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Musculoskeletal > Fractures and Trauma > Flashcards

Fractures and Trauma Flashcards

1
Q

Describe the difference between primary and secondary fracture healing?

A

Primary- minimal gap, bone bridges the gap wit new bone, this happens in hairline fractures or when compression screws or plates have been put in

Secondary- Most fractures space needs to be filled temporarily to act as a scaffold for new bone to be laid down, this involves an inflammatory response.

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2
Q

Describe the seven steps of secondary fracture healing?

A

WHOLE PROCESS IS CALLED ENDOCHONDRAL OSSIFICATION

1) fracture occurs and there is haematoma with inflammation from damaged tissues
2) Macrophages and osteoclasts remove debris and resorbs the bone ends
3) Granulation tissue forms from fibroblasts and new blood vessels
4) Chondroblasts form cartilage—> soft callus
5) Osteoblasts lay down bone matrix (type 1 collagen)
6) Calcium mineralisation produces immature woven bone —–> hard callus
7) Remodelling occurs with organisation along lines of stress into lamellar bone

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3
Q

Soft callus is formed by the _____ week

A

2nd-3rd

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4
Q

Hard callus appears ________ weeks after fracture

A

6-12 weeks

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5
Q

What does secondary healing need to be successful?

A

A good supply (to give nutrients and stem cells) and a little but not too much movement or stress

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6
Q

What happens if a fracture is not moved at all?

A

Atrophic non-union

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7
Q

Name 4 things that can impair fracture healing?

A

Smoking, vascular disease, chronic ill health and malnutrition

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8
Q

When does hypertrophic non-union occur?

A

There is excessive movement so despite abundant hard callus the gap cannot bridge

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9
Q

What is hypertrophic and atrophic non-union?

A

Hypertrophic- callus has formed but bone fracture hasn’t healed, biologically viable bone end
Atrophic- fracture can’t heal due to inadequate blood supply

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10
Q

Name 11 complications of fractures?

A

1) Compartment syndrome
2) Nerve injury
3) Vascular Injury
4) Skin and soft tissue problems
5) Problems with union
6) DVT
7) Fracture Disease
8) Avascular Necrosis
9) Post traumatic OA
10) CRPS chronic regional pain syndrome
11) Infected fracture fixation

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11
Q

Describe causes, signs and treatment of compartment syndrome?

A

Rising pressure in the fascia due to bleeding and inflammatory exudate. Cardinal signs= increased pain on passive stretching and pain outwith the anticipated severity. Must remove tight bandages and perform a fasciotomy.

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12
Q

Knee dislocation risks the ___1___ artery
Paediatric supracondylar elbow fractures risks the ___2___ artery and shoulder trauma risks the ___3__ artery. Pelvic fractures can be associated with _____4____

A

1) popliteal
2) brachial
3) axillary
4) life threatening arterial or venous bleeding

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13
Q

What is the slowest healing bone in the body?

A

Tibia

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14
Q

Metaphyseal fractures heal more or less quickly than cortical?

A

More

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15
Q

Name 4 types of fracture that are at risk of problems healing due to a poor blood supply?

A

Scaphoid, distal clavicle, subtrochanteric fractures of the femur and Jones of the 5th metatarsal

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16
Q

Why may some intra articular fractures not unite?

A

Synovial fluid inhibits healing

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17
Q

Why is DVT a complication of fractures? What should be done to reduce risk?

A

Particularly in lower limb fractures as immobility, if thought to be at risk should be given prophylactic LMWH

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18
Q

What is fracture disease? Treatment?

A

Stiffness and weakness from injury and cast that usually resolves with physio

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19
Q

What is CRPS?

A

Chronic regional pain syndrome- a complication following injury where you get heightened pain, may also get skin changes

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20
Q

If the pelvic ring is disrupted in one place there is likely ________________

A

another disruption (fracture or ligamentous injury)

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21
Q

What are major and not uncommon complications of pelvic fractures?

A

Branches of the internal iliac artery system and pre sacral venous plexus are prone to injury with serious risk of hypovolaemia. Nerve roots and branches of the lumbo-sacral plexus are also prone to injury.

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22
Q

What are the three types of pelvic fracture?

A

Lateral compression
Anteroposterior compression
Vertical shear

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23
Q

Describe a pelvic lateral compression fracture?

