management of specific fractures Flashcards
what are the general principles of trauma and orthopaedics?
trauma: emergency broken bones advance trauma life support reduce the fracture hold the fracture rehabilitate while the fracture heals
orthopaedics: longer term conditions like arthritis history examination (look >> feel >> move) investigations
what are the clinical signs of a fracture?
Pain Swelling Crepitus Deformity Adjacent structural injury: Nerves/vessels/ligament/tendons
what investigations are done for fractures?
radiograph X-ray most common
CT
MRI
bone scan
how do you describe a fracture radiograph?
Location: which bone and which part of bone?
Pieces: simple/multifragmentary?
Pattern: transverse/oblique/spiral
Displaced/undisplaced?
Translated/angulated?
X/Y/Z plane
what are the types of displacement?
can move in a straight line or rotation
imagine XYZ axes, can move in each of these directions
translation=straight line: medial lateral anterior posterior proximal distal
angulation: varus valgus dorsal volar internal external
what are the general principles of fracture healing?
bleeding -> inflammation -> new tissue formation -> remodelling
blood -> neutrophils/macrophages -> BLASTS (osteo/fibro/chondro) (endochondral ossification - starts as cartilage) (intramembranous osification - straight to bone) -> macrophages, osteoblasts, clasts
what happens in the inflammation, repair and remodelling stages of fracture healing?
inflammation:
Haematoma formation
Release of Cytokines
Granulation tissue and blood vessel formation
repair: Soft Callus formation (Type II Collagen - Cartilage) Converted to hard callus (Type I Collagen - Bone)
remodelling:
Callus responds to activity, external forces, functional demands and growth
Excess bone is removed
Wolff’s Law: Bone Grows and Remodels in response to the forces that are placed on it
what is primary bone healing?
Intramembranous ossification:
absolute stability
Primary Bone Healing:
Intramembranous healing
Absolute stability
Direct to woven bone
what is secondary bone healing?
Endochondral ossification:
relative stability
Secondary bone healing Endochondral healing Involves responses in the periosteum and external soft tissues Relative stability Endochondral ossification: more callus
what are fracture healing times?
3-12 Weeks depending on site
Signs of healing visible on XR from 7-10 days
Phalanges: 3 weeks Metacarpals: 4-6 weeks Distal radius: 4-6 weeks Forearm: 8-10 weeks Tibia: 10 weeks Femur: 12 weeks
in general, upper limbs heal faster than lower limbs
what are the general principles of fracture management?
reduce:
closed
open
hold:
metal
no metal
rehabilitate:
move
physiotherapy
use
what are the methods of reduction?
open:
mini incision
full exposure
closed:
manipulation (pulling on skin)
traction -
skin
skeletal (pins in bone)
what are the methods of holding a fracture?
closed:
plaster
traction - skin OR skeletal
fixation:
metal in or around bone
what are the methods of fixation?
internal:
intermedullary: pins OR nails
extramedullary: plates/screws OR pins
external:
monoplanar
multiplanar
what are the methods of rehabilitation?
use:
pain relief
retrain
move
strengthen
weight bear
what are fracture complications?
General (early or late) (remote from the site of fracture):
Fat embolus
DVT
Infection
Prolonged immobility (UTI, chest infections, sores)
Specific (at the site of fracture): Neurovascular injury Muscle/tendon injury Non union/mal union Local infection Degenerative change (intraarticular) Reflex sympathetic dystrophy
what are the factors affecting tissue healing?
mechanical environment:
movement
forces
biological environment: blood supply immune function infection nutrition
what are the causes and risk factors for neck of femur fractures?
causes:
Osteoporosis (older)
Trauma (younger)
Combination
History:
Age
Comorbidity- respiratory/cardiovascular/diabetes/cancer
Preinjury mobility- independent/shopping/walking/sports
Social hx: relatives, stairs, etoh
what are the properties of neck of femur fractures?
Intracapsular (above the inertrochanteric line)
Blood supply is more likely to be compromised
risk of avascular necrosis is higher (death of bone due to lack of blood supply)
how do you decide whether to fix or replace a NOF fracture?
Extracapsular: minimal risk to blood supply and AVN: fix with plate and screws (Dynamic hip screw)
Intracapsular: if undisplaced: less risk to blood supply: fix with screws
If displaced: 25-30% risk AVN: replace in older patients; fix if young
how do you decide whether to do a hemiarthroplasty or replace the head and acetabulum?
head and acetabulum: Walks >mile day Independent Minimal comorbidities Total hip replacement
Hemiarthroplasty:
Lower mobility
Multiple comorbities
Hemiarthroplasty (but metal will rub on socket)
how does a shoulder dislocation present and what clinical examinations and investigations do you do?
presentation: often following direct trauma (eg. rugby) pain restricted movement loss of normal shoulder contour
clinical examination:
assess neurovascular status - axillary nerve
investigations:
x ray prior to any manipulation - identify fracture (humeral neck, greater tuberosity avulsion or glenoid)
scapular-Y view/modified axillary in addition to AP
how do we manage shoulder dislocation?
numerous techniques
but you have to basically out the head back into the glenoid fossa without breaking anything
what are complications of a shoulder dislocation?
hill-sachs defect: bit of bone knocked off the head of the humerus
bankart lesion:
chunk of the glenoid fossa knocked off
these can contribute to repeat dislocations
how do we manage distal radius fractures?
if the bones arent displaced or have come back together neatly and are stable:
plaster
displaced:
K wire - pin into the wrist
or open reduction and internal fixation with plate and screws
what are some common fractures?
neck of femur shoulder dislocation distal radius scaphoid (wrist carpal) tibial plateau ankle fracture (most commonly fibula, or medial malleolus of tibia)
