Fractures and Dislocations Flashcards
Number of fractures that occur annually in the UK
1 million
State the serious complications of fractures
Fat embolism, compartment syndrome and complex regional pain syndrome type 1
What is a fracture
A break in the structural continuity of bone which may be a crack, break, split, crumpling or buckle
What should be considered when describing a fracture
Mechanism and energy of the injury Skin and soft tissue involvement Site Shape Communication Deformity Associated injuries
2 Main aims of treating fractures
Relieving Pain
Restoring function
When in the skin damaged in fractures
Open fractures, degloving, ischaemic necrosis
When are muscles damaged in fractures
Crush injury and compartment syndromes
In how many fractures is healing delayed or imparied
5-10%
How do soft tissues heal
By replacing injured tissue with a fibrous scar
How does bone heal
Regeneration of normal bone anatomy
Primary Bone Union
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
If a patient is treated with Open reduction internal fixation how does the bone heal
Via primary bone healing. The process is slow but rehabilitation is rapid.
If a patient is treated with nailing or external fixation how does the fracture heal
Via callus. This is a rapid process, and rehabilitation is rapid
Upper limb repair in adult
6-8 weeks
Upper limb repair in child
3-4 weeks
Lower limb repair in adult
12-16 weeks
Lower limb repair in child
6-8 weeks
How can the amount of healing of a fracture be measured
clinically, radiologically (bridging callus formation or remodelling), biochemically (amout of stiffness)
When is a fracture healed
When a patient can bear weight and proven by the X-ray. Remodelling will be complete.
State an early systemic problem of fractures
Hypovolaemia, crush syndrome and fat embolism
State a late systemic problem of fractures
Psychological and social aspects
State possible systemic complications of fractures
Bed rest complications (DVT, PE), tetanus
State some early local problems of fractures
neurovascular damage
skin/wound problems
compartment syndrome
State the late local problems of fractures
delayed union
nonunion
avascular necrosis
State the possible local complications of fractures
Infection, malunion CRPS type 1 implant failure joint stiffness
Host factors influencing fracture repair
Nutritional and hormonal status/drugs/CNS injury
Local factors influencing fracture repair
Soft tissue injury, bone loss, radiation, tumour, blood supply, infection, type of bone, synovial fluid
When will treatment of fractures result in delayed or non-union
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)
Atrophic non-union
This is bone loss - soft tissue interposition or pathological bone via infection or tumour
Hypertrophic non-union
Attempt at healing but the fracture site is too mobile
Risk factors for infected non-union
contamination in open fracture introduction at time of operation multiple operations unstable fixation metastatic sepsis on foreign body implant immunologically compromised patients
Treatment of infected non-union
suspect diagnose remove dead, devitalised and infected tissue obtain organism (if possible) treat infection and stabilise fracture
Avascular necrosis
Loss of blood supply
Common fractures in which avascular necrosis is found
Hip (intracapsular neck of the femur), scaphoid and talus
Transverse fracture
This is caused by a force applied directly to the site at which the fracture occurs.
Spiral or oblique fracture
Produced by a twisting force. Usually at each end of a long bone
Greenstick fracture
This occurs in children whose bones are soft. The bone bends without fracturing across completely.
Crush fracture
This occurs in cancellous bone as a result of a compression force
Burst Fracture
This occurs in a short bone, such as vertebra from strong direct pressure
Avulsion fracture
Caused by traction, a bony fragment usually being torn off by a tendon or ligament
Fracture dislocation or subluxation
This is a fracture which involves a joint and results in malalignement of the joint surfaces
when is a fracture termed complicated
When there is soft tissue damage to nerves, vessels, or internal organs
Impacted fracture
when fragements of bone are driven into eachother
Stable fracture
When the fracture is held firmly by soft-tissue attachments, usually periosteum
Unstable fracture
One which is displaced or has the potential to displace
Displacement
Shortening, rotation, sideways shift or tilt, and reduction of the fracture will usually involve reversing these displacements
Dislocation
Complete loss of congruity of the joint surfaces
Subluxation
Partial loss of contact of the joint surfaces
Salter and harris type 1
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
Salter and harris type 2
The commonest type in which the fracture line runs across the epiphyseal line and then obliquely shearing off a small triangle of metaphysis
Salter and Harris type 3
The epiphysis may be split vertically and a fragment displaced along the epiphyseal line
Salter and Harris type 4
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.
Salter and Harris type 5
Severe crushing of the epiphysis may occur from longitudinal compression and this is very likely to result in growth arrest and deformity
Symptoms of fractures
Pain, loss of function, loss of sensation or motor power,
Signs of fractures
Tenderness, deformity, swelling, local temperature increase, abnormal mobility or crepitus, loss of function
Main investigation conducted into fractures
X-ray, CT for pelvic fractures
Three principles of management of fractures
Reduce
Maintain reduction
Rehabilitate
Treatment of open fractures
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.
Technique of reduction used normally
Manipulation under anaesthesia
Traction
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)
Open reduction
Allows accurate reduction. It is usually used in cases where closed reduction will not be effective enough.
Closed reduction and fixation
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
3 ways of maintaining fracture reduction
Intrinsic stability
External splintage
Internal Fixation
Cast Bracing
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.
Traction
Pulling bones directly or indirectly in order to reduce and hold fractures.
Skin traction
The force is exerted along the skin by using strapping to attach the chord and the weight.
Skeletal traction
This is applied by means of a pin or similar device applied directly through bone
Fixed Traction
The traction is applied aginst a counter foce applied to the patients body.
Sliding or balanced traction
The patients weight is balanced against an applied load, utilising frictional and gravitational forces to counterbalance the applied traction
Simple Traction
Useful for the hip
Longitudinal traction
This is used for fractures of the femur.
Hamilton-Russel Traction
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.
Why is internal fixation beneficial
Promotes soft tissue repair
Screw Fixation
This is usually used to attach small bony fragments like the malleoli
Intramedullary Nail
Involves the passage of a rod into the medullary canal of a long bone and across the fracture site.
Wires
These are used to hold bone fragments (Kirschner wires for Colles fractures)
Fracture Fixation should be used in the following situations
- When adequate redution cannot be maintained by external splintage (involving joint surfaces)
- Allow early movement of a limb or a joint
- To avoid long period of immobilisation in bed
- Multiple trauma
5 certain pathological fractures - malignancy
Rehabilitation
Movement of the joint immediately, physiotherapy is often required
Crush syndrome
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
Compartment syndrome
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.
