Long bone fractures Flashcards
Define the terms diaphysis, metaphysis, epiphysis and physis
Diaphysis - shaft of long bone
Metaphysis - between the diaphysis and epiphysis
Epiphysis - end of long bone
Physis - growth plate
List the main long bones of the body
Tibia & fibula Femur Radius & ulna Humerus Metatarsals, metacarpals and phalanges Clavicle
What is primary bone healing?
Healing where the gap between two ends of bone is minimal
What type of fracture will heal by primary bone healing?
Hairline (after fixation with plate and screws)
What is secondary bone healing?
There is a gap between the two ends of the bone which fills with granulation tissue > soft callus > hard callus/bone
Which is more common primary or secondary bone healing?
Secondary
What is the sequence of fracture healing?
Haematoma > Soft callus > Chondral ossification > Hard callus > Bone remodelling
What are the important steps in an assessment of a fracture?
Closed vs open
Neurovascular status
Soft tissue injury
Compartment syndrome
What can and should be immediately given for a fracture?
Analgesia
What is a comminuted fracture?
A fracture with more than two segments
When do comminuted fractures tend to happen?
High energy injuries
Poor quality bone
How can fractures be managed non-operatively?
Cast (plaster of paris, lightweight)
Functional bracing
Traction
Which age groups typically get traction?
Young
Elderly
What are the different types of internal fixation?
K-wires
Cerclage wires
Onlay devices (plates & screws)
Inlay devices (intramedullary nail)
What are the different types of external fixation
Monolateral
Circular
What does ORIF stand for?
Open reduction internal fixation
How might certain intra/periarticular fractures be managed?
Joint replacement
High energy fractures +/- soft tissue swelling should be treated with ORIF. T/F
False - healing poor and non-union rates high, either way until soft tissues settle or use other techniques
How should a stable, minimally displaced, extra-articular fracture be managed?
Conservatively - splint
When is reduction used?
When fracture position is unacceptable
An unstable fracture should be operatively managed under which circumstance?
When the patient is fit and able to undergo operation
When might intra-articular fractures be managed non-operatively?
When they are stable and non-displaced
How should displaced intra-articular fractures be managed? Why?
Operatively with internal fixation
Prevent post-traumatic osteoarthritis
When might joint replacement be used in a peri-articular fracture?
When non-union risk or avascular necrosis risk is high
How should open fractures be managed?
Antibiotics
Tetanus Ig if not vaccinated
Debridement
Operative stabilisation
How should compartment syndrome be managed?
Fasciotomy and operative stabilisation
How should vascular injury be managed?
Reduction, stabilisation, reassess +/- revascularisation
How should nerve injury be managed?
Open - explore
Closed - reduce, stabilise, reassess and monitor
When should metronidazole be given (in addition to other antibiotics) with an open fracture?
If it has visible dirt in the fracture wound
Which antibiotics should be prescribed for an open fracture?
Gentamicin and flucloxacillin/co-trimoxazole
Is a femoral shaft fracture usually low or high energy? What is the exception to this?
High. Pathological fracture
What are the risks with femoral shaft fracture?
Hypovolaemia (fluid replacement, blood transfusion)
Fat embolism
Acute respiratory distress syndrome
What type of analgesia is given in a femoral shaft fracture?
Femoral nerve block
How is a femoral shaft fracture treated?
Stable - Thomas splint
Unstable - Intramedullary nailing
Are extra-articular distal femur fractures stable or unstable? Why?
Unstable. The muscles cause flexion
How is an extra-articular distal femur fracture managed?
Thomas splint
Intermedullary nail if more proximal
Plate and screw if very distal
How are intra-articular distal femur fractures managed?
Reduction and rigid fixation with plate and screws
Is a proximal tibial fracture high or low energy?
High energy in the young
Low energy in the old
What kind of force is usually responsible for proximal tibial fractures? What pattern of fracture does this cause?
Valgus
Lateral tibial plateau fracture with articular disruption
How is a proximal tibial fracture managed?
Temporary external fixation if high energy with substantial swelling
Anatomical reduction with rigid fixation +/- bone graft
What is a common complication of proximal tibial fractures?
Post traumatic osteoarthritis
How is a proximal tibial fracture assessed?
CT scan
Are tibial shaft fractures high or low energy?
Either
What is a common complication that tibial shaft fractures must be monitored for?
Compartment syndrome
How well is 1) angulation and 2) internal rotation tolerated in a tibial shaft fracture?
1 - well tolerated within 5 degrees
2 - poorly tolerated
How long does a tibial shaft fracture take to heal and over which time frame indicates non-union?
4 months. 1 year
How is a tibial shaft fracture managed?
Conservative - plaster
Surgical - intermedullary nailing, plate, ex-fix
How is compartment syndrome diagnosed?
Clinically
What is an intra-articular distal tibial fracture called?
