management of specific fractures

Question 1

what are the general principles of trauma and orthopaedics?

Answer 1

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

Question 2

what are the clinical signs of a fracture?

Answer 2

Pain
Swelling
Crepitus
Deformity
Adjacent structural injury:
Nerves/vessels/ligament/tendons

Question 3

what investigations are done for fractures?

Answer 3

radiograph X-ray most common
CT
MRI
bone scan

Question 4

how do you describe a fracture radiograph?

Answer 4

Location: which bone and which part of bone?

Pieces: simple/multifragmentary?

Pattern: transverse/oblique/spiral

Displaced/undisplaced?

Translated/angulated?

X/Y/Z plane

Question 5

what are the types of displacement?

Answer 5

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

Question 6

what are the general principles of fracture healing?

Answer 6

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

Question 7

what happens in the inflammation, repair and remodelling stages of fracture healing?

Answer 7

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

Question 8

what is primary bone healing?

Answer 8

Intramembranous ossification:
absolute stability

Primary Bone Healing:
Intramembranous healing
Absolute stability
Direct to woven bone

Question 9

what is secondary bone healing?

Answer 9

Endochondral ossification:
relative stability

Secondary bone healing 
Endochondral healing
Involves responses in the periosteum and external soft tissues
Relative stability
Endochondral ossification: more callus

Question 10

what are fracture healing times?

Answer 10

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

Question 11

what are the general principles of fracture management?

Answer 11

reduce:
closed
open

hold:
metal
no metal

rehabilitate:
move
physiotherapy
use

Question 12

what are the methods of reduction?

Answer 12

open:
mini incision
full exposure

closed:
manipulation (pulling on skin)

traction -
skin
skeletal (pins in bone)

Question 13

what are the methods of holding a fracture?

Answer 13

closed:
plaster

traction - skin OR skeletal

fixation:
metal in or around bone

Question 14

what are the methods of fixation?

Answer 14

internal:

intermedullary: pins OR nails
extramedullary: plates/screws OR pins

external:
monoplanar
multiplanar

Question 15

what are the methods of rehabilitation?

Answer 15

use:
pain relief
retrain

move

strengthen

weight bear

Question 16

what are fracture complications?

Answer 16

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

Question 17

what are the factors affecting tissue healing?

Answer 17

mechanical environment:
movement
forces

biological environment: 
blood supply
immune function
infection 
nutrition

Question 18

what are the causes and risk factors for neck of femur fractures?

Answer 18

causes:
Osteoporosis (older)
Trauma (younger)
Combination

History:
Age
Comorbidity- respiratory/cardiovascular/diabetes/cancer
Preinjury mobility- independent/shopping/walking/sports
Social hx: relatives, stairs, etoh

Question 19

what are the properties of neck of femur fractures?

Answer 19

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)

Question 20

how do you decide whether to fix or replace a NOF fracture?

Answer 20

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

Question 21

how do you decide whether to do a hemiarthroplasty or replace the head and acetabulum?

Answer 21

head and acetabulum:
Walks >mile day
Independent
Minimal comorbidities
Total hip replacement

Hemiarthroplasty:
Lower mobility
Multiple comorbities
Hemiarthroplasty (but metal will rub on socket)

Question 22

how does a shoulder dislocation present and what clinical examinations and investigations do you do?

Answer 22

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

Question 23

how do we manage shoulder dislocation?

Answer 23

numerous techniques

but you have to basically out the head back into the glenoid fossa without breaking anything

Question 24

what are complications of a shoulder dislocation?

Answer 24

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

Question 25

how do we manage distal radius fractures?

Answer 25

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

Question 26

what are some common fractures?

Answer 26

neck of femur
shoulder dislocation
distal radius
scaphoid (wrist carpal)
tibial plateau 
ankle fracture (most commonly fibula, or medial malleolus of tibia)