Management of specific fractures 2 Flashcards
What is a perilunate dislocation?
part of a broader group of injuries called perilunate instability
What does perilunate instability result from?
from disruption to any of the ligament complexes that surround the lunate
How is perilunate instability different from lunate dislocation?
Articulation with the radius and surrounding carpal bones (scaphoid, triquetrum, capitate and hamate) is maintained while in lunate dislocation it is not
Are lunate and perilunate dislocations often missed?
relatively rare, both lunate and perilunate dislocation are often missed – in up to 25% of cases at initial presentation
What is the mayfield classification of perilunate instability and carpal dislocation?
- Stage 1: Scapho-lunate dissociation
- Stage 2: Lunocapitate disruption
- Stage 3: Lunotriqeutral disruption
- Stage 4: Lunate dislocation
What is Scapho-lunate dissociation?
Widening of scaphoid and lunate due to scapholunate ligament disruption
What is Lunocapitate disruption?
- Lunate remains normally aligned with distal radius, remaining carpal bones dislocated
- Capitate and lunate widening
- High association with scaphoid fractures
What is Lunotriqeutral disruption?
- Capitate and lunate are not aligned with distal radius
- Lunate-triquestral ligament disrupted
- High associated with triquetral fractures
What is Lunate dislocation?
- Dislocation of lunate with a ‘tipped’ teacup’ sign
2. Dorsal radiolunate ligament injury
What is the non-operative management of perilunate instability?
- Closed reduction and casting has no indication and often poor outcomes compared to non-operative management
- High risk of recurrent dislocation
What is the operative management of perilunate instability in acute injury?
- (<8 weeks)
- Open reduction
- ligament repair and fixation
- good functional outcomes
What is the operative management of perilunate instability in non-acute injury?
- (>8 weeks)
- Proximal row carpectomy
- converts wrist into simple hinge type
What is the operative management of perilunate instability in chronic injury?
- Arthrodesis of wrist
2. reduction of pain especially if degenerative changes
What is the presentation of a pelvic fracture?
- Usually a result of high energy trauma
* Patients can become very unstable – a lot of visceral organs and vasculature are adherent to the pelvis
What is the examination of a pelvic fracture?
- ABCDE approach - don’t forget to examine the perineam/urethral opening
- Digitate – PV or PR examinations – check for visceral damage or bleeding
What is the investigation of a pelvic fracture?
- Plain radiographs
- Urethrogram
- CT +/- angiography
What are the different pelvic fracture classifications?
- Lateral compression
- Anterior-posterior compression
- Vertical shear
What is the management of pelvic fracture?
- Always stick to ATLS and ABCDE principles
- Hypovolaemia is common
- Definitive treatment via a specialist centre with pelvic surgeons
- Principle to restore integrity of pelvic ring and alignment of sacroiliac joints
How do you manage of hypovolaemia?
- IV access and resuscitate the patient, think of major haemorrhage protocols early
- Pelvic binders are use as a tamponade device but need to be placed accurately (over greater trochanters)
- Ongoing instability should suggest laparotomy or angiographic embolisation
How do you restore integrity of pelvic ring and alignment of sacroiliac joints?
- Internal fixation with plate and screws
* External fixation if patient unstable and not suitable for invasive surgery
What is a proximal femur fracture sometimes called?
‘hip’ or ‘neck of femur (NOF)’ fractures
Are proximal femur fractures common?
- Very common, accounting for 25%+ of all fractures treated in hospitals
- Rare in young – usually high energy major trauma
Why do proximal femur fractures occur?
•Pathological fracture, often a result of osteoporosis and minimal trauma in the elderly
What can proximal femur fractures be a marker of?
-A marker of general frailty and has a higher mortality than breast cancer
•10% can die within a month
•30% die within a year
•50% of patients will not return to their pre-injury level of independence
What is the history like in proximal femur fracture assessment?
- Often a fairly inconspicuous history of a minor fall
- May report groin, thigh or buttock pain
- Want to ask about preceding symptoms, always think of pathological causes for a fall e.g. MI, TIA/stroke, seizure,
What is the examination like in proximal femur fracture?
- MSK – look, feel, move
* Thorough secondary survey and top-to-toe examination to look for other injuries
What is the investigation like in proximal femur fracture?
- Plain radiographs
* CT if not identified but high suspicion
What is the pre-operative management for a proximal femur fracture?
- Most hospitals will have a NOF protocol or proforma
* National guidance for management of patients with suspected NOFs to standardise treatment
What is the initial ED management of proximal femur fracture?
- Rule out any other injury/pathology causing fall
- Involvement of orthogeriatricians/medical team early
- Pain relief – consider fascia iliaca block in ED if necessary
- Catheterise – limited mobility
- Blood tests,
- ECG/Chest X-ray if >55
- Pre-operative optimisation – fluids, transfusion?
What are the intracapsular classifcations of proximal femur fracture?
- subcapital
- transcervical
- baiscervical
What are the extracapsular classifcations of proximal femur fracture?
