Long Bone Fractures, Fracture Process, and Fracture Management Flashcards
How are long bones characterised?
Diaphysis (shaft), metaphysis (beside or around the growth plate), epiphysis (upon the growth plate)
Examples of long bones in the human skeleton?
Femur, tibia and fibula
Humerus, radius and ulna
Clavicle
Metacarpals and phalanges
Metatarsals and phalanges
Structures of long bones?
Diaphysis is made of cortical bone (laid down around blood vessels, to form Haversian canals)
Ends of long bones are made of trabecular/cancellous bone (spongy for shock absorption)
The two types of fracture healing methods?
Primary bone healing (used for minimal fracture gaps) - the bone is able to fill the gap, e.g: hairline fractures; if this is the case, plate and screws can be used for fixation
Secondary bone healing (majority of cases) - the fracture gap fills with granulation tissue; then, cartilage is laid down, to form a soft callus, and then bone (endochondral ossification) to form a hard callus
Examples of when primary and secondary bone healing occur?
Primary - hairline fractures; plate and screws are used for fixation
Secondary - Colles fracture and “pop”; fixed using intra-medullary nails and external fixators
Principles of fracture treatment?
- Save life first (resuscitation - ABCD)
- Save the limb
- Treat pain (iv morphine)
- Maintain viable skin and soft tissue envelope
- Restore function
General management of a fracture?
- Resuscitation (ABCD if high-energy)
- Analgesia
- Assessment:
- Closed vs open (greater infection risk)
- Neurovascular status
- Soft tissue injury
- Splintage
- Ix (X-ray, CT scan)
- Reduction (if the position is unacceptable)
- Holding (operative OR non-operative, with plaster casts and splints)
5 types of fracture patterns/configurations?
Transverse - broken piece of bone is at a right angle to the bone’s axis, due to pure bending of the bone
Oblique - break has a curved or sloped pattern; two ends slide off one another with weight-bearing
Spiral (AKA torsion fracture) - occurs when due to rotational force on bone; these are more vertical and longer than oblique fractures
Comminuted - forms >2 fragments, due to high-energy injuries
Segmental - bone broken in 2 places
Types of fracture positions?
Can shift proximally, distally, medially or laterally
There can be:
- Distraction (ends pulled apart) without displacement/angulation
- Displacement of one end of the bone, e.g: laterally, without angulation; OR there can be complete displacement with shortening and no angulation
- Angulation without displacement
- Displacement + angulation
- Displacement + shortening + angulation
Methods of non-operative holding of fractures?
- Cast (POP, lightweight)
- Functional bracing (these can prevent fracture assoc. stiffness as joints can still move)
- Traction (uncommon, as long period of bed rest required, but still used with frail patients)
Methods of operative holding of a fracture?
Internal fixation:
- Wires
- Onlay devices (plate and screws)
- Inlay devices (intra-medullary nail)
External fixation (advantageous in that the length and angulation can be changed throughout treatment)
For some intra OR peri-articular fractures - joint replacement can be done, if there is a high risk of OA or AVN
General principles of manageing different types of fractures?
Simple, minimally displaced, extra-articular fracture with an acceptable alignment and stability = conservative management (splinting, etc)
Unacceptable position = NEEDS reduction
Unstable fracture in a fit patient = operative stabilisation
High-energy OR if there is substantial soft tissue swelling = waiting until soft tissues settles and then use indirect techniques, e.g: nailing OR external fixation (avoid ORIF)
What is ORIF and why must it be avoided in high-energy fractures OR situations where is there is a lot of soft tissue swelling?
Open Reduction Internal Fixation
Wounds should not be made in unhealthy skin, so this is avoided in the above scenario
General principles of treating intra-articular and peri-articular fractures?
Undisplaced intra-articular fractures + stable = non-operative treatment
Displaced intra-articular fracture = anatomic reduction and rigid interal fixation (ORIF) to prevent post-traumatic OA
Peri-articular fractures + risk of non-union or AVN = consider joint replacement
General principles of managing complication fractures?
- Open fractions:
- Antibiotics - flucloxacillin (gram +ves) + gentamicin (gram -ves) + metronidazole (to cover anaerobes if the wound is soil contaminated); co-amoxiclav covers all of these
- Tetanus - if any doubt over immunisation, give tetanus Ig
- Compartment syndrome: fasciotomy and operative stabilisation
- Vascular injury: reduction, stabilisation and reassessment of circulation; may require revascularisation
- Nerve injury: if there is an open fracture, explore further; if closed fracture, reduce + hold and observe
Describe femoral shaft fractures
Usually, due to a high-energy injury, so there normally assoc. injuries, OR a pathology, e.g: osteoporosis
There is approximately 1-2 litres blood loss and a risk of fat embolism and ARDS
Treatment of femoral shaft fractures?
Resuscitation (fluids and O2) - ABCD
Analgesia (can do a femoral nerve block)
Splintage (Thomas splint reduces blood loss and risk of fat embolism)
If fracture is unstable, intra-medullary nail
Two types of distal femur fractures and principles of treating each?
Extra-articular:
- If unstable, the pulls on muscles can cause flexion at the fracture site
- A Thomas splint can be used and, if the fracture is not too distal = plating; if it is too distal = plating
Intra-articular:
- Anatomical reduction and rigid fixation
- Plates and screws
Describe proximal tibial fractures
In young patients, these are high-energy fractures; in older patients, tend to be lower-energy with underlying pathology, e.g: osteoporosis; a high proportion get post-traumatic OA
Usually, due to a VALGUS STRESS causing a lateral tibial plateau fracture, with disruption of the articular surface
CT scan is required
Treatment of proximal tibial fractures?
