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MSKsara > fractures and healing > Flashcards

fractures and healing Flashcards

1
Q

what is the difference between cortical and spongey bone?

A

cortical bone - compact bone - dense and strong

spongey bone - also known as cancellous and trabecular bone. softer and more flexible/weaker. greater surface areas so better for metabolic processes. spaces between trabeculae are filled with marrow.

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2
Q

what is contained within spongey bone?

A

marrow

  • yellow marrow: adipocytes
  • red marrow: haematopoietic stem cells.
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3
Q

what is bone covered in and why?

A

periosteum. - connective tissue to provide vasculature to bone.

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4
Q

what is the epiphyseal plate?

A

part of epiphysis where bone can grow. present in children. contains hyaline cartilage ready for endochondral ossification a.k.a growth plate.

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5
Q

what are the functions of bone?

A

protection, support, structure, haematopoiesis and mineral and fat storage

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6
Q

what are the different cellular components in bone and what are their functions?

A

osteoblasts - lay down unmineralised bone (osteoid)

osteocytes - osteoid becomes mineralised and traps osteoblasts so that they become osteocytes which monitor mineralisation to regulate bone mass density

osteoclasts - resorption of bone

osteogenic cells. - stem cells.

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7
Q

name 3 major things bone is made up of

A

Cells
ECM:
- organic: collagen type 1, proteoglycans, lipids, glycosaminoglycans
- inorganic: calcium hydroxyapatite (main salt)

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8
Q

outline endochondral ossification

A

hyaline cartilage is replaced by osteoblasts laying down osteoid. this then becomes mineralised and reorganised to form stronger more organised lamellar bone
long bones

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9
Q

outline intramembranous ossification

A

mesenchymal tissue condenses to form bone

flat bones

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10
Q

what is meant by bone remodelling?

A

the osteoclasts break down old bone and osteoblasts lay down new bone. this occurs at regions where bone is stressed in order to strengthen it.
it occurs in a pattern known as cutting cone: osteoclasts are at front of cone breaking down bone and osteoblasts follow filling in the cone

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11
Q

state 2 medications that increase the likelihood of stress fractures

A

steroids and methotrexate

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12
Q

why is the fracture pattern important to know?

A

tells you the mechanism of injury
predicts outcome
for example segmental fractures are associated with delayed union, non union and infection

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13
Q

state 3 types of incomplete fractures

A

buckle
greenstick
fissure

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14
Q

What is a buckle fracture? who does it mainly affect?

A

the cortex buckles due to compression of spongey bone. characterised by bulging of cortical shaft.
usually in children at metaphysis of distal radial metaphysis

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15
Q

what is a greenstick fracture? who does it mainly affect?

A

one side of bone is fractures due to bending caused by forced from the opposite side.
children.

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16
Q

what is a fissure fracture?

A

outer layer of bone broken. fracture goes down through the bone

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17
Q

what are the 4 stages of fracture healing?

A

1 - haematoma formation
2- soft callus formation
3- hard callus formation
4- remodelling

can also be divided into
inflammatory (stage 1 i.e. haematoma formation) - 2-3days
reparative (stage 2 and 3) - 2 days to 2 weeks
remodelling - 2 years

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18
Q

describe the stages of fracture healing?

A

HAEMATOMA FORMATION:

  • blood vessels are torn and constrict to form haematoma
  • cytokines, growth factors and vasoactive factors released e.g. FGF , BMP
  • mast cells, platelets, macrophages and fibroblasts infiltrate
  • macrophages remove dead tissue and eventually breakdown haematoma.
  • granulation tissue (procallus) is formed - collagen and new blood vessels
  • osteoclasts remove dead bone at fracture site

SOFT CALLUS FORMATION:

  • periosteal cells proximal to fracture site produce chondroblasts which produce hyaline cartilage (fibrocallus)
  • periosteal cells distal to fracture site produce osteoblasts to undergo endochondral ossification to form osteoid as woven bone.
  • eventually fracture site is bridged by woven bone and cartilage

HARD CALLUS FORMATION:
- mineralisation of woven bone and remodelling into lamellar bone. All cartilage has now been replaced

REMODELLING:
- cutting cone to strengthen bone. This requires tension and forces acting on the bone.

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19
Q

what 3 things are important for fracture healing?

