Fractures Flashcards
what are the acute complications of fractures
Compartment syndrome
visceral injury
Vascular Injury
Nerve Injury
Infection
Rhabdomyolysis
Bleeding
what is compartment syndrome
increased pressure in osteofascial compartment leading to ischaemia and necrosis due to a viscous cycle of increased pressure forcing fluid out of capillaries which causes increased pressure forcing out further fluid and so on
when does damage tend to occur in compartment syndrome
6 hours
what compartments are usually affected with compartment syndrome
forearm/leg flexor
what are the clinical features of compartment syndrome
worst pain ever - described as bursting
not relieved by strong opioid analgesia
still a pulse and limb is warm and red
how do you diagnose compartment syndrome
lot done clinically but if there is doubt compartment pressure can be done
> 30 over diastolic blood pressure means immediate fasciotomy is required
what is the management for compartment syndrome
Remove cast/bandage/dressing
Elevate limb
Immediate fasciotomy if high clinical suspicion or positive pressure readings
Debridement if any necrosis present
Aggressive IV fluids due to risk of myoglobinuria and AKI
Leave wound open and inspect in 2 days for potential closure
what suggests vascular injury in a fracture
6 Ps
pain pulseless perishingly cold parasthesia paralysis pale
what are chronic complications of fractures
Infection
DVT/PE
Pressure sores
Delayed union
non-union
mal-union
avascular necrosis
joint instability
OA
complex regional pain syndrome
what are local risk factors for delayed union of a fracture
poor blood supply
infection
poor apposition of bone ends
presence of foreign bodies
what are systemic risk factors for delayed union of a fracture
poor nutritional status
smoking
corticosteroid therapy
what are clinical features of delayed union of a fracture
persisting fracture tenderness
on XR - very little callous formation, fracture line still visible
what’s the treatment for delayed union of a fracture
elimiate any local or systemic cause
immobilise bone in plaster
promote muscular exercise within the cast to encourage union
when is fracture non-union diagnosed
when the fracture hasn’t healed over 2x the time expected
clinical features on non-union of a fracture
Movement can be elicited at the site
Pain dimishes as the site gap becomes a pseudoarthritis
XR – fracture is clearly visible
what are the subtypes of non-union of a fracture
hypertrophic non-union where the fracture ends are enlarged
atrophic non union where there is no evidence of bone growth and the ends are tapered
how do you treat non union of a fracture
Conservative
Splinting
Functional bracing
Surgical
Rigid fixation +/- bone graft
what is mal-union of a fracture
bones unite in the wrong position
usually due to inadequate reduction or immobilisation
what are the treatments for mal-union of a fracture
remanipulation
osteotomy
internal fixation
limb lengthening procedures
what is a colles fracture
fracture of distal radius with dorsal displacement of the distal fracture
what mechanism of injury causes a colles fracture
FOOSH (fall on outstretched hand)
what patient group is most commonly associated with colles fracture
elderly women with osteoporosis
what physical change change is seen in colles fracture
Dorsal displacement of radius and radial impaction leading to a shortened radius compared to the ulna
Classically called a dinner fork deformity
whats the treatment for a colles fracture
initial manipulation and traction
application of a plaster to maintain traction
if good position = XR 1 + 2 weeks after to assess
if not positioned well or is a communated fracture = open reduction/internal fixation via a plate
what are common complications of colles fracture
median nerve damage/post traumatic carpal tunnel syndrome
what is a smiths fracture
opposite of colles - FOOSH but with back of hand striking floor first
distal radial fracture with volar displacement of the distal fragment
how do you treat a smiths fracture
generally more unstable so open reduction + internal fixation
what is the most commonly fractured carpal bone
scaphoid fracture
what mechanism of injury causes a scaphoid fracture
similar to colles - FOOSH, usually hyperextension of wrist
where is the pain worse in scaphoid fractures and what movements are weak
anatomical snuffbox
weak pinch grip
how is a ?scaphoid fracture investigated
scaphoid series of x rays
AP, lateral, + 2 oblique views
what should be done if you suspect a patient has had a scaphoid fracture but initial investigations are normal
treat as a fracture patient with repeat XRs out of plaster at 2 weeks and repeat clinical exam
what is the treatment of scaphoid fracture
plaster + thumb immobilisation
what time period is a scaphoid fracture expected to get better for
6-8 weeks
what are the risks of scaphoid fractures
10% non union
avascular necrosis
what is the monteggia fracture
proximal ulnar fracture with associated dislocation of the proximal radial head
(MUrderous)
what is the galaezzi fracture
proximal radial fracture with asociated dislocation of the proximal ulnar head
what is more common between the monteggia and galeazzi fracture
monteggia
what is a complication of monteggia and galeazzi fractures
anterior interosseus nerve injury
what would an anterior interosseus nerve injury cause
loss of pinch grip between thumb and forefinger due to flexor digitorum profundus and flexor pollicus longus
what is a barton’s fracture
distal radius fracture involving the articular surface with dislocation of the radiocarpal joint
what is a bennets fracture
intra-articular fracture of base of thumb metacarpal
what would you expect to find on examination in a femoral neck fracture
hip pain on passive movements
if fracture displaced: shortened, externally rotated leg
what arterys supply the femoral head
intramedullary vessels
medial/lateral circumflex artery
artery of ligamentum teres
what blood supply is interrupted in displaced femur fractures
circumflex blood supply
intermedullary
remaining artery of ligamentum teres is not enough
