management of specific fractures Flashcards
What is the difference trauma vs orthopaedics?
Orthopaedics- look, feel, move, Xray
Trauma- Reduce, hold (plaster, internal fixation, external fixation), rehabilitate (usually 6 weeks later
What are the main principles of assessing and managing trauma?
Fracture is usually the least important bit
Keep the patient alive first- ATLS
Airway
Breathing
Circulation
Disability
Fracture is sometimes treated as part of C or in secondary survey (Reduce, hold, rehabilitate)
What are the clinical signs of a fracture?
Pain
Swelling
Crepitus
Deformity
Collateral damage- nerves, vessels, tendons, ligaments
How do we investigate a fracture
Xray (in most cases)
CT is sometimes indicated- to make diagnosis/ to assess pattern
MRI if unsure
Bone scan
What features of a fracture do we discuss when describing a radiograph?
Location- which bone and where in that bone is the fracture located
Pieces- simple, multi fragmentary
Pattern- transverse/ oblique/ spiral
Displacement- displaced/ undisplaced/ minimally displaced
Translated/ angulated
X/Y/Z plane
What are translations in fractures?
Straight line movements
Anterior or posterior
lateral or medial
proximal or distal
What are angulations in fractures
varus/ valgus- coronal plane (away from midline)
dorsal/ volar -sagittal plane
internal rotation/ external rotation
What are the two ways in which a fracture can heal
Direct fracture healing- there is anatomical reduction, absolute compression and stability, no callus forms
Indirect fracture healing- sufficient reduction, micro movement, callus forms
What are the broad steps in healing?
Bleeding
Inflammation
Repair
Remodelling
What happens during the inflammation stage of healing?
Haematoma formation
Cytokine release
Granulation tissue and new blood vessel formation
What happens during the repair stage of healing?
Soft callus formation (type II collagen- cartilage)
Converted to hard callus (type I collagen- bone)
What happens during the remodelling stage of healing?
Callus responds to external forces, activity, functional demands and growth
excess bone is 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 bone to heal?
6 weeks
3-12 weeks depending on the patient
When are signs of healing visible on Xray?
7-10 days
How long does it take for the following fractures to heal: phalanges, metacarpals, distal radius, forearm, tibia, femur?
Phalanges: 3 weeks
Metacarpals: 4-6 weeks
Distal radius: 4-6 weeks
Forearm: 8-10 weeks
Tibia: 10 weeks
Femur: 12 weeks
What are the 2 methods of fracture reduction? Give examples.
Name 3 methods of holding a fracture
Plaster/ splint
Internal fixation- intramedullary, extramedullary
External fixation- monoplanar, multiplanar
What are general complications of fractures?
Fat embolus (hours)
DVT (days- weeks)
PE
Infection
Prolonged immobility- UTI, chest infection, bed sores
Name some specific complications of fractures
Neurovascular injury
Muscle/ tendon injury
Non-union/ Mal-union
Local infection
Degenerative changes (intraarticular)
Reflex sympathetic dystrophy
What factors affect fracture healing?
Mechanical environment- movement, forces
Biological environment- blood supply, nutrition, infection, immune function
What causes NoF fractures?
Osteoporosis (older)
Trauma (younger)
Combination
What would you want to know from the history of a person with a NoF fracture?
Age
Comorbidities (cardiovascular, respiratory, diabetes, cancer)
Preinjury mobility (were they independent? shopping? walking? sports?)
Social hx (relatives? stairs at home? EtOH?)
Look at this picture of NoF anatomy son.
red dotted line is the attachment of the capsule along the intertrochanteric line on the front line
- On the back of the femur the capsule goes halfway up NOF
- Anything above dotted line is intracapsular and everything below it is extracapsular (there’s a half zone on the back where it’s extracapsular there but around the front it’s intracapsular)
What types of NoF fractures are there by location?
Supcapital (intracapsular)
Transcervical (extra capsular)
Basicervical (extra capsular)
Subtrochanteric
Intratrochanteric
What complications can arise from intracapsular fractures?
