Management of Specific Fractures

Question 1

Trauma process

Answer 1

ATLS
Reduce
Hold
Rehabilitate (Move)

Question 2

Orthopaedics process

Answer 2

History
Examination
(Look Feel Move)
Investigations

Question 3

Clinical signs of fracture

Answer 3

Pain
Swelling
Crepitus
Deformity
Adjacent structural injury - nerves/vessels/ligament/tendons

Question 4

investigations of fractures

Answer 4

Common- radiograph or X ray
More expensive- CT, MRI or bone scan

Question 5

Describing fracture

Answer 5

location
Pieces (simple/multi-fragmentary)
Pattern (transverse/oblique/spiral)
Displaced/Undisplaced
Translated/angulated
X/Y/Z plane

Question 6

Displacement

Answer 6

Translation (lateral)

Proximal/distal
Anterior/posterior
Medial/lateral

Angulation (valgus)

Internal/external rotation
Dorsal/volar
Varus/valgus

Question 7

Wolff’s law

Answer 7

Bone grows and remodels in response to forces placed on it

Question 8

Stability of ossification

Answer 8

Intramembranous - absolute
Endochondral - relative

Question 9

Intramembranous healing

Answer 9

Primary bone healing
Direct to woven bone
Stable fracture where ends are almost touching

Question 10

General principle of fracture management

Answer 10

Reduce - closed/open
Hold - no metal/metal
Rehabilitate - move/physiotherapy/use

Question 11

Closed reduction

Answer 11

Manipulation
Traction - skin/skeletal (pins in bone)

Question 12

Open reduction

Answer 12

Mini-incision
Full exposure

Question 13

Closed hold

Answer 13

Plaster
Traction - skin/skeletal

Question 14

Internal fixation

Answer 14

Intramedullary - pins/nails
Extramedullary - plate/screws/pins

Question 15

External fixation

Answer 15

Monoplanar
Multiplanar

Question 16

Rehabilitate

Answer 16

Use - pain relief/retrain
Move
Strengthen
Weight bear

Question 17

Mechanical factors affecting healing

Answer 17

Movement
Forces

Question 18

causes of fractured NoF

Answer 18

Osteoporosis (older)
Trauma (younger)
Combination

Question 19

Intracapsular NoF anatomy

Answer 19

Blood supply more likely to be compromised
Risk of avascular necrosis higher
Replace instead of fix if older

Question 20

shoulder dislocation presentation

Answer 20

Often direct trauma
Pain
Restricted movement
Loss of normal shoulder contour

Question 21

shoulder dislocation investigation

Answer 21

X ray prior to manipulation - identify fracture
Scapular-Y review/modified axillary in addition to AP

Question 22

Cells of fracture healing

Answer 22

Bleeding - Blood
Inflammation - Neutrophils, macrophages
New tissue formation - Fibroblasts, osteoblasts, chondroblasts
Remodelling - Macrophage, osteoclasts, -blasts

Question 23

What does new tissue form to become

Answer 23

Collagen - chondral precursor - cartilage precursor - endochondral ossification

OR

Directly into bone - intramembranous ossification

Question 24

Detail of fracture healing

Answer 24

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 - cartilage)

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

Question 25

Endochondral healing

Answer 25

Secondary bone healing
Go to chondral precursor which then produce bone cells
Involves response in periosteum and external soft tissues
More callus
Relative stability

Question 26

Fracture healing time

Answer 26

Upper limbs quicker than lower limbs

Phalanges - 3 weeks
Metacarpals - 4-6 weeks
Distal radius - 4-6 weeks
Forearm - 8-10 weeks
Tibia - 10 weeks
Femur - 12 weeks

Question 27

General fracture complications

Answer 27

Fat embolus
DVT
Infection
Prolonged immobility (UTI, chest infections, sores)

Question 28

Specific fracture complications

Answer 28

Neurovascular injury
Muscle/tendon injury
Non union/mal union
Local infection
Degenerative change (intraarticular)
Reflex sympathetic dystrophy

Question 29

Biological factors affecting tissue healing

Answer 29

Blood supply
Immune function
Infection
Nutrition

Question 30

shoulder dislocation clinical examination

Answer 30

Assess neurovascular status - axillary nerve

Question 31

shoulder dislocation management

Answer 31

Traction-counter traction +/- gentle internal rotation to disimpact humeral head
Could use Stimson method if alone
Ensure relaxation- entonox, benzodiazepines

Question 32

shoulder dislocation complications

Answer 32

Hill Sachs defect
Bankart lesion

Question 33

Distal radius fracture management

Answer 33

Cast/splint - temporary. Definitive if minimally displaced, articulate fracture
MUA - with K-wire fixation. For extra articular fractures with instability
Open reduction internal fixation - with plate and screws. For displaced and unstable fractures not suitable for K-wires

Question 34

Tibial plateau fracture overview

Answer 34

proximal tibia - key weight bearing surface with distal femur
Joint surface is flat and comprises of both medial and lateral plateaus with central tibial spine as insertion point for ligament
Extreme valgus/Varus force can cause fracture
Concomitant ligamentous or meniscal injury not uncommon

Question 35

Tibial plateau fracture management

Answer 35

Non operative - only truly Undisplaced fractures with good joint line congruency assessed on CT or high fidelity imaging

Operative - predominance, restoration of articular surface using comination of plate and screws, bone graft or cement may be necessary to prevent further depression

Question 36

ankle fracture management

Answer 36

non operative - non weight bearing below knee cast 6-8 weeks.

operative - open reduction internal fixation