Fractures (trauma, stress, pathological) incl. classifications, radiology, management, complications, healing and stability

Question 1

What are the three types of connective tissues?

Answer 1

1. Bony -osteoid made by osteoblasts
2. Cartilagenous - chondroid made by chondroblasts
3. Fibrous - collagenous tissue made by fibroblasts

Question 2

What types of collagen are found in skin and bone?

Answer 2

Skin - types I and III

Bone - types I

Hyaline cartilage - type II

Question 3

What are the parts of a long bone? Which part is most metabolically active?

Answer 3

Epiphysis, metaphysis (near epiphyseal lin) and diaphysis

Metaphysis is most metabolically active

Question 4

What orientation do pathological fractures usually have?

Answer 4

They are usually transverse

Question 5

Does bone growth occur equally along the bones?

Answer 5

No - ‘to the elbow I grow, from the knee I flee’

Bone growth is more active at the farthest ends from the elbow and nearest to the knee

Question 6

What are the types of joints?

Answer 6

1. Fibrous joints/syndesmoses
2. Cartilaginous joints/synchondroses
3. Synovial joints - allow greatest mobility

Question 7

What is hilton’s law?

Answer 7

The nerve supply of a joint is the same as that of the overlying muscles moving the joint and the skin over the insertions

Question 8

What is the name for an injury where skin is sheared from the deeper layers?

Answer 8

Degloving injury

Question 9

How are gunshot wounds classified and which are more common?

Answer 9

Low-velocity - more common e.g. by handgun or revolver

High-velocity e.g. assault rifle

Question 10

Why are high-velocity gunshot wounds more dangerous despite looking innocent?

Answer 10

Phenomenon known as cavitation

Organs are pulled along the path of the bullet

Air/debris may be sucked in causing more contamination

Question 11

What is a comminuted fracture?

Answer 11

When bone is broken into more than 2 fragments

Question 12

What are the different ways of describing fracture type?

Answer 12

Transverse - usually due to force applied directly to the site

Spiral or oblique fracture - due to twisting force

Greenstick - cortex on concave side usually remains intact

Crush fracture - cancellous bone due to compression fracture

Burst fracture - usually in short bone like vertebrae due to impaction of the disc

Avulsion - caused by traction and bony fragment torn off by tendon/ligament

Fracture dislocation/subluxation - malalignment of joint surfaces

Question 13

What is a ‘complicated’ fracture?

Answer 13

One that is associated with damage to nerves, vessels or internal organs

Question 14

What type of fracture?

Answer 14

Crush fracture

Question 15

What is the difference between dislocation and subluxation?

Answer 15

dislocation is a complete loss of congruity of the joint surfaces

subluxation is a partial loss of contact of the joint surface

Question 16

What type of fracture?

Answer 16

Burst fracture

Question 17

Summarise the salter-harris classification.

Answer 17

Question 18

In the stages of fracture healing when does callus formation occur? What about complete radiological union?

Answer 18

Question 19

What are the 3 main principles of fracture management?

Answer 19

1. Reduce
2. Immobilise/maintain reduction
3. Rehabilitate

Question 20

Should open fractures be closed straight away?

Answer 20

No - risk of infection needs to be eliminated first, sepsis excluded

Sometimes closure can be done early if there is little contamination and the open fracture is less than 6 hours old

Question 21

What are the reasons for fracture reduction?

Answer 21

1. Cosmesis
2. Function
3. Mobility
4. Union
5. Neurovascular compromise

Question 22

What are the advantages and disadvantages of the plaster of Paris?

Answer 22

Question 23

What are the types of fracture reduction?

Answer 23

1. Manipulation under anaesthesia
2. Traction - slow reduction when manipulation is inappropriate e.g. risky anaesthetic
3. Open reduction - accurate but risk of infection
4. Closed reduction and fixation

Question 24

What are 3 different techniques used for maintaining fracture stability?

Answer 24

Intrinsic stability i.e. require no stabilisation

External splintage -

• casting - e.g. plaster of Paris (but this is heavy), polythene, plastazote
• cast bracing - hinged or jointed
• traction - usually needs in patient stay so less used now;many different types
• frame fixation

Internal fixation - bone stability promotes soft tissue healing;

• screws
• plates
• compression plates
• IM nails
• wires

Question 25

What are the advantages and disadvantages of internal fracture fixation?

Answer 25

Question 26

In what situations is fracture fixation important?

Answer 26

* When external splinatge is not adequate reduction * When early movement is needed * When you must avoid long periods of immobility e.g. elderly * In cases of multiple trauma to simplify treatment * In some pathological fractures where union is uncertain

Question 27

Name this traction.

Answer 27

Gallows or Bryant traction

Question 28

What fractures is this traction used for?

Answer 28

Tibial or femoral fractures

Question 29

Answer 29

Question 30

What are the main immediate complications from fracture?

Answer 30

1. Shock - from haemorrhage which is internal or external 2. Injury to important organs e.g. brain, lung, liver 3. Injury to nerves or vessels 4. Skin loss or damage

Question 31

What are the intermediate complications of fracture (i.e. occuring during treatment)?

Answer 31

1. DVT/PE 2. Chest infection 3. Renal calculi, acute retention, other UTI 4. Fat embolism syndrome - usually 3-10 days after fracture of long bone, cause unknown. Presents as confusion and resp difficulties 5. Crush syndrome - extensive tissue damage results in ATN with renal failure; may be prevented by removing damaged tissue Locally: 1. Compartment syndrome 2. Gangrene 3. Pressure sores and nerve palsies 4. Infection and wound breakdown 5. Loss of alignment 6. Tetanus and gas gangrene

Question 32

What are the late complications of fractures?

Answer 32

General - PTSD or psychological disturbance Local 1. Delayed and non-union 2. Late wound sepsis with skin breakdown 3. Failure of internal fixation 4. Joint stiffness and contracture 5. Regional pain syndrome - previously known as reflex sympathetic dystrophy, Sudek's atrophy or algodystrophy. Unknown cause. Causes pain, swelling and discolouration with patchy porosis on XR which then resolves after weeks-months. 6. Osteoarthritis

Question 33

What is a sign of delayed union?

Answer 33

No callus formation

Question 34

Name 3 factors which affect fracture union.

Answer 34

* Age - favourable in young, no effect in old * Fracture site - blood supply * Degree of violence - slower * Infection * Immobilisation * Bone or generalised disease * Distraction of the bone ends