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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
What fixation
``` 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
26
What do you do after fixation of joint
Immobilise proximal and distal joint | May need bone graft or skin coverage
27
When do you amputate
Irretrievable soft tissue or bone damage MESS Score Life threanting
28
What can be used to treat fracture
``` 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 ```
29
What is aim of rehab
Resotre patient to pre-injury level | Immobility will lead to loss of bone and muscle mass
30
What are complications of fracture
``` 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 ```
31
What is malunion
Fracture heals but not in correct way
32
What is AVN
Compromise of blood supply and bone diseases
33
What bones are common
Head of femur Proximal scaphoid As retrograde blood supply
34
What increases risk of AVN
``` Long term steroid Chemo Alcohol Trauma Smoking Fracture ```
35
How do you Dx AVN
MRI = gold | X-ray may show osteopenia or micro fractures
36
How is it treated
Joint replacement
37
What does AVN cause
Pain | Increased risk of fracture
38
What causes delayed union of bone
``` High energy Instability Infection Steroid Immunosuppression Smoking Warfarin NSAID = avid if possible Ciprofloxacin ```
39
What is the blood supply to the femoral head
Medial and lateral femoral circumflex | Some from ligamentum teres
40
What does this blood supply mean
At risk of AVN if above inter-trochnateric line (intracapsular)
41
What are site of hip / femur fractures
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 ```
42
What is intra and extra capsular
Intra = any above intertrochanteric - Subcapital - Transvervical
43
What is common fracture in elderly
Neck of femur 'transcervical' | Proximal fracture of femur
44
What are symptoms of hip fracture
Pain Leg length discrepancy Externally rotated Unable to weight bear
45
What are symptoms of femoral shaft fracture
``` Deformity Swelling Pain Leg shortening Soft tissue injury or bleeding as huge force required ```
46
What are RF for hip fracture
``` Same as osteoporosis Age Low BMI / muscle mass i.e. sarcopenia Female Early menopause Steroid Smoking ETOH Falls risk ```
47
What do you do if admitted with hip fracture
X-ray Examination FBC, U+E, LFT, group and save
48
What do you do for occult
MRI | Have a high degree of suspicion if extreme pain and can't see on X-ray
49
What do you do if low impact
Screen for pathological causes
50
What are types of hip fracture for intracpasular Garden - For intracapsular fractures only !!
``` 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
What do you do prior to Rx of hip fracture and what is gold standard of NOF
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
What do you do for intracapsular undisplaced
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
What do you do for intracapsular displaced
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
What do you do for extracapusar
Dynamic hip screw Intramedullary nail Blood supply should not have been damaged
55
When do you do intramedullary nail
Oblique Transverse Subtrochnateric
56
What is aim of Rx
Immediate weight bearing
57
What are complications of surgery
Immediate - Bleed - Damage to nerve / vessel - 2 fracture in surgery Early - Infected haematoma - DVT / PE Late - Dislocation - AVN if fix
58
What causes tibial fracture
Knee forced into valves or varus
59
Who is it common in
Elderly
60
What is the classification
Schatzker
61
What is a toddler's fracture
Spiral undisplayed distal tibial fracture common in toddlers
62
What causes
Minor trauma | Can be sign of NAI
63
What are the signs
``` Tender Swelling Warmth Unable to weight bear X-ray may not show ```
64
How do you treat
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
How are ankle fractures classified and normal anatomy
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
What are different types of Weber and Rx
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
What are the rules to determine if X-ray
``` Ottawa Pain in malleolar zone + Inability to weight bear for 4 steps Tender distal tibia Tender distal fibula ```
68
How do you Rx ankle fracture
Depends on stability and co-morbid
69
What must be done ASAP if deformity
Reduction to take pressure of skin | High risk of necrosis
70
When do you do surgical repair and what
``` Young Unstable Displacemnt High velocity Proximal ORIF / plate / screws ```
71
When do you do conservative and what are options
Elderly as thin bones won't hold Stable fracture Mild displacement Cast followed by controlled ankle motion boot when healing taken place
72
What causes a distal radius fracture / wrist
High energy in young | Low impact in elderly
73
How does wrist fracture present
Deformity
74
How does radial head fracture present
Local tenderness over elbow | Sharp pain at lateral elbow at extremes of rotation
75
What should you do if low energy
DEXA
76
How do you Rx
Closed reduction and cast ORIF External fixation
77
What are associated injuries with distal radius fracture
Ulnar styloid Disruption of distal radio-ulnar joint Soft tissue injury
78
What causes a scaphoid fracture
FOOSH
79
What should you examine for in acute painful wrist
Scaphoid | Distal radius
80
What are symptoms of scaphoid fracture
``` 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
How do you Dx
X-ray but may not show CT / MRI Refer to ortho if suspect as risk of AVN
82
How do you Rx
Immobilise Splint Fracture clinic
83
What are complications
AVN | Damage to dorsal arch of radial artery
84
What are other causes of wrist pain
Distal radial fracture | Rupture of EBL - can't move thumb
85
Where are proximal humeral fractures common
Through surgical neck | Greenstick in children
86
How do you Rx
Collar and cuff 3 weeks Physio ORIF if significant
87
What has high risk of AVN
>1cm displacement
88
What should you do if suspect rib fracture
Check sats / HR Ausculate chest Check expansion
89
When do you Rx with surgery
Pain no managed Breathing affected Deformity
90
Complications of rip fracture
Pneumothorax | Chest infection if inadequate ventilation so give analgesia
91
What is Whiplash
Cervical strain caused by sudden neck extension + rebound flexion Common in rear end crash
92
What ae symptoms
Pain and stiffness
93
How do you Rx
Reassure Prompt recovery to activity Analgesia If >1 hours = likely permanent
94
What is compartment syndrome
Raised pressure within closed anatomical space When compartment pressure > capillary pressure = ischaemia Results in tissue ischaemia and necrosis if untreated
95
What are common causes of compartment syndrome
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
What causes decrease in compartment size
Tight plaster cast External pressure e.g. lying on arm Anti-shock garments
97
What causes increase in contents
Haemorrhage folllowing soft tissue energy or fracture Post op swelling Post ischaemic swelling
98
What are signs of compartment syndrome
``` 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
How do you Dx
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
How do you Rx
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
What are complications
``` 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
What do you give before treatment
IV fluids
103
What worsens condition
Anti-coagulation
104
When does fat embolism typically present
12-72 hours after | Typically fracture of long bone so fix quickly
105
What is classic triad
Resp distress Cerebral sign Petechiae
106
What are res signs
``` Tachycardia Tachypnoea Dyspnoea Pyrexia Hypoxia / low sars ```
107
What are derms signs
Red / brown impalpable petechiae | Subconjunctival haemorrhage
108
What are CNS signs
Confusion Agitation Retinal haemorrhage on fundsocpoy
109
How do you Dx
Clinical | CTPA- may not show if distal
110
How do you Rx
Fixation of long bone fracture DVT prophylaxis Supportive
111
What should you beware of post-fracture / immobile
PE | Fat embolism
112
What is a Monteggia
Proximal ulnar fracture with anterior displacement of radial head
113
What is seen on OSCE
Bottom half of ulnar broken and radius displaced
114
What is Galeazzi
Middle or distal 1/3 of radius fractures | Dislocation of distal radial ulnar joint
115
Look up image
OK
116
What is Colles and what is Smith and what can you damage
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
What is deep posterior compartment of leg
Popliteus Tibialis posterior FDL FHL
118
What is superficial posterior
Gastropnemius Plantaris Soleus
119
Remember cross-section of leg
OK

MSK (21 decks)

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