HD 6 - Management of fractures and joint replacements

Question 1

What type of bone fractures occur?

Answer 1

• Direct force
• Indirect force e.g. spiral long bone fractures
• Stress fractures – repeated minor injury
• Pathological fractures – abnormal bone
• Closed
• Open/compound
• Transverse
• Greenstick
• Communicated

Question 2

What x-ray views are needed to properly diagnose a fracture?

Answer 2

2 views at 90 degrees

Parallax

Question 3

How is a fracture inspected?

Answer 3

• General appearance = guarding (muscle spasm)/gait
• Colour – redder / pale – depends on blood supply
• Swelling - oedema vs ‘compartment syndrome’ –
• Bruising
• Open (compound) - early closure

Question 4

What is compartment syndrome?

Answer 4

Fracture in area, tight fascial planes (i.e. in legs), swelling/bleeding in area causing swelling in fascial area, increased pressure = numbness/ no blood supply

Question 5

How is a fracture palpated?

Answer 5

• Careful palpation: Swelling, distal pulses/capillary refill = time taken for colour to return to an external capillary bed after pressure is applied to cause blanching, temperature
• Neurological: Pin prick / cotton wool, reflexes
• Body – medial (midline)/ distal (away)

Question 6

What is the difference between active and passive movement for fractured bone exam?

Answer 6

Active – patient moves joint themselves

Passive – surgeon moves joint

Question 7

Where are the Le Fort midface fractures?

Answer 7

• 1 - palate
• 2 – through nasal bridge
• 3 – passes to zygomatic bone

Question 8

When do greenstick fractures occurs?

Answer 8

In a young, soft bone in which the bone bends and breaks

Question 9

What are the classifications of fractured bones?

Answer 9

• Displacement (displaced if 2 ends are not in anatomical apposition) = impaction, distraction, rotation, angulation
• Avulsion, fracture dislocation – linked to joint
• Stability
• Integrity of overlying skin

Question 10

What are the 3 phases of fracture healing?

Answer 10

Inflammatory
Reparative
Remodelling

Question 11

Describe the inflammatory phase of fracture healing.

Answer 11

• Bleeding and clot formation
• Acute inflammatory response
• Bone necrosis at fracture end
• Macrophage infiltration removes dead material
• Formation of vascular granulation tissue = BISPHOSPHONATES IMPEDE THIS STAGE

Question 12

Describe the reparative phase of fracture healing.

Answer 12

• Ideally cortex to cortex
• Provisional callus / external callus
• Medullary reaction
• Over 6-12 weeks direct ossification occurs throughout the fracture gap

Question 13

Describe the remodelling phase of fracture healing.

Answer 13

Occurs for up to 2 years under functional loads/forces

Question 14

What are the 4 main fracture management points?

Answer 14

• Reduction - closed or open - ‘ORIF’
• Fixation
• Immobilisation
• Rehabilitation

Question 15

What is ORIF?

Answer 15

ORIF = OPEN REDUCTION INTERNAL FIXATION = keeping everything in right place
• 2-part surgery
• First, the broken bone is reduced or put back into place
• Next, an internal fixation device is placed on the bone

Question 16

What is reduction management in a bone fracture?

Answer 16

• Re-establish anatomy
• Degree of accuracy depends on function
• Urgent if vascular compromise

Question 17

What is fixation management in a bone fracture?

Answer 17

• Intrinsic Stability
• External fixation = cast / frames
• Internal fixation = plates, screws, nails

Question 18

What is rehabilitation management in a bone fracture?

Answer 18

• Minimise immobilisation
• Early mobilisation
• Physiotherapy

Question 19

What are the immediate complications of fracture fixation?

Answer 19

• Haemorrhage
• Tissue loss
• Nerves / vessels
• Internal organs
• Compartment syndrome (5P’s): pale, pulseless, paraesthesia, pain (extreme), paralysis

Question 20

What are the early complications of fracture fixation?

Answer 20

Local

• Necrosis
• Infection
• Failure of alignment / fixation

General

• Fat embolism – Confusion, respiratory difficulty, rash
• Crush syndrome – Renal failure = muscle damage, release substance which increases metabolites = kidney cannot get rid of them as quick as they need to
• DVT / PE

Question 21

What are the late complications of fracture fixation?

Answer 21

• Malunion – wrong place
• Delayed union – mobility / no callus
• Non-union – separated closed ends
• Joint stiffness and contracture
• Infection

Question 22

When is a joint replacement indicated?

Answer 22

• Indicated in primarily in degenerative disease

* Secondary to surgical resection

Question 23

What can joint replacements be made out of?

Answer 23

Stainless steel, titanium, polymers and combos

Question 24

What is the guidance of joint replacement and dental prophylaxis?

Answer 24

• Suggestion of bacteraemia production following dental treatment
• Orthopaedic surgeons have advocated risk of infection at the prosthesis due to this bacteraemia and can favour idea of prophylactic antibiotics to prevent infection at the joint
• Current guideline’s advice antibiotics are not required prophylactically