Management of specific fractures Flashcards
What is a fracture?
a discontinuity of bone
How do you describe fractures?
- Orientation: transverse, oblique, spiral, comminuted
- Location: epiphysis, metaphysis, dispahysis
- Displacement: displaced, undisplaced
- Skin penetration: open and closed
What are the different classification systems for fractures?
- 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
What does AO/OTA classification consider?
- the bone
- where the fracture is
- the type
- the group
- the subgroup
What is primary (or direct) bone healing?
- Intramembranous healing, occurs via Haversian remodeling
- Little (<500mm) or no gap
- Slow process
- Cutter cone concept – like bone remodelling
What is secondary (or indirect) bone healing?
- Endochondral healing, involves responses in the periosteum and external soft tissues
- Fast process resulting in callus formation (fibrocartilage)
What are the steps for fracture healing?
- Haematoma formation
- Soft callus formation
- Hard callus formation
- Remodelling
What happens in haematoma formation?
- Damaged blood vessels bleed forming a haematoma.
2. Neutrophils release cytokines signaling macrophage recruitment
What happens in soft callus formation?
Collagen and fibrocartilage bridge the fracture site and new blood vessels form
What happens in hard callus formation?
Osteoblasts, brought in by new blood vessels, mineralise the fibrocartilage to produce woven bone
What happens in remodelling?
Months to years after injury osteoclasts remove woven bone and osteoblasts laid down as ordered lamellar bone
What are the pre-requisites for fracture healing?
- Minimal fracture gap
- No movement if direct (primary) bony healing or some movement if indirect (secondary) bone healing
- Patient physiological state – nutrients, growth factors, age, diabetic, smoker
What is Wolff’s law in bone remodelling?
bone adapts to forces placed upon it by remodelling and growing in response to these external stimuli
What happens in a child with bone remodelling?
if the femur heals bent, axial loading should be direct, with remodelling occurring through axial loading
What does the periosteum do in bone remodelling?
Periosteum on the concave side will make more bone while on the convex side, bone will be resorbed
How long can it take for fractures to heal?
- Fracture healing can be expected within a pre-defined timeframe, usually ~6 months, with some exceptions:
- Lower limb fractures taking twice as long as upper limb fractures to heal
- Paediatric fractures heal twice as quickly as adults
What is non-union fracture healing?
- Failure of bone healing within an expected time frame
- Atrophic – healing completely stopped with no XR changes, often physiological
- Hypertrophic – too much movement, causing callus healing
What is malunion fracture healing?
•Bone healing occurs but outside of the normal parameters of alignment
What are the steps in fracture management?
- Resuscitate - save the patients life, then worry about the fracture!!
- Reduce – bring the bone back together in an acceptable alignment
- Rest – hold the fracture in position to prevent distortion or movement
- Rehabilitate - get function back and avoid stiffness
- Think about period of immobility:
•functional limitations and support needed
•wider MDT
•VTE prophylaxis
What is some conservative fracture management?
- Rest, ice, elevation
- Plaster, fibreglass cast or split
- Traction - skin/bone
What is some surgical fracture management?
- External fixation:
- Mono/biplanar
- Multiplanar - ring - ORIF
- IM Nail
- MUA + K-wire
- Arthroplasty:
- Hemiarthroplasty
- total joint replacement
How do you diagnose a fracture?
- History and examination – tenderness/limb pain/swelling
* Obtain X-ray of affected region, ensure in at least two planes
What is the presentation of shoulder dislocation?
- Variable hx but often direct trauma
- Pain
- Restricted movement
- Loss of normal shoulder contour
What is the clinical examination of shoulder dislocation?
•Assess neurovascular status – axillary nerve
What are the investigations for 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
What is an anterior shoulder dislocation?
- Commonest type; ~90%
- Bimodal distribution
- Humeral head not overlying glenoid
What is a posterior shoulder dislocation?
- Rare; ~6%
- Associated with seizures/shocks
- ‘Lightbulb sign’ on XR
What is an inferior dislocation?
- Rare; <2-4%
- Arm held abducted above head
- Humeral head not articulating correctly
What is the management of shoulder dislocation?
