Fractures and Dislocations Flashcards
2 ways for fractures to heal
Primary bone healing
Secondary bone healing
what are features of secondary bone healing
fracture gap fills with granulation tissue then cartilage (soft callus) then bone (enchondral ossification, hard callus)
this is used for most cases
worries of comminuted breaks
high energy usually so watch soft tissue and for compartment syndrome
also left with poor quality bone
what are peri articular fractures
fractures that occur in or immediately adjacent to a joint
if is a high energy break or there is substantial soft tissue swelling what should be avoided
ORIF
what are intra articular fractures
fractures which the break crosses into the surface of a joint. They always result in some degree of cartilage damage
how should displaced intra-articular fractures be treated
anatomic reduction
rigid internal fixation
prevents post OA
what are risks with peri-articular fractures and how can then be treated to avoid this
non-union or AVN
Tx – joint replacement
Tx for open fractures
Antibiotics - normally co-amoxiclav
Tetanus
Early debridement
Operative stabilisation
Tx for compartment syndrome
Fasciotomy
Operative stabilisation
Tx for vascular injury
reduction, stabilisation and then reassess circulation
may need revascularisation procedure
Tx for nerve injury
Open #»_space; explore
Closed #»_space; reduce fracture, hold, recheck and observe
extra-articular distal femur fractures Tx
Unstable - pull of muscles causes flexion at #
Thomas splint
Can nail/plate it
intra-articular distal femur fractures Tx
anatomical reduction, rigid fixation
plate and screws
what are extra-articular #
fractures that do not involve the joint surface
Mx of proximal tibial fractures
anatomical reduction
rigid fixation
what Ix can be used after x-ray if more info is needed
CT scan
what is the slowest healing fracture in the body
tibial shaft #
16 weeks to union
> 1 year non-union
what is poor tolerated in tibial shaft #
internal rotation
what is an intra-articular distal tibial # called
pilon #
fracture of the distal part of the tibia, involving its articular surface at the ankle joint
what type of proximal humerus # risk AVN and non-union
comminuted #
what can be considered in proximal humerus # for head splitting #
arthroplasty
will provide pain relief but ROM poor
what is at risk in humeral shaft #
radial nerve injury
when is internal fixation used in humeral shaft #
non-union pathological # poly-truama open # high energy
intra-articular distal humerus #Tx
ORIF
what is responsible for supination/pronation at the elbow
radial head
radial head fracture - what is can occur with and treatment
can occur with dislocated elbow
minimally displaced»_space; treated conservatively
comminuted»_space; excise +/- replacement
what sign seen on an x-ray in radial head fractures
fat pad sign
Radius fractured in isolation, suspect a dislocation of the distal RU joint
Galeazzi fracture dislocation
Ulna fractured in insolation, suspect a dislocation of the radial head
Monteggia fracture dislocation
Tx for Galeazzi/Monteggia
ORIF fractured bone
then dislocation should be reduced
what is nightstick fracture
direct blow to ulna causing isolated ulna fracture
Colles fracture
FOOSH
extra-articular # of distal radius
dorsal angulation
dorsal displacement
Tx for Colles fracture
Stable, minimally displaced / angulated POP
Displaced simple # MUA
Displaced, comminution MUA & K-wiring, ORIF
complications of colles fracture
median nerve compression
EPL rupture
CRPS - Complex regional pain syndrome
loss grip strength
appearance of Colles fracture on x-ray
dinner fork deformity
fall onto back of hand
extra-articular, volar displacement and angulation
Smiths #
Barton #
Intra-articular, Volar or dorsal rim # of the distal radius»_space; subluxation carpus
what are early local complications of fractures
- compartment syndrome
- vascular injury w/ distal ischaemia
- nerve injury
- skin necrosis
3 types of nerve injury
1st degree - Neurapraxia
2nd degree - Axonotmesis
3rd degree - Neurotmesis
features of neurapraxia