- intertrochanteric
- subtroachnateric
- reverse oblique
What are three management options for an intracapsular proximal femur fracture?
- Total hip arthroplasty
- Hemiarthroplasty
- Cannulated screws
What are two management options for an extracapsular proximal femur fracture?
- DHS
2. IM nail
When is total hip arthroplasty used?
- Mobile with <1 walking stick outdoors
- No cognitive impairment
- Medically suitable for procedure and anaesthetic
Why is hemiarthroplasty used?
- Mobile with >1 walking stick outdoors
- Reduced AMTS
- Comorbidities or reduced baseline not benefiting from THR
When is cannulated screws used?
- Undisplaced fractures where vessels unlikely to be disrupted
- Young patients
- Compliant with non-weightbearing while fracture heals
Why is DHS used?
- For 2-, 3- and 4-part intertrochanteric fractures
2. Provides compression as prosthesis is perpendicular to fracture line
When is IM nail used?
- Subtrochanteric fractures are unstable due to pull of hip girdle
- Reverse oblique pattern not amenable to DHS as fracture line not perpendicular
What is the post-operative management for proximal femur fracture?
- MDT approach is absolutely vital!
- Geriatrician input from admission
-Bone health
-Medical optimisation
-Secondary fall prevention - Physiotherapy
•Prevent leading causes of death – hospital acquired infections, DVTs/PEs by early mobilisation - Occupational Therapy/Social Worker
-Help with post-operative care needs, package of care and assistance or aids at home
When does a femoral shaft fracture occur?
- Femur is the largest bone in the body and a significant force is required to fracture it
- A high incidence of concomitant life threatening injuries can exist – always assess using ABCDE and ATLS protocol
What should be included in clinical examination of femoral shaft fracture?
neurovascular status of the affected limb
What imaging should be used in a femoral shaft fracture?
X-rays is always useful and as in any diaphyseal injury always take X-rays of the joints above and below to look for fractures or dislocation
What is used in the management of a femoral shaft fracture?
- Resuscitate patients as necessary – hypovolaemia is not uncommon as long bone fractures can bleed a lot!
- Traction is useful in the first instance as a way of temporarily reducing both pain and bleeding
- Operative fixation
What operative fixation is used in management of a femoral shaft fracture?
- Intramedullary nailing – can be either antegrade (from the hip) or retrograde (from the knee) as surgeon preference, injury pattern, or existing prostheses dictates
- Open reduction and internal fixation can be used if nailing unsuitable e.g. a segmental fracture, knee or hip replacements
What does the proximal tibia comprise?
a key weightbearing surface as part of your knee joint, articulating with the distal femur
What can cause a tibial plateau fracture?
- 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
What is the lateral classification of tibial plateau fractures?
- Type 1: split
- Type 2: split and depression
- Type 3: depression
What is the medial classification of tibial plateau fractures?
-Type 4: medial plateau
What is the medial and lateral classification of tibial plateau fractures?
- Type 5: bicondylar
- Type 6: metaphyseal-disphyseal dissocation
What is the non-operative management of tibial plateau fracture?
Only truly undisplaced fractures with good joint line congruency assessed on CT or high fidelity imaging
What is the operative management of tibial plateau fracture?
- Predominance of treatment will be operative
- Restoration of articular surface using combination of plate and screws
- Bone graft or cement may be necessary to prevent further depression after fixation
What is ankle joint comprised of?
talus articulating with tibia and fibula
What is joint stability provided by?
- Ligaments
1. Medially: talofibular and calcaneofibular ligaments
2. Laterally: deltoid ligament - Bone projections:
1. . Medially: medial malleolus of tibia
2. Laterally: lateral malleolus of fibula
3. Posteriorly: posterior malleolus of tibia
What can an ankle fracture happen due to?
Can occur with twisting or axial
•Often have extensive soft tissue swelling and inability to weightbear
Why is clinical examination useful in ankle fracture?
dentify tenderness over ligament complexes and X-ray to ascertain talar shift are important to assess stability
What is Weber A classification of ankle fractures?
- below the level of the syndesmosis
- ligament disruption and joint stability unlikely
What is Weber B classification of ankle fractures?
- at the level of the syndesmosis
- ligament disruption and joint stability possible and stress testing or weightbearing assessment for talar shift necessary
What is Weber C classification of ankle fractures?
- above the level of the syndesmosis
- ligament disruption and joint instability likely
What is the non-operative management of ankle fractures?
- Non-weightbearing 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)
What is the operative management of ankle fractures?
- Soft tissue dependent – patients need strict elevation as injuries often swell 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 date 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
What do twisting injurys disrupt?
the syndesmosis and causes a high fibula fracture
What do you need to examine in twisting injuries?
clinically examine and check for proximal tenderness in ankle fractures, patients may have distracting pain and be unaware
When do you need to think about a maisonneuve fracture?
If there is widening of the syndesmosis on radiographs but no obvious fibula fracture always think about a Maisonneuve fracture – energy has to dissipate somewhere
How do you ensure no missed fracture?
Request long length X-rays to visualise the full fibula and ensure no missed fracture
