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MSK Cortext > General Trauma - Fractures > Flashcards

General Trauma - Fractures Flashcards

1
Q

what is a fracture?

A

medical term for a break in the bone

- can be complete or incomplete

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2
Q

what is primary bone healing?

A

method of bone healing when fracture gap is small (<1mm), hairline fractures and fractures which are compressed with plates and screws
bone simply bridges the gap with new bone formed by osteoblasts

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3
Q

what is secondary bone healing?

A

inflammatory response temporarily fills a larger gap with pluropotential stem cells at the fracture site to act as a scaffold for new bone to be laid down

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4
Q

what is the process of secondary bone healing?

A
  • fracture occurs
  • haematoma occurs with inflammation from damaged tissues
  • macrophages and osteoclasts remove debris and resorb the bone ends
  • granulation tissue forms from fibroblasts and new blood vessels
  • chondroblasts form cartilage (soft callus) - 2-3 weeks
  • osteoblasts lay down bone matrix (type 1 collagen) = echondral ossification
  • calcium mineralisation produces immature woven bone (hard callus) - 6-12 weeks
  • remodelling occurs with organisation along lines of stress into lamellar bone
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5
Q

what is required for secondary bone healing to take place?

A

good blood supply for oxygen, nutrients and stem cells
a little movement/stress
nutrition
not smoking
can result in atrophic non union or hypertrophic non union without

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6
Q

what are the 5 patterns of fracture?

A

transverse - due to bending force
oblique - due to shearing force (fall from height, deceleration)
spiral - due to torsional, rotational forces
comminuted - due to high energy injury
segmental - bone fractured in 2 separate places

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7
Q

what are the features of each fracture type?

A

transverse - can angulate or cause rotational malalignment
oblique - tend to shorten and angulate, fixed with screw
spiral - rotational instability and can angulate, screws can be used
comminuted - 3 or more fragments, soft tissue swelling, periosteal damage, reduced blood supply, unstable, needs surgery
segmental - very unstable and need long rods or plates

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8
Q

how can a fracture of a long bone be described?

A

site - proximal, distal, middle
type of bone - diaphyseal, metaphyseal, epiphyseal
intra/extra-articular
displacement

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9
Q

what does displacement of a fracture depend on?

A

translation
angulation
rotation

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10
Q

how can translation of a distal fragment be describe?

A

anteriorly or posteriorly displaced
medially or laterally translated
- terms replaced by volar/palmar and radial/ulnar when in the hand
degree estimated with reference to width of bone

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11
Q

what is a 100% displacement of fracture known as?

A

off ended fracture

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12
Q

what is angulation?

A

the direction in which the distal fragments points towards and the degree of this deformity

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13
Q

how is angulation described?

A

medial/lateral and anterior/posterior
radial/ulnar and dorsal/volar in upper limb
varus/valgus and in lower limb
measured in degrees from the longitudinal axis of diaphysis of long bone

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14
Q

why is angulation important?

A

gives info about direction of forces, reversed direction of forces required to reduce the fracture
can lead to deformity, loss of function and post traumatic OA

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15
Q

what is rotational malalignment?

A

rotation of the distal fragment relative to the proximal fragment
unstable and needs to be corrected

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16
Q

what are the clinical signs of a fracture?

A

localised bony tenderness
swelling
deformity
crepitus - from bone ends grafting with unstable fracture

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17
Q

general rule for X ray of possible fracture?

A

if patient cant weight bear on an injured lower limb - request an X ray

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18
Q

how do you assess an injured limb?

A

open or closed
neurovascular status
presence of compartment syndrome
assess skin and soft tissue envelope

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19
Q

how can a fracture be investigated?

A

radiograph - 2 views always requested (AP and lateral/sometimes oblique)
tomogram - moving x ray, used for mandibular fractures
CT - complex bones/fractures, show articular damage, surgical planning
MRI - if normal x ray
Technetium bone scans - stress fractures (don’t show in X ray)

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20
Q

describe the initial management of a long bone fracture

A

clinical assessment
analgesia
splintage/immobilization (backslab, sling, orthosis, Thompson splint)
investigation
reduce before X ray if grossly displaced or risk to skin

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21
Q

describe definitive management of undisplaced or minimally displaced/angulated fractures

A

non-operative with splintage or immobilization then rehab

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22
Q

how are displaced or angulated fractures managed definitivey

A

reduction under anaesthesia
closed reduction and cast application
surgical stabilisation (plates, screws, pins, nails, external fixation etc)

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23
Q

how is an unstable extra-articular diaphyseal fracture managed?

A

can be fixed with ORIF using plates and screws

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24
Q

when should ORIF be avoided and what is used instead in such a case?

A

soft tissue swelling
high energy blood supply
if ORIF would cause blood loss (femoral shaft)
if plate fixation at the site would be prominent (tibia)
instead closed reduction and indirect internal fixation with intramedullary nail

25
Q

what methods of fracture healing cause primary and secondary healing?

