Fractures: General Management

Question 1

Causes of fractures?

Answer 1

Trauma (excessive force to bone)
Stress (repetitive low-velocity injury)
Path (abnormal bone which fractures after minimal trauma)

Question 2

What does fracture diagnosis involve?

Answer 2

Evaluate fracture (site, injury type), associated injuries, distal NV deficits

So clinical examination + radiographs of prox. and distal joints

Question 3

How should fracture x-rays be assessed?

Answer 3

Bone length changes
Angulation of distal bone
Rotational effects
Presence of materials like glass

Question 4

What are the five types of fracture?

Answer 4

COSTS

Comminuted
Oblique
Segmental
Transverse
Spiral

Question 5

What is a comminuted fracture?

Answer 5

> 2 fragments

Question 6

What is an oblique fracture?

Answer 6

Oblique to the long axis of the bone

Question 7

What is a segmental fracture?

Answer 7

More than one fracture along the bone

Question 8

What is a transverse fracture?

Answer 8

Perpendicular to the long axis of the bone

Question 9

What is a spiral fracture?

Answer 9

Severe oblique fracture + rotation along long axis of the bone

Question 10

What is the difference between an open vs. closed injury?

Answer 10

Open: exposed tissue/organs.
Closed: no exposure to underlying tissue/organs.

Question 11

What is the Gustilo-Anderson classification system used for?

Answer 11

Classification system for open fractures.

Question 12

Describe the Gustilo-Anderson classification system?

Answer 12

1 - low energy wound <1cm
2 - >1cm wound + mod soft tissue damage
3 - high energy wound >1cm + ext soft tissue damage

Question 13

What are the subgroups of grade 3 of the Gustilo-Anderson classification system?

Answer 13

3A - adequate soft tissue coverage
3B - inadequate soft tissue coverage
3C - a/w arterial injury

Question 14

General points in fracture Mx?

Answer 14

Reduce
Immobilise - incl. prox and distal joints
Rehabilitate

(+ Monitor NV status - esp. after reduction + immobilisation)

Question 15

Mx for open fracture wounds?

Answer 15

EMERGENCY

INITIAL:
ABCDE + C-spine
Haemorrhage control (direct pressure)
Analgesia
Assess: NV status, soft tissues, photography
Antisepsis: wound swab, irrigation, betadine/saline-soaked impermeable dressing
Immobilisation: align # + splint
Abx: fluclox IV/IM + benpen IV/IM OR augmentin + tetanus prophylaxis

THEATRE (<6h of injury):
Debridement and lavage
External fixation (<72h)

Question 16

What should be avoided in open fracture wound Mx?

Answer 16

Internal fixation devices (or use with extreme caution)

Question 17

All farm wound injuries are automatically classed as what G-A grade?

Answer 17

At least grade 3A

Question 18

When should open contaminated wounds be debrided?

Answer 18

<12h for high energy injuries
<24h for all other injuries

Question 19

What is the definitive management of open fractures?

Answer 19

Wound debridement/excision (<24h) on routine emergency trauma operating lists

External fixation device at time of primary debridement

Definitive soft tissue construction within 1wk

Question 20

When may one go straight to surgical fixation in open fracture Mx?

Answer 20

Only done initially if it can be followed by definitive soft tissue coverage

External fixation device is generally first used in interim until soft tissue coverage is achieved

Question 21

What is the most important sign which would indicate an urgent need for surgery in a distal humeral fracture?

Answer 21

Distal neurovascular deficit

Fractures here = risky to brachial artery. Fractured end of distal humerus could shear it -> distal NV loss. NEEDS IMMEDIATE EXPLORATION.