- Vigorous manipulation or twisting manipulation should be avoided to avoid fractures
- Safest method is to use traction-counter traction +/- gentle internal rotation to disimpact humeral head
- Ensure adequate patient relaxation – Entonox; benzodiazepines
- If alone could use Stimson method
- Undertake in safe environment, especially in elderly e.g. resus, ask for senior/anaesthetic support early on if necessary
What are neurovascular complications for shoulder dislocation?
- At time of presentation due to trauma sustained e.g. axillary nerve injury
- Iatrogenic as a result of reduction manoeuvre
- Delayed onset due to an evolving haematoma post injury/manipulation
What damage to the labrum and/or glenoid can happen in shoulder dislocations?
•Bankart lesion – soft or bony
What damage to the humeral head can happen in shoulder dislocations?
•Hill-Sachs lesion
What recurrent lesions can happen in shoulder dislocations?
•Lifetime risk increases i.e. younger the patient, the greater the risk of repeat dislocation
What is the presentation of a proximal humerus fracture?
- Fall onto an outstretched hand
* Typically in the elderly or those with osteoporosis
What are the investigations for a proximal humerus fracture?
- Plain x-rays
* CT if concern over articular involvement or high degrees of comminution
What are the classification for a proximal humerus fracture?
(described by Neer)
•Surgical neck fractures (2 parts)
•Avulsion fractures of GT (2 parts)
•Comminuted fractures (>3 parts)
What are 2 types of 2 part fractures?
- surgical neck fracture
- greater tubersotiy fracture
What is a collar cuff proximal humerus fracture management?
- 2-part fracture, minimally displaced
- High surgical risk / comorbidities
- Compliant with post-operative care
What is orif - plate and screws for proximal humerus fracture management?
Any fracture with displacement i.e. 2-part+ but not highly comminuted
What is arthroplasty for proximal humerus fracture management?
Humeral head fracture with large displacement and thus high risk of non-union
What is reverse arthroplasty for proximal humerus fracture management?
- Unrepairable rotator cuff
- Previous unsuccessful shoulder replacement
- Complex fracture/chronic shoulder dislocation
What is the presentation of a distal radius fracture?
- Very common, bimodal distribution
- Often present with clear mechanism of falling onto affected area, swelling and visible deformity
- Commonest presentation is dorsal displacement due to fall on outstretched hand
What are the investigations of a distal radius fracture?
- Plain radiographs – PA/lateral views to assess fracture type
- Thorough clinical examination to avoid concomitant injuries
What are extra-articular distal radius fractures?
- Dorsal angulation: colles fracture
2. Volar angulation: smith fracture
What are intra-articular distal radius fractures?
- Dorsal angulation: dorsal barton
2. Volar angulation: volar/reverse barton
When is a cast/splint used in distal radius fracture management?
- Temporary treatment for any distal radius fracture – reduction of fracture and placement into cast until definitive fixation
- Definitive if minimally displaced, extra articular fracture
When is a MUA and K wire used in distal radius fracture management?
- 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
When is a ORIF used in distal radius fracture management?
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 the goal of operative management in distal radius fracture management?
- Restore articular surface congruency
- Radial inclination: 22 degrees
- Radial height: 11mm
- Volar tilt: 11 degrees
What is the first row of carpal bones lateral to medial?
- Scaphoid
- Lunate
- Triquetrum
- Pisiform
What is the second row of carpal bones lateral to medial?
- Trapezium
- Trapezoid
- Capitate
- Hamate
- If struggling remember ‘trapezium under thumb’
What is the presentation of scaphoid fracture?
- Commonest carpal bone injury, usually young patients
* Typically a fall backwards onto their hand, but think in any distal radius
What is the clinical examination of scaphoid fracture?
- Anyone with FOOSH or with distal radius fracture should have scaphoid exam
- Palpation of anatomical snuffbox, scaphoid tubercle or telescoping of thumb
What investigations are carried out in a scaphoid fracture?
- Plain radiographs difficult to assess – request scaphoid views
- Delayed radiographs if normal but clinical suspicion
- Consider CT/MRI if still concerned
What is the management of scaphoid fracture displaced?
- Retrograde blood supply means high risk of non-union/AVN of proximal pole
- Most displaced fractures disrupt this and therefore ORIF usually undertaken
What is the management of scaphoid fracture undisplaced?
- Can be treated conservatively in a scaphoid cast
2. Length of time to heal can be long, some surgeons opt for fixation as a result