A

ORIF = primary
closed reduction with intramedullary nail = secondary
external fixation = secondary

26
Q

how are displaced intra-articular fractures managed?

A

require anatomic reduction and rigid fixation by way of ORIF with wires, screw and plates

27
Q

how are fractures involving a joint with predicted poor outcome managed?

A

joint replacement or arthrodesis

28
Q

why are older patients often treated non-operatively?

A

co morbidities
higher surgery complication risks
less satisfactory rehab results
lower functional demand

29
Q

how can fracture complications be categorised?

A

early/late

local/systemic

30
Q

what are some early local complications?

A

compartment syndrome
vascular injury - ischaemia
nerve compression
skin necrosis

31
Q

what are some early systemic complications?

A 
hypovolaemia
fat embolism
shock
ARDS
renal failure
multi organ dysfunction
systemic inflammatory response syndrome
death
32
Q

what are some late local complications?

A 
stiffness
loss of function
chronic pain
infection
non union
mal union
volkmanns ischaemic contracture
OA
DVT
33
Q

what is the main late systemic complication?

A

PE

34
Q

what are the symptoms of compartment syndrome?

A

severe pain on passive stretching of involved muscle
severe pain more than expected in clinical context
paraesthesia and numbness
swelling
tenderness
loss of pulse at end stage

35
Q

management of compartment syndrome?

A

remove any tight bandages

emergency fasciotomy - leave open for a few days then secondary closure/skin graft

36
Q

complication of compartment syndrome?

A

volkmanns ischaemic contracture

ischaemic muscle with necroes resulting in fibrotic contracture

37
Q

what can happen to vessels in fractures?

A 
stretched
compressed
torn
transected
partial tear > thrombosis > arterial occlusion
38
Q

give some possible complications of vascular injury

A

ischaemia - amputation

hypovolaemic shock

39
Q

what injuries are most likely to cause vascular injury?

A 
penetrating injury
knee dislocation
paediatric supracondylar fracture
shoulder trauma
pelvic fractures
40
Q

how can temporary restoration of circulation be achieved?

A

vascular shunt
vascular repair with bypass graft or endoluminal stent
skeletal stabilisation with internal/external fixation to protect repair

41
Q

what is done for an ongoing haemorrhage from artery injury in pelvis?

A

angiographic embolization

42
Q

what skin sign can indicate that an emergency reduction of a fracture is needed and why?

A

tenting of skin and blanching
protrusion through skin
to avoid subsequent necrosis

43
Q

what causes degloving and what are the features of this?

A

shearing force on the skin causing avulsion of the skin from its blood vessels
skin wont blanch on pressure and have no sensation
can have an underlying haematoma increasing pressure on skin and occluding capillaries

44
Q

what is a fracture blister?

A

inflammatory exudate causes lifting of the epidermis of the skin (like burn)

45
Q

why is surgery not preferred which soft tissue is swollen?

A

wound may not be able to close or if it does it may be very tight and the tension can lead to necrosis and wound breakdown

46
Q

what are the signs of fracture healing?

A

resolution of pain and function
absence of point tenderness
no local oedema
resolution of movement at fracture site

47
Q

what are the signs of non union?

A

ongoing pain and oedema
movement at fracture site
bridging callus seen on imaging

48
Q

what is delayed union and what can cause it?

A

fracture that doesn’t heal within expected time

can be caused by infection

49
Q

what are the 2 types of non-union and what causes them?

A

hypertrophic - instability, excessive motion, infection

atrophic - rigid fixation with gap, poor blood supply, chronic disease, soft tissue interposition, infection

50
Q

name some fractures which are prone to non-union?

A 
scaphoid
distal clavicle
subtrochanteric femur
jones fracture
some intra-articular fractures
51
Q

what is fracture disease?

A

stiffness and weakness due to the fracture and subsequent splintage
fixed with physio

52
Q

bones prone to AVN? how are they managed?

A

femoral neck
scaphoid
talus
THR or arthrodesis

53
Q

what type of fracture causes post traumatic OA?

A

intra-articular
fracture malunion
ligamentous instability

54
Q

what is chronic regional pain syndrome?

A 
heightened chronic pain after injury
constant burning/throbbing
sensitivity to non-painful stimuli
chronic swelling
stiffness
painful movement
skin colour changes
55
Q

what can cause CRPS and how is it managed?

A

Type 1 = unknown
Type 2 = peripheral nerve injury
management = pain relief (analgesics, nerve block, antidepressants, anti epileptics)

56
Q

how does infection affect fracture healing?

A

slows it down when active

fracture can unite when infection is suppressed

57
Q

how is infected fracture fixation managed?

A

antibiotics and surgical washout
if present for longer than a few weeks - metal needs removed
if infection cant be suppressed - remove all implants and debride infected bone

58
Q

management of medullary infection?

A

medullary canal reamed out and a new nail implanted
or
external fixator

59
Q

management of infected non-union of a plate and screw fixation?

A

external fixator

MSK Cortext (61 decks)

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