Fractures Flashcards
Which of the following are high energy or low energy:
- Sports injury
- RTA
- Fall
- Fall from height
Low
- sports injury
- fall
High
- RTA
- fall from height
In what circumstances does primary bone healing take place?
Hairline fractures (fractures <1mm displacement)
In secondary bone healing (what occurs in the majority of fractures) a soft callus forms first followed by a hard callus before remodelling takes place.
What occurs before soft callus is formed?
What is soft callus formed of?
What is hard callus formed of?
What is remodelling?
Formation of hematoma at break site
Soft callus - cartilage
Hard callus - calcium mineralization leads to
immature bone
Remodelling - pattern of constant replacement of old bone
For each of the following descriptions state the name of the most likely pattern of fracture:
- Fractured at 2 separate points on the shaft
- Fracture v. unstable to rotational force, occurred due to torsional forces
- Fracture obtained from sudden deceleration, shortened limb
- Fracture with 3 or more fragments, sustained through high energy injury
- Fracture obtained from bending force with one side of bone under compression and other under tension
- Fractured at 2 separate points = segmental
- Fracture v. unstable to rotational force, occured due to torsional forces = spiral
- Fracture obtained from sudden deceleration, shortened limb = oblique
- Fracture with 3 or more fragments, high energy injury = comminated
- Fracture obtained from bending force = transverse
Difference between intra and extra articular fracture?
Intra = fracture goes into joint
How is a fracture of a long bone described?
Affecting proximal, middle or distal 3rd
Affecting diaphysis, metaphysis or epiphysis
What is an “off-ended” fracture?
100% translation/displacement
Fractures can be displaced in 3 ways - name them
- Translation/displaced
- Rotation
- Angulation
What is the most important thing to remember when describing fractures?
Describe the distal part of fracture in relation to proximal part
What are the 4 clinical signs of a fracture?
- Deformity
- Localised bony tenderness
- Crepitus
- Swelling
If a patient cannot weight bear on injured lower limb what should be requested?
X-ray
What 4 things must be remembered to be noted in assessment of an injured limb?
- Neurovascular assessment
- Closed/open
- Status of skin/soft tissue enveloping fracture
- Compartment syndrome?
Under certain circumstances (bone grossly displaced, risk of skin damage, obvious fracture dislocation) the fracture may be reduced prior to Xray being taken.
Will this impact on fractures showing up on Xray?
When a fracture is causing excessive pressure on the skin, how may this present?
Nope - will still show up
Tenting of the skin (raised and under lots of pressure)
“Blanching” (white)
What is ORIF?
Open reduction + Internal fixation
How are intra-articular fractures managed?
ORIF
What kind of fracture would a period of splintage/ immobilization be adequate management?
Stable minimally displaced/angulated fractures
When a displaced/angulated fracture is deemed unacceptable to be left, closed reduction under anaesthetic occurs.
What then follows?
Cast application performed with many X-rays to ensure correct positioning
Compartment syndrome can result as complication of long bone fracture (particularly in the forearm and leg).
What is it though?
Increase in pressure in compartments -> venous supply obstructed -> arterial supply obstructed -> hypoxia
Patient A recently suffered a tibial fracture which has been bandaged and today is presenting with “deep sharp” pain in leg which she feels is worse when she stretches it.
On examination the muscle is solid and hard to the touch and tender.
What is done next?
What must not be done to reduce pressure?
- Phone Senior
- Remove all bandages and casts
- DO NOT ELEVATE
Fasciotomy - open surgery cutting through fascia - left for a few days before underlying cause of compartment syndrome is identified
What can result from compartment syndrome not being treated quickly enough?
Volkmann’s contracture - due to necrosis of muscle
What must be done if there are signs of reduced distal circulation?
Emergency surgical vascular review + emergency surgery management
Define de-gloving.
How does it present?
Avulsion of skin from underlying blood vessels
Non-blanching
~Insensate (loss of sensation)
If skin is very swollen and contused (bruised), surgery through it is not recommended. Why?
It may not be able to fully heal -> infection -> necrosis
If suspicious of non-union, X-rays or CT scans can be done to view what?
Bridging callus
What tend to heal faster metaphyseal or cortical fractures?
Metaphyseal
What is the slowest healing bone in the body?
Tibia
What causes hypertrophic non-union? Describe what it looks like on Xray
What causes atrophic non-union? Describe what it looks like on Xray
Hypertrophic
- due to too much movement when healing taking place
- large callus formation
Atrophic
- not enough nutrients to the area
- too large a space between fragments
- no evidence of callus formation on Xray
DVT is a common complication particularly of pelvis and major lower limb fractures. What should be given as prophylactic to each “at-risk” patient?
LMWH
What is fracture disease?
Stiffness and weakness due to fracture and time in cast
Post injury a patient presents with
- unexplained neurological pain
- skin changes
- allodynia (pain response to non-painful stimuli e.g. touch)
- swelling
What are they suspected of having?
How is this managed?
CRPS - complex regional pain syndrome
Pain specialists
What classification system is in place to define open wounds around fractures?
Gustilo classification
What is the initial A&E management of an open fracture?
How are they managed more long term?
IV co-amoxiclav (IV co-trimoxazole + metronidazole if pen. allergic) - within 3 hours of injury
Tetanus jag (if unknown give vaccine, if v.contaiminated give Ig as well)
Sterile dressing
Internal or external fixation with early and thorough debridement
What tissues accept a skin graft?
Muscle
Fascia
Granulation tissue
Periosteum
NOT fat
What are the 4 P’s associated with compartment syndrome?
Pain
Pallor
Parathesia
Pulseness (late stage)
In what circumstances is external fixation used?
When poor soft tissue envelope
What type of fracture would result in increase in bone length?
What type of fracture would result in bone shortening without loss of alignment?
Increase bone length -> Distraction
Bone shortening without loss of alignment -> impaction
What is the name for open fractures caused by:
- out > in
- in > out
What wound is usually, but not always, small wounds?
out > in = penetrating
in > out = secondary
Small wounds = secondary
What pain relief is initially given for fractures?
IV morphine
Nerve blocks
What type of fracture should bound to prevent blood loss?
Pelvic injuries
When documenting fractures in a history why should anagrams such as FOOSH be avoided?
Give a v detailed history like a proper statement in case needed for court
What condition is associated with pain on PASSIVE stretching?
Compartment syndrome
What type of fractures are compartment syndrome most closely related with?
Supracondylar
Tibial shaft
