fractures

Question 1

what coud you use when describing location of a fracture/

Answer 1

Which bone?

Thirds (long bones)
 Proximal, middle, distal third

Anatomic orientation
 E.g. proximal, distal, medial,
lateral, anterior, posterior

Anatomic landmarks
 E.g. head, neck, body /
shaft, base, condyle

Segment (long bones)
 Epiphysis, physis,
metaphysis, diaphysis

Question 2

What type of fracture is this?

Answer 2

transverse fracture

• occurs with pure bending force where the cortex on one side fails in compression and the cortex on the other side in tension
• usually don’t shorten (ubless completely displaced) but may angulate or result in rotational malialignment

Question 3

what type of fracture is this?

Answer 3

oblique

• occur with shearing force (e.g. fall from height, deceleration)
• can be fixed with interfragmentary screw
• tend to shorten and may also angulate

Question 4

what type of fracture is this?

Answer 4

Segmental

• occur when bone is fracture in two seperate places
• very unstable and require stabilisation with long rods or plates

Question 5

what type of fracture is this?

Answer 5

linear/ longitudinal/ splint

Question 6

what type of fracture is this?

Answer 6

Comminuted (>3 pieces)

• generally reflection of higher energy injury (or poor bone quality)
• there may be substantial soft tissue swelling and periosteal damage with reduced blood supply to the fracture site which may impair healing
• very unstable and tend to be stablised surgically

Question 7

what type of fracture is this?

Answer 7

impaction/ compression

Question 8

what type of fracture is this?

Answer 8

Avulsion

Question 9

describing a fracture

Answer 9

can be described according to the site of the fracture, whether its position is satisfactory or not and its stability (likelihood of displacing) which is related to the fracture pattern and degree of initial displacement

A fracture of long bone can be described according to the site of the bone involved in terms of proximal, middle or distal third. It can also be described according to type of bone involved (diaphyseal, metaphyseal or epiphyseal)

A fracture at the end of a long bone (metaphyseal/epiphyseal) can be intra articular (extending into joint) or extra-articular. Intra-articular fractures have a greater risk of stiffness, pain, and post-traumatic OA.

Fracture displacement depends on the degree of translation, angulation and rotation

Question 10

describe translation

Answer 10

Sometimes confusingly called ‘displacement’

Extent to which Fx fragments are not axially aligned

Convention: describe displacement of distal fragment relative to proximal

Describe in % of bone width / direction (100% generally referred to as “off-ended” fracture)

** translation of distal fragment can be described as anterior or posterior displacement and medially or laterally translated

Question 11

describe angulation

Answer 11

The extent to which Fx fragments are not anatomically aligned in a angular fashion

Convention: describe angulation in the direction that the distal end of the bone is pointing to relative to where it should be

Describe in degrees

Question 12

describe rotation

Answer 12

Extent to which Fx fragments are rotated relative to each other

Convention: describe which direction the distal fragment is rotated relative to the proximal portion of the bone

Question 13

other signs of fracture on Xray

Answer 13

periosteal reaction

callus

fat pad sign - means there is intra-articular effusion. post injury = blood;

posterior fat pad sign always abnormal 9anterior can be normal

Question 14

management on subcapital and transcervical displaced fracture in the elderly

Answer 14

Unipolar hemiarthroplasty

Involves an open exposure of the hip joint - Anterolateral / Posterior • Resection and replacement of the native femoral head • Large metal head articulates with native acetabulum • Possible drawer backs: Dislocation risk, infection, loosening

Question 15

management on subcapital and transcervical displaced fracture in the slightly fitter

Answer 15

Bipolar hemiarthroplasty

Involves an open exposure of the hip joint

Resection and replacement of the native femoral head

22mm metal head articulated with polyethylene liner, which is encased in a large metal head liner, which articulates with native acetabulum

Advantages: ? ↑ROM; ↓Acetabular erosion • Disadvantages: Dislocation risk, infection, loosening

Question 16

subcapital and transcervical displaced fracture in the biologically fit and young

Answer 16

Total hip arthroplasty •

Advantages: ? ↑ROM; addresses deformity/pre- existing arthritis; longevity compared to hemiarthroplasty •

Disadvantages: Dislocation risk, infection, loosening

Question 17

undisplaced or stable impacted fractures

Answer 17

Cannulated screws

Suitable in #s with an intact chondral buttress, such as high transcervical or subcapital #s •

