Fractures and Dislocations

Question 1

Number of fractures that occur annually in the UK

Answer 1

1 million

Question 2

State the serious complications of fractures

Answer 2

Fat embolism, compartment syndrome and complex regional pain syndrome type 1

Question 3

What is a fracture

Answer 3

A break in the structural continuity of bone which may be a crack, break, split, crumpling or buckle

Question 4

What should be considered when describing a fracture

Answer 4

Mechanism and energy of the injury 
Skin and soft tissue involvement
Site
Shape
Communication 
Deformity 
Associated injuries

Question 5

2 Main aims of treating fractures

Answer 5

Relieving Pain

Restoring function

Question 6

When in the skin damaged in fractures

Answer 6

Open fractures, degloving, ischaemic necrosis

Question 7

When are muscles damaged in fractures

Answer 7

Crush injury and compartment syndromes

Question 8

In how many fractures is healing delayed or imparied

Answer 8

5-10%

Question 9

How do soft tissues heal

Answer 9

By replacing injured tissue with a fibrous scar

Question 10

How does bone heal

Answer 10

Regeneration of normal bone anatomy

Question 11

Primary Bone Union

Answer 11

this is when cortical bone ends accurately and closely apposed and ridgidly immobilised. There is no callus. It is essentially the remodelling of the bone but is very slow

Question 12

If a patient is treated with Open reduction internal fixation how does the bone heal

Answer 12

Via primary bone healing. The process is slow but rehabilitation is rapid.

Question 13

If a patient is treated with nailing or external fixation how does the fracture heal

Answer 13

Via callus. This is a rapid process, and rehabilitation is rapid

Question 14

Upper limb repair in adult

Answer 14

6-8 weeks

Question 15

Upper limb repair in child

Answer 15

3-4 weeks

Question 16

Lower limb repair in adult

Answer 16

12-16 weeks

Question 17

Lower limb repair in child

Answer 17

6-8 weeks

Question 18

How can the amount of healing of a fracture be measured

Answer 18

clinically, radiologically (bridging callus formation or remodelling), biochemically (amout of stiffness)

Question 19

When is a fracture healed

Answer 19

When a patient can bear weight and proven by the X-ray. Remodelling will be complete.

Question 20

State an early systemic problem of fractures

Answer 20

Hypovolaemia, crush syndrome and fat embolism

Question 21

State a late systemic problem of fractures

Answer 21

Psychological and social aspects

Question 22

State possible systemic complications of fractures

Answer 22

Bed rest complications (DVT, PE), tetanus

Question 23

State some early local problems of fractures

Answer 23

neurovascular damage
skin/wound problems
compartment syndrome

Question 24

State the late local problems of fractures

Answer 24

delayed union
nonunion
avascular necrosis

Question 25

State the possible local complications of fractures

Answer 25

``` Infection, malunion CRPS type 1 implant failure joint stiffness ```

Question 26

Host factors influencing fracture repair

Answer 26

Nutritional and hormonal status/drugs/CNS injury

Question 27

Local factors influencing fracture repair

Answer 27

Soft tissue injury, bone loss, radiation, tumour, blood supply, infection, type of bone, synovial fluid

Question 28

When will treatment of fractures result in delayed or non-union

Answer 28

inadequate immobilisation distraction of # by fixation device or traction repeated manipulations periosteal stripping & soft tissue damage at operation anatomical vascular suspectibility, eg. femoral neck, scaphoid, talus, (distal tibia)

Question 29

Atrophic non-union

Answer 29

This is bone loss - soft tissue interposition or pathological bone via infection or tumour

Question 30

Hypertrophic non-union

Answer 30

Attempt at healing but the fracture site is too mobile

Question 31

Risk factors for infected non-union

Answer 31

``` contamination in open fracture introduction at time of operation multiple operations unstable fixation metastatic sepsis on foreign body implant immunologically compromised patients ```

