(msk) management of specific fractures Flashcards
what are the general principles of trauma?
ATLS (advance trauma life support)
reduce
hold
rehabilitate (move)
e.g. response to emergency broken bones
what are the general principles of orthopaedics?
history
examination
(look, feel, move)
investigations
e.g. response to arthritis
what are the clinical signs of a fracture?
pain
swelling
crepitus (crunching bw broken bones)
deformity
adjacent structural injury (nerves, vessels, ligaments, tendons)
which radiological investigations can be carried out for a fracture?
radiograph/X-ray = most common
bone scan
CT scan
MRI scan
(latter 3 are more expensive)
how is a fracture radiograph described?
1) LOCATION - which bone and which part of bone? (diaphysis, metaphysis, epiphysis)
2) PIECES - simple/multifragmentary?
3) PATTERN - transverse/oblique/spiral
4) EXTENT of movement - displaced/undisplaced?
5) DIRECTION of movement - translated/angulated?
6) X/Y/Z plane
what are the ways in which a fracture can be translated?
X = medial/lateral Y = proximal/distal Z = anterior/posterior
what are the ways in which a fracture can be angulated?
X = valgus/varus Y = internal/external rotation Z = dorsal/volar
wich plane of motion does valgus/varus angulation take place?
coronal plane
wich plane of motion does internal/external rotation angulation take place?
axial plane
which plane of motion does dorsal/volar angulation take place?
sagittal plane
what are the four steps to fracture healing?
bleeding
inflammation
proliferation (i.e. soft and then hard callus formation)
remodelling
briefly explain the process of fracture healing
bone breaks
haematoma formation brings inflammatory mediators, cytokines, neutrophils & macrophages with it
= induce inflammation
fibroblasts, chondroblasts, osteoblasts fill the region and form a soft callus made primarily of cartilage (type II collagen)
cartilage eventually replaced by bone gradually, forming a hard callus (type I collagen)
hard callus responds to activity, external forces, functional demands and growth + excess bone is removed
why is haematoma formation important in fracture healing?
bleeding brings with inflammatory mediators, cytokines, neutrophils and macrophages with it to stimulate inflammation
which cells are responsible for soft callus formation?
mesenchymal stem cells differentiate into the fibroblasts, chondroblasts, and osteoblasts responsible for soft callus formation
differentiate between soft and hard callus
soft callus is made up of cartilage primarily (type II collagen)
hard callus is made up of bone primarily (type I collagen)
why don’t displaced fractures heal very well and how can this be overcome?
the distance between the fractured portions of bone is much larger and so it is much harder for soft callus to form
= displaced fractures need to be reduced
how does soft callus become hard callus?
when the cartilage of soft callus is replaced by bone via intramembranous or endochondral ossification = hard callus formation
how does a fractured bone gradually return to its original shape?
when the hard callus formed is placed under environmental stresses and external forces, the bone is remodelled
excess bone is removed and the fracture site is smoothed and sculpted until it looks much more normal
how long does each stage of fracture healing take?
tissue destruction & haematoma formation
inflammation (1 week)
soft callus formation (week 2-3)
hard callus formation (week 4-12)
remodelling (months to years)
what is Wolff’s law?
the idea that bone grows and remodels in response to the forces that are placed on it
in each stage of fracture healing, what type of tissue is present?
bleeding = haematoma
inflammation = granulation tissue
soft callus formation = fibrocartilagenous tissue
hard callus = bone tissue
what are the two types of bone healing?
primary bone healing = intramembranous healing
secondary bone healing = endochondral healing
what is intramembranous (primary) bone healing?
involves a direct attempt by cortex to re-establish itself after a fracture WITHOUT formation of a fracture callus
(response only in the bone)
what is endochondral (secondary) bone healing?
classical stages of injury: bleeding, inflammation, soft & hard callus formation, remodelling
(responses in the periosteum & soft tissue)
when does intramembranous (primary) bone healing take place?
