MANAGEMENT OF SPECIFIC FRACTURES Flashcards
What are the clinical signs of a fracture?
Pain Swelling Crepitus Deformity Adjacent structural injury (nerves/vessels/ligaments/tendons)
List the imaging techniques that can be done to investigate fractures
Radiograph/Xray
CT scan
MRI
Bone scan
What are the 5 details when describing a fracture radiograph?
Location Pieces: simple/multifragmentary Pattern: transverse/oblique/spiral Displacement: (translated/angulated)/undisplaced Plane: XYZ
What is translational displacement and it what planes can it occur?
Lateral straight line displacement
Proximal/distal (Y plane)
Anterior/posterior (Z plane)
Medial/lateral (X plane)
What is angulational displacement and it what planes does it occur?
Internal/external rotation (Y plane)
Dorsal/volar (Z plane)
Varus/valgus (X plane)
What are the 4 steps in fracture healing and what cells do they involve ?
Bleeding
Inflammation (neutrophils, macrophages)
New tissue formation/repair (-blasts)
Remodelling (macrophages, osteoclasts, -blasts)
Describe what occurs in the inflammation step of fracture healing
Haematoma formation
Cytokine release
Granulation tissue and blood vessel formation
Describe what occurs in the repair step of fracture healing
Soft callus formation (type II collagen - cartilage)
Converted to hard callus (type I collagen - bone)
Describe what occurs in the remodelling step of fracture healing
Callus responds to activity, external forces, functional demands and growth (Wolff’s law)
Excess bone is removed
What is primary bone healing?
When the fragments are close together allowing for intramembranous healing and absolute stability with mesenchymal stem cells forming woven bone directly
What is secondary bone healing?
When the fragments aren’t completely together causing endochondral healing and relative stability. Done by endochondral ossification which results in more callus
How long does it take for a fracture to heal?
3-12 weeks depending on site
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 to help heal fractures?
Reduce (open and closed)
Hold (closed and fixation)
Rehabilitate (use, move, strengthen, physiotherapy)
What are the different options for reduction of a fracture?
Closed:
- manipulation
- traction (skin or skeletal - pins in bones)
Open:
- mini-incision
- full exposure
What are the different options for holding of a fracture?
Closed:
- Plaster
- Traction (skin or skeletal)
Fixation (many options)
What are the options of fixation of a fracture?
Internal:
- Intramedullary (pins or nails)
- Extramedullary (plates/screws or pins)
External:
- Monoplanar
- Multiplanar
What are some general complications of fractures?
Fat embolus
DVT
Infection
Prolonged immobility
What are some specific complications of fractures?
Neurovascular injury Muscle/tendon injury Non union/mal union Local infection Degenerative change (intra-articular) Reflex sympathetic dystrophy
What are some factors affecting tissue healing?
Mechanical environment:
- Movement
- Forces
Biological environment:
- Blood supply
- Immune function
- Infection
- Nutrition
What are the causes for a fractured neck of femur?
Osteoporosis
Trauma
Combination
Are the femoral head and femoral neck considered intra or extra capsular?
Intracapsular
Are the less trochanter and greater trochanter of the femur considered intra or extra capsular?
Extracapsular
Why is an intracapsular fracture of the femur considered more dangerous?
Blood supply is more likely to be compromised leading to a higher risk of avascular necrosis
How would you treat an extracapsular fracture to the femur?
Fix with plate and screws due to low risk of avascular necrosis
How would you treat an undisplaced intracapsular fracture to the femur?
Fix with screws due to less risk to blood supply
How would you treat an displaced intracapsular fracture to the femur?
Replace in a > 55 yrs patient and fix if young patient
25-30% of avascular necrosis
What would a fit and mobile patient > 55 yrs who fractured their neck of femur have as treatment?
Total hip replacement
What would a less fit and mobile patient > 55 yrs who fractured their neck of femur have as treatment?
Hemiarthroplasty
How does a shoulder dislocation present?
Variable history but often direct trauma
Pain
Restricted movement
Loss of normal shoulder contour
What can be done to investigate a patient with a shoulder dislocation?
X-ray prior any manipulation to identify fracture
Scapular y view
How is a shoulder dislocation managed?
Reduce dislocated shoulder Traction-counter traction +/- gentle internal rotation to disimpact humeral head (safest method) Patient relaxation (entonox, benzodiazepines)
Avoid vigorous/twisting manipulation to avoid fractures
What are some complications of shoulder dislocation?
Hills-Sachs defect
Bankart lesion
What is a Hills-Sachs defect?
When humerus dislocates it collides with the glenoid and causes a dent in the posterior humeral head
What does management of a distal radius fracture involve?
Cast/Splint - temporary until definitive fixation or definitive if minimally displaced and extra-articular
Mua and K-wire - extra-articular but have instability particularly in children
ORIF (open reduction and internal fixation) - displaced, unstable fractures
What is most likely fractured if a patient falls over and complains of wrist pain?
Scaphoid bone
What is a lipohaemarthrosis?
Presence of intra-capsular floating fat in a joint cavity seen via imaging. It is indicative of a a intra-articular fracture
How is a tibial plateau fracture managed?
Non-operative - only truly undisplaced fractures with good joint line congruency assessed on imaging
Operative - restoration of articular surface using plates and screws. Bone graft/cement may be necessary to prevent further depression after fixation
What is the management for an ankle fracture?
Non-operative:
- Below knee cast (6-8 weeks) then walking boot then
physiotherapy
- Weber A if stable and Weber B if no evidence of
instability
Operative:
- Patients need strict elevation as injury swells
considerably
- Open reduction internal fixation +/- syndesmosis repair
using either screw or tightrope
- Syndesmosis screw can be left or removed at later date
- Weber B/C
