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MSK > Fractures > Flashcards

Fractures Flashcards

1
Q

What is a fracture

A

Any break in continuity of bone

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2
Q

What causes fractures

A

High energy in normal bone = traumatic
Repetitive stress = stress fracture
Low energy in pathological

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3
Q

What are causes of pathological

A

Osteoporosis / other bone disease
Primary malignancy
Bone mets

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4
Q

How are open fractures graded

A

Gustilo grading

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5
Q

What is a type 1 open fracture

A

Wound <1cm

Clean and simple

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6
Q

What is a type 2 open fracture

A

Wound >1cm but <10cm

Moderate soft tissue damage

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7
Q

What is a type 3 open fracture

A

Wound >10cm
Extensive soft tissue damage
Complex pattern
Any gunshot / farm injury or bone loss = type 3
Requires specialist centre with vascular / plastic surgeon

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8
Q

What is type 3 A,B,C

A 
A = adequate periosteal coverage
B = recovers flap or graft
C = vascular injury that needs repaired
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9
Q

What is stage 1 of fracture repair

A

Inflammation - fibroblast / neutrophils, cytokines and growth factor released
24-72 hours
Haematoma forms
Proliferation of undifferentiated cells (become osteoblasts)
Granuloma forms (granulation tissue) = external callus

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10
Q

What is stage 2

A 
Soft callus formation 
- Fibroblast = chondroblast which form hyaline callus
Osteoblast deposit collagen
Forms primary callus
Occur day 4-40
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11
Q

What is stage 3 of fracture repair

A

Hard callus formation

Clinical union of bone

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12
Q

What is stage 4 of fracture repair

A

Bone remodelling
Can continue for years
Shape of bone altered by resorption or replacement
Lamella bone formed with parallel collagen

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13
Q

What does ORIF do

A

Leads to primary bone healing
Remodelling immediate
No inflammatory repair or callus formation

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14
Q

How does soft tissue heal

A

Secondary intention

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15
Q

What must you always do with a fracture very early

A

ABCDE assessment
If unstable = ATLS
X-ray
Look for associated injury / haemorrhage
Assess distal neuromuscular
Vascular - temp, CRT, pulses to see if limb viable
Nerve - motor and sensory function
Careful imaging
Early debridement
Often leave open and irrigate with water then cover with saline dressing

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16
Q

What are indications for emergency 6 hour surgery

A 
Open fracture
Polytrauma
Marine / farm as risk of necrotising fasciitis 
Gross contamination
Neurovasuclar compromise 
Compartment syndrome
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17
Q

What is the MESS score

A 
Determines need for amputation 
Skeletal / soft tissue
Shock 
Ischaemia
Age
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18
Q

What suggests poor prognosis

A

> 6 hours

Tibial nerve divided

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19
Q

How long does UL tend to take to heal

A

6-8 weeks

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20
Q

How long does LL tend to take to heal

A

12-16 weeks

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21
Q

How long does it take for children to heal

A

About half of this

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22
Q

What guidelines for open fracture

A

BOAST 4

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23
Q

What do open fractures get

A 
6A's 
Assess
- ATLS / neuromuscular 
- X-ray 
- Air in soft tissue suggest open fracture (ski emphysema) 
- Take a photo  
Analgesia
IV Ax
- Broad spec - IV co-amox
Anti-septic 
- Wound irrigation = large volume and clear any gross contamination 
- Betadine dressing
- Swab for micro 
Alignment if deformity / splint
Anti-Tetanus - IM Ig + vaccine if not had all 5 
- Burns requiring surgery >6 hour wait
- Soil containation
- FB
- Compound fracture
- Systemic sepsis
Theatre ASAP and within 6 hours
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24
Q

What is required before fixation

A

Revascularisation
Reduction if displaced
- Aligment is more important than perfect opposition as this can be done at surgery
- Reduce in A+E
- Closed reduction under GA or LA = paeds
- Open reduction if failed conservative or requires more accurate or intra-articular or open fracture

Open reduction is often coupled with internal fixation

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25
Q

What fixation

A 
Conservativ
- Sling
- Plaster cast - do back slap with open front for first few days to allow swelling 
Internal fixation 
- Pins / plate / screw
- Usually with open reductio 
- Aids early mobilisation 
- Avoid if open fracture

External fixator often

  • If open fracture as making incision won’t heal
  • Excessive swelling
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26
Q