Question 32

Treatment of infected non-union

Answer 32

``` suspect diagnose remove dead, devitalised and infected tissue obtain organism (if possible) treat infection and stabilise fracture ```

Question 33

Avascular necrosis

Answer 33

Loss of blood supply

Question 34

Common fractures in which avascular necrosis is found

Answer 34

Hip (intracapsular neck of the femur), scaphoid and talus

Question 35

Transverse fracture

Answer 35

This is caused by a force applied directly to the site at which the fracture occurs.

Question 36

Spiral or oblique fracture

Answer 36

Produced by a twisting force. Usually at each end of a long bone

Question 37

Greenstick fracture

Answer 37

This occurs in children whose bones are soft. The bone bends without fracturing across completely.

Question 38

Crush fracture

Answer 38

This occurs in cancellous bone as a result of a compression force

Question 39

Burst Fracture

Answer 39

This occurs in a short bone, such as vertebra from strong direct pressure

Question 40

Avulsion fracture

Answer 40

Caused by traction, a bony fragment usually being torn off by a tendon or ligament

Question 41

Fracture dislocation or subluxation

Answer 41

This is a fracture which involves a joint and results in malalignement of the joint surfaces

Question 42

when is a fracture termed complicated

Answer 42

When there is soft tissue damage to nerves, vessels, or internal organs

Question 43

Impacted fracture

Answer 43

when fragements of bone are driven into eachother

Question 44

Stable fracture

Answer 44

When the fracture is held firmly by soft-tissue attachments, usually periosteum

Question 45

Unstable fracture

Answer 45

One which is displaced or has the potential to displace

Question 46

Displacement

Answer 46

Shortening, rotation, sideways shift or tilt, and reduction of the fracture will usually involve reversing these displacements

Question 47

Dislocation

Answer 47

Complete loss of congruity of the joint surfaces

Question 48

Subluxation

Answer 48

Partial loss of contact of the joint surfaces

Question 49

Salter and harris type 1

Answer 49

The fracture line passes cleanly along the epiphyseal line with no metaphyseal fragment,. This type tends to occur in young children and in pathological conditions such as spina bifida and scurvy

Question 50

Salter and harris type 2

Answer 50

The commonest type in which the fracture line runs across the epiphyseal line and then obliquely shearing off a small triangle of metaphysis

Question 51

Salter and Harris type 3

Answer 51

The epiphysis may be split vertically and a fragment displaced along the epiphyseal line

Question 52

Salter and Harris type 4

Answer 52

The fracture extends through the epiphyseal line from the metaphysis into the epiphysis. This type may interfere with growth because union may take place across the growth plate.

Question 53

Salter and Harris type 5

Answer 53

Severe crushing of the epiphysis may occur from longitudinal compression and this is very likely to result in growth arrest and deformity

Question 54

Symptoms of fractures

Answer 54

Pain, loss of function, loss of sensation or motor power,

Question 55

Signs of fractures

Answer 55

Tenderness, deformity, swelling, local temperature increase, abnormal mobility or crepitus, loss of function

Question 56

Main investigation conducted into fractures

Answer 56

X-ray, CT for pelvic fractures

Question 57

Three principles of management of fractures

Answer 57

Reduce Maintain reduction Rehabilitate

Question 58

Treatment of open fractures

Answer 58

Debridement to prevent osteomyelitis which could result in non-union. The wounds should be left open and covered with sterile dressing. Antibiotics should always be given after culture swabs have beem talem.

Question 59

Technique of reduction used normally

Answer 59

Manipulation under anaesthesia

Question 60

Traction

Answer 60

Some fractures and dislocations can be reduced slowly by traction. This is usually when manipulation is is inappropriate if anaestetic is dangerous (subluxation or dislocation of one or more facets of the cervical spine)

Question 61

Open reduction

Answer 61

Allows accurate reduction. It is usually used in cases where closed reduction will not be effective enough.

Question 62

Closed reduction and fixation

Answer 62

For some fractures, such as those treated by intramedullary nailing or external fixation, the reduction is indirectly achieved, with traction and the fracture stablisied with a nail or a fixator

Question 63

3 ways of maintaining fracture reduction

Answer 63

Intrinsic stability External splintage Internal Fixation

Question 64

Cast Bracing

Answer 64

Hinged or jointed cast. It has been used for fractures of the femur and the tibia. In femoral fractures the fracture will usually be healed by traction for around 3-6 weeks until it is considered to be stable and then the cast wil be fitted and the patient will be able to mobilise.

Question 65

Traction

Answer 65

Pulling bones directly or indirectly in order to reduce and hold fractures.

Question 66

Skin traction

Answer 66

The force is exerted along the skin by using strapping to attach the chord and the weight.

Question 67

Skeletal traction

Answer 67

This is applied by means of a pin or similar device applied directly through bone

Question 68

Fixed Traction

Answer 68

The traction is applied aginst a counter foce applied to the patients body.

Question 69

Sliding or balanced traction

Answer 69

The patients weight is balanced against an applied load, utilising frictional and gravitational forces to counterbalance the applied traction

Question 70

Simple Traction

Answer 70

Useful for the hip

Question 71

Longitudinal traction

Answer 71

This is used for fractures of the femur.

Question 72

Hamilton-Russel Traction

Answer 72

This was designed to apply a traction force in line with the shaft of the femur whilst allowing movement of the hop and the knee.

Question 73

Why is internal fixation beneficial

Answer 73

Promotes soft tissue repair

Question 74

Screw Fixation

Answer 74

This is usually used to attach small bony fragments like the malleoli

Question 75

Intramedullary Nail

Answer 75

Involves the passage of a rod into the medullary canal of a long bone and across the fracture site.

Question 76

Wires

Answer 76

These are used to hold bone fragments (Kirschner wires for Colles fractures)

Question 77

Fracture Fixation should be used in the following situations

Answer 77

1. When adequate redution cannot be maintained by external splintage (involving joint surfaces) 2. Allow early movement of a limb or a joint 3. To avoid long period of immobilisation in bed 4. Multiple trauma 5 certain pathological fractures - malignancy

Question 78

Rehabilitation

Answer 78

Movement of the joint immediately, physiotherapy is often required

Question 79

Crush syndrome

Answer 79

This is associated with extensive soft tissue damage or ischaemia of a large volume of tissues. Results in acute tubular necrosis with renal failure. Can be prevented by amputation of the limb. Dialysis may be necessary

Question 80

Compartment syndrome

Answer 80

Occurs in tibial fractures where swelling causes venous engorgement in the compartment rcausing muscle necrosis. Presents as increased pain and paraesthesia and pain on passive movement of the toes.