Management of specific fractures

Question 1

what are the general principles for treating trauma to bone

Answer 1

advanced trauma life support
reduce fracture
hold fracture
rehabilitate once fracture has healed

Question 2

what are the general principles for orthopaedics

Answer 2

history
examination
look>feel>move
investigations

Question 3

what are the clinical signs of a fracture

Answer 3

pain
swelling
crepitus
deformity
adjacent structural injury - nerves,vessels,ligaments,tendons

Question 4

what are the investigations for fractures

Answer 4

radiographs
bone scan
xray
ct

Question 5

how do you describe a fracture radiograph

Answer 5

location - which bone and which part
pieces - simple, multifragmentary
pattern - transverse/oblique/spiral?
displaced/undisplaced?
translated/angulated?
xyz plane

Question 6

how do fractures heal

Answer 6

bleeding->inflammation->new tissue formation->remodelling

blood->neutrophils,macrophages -> fibro/chndro/osteoblasts->collagen->macrophages,osteoclasts/blasts

Question 7

what happens in the inflammation stage of fracture healing

Answer 7

haematoma formation
release of cytokines
granulation tissue and blood vessel formation

Question 8

what happens in the repair stage in the fracture healing

Answer 8

soft callus formation
(type 2collagen to cartilage)
converted to hard callus
type 1 collagen to bone)

Question 9

what happens in remodelling stage in fracture healing

Answer 9

callus responds to activity, external forces, functional demands and growth
excess bone is removed

Question 10

what is primary bone healing

Answer 10

• intramembranous healing
• absolute stability
• direct to woven bone

Question 11

what is secondary bone healing

Answer 11

• endochondral healing
• involves responses in periosteum and external soft tissues
• relative stability
• endochondral ossification - more callus

Question 12

what are the closed methods for reduction

Answer 12

manipulation

traction - pulling skin or sticking pins in bones (skeletal)

Question 13

what are the open methods for reduction

Answer 13

mini incision

or full exposure

Question 14

what are some general fracture complications

Answer 14

fat embolus
dvt
infection
prolonged immobility - uti, chest infections, sores

Question 15

what are some specific fracture complications

Answer 15

neurovascular injury
muscle/tendon injury
non union/mal union
local infection
degenerative change - intraarticular 
reflex sympathetic dystrophy

Question 16

factors affecting tissue healing

Answer 16

mechanical environment - movement and forces

biological environment - blood supply, immune function, infection and nutrition

Question 17

what are some causes of fractured neck of femur

Answer 17

osteoporosis - older
trauma - younger
combination

Question 18

when would you expect to see fractured neck of femur

Answer 18

age
cormorbidity - respiratory/cardiovascular/diabetes/cancer
preinjury mobility/shopping/walking/sports
social hx

Question 19

how to fix/replace extracapsular fractures

Answer 19

will be minimal risk to blood supply and avascular necrosis - fix with plate and screws

Question 20

how to fix/replace intracapsular fractures

Answer 20

if undisplaced and less risk to blood supply - fix with screws
if displaced and 25-30% risk avn - replace in older patients and fix in younger patients

Question 21

how does a shoulder dislocation present

Answer 21

variable hx but usually direct trauma
pain
restricted movement
loss of normal shoulder contour

Question 22

how would you carry out a clinical examination for shoulder dislocation

Answer 22

assess neurovascular status- axillary nerve
xray prior to any manipulation - identify fracture e.g humeral neck/glenoid
scapular

Question 23

what is management techniques for shoulder dislocation

Answer 23

numerous techniques - to reduce dislocated shoulder
vigorous manipulation/twisting manipulation should be avoided to avoid fractures
patient relaxation - entonox, benzodiazepines
stimson method if alone

Question 24

how to manage distal radius fracture

Answer 24

cast and splint - temporary treatment, reduction of fracture
mua and k wire - for extra articular fractures (pin into wrist)
orif - any displaced, unstable fractures not suitable for k wires or with intra articular involvement

Question 25

non operative management for tibial plateau fracture

Answer 25

only truly undisplaced fractures with good joint line congruency assessed on ct/high fidelity imaging

Question 26

operative management for tibial plateau fracture

Answer 26

restoration of articular surface using combination of plate and screws
bone graft/cement may be necessary to prevent further depression after fixation

Question 27

non operative management for ankle fracture

Answer 27

non weightbearing below knee cast for 6-8wks - can transfer into walking boot then physiotherapy to improve range of motion/stiffness from joint isolation
weber a - below syndesmosis and therefore thought to be stable
weber b - if no evidence of instability

Question 28

operative management for ankle fracture

Answer 28

soft tissue dependent - patients need strict elevation as injuries often swell considerably
open reduction internal fixation +- syndesmosis repair
syndesmosis screws can be left in situ but may break after sometime
weber b - unstable fractures
weber c - fibular fracture above level of syndesmosis therefore unstable