Management Of Specific Fractures Flashcards by Elizabeth Akeju

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

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What is considered when assessing a fracture?

Pain
Swelling
Crepitus
Deformity
Collateral damage
- Nerve
- Vessel

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What are the investigations for fractures?

XRay (in most cases)
CT sometimes indicated to make diagnosis and assess pattern
MRI if unsure

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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?

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What is the difference between varus and valgus?

Varus - outward
Valgus - inward

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Why do fractures displace?

Because of the muscles
Displace towards strongest muscles

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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

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What steps are involved in the inflammation stage of indirect fracture healing?

Haematoma formation
Release of cytokines
Granulation tissue and blood vessel formation

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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)

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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

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What is Wolff’s Law?

Bone grows and remodels in response to the forces that are placed on it

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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

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How are fractures managed?

Reduce:
- Closed
- Open
Hold:
- Plaster/splint
- External fixation
- Internal fixation
Rehabilitation:
- Early/late
- Weight bearing
- Physiotherapy

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What are the general complications of fractures?

Can be early or late
Fat embolus
DVT
Infection
Prolonged immobility (UTI, chest infections, sores)

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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)

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What mechanical factors affect fracture healing?

Movement
Forces

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What biological factors affect fracture healing?

Blood supply
Immune function
Infection
Nutrition

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What are the causes of fractured neck of femur?

Osteoporosis (older)
Trauma (younger)
Combination

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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 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