MSK - Management of Specific Fractures Flashcards
What are the main clinical signs of a fracture?
- Pain
- Swelling
- Crepitus
- Deformity
- Adjacent structural injury: Nerves/vessels/ligament/tendons
What is crepitus?
A grating or crackling sound due to the friction between bone + bone or bone + cartilage
What are the different ways of imaging a fracture?
Radiograph (X-ray)
Bone scan
CT scan
MRI scan
Name the modality of this imaging.
Radiograph (X-ray)
Name the modality of this imaging.
Radiograph (X-ray)
Name the modality of this imaging.
CT scan
Name the modality of this imaging.
MRI scan
Name the modality of this imaging.
Bone scan
How do you describe a fracture on a radiograph? What are you looking for?
- Location: which bone and which part of bone?
- Pieces: simple/multifragmentary?
- Pattern: transverse/oblique/spiral
- Displaced/undisplaced?
- Translated/angulated?
- X/Y/Zplane
What are the main patterns of fractures?
What are the 2 types of displacement?
Translated
Angulated
What are the different planes of translation?
What are the different planes of angulation?
What are the 2 main types of bone healing?
Intermembranous healing
Endochondral healing
What are the general principles of tissue healing? What cells are involved?
Bleeding (blood)
Inflammation (neutrophils, macrophages)
New tissue formation (fibroblasts, osteoblasts, chondroblasts)
Remodelling (macrophages, osteoclasts, osteoblasts)
What are the 3 main steps of fracture healing?
Inflammation
Repair
Remodelling
What is involved in the inflammation stage of fracture healing?
Haematoma formation
Release of cytokines
Granulation tissue and blood vessel formation
What is involved in the repair phase of fracture healing?
Soft callus formation (Type II Collagen - Cartilage)
Converted to Hard callus (Type I Collagen - Bone)
What is involved in the remodelling phase of fracture healing?
Callus responds to activity, external forces, 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 upon it
What is primary bone healing?
Intramembranous healing
What is secondary bone healing?
Endochondral healing
What are the features of intramembranous healing?
Absolute stability
Direct to woven bone
What are the features of endochondral healing
Involves responses in the periosteum and external soft tissue
Relative stability
More callus
What is the average fracture healing time for the phalanges?
3 weeks
What is the average fracture healing time for metacarpals?
4-6 weeks
What is the average healing time for distal radius?
4-6 weeks
What is the average healing time for a fracture in the forearm?
8-10 weeks
What is the average fracture healing time for tibia?
10 weeks
What is the average fracture healing time for the femur?
12 weeks
What are the general steps to managing a fracture?
Reduce
Hold
Rehabilitate
What are the different options and pathways possible in reduction?
What are the different options and pathways involved in the ‘hold’?
What are the different options and pathways involved in fixation?
What are the different options and pathways in rehabilitation?
What type of fixation is this?
Internal Extramedullary
What type of fixation is this?
Plaster (external fixation)
What type of fixation is this?
External monoplanar
What type of fixation is this?
External multiplanar
What type of fixation is this?
Internal intramedullary
What are some general fracture complications?
Fat embolus
DVT
Infection
Prolonged immobility (UTI, chest infections, sores)
What are the specific fracture complications at the site of fracture?
Neurovascular injury Muscle / tendon injury Non-union / mal-union Local infection Degenerative change (intra-articular) Reflex sympathetic dystrophy
What factors in the mechanical environment affect tissue healing?
Movement
Forces
What factors in the biological environment affect tissue healing?
Blood supply
Immune function
Infection
Nutrition
What are common causes of fractured neck of femur?
Osteoporosis (older)
Trauma (younger)
Combination of both
What do you look for in the history in a neck of femur fracture?
Age
Comorbidities (resp, cvd, diabetes, cancer)
Pre-injury mobility independent, shopping, walking, sports
Social history (relatives, stairs, alcohol history)
Name these parts of the femur.
A = head of femur B = neck of femur C = lesser trochanter D = greater trochanter
Name the structures here.
Identify whether these fractures are intracapsular or extra capsular.
Which of these fractures is displaced?
Radiograph 2
What is the risk of compromised blood supply and AVN with extracapsular fractures?
Minimal risk to blood supply and AVN
How do you treat an extracapsular NoF fracture?
Fix with plate and screws (dynamic hip screw)
Usually doesn’t need replacement
What is the risk of compromising blood supply and AVN with intracapsular fractures?
Undisplaced = less risk to blood supply
If displaced = higher risk of compromising blood supply, 25-30% risk of AVN
How do you treat a displaced intracapsular fracture?
