Management Of Specific Fractures Flashcards
Is the fracture usually the main priority?
No, keep the patient alive first:
Airway
Breathing
Circulation
Disability
Fracture can be treated as part of ‘C’ if affecting circulation, e.g. blood loss
What is considered when assessing a fracture?
Pain
Swelling
Crepitus
Deformity
Collateral damage
- Nerve
- Vessel
What are the investigations for fractures?
XRay (in most cases)
CT sometimes indicated to make diagnosis and assess pattern
MRI if unsure
How do you describe a fracture radiograph?
Name, date, projection
Location:
Which bone?
Which side?
Which part of bone - is it intra-articular (did it enter the joint)?
Pieces: simple/multifragmentary
Pattern: transverse/oblique/spiral
Displaced/minimally displaced
What plane: translated/angulated/rotated?
What is the difference between varus and valgus?
Varus - outward
Valgus - inward
Why do fractures displace?
Because of the muscles
Displace towards strongest muscles
What are the differences between direct and indirect fracture healing?
Direct:
- Bone ends are joined
- Anatomical reduction allows for natural bone turnover and growth - important for joint health
- Absolute stability/compression
- No callus
Indirect fracture healing
- Sufficient reduction
- Micromovement - some movement at fracture site
- Callus formation
- Not concerned with joint functionality
What steps are involved in the inflammation stage of indirect fracture healing?
Haematoma formation
Release of cytokines
Granulation tissue and blood vessel formation
What steps are involved in the repair stage of indirect fracture healing?
Soft callus formation (type II collagen - cartilage)
Converted to hard callus (type I collagen - bone)
What steps are involved in the remodelling stage of indirect fracture healing?
Callus responds to activity, external forces, functional demands and growth
Excess bone removed
What is Wolff’s Law?
Bone grows and remodels in response to the forces that are placed on it
How long does it take for fractures to heal?
3-12 weeks depending on site and patient
Healing visible on XR from 7-10 days
Phalanges: 3 weeks
Metacarpals: 4-6 weeks
Distal radius: 4-6 weeks
Forearm: 8-10 weeks
Tibia: 10 weeks
Femur: 12 weeks
How are fractures managed?
Reduce:
- Closed
- Open
Hold:
- Plaster/splint
- External fixation
- Internal fixation
Rehabilitation:
- Early/late
- Weight bearing
- Physiotherapy
What are the general complications of fractures?
Can be early or late
Fat embolus
DVT
Infection
Prolonged immobility (UTI, chest infections, sores)
What are the specific complications of fractures?
Neurovascular injury
Muscle/tendon injury
Non union/mal union
Local infection
Degenerative change (intraarticular)
Reflex sympathetic dystrophy - also known as complex regional pain syndrome (neurological)
What mechanical factors affect fracture healing?
Movement
Forces
What biological factors affect fracture healing?
Blood supply
Immune function
Infection
Nutrition
What are the causes of fractured neck of femur?
Osteoporosis (older)
Trauma (younger)
Combination
What would you ask in a history for a fractured neck of femur?
Age
Comorbidity
Preinjury mobility
Social hx: relatives, stairs
Describe the different planes of displacement
What’s the difference between translation, angulation, rotation and impaction?
Describe the different routes for reduction
Label this image
Label this image with the names of the different types of NoF fracture
What must be considered when managing an intracapsular NoF fracture?
Blood supply is more likely to be compromised
Avascular necrosis (AVN)
Non-union
How are intra and extracapsular NoF fractures managed?
Extracapsular - fix
Intracapsular - fix or replace - depends on displacement and age
What do these two images show?
Left - hemiarthroplasty
Right - total hip arthroplasty
What does this x-ray show?
Shoulder dislocation
How does shoulder dislocation typically present?
Variable hx but often direct trauma
Pain
Restricted movement
Loss of normal shoulder contour
What clinical examinations are done for shoulder dislocation?
Assessment of neurovascular status - axillary nerve
What investigations are done for suspected shoulder dislocation?
X-ray prior to manipulation - identify fracture
Scapular-Y view/modified axillary in addition to AP view
What technique should be avoided in shoulder dislocation management?
Vigorous manipulation or twisting - may cause fractures
What are the safest methods for shoulder dislocation management?
Traction-counter traction +/- gentle internal rotation to disimpact humeral head
If alone, could use Stimson method
Ensure adequate patient relaxation - can give Entonox or benzodiazepines
Undertake in a safe environment, esp. with elderly
What do these images show?
Hills-Sachs defect - posterolateral humeral head depression fracture (dent) resulting from the impaction with the glenoid rim, usually following an anterior glenohumeral dislocation
Bankart lesion - Glenoid labrum tear in the anterior joint
What does this radiograph show?
When is a cast/splint used in distal radius fracture management?
Temporary treatment for any distal radius fracture - reduction and placement into cast until definitive fixation
Definitive if minimally displaced, extra articular fracture
When is a manipulation under anaesthesia (MUA) with K wire used in distal radius fracture management?
Fractures that are extra-articular but have instability
Typically used for children
Wires can be removed in clinic post-op
When is open reduction internal fixation used in distal radius fracture management?
Displaced, unstable fractures not suitable for K-wires or with intra-articular involvement
Involves use of plate and screws
What does this x-ray show?
What does this x-ray show?
What can cause a tibial plateau fracture?
Extreme varus/valgus force or axial loading across knee
Impaction from the femoral condyles can cause the tibial plateau to depress or split
What may also accompany a tibial plateau fracture?
Concomitant ligamentous or meniscal injury
How is a tibial plateau fracture managed?
Non-operative:
- Only for truly undisplaced fractures with good joint line congruency assessed on CT or high fidelity imaging
Operative:
- Majority of cases
- Restoration of articular surface using combination of plate and screws
- Bone graft or cement may be necessary to prevent further depression after fixation
What does this x-ray show?
Outline non-operative management of an ankle fracture
Non-weight bearing below knee cast -> 6-8 weeks
Transfer to walking boot
Then physio 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
Outline operative management of an ankle fracture
Soft tissue dependent - requires strict elevation as injuries often swell
Open reduction internal fixation +/- syndesmosis repair using either screw or tightrope technique
Weber B - unstable fractures
Weber C - fibular fracture above level of syndesmosis therefore unstable