What do you do after fixation of joint

A

Immobilise proximal and distal joint

May need bone graft or skin coverage

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27
Q

When do you amputate

A

Irretrievable soft tissue or bone damage
MESS Score
Life threanting

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28
Q

What can be used to treat fracture

A 
Immobilisation of distal and proximal joint
Conservative 
Manipulation of deformity
External fixation - bar / frame / wire
Internal fixation - screw / plate / intramedullary nail 
Excision of loose fragments 
Prosthesis
Amputation
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29
Q

What is aim of rehab

A

Resotre patient to pre-injury level

Immobility will lead to loss of bone and muscle mass

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30
Q

What are complications of fracture

A 
Neurovascular 
Visceral damage 
Dislocation 
Subluxation = partial
Fat embolism
- Commonly with long bone so always fix early  
DVT
Compartment syndrome
AVN
Growth plate disturbance if paediatric 
Mal or non-union
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31
Q

What is malunion

A

Fracture heals but not in correct way

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32
Q

What is AVN

A

Compromise of blood supply and bone diseases

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33
Q

What bones are common

A

Head of femur
Proximal scaphoid
As retrograde blood supply

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34
Q

What increases risk of AVN

A 
Long term steroid
Chemo
Alcohol
Trauma
Smoking 
Fracture
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35
Q

How do you Dx AVN

A

MRI = gold

X-ray may show osteopenia or micro fractures

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36
Q

How is it treated

A

Joint replacement

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37
Q

What does AVN cause

A

Pain

Increased risk of fracture

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38
Q

What causes delayed union of bone

A 
High energy
Instability
Infection
Steroid 
Immunosuppression
Smoking
Warfarin
NSAID = avid if possible 
Ciprofloxacin
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39
Q

What is the blood supply to the femoral head

A

Medial and lateral femoral circumflex

Some from ligamentum teres

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40
Q

What does this blood supply mean

A

At risk of AVN if above inter-trochnateric line (intracapsular)

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41
Q

What are site of hip / femur fractures

A

Intracapsular
Subcapital - top of neck
Transcervical - through neck

Extra-capsular 
Intertrochanteric - on the line 
- Anterior line between greater and lesser trochanter 
Subtrochanteric - 5cm from line 
Proximal shaft
Middle shaft
Distal shaft
Supracondylar
Intercondylar
Condylar
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42
Q

What is intra and extra capsular

A

Intra = any above intertrochanteric

  • Subcapital
  • Transvervical
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43
Q

What is common fracture in elderly

A

Neck of femur ‘transcervical’

Proximal fracture of femur

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44
Q

What are symptoms of hip fracture

A

Pain
Leg length discrepancy
Externally rotated
Unable to weight bear

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45
Q

What are symptoms of femoral shaft fracture

A 
Deformity 
Swelling
Pain
Leg shortening
Soft tissue injury or bleeding as huge force required
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46
Q

What are RF for hip fracture

A 
Same as osteoporosis
Age
Low BMI / muscle mass i.e. sarcopenia 
Female
Early menopause
Steroid 
Smoking 
ETOH 
Falls risk
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47
Q

What do you do if admitted with hip fracture

A

X-ray
Examination
FBC, U+E, LFT, group and save

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48
Q

What do you do for occult

A

MRI

Have a high degree of suspicion if extreme pain and can’t see on X-ray

49
Q

What do you do if low impact

A

Screen for pathological causes

50
Q

What are types of hip fracture for intracpasular

Garden
- For intracapsular fractures only !!

A 
1 = incomplete + undisplaced
2 = complete + undisplaced
3 = complete + partially displaced (usually rotated and angulated) 
4 = complete bony disruption

Risk of AVN increases as higher risk of tearing blood vessel
3+4 = definite arthroplasty as blood supply likely damaged
Can consider fixation in 1+2

51
Q

What do you do prior to Rx of hip fracture and what is gold standard of NOF

A

Analgesia - nerve block common
Fluid resus
DVT prophylaxis - LMWH

Rx
1,2 screw
3,4 Austin more

Surgery 36 hour
Geries review - AMTS and delerium
Phyio and nutrition

52
Q

What do you do for intracapsular undisplaced

A

Internal fixation + Canulated screw
- Small risk of blood vessels disrupted so can do this if young to preserve hip

Hemiarthropalsty if unfit

THR if

  • Suitable anaesthetic
  • Can walk with no more than 1 stick
  • No cognitive
53
Q