A

compaction
well aligned / correct position
good blood supply

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20
Q

what is primary and secondary bone healing?

A

primary: bone is well opposed such that healing can occur directly between fragments. there is no need for a callus to form and instead cutting cone forms directly across fracture site so that bone can be laid down directly. Try to achieve this with reduction. A.K.A healing by direct union.

secondary bone healing: less opposed fragments so a callus is required to bridge the fragments and this can then be mineralised to hard bone. A.K.A healing by indirect union

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21
Q

what is perkins classification?

A

classifies fracture healing time depending on position, type and region of fracture

spiral fractures:

- union : 3 weeks for UL and 6 weeks LL
- consolidation : 6 weeks UL and 12 weeks LL

transverse fractures

  • union: 6 weeks UL, 12 weeks LL
  • consolidation: 12 weeks UL and 24 weeks LL
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22
Q

what is wolff’s law?

A

the position of trabeculae in a bone depends upon stress/ forces acting on the bone. Therefore weight bearing is important after fraction to ensure the bone heals in the correct direction

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23
Q

how does fracture healing times compare in children and smokers?

A

half the normal healing times for children

double normal healing times for adults

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24
Q

what hormones can affect bone healing?

A

oestrogen - stimulates fracture healing
thyroid hormones - stimulate osteoclasts
PTH - continuous stimulates osteoclasts but intermittent stimulates osteoblasts
GH stimulates bone formation

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25
Q

what is a compound fracture?

A

also known as an open fracture

fracture protrudes out, through the skin.

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26
Q

what is meant by degloving?

A

skin has pulled away - used when describing open fractures.

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27
Q

what is the gustilo and Anderson classification system?

A

classification system for open fractures based on wound size, extent of soft tissue damage and contamination, presence of skin flap/ tissue coverage, state of the periosteum and the vasculature.
graded as 1, 2, 3a,3b and 3c

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28
Q

briefly summarise the difference between grade 1 and 2 on gustilo and Anderson classification

A

grade 1 and 2 both have good tissue coverage, periosteum and vasculature in tact.

in grade 1 there is a small wound (<1cm), minimal soft tissue damage and minimal contamination
in grade 2 there is a wound of >1cm, moderate soft tissue damage and contamination.

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29
Q

briefly summarise the difference between grade 2 and 3 on gustilo and Anderson classification

A

In grade 2 there is good tissue coverage and periosteum and vasculature are intact. moderate tissue damage and contamination.
whereas in grade 3 there is extensive tissue damage and contamination.
- grade 3a: periosteal stripping
- grade 3b: periosteal stripping and inadequate soft tissue coverage
- grade 3c: periosteal stripping and inadequate soft tissue coverage and vasculature is disrupted

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30
Q

what grade do we classify farmyard open fractures or highly contaminated open fractures?

A

immediately classed as grade III irrespective of size of wound and tissue coverage

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31
Q

what happens as the Gustilo and Anderson grade increases?

A

rate of amputation and risk of infection increases

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32
Q

which wounds are not suitable for closure in A and E?

A 
stab wounds to neck or trunk
involve tendon, joint or NV damage
contaminated/infected
associated with crush injuries/ skin loss
>12 hours old.
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33
Q

state briefly the different steps in management of open fractures

A

assessment: ATLS, NV status, compartment syn
immediate management:
- tourniquet / pressure to stop any bleeding
- analgesia, antiemetic, fluids, oxygen
- take a picture of wound
- debridement/irrigation
- correct any obvious deformity by traction
- take another photo
- initial cover with saline soaked pads
inform orthopaedics
Blood: inc G&S/Xmatch
Abx
Tetanus status check
re check NV status esp after reduction
Xray - 2 views lateral/AP
Surgery - either internal fixation or external fix and then internal fix.
close up wound

34
Q

what are the complications of open fractures?

A

early: compartment syndrome, amputation, NV damage, haemorrhage

late:
- infection - osteomyelitis
- non union can occur due to damaged blood supply. in such a case surgery is required to shave of bone edges and give a bone graft and repeat internal fixation. (bone graft has osteogenic potential

35
Q

what are the indications for amputation in open fractures?

A 
incomplete traumatic amputation
uncontrollable blood loss
ischaemia for 4-6 hours 
segmental muscle loss of 2 compartments
bone loss of >1/3 of tibia
36
Q

what is tetanus?

