Management Of Specific Fractures Flashcards
What is trauma?
Emergency broken bone support
In hospital treat via - Advanced trauma life support
- Reduce fracture
- Hold fracture via external or internal fixation
- Rehabilitate (move) when fracture is healed normally 6 weeks
What is orthopaedics?
More longer term conditions e.g. osteoarthritis
- What are the principles for it?
- History and examination
- look → feel → move and X ray
- Investigations
What are the clinical signs of a fracture?
- Pain
- Swelling
- Crepitus
- Deformity
- Adjacent structural injury: nerves/vessels/ligament/tendons
How do we investigate fractures?
- Radiograph (Xray)- most popular
- CT scan to make diagnosis or assessment pattern
- MRI scan if unsure
How do we describe radiographs?
- Location- which bone and which part of bone?
- Pieces- simple/multifragmentary?
- Pattern- transverse/oblique/spiral
- Displaced/undisplaced/minimally displaced
- Translated/angulated?
- X/Y/Z plane
X/Y/Z plane- what are the 2 types of movements we can have of bones?
- Translations- what direction is the movement?Straight line movements where you can have:
- medial and lateral translation
- proximal and distal translation
- anterior and posterior translation
- Angulation- what direction is the movement?Rotation movements:
- Varus/valgus movement is in coronal plane towards and away from midline
- Dorsal/volar movement is in sagittal plane
- Internal/external rotation is in axial plane
What are general complications of fractures (early or late)? (4)
- Fat embolus
- DVT
- Infection
- Prolonged immobility (UTI, chest infections, sores)
What are more specific complications 6
- Neurovascular injury
- Muscle/tendon injury
- Non union/mal union
- Local infection
- Degenerative change (intraarticular)
- Reflex sympathetic dystrophy
neck of femor fractures causes in older and younger pts
- Osteoporosis in older patients
- Trauma in younger patients
- Combination of both
What do we want to know about in the patient’s history NOF
- Age
- Comorbidities- cardiovascular/respiratory/diabetes/cancer
- Preinjury mobility- were they independent/shopping/walking/sports?
- Social Hx: relatives? do they have stairs at home? ETOH?
Types of NOF
Subcapital (intracapsular
Transcervical (intracapsular)
Basicervical (extracapsular)
Intertrochanteric (extracapsular)
Subtrochanteric
How do we determine whether to either fix or replace a fracture? (2) hip
- The location of the fracture
- The degree of displacement
- What if the fracture is extracapsular?
- Blood supply to femur likely to be preserved so head of femur is likely to survive
- So we fix this fracture with plate and screws or nails (dynamic hip screw). Known as internal fixation
- What if the fracture is intracapsular?
- If the bone fragments haven’t moved apart and it’s likely the blood supply is still intact, we can fix the fracture with screws
- If the bone fragments have displaced, there’s a 25-30% chance of avascular necrosis so we think more about replacing the head of the femur as it might die. If pt less than 55 reduce and fix with screws if older than 65 and they are fit and mobile do total hip replacement but if not then hemiarthroplasty
When do we do a total hip replacement vs hemiarthroplasty?
- Total hip replacement if patient is:
- Walks >mile a day
- Independent
- Minimal comorbidities
- Hemiarthroplasty (leave acetabulum as bone but replace head and neck of femur) if patient has:
- Lower mobility
- Multiple comorbidities
How does shoulder dislocation present
- Variable history but often direct trauma
- Pain
- Restricted movement
- Loss of normal shoulder contour
- How do we investigate it?
(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 addition to AP
-assess neurovascukar structure eg Axillary nerve
How do we manage shoulder fracture
- There are numerous techniques to reduce shoulder dislocation
- Vigorous manipulation or twisting should be avoided to avoid fractures
- Safest method is traction counter traction with internal rotation
- Ensure adequate patient relaxation e.g. entonox or benzodiazepines
- If alone could use Stimson method (using hanging weights)
- Undertake in safe environment esp in elderly e.g. resus, ask for senior/anaesthetic support early on if necessary
What is a complication of shoulder dislocation?
- Hill-Sachs defect- what is it?As humerus comes out, it bangs on glenoid and a fleck of bone comes off (called a Bankart lesion)
Leads to recurrent shoulder dislocation
Distal radial fracture 3 ways of management
- Cast/splint(non operative)- when is it done?
-undisplaced stable fractures- Temporary treatment for any distal radial fracture- reduction of fracture and placement into cast until definitive fixation
- Definitive if minimally displaced, extraarticular fracture
Slow rehab and stiff but no surgery
- MUA and K-wire- when is it done?
- For fractures that are extra-articular and displaced particularly in children
- MUA (manipulation under anaesthesia) in theatre with K-wire (Kershner wire- a pin in the wrist) fixation can be used
- Wires can be removed in clinic post op
Small operation with slow rehab and stiffness
ORIF
Used for complex fractures that are displaced and unstable and not suitable for k wires or with intra articular involved
Intra articular
Volar instability
Unable to reduce
Faster rehab,big surgery and complications
What are is the most commonly fractured bone in ankle fractures?
Fibula
How do we manage ankle fractures non-operatively?
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
What is a Weber A fracture?
Below syndesmosis is without damage to ligaments therefore stable
Treat non operatively
What is a Weber B fracture?
At the level of ankle joint and may extend to fibula
When are Weber B fractures managed non-operatively?
no evidence of instability (no medial/posterior malleolus fractures and no talar shift)
How do we manage ankle fractures operatively?
- Soft-tissue dependent- patients need strict elevation as injuries often swell considerably
- ORIF (open reduction and 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 date if needed
- Done to Weber B unstable fractures
Dine to Weber c (fibular fracture above the level of syndesmosis therefore unstable)
What is a Weber C fracture and why is it operated on every time?
- Above ankle joint
- i.e. fibular fracture above level of syndesmosis so will be unstable
Hugh energy vs low energy injuries
High energy
Usually significant trauma on normal bone in young ppl.transverse fracture patterns and comminution
Implications of high energy
Periosteal stripping (loss of blood supply)
Wide zone of injury
Other injuries
Fracture healing
Direct fracture healing
Anatomical reduction
Absolute stability/compressiom
No callus
Indirect fracture healing
Sufficient reduction
Micro movement
Callus
Indirect fracture healing
Wolffs law bone grows and remodels in response to forces placed on it
Inflammation-Haematoma formation,release of cytokines,granulation tissue and blood vessel formation
Repair-soft callus (type 2 collagen-cartilage) converted to hard callus (type 1 collagen-bone)
Remodeling-callus responds to activity, functional demands,external forces and growth)
Haematopoiesis formation
Fibrocartilagenous callus formation
Bony callus formation
Bone remodeling
Time for bone to heal
3-12 weeks depending on site,normally 6 weeks
Signs of growth 7-10 days
Phalanges-3weeks
Metacarpals-4/6 weeks
Distal radius-4/6 weeks
Forearm-8/10 weeks
Tibia-10 weeks
Femur-12 weeks
Managing fractures
Reduce:open,closed
Hold:plaster,splint,external or internal fixation
Rehabilitate:early late,weight bearing,physiotherapy
Reduction
If closed then manipulation or traction. With traction skin/skeletal
If open do mini incision or full exposure
Factors affecting fracture healing
Mechanical environment-movement/firces
Biological environment-blood supply,infection,immune function,nutrition
NOF anatomy
In intracapsular fractures blood supply more likely to be compromised
Non union
Avascular necrosis
Loss of shentons line
Distal radius fractures decision making
Intra articular or extra articular
Volar or dorsal
Closed reduction possible?
Patient factors
Tibial plateau fracture
Proximal tibia contains a weight bearing surface as a a part of the knee
It’s flag and comprises of medial and lateral plateaus with a central tibial spine acting as an insertion point for ligaments
Extreme valgus or varus force or axial loading can cause a tibial plateau fracture with impact ion of femoral condyles causing the soft bone of the tibial plateau to depress or split
Concomitant ligamanetous or meniscal injury is nit uncommon
Tibial plateau fracture management
Non operative
Only truly undisplaced fractures with a good joint line congruency on ct
Operative
Predominantly treatments will be operative
Restoration kc of articular surface using combination of plates and screws
Bone graft or cement mag be necessary to prevent further depression after fixation