What do you do for intracapsular displaced

A

Assume blood supply has been disrupted as displaced so high risk of AVN
For young patient can try ORIF as better to keep own hip and may have collateral

THR if not able to do ORIF / or if AVN occurs after

Hemiarthroplasty if very unfit / confused / can’t do rehab

54
Q

What do you do for extracapusar

A

Dynamic hip screw
Intramedullary nail
Blood supply should not have been damaged

55
Q

When do you do intramedullary nail

A

Oblique
Transverse
Subtrochnateric

56
Q

What is aim of Rx

A

Immediate weight bearing

57
Q

What are complications of surgery

A

Immediate

  • Bleed
  • Damage to nerve / vessel
  • 2 fracture in surgery

Early

  • Infected haematoma
  • DVT / PE

Late

  • Dislocation
  • AVN if fix
58
Q

What causes tibial fracture

A

Knee forced into valves or varus

59
Q

Who is it common in

A

Elderly

60
Q

What is the classification

A

Schatzker

61
Q

What is a toddler’s fracture

A

Spiral undisplayed distal tibial fracture common in toddlers

62
Q

What causes

A

Minor trauma

Can be sign of NAI

63
Q

What are the signs

A 
Tender
Swelling
Warmth
Unable to weight bear 
X-ray may not show
64
Q

How do you treat

A

Cast + follow up in fracture clinic
If no fracture seen still put in cast and X-ray in 10 days
If child not in significant pain then treat out of cast

65
Q

How are ankle fractures classified and normal anatomy

A

Weber

Tibia and fibular connect to talus (tibial talar)
Syndesmosis between tibia and fibula
Also have subtalar joint (talus and calcaneus)

3 malleolus

  • Lateral
  • Medial
  • Posterior
66
Q

What are different types of Weber and Rx

A

A = below syndemosis
- Rx = conservative with air cast boot

B = at syndesmosis

  • If no tear = conservative as stable
  • If syndesmosis torn = surgery (will have gap on X-ray between tibia and fibula)

C = above syndesmosis
- Unstable so need to fix with surgery

67
Q

What are the rules to determine if X-ray

A 
Ottawa
Pain in malleolar zone + 
Inability to weight bear for 4 steps
Tender distal tibia
Tender distal fibula
68
Q

How do you Rx ankle fracture

A

Depends on stability and co-morbid

69
Q

What must be done ASAP if deformity

A

Reduction to take pressure of skin

High risk of necrosis

70
Q

When do you do surgical repair and what

A 
Young
Unstable
Displacemnt
High velocity
Proximal 
ORIF / plate / screws
71
Q

When do you do conservative and what are options

A

Elderly as thin bones won’t hold
Stable fracture
Mild displacement
Cast followed by controlled ankle motion boot when healing taken place

72
Q

What causes a distal radius fracture / wrist

A

High energy in young

Low impact in elderly

73
Q

How does wrist fracture present

A

Deformity

74
Q

How does radial head fracture present

A

Local tenderness over elbow

Sharp pain at lateral elbow at extremes of rotation

75
Q

What should you do if low energy

A

DEXA

76
Q

How do you Rx

A

Closed reduction and cast
ORIF
External fixation

77
Q

What are associated injuries with distal radius fracture

A

Ulnar styloid
Disruption of distal radio-ulnar joint
Soft tissue injury

78
Q

What causes a scaphoid fracture

A

FOOSH

79
Q

What should you examine for in acute painful wrist

A

Scaphoid

Distal radius

80
Q

What are symptoms of scaphoid fracture

A 
Pain along radial aspect of wrist and base of thumb
Loss of grip strength
Max tenderness over anatomical snuff
Joint effusion
Pain on ulnar deviation
81
Q

How do you Dx

A

X-ray but may not show
CT / MRI
Refer to ortho if suspect as risk of AVN

82
Q

How do you Rx

A

Immobilise
Splint
Fracture clinic

83
Q

What are complications

A

AVN

Damage to dorsal arch of radial artery

84
Q

What are other causes of wrist pain

A

Distal radial fracture

Rupture of EBL - can’t move thumb

85
Q

Where are proximal humeral fractures common

A

Through surgical neck

Greenstick in children

86
Q

How do you Rx

A

Collar and cuff 3 weeks
Physio
ORIF if significant

87
Q

What has high risk of AVN

A

> 1cm displacement

88
Q

What should you do if suspect rib fracture

A

Check sats / HR
Ausculate chest
Check expansion

89
Q

When do you Rx with surgery

A

Pain no managed
Breathing affected
Deformity

90
Q

Complications of rip fracture

A

Pneumothorax

Chest infection if inadequate ventilation so give analgesia

91
Q

What is Whiplash

A

Cervical strain caused by sudden neck extension + rebound flexion
Common in rear end crash

