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Y2 - BRS - MSK > Management of Specific Fractures > Flashcards

Management of Specific Fractures Flashcards

1
Q

What is bone?

A

Connective tissue that has a unique histological composition

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2
Q

What are the 5 functions of bone?

A
  1. Support = framework and shape of the body
  2. Protection = surrounds major internal organs and vasculature
  3. Locomotion = joints to allow flexibility and attachment site of muscles
  4. Haematopoesis = reservoir of stem cells forming blood cells
  5. Lipid and mineral storage = adipose tissue stored within bone marrow and calcium within hydroxyapatite crystals
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3
Q

What are 5 different types of bone?

A
  1. Flat bones - protect internal organs e.g. skull, thoracic cage, sternum, scapula
  2. Long bones - support and facilitate movement e.g. humerus, radius, ulna, metacarpals
  3. Irregular bones - vary in shape and structure e.g. vertebrae, sacrum, pelvis – pubic, ilium or ischium
  4. Short bones - no diaphysis, as wide as they are long, provide stability and some movemente.g. carpals, tarsals,
  5. Sesamoid bones - embedded within tendons, allows for dynamic action, also protects tendon from excessive stress / wear e.g. patella
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4
Q

What is the anatomy of the long bone?

A

Epiphysis = end
Metaphysis
Diaphysis = main body of the bone

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5
Q

What is found in the cross section of bone?

A

Epiphysis = cancellous (spongey) bone

In the cortex (i.e. border) = compact / cortical bone

Epiphyseal line = growth plate

Periosteum and nutrient arteries = provided blood supply and nutrients to bone

Medullary cavity

Yellow bone marrow surrounded by endosteum

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6
Q

What are the 2 bone ultrastructures of bone?

A
  1. Primary = woven bone:
    - First type of bone to be formed in embryonic development and fracture healing
    - Consists of osteoid, randomly arranged collagen fibres
    - Temporary structure replaced by mature lamellar bone
  2. Secondary = lamellar bone:
    - Bone of the adult skeleton
    - Highly organised sheets of mineralised osteoid, making it much stronger than woven bone
    - Can be divided into compact and cancellous
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7
Q

What is the ultrastructure of compact (cortical) VS spongy (cancellous) bone?

A

Compact (cortical) bone =

  • Found in the diaphysis, forms the outer part of bone
  • Organised in concentric circles around a vertical Haversian canal
  • Haversian canal are connected by Volkmann’s canals which contain small vessels that also supply periosteum |-|_| (so the vertical lines are haversian canals, the horizontal lines are volkmann’s canals)
  • Osteocytes located between lamellae, within small cavities called lacunae - these are interconnected by a series of tunnels called canaliculi.
  • Entire structure is known as an osteon, the functional unit of bone

Spongy (cancellous) bone =

  • Found in the epiphysis, irregular crosslinking of trabeculae to form porous yet strong bone resistant against multidirectional lines of force
  • Large spaces between trabeculae giving it a honeycombed appearance, contains red bone marrow
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8
Q

What are the biochemical and structural support components that make up the extracellular matrix of bone?

A

Mineral salts - calcium hydroxyapatite (70% of bone)

Collagen - Type I (90%) and Type V

Calcification of bone occurs when mineral salts interpose between collagen fibres, ECM is called osteoid before this

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9
Q

What are the cellular components of bone?

A

Osteobasts - synthesiseuncalcified ECM (osteoid)

Osteocytes - as osteoid mineralizes, osteoblasts are entombed between lamellae, becoming osteocytes; regulate bone mass by monitoring mineral composition and protein content

Osterclasts - they are multinucleate cells derived from monocytes and resorb bone, they release H+ ions and lysosomal enzymes

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10
Q

How does bone ossify (i.e. grow)?

A

2 methods:

  1. Endochondral =
    Formation of bone onto a temporary cartilage scaffold e.g. hyaline cartilage replaced by osteoblasts secreting osteoid in femur = provides length
  2. Intramembranous =
    Formation of bone directly onto fibrous connective tissue e.g. temporal bone or scapula = provides width to bone
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11
Q

How does the blood supply between bone and cartilage differ?

