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management of specific fractures Flashcards

1
Q

What are clinical signs of a fracture?

A

Pain, swelling, crepitus, deformity, adjacent structural injury (nerves, vessels, ligament, tendon)

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2
Q

What are different investigations used for fractures?

A

Radiograph, bone scan, CT, MRI

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3
Q

How to describe a fracture radiograph?

A
  1. Location (which bone & which part of it)
  2. pieces (simple/multifragmentary).
  3. pattern (transverse/oblique/spiral)
  4. displaced/undisplaced -> translated/angulated
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4
Q

How do we describe displacement (translation & angulation)?

A
  • Translation is lateral displacement (anterior/posterior, medial/lateral, proximal/distal).
  • Angulation - if distal part more lateral valgus, if distal part more medial varus. + internal/external rotation, dorsal/volar, varus/valgus
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5
Q

How do fractures heal?

A
  1. inflammation: Bleeding brings cells & inflammatory mediators to site (inflammation - neutrophils, macrophages) that form granulation tissue & blood vessel formation.
  2. repair: Fibroblasts/osteoblasts/chondroblasts make new tissue. Initially get soft callus (type II collagen - manly cartilage) which is then converted to hard callus (type I - bone).
  3. remodelling: Callus remodels by responding to activity & forces applied to it.
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6
Q

What is primary bone healing?

A

When bones are close together (stable fracture) we get intramembranous healing when mesenchymal stem cell goes straight to osteoblast and we get woven bone.

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7
Q

What is secondary bone healing?

A

When bones more displaced and not as stable we get endochondral healing with mesenchymal stem cell going to chondral precursor which will then produce bone cells. More callus produced.

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8
Q

What are the general rules on fracture healing times, how long does it generally take?

A

Generally upper limbs heal quicker than lower limbs. Generally take 3-12 weeks to heal.

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9
Q

How quickly can you see signs of healing on x-ray?

A

From 7-10 days

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10
Q

How long does it take for phalanges, metacarpals, distal radius, forearm, tibia, femur to heal?

A

Phalanges = 3 weeks. Metacarpals: 4-6wks. Distal radius: 4-6 wks. Forearm-8-10wks. Tibia-10wks. Femur-12wks.

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11
Q

What do fracture healing times vary with?

A

Vary with age, biology and comorbidities

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12
Q

How can you reduce a fracture?

A
  1. closed - manipulation or traction (pulling on skin, or skeletal - putting pins in bone and pulling)
  2. open - mini incision or full exposure
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13
Q

How can you hold a fracture?

A
  1. closed - plaster or continued traction over weeks (skin/skeletal)
  2. fixation (putting metals in or around bone) - 1. internal - intramedullary (pins & nails) or extramedullary (plate, screws, pins), 2. external - monoplanar or multiplanar
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14
Q

How do you rehabilitate a fracture?

A

Use (pain relief, retrain), move, strengthen, if lower limbs weight bear

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15
Q

What are some general and specific fracture complications?

A
  • General: fat embolus, DVT, infection, prolonged immobility (UTI, chest infection, sores).
  • Specific: neurovascular injury, muscle/tendon injury, non-union/malunion, local infection, degenerative change (intra-articular), reflex sympathetic dystrophy
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16
Q

What are factors affecting tissue healing?

A
  • Mechanical environment - movement, forces.

- Biology - blood supply, immune function, infection, nutrition

17
Q

What are causes of fractured neck of femur?

A

Osteoporosis (older), trauma (younger) or combination

18
Q

What do you have to consider in fractured neck of femur history?

A

Age, comorbidities, pre-injury mobility, social history (home history included)

19
Q

What is the anatomy of the neck of femur? Where does the blood supply come from? What is the intratrochanteric line and what does it define?

A
  • Femoral head and neck below. Capsule below. Lesser trochanter medially, greater trochanter above and laterally.
  • Blood supply comes from capsular vessels.
  • Intratrochanteric line joins lesser and greater trochanters. Anything above this line is intracapsular and anything below extracapsular
20
Q

When is there risk of avascular necrosis in neck of femur fractures?