A

Clostridium tetani is a gram positive bacteria that lives in soil, manure and saliva. it produces tetanus toxin which is a neurotoxin causing muscle spasms.

37
Q

how does the tetanus vaccine work?

A

give 3 IM / deep SC injections of tetanus toxoid at monthly intervals from age of 2 months of age and then repeat 1 at 4yrs and one at 14yrs.
5 injections for life long immunity.

38
Q

what is HATI (tetanus)?

A

human anti tetanus Ig

i.e. antiserum containing immunoglobulins against tetanus.

39
Q

when is tetanus HATI or vaccine considered ?

A

consider in bite injuries, open contaminated fractures, puncture wounds.
if not previously immunised the individual requires HATI
if previously immunised but require booster give booster and HATI

40
Q

what does debridement/irrigation of a wound involve?

A

remove any foreign material / damaged tissues
wound excision - edges of wound excised to leave healthy skin edges
washed out (irrigation) with saline

41
Q

which analgesics are given for open fractures?

A

preferably opioids

second line is ketamine

42
Q

which Abx are indicated for open fractures?

A

for all grades give Co-amoxiclav ASAP (within 3 hours) and then 8hourly
gentamicin can be given at debridement/surgery
then continue co-amoxiclav after surgery

in grade 1 abx for 24 hours. for all other grades for 72 hours

note cefuroxime can be given instead
and clindamycin for penicillin allergies.

43
Q

how quickly is surgery indicated for open fractures?

A

within 12 hours
grade III within 6 hours
vascular damage or compartment syn = 6 hours

44
Q

what are the different ways wounds can be closed?

A

simple suturing if the skin is able to cover it without any tension.
otherwise:
- skin graft: loss of skin
- local flap: use muscle nearby and rotate it to cover the are and then skin graft
- free flap: muscle from elsewhere + blood supply to cover + reconnect vessles + skin graft.

45
Q

what is the mangled extremity score?

A

predicts likelihood of needing an amputation (score of more than 7 requires amputation)
based on the skeletal soft tissue injury, shock, limb ischaemia and age.
max score of 14

46
Q

what is the issue with fractures that affect the epiphyseal plate?

A

can lead to growth arrest and deformity. for example on side of growth plate stops working so bone grows only on one side and therefore scews towards other side.

47
Q

Describe the salter Harris classification system

A

type 1: complete transverse fracture through physeal (growth plate)
type 2: through growth plate and metaphysis
type 3: growth plate and epiphysis
type 4: growth plate, metaphysis and epiphysis
type 5: compression fracture of growth plate

48
Q

what does salter harris classification indicate?

A

As the classification number increases there is increased risk of growth arrest

49
Q

which salter harris classification is most common and least common?

A

most common - 2

least common - 5

50
Q

what is a triplane fracture?

A

salter harris type III in one plane and type IV in another plane.

51
Q

what is meant by non union?

A

bones do not unite and remain separate
this can be atrophic - no attempt to unite
this can be hypertropic - trying to heal

52
Q

what is meant by delayed union?

A

fracture takes longer to heal

- healing time depends on bone and type of fracture as well as other factors

53
Q

what are the systemic factors that affect bone healing?

A 
CVS disease/diabetes: reduced nutrient delivery
 osteoporosis
poor nutrition
smoking
age

vit D deficiency
hormones e.g. low oestrogen in menopause

NSAIDs,
steroid use: reduced inflammation and increased

polio
brain injury increases healing process
functional activity increases healing process.

54
Q

what is malunion?

A

bone fragments do not perfectly align after a fracture

due to poor opposition or poor compliance with a brace.

55
Q

what local factors affect bone healing?

A 
infection
pathological fracture
reduced blood supply (associated with high energy fractures e.g. soft tissue damage/comminution)
AVN
poor opposition
increased mobility
soft tissue interposition
56
Q

does the type of bone affect how important union is after a fracture?

A

yes - humerus and clavicle can tolerate malunion to certain amount because no weight bearing
lower limb more important to have union
articular surface fractures it is more important for accurate union to prevent later OA

57
Q

What is reduction of a fracture/dislocation?

A

process by which the bones are brought back into their normal anatomical position

58
Q

what are external splints used for in fractures?