A

Bone has very good blood supply compared to cartilage

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12
Q

Once bone is formed, what happens?

A

Constant state of turnover - remodelling

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13
Q

How does bone remodelling work?

A

Bone removal undertaken by osteoclasts = essential for body’s metabolism as removal of bone increases calcium in blood

Bone production undertaken by osteoblasts =
osteoblasts have receptors from PTH, prostaglandins, vitamin D and cytokines that activate and allow them to synthesisebone matrix

Synergistic / co-ordinated action between 2 = allow for bone remodelling

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14
Q

How are osteoblasts activated?

A

PTH

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15
Q

Where do osteocytes form from?

A

From osteoblasts, which lay down concentric lamellae and form osteons

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16
Q

Why is bone remodellling relevant cliincally?

A

Nutrient deficiencies = bone disorders

Osteoporosis =

  • Decrease in bone density, reducing structural integrity
  • Osteoclast > osteoblast activity
  • Increased risk of fragility fracture
  • Three types: postmenopausal, senile, secondary

Rickets / Osteomalacia =

  • Vitamin D or calcium deficiency in children (rickets) or adults (osteomalacia)
  • Osteoid mineralizes poorly and remains pliable
  • In rickets, epiphyseal growth plates can become distorted under weight of the body - bendy bones
  • Osteomalacia = increased risk of fracture

Osteogenesis imperfecta =

  • Abnormal collagen synthesis
  • Increased fragility of bones, bone defomirtiesand blue sclera
  • Rare, genetic autosomal dominanyinheritance
  • Can be mistaken as NAD in children diagnosis important medicolegally
17
Q

What is a fracture?

A

Discontinuity of bone

18
Q

What are the 4 key points in describing a fracture clinically?

A

Orientation - of fracture e.g. transverse, oblique, spiral, comminuted

Location - position on bone e.g. proximal third, middle third or distal third

Displacement - can either be displaced or undisplaced

Skin penetration - can either be an open or closed fracture

19
Q

Why do we classify fractures using those 4 points?

A

Improves communication

Assists with prognosis and treatment

20
Q

What are the 3 different classification systems?

A

Descriptive classification e.g. Garden, Schatzker, Neer, Wber

Associated soft tissue injury e.g. Tscherne(closed) or Gustilo-Anderson (open)

Universal classification e.g. OTA classification

21
Q

What is the AO/OTA classification system?

A

Number for bone
Number for where (proximal/distal)
Number for subgroup of type of fracture

22
Q

What are the 2 types of fracture healing?

A

Primary (or direct) bone healing

Secondary (or indirect) bone healing

23
Q

What is primary (or direct) bone healing?

A

Intramembranous healing, occurs via Haversian remodeling

Little (<500mm) or no gap

Slow process

Cutter cone concept – like bone remodelling

24
Q

What is secondary (or indirect) bone healing?

What are the 4 steps of secondary bone healing?

A
  • Endochondral healing, involves responses in the periosteum and external soft tissues
  • Fast process resulting in callus formation (fibrocartilage)
  1. Haematoma formation =
    Damaged blood vessels bleed forming a haematoma, neutrophils release cytokines signaling macrophage recruitment
  2. Soft callous formation =
    Collagen and fibrocartilage bridge the fracture site and new blood vessels form
  3. Hard callus formation =
    Osteoblasts, brought in by new blood vessels, mineralise the fibrocartilage to produce woven bone
  4. Remodelling =
    Months to years after injury osteoclasts remove woven bone and osteoblasts laid down as ordered lamellar bone
25
Q

What are the ideal conditions for fracture healing?

How long does fracture healing take?

A

Minimal fracture gap
No movement if direct bone healing or some movement if indirect bone healing
Patient physiological state - nutrients, growth factors, age, diabetic, smoker

26
Q

How do these conditions feed into clinical management of fracture healing?