- Avascular necrosis- due to interruption of blood supply
Blood supply to femoral head (mainly from medial and lateral circumflex branches of profunda femoris) goes through capsule, so neck fracture can lead to head necrosis (avascular necrosis) - non-union
What factors decide whether to fix or replace NoF fracture?
Location/ displacement
Age
Management of extra capsular NoF
Internal fixation (with plate and screws/ nails)
Management of intra capsular undisplaced NoF
Fixation with screws
Management of intra capsular displaced NoF where patient is <55 years old
Reduction and fixation with screws
Management of intra capsular displaced NoF where patient is >65 years old and fit and mobile
total hip replacement
Management of intra capsular displaced NoF where patient is >65 years old and less fit
hemiarthroplasty
Dislocated shoulder radiograph
How would a dislocated shoulder present?
Variable history but often direct trauma
Pain
Restricted movement
Loss of normal shoulder contour
What is an important clinical examination performed for patients present with a dislocated shoulder?
Assess neuromuscular status- axillary nerve
What investigations are carried out for shoulder dislocation?
Xray prior to any manipulation: identify fracture (e.g. humoral neck, greater trochanter avulsion fracture, glenoid)
Scapular Y-view/ modified axillary in addition to AP
Management for shoulder dislocations
There are numerous techniques for reducing a dislocated shoulder
Vigorous manipulation/ twisting manipulation should be avoided to avoid fractures
The safest method is to use traction-counter traction +/- gentle internal rotation to disimpact humeral head
If alone, could use Stimson method (using hanging weights)
ensure adequate patient relaxation e.g. entonox, benzodiazepines
Undertake in a safe environment, especially if elderly e.g. resus, ask for senior/ anaesthetic support early on if necessary.
Name a complication of shoulder dislocation and what can this lead to?
Hill-Sachs defect (as humerus comes out, it bangs on glenoid and a fleck of bone comes off, called a Bankart lesion)
can lead to recurrent shoulder dislocation
What are the three ways in which a distal radius fracture is managed?
Cast and splint- temporary treatment for any distal radius fracture: fracture is reduced and fixed within cast until definitive treatment. this is definitive treatment for minimally displaced, extra-articular fractures
MUA and K-wire- for fractures that are extra-articular but have instability, particularly in children. Wires can be removed in clinic post-op.
ORIF- any fracture that is displaced, unstable and unsuitable for K-wires or with intra-articular involvement can be treated with open reduction and internal fixation with plate and screws
describe how a tibial plateau fracture can occur
The proximal tibia is a key weight-bearing surface and forms part of the knee joint articulating with the distal femur
The tibial surface is mostly flat, with medial and distal tibial plateaus and a central tibial spine for ligament attachment.
Any excessive varus/ valves force or axial loading across the knee can cause a tibial plateau fracture, with the impaction of the femoral condyles causing the relatively soft tissue of the tibial plateau to depress/ split
concomitant ligament/ meniscus injury is not uncommon
Non-operative management for tibial plateau fracture
only done for truly undisplayed fractures with good joint line congruency assessed on CT or high fidelity imageing
reduce, hold, rehabilitate
operative management for tibial plateau fracture
Predominant treatment
Articular surface is restored using a combination of plates and screws
Bone graft or cement may be necessary to prevent further depression after fixation
What fractures make up a trimalleolar fracture?
Oblique (lateral) malleolus fracture- fibula
Medial malleolus fracture- tibia
Posterior malleolus fracture- tibia
What is the most frequently fractured ankle bone
fibula
Non-operative ankle fracture management
Non-weightbearing below knee cast for 6-8 weeks, can transfer into walking boot and then physio to improve range of motion/stiffness from joint isolation
Weber A and Weber B if no evidence of instability (no posterior/ medial malleolus fracture and no talar shift)
Operative ankle fracture management
Soft-tissue dependent- patients need strict elevation as injuries often swell considerably
ORIF +/- 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 date if needed
Unstable Weber B and Weber C fractures
What is a Weber A fracture
simple fracture to bottom part of fibula (below syndesmosis)
What is a Weber B fracture
Fracture of fibula at level where it ligamentally joins to the tibia (syndesmosis)
What is a Weber C fracture
Fibular fracture above level of syndersmosis (where tibia and fibula join ligamentously) therefore unstable
