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Musculoskeletal > Fractures- Ayers > Flashcards

Fractures- Ayers Flashcards

1
Q

Discuss difference between Non-articular vs. Intra-articular fractures

A

Non-articular fractures do not involve the joint surface.

Intra-articular fx involve the joint surface (articular surface) and can lead to post-traumatic arthritis.

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2
Q

Name the different fracture (fx) patterns.

A
  1. Spiral
  2. Oblique
  3. Transverse
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3
Q

Name different types of Diaphyseal Fractures

A

Type A:
-Simple fracture with 2 fragments

Type B:
-Butterfly fracture with a free wedge of bone

Type C:

  • Comminuted fracture
  • Complex
  • Contact lost between the bone fragments.
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4
Q

Fracture healing, Infection and amputation rate are a function of what?

A

Degree of Soft tissue injury

Note: We must also evaluate degree of Periosteal stripping in the OR.

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5
Q

Describe Type I Open Fracture

A
  • Inside out injury (fractured bone penetrating through skin).
  • Minimal soft tissue damage
  • Periosteum is minimally damaged
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6
Q

Describe Type II Open fracture

A
  • Inside out or Outside in mechanism
  • Moderate soft tissue damage
  • Some necrotic muscle
  • Some Periosteal stripping
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7
Q

Describe a Type IIIA Open Fracture

A
  • Outside in injury
  • Extensive muscle devitalization
  • Bone coverage with existing soft tissue is not a problem.
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8
Q

Describe a Type IIIB Open fracture

A
  • Outside in injury
  • Extensive muscle devitalization
  • Requires a local or free flap for bone coverage and soft tissue closure.
  • Periosteal stripping
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9
Q

Describe a Type IIIC Open fracture

A
  • High energy
  • Major vascular injury requiring repair
  • High risk for infection and/or amputation
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10
Q

What is Comminution?

A

The amount of bone fragments from the fracture.

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11
Q

Will most fractures heal without intervention?

A

Yes.

Exceptions: (Confirm this)

  • Ribs and Clavicles
  • Nonunion model difficult to create.

Note: Intervention is aimed at putting bone is best realignment to achieve the best functional outcome.

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12
Q

Fractures that heal non-operatively occur via what?

A

Callus:

-Which is highly vascularized bone growth that appears around the fracture site.

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13
Q

Name the 2 factors required for bone healing.

A
  • Good blood supply

- Good mechanical stability

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14
Q

Name the 3 blood supplies of Long bones

A
  1. Nutrient artery (intermedullary)
  2. Periosteal vessels
  3. Metaphyseal vessels
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15
Q

Name 2 mechanisms of Bone formation

A
  1. Endochondral

2. Direct bone formation (Cutting Cones)

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16
Q

What are the 6 Stages of Fracture healing?

A
  1. Impact
  2. Induction (Hematoma formation leading to inflammatory cells)
  3. Inflammation
  4. Soft Callus (Chondroid matrix)
  5. Ossification (Woven bone formation)
  6. Remodeling (Lamellar bone formation)
17
Q

What is Endochondral bone formation?

A
  • Process by which Long bones grow in length.
  • Cartilage laid out. Chondrocytes then hypertrophy, degenerate, and ossify.
  • Vascular invasion occurs followed by ossification
18
Q

What is Endochondral (indirect) bone formation?

A
  • Mechanism for healing fractures that are not rigidly fixed.
  • Most common
  • Bridging periosteal soft callus comes into communication with medullary hard callus
  • Ossification takes place
  • Rapid process (weeks)
19
Q

What is Direct bone healing? Timing?

A

-Method of bone healing when the fracture is rigidly fixed with no internal movement.

  • Fracture callus is not formed. Lamellar bone laid down instead.
  • Osteoblasts originate from endothelial and perivascular cells.

-Slow process (months to years).

20
Q

Describe mechanism of Direct bone healing

A
  1. Cutting cone formed that crosses fracture site.
    - Osteoclasts at tip of cone that chisel path
    - Osteoblasts at tail of cone that lay down Lamellar bone.
  2. Fracture site is gradually healed by formation of Secondary osteons.

Note: Very slow process (months to years).

21
Q

What is Contact Healing?

A
  • Direct Bone Healing
  • Direct contact between the fracture ends allow healing to be with Lamellar bone immediately.

Note: There is no cartilage or soft callus intermediate.

22
Q

What is Gap Healing?

A

-Gaps less than 200-500microns are initially filled with Woven bone that is remodeled into Lamellar bone over time.

  • Larger gaps are healed by Indirect Bone healing.
  • Therefore, filled with a fibrous tissue that is ossified over time (Secondary Ossification).
23
Q

What is BMP2?

A
  • Bone morphogenic protein 2.

- Available to surgeons to stimulate bone formation in patients.

24
Q

Are most fractures Closed or open?

A

-Closed (76.5% of them)

25
Q

What is the most common long bone fracture?

A
  • The closed tibial fracture.
  • The ipsilateral fibula is commonly fractured as well.

Note: With closed fractures, always monitor the possible development of Compartment syndrome. May take several days to develop.

26
Q

What is the order of Radiographic imaging?

A
  • Anterior/Posterior and Lateral on Initial visit.

- Oblique on follow up to assess healing.

27
Q

What are the management options for Closed Tibial fractures?

A

PINE

Plates
Intramedullary nails
Non-surgical treatment
External Fixation (Reserved for most serious injuries.)

Note: Picture the downhill skier that crashed into a PINE tree and close-fractured their tibia.

28
Q

Name the Non-Operative Treatment indications for closed tibia fracture

A
  1. Stable Fracture pattern
  2. Minimal soft tissue injury
  3. Ability to bear weight in fracture cast or brace.

Downside:

  • Leg shortening
  • High loss to follow up (60%)
29
Q

What are the Surgical indications for a Closed Tibial fracture?

A
  • Moderate soft tissue injury (a closed cast is not recommended due to the risk of compartment syndrome).
  • Unstable fracture pattern
  • Compartment Syndrome
  • Ipsilateral Femur Fracture
30
Q

What are the surgical options for Closed tibial fractures?

A
  • Intramedullary Nail
  • ORIF with plate (Open reduction internal fixation)
  • External Fixation
31
Q

What are the advantages of Intermedullary nail?

A
  • Less malunion
  • Less shortening
  • Earlier weight bearing
  • Cheaper than cast if time off work included.
32
Q

What are the advantages and disadvantages of plating?

A

Advantages:

  • Anatomic reduction usually obtained
  • High functional outcome.

Disadvantages:

  • High risk of infection because we are opening a closed fracture to do the surgical procedure.
  • Higher hardware failure rate than IM nail.
33
Q

What is External fixation and what are the advantages?

A
  • Half pins drilled into the bone.
  • Clamps and connecting bar applied
  • Reserved for serious injuries or Periarticular fractures.
  • Last resort

Advantages:

  • Can be applied quickly in polytrauma patient
  • Allows monitoring of soft tissue compartments

Disadvantages:

  • Non-union
  • Loss of reduction upon pin removal
  • Pin track infection risk
34
Q

List the Fracture Lecture Conclusion points

A
  • Closed stable fractures can be treated in a cast since bone can heal itself.
  • Unstable fractures are best treated with Intramedullary nail.

Musculoskeletal (9 decks)

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