A

Pre-defined time-frame expectations e.g. most fractures heal ~6months

Pump up those with nutrients before procedures

Increased risks = diabetes, smoking

Children (pardiatric patients) heal 2x quicker than adults - follow-ups planned accordingly (like 1 week later, to ensure you target the window of opportunity to align a future displacement)

Lower limb fractures taking twice as long as upper limb fractures to heal

27
Q

What is Wolff’s law?

A

Bone, i.e. outside their fracture state, remodels based on external stimuli (forces placed upon the bone)

So in a child, the femur will heal bent due to body weight - remodelling occurs due to axial loading

Periosteum on the concave side will make more bone while on the convex side, bone will be resorbed

28
Q

What are some fracture healing complications?

Non-union VS Malunion

A

Non-union = failure of bone to heal within an expected time frame:

  • May be due to atrophy (usually result of physiological problems e.g. smoking, diabetes, malnutrition) = healing completely stopped with no Xray changes
    OR
  • Hypertrophic = too much movement causing callus healing = too much callus formed (on the sides of the bone called elephant foot) = does not unite to form a hard callus

Malunion = bone healing occurs but outside of the normal parameters of alignment - so bone healing is taking place in the wrong place

Names of different fracture healing complications include: malunion, atrophic non-union, hypertrophic non-union (horse hoof), hypertropic non-union (elephant foot), pseudoarthrosis

29
Q

What are the steps of fracture management?

A

Resuscitate = save the patient’s life, then worry about the fracture

Reduce = bring bone back together in an acceptable alignment so soft tissue is no longer being violated by jagged edge of broken bone = reduced pain and also prevents further blood loss

Rest = hold the fracture in position to prevent distortion or movement how fracture in great / acceptable position to prevent distortion or movement

Rehabilitate - get function back and avoid stiffness - prevent muscle atrophy during the time frame of bone healing = physiotherapy v. important

30
Q

What are the consequences of immobility?

A

Functional limitations = depending on where the injury is, cannot walk, cannot use an arm, etc.

Support needs = transport, catheters, daily needs from limitations

VTE (venous thromboembolism) prophylaxis

Required wider MDT support

31
Q

What are the conservative fracture management options?

A

PRICE - protect, rest, ice, compress, elevate

Non-operatively use circumferential, plaster or fibreglass casts
If an area cannot be cast - use a splint

Or use traction = important in long bones e.g. femur, humerus = sticky thing attached onto limb and weights attached to end hanging off = gravititation weight too - realigns the fracture

32
Q

Why are definitive (e.g. circumferential) casts not good?

A

Swelling - acute injuries tend to swell

Pushes against structures within body - blood flow can be compromised

Leads to compartmental syndrome

33
Q

What are surgical fracture management options?

A

MUA + K-wire = reduces with patient under anaesthesia = useful in children due to thick periosteums preventing fracture aligment from holding in place (displacement common)

ORIF = Open Reduction Internal Fixation

IM nail = intramedullary nails = useful for long bone fractures - insufficient soft tissue coverage for extramedullary methods but can be very dangerous since you can disrupt the physiology of a patient

External fixation =
- Mono/biplanar = sits within one or two planes = goes in from outside the skin - apply rods on the outside and build a construct that allows for stability of the fracture pattern = used often in open fractures where there is poor soft tissue coverage
OR
- Multiplanar = ring fixation = when other methods have failed and patient is non-compliant with intramedullary methods = use of computer tomography to say where to place the pins = multiplanar construct thats more stable

34
Q

How do you diagnose a fracture?

A

History and examination - tenderness / limb / pain / swelling

Obtain x-ray of affected region, ensure in at least 2 different planes

35
Q

How do approach orthopaedic X-rays?

A 
Projection = at least 2 views / planes
Patient details
Technical adequacy
Obvious abnormality
Systematic review of X-ray
Summarise
36
Q

What is important when checking patient details?

A

NHS number

2 people may have the same name

Y2 - BRS - MSK (10 decks)

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