Management of specific fractures Flashcards
What is the difference between orthopedics and trauma?
1st assessment at orthopedics:
Look
Feel
Move
XRay
If trauma is detected, treat:
- Reduce
- Hold:
* Plaster
* External fixator
* Internal fixation
- Rehabilitate:
* Normally six weeks later
When assessing and managing trauma resulting in a fracture what should you deal with first?
- The fracture is usually the least important bit
- Keep the patient alive first – ATLS (advanced trauma life support)
- Airway
- Breathing
- Circulation
- Disability (ie neurology)
- Treat as part of ‘C’ occasionally or in secondary survey
What features of a fracture should you assess for?
- Pain
- Swelling
- Crepitus (a popping, clicking or crackling sound in a joint)
- Deformity
- “Collateral damage”
- Nerve
- Vessel
What investigations are used to assess fractures?
- XR (in most cases)
- CT sometimes indicated:
To make diagnosis
To assess pattern - MRI if unsure
What should you mention when describing a fracture radiograph?
Location: which bone and which part of bone?
Pieces: simple/multifragmentary?
Pattern:
- transverse (when your bone is broken perpendicular to its length)
- oblique (bone is broken at an angle)
Displaced/undisplaced
Translated/ lateral (bones remain aligned but moves away from each other) or angulated/ valgus/ varus (one bone slanted/ at the angle to the other)
X/Y/Z plane
What are the 2 types of angulation you can have?
Valgus (bends inwards/ an excessive inward angulation)
Varus (bends outwards/ an excessive outward angulation)
What is impaction in terms of fractures?
Impaction fractures happen when a bone is compressed. This puts pressure on the area, therefore causing parts of the bone to crumble under the weight of the compression
What are the types of fracture healing you can have?
- Direct fracture healing:
“ the bony fragments are fixed together with compression- The bony ends are joined and healed by osteoclast and osteoblast activity”
- Anatomical reduction
- Absolute stability/compression
- No callus - Indirect fracture healing:
“consists of both endochondral and intramembranous bone healing”
- Sufficient reduction
- Micromovement
- Callus
Describe the process of indirect 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 - Bone) - REMODELLING:
- Callus responds to activity, external forces, functional demands and growth
- Excess bone is removed
What is “Wolff’s Law”?
Wolff’s Law: Bone Grows and Remodels in response to the forces that are placed on it
What is the time it takes for a fracture to heal?
Actually 3-12 Weeks depending on site & patient
Signs of 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 - Rehabilitate:
- Early / late
- Weight bearing
- Physiotherapy
How is an open fracture reduced?
Either:
- Mini incision
- Full exposure
How is a closed fracture reduced?
Either:
1. Manipulation
2. Traction:
* skin
* Skeletal (pins in bone)
Why types of fixation can you have?
- Internal
- External
- Medullary
- Mono/mupltiplanar
What complications can be caused from a fracture?
General (early or late):
- Fat embolus
- DVT
- Infection
- Prolonged immobility (UTI, chest infections, sores)
Specific
- Neurovascular injury
- Muscle/tendon injury
- Non union/mal union
- Local infection
- Degenerative change (intraarticular)
- Reflex sympathetic dystrophy
What factors affect fracture healing?
Mechanical environment:
- Movement
- Forces
Biological environment:
- Blood supply
- Immune function
- infection
- nutrition
What are the causes of a fractured neck of femur?
Causes:
Osteoporosis (older)
Trauma (younger)
Combination
What needs to be explored in a history for a fractured neck of femur?
- Age
- Comorbidity respiratory/ cardiovascular/ diabetes/ cancer
- Preinjury mobility independent/ shopping/ walking/ sports
- Social history: relatives, stairs, alcohol intake
What are the types of neck of femur fractures by location?
- Subcapital (The fracture line extends through the junction of the head and neck of femur- below the femoral head)
- Transcervical (across the mid-femoral neck)
- Basicervical (across the base of the femoral neck)
- subtrochanteric (fractures of the proximal femur that occur within 5 cm of the lesser trochanter)
- part intertrochanteric (Intertrochanteric fractures are defined as extracapsular fractures of the proximal femur that occur between the greater and lesser trochanter)
How are neck of femur fractures managed?
- Extracapsular fractures - fix with screws or nails
- Intracapsular fractures
- A bit more complex
(replace in some cases)
Do you fix or replace a fracture?
depends on location/displacement and age
How would you fix a extracapsular neck of femur fracture?
Internal fixation (plate and screws or nail)
How would you fix an intracapsular displaced neck of femur fracture?