A

When intracapsular more likely blood supply is compromised causing avascular necrosis, if displaced even higher risk

21
Q

What is treatment for each type of neck of femur fracture and why?

A
  1. extracapsular: fix with plate and screw (dynamic hip screw) - because minimal risk of AN.
  2. intracapsular undisplaced - fix with screws.
  3. intracapsular displaced - high risk of AVN - replace in older patients >65, fix if young <55. if more mobile - total hip replacement (acetabulum + head of femur). If less mobile/multiple comboribidities do hemiarthroplasty
22
Q

In which fossa should the humerus be?

A

Glenoid fossa

23
Q

How do dislocated shoulders present?

A

Direct trauma, pain, restricted movement, loss of normal shoulder contour

24
Q

What is involved in clinical exam of shoulder dislocation? What imaging is needed?

A

Assess neurovascular status (axillary nerve, ligaments, tendons). Plain X ray before manipulation to see fractures. Scapular Y view/modified axillary + AP

25
Q

How do you manage a shoulder dislocation?

A
  • For reduction - avoid vigorous manipulation/twisting to avoid fractures.
  • Safest method is use traction counter traction +/- gentle internal rotation to disimpact humeral head.
  • For patient relaxation - benzodiazepines, entonox.
  • If alone use stimson method.
  • Do in safe environment especially if elderly
26
Q

What is a complication that can occur during reduction of the shoulder dislocation & what can this lead to?

A
  • Humerus as it comes out bangs on glenoid causing bankart lesion on glenoid & hill-sachs on humerus on part that took bone out.
  • Can lead to recurrent dislocation
27
Q

How do you manage a distal radius fracture? What needs to be considered?

A
  • If bones haven’t moved - plaster. Cast/splint temporary, reduce and place in cast until definitive fixation.
  • If minimally displaced extra-articular fracture definitive fixation.
  • For extra-articular fractures with instability MUA & K wire fixation (mainly in kids), wires can be removed post-op.
  • for displaced unstable fractures not suitable for K wires or if have intra-articular involvement do open reduction internal fixation (ORIF) with plate and screws
28
Q

What is a lipohaemarthrosis? What does it indicate?

A

Fat fluid line. Pathognomonic of fracture within joint

29
Q

What is the structure of the tibial plateau?

A

Proximal tibia key weight-bearing. Flat and has medial and lateral plateaus with central tibial spine for insertion of ligaments.

30
Q

What can cause a tibial plateau fracture? What concomitant injury can accompany it?

A
  • Any extreme valgus/varus force on axial loading across knee can cause tibial plateau fracture, with impaction of femoral condyles causing soft bone of plateau to depress or splint.
  • Concomitant ligamentous or meniscal injury not uncommon
31
Q

How do you manage a tibial plateau fracture?

A
  • Non-operative if un-displaced fracture with good joint line congruency assessed on CT or high fidelity imaging.
  • Operative mostly, restore articular surface with plates and screws, bone graft or cement may be needed to prevent more depression after fixation
32
Q

How do you manage an ankle fracture?

A
  1. non-operative - non-weight bearing below knee cast 7-8wks, then walking boot and physiotherapy, if weber A (stable) or weber B with no evidence of instability (no medial/posterior malleolus fracture and no talar shift)
  2. operative - soft tissue dependent so need strict elevation as injuries swell, ORIF (open reduction internal fixation) +/- syndesmosis repair using either screws or tightrope technique. Screws can be left there but may break so need removal. This is for weber B (if unstable - talar shift/medial or posterior malleolus fracture) or weber C (fracture above level of syndesmosis so unstable)
33
Q

What is weber A & what is needed?

A

Fracture below syndesmosis so syndesmosis intact and usually stable. Knee cast –> walking boot –> physiotherapy

34
Q

What is weber B & what is needed?

A

Fracture at level of syndesmosis so syndesmosis may be intact or partially torn, so may be stable or unstable. If stable - knee cast, walking boot, then physiotherapy. If unstable - ORIF

35
Q

What is weber C & what is needed?

A

Fracture above level of syndesmosis so syndesmosis damaged, unstable. ORIF

BRS (81 decks)

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