what blood supply if interrupted in non displaced femur fractures
intermedullary
what are the 3 subtypes of femur fractures
intracapsular
intertrochanteric
subtrochanteric
what is defined as an intracapsular fracture of the femur
NOF fractures
proximal to capsular insertion of the femoral head just above intertrochanteric line
what is the garden criteria and what is each subheading in the criteria
criteria used when assessing intracapsular femur fractures
1 = incomplete impacted fracture
2= complete fracture across neck but not displaced
3 = complete fracture, partial dislocation with some continuity between heads
4 = complete fracture, no continuity between heads
how do you manage garden 1-2 intracapsular fractures of the femur
Open reduction and internal fixation
Low risk of AVN so with cannulated hip screws
how do you manage garden 3-4 intracapsular fracture of the femur + why is it different to garden 1-2
hemiarthoplasty if not that mobile or independent, total hip replacement if patient is mobile and competent with ADLs
however in younger patients open reduction and internal fixation generally done due to better prognosis
high risk of avascular necrosis
what is defined as an intertrochanteric fracture of the hip
fracture line is between trochanters and is therefore extracapsular
how do you manage intertrochanteric fractures
dynamic hip screw
how do you manage subtrochanteric fractures
intermedullary nail and hip screw
what is defined as a subtrochanteric fracture
fracture line is below the trochanters
what vertebral fractures are common
wedge fractures from osteoporosis
otherwise mainly trauma
how does a vertebral wedge fracture present
marked pain - worse on movement
spine kyphosis
what investigations should be done if you suspect osteoporitic fractures
AP + lateral x rays of spine
whats the treatment of osteoporotic fractures
Bed rest 1-2 weeks until pain subsides
Conservative
Mobilisation and muscle strengthening exercises
Marked wedging (>25% anterior height reduction) then a thoraco-columnar brace for 3 months may be used
Surgical
Kyphoplasty
Cement is injected into the collapsed vertebrae
Indicated in patients with ongoing pain that is confirmed to be at the level of the fracture
what’s a jeffersons fracture
C1 spinal fracture due to axial compression forces
how do you diagnose a jeffersons fracture
open mouth XR
whats a hangmans fracture
C2 fracture due to hyperextension of the neck
whats highly associated with an odontoid fracture
spinal cord injury
what is the most common fracture in adults
tibial
how do you treat tibial fractures
undisplaced/minimally undisplaced = full length cast
displaced fracture = reduction under anaethesia with XR guidance before cast application
limb is elevated and observed for 48 hours to assess for compartment syndrome
check with XR at 2 weeks
at 4 weeks change to below knees to allow weight bearing
what patients tend to get ankle fractures
young athletes, osteoporitic older women
how is a lateral ankle fracture classified
Weber classification
Weber A
Fracture is below the level of syndesmosis (tibulofibular joint)
Syndesmosis intact
Weber B
Fracture at the level of the syndesmosis
Syndesmosis partially intact
Weber C
Fracture above the level of the syndesmosis
Syndesmosis non-intact
what is a sign of ankle instability
talar shift
how do you manage a Weber A ankle fracture
Generally stable and therefore rarely requires operative management
6 weeks plaster usually sufficient
how do you manage a Weber B ankle fracture
Trial of conservative management if only one malleoli affected
Repeat XR at weeks 1,2+3 if any doubt remains about displacement
More than one malleoli fractures are never stable and therefore should be treated surgically (open reduction/internal fixation)
How do you manage a Weber C fracture
Never stable
Open reduction/internal fixation
If patient is able to tolerate
what are the ottowa rules for scanning an ankle fracture
XR of ankle only required if the patient is unable to weight bear, has pain and bony tenderness at the lateral/medial malleoli
XR of foot only required if if patient is unable to weight bear and has bony tenderness over navicular or base of 5th metatarsal
what are the salter harris classifications
I - Straight across the epiphyseal plate
II - part of it is above
III - part of it is below
IV - fracture is above + below (or through)
V - crush injury (erasure of the growth plate)
what is the general management of a closed long bone fracture
A to E resus
Pain relief
Imaging of whole bone, with joint above and below
Manipulation and stabilisation in a cast
Ensure ankle at 90 degrees dorsiflexion
Reimage to check positioning
Check for complications
Distal neurovascular status
Further management depends on the positioning post-manipulation
If fracture is well reduced conservative management may be used with long term immobilisation and prolonged follow up
If it has not, surgical management indicated
what is the general management of open long bone fractures
A-E resus
Pain relief
Checking of neurovascular status
Assess degree of soft tissue injury
IV ABx +/- tetanus prophylaxis
Imaging + theatre within 6 hours for definitive management and irrigation
Plastic surgery input may be required
what is the gustilo + anderson criteria
Gustilo + anderson criteria used
1 - Simple fracture, wound <1cm
2 – simple fracture, wound >2cm
3 – multifragmented fracture
3A: with adequate soft tissue cover
3B: requiring plastics input
3C: associated with vascular injury
what is the general management of every hip fracture patient
Full falls history should be done
Any previous fractures/bone pain before fall
Malignancy/osteoporosis
How long patient was on floor
Bloods Coagulation G+S FBC U+E CK if long lie
ECG
CXR
AP pelvis/lateral Xray
Whole femur should be imaged if a pathological fracture is suspected
whats the prognosis of hip fractures
10-20% of patients require a change to a more dependent residental status
10-50% die within a year of a hip fracture
Mobilisation within 24 hours of treatment gives best outcomes