A

Side impact, 1/2 pelvis is displaced medially, fractures of the pubic rami or ischium with SI joint disrupted.

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24
Q

Describe a pelvic anteroposterior compression fracture?

A

Wide disruption of the pubic symphysis “open book” massive bleeding which can be contained within the pelvis as volume builds as it can hold more when displaced eventually tamponade and clotting can occur though.

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25
Q

Describe a pelvic vertical shear fracture?

A

Axial force, fall from height, semi pelvis is displaced superiorly, limb shortening on one side and risk of nerve injury.

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26
Q

What are the three ligaments of the hip capsule?

A

Iliofemoral, Ilioischial and Iliopubic

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27
Q

2 main arteries that supply the head of the femur in adults?

A

Medial and lateral circumflex

Branches of the profunda femoris artery

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28
Q

Who tends to get hip and proximal femur fractures?

A

These mainly occur in the elderly (over 60 yrs), more females than males due to higher levels of osteoporosis. Young adult fractures are a different subset and the injuries tend to be higher energy.

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29
Q

Describe intra and extra capsular fractures in regards to non union and AVN ?

A

Intra: arterial blood supply to the femoral head can be disrupted and there is a risk of AVN and non-union of the fracture.
Extra: These should not cause ACN and have a high union rate.

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30
Q

A high functioning person has an intra capsular hip fracture- what is the treatment? Explain

A

Total hip replacement
Despite this surgery having a higher risk of complications it gives them the best chance of getting back to their previous high function.

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31
Q

A low functioning person has an intra capsular hip fracture- what is the treatment? Explain

A

Hemi arthoplasty
The surgery is less complex as total and less risk of dislocation and infection but the mobility isn’t as good, as they don’t have great mobility anyway this option makes more sense.

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32
Q

3 types of extra capsular proximal femoral fractures?

A

Basicervical, intertrochanteric, subtrochanteric

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33
Q

Most extra capsular proximal femoral fractures are treated with? What about subtrochanteric?

A

keep patients hip- do internal fixation with compression and dynamic hip screw
Subtrochanteric= intramedullarly nail

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34
Q

Mechanism of femoral shaft injuries?

A

High energy injuries and often concomitant fracture else where.

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35
Q

With displaced femoral shaft fractures there is risk of ….

A

substantial blood loss and fat embolism

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36
Q

Treatment of femoral shaft fractures?

A

Need nerve block, thomas splint and surgery- usually close reduction with IMN

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37
Q

Mechanism of injury with tibial shaft fractures?

A

Usually occur with indirect force and either bending or rotational energy

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38
Q

Why are open tibial shaft fractures not uncommon?

A

The tibial shaft is subcutaneous

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39
Q

What is the commonest cause of compartment syndrome after trauma? Which compartment?

A

Tibial fractures

Anterior leg

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40
Q

Soft tissue sprains of what are common? Characteristic features?

A

Ankle ligament sprains anterior and posterior talofibular ligaments and calcaneofibular ligament
Characteristic features= pain, bruising, tenderness

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41
Q

Someone comes in with an ankle injury what merits an X-ray?

A

Any severe localised tenderness of distal tibia or fibula or inability to weight bear for four steps.

42
Q

What is a stable ankle fracture?

A

Isolated distal fibular with no medial fracture or rupture of deltoid ligament

43
Q

What are stable ankle fractures treated with?

A

Walking cast or splint for 6 weeks

44
Q

What do unstable ankle fractures need?

A

ORIF

45
Q

Why may you need to wait to do surgery on an ankle fracture?

A

They are associated with substantial soft tissue swelling

46
Q

Describe a mid foot fracture-dislocation (lisfranc injury)

A

Uncommon injury
Fracture of base of 2nd metatarsal is associated with dislocation of the base of the 2nd metatarsal
X-ray may be normal
Grossly swollen bruised foot which they are unable to weight bear

47
Q

Fractures of the base of the __1___ are common and occur due to inversion injury
The _2___ metatarsal is rarely fractured but when it is it needs fixed as is very important for foot function
The __3__ metatarsal is a common site for stress fractures (spontaneous fractures after increased activity)

A

1) fifth
2) first
3) second

48
Q

When may you decide to fixate an intracapsular proximal femur fracture as opposed to joint replacement? What would you have to explain to them?

A

In a young person
You would explain that there is a risk of AVN and non union but better to have 50/50 chance of keeping their own hip vs a definite hip replacement. If non union they can always get hip replacement down the line.

