HD 6 - Management of fractures and joint replacements Flashcards
What type of bone fractures occur?
- 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
What x-ray views are needed to properly diagnose a fracture?
2 views at 90 degrees
Parallax
How is a fracture inspected?
- General appearance = guarding (muscle spasm)/gait
- Colour – redder / pale – depends on blood supply
- Swelling - oedema vs ‘compartment syndrome’ –
- Bruising
- Open (compound) - early closure
What is compartment syndrome?
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
How is a fracture palpated?
- 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)
What is the difference between active and passive movement for fractured bone exam?
Active – patient moves joint themselves
Passive – surgeon moves joint
Where are the Le Fort midface fractures?
- 1 - palate
- 2 – through nasal bridge
- 3 – passes to zygomatic bone
When do greenstick fractures occurs?
In a young, soft bone in which the bone bends and breaks
What are the classifications of fractured bones?
- 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
What are the 3 phases of fracture healing?
Inflammatory
Reparative
Remodelling
Describe the inflammatory phase of fracture healing.
- 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
Describe the reparative phase of fracture healing.
- Ideally cortex to cortex
- Provisional callus / external callus
- Medullary reaction
- Over 6-12 weeks direct ossification occurs throughout the fracture gap
Describe the remodelling phase of fracture healing.
Occurs for up to 2 years under functional loads/forces
What are the 4 main fracture management points?
- Reduction - closed or open - ‘ORIF’
- Fixation
- Immobilisation
- Rehabilitation
What is ORIF?
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
What is reduction management in a bone fracture?
- Re-establish anatomy
- Degree of accuracy depends on function
- Urgent if vascular compromise
What is fixation management in a bone fracture?
- Intrinsic Stability
- External fixation = cast / frames
- Internal fixation = plates, screws, nails
What is rehabilitation management in a bone fracture?
- Minimise immobilisation
- Early mobilisation
- Physiotherapy
What are the immediate complications of fracture fixation?
- Haemorrhage
- Tissue loss
- Nerves / vessels
- Internal organs
- Compartment syndrome (5P’s): pale, pulseless, paraesthesia, pain (extreme), paralysis
What are the early complications of fracture fixation?
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
What are the late complications of fracture fixation?
- Malunion – wrong place
- Delayed union – mobility / no callus
- Non-union – separated closed ends
- Joint stiffness and contracture
- Infection
When is a joint replacement indicated?
- Indicated in primarily in degenerative disease
* Secondary to surgical resection
What can joint replacements be made out of?
Stainless steel, titanium, polymers and combos
What is the guidance of joint replacement and dental prophylaxis?
- 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