Limited approach required (? + capsulotomy) • Low profile and bone preserving •

Compression at the fracture site •

Biomechanical advantages of 3 screws •

Importance of placement / configuration

Question 18

basicervical fracture management

Answer 18

Biological and mechanical transition between intracapsular fractures and intertrochanteric fractures •

distal to capsule; vascular supply survives; decreased rate of AVN → FIXATION •

Bony neck cortices not intact → not favourable to cannulated screws •

Dynamic hip screws better resist bending forces

Question 19

intertrochanteric fracture

Answer 19

Zone of transition between the femoral neck and shaft 

Extracapsular, therefore, blood supply to femoral head unaffected and AVN risk ↓ 

Bony neck cortices not intact → not favourable to cannulated screws 

Dynamic hip screws better resist bending forces

Question 20

intertrochanteric fracture management

Answer 20

Dynamic hip screw •

Involves a limited approach to lateral proximal femur, fracture site not opened •

On-table reduction on trauma table •

Guide wire passed using fixed angle guide •

Large bore cannulated, partially threaded screw passed +/- de-rotation wire/screw • Importance of screw positioning (TAD) •

De-rotation plate allows compression at fracture site, increasing healing, decreasing non-union

Question 21

describe secondary fracture healing process

Answer 21

Question 22

name 5 fracture patterns

Answer 22

Question 23

name 3 fracture patterns

Answer 23

Question 24

treatment options for fracture

Answer 24

Non-surgical – boot, cast, splint, traction, etc •

Percutaneous wires •

External fixator • I

ntramedullary fixation •

Open reduction and internal fixation (ORIF) •

Arthroplasty •

Excison/amputation

Question 25

limping child

Answer 25

Question 26

what is buckle fracture

Answer 26

Compressive force in children

Question 27

what is Greenstick fracture

Answer 27

Force to one side of bone may cause break in only one cortex in children

Question 28

Plastic deformation

Answer 28

In very young children, neither cortex may break

Question 29

salter harris classification

Answer 29

higher grade fractures are more likely to cause growth disturbance

I. Fracture passes transversely through physis separating epiphysis from metaphysis

II Transversely through physis but exits through metaphysis – Triangular fragment

III. Crosses physis and exits through epiphysis at joint space

IV. Extends upwards from the joint line, through the physis and out the metaphysis

V. Crush injury to growth plate

Question 30

most common elbow fracture in children

Answer 30

supracondylar

Weakest part of the elbow joint where humerus flattens and flares

– Most are extension type (98%)

• Classified by Gartland – I, IIa, IIb, III

Potential for vascular compromise

– Check pulse!!! Reduce fracture if pulse compromised

– Check nerve function in hand

Question 31

elbow landmarks

Answer 31

Question 32

Gartland classification for supracondylar fractures

Answer 32

Gartland Classification (Extension Type): I – Undisplaced (treat conservatively) IIa – Displaced posteriorly but intact posterior periosteal hinge and anterior humeral line transects capitellum (normally treat conservatively) IIb - Displaced posteriorly but intact posterior periosteal hinge. Anterior humeral line does not transect capitellum (needs MUA +/- wires) III - Displaced posteriorly. No posterior periosteal hinge (needs MUA +/- wires)

Question 33

toddlers fracture

Answer 33

Children younger than 2 years old learning to walk

 No specific injury notable most of the time

 Child refuses to bear weight on leg – Examine hip, thigh and knee to r/o other causes of limping

 Often undisplaced spiral fracture of tibia with no fibular fracture

 Initial x-ray often normal- diagnosis on f/u films with lucent line or periosteal reaction

Question 34

factors suggesting NAI

Answer 34

Majority of fractures in child < 1 year are from abuse

Greater risk of abuse:

– first-born

– premature infants

– stepchildren

– children with learning or physical disabilities 

Most common sites: femur, humerus, tibia

Unexplained fractures in different stages of healing

Femoral fracture in child < 1 year 

Scapular fracture in child 

Epiphyseal and metaphyseal fractures of the long bones

Question 35

NAI bone fracture investigations

Question 36

Clinical signs of fracture

Answer 36

Localised bony (marked) tenderness - not diffuse mild tenderness

Swelling

deformity

Crepitus - from bone ends grating with an unstable fracture

*not all MSK injuries require X-ray to exclude fratures. Most are done on clincial judgement. Guidelibes e.g. ottawa for ankle injury exist. General rule - if a patient cannot weight bear, X-ray.

Question 37

Assessment of injured limb

Answer 37

• open or closed
• distal neurovascular status
• compartment syndrome?
• status of the skin and soft tissue envelope

Question 38

Investigations of fracture

Answer 38

• X-ray - usually AP and lateral. TWO VIEWS ALWAYS REQUIRED.
• CT can be used for complex fractures and can help determine the degree of articular damage and help surgical planning for complex intra-articular fractures
• MRI can be used for occult fractures where there is clinical suspicion but normal X-ray
• Technetium bone scans can be useful to detect stress fractures (e.g. hip, femur, tibia, fibula, 2nd metatarsal) as these fail to show up on x-ray until hard callus begins to form

Question 39

initial management of a long bone fracture

Answer 39

Assessment & analgesia

splintage/immobilization of the limb (temporary plaster slab, sling, orthosis, thomas splint if femoral shaft)

investigations

If fracture is grossly displaced, if there is obvious dislocation, if there is risk of skin damage from excessive pressure, reduction of the fracture shoul dbe perfoemed before waiting for x-rays. xray post reduction should still demonstrate ay fracture adequately.

Question 40

definitive fracture management of undisplaced, minimally displaced, and minimally angulated fractures which are considered to be stable

Answer 40

non-operatively with a period of splintage or immobilization and then rehabilitation

Question 41

definitive fracture management of displaced or angulated fractures where position is unacceptable

Answer 41

require reduction under anesthetic. They may perform closed reduction and cast application with serial X-rays to ensure no loss of position.

Question 42

definitive management of unstable injuries

Answer 42

surgical stabilisation which mau involve the use of small percutaneous pins (K-wires) for small fragments, cerclage wires, screws, plates & screws, intramedullary nails or external fixation

Question 43

definitive management of unstable extra-articular diaphyseal fractures

Answer 43

open reduction and internal fixation (ORIF) using plates and screws with the aim of anatomic reduction and rigid fixation leading to primary bone healing

It may be preferable to avoid ORIF particularly where the soft tissues are too swollen, where the blood supply to the fracture site is tenuous (high energy), where ORIF may cause extensive blood loss (eg femoral shaft) or plate fixation may be prominent (eg tibia). In this case closed reduction and indirect internal fixation with an intramedullary nail with dissection distant to the fracture site may be used with the aim of a functional reduction and stable fixation allowing micromotion required for secondary bone healing.

Another alternative for extra‐articular diaphyseal fractures is external fixation which again aims for secondary bone healing however carries the risk of pin site infection and loosening.

Question 44

definitive management of displaced intra-articular fractures

Answer 44

anatomic reductoin and rigid fixation by ORIF using wires, screws and plates.

Fractures involving a joint with predictable poor outcome may be treated with joint replacement or arthodesis

Question 45

Complications of fractures

Answer 45

Early local: compartment syndrome, vascular injury with ischaemia, nerve compression or injury, and skin necrosis

Early systemic: hypovolaemia, fat embolism, shock, ARDS, acute renal failure, SIRS, multi-organ dysfunction syndrome, death

Late local: stiffnessm loss of function, chronic regional pain syndrome, infection, non-union, malunion, Volkmann’s ischaemic contacture, post traumatic Oa and DVT

late systemic: PE (tends to be several days to weeks but can occur much sooner)

Question 46

open fracture managment

Answer 46

ABx

prompt surgery - debridement + internal or external fixation (list 3 reasons why)

May just need closed primarily if not contamined and skin and muscle is viable and can be closed without tension (resulting in skin necrosis and wound breakdown)

Question 47

dislocation and instability management

Answer 47

Any dislocation should be reduced as soon as possible. Most dislocations can be reduced by closed manipulation under sedation and analgesia or occasionally general or regional anaesthetic. Delayed presentation of a dislocation (eg in alcoholics) increases the risk of requiring an open reduction and recurrent insatbility.

Dislocations may occur after significant trauma however people with hypermobility (including Ehlers Danlos and Marfan’s) may sustain a dislocation with a seemingly innocuous injury and some can voluntarily dislocate joints (eg shoulder).

Dislocations can occur with associated injuries including tendon tears, nerve injury, vascular injury and compartment syndrome. Recurrent dislocation may require soft tissue repair / reconstruction or occasionally bony surgical prcedures.

Fractures can occur with dislocations (known as fracture‐dislocation) and these may reduce with closed reduction however ORIF may be required if reduction cannot be achieved, if a bony fragment prevents congruent reduction or if the joint is very unstable.

Question 48

complete spinal cord injury

Answer 48

Complete spinal cord injury results in no sensory or voluntary motor function below the level of the injury (reflexes should return). The level of the injury is determined by the most distal spinal level with partial function (after spinal shock has resolved) as determined by the presence of dermatomal sensation and myotomal skeletal muscle voluntary contraction. The prognosis for recovery from complete cord injuries is poor.

Question 49

incomplete spinal cord injury

Answer 49

With incomplete spinal injuries, some neurologic function (sensory and/or motor) is present distal to the level of injury. In general, the greater the function present,the faster the recovery is and the better the prognosis. Sacral sparing with preservation of perianal sensation, voluntary anal sphincter contraction and big toe flexion(FHL muscle, S1/2) indicates some continuity of the corticospinal (motor) and spinothalamic (course touch, pain, temperature) tracts. The presence of sacral sparingindicates an incomplete cord injury with a better prognosis than a complete injury.