If due to a high-energy injury + substantial soft tissue damage, may consider temporary external fixation
Management:
- ORIF (anatomical reduction with rigid fixation)
- Elevation of the depressed articular fragments and bone shaft
Describe tibial shaft fractures
Can be low/high energy; open fractures are not uncommon
These fractures that are very closely assoc. with COMPARTMENT SYNDROME
Treatment of tibial shaft fractures?
5 degrees of angulation can be tolerated but internal rotation is poorly tolerate
Take 16 weeks till union and >1 year if there is non-union
Conservative Mx - plaster cast
Operative Mx - IM nail, plate and screws or external fixation
Describe distal tibial fracture
AKA pilon fractures, if intra-articular; usually high-energy injuries, e.g: falling from a height, with assoc. injuries of spine, pelvis and calcaneus AND significant soft tissue injury
Ix - CT scan
Treatment of distal tibial fractures?
SURGICAL EMERGENCY (urgent bridging with external fixation and then wait until the soft tissue swelling settles); once this has settled, internal fixation
Describe different types of ankle fractures, the situations in which they arise and treatment
Isolated distal fibular fracture OR minimally displaced medial malleolus fracture = stable and conservative treatment
Bimalleolar fractures = unstable the talus shifts
Distal fibular fractures can occur with deltoid ligament rupture (the talus shifts)
Complications and treatment of talar shift?
Even 1mm of talar shift increases the joint force - ORIF is required
Describe proximal humerus fractures
Most are elderly osteoporotic fractures; they can be assoc. with brachial plexus injury or axillary artery injury
In more comminuted fractures, the risk of AVN and non-union is higher
Treatment of proximal humerus fractures?
Often, no matter what is done, the result is poor
If elderly, mostly conservative Mx - the results are poor but surgery is not advised as the results for it are poor due to stiffness and rotator cuff dysfunction
If the head is split, consider arthroplasty (provides pain relief but poor ROM)
In younger patients, if the fracture is displaced, internal fixation
MAIN COMPLICATION OF HUMERAL SHAFT FRACTURES?
Radial nerve winds around the shaft and it can be injured in the spiral groove (usually causing neuropraxia); this clinically manifests as WRIST DROP
Treatment of humeral shaft fractures?
Can tolerate substantial angulation without a loss of function; there is 10% risk of non-union with both conservative Mx and internal fixation
Internal fixation is reserved for:
- Non-union
- Pathological fractures
- Polytrauma
- Open fractures
- High-energy injuries
- If the person is not tolerating a brace
Describe distal humerus fractures and treatment
Tend to be intra-articular; ORIF is used
Describe olecranon fractures and treatment
Often, avulsion fracture from triceps (inserts onto the olecranon) contraction
They are usually fixed, unless the patient is of low demand
Describe radial head fractures
NOTE: remember that the radial head is at the elbow, not the wrist, and is involved with supination/pronation
This types of fracture can occur with a dislocated elbow
Treatment of radial head fractures?
Minimally displaced marginal fractures - conservative treatment (unless there is a fragment of bone prevening movement)
For comminuted fracture - excise +/- replacement
Rule when assessing forearm fractures?
If indirect forces are responsible, e.g: falling on a hand, and there is one diaphyseal fracture, there is a high chance of a fracture or a dislocation/subluxation of the other
Two types of fracture dislocations of the forearm and when they should be suspected?
Galeazzi fracture dislocation - fracture of the radius with dislocation of the distal radioulnar joint; thus, if the radius is fractured in isolation, suspect a dislocation of the distal radioulnar joint
Monteggia fracture dislocation - fracture of the ulna with dislocation of the head of the radius; thus, if the ulna is fractured in isolation, suspect a dislocation of the radial head
Treatment of forearm fractures?
If both forearm bones are fractured - ORIF
If Monteggia or Galeazzi fracture - ORIF for the fractured bone and, once this is reduced, the radial head or distal ulna must be reduced
Describe nightstick fractures
Caused by a direct blow to the ulna, e.g: a defensive injury, and may cause an isolated ulnar fracture - can be managed conservatively
What is a Colles fracture?
A fracture of the distal radius, at the wrist and can be caused by a fall on an outstretched hand (FOOSH) - caused an extra-articular fracture with dorsal angulation and dorsal displacement
Treatment of Colles fractures?
If stable and minimally displaced/angulated - POP cast
Simple fracture that is displaced - manipulation under anaesthetic (MUA)
Displaced and comminuted fracture - MUA and wiring, ORIF
Complication of Colles fractures?
Median nerve compression
EPL rupture
CRPS (complex regional pain syndrome) - chronic pain, swelling, pins and needles that occur due to an unknown reason and may occur with innocuous injuries
Loss of grip strength
Different types of distal radius fractures?
Smith’s fracture (fall onto the back of the hand) - extra-articular fracture with volar displacement and angulation; it is very unstable and required ORIF
Barton’s fracture - intra-articular fracture with volar/dorsal fracture on lateral; this causes subluxation of the carpus and requires ORIF
Comminuted intra-articular fracture - has small fragments and requires external fixation +/- wiring
What is polytrauma?
>1 major fracture (long bones +/- pelvis); usually, high-energy injury with major blood loss, esp. if there are pelvis or femoral shaft fracture
Complications:
- Fat embolism
- Risk of SIRS, ARDS and MODS
- Surgery has further blood loss and hypotension with hypoperfusion; there can be a lethal triad of hypothermia, acidosis and coagulopathy
Treatment of polytrauma?
Aim: rapid skeletal stabilisation with reduced biological load, i.e: reduce blood loss and embolism
External fixation, rapid plate fixation and nailing
Only treat (minor fractures can be left until later):
- Pelvic, femoral and tibial fractures
- Injuries with vascular compromise
- Open fractures
- (impending) Compartment syndrome