Replace in older patients (age > 55)
Fix in young
How do you treat an undisplaced intracapsular NoF fracture?
Fix with screws
What are the 2 ways in which you can do a hip replacement?
Total hip replacement
Hemiarthroplasty
What is a total hip replacement?
Replace the femoral head and the acetabulum with prostheses
What is a hemiarthroplasty?
Replace just the femoral head (however metal head will rub against the socket)
When is a total hip replacement preferred over a hemiarthroplasty?
Patients walk more than a mile a day
Independent
Minimal comorbidities
When is a hemiarthroplasty preferred over a total hip replacement?
Patients with :
Low mobility
Multiple comorbidities
What is the general blueprint to treating any patient that has a NoF fracture?
What does this X-ray show?
How do those with a shoulder dislocation normally present?
Variable history but often direct trauma
Pain
Restricted movement
Loss of normal shoulder contour
What should be clinically examined in a shoulder dislocation?
Assess neurovascular status - axillary nerve
What investigations can be done for a shoulder dislocation?
X-ray prior to any manipulation
Identify the fracture
Take scapular Y-view / modified axillary in addition to AP
How do you manage a shoulder dislocation?
What are the possible complications of a shoulder dislocation?
Hill-Sachs defect = humeral head ‘collides’ with the anterior part of the glenoid, causing a lesion
Bankart lesion = some of the glenoid bone is broken off with the anterior labrum
What do these x-rays show?
What are the 3 ways in which you manage a distal radius fracture?
Cast/splint
MUA + K-wire
ORIF
When is a cast / splint used to manage a distal radius fracture? What is this method?
Temporary treatment for any distal radius fracture
Reduction of fracture and placement into cast until definitive fixation
Used if minimally displaced, extra-articular fracture
What is the MUA + K-wire method and when is it used to manage a distal radius fracture?
MUA in theatre with K-wire fixation, wires are removed in clinic post-op
Used when fractures are extra-articulated but have instability, particularly in children
What is ORIF and when is it used to manage a distal radius fracture?
ORIF = open reduction + internal fixation with plate and screws
Used for any displaced, unstable fractures not suitable for K-wires, or with any intra-articular involvement
What does this x-ray show?
What does this x-ray show?
What is the pathophysiology of a tibial plateau fracture?
What other injuries are common with tibial plateau fracture?
Concomitant ligamentous or meniscal injury
When do you manage a tibial plateau fracture non-operatively?
Only truly undisplaced fractures with good joint line congruency assed on CT or high fidelity imaging
How do you manage a tibial plateau fracture operatively?
Restoration of articular surface using combination of plate + screws
Bone graft or cement may be necessary to prevent further depression after fixation
What does this x-ray show?
What are the Weber classifications of ankle fractures?
Weber A
Weber B
Weber C
What is a Weber A ankle fracture?
describes a fracture of the lateral malleolus distal to the syndesmosis (the connection between the distal ends of the tibia and fibula)
- Below the level of the tibial plafond (syndesmosis)
- Tibiofibular syndesmosis intact
- Deltoid ligament intact
- Occasional oblique or vertical medial malleolus fracture
What is a Weber B ankle fracture?
fracture at the level of the tibial plafond (syndesmosis). Fracture of the fibula at the level of the syndesmosis.
- At the level of the ankle joint, extending proximally in an oblique fashion up the fibula
- Tibiofibular syndesmosis intact or only partially torn, but no widening of the distal tibiofibular articulation
- Medial malleolus may be fractured or deltoid ligament may be torn
What is a Weber C fracture?
fracture proximal to the level of the tibial plafond and often have an associated syndesmotic injury
- Above the level of the ankle joint
- Tibiofibular syndesmosis injured with widening of the distal tibiofibular articulation
- Medial malleolus fracture or deltoid ligament injury may be present.
What is the non-operative manage t for ankle fracture?
Non-weight bearing, below the knew cast for 6-8 weeks
Can transfer to walking boot and then physiotherapy to improve range of motion and stiffness from joint isolation
When is the non-operative management for an ankle fracture used?
Weber A i.e. below syndesmosis and therefore thought to be stable
Weber B is no evidence of instability (no medial / posterior malleolus fracture and talar shift)
What is the operative management for an ankle fracture?
Soft tissue dependent - patients need strict elevation as injuries often swell considerably
ORIF +/- syndesmosis repair using 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
When is the operative management for ankle fracture used?
Weber B (unstable fracture - talar shift/medial or posterior malleoli fractures) Weber C (very unstable so necessary )
