Management of Specific Fractures Flashcards by Yipei Sun

Trauma process

ATLS
Reduce
Hold
Rehabilitate (Move)

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Orthopaedics process

History
Examination
(Look Feel Move)
Investigations

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Clinical signs of fracture

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

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investigations of fractures

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

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Describing fracture

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

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Displacement

Translation (lateral)

Proximal/distal
Anterior/posterior
Medial/lateral

Angulation (valgus)

Internal/external rotation
Dorsal/volar
Varus/valgus

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Wolff’s law

Bone grows and remodels in response to forces placed on it

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Stability of ossification

Intramembranous - absolute
Endochondral - relative

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Intramembranous healing

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

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General principle of fracture management

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

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Closed reduction

Manipulation
Traction - skin/skeletal (pins in bone)

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Open reduction

Mini-incision
Full exposure

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Closed hold

Plaster
Traction - skin/skeletal

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Internal fixation

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

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External fixation

Monoplanar
Multiplanar

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Rehabilitate

Use - pain relief/retrain
Move
Strengthen
Weight bear

Mechanical factors affecting healing

Movement
Forces

causes of fractured NoF

Osteoporosis (older)
Trauma (younger)
Combination

Intracapsular NoF anatomy

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

shoulder dislocation presentation

Often direct trauma
Pain
Restricted movement
Loss of normal shoulder contour

shoulder dislocation investigation

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

Cells of fracture healing

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

What does new tissue form to become

Collagen - chondral precursor - cartilage precursor - endochondral ossification

Directly into bone - intramembranous ossification

Detail of fracture healing

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

Endochondral healing

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

Fracture healing time

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

General fracture complications

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

Specific fracture complications

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

Biological factors affecting tissue healing

Blood supply Immune function Infection Nutrition

shoulder dislocation clinical examination

Assess neurovascular status - axillary nerve

shoulder dislocation management

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

shoulder dislocation complications

Hill Sachs defect Bankart lesion

Distal radius fracture management

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

Tibial plateau fracture overview

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

Tibial plateau fracture management

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

ankle fracture management

non operative - non weight bearing below knee cast 6-8 weeks. operative - open reduction internal fixation