Temporary conduction block / demyelination
Should resolve within 28 days
features of axonotmesis
Nerve cell axon dies distally from point of injury = Wallerian degeneration
Structure of nerve (endoneurial tubes) intact
Regenerates at 1mm per day
what is Wallerian degeneration
when Nerve cell axon dies distally from point of injury
features of neurotmesis
Nerve transected – rare with # or dislocation
No recovery without surgery
what are indications for exploration of nerve injury
open fracture
penetrating injury
neuralgic pain»_space; ongoing compression
if no function returns, what can be done for nerve injury
NCS - provides info on recovery potential and prognosis
Nerve grafting
Tendon transfers
what are early systemic complications of fractures
Hypovolaemia Fat embolism Acute Respiratory Distress Syndrome Systemic Inflammatory Response Syndrome Multi-Organ Dysfunction Syndrome
late local complications of fracture
stiffness, loss of function post-trumatic OA Non union - atrophic/hypertrophic Malunion CRPS AVN DVT Osteomyelitis Volkmann's ischaemic contracture
what does malunion cause
pain
stiffness
loss of function
deformity
what fractures get x-rays to confirm union
diaphyseal fractures of major long bones
signs of fracture healing
pain improved
no tenderness
no movement at fracture site
no swelling or oedema
what causes atrophic non-union
Poor blood supply to fracture site Fracture gap too big and no movement Systemic disease Smoking Medicines – steroids, NSAIDs, bisphosphonates
what is difference between atrophic and hypertrophic non-union
atrophic - no callus formed
hypertrophic - callus formed
causes of hypertrophic non-union
too much movement at fracture site
Abundant callus response but failure union
what can cause both type of non-union
infection
what is volkmann’s ischaemic contracture
permanent shortening of forearm flexor muscles
causes clawlike deformity of the hand, fingers, and wrist.
more common in children
causes of volkmann’s ischaemic contracture
ischemia to the forearm
occurs when there is increased pressure due to swelling i.e. compartment syndrome
signs/symptoms of volkmann’s ischaemic contracture
5 P’s
Pain (earliest manifestation), especially accentuated by passive stretching Pallor Pulselessness Paresthesias Paralysis
what is CRPS and Tx
exaggerated pain response after injury
Tx - pain specialists
definition of allodynia
experience of pain from non-painful stimuli
late systemic complications of fractures
pulmonary embolus
what is the blood supply to femoral head
Intramedullary artery of shaft of femur
Medial & lateral circumflex branches of profunda femoris
Artery of ligamentum teres
Hx of proximal femoral fractures
fall
pain
unable to weight bear
Signs of proximal femoral fracture
shortening
external rotation
why do children’s bones bend before they will snap
periosteum is much thicker
what is Wolfs law
Bone in a healthy person or animal will adapt to the loads under which it is placed
what is Heuter-Volkmann principle
Compression forces inhibit growth and tensile forces stimulate growth
features of Hx indicative of NAI
MOI/Hx does not match nature or severity of injury
Inconsistency in Hx
Delay in seeking help
NAI features
Any obvious or suspected fractures in a child under
what are the 3 movements that can be done to test nerve supply in the hand
Thumbs up - Radial
Starfish - Ulnar
Ok sign - Median
principles of fracture management
Reduce
Retain
Rehabilitate
most commonly used treatment in kids
plaster of paris
Tx for diaphyseal fracture in kids
immobilize joint above and below to prevent rotation
Tx for metaphyseal fractures in kids
rotation not an issue immobilise adjacent joint
internal fixation used in kids
less invasive and rigid than in adults
e.g. Percutaneous K wires, cannulated screws
what is used for long bone fixation
flexible nails
used for femur
adv and disadv for flexible nails
ADV
Predictable position rapid healing
Early joint mobilisation and weight bearing
DISADV
Infection risk
Risk of anaesthesia
when is fixation usually indicated
Displaced Intra articular fractures
Displaced growth plate injuries
Open fractures
Multiple injuries
when is external fixation indicated
Contaminated wounds
Acute vascular injury
Burns
Multiple injuries
is dislocations, what must be examined and documented
vascular supply
neurology
so can determine if intervention has helped
most common shoulder dislocation
anterior
humeral head anterior to the glenoid
MOI of anterior shoulder dislocation
fall with shoulder with external rotation
what is at risk in anterior shoulder dislocations
axillary nerve
MOI of posterior shoulder dislocation (humeral head posterior to glenoid)
Fall with shoulder in internal rotation
Direct blow to anterior shoulder
what do people with inferior shoulder dislocations look like
arm held in abduction i.e. above their head
what needs to be checked in inferior shoulder dislocations
brachial plexus
brachial artery
x-ray sign of posterior dislocation
light bulb sign
Mx of shoulder dislocations
closed reduction under sedation
for locked posterior dislocation - open reduction
chronic - stabilisation and rehabilitation
what are some reduction methods for shoulder dislocations
Hippocratic, Kocher’s, in-line traction
what does the recurrent instability risk depend on
Related to age,
risk of recurrence decreases with age
MOI for elbow dislocation
fall onto outstretched hand
what is at risk in elbow dislocations
Radial head #
Coronoid process #
what is the types of elbow dislocation and what is most common
Posterior (most common)
Anterior
Medial/Lateral
special type of dislocation seen in children
Pulled elbow
lax annular ligament around radial head, radial head has escaped
Mx of elbow dislocation
Closed reduction under sedation
Open reduction rarely required
2 weeks in sling & rehabilitation
traction methods in elbow dislocation and risk of recurrent instability
Traction in extension +/- pressure over olecranon
Low
MOI of IPJs dislocation
hyperextension injury; direct axial blow
always posterior
possible complications of IPJs dislocations
Head of phalanx button-holes through volar plate
Recurrent instability due to associated fracture
Mx of IPJs dislocations
closed reduction under digital or metacarpal block
2 weeks in neighbour strapping
volar slab in Edinburgh position if unstable
MOI of patella dislocations
sudden quads contraction with a flexing knee
always lateral
most common in teens, F > M
what is patella dislocations associated with
hypermobility
under developed lateral femoral condyle
increased Q angle (genu vaglum or increased femoral neck ante version)
Weak vastus medialis
what is torn in patella dislocations
medial retinaculum
causes pain
what is seen on examination of a patella dislocation
effusion - haemarthrosis
patella apprehension test is positive
Mx of patella dislocation
reduce with knee extensions
aspirate - large effusions of the knee are very uncomfortable
brace
physio
Mx of repeat patella dislocations
lateral release/medial reefing
patella tendon realignment
what are the signs suggestive of a spontaneous relocation of a dislocated knee
Lat collateral lig injury + peroneal nerve injury
what can be injured in a knee dislocation
popliteal artery/vein
peroneal nerve
Mx of knee dislocation
Reduction under sedation
Stabilise in splint or External-Fixation
Ix of knee dislocation
plain radiography - associated #
MRI
Surgical treatment for the knee
Vascular repair (6hr window)
Nerve repair
Sequential ligamentous repair
complications of knee dislocation
Arthrofibrosis (excessive scar tissue, painful restriction of joint movement) and stiffness
Ligament laxity
Nerve or arterial injury
Hip dislocation associated #
posterior
posterior acetabular wall #
femoral #
presentation of hip dislocation
flexed, internally rotated and adducted knee
Mx of Hip dislocation
Neurovascular assessment (particularly the Sciaitic nerve) Radiographs (changes can be subtle) Urgent reduction Stabilise in tractions if required Further imaging (CT)
complications of hip dislocation
Sciatic nerve palsy
Avascular necrosis of the femoral head
Secondary osteoarthritis of hip
Myositis ossificans
