Fractures Overview Flashcards
When do fractures heal by 1st intention (primary healing)?
If there is a minimal fracture gap
- e.g. in hairline fractures or if fixed with compression screws + plates
When do fractures heal by secondary healing?
When there is a gap (most fractures)
Describe the process of secondary healing?
Gap is filled temporarily with cells acting as a scaffold for new bone
Inflammation –> soft callus (2-3 weeks) –> hard callus (6-12 weeks) –> remodelling
Why might non-union of a fracture occur?
Lack of blood supply No movement Too big a gap Tissue in the gap Smoking Vascular disease Ill health Malnutrition
Name the different types of fracture pattern
Transverse Oblique Spiral Comminuted (3 or more fragments) Segmental (bone fractured in two separate places)
What are the different ways to describe the site of fracture?
Proximal, middle or distal 1/3
Diaphyseal (shaft), metaphyseal, epiphyseal
Intra or extra articular
Which two terms are used to describe the way the fracture parts are positioned?
Displacement
Angulation
What are the mean components of assessing an injured/fractured limb?
Open or closed?
Distal neurovascular status
Compartment syndrome?
Status of skin + soft tissue envelope
How do you assess distal neurovascular status?
Pulses Cap refill Temperature Colour Sensation Power
Which signs my indicate a fracture?
Localised bony (marked) tenderness Swelling Deformity Crepitus Cannot weight bare (lower limb)
Which investigation in usually done for a suspected fracture?
Xray –> AP and lateral views
When might a CT be used to assess a fracture?
Complex bones e.g. vertebrae, pelvis, calcaneous, scapular glenoid
Can help with surgical planning for intra-articular fractures e.g. tibial plateau, distal tibia
When might MRI be used to assess a fracture?
To detect occult fractures when xray is normal but a high clinical suspicion e.g. hip, scaphoid
What is the initial management of a long bone fracture?
Analgesia (IV morphine)
Splintage/immobilisation
Xray
Why does management of open fractures differ from closed fractures, and how?
Increased risk of infection
- broad spectrum antibiotics
- prompt surgery –> debridement + internal/external fixation
What are the early local complications of fractures?
Compartment syndrome
Vascular compromise/ischaemia
Nerve damage
Skin necrosis
What are the early systemic fracture complications?
Hypovolaemia Fat embolism ARDS AKI SIRS MODS
What are the late local fracture complications?
Stiffness Loss of function Chronic regional pain syndrome Infection Non-union Mal-union OA Volkmann's ischaemic contracture DVT
What are the late systemic fracture complications?
PE (although can be an early complication)
What is compartment syndrome?
Increased pressure within tight fascial compartment –> ischaemia of the muscle
SURGICAL EMERGENCY
What are the clinical features of compartment syndrome?
Increased pain on passive stretching of involved muscle
Severe pain outwith anticipated severity in clinical context
Intensely swollen and tender
Paraesthesia common
Loss of pulses at end stage –> too late
How is compartment syndrome managed?
Emergency fasciotomies
- incisions left open, reassess after 24-48 hours
What needs to be monitored after a patient has compartment syndrome and why?
Renal function
–> effects of rhabdomyolysis or reperfusion injury
What is the general prognosis of nerve injury due to fracture?
Usually resolves/improves with time unless nerve is completely transected
Which nerve is commonly injured in a Colles fracture?
Median nerve
Which nerve is commonly injured in an anterior shoulder dislocation?
Axillary nerve
Which nerve is commonly injured in a humeral shaft fracture and where does it lie?
Radial nerve in spiral groove
Which nerve is commonly injured in a supracondylar fracture of the elbow?
Median nerve (anterior interosseous branch)
Which nerve might be injured in a posterior hip dislocation?
Sciatic nerve
Which nerve may be injured in a ‘bumper’ injury to lateral knee?
Common peroneal nerve
What should be done if there are any signs of reduced distal circulation after a fracture?
Urgent vascular surgical review + emergency theatre
- angiography in theatre might help localise
- vascular shunt/bypass
Which artery may be occluded after a knee dislocation?
Popliteal artery
Which artery may be occluded following a paediatric supracondylar elbow fracture?
Brachial artery
Which artery may be damaged in shoulder trauma?
Axillary artery
How might the skin be threatened following a fracture?
Tension on skin from displaced/angulated bones (tenting + blanching) –> devitalisation + necrosis with skin breakdown
Degloving removes skin from blood supply –> ischaemia and necrosis
How should you manage a fracture which shows signs of skin tenting/blanching?
Reduce fracture as an emergency
Which signs might indicate non-union of a fracture?
Ongoing pain + oedema
Movement at fracture site
Which bones take an especially long time to heal?
Tibia (slowest to heal, 16+ weeks) Femoral shaft (3-4 months)
Name some common sites of fracture non-union?
Scaphoid waist
Distal clavicle
Subtrochanteric femur
Jones fracture of 5th metatarsal
What is fracture disease?
Stiffness + weakness at the site of a previous fracture
Which sites are particularly susceptible to AVN when fractured?
Scaphoid
Femoral neck
Talus
What is complex regional pain syndrome?
Persistent and debilitating pain experienced long after an injury has healed - poorly understood
