O&T SC060: I Hurt My Arm: Dislocations And Fractures

Question 1

Function of bone

Answer 1

1. Support body / parts of body
2. Movement of body parts + Locomotion
3. Attachment of tendons + muscles
4. Protect internal organs

Question 2

Diagnosis of fracture

Answer 2

History:
1. Trauma (unless pathological fracture)
2. Pain

P/E:
1. Tenderness
2. Loss of movement
3. Weakness

Investigations:
1. X-ray
- 2 views (AP + Lateral)
- 2 occasions (recheck 1-2 weeks later: may reveal fracture line after bone ends resorption —> fracture gap slightly widen)
- 2 joints (proximal + distal)
- 2 limbs (for children since bones not yet fully ossified)

Question 3

Assessment of fracture

Answer 3

1. Bone
   - Rule of 2
2. Soft tissue
   - Always accompany fracture —> Open / Closed fracture
3. Neurovascular
   - e.g. Radial nerve lesion (Temporary palsy / Transected / Impinged) in Humeral shaft fracture —> Wrist + Finger drop

Question 4

How do fractures heal?

Answer 4

1. Direct healing
   - when a fracture is rigