Management of Specific Fractures Flashcards
What are the clinical signs of a fracture?
Pain, Swelling, Crepitus, Deformity, Adjacent structural injury to nerves/vessels/ligaments/tendons
DCAPS
How are fractures investigated?
MRI scan, CT scan, Radiograph, Bone scan
What needs to be included when describing a fracture radiograph?
Location (diaphysis, metaphysis, epiphysis) Pieces: simple/multifragmentary Pattern: transverse/oblique/spiral Displaced/undisplaced? Translated/angulated? X/Y/Z plane
What are the forms of displacement?
Translation involves bone movement in the mediolateral plane on X axis, proximal distal in Y plane and anterioposterior in Z plane. Angulation can occur in internal and external rotation in Y plane, varus/valgus in X plane and dorsal, volar in Z plane.
What are the main principles of fracture healing?
Bleeding (blood), Inflammation (neutrophils and macrophages), New tissue formation (-blasts), Remodelling (osteoclasts, osteoblasts)
What occurs in the inflammation stage?
Haematoma formation, prostaglandin/cytokine release, granulation tissue and blood vessel formation (growth factors increase local blood flow and periosteal supply takes over).
What occurs in the repair stage?
Soft callus formation - occurs with type 2 collagen with cartilage. This is converted to hard callus with type 1 collagen, laying down osteoid.
What happens in the remodelling stage?
Callus responds to activity, external forces, functional demands and growth. Excess bone is removed. Wolff’s Law states that bone grows and remodels in response to the forces placed on it.
Contrast primary bone healing with secondary
Primary Bone Healing: Intramembranous healing, Absolute stability, Direct to woven bone
Secondary bone healing: Endochondral healing, Involves responses in the periosteum and external soft tissues, Relative stability, Endochondral ossification: more callus
Describe average fracture healing times at various sites
Phalanges: 3 weeks Metacarpals: 4-6 weeks Distal radius: 4-6 weeks Forearm: 8-10 weeks Tibia: 10 weeks Femur: 12 weeks
What are the general principles of fracture treatment?
Reduce (can be closed or open), Hold (with metal or without), Rehabilitate (move, physiotherapy, use)
What does reduction involve?
Closed reduction involves manipulation or traction (can be skeletal with pins in bone or skin). Open reduction can involve full exposure or mini-incision.
What does hold involve?
Can be fixation or closed with plaster or traction (skin or skeletal).
What are the types of fixation?
External can be monoplanar or multiplanar. Internal can be intramedullary or extramedullary. Intramedullary can use pins and nails while extramedullary uses plate/screws and pins.
What does rehabilitate involve?
Use bone with pain relief and retraining. Move, strengthen and weight bear.
What are general fracture complications?
Fat embolus
DVT
Infection
Prolonged immobility (UTI, chest infections, sores)
What are specific fracture complications?
Neurovascular injury Muscle/tendon injury Non union/mal union Local infection Degenerative change (intraarticular) Reflex sympathetic dystrophy
What factors affect fracture healing?
Mechanical environment (movement and forces). Biological environment: blood supply, immune function, infection and nutrition.
What are causes of a fractured neck of femur?
Osteoporosis (older)
Trauma (younger)
Combination
What does a typical history for someone with a fractured neck of femur look like?
Age
Comorbidity: respiratory/cardiovascular/diabetes/cancer
Preinjury mobility: independent/shopping/walking/sports
Social hx: relatives, stairs, etoh
What are different types of neck of femur fractures?
Subcapital (intracapsular), Transcervical (extracapsular), Intertrochanteric (extracapsular) and subtrochanteric
What is a problem with neck of femur fracture?
If intracapsular, blood supply is more likely to be compromised and avascular necrosis possible.
How is decision to fix or replace made with neck of femur fracture in those over 65?
If 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
What are treatment options for someone with displaced intracapsular fracture above 55 years?
If they walk >mile day, are independent and have minimal comorbidities: Total hip replacement
If they have lower mobility, multiple comorbities: hemiarthroplasty (but metal will rub on socket)
Describe typical presentation, examination andinvestigation of shoulder dislocation
Variable history but often direct trauma, pain, restricted movement and loss of normal shoulder contour
Examination: assess neurovascular status (axillary nerve)
Investigation: x-ray prior to any manipulation and identify fracture (humeral neck, greater tuberosity avulsion or glenoid), Scapular Y view and modified axillary in addition to AP.
What are management options for shoulder dislocation?
Numerous techniques for reduction, vigorous manipulation/twisting should be avoided, safest method is traction/counter traction with gentle internal rotation to disimpact humeral head, ensure adequate patient relaxation, could use stimson method when home alone
What are complications of a shoulder dislocation?
Hill Sachs defect - a compression fracture or “dent” of the posterosuperolateral humeral head that occurs in association with anterior instability or dislocation of the glenohumeral joint.
Bankart lesion - a lesion of the anterior part of the glenoid labrum of the shoulder.
How is a distal radius fracture managed?
- Cast/Splint - temporary treatment. Reduction of fracture and placement into cast until definitive fixation. Definitive if minimally displaced, extra-articular fracture.
- MUA (manipulation under anaesthetic) and K-wire - used for fractures that are extra-articular but have instability esp in children. MUA in theatre with K-wire fixation can be used. Wires can then be removed in clinic post-op.
- ORIF (open reduction with internal fixation) - Any displaced, unstable fractures not suitable for K-wires or with intra-articular involvement may benefit from open reduction internal fixation with plate and screws.
What is a complication of tibilal plateau fracture?
Lipohaemarthrosis - impact on bone means marrow leaks out leading to fat and aqueous contents floating to surface of joint space.
Describe overview of tibial plateau fracture
Proximal tibia is a key weightbearing surface as part of knee joint, articulating with distal femur. Joint surface is relatively flat comprising medial and lateral plateaus with central tibial spine acting as insertion point for ligaments.
What can cause a tibial plateau fracture?
Any extreme valgua/varus force or axial loading with impaction across knee. Impaction of femoral condyles cause comparatively soft bone of tibial plateau to depress/split. Concomittant ligamentous or meniscal injury not uncommon.
How is tibial plateau fracture managed?
Non operative: Only truly undisplaced fracture with good joint line congruency assessed on CT or high fidelity imaging.
Operative: most operative. Restoration of articular surface using combination of plates and screws. Bone graft or cement may be necessary to prevent further depression after fixation.
How is a trimalleolar fracture managed non-operatively?
Non-weight bearing below knee cast for 6-8 weeks, can then transfer into walking boot and finally physiotherapy to improve range of motion/stiffness from joint isolation.
Weber A - below syndesmosis and therefore stable
Weber B - if no evidence of instability (no medial/posterior malleolar fracture or talar shift).
How is a trimalleolar fracture managed operatively?
Soft tissue dependent - patient needs strict elevation as injury swells considerably.
ORIF + syndemosis repair using either screw or tightrope technique
Syndesmosis screws can be left in situ but may break after some time so therefore can be removed at a later date if necessary.
Weber B - unstable fractures: talar shift/medial or posterior malleoli fracture
Weber C - fibular fracture above level of syndesmosis and hence unstable