A

these include casts e.g. plaster of paris. Hold the bone in place to reduce healing time and prevent displacement

59
Q

what are the risks of casts?

A

if put on too tightly it can lead to pain, pressure sores, swelling and compartment syndrome.
however if too loose it is not going to stabilise the fracture well.

60
Q

what is the difference between plaster of paris and polyester cast?

A

plaster of paris - cotton wool + plaster of paris - not very strong.
polyester is hard light and stronger

61
Q

when are K wires used?

A

Good for fractures with small fragments i.e. hold the fragments together.
they can also be inserted percutaneously

62
Q

what is the advantage of open reduction and internal fixation?

what are the disadvantages?

A

speeds up bone healing because fragments will be well opposed. (therefore reduced risk of malunion and non union)
less likely to displace and lead to deformity
earlier mobilisation/ weight bearing which reduces risk of stiffness.

however more likely to be infected. There is also a need and risk associated with general anaesthesia.

63
Q

when is external fixation used?

A

soft tissue swelling.
use this method to wait for swelling to reduce and quality of tissue to improve.
then can follow by internal reduction.

64
Q

what are the different methods for fixation of a fracture?

A

cast splintage
functional bracing.
internal fixation
external fixation

65
Q

what advice is given to patients after fracture?

A
  • advice on when they can weight bear, drive etc and how to wear splint.
  • physiotherapy
  • Give advice on early recognition of complications: infection and compartment syndrome.
  • organise for them to come back for Xray
  • early movement is encouraged to restore limb function, prevent oedema, stiffness and muscle strength, and stimulates blood flow (helps healing)

also elevate to prevent oedema

66
Q

discuss the different types of bone grafts

A

Autograft: bone from self e.g. usually pelvis
Allograft: from another human
xenograft: from another species.

67
Q

how are BMPs used in treatment?

A

bone morphogenic proteins are human growth factors that stimulate bone healing. can give these to patients with fractures.

68
Q

what is eXogen?

A

ultrasound that is used to aid fracture healing.

sound waves produced by the ultrasound stimulates the bone to heal.

69
Q

what are the indications to treat a fracture surgically?

A

NO PUFI (acronym):

  • neurovascular damage
  • open fracture
  • polytrauma e.g. floating shoulder
  • Unstable
  • failed conservative
  • Intra-articular step
70
Q

what is the mortality rate for hip fractures?

A

10% at 30 days

30% at 1 year

71
Q

what are the causes of pathological fractures?

A

infection
cancer - primary or met
metabolic bone disease e.g. osteoporosis

72
Q

when should a pathological fracture be suspected?

A 
bone pain 
little trauma 
other illness e.g. known thyroid disease
medication e.g. steroids. 
abnormal XRAY
73
Q

what investigations would you do if you suspected a pathological fracture?

A

Xray other bones to look for abnormalities
CXR
bone scan
CT/MRI to look for primary tumours
bloods - U&Es, TFTs, PSA, FBC
urinalysis - haematuria (RCC) and bence jones proteins (myeloma)
biopsy of the bone

74
Q

how do we treat pathological fracture?

A

internal fixation of pathological fractures
correct cause
more likely to need replacement/ bone graft

75
Q

what are the complications of pathological fractures?

A

haemorrhage
pulmonary embolism
malunion/ non union

76
Q

how can we prevent fractures?

A

risk assessment in elderly e.g balance, failing, frailty
physio to improve balance and strength
ADCAL to improve strength of bones
if high risk of fracture, surgeon can prophylactically fix it with intramedullary nail.

77
Q

describe the mechanism of injury for spiral, transverse, oblique fractures

A

spiral - twisting
transverse - direct blow
oblique - bending

78
Q

do butterfly fragments need to be removed?

A

no they absorbed themselves

79
Q

What can we say about fractures in the same plane of motion?

what fractures are well tolerated and which ones arent

A

they are well tolerated.
E.g. if femur fracture projects forwards this is better tolerated because knee goes forward too.

other things making a fracture well tolerated:

  • ball and socket joint above
  • fractures in children

rotational deformities are NOT well tolerated

80
Q

what does non-union look like on Xray

A

sclerotic less well defined edges that are not united

81
Q

which pattern of fractures heal better?

A

spiral - large surface area also usually less soft tissue damage (unlike transverse

82
Q

where are bone grafts usually taken from?

A

iliac crest soft bone

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