when the fracture edges are closely approximated and held there without much motion
e.g. after surgical plating
when does endochondral (secondary) bone healing take place?
when the ends of the fractured bones are near enough to heal but not perfectly opposed, or when there is some motion at the fracture site
differentiate between primary and secondary bone healing
primary intramembranous healing =
- absolute stability
- involves a direct attempt by cortex to re-establish itself after interruption WITHOUT formation of a periosteal fracture callus
secondary endochondral healing =
- relative stability
- classical stages of injury: bleeding, inflammation, soft & hard callus formation, remodelling
when are signs of healing visible on an X-ray?
approx 7-10 days after fracture
what happens when the fracture edges are too far apart or if there is too much motion at the fracture site?
unless the fracture is reduced, the fracture will not heal at all
differentiate between primary and secondary bone healing
primary bone healing =
- absolute stability
- fracture edges closely approximated
- little/no movement at the site of fracture
- no fracture callus formation
secondary bone healing =
- relative stability
- fracture edges not as closely approximated
- some movement at the site of fracture
- fracture callus formation occurs
how long does fracture healing take?
usually 3-12 weeks depending on site of fracture
how long do phalanges normally take to heal?
approx 3 weeks
how long do metacarpals normally take to heal?
approx 4-6 weeks
how long does the distal radius normally take to heal?
approx 4-6 weeks
how long does the forearm normally take to heal?
approx 8-10 weeks
how long does the tibia normally take to heal?
approx 10 weeks
how long does the femur normally take to heal?
approx 12 weeks
what do bone healing times depend on?
age, comorbidities etc
what heals faster: upper or lower limb?
usually the upper limb heals faster than the lower limb
hands > feet
what are the three stages of fracture management?
reduce (closed/open)
hold (metal/no metal)
rehabilitate (move, use, physiotherapy, strengthen/weight-bear)
what is fracture reduction?
realignment of bone to prevent deformities
what are the types of fracture reduction?
open reduction
closed reduction
what are the types of closed reduction?
manipulation (pulling on skin)
traction = skin traction OR skeletal traction (using pins)
what are the types of open reduction?
mini-incision
full exposure
what is fracture holding?
holding the fracture either with or without metal
what are the types of fracture holding?
fixation = with metal
closed = without metal
what are the types of closed fracture holding?
plaster
traction = skin, skeletal
what is fracture fixation?
stabilising the fracture using metal
what is internal fixation?
stabilising the fracture with metal under the skin
what is external fixation?
stabilising the fracture with metal outside the skin
what are the types of internal fixation?
intramedullary fixation
extramedullary fixation
what are the types of external fixation?
monoplanar
multiplanar
define intramedullary fixation
stabilising the fracture by placing metal in the canal of the bone
define extramedullary fixation
stabilising the fracture by placing metal on the cortex/surface of the bone
give examples of intramedullary fixation
pins, nails
give examples of extramedullary fixation
plates, screws, pins
what does fracture rehabilitation include?
use (pain-relief, retrain)
move
physiotherapy
strengthen
weight-bear (especially if lower limb)
define general and specific fracture complications
general = complications away from the site of fracture
specific = complications at the site of fracture
how can fracture complications be classified based on time?
immediate = within first 24 hours of fracture
early = within 30 days of fracture
late = after first 30 days of fracture
give examples of general fracture complications
fat embolus
deep vein thrombosis
infection
prolonged immobility can cause chest infections, sores, UTIs
give examples of specific fracture complications
neurovascular injury (e.g. avascular necrosis)
muscle/tendon injury (e.g. compartment syndrome)
local infection
non-union/malunion
degenerative changes
reflex sympathetic dystrophy
list factors that affect tissue healing
mechanical environment:
- movement
- surrounding, external forces
biological environment:
- blood supply
- immune function
- infection present?
- nutrition
list factors that affect tissue healing
mechanical:
- movement
- surrounding, external forces
biological:
- blood supply
- immune function
- infection present?
