
- Diaphysis
- Resists bending and torsion
- Laid down circumferentially
- Less biologically active
Describe the features of cancellous bone
- Metaphysis
- Resists and absorbs - compression
- Site of longitudinal growth
- Very biologically active
What is a fracture?
A break in the structural continuity of bone
Why can bones fail?
- High energy transfer in normal bones
- Repetitive stress in normal bones
- Low energy transfer in abnormal bones (osteoporosis, metastatic tumour etc.)
Describe stage 1 of fracture repair
- Inflammation
- Begins immediately after fracture
- Haematoma and fibrin clot
- Platelets, PMNs, neutrophils, monocytes and macrophages
- By products of cell death - lysosomal enzymes
- Fibroblasts
- Mesenchymal and osteoprogenitor cells
- Angiogenesis
How can we affect stage 1 of fracture repair?
- NSAIDs
- Loss of haematoma: open fractures or surgery
- Extensive tissue damage: poor blood supply
Describe stage 2 of fracture repair
- Soft callus
- Begins when pain and swelling subside
- Lasts until bony fragments are united by cartilage or fibrous tissue
- Some stability of the fracture
- Angulation can still occur
- Continued increase in vascularity
How can we effect stage 2 of fracture repair?
- Replace cartilage
- Bone graft or bone substitutes
Which bone graft is the gold standard?
Autogenous cancellous bone graft
Describe stage 3 of fracture repair
- Conversion of cartilage to woven bone
- Typical long bone fracture: endochondral and membranous bone formation
- Increasing rigidity and obvious callus
Describe stage 4 of fracture repair
- Conversion of woven bone to lamellar bone
- Medullary canal is reconstituted
- Bone responds to loading characteristics Wolff’s law
What is delayed union?
-Failure to heal in expected time
What are the risk factors for delayed union?
- High energy injury
- Distraction
- Instability
- Infection
- Steroids
- Immune suppressants
- Smoking
- Warfarin
- NSAID
- Ciprofloxacin
What is non union and how does it present?
- Failure to heal
- Failure of calcification of fibrocartilage
- Instability
- Abundant callus formation
- Pain and tendernes
- Persistent fracture line
- Sclerosis
How can delayed healing be managed?
- Different fixation
- Dynamisation
- Bone grafting