92
Q

What ae symptoms

A

Pain and stiffness

93
Q

How do you Rx

A

Reassure
Prompt recovery to activity
Analgesia
If >1 hours = likely permanent

94
Q

What is compartment syndrome

A

Raised pressure within closed anatomical space
When compartment pressure > capillary pressure = ischaemia
Results in tissue ischaemia and necrosis if untreated

95
Q

What are common causes of compartment syndrome

A

Fractures = most common
- Cause oedema and raised pressure reducing venous drainage, leads to hypoxia and death
- Tibia in leg
- Supracondylar in arm
Most common = anterior compartment of leg as smallest but beware of deep

Other 
Ischaemia reperfusion injury
Crush injury
Long lie
Surgery
96
Q

What causes decrease in compartment size

A

Tight plaster cast
External pressure e.g. lying on arm
Anti-shock garments

97
Q

What causes increase in contents

A

Haemorrhage folllowing soft tissue energy or fracture
Post op swelling
Post ischaemic swelling

98
Q

What are signs of compartment syndrome

A 
Pain 
- On passive stretch e.g. big toe 
- Worse on movement
- Out of proportion to injury
- On palpation of compartment 
- Despite reduction and analgesia 
Swelling  
6P's = late sign and often irreversible 
Parathesia
Pallor
Paralysis
Altered CRT 
May still feel pulses as compartment affects microvascular not macro
Increased HR/ RR
NV = late sign
99
Q

How do you Dx

A

Clinical
PAIN ON PASSIVE STRECT
Always leave toe open so can test if putting in cast
Assess neurovascular status
>20 pressure on intra-compartment pressure

100
Q

How do you Rx

A

Analgesia
Remove any constricting dressing + splint cast
Hold limb at level of heart - elevate
Call registrar if suspect
Prompt and extensive fasciotomy within 6 hours
- Decompress all compartments of area affected
Debirde and amputate necrotic tissue

101
Q

What are complications

A 
Contracturese 
Volkman's ischaemic contracture in untreated forearm 
Necrosis
Infection 
Rhabdomyloysis 
Amputation
Chronic pain 
Myoglobinuria after fasciotomy
Renal failure due to ATN from habomylosis
102
Q

What do you give before treatment

A

IV fluids

103
Q

What worsens condition

A

Anti-coagulation

104
Q

When does fat embolism typically present

A

12-72 hours after

Typically fracture of long bone so fix quickly

105
Q

What is classic triad

A

Resp distress
Cerebral sign
Petechiae

106
Q

What are res signs

A 
Tachycardia
Tachypnoea
Dyspnoea
Pyrexia
Hypoxia / low sars
107
Q

What are derms signs

A

Red / brown impalpable petechiae

Subconjunctival haemorrhage

108
Q

What are CNS signs

A

Confusion
Agitation
Retinal haemorrhage on fundsocpoy

109
Q

How do you Dx

A

Clinical

CTPA- may not show if distal

110
Q

How do you Rx

A

Fixation of long bone fracture
DVT prophylaxis
Supportive

111
Q

What should you beware of post-fracture / immobile

A

PE

Fat embolism

112
Q

What is a Monteggia

A

Proximal ulnar fracture with anterior displacement of radial head

113
Q

What is seen on OSCE

A

Bottom half of ulnar broken and radius displaced

114
Q

What is Galeazzi

A

Middle or distal 1/3 of radius fractures

Dislocation of distal radial ulnar joint

115
Q

Look up image

A

OK

116
Q

What is Colles and what is Smith and what can you damage

A

Distal radial fracture with dorsal displacement

Distal radial fracture with volar displacement

Medial nerve - unable abduct thumb
If radial = unable extend wrist
If ulnar = weak ring and little finger

117
Q

What is deep posterior compartment of leg

A

Popliteus
Tibialis posterior
FDL
FHL

118
Q

What is superficial posterior

A

Gastropnemius
Plantaris
Soleus

119
Q

Remember cross-section of leg

A

OK

MSK (21 decks)

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