- nutrition
what are the main causes of a neck of femur fracture?
osteoporosis (elderly patients)
trauma (younger patients)
what do we want to elicit in a history from a NoF fracture patient?
age
comorbidities
pre-injury mobility (independence, walking status)
social history (physical home environment, relatives, drug/alcohol, lifestyle)
in NoF fractures, how are the boundaries of intra/extracapsular fractures different anteriorly and posteriorly?
anteriorly = line separating the capsules in on the intertrochanteric line so all of the femoral neck anteriorly is intracapsular
posteriorly = line separating the capsules is approx the midpoint of the femoral neck so the upper femoral neck is intracapsular and everything below is extracapsular
(use posterior line more often to determine intra/extracapsular!)
why are intracapsular NoF fractures more dangerous?
within the capsule
= more significant blood supply that provides blood to the femoral head
so intracapsular fracture can impair blood supply to a greater extent (increased risk of avascular necrosis of femoral head)
what is avascular necrosis?
bone death due to lack of blood supply
increased risk of this in intracapsular NoF fractures
how is an extracapsular NoF fracture managed (fix/replace) and why?
internal fixation (w screws/plate/pins) = dynamic hip screw
as fracture is extracapsular, minimal risk to the blood supply to the femoral head + minimal risk of avascular necrosis
how is an intracapsular NoF fracture managed (fix/replace) and why?
if non-displaced = risk of avascular necrosis still relatively lower as most of the blood supply is intact so = internal fixation
if displaced = risk of avascular necrosis much higher as most of the blood supply is impaired so = hip replacement
(replace in older patients, fix in young)
what are the two ways in which a displaced intracapsular fracture is replaced?
1) total arthroplasty
2) hemiarthroplasty
what determines if you carry out a total arthroplasty or a hemiarthroplasty?
level of mobility of a patient + comorbidities
i.e. more mobile + less comorbid the patient is, more likely to do a total arthroplasty
what is a total arthroplasty?
complete replacement of the acetabulum and the femoral head with a prosthesis
what is a hemi-arthroplasty?
replacement of only the femoral head with a prosthesis
acetabulum is left as bone
in which category of patients is a total arthroplasty indicated?
1) more mobile + independent
2) fewer/no comorbidities
in which category of patients is a hemiarthroplasty indicated?
1) less mobile
2) multiple comorbidities
how is an undisplaced intracapsular NoF fracture managed?
internal fixation with screws
how is a displaced intracapsular NoF fracture managed?
if young + fit (<55)
= reduce + internal fixation w screws
if older (>65) = depending on mobility, total or hemiarthroplasty
how do patients with a dislocated shoulder present?
pain, swelling
restricted movement
loss of normal shoulder contour
(most commonly caused by trauma)
what must you assess when examining a dislocated shoulder?
neurovascular status (e.g. axillary nerve)
+ other surrounding structures like the nerve, muscle, tendons, ligaments and vessels
what is the primary investigation that is done for a dislocated shoulder?
plain X-ray (AP)
can also do a scapular Y-view or a modified axillary X-ray
how is a shoulder dislocation managed?
1) avoid aggressive/vigorous twisting manipulations as these can risk fractures
2) ensure patient is sufficiently relaxed (administer bendodiazepines, entonox)
3) carry out reduction is a safe environment w adequate support
- safest method: traction-counter traction method w gentle internal rotation
- if alone, then Stimson method can be used
what three things must you ensure before reducing a dislocated shoulder?
1) avoid aggressive/vigorous twisting manipulations as these can risk fractures
2) ensure patient is sufficiently relaxed (administer bendodiazepines, entonox)
3) carry out reduction is a safe environment w adequate support
which shoulder reduction techniques are used primarily to manage a shoulder dislocation?
safest method: traction-counter traction method w gentle internal rotation
BUT
if alone, then Stimson method can be used
what are two possible complications of shoulder dislocations?