49
Q

If an isolated fracture or dislocation of one of the forearm bones is found what should you have??

A

High index of suspicion that there is a fracture or dislocation of the other bone as it forms a bony ring which hardly ever gets disrupted in only one place!

50
Q

What do you most intra articular injuries require?

A

ORIF

51
Q

Mechanism of majority of humeral neck fractures?

A

Low energy in osteoporotic bone due to a fall onto the outstretched hand or directly onto the shoulder

52
Q

Common pattern of humeral neck fracture?

A

Fracture of the surgical neck with medial displacement of the humeral shaft due to the pull of the pectorals major muscle

53
Q

Describe treatment of humeral neck fractures?

A

Most minimally displaced can be treated with a sling and gradual return to mobilisation. Displaced fractures position often improves once muscle spasm settles but persistent may need internal fixation.

54
Q

Mechanism of traumatic anterior shoulder dislocation?

A

Excessive external rotation or a fall onto the back of the shoulder

55
Q

What will patient with anterior shoulder dislocation look like?

A

Loss of symmetry of the shoulders is seen with roundness of the shoulder and the arm is held in adducted position supported by the other arm

56
Q

What do you need to check if someone has an anterior shoulder dislocation?

A

Function of the axillary nerve
Test sensation over the badge patch, try and assess deltoid although this can be difficult in the acute phase due to pain.

57
Q

Treatment of anterior shoulder dislocation?

A

Closed reduction under sedation with NV assessment before and after and a sling for 2-3 months then physio.

58
Q

Mechanism of traumatic posterior shoulder dislocation?

A

Posterior form on adducted and internally rotated arm

59
Q

How may you diagnose a posterior shoulder dislocation?

A

Humeral head may be palpated posteriorly

May see light bulb sign on X-ray

60
Q

Complication of a humeral shaft fracture?

A

Radial nerve damage

61
Q

Describe mechanism and treatment of an olecranon fracture?

A

Fall onto point of elbow with contraction of triceps

Need ORIF to restore tricep function and restore the articular surface.

62
Q

Define a nightstick fracture?

A

Isolated fracture of the ulna after a direct blow

63
Q

Define a monteggia fracture dislocation?

A

Fracture of the ulna with dislocation of the radial head at the elbow

64
Q

Define a Galeazzi fracture dislocation?

A

Fracture of radius with dislocation of ulna at the distal radio ulnar joint

65
Q

Define a Colles Fracture?

A

Extra articular fracture of the distal radius with dorsal displacement or angulation

66
Q

A dinner fork deformity is seen in ….

A

Colles fracture

67
Q

Describe mechanism and who tends to get Colles fractures?

A

Tend to occur in FOOSH injuries usually those over 60

68
Q

Complication of Colles fracture?

A

Median nerve compression from stretch of the nerve or a bleed into the carpal tunnel

69
Q

Define a smith fracture?

A

Extra articular fracture of the distal radius with volar displacement or angulation.

70
Q

Mechanism of a smith fracture?

A

Fall onto the back of a flexed wrist

71
Q

Treatment of smith vs colles fracture?

A

Colles can be conservative or surgical depends on displacement

All smiths need ORIF as highly unstable

72
Q

Define a Barton’s Fracture

A

Intra-articular fractures of the distal radius involving the dorsal or volar rim where the carpal bones of the wrist joint subluxation with the displaced rim fragment. As intra articular ORIF is needed

73
Q

Mechanism of Scaphoid fracture?

A

Usually a FOOSH

74
Q

Presentation of scaphoid fracture?

A

Pain and tenderness in the anatomical snuff box and pain on compressing the thumb metacarpal

75
Q

Describe X-rays and scaphoid fractures?

A

Fractures can be difficult to visualise on x ray and 4 views are taken if they are suspected. Around 5% are not visible on X-ray but show up on radiographs 2 weeks later after resorption of the fracture ends in the 1st stage of healing.

76
Q

Initial treatment of a scaphoid fracture?

A

If a scaphoid fracture is suspected but not on X-ray then wrist is still splinted and further clinical assessment is arranged for 2 weeks - “clinical scaphoid fracture”
Undisplayed fractures may be treated with a plaster cast for 6-12 weeks.

77
Q

Describe complications and treatments of them in scaphoid fractures?