Pilon fracture
Is an intra-articular tibial fracture high or low energy?
High
What are the associated injuries of a distal tibial fracture?
Spine, pelvis, calcaneous
How is a distal tibial fracture managed?
Urgent external fixation +/- limited internal fixation >
Soft tissues settle >
Internal fixation
How are distal tibial fractures assessed?
CT scan
When may ankle fractures be treated conservatively?
Isolated distal fibular fracture
Minimally displaced medial malleolus
What are the two causes of talar shift?
Bimalleolar fractures (unstable) Distal fibular fracture with ruptured deltoid ligament
How at risk of post-traumatic OA are ankle fractures?
Most are high risk
How is talar shift managed? Why?
ORIF. Change in joint force causes massive increase in OA risk
What is the main cause of proximal humerus fractures and in which type of patient?
Osteoporosis. Elderly
What are the risks of proximal humerus fractures?
Brachial plexus injury
Axillary artery injury
What are the risk in comminuted proximal humerus fractures?
Avascular necrosis
Non-union
How are proximal humerus fractures managed?
Elderly - conservative
Head splitting/comminuted fracture - arthroplasty
Young and displaced - internal fixation
What are the benefits of arthroplasty in proximal humerus fractures? The drawbacks?
Pain relief. Poor range of movement
Why is surgery not chosen for proximal humerus fractures in the elderly?
Stiffness and rotator cuff dysfunction causes poor healing
What is the risk with humeral shaft injuries?
Radial nerve injury (neurapraxia)
Can angulation be tolerated with humeral shaft injuries?
Yes
How is humeral shaft fracture managed?
Bracing
When might humeral shaft fractures be managed surgically?
Non-union Pathological Polytrauma Open fracture High energy Not tolerating brace
How is a distal humerus fracture managed?
Intra-articular - ORIF
Elderly - arthroplasty
Most olcranon fractures are avulsion. T/F
True - due to quadriceps contraction
How are olcranon fractures managed?
Internal fixation unless elderly with low demand
Which fracture often occurs in conjunction with an elbow dislocation?
Radial head fracture
How are radial head fractures managed?
Minimally displaced - conservative
Fragment blocking movement/displaced with large fragments - fixation
Comminuted - excise +/- replacement
What is a Galeazzi fracture dislocation?
Isolated radial fracture and distal radio-ulnar joint disocation
What is a Monteggia fracture dislocation?
Isolated ulnar fracture and dislocation of radial head
How is a forearm fracture of both the radius and ulna managed?
ORIF
How is a Galeazzi or Monteggia fracture managed?
ORIF (dislocation should reduce)
What is a nightstick fracture? How is it managed?
Isolated fracture of the ulna. Conservatively
How does a nightstick fracture occur?
Direct blow to the ulna
What is a Colle’s fracture?
Extra-articular, dorsal angulation and dorsal displacement of the distal radius
How is a Colle’s fracture managed?
Stabled/minimally displaced - Plaster of paris
Simple displacement - manipulation under anaesthetic
Displaced comminution - manipulation under anaesthetic & k-wires or ORIF
What are the complications of Colle’s fracture?
Median nerve compression
EPL rupture
Chronic regional pain syndrome
Loss of grip strength
What is the typical mechanism by which a Colle’s fracture occurs?
Fall onto an outstretched hand
What type of fracture can result in a dinner fork deformity?
Colle’s fracture
What is the typical mechanism by which a Smiths fracture occurs?
Fall onto the back of the hand
What is a Smith’s fracture?
Extra-articular, volar displacement and angulation of the distal radius
How is a Smith’s fracture managed?
ORIF
What is a Barton’s fracture?
Intra-articular, volar or dorsal on lateral +/- carpal subluxation of the distal radius
How is a Barton’s fracture managed?
ORIF
How is a comminuted intra-articular fracture of the distal radius managed?
External fixation +/- k-wires
How many x-ray views does a scaphoid fracture required? What else must be done?
- Must be x-rayed a number of days after to confirm
How is a perilunate dislocation of the wrist managed?
Urgent reduction
How is polytrauma defined?
More than one major fracture (long bones/pelvis)
What are the two worst fractures in terms of blood loss/fat embolism?
Pelvic and femoral shaft fracture
What is the risk in terms of inflammatory cascades during polytrauma?
Systemic inflammatory response syndrome
Adult respiratory distress syndrome
Multiple organ dysfunction syndrome
What is the lethal triad in relation to blood loss and polytrauma?
Hypothermia, acidosis and coagulopathy
How is a pelvic fracture managed?
Pelvic binder
What is consumption coagulopathy?
Bleeding uses up all clotting factors
What are the most pressing injuries to treat in polytrauma?
Pelvic, tibial or femoral fracture
Vascular compromise
Open fractures
Compartment syndrome
