Long bone fractures: management and complications Flashcards
How do you describe fractures radio logically?
- Patient demographics
- X ray type + which bone / joint
- Most obvious deformity is…
Location:
- Which part of the bone: diaphysis (1/3)/metaphysis/epiphysis
- Intra/extra articular
Configuration: Transvere/Spiral/Oblique/ Greenstick/ Impacted
Simple/Multi fragmented
Displaced (relation to distal bone)
+/- Angulation
(cant see rotation on X-ray only clinically)
Define an open fracture?
An open fracture is a soft tissue injury complicated with a fracture. Aka fracture + a cut.
Describe the risk factors/mechanism of fractures? Aka different broad categories.
Fracture without significant trauma: Abnormal bone pathological fracture
Normal bone: Either significant force or low impact injury + osteoporosis
What are the risk factors for osteoporosis?
Age
Female
Low oestrogen exposure (late menarche/early menopause)
Caucasian
Inactivity
Underweight in 1st 20years of life
Smoking
Steroid use
Describe the initial management of an open long bone fracture?
Analgesia Pain relief - IV morphine, Splint (plaster or vacuum splint) IV abx +/- Tetanus jab Take a photo Gross cleaning (remove debris). saline soaked gores Sterile dressing Imaging (Xraym CT if intra-articular) Bloods: X match/ Gr+s, FBC, clotting
Followed by conservative/surgical mgmt
What are the major types of surgical management of fractures?
Open reduction and internal fixation with a:
- Screw
- Nail
- Plate
- K wires
External fixation
Hemi/full arthroplasty
May need:
- Debridement and washout
- Skin graft , wound closure
How should you initially manage a severe concomitant fracture?
Same as above plus:
- Debridement
- Vaccum pump
- External fixator
What is the Gustilo classification?
It is a classification of open fractures:
I Wound less than 1 cm in length
II Wound 1 -10 cm damage, or loss or an open sentimental fracture.
IIIA Type III fracture with significant soft tissue injury but there is still adequate periosteal coverage of the fracture bone (ADEQUATE SOFT TISSUE)
IIIB Type III fracture with extensive soft-tissue loss and periosteal stripping and bone damage. Usually associated with massive contamination. Will often need further soft-tissue coverage procedure (i.e. free or rotational flap) (PLASTICS INPUT NEEDED)
IIIC Type III fracture associated with an arterial injury requiring repair, irrespective of degree of soft-tissue injury. (VASCULAR INJURY)
What are the 4 stages of fracture healing?
- Inflammation (haematoma to fibrovascular stroma (new capillaries and inflam cells absorb haematoma) 1- 21days
- Soft callus (fibrocartilage) 1-4months
- Hard callus (woven bone formation) 4-6months
- Remodelling (lamellar bone replaces woven) years
Note: new bone formation starts periosteally and progresses towards the fracture line
What are the short term complications of a fracture?
Infection (more likely if open) Blood loss Fat embolism Vascular (suggested by 6 p's) Nerve injury Compartment syndrome Visceral injury e.g. pneumothorax Rhabdomylosis (if crush injury or long lie)
What is compartment syndrome?
Swelling within compartment causes increase in pressure which exceeds systolic arterial pressure therefore cuts off blood supply causing necrosis.
Describe the terms delayed and non union?
Delayed union: A fracture which is taking longer than expected to heal
Non union:
- A fracture which has failed to heal and in which the healing process has stopped.
- This must be confirmed with serial X-rays.
- Diagnosed when it has no healed after 2 times the expected time.
Mal-union: the fracture has healed and bones united, however in an unsatisfactory position
What are the risk factors for non-union?
Injury:
- High energy injury
- Open or comminuted #
- Crush
Patient:
- Co-morbidities (diabetes, vascular disease, smoker, anaemia, low vit D)
- Poor compliance
- Steroids
Fracture:
- Excessive movement/complete lack of movement*
- Infection
- Devitalisation (cutting away periosteum/soft tissue)
- Lack of blood supply
*Movement encourages healing therefore complete lack of movement due to over fixation can result in a non union
What is algodystrophy?
Also known as ‘Complex regional pain syndrome’.
It is a poorly understood chronic pain condition in which there is pain, swelling and skin changes in a limb.
This usually follows a history of trauma however the effects are disproportionate to the severity of the injury.
Describe the initial assessment of a patient presenting with a fracture
A-E
History: associated injures, AMPLE, mechanism of injury
Examination: neurovascular status, compartment syndrome, open/closed fracture, other injuries
X-ray:
- Two plain (orthogonal) views of injury
- Joint above and joint below