- Less than 55yrs: reduce and fixation with screws
- > 65 yrs replace:
- Fit and mobile: total hip replacement
- Less fit: hemiarthroplasty
How would you fix an intracapsular undisplaced neck of femur fracture?
- Fixation with screws
How does a shoulder dislocation present?
- Variable history but often direct trauma
- Pain
- Restricted movement
- Loss of normal shoulder contour
What clinical examination is used to assess a dislocated shoulder?
- Assess neurovascular status- axillary nerve
What investigations are used to monitor shoulder dislocation?
- X-ray prior to any manipulation- identify fracture e.g, humeral neck, greater tuberosity avulsion or glenoid
- Scapular- Y view/ modified axillary in addiction to AP
How is a dislocated shoulder managed?
- Numerous techniques to reduce a dislocated shoulder
- Vigorous manipulation or twisting manipulation should be avoided to avoid fractures
- Safest method is to use traction- counter +/- gentle internal rotation to disimpact humeral head
- Ensure adequate patient relaxation- Entonox; benzodiazepines
- If alone could use Stimson method
- Undertake in safe environment, especially e.g. resus, ask for senior/ anesthetic support early on if necessary
What complications can occur from a shoulder dislocation?
- Hill- Sachs defect:
- injury that occurs secondary to an anterior shoulder dislocation.
- The humeral head ‘collides’ with the anterior part of the glenoid, causing a lesion, bone loss, defect and deformity of the humeral head.
- This may cause a change loss of range of motion, feelings of instability and pain - Bankart lesion:
- a type of shoulder injury that occurs following a dislocated shoulder.
- It is an injury of the anterior (inferior) glenoid labrum of the shoulder.
- When this happens, a pocket at the front of the glenoid forms that allows the humeral head to dislocate into it
What is a distal- radius fracture?
The radius is one of two forearm bones and is located on the thumb side. The part of the radius connected to the wrist joint is called the distal radius. When the radius breaks near the wrist, it is called a distal radius fracture.
How is a distal radius fracture managed?
- cast/ splint:
- Temporary treatment for any distal radius fracture- reduction of fracture and placement into cast until definitive fixation
- Definitive if minimally displaced, extra articular fracture - MUA & K-WIRE:
- For fractures that are extra-articular but have instability, particularly in children, MUA in theatre with K-wire fixation can be used
- Wires can then be removed in clinic post- op - ORIF:
- Any displaced, unstable fractures not suitable for K-wires or with intra-articular involvement may benefit from open reduction internal fixation with plate and screws
What is a scaphoid fracture?
A scaphoid (navicular) fracture is a break in one of the small bones of the wrist. This type of fracture occurs most often after a fall onto an outstretched hand. Symptoms of a scaphoid fracture typically include pain and tenderness in the area just below the base of the thumb.
What is a Tibial plateau fracture?
- The proximal tibia comprises a key weight bearing surface as part of your knee joint, articulating with the distal femur
- Tibial joint surface is relatively flat and comprises of both medial and lateral plateaus with a central tibial spine acting as an insertion point for ligaments.
- Any extreme valgus/ varus force or axial loading across the knee can cause a tibial plateau fracture, with impaction of the femoral condyles causing the comparatively soft bone of the tibial plateau to depress or split
- Concomitant ligamentous or meniscal injury is not uncommon
How is a tibial plateau fracture managed?
Non-operative:
- only truly undisplaced fractures with good joint line congruency assessed on CT or high fidelity imaging
Operative:
- Predominance of treatment will be operative
- Restoration of articular surface using combination of plane and screws
- Bone graft or cement may be necessary to prevent further depression after fixation
What is a trimalleolar fracture?
Trimalleolar fractures happen when you break the lower leg sections that form your ankle joint and help you move your foot and ankle
How are ankle fractures managed?
Non- operative:
- Non- weight bearing below knee cast for 6-8 weeks, can transfer into walking boot and then physiotherapy to improve range of motion/ stiffness from joint isolation
- Weber A i.e. below syndesmosis and therefore thought to be stable
- Weber B if no evidence of instability (no medial/ posterior malleolus fracture and no talar shift)
Operative:
- Soft tissue dependent- patients need strict elevation as injuries often well considerably
- Open reduction internal fixation +/- syndesmosis repair using either screw or tightrope technique
- Syndesmosis screws can be left in situ but may break after some time so therefore can be removed at a later if necessary
- Weber B (unstable fractures- talar shift/ medial or posterior malleoli fractures)
- Weber C i.e. fibular fracture above the level of the syndesmosis therefore unstable