A

They are prone to non-union due to synovial fluid inhibiting fracture healing and AVN due to weak blood supply.
AVN once established is difficult to treat and if patients are symptomatic they may require partial or total wrist fusion
Non unions and displaced fractures can have surgery

78
Q

Penetrating injuries- what is at risk if volar or dorsal?

A

Volar risks flexor tendon, digital nerves and arteries

Dorsal risks extensor tendons

79
Q

Describe metacarpal injuries?

A

3rd, 4th and 5th are treated conservatively

5th usually occurs with a punching injury

80
Q

How are most phalangeal fractures treated?

A

Most are treated with neighbour strapping or splinting

81
Q

Define spinal shock?

A

Physiologic response to injury with complete loss of sensation and motor function and loss of reflexes below the level of injury

82
Q

Define neurogenic shock?

A

Secondary to temporary shut down of sympathetic outflow from the cord from T1-L2 usually due to injury in the cervical or upper thoracic cord leading to hypotension and bradycardia which usually resolves within 24-48hrs.

83
Q

Difference between spinal and neurogenic shock?

A

Neurogenic shock describes the hemodynamic changes resulting from a sudden loss of autonomic tone due to spinal cord injury. … Spinal shock, on the other hand, refers to loss of all sensation below the level of injury and is not circulatory in nature.

84
Q

Relevant medications in a major trauma to know about?

A

Anti coagulation drugs, blood pressure medication (beta blockers specifically)

85
Q

Where is control of C spine and exsanguinating haemorrhage in the ABCDE assessment?

A

A

86
Q

In circulation you need to assess if the patient is bleeding- where does most bleeding come from?

A

external, abdomen, chest and long bones

87
Q

In multi system trauma the usual fluid of choice is….

A

blood

88
Q

Minimum and maximum GCS score?

A

Minimum - 3 which is bad

Maximum - 15 which is the normal for an alert well person

89
Q

How do you usually clear the C spine?

A

Usually clear C spine with CT

If minor accident do Nexus criteria

90
Q

Metaphyseal bone has a thinner cortex and therefore heals…

A

quicker in comparison to the diaphysis

91
Q

4 differences in child fractures vs adults and healing ?

A

1) Childrens bones are more elastic and pliable and tend to buckle or partially fracture or splinter with some degree of continuity.
2) The periosteum in children’s bones is much thicker and tends to stay intact and help stability
3) They tend to heal quicker due to the thicker periosteum being a rich source of osteoblasts
4) Children’s bones have a greater potential for remodelling so more angulation can be allowed (this decreases with age and in girls earlier)

92
Q

What is the most common Salter Harris fracture? Do they cause growth problems?

A

Type 2

Highly unlikely to cause growth problems

93
Q

Describe Salter Harris Classifications

A

Type 1= pure physical separation
Type 2= physical separation with small amount of metaphysic
Type 3 and 4= intra articular, split physis in half
Type 5= compression (not seen on X-ray)

94
Q

Which is stable a buckle or greenstick?

A

Buckle always stable

Greenstick may be unstable due to angulation

95
Q

Why are supracondylar fractures of the elbow common in children?

A

Supracondylar region of the distal humerus is relatively weak in a growing child so fractures are common

96
Q

How do supracondylar fractures of the elbow typically occur?

A

Extension type is Common- heavy fall onto outstretched hand

Flexion type is less common- fall onto the point of a flexed elbow

97
Q

Potential complications of supracondylar fracture of the elbow? What do you need to test?

A

Pressure on the brachial artery and the anterior interosseous branch of the median nerve.
For median nerve check the child can make the OK sign

98
Q

When do femoral shaft fractures occur?

A

Due to fall onto a flexed knee or indirect bending or rotational forces

99
Q

In children less than 2 yrs old what are more than 50% of femoral shaft fractures due to?

A

NAI - child abuse

100
Q

Describe treatment of femoral shaft fractures depending on age?

A

In children less than two years either Gallows traction or hip spica cast
In 2-6 thomas splint or spica
In 6-12 flexible IMN
In over 12 adult IMN

101
Q

Describe tibial fractures in children?

A

Undisplayed fractures are common in toddlers and require a short time in a cast
Cast is treatment majority of child tibial fractures

102
Q

Artery to the head of the femur is a branch of the

A

obturator artery

Musculoskeletal (18 decks)

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