Limb Trauma Flashcards
What is the mortality associated with #NOF?
- 10% die within one month
- 25-30% die within one year
What are the risk factors for #NOF?
- age
- osteoporosis
- osteomalacia
- falls
- instability
- lack of core strength
- gait abnormality
- sensory impairment
How are #NOF classified and sub-classified?
- Intracapsular
- sub capital
- transcervical
- basal
- Extracapsular
What are the clinical features of #NOF?
- hip pain radiating to the knee
- inability to weight bear
- affected leg appears shortened, adducted and externally rotated
- rotation is painful
How is #NOF diagnosed?
- AP pelvic and lateral hip XR
- CT to determine determine displacement and comminution
- MRI useful in ruling out occult #, e.g. # suspected but not shown on XR
What is the initial management of #NOF?
- ABCDE assessment and intervention
- DVT assessment
- ECG
- adequate analgesia
- early assessment for cognitive impairment
- catheter
What are the principles of secondary management of #NOF?
- surgery as soon as medically fit
- early mobilisation post-surgery
What surgeries may be used to manage #NOF and when is each type used?
- Hemi- or total arthroplasty for intracapsular #
- Dynamic hip screw fixation for extra capsular fracture
- Cannulated screw fixation for undisplaced intra- or extra capsular #
Femoral # is almost always due to _____, e.g. ________
almost always due to high energy trauma
e.g. RTA, gunshot wound, fall from height
Where do pathological femoral # occur?
metaphyseal/diaphyseal junction
If the degree of trauma is inconsistent with the # that has been identified, what should you do?
Investigate to r/o pathological #
What are the clinical features of femoral fracture?
- pain
- swelling
- deformity: complete external rotation
- shorting of the affected leg
- features of shock due to haemorrhagic hypovolaemia (up to 1.5L loss)
How is femoral # in children managed?
- r/o NAI
- gallows traction for children <2y
- hip spica
- external fixation, plate or elastic nails in older children
What is a Salter-Harris Type I injury? and what is the prognosis?
Injury straight through the growth plate (physis) - excellent prognosis, managed non-operatively
What is a Salter-Harris Type II injury? and what is the prognosis?
Injury above the growth plate (involving the physis and metaphysis) - excellent prognosis, managed non-operatively
What is a Salter-Harris Type III injury? and what is the prognosis?
Injury lower than the growth plate (involving the physis and epiphysis, extending into the joint) - often unstable
What is a Salter-Harris Type IV injury? and what is the prognosis?
Injury through the growth plate (involving metaphysis, physis, epiphysis and joint surface) - prone to limb length discrepancies
What is a Salter-Harris Type V injury? and what is the prognosis?
Crush injury resulting in erasure of the growth plate (physis) - prone to limb length discrepancies
What are the most common acute knee injuries?
- acute patellar dislocation
- collateral ligament rupture
- contusion
- meniscus injury
- ACL injury
How is patellar dislocation managed?
- brace for 2-4 weeks
- physiotherapy
How are collateral ligament ruptures managed?
- brace if the knee is lax
- physiotherapy
How do ACL injuries occur?
- twisting injuries e.g. changing direction suddenly while running, tackles in football
- hyperextension of the knee due to a fixed foot and onward motion of rest of the body e.g. skiing, landing incorrectly from a jump
What are the most common long bone fractures?
tibia and fibula
What is the management of knee injuries?
- investigate with MRI
- rest
- ligament repair if indicated
- arthroscopic intervention if meniscal injury
What percentage of tibial fractures are open?
23%
What are the common causes of tibia/fibula #?
- RTA
- Sports
- Assault
- Falls
What are the clinical features of tibia/fibular #?
- pain
- deformity
How are suspected tibia/fibula # investigated?
- acute: AP and lateral view XR
- delayed: AP, lateral and oblique view XR showing knee and ankle joints
What are the indications for managing a tibia/fibular # with closed reduction under GA and a long leg cast?
- closed #
- undisplaced or minor-moderate displacement
- low energy trauma
- young adults
When is ORIF indicated for tibia/fibula #?
- vascular or neural injuries
- segmental #
- inadequate reduction
- displaced intra-articular #
What is a tibial plafond #?
Intra-articular distal tibia #
What is a tibial plateau #?
Intra-articular proximal tibia #
What are the potential complications of tibial #?
- compartment syndrome
- delayed union
- non-union
- malunion
- shortening
- infection
- joint stiffness
- refracture
- fat embolism
How are ankle fractures classified?
Danis-Weber classification
What is a Weber A #? what is their prognosis?
of the lateral malleolus distal to the syndesmosis
usually stable so can be treated in below knee cast or boot for 6 weeks
What is a Weber B #? what is their prognosis?
of the fibula at the level of the syndesmosis
variable stability - may be possible to treat with immobilisation or may need surgery
What is a Weber C #? what is their prognosis?
fibula # proximal to the syndesmosis
unstable - required ORIF
What is a Pilon #? how do they occur and what is their prognosis?
intra-articular distal tibia #
caused by rotational or axial forces
often co-morbid with other associated injuries, often produce comminution
requires emergency orthopaedic consult, immobilisation and likely surgery
A major complication of displaced talar fractures is _____
avascular necrosis
How are calcaneal # managed?
- non WB immobilisation for 12 weeks
- fixation if articular surface affected (to reduce future arthritis)
How are undisplaced metatarsal # managed?
conservative
BK cast or boot
How are phalangeal # managed?
neighbour strapping
What are the 6 basic steps to describe a #?
- which bone?
- where on the bone? (think in thirds)
- type of fracture?
- number of fragments?
- any displacement?
- intra-articular involvement?
What are the types of fracture displacement?
- translation (post/ant, med/lat, rad/uln)
- angulation
- distraction
- shortening
- rotation
What are the types of complete fracture? Describe them
Transverse: fracture at right angles to the shaft
Oblique: fracture at an angle to the shaft
Spiral: caused by twisting injury
Comminuted: 2 or more bone fragments
Impacted: fractured bone forced together
Displacement of a # is described in terms of the distal fragment in comparison to the proximal fragment. True or false?
True
What does a DEXA scan measure?
bone mineral density
What does the t score from a DEXA scan represent?
how many SD the individuals BMD is from the ideal BMD
What does the z score from a DEXA scan represent?
how many SD the individuals BMD is from that of comparable individuals (matched for sex and age)
What are the types of incomplete fracture? Describe them
Torus/Buckle: a bulge in the cortex
Bowing: associated bend in the bone shaft
Greenstick: bending of the shaft with a fracture on the convex surface
Salter-Harris: involving the growth plate
Adults are more likely to sustain incomplete fractures than children, due to their greater bone mineral density. True or false?
False - incomplete fractures most commonly occur in children
There is a greater risk of infection with closed fractures. True or false?
False - there is a greater risk of infection with open fractures
What are the components of the ABCS approach to XR interpretation?
Alignment and joint space
Bone texture
Cortices
Soft tissues
How would you interpret a DEXA t score?
T-score of -1.0 or above = normal bone density
T-score between -1.0 and -2.5 = low bone density, or osteopenia
T-score of -2.5 or lower = osteoporosis
How long do fractures in smaller bones e.g. the clavicle take to heal?
~6weeks
How long to fractures in long bones e.g. the femur take to heal?
12-18weeks
What does it mean if a fracture is “off-ended”?
If the distal fragment is translated further than the width of the bone, it is said to be ‘off-ended’
In a flexor tendon injury to the hand, what will be the impact on passive and active movements?
- passive unaffected (but may be painful)
- active impaired
How do you test whether flexor digitorus profundus is intact?
- Immobilise MCP, PIP and ask patient to flex DIP
- If possible to flex then FDP is at least partially intact and able to pull on the PP
How do you test whether flexor digitorus superficialis is intact?
- Fix all but suspect finger in the extended position to remove the effect of FDP (mass action muscle, no independent action) and ask patient to flex suspect finger
- If FDS is not intact then patient cannot flex the finger
What is the “fallout sign”?
Abnormal cascade of digits of the hand due to both flexor tendons being severed
How does the shoulder typically dislocate?
Anteriorly