1) Hill-Sachs defect
2) Bankart lesions
what is a Hill-Sachs defect?
when the shoulder becomes anteriorly dislocated, the humerus can push onto the glenoid bone, creating an indent/impression on the humoral head = Hill-Sachs defect
what is a Bankart lesion?
when the shoulder is anteriorly dislocated, the movement of the humerus causes
1) a tear in the glenoid labrum = labral tear/Bankart lesion
2) a portion of the glenoid bone to be smashed off the main segment = bony Bankart lesion
differentiate between a Bankart lesion and a bony Bankart lesion
a Bankart lesion occurs when the humerus dislocates and tears part of the glenoid labrum
a bony Bankart lesion occurs when the dislocation of the humerus smashes a portion of the glenoid bone off the main segment
why are Hill-Sachs defect and Bankart lesions problematic and how can they be addressed?
the compromise the stability of the glenohumeral shoulder joint, facilitating shoulder dislocations
= recurrent dislocations occur, which needs to be corrected by surgery
differentiate between extra-articular and intra-articular fractures
extra-articular = fracture line does NOT extend into the joint
intra-articular = fracture line does extend into the joint; more serious
what are the three ways in which a fracture of the distal radius is managed?
1) cast/splint
2) K-wire or mUA
3) ORIF
when is a plaster indicated for a distal radius fracture?
minimally displaced, fairly stable, extra-articular fracture
plaster still used to hold fracture after reduction and before fixation
when is K-wire fixation indicated for a distal radius fracture?
displaced, unstable, extra-articular fractures
what is ORIF?
open reduction and internal fixation (with plate/screws)
when is ORIF with plate or screws indicated for a distal radius fracture?
displaced, unstable intra-articular fractures OR extra-articular where K-wires cannot be used
what are K-wires?
Kirschner wires
thin wires, which are pushed or drilled into the bone across the break to keep both sides stable while healing goes on
(wires removed in the post-op clinic)
what is MUA?
manipulation under anaesthetic
e.g. anaesthetic is usually given for K-wire fixation
what is a lipohemarthrosis?
results from an intra-articular fracture with escape of fat and blood from the bone marrow into the joint
(frequently seen in tibial plateau/distal femoral fractures)
what is lipohemarthrosis pathognomonic of?
fracture of a joint nearby
what can cause a tibial plateau fracture?
any extreme valgus/varus force OR axial loading across the knee
what can impaction of the femoral condyles cause?
can cause the comparatively soft bone of the tibial plateau to depress or split
which injuries can occur alongside a tibial plateau fracture?
ligamentous or meniscal injury
when are tibial plateau fractures managed non-operatively?
when the fracture is undisplaced/minimally displaced with a good joint line congruency
how are tibial plateau fractures managed operatively?
1) internal fixation with screws and plates to restore joint
2) may need bone graft or cement to prevent further depression after fixation
why may a bone graft be needed after internal fixation of a tibial plateau fracture?
the bone of the tibial plateau is relatively soft
= to prevent further depression of the plateau that can be caused by impaction of the femoral condyles, bone graft is placed
what is the non-operative management of an ankle fracture?
1) non weight-bearing below the knee for 6-8 weeks in a cast
2) walking boot
3) physiotherapy to improve range of motion/stiffness
what are the classifications of ankle fractures?
Weber A = below syndesmosis so thought to be stable
Weber B = at the level of the syndesmosis
Weber C = fibular fracture above the level of the syndesmosis therefore unstable
which ankle structure is ankle fracture categorisation (Weber system) based on?
distal tibiofibular syndesmosis
below = weber A; at the level = weber B; above = weber C
what is the operative management of an ankle fracture?
1) ankles can swell considerably due to fracture = strict elevation
2) ORIF + syndesmosis repair with screws or tightrope technique
(syndesmosis screws can be left in situ and broken and removed later)
how can ankle swelling due to an ankle fracture be addressed?
strict elevation
= keeping your foot raised helps decrease pain and swelling
how can ankle swelling due to an ankle fracture be addressed?
strict elevation
= keeping your foot raised helps decrease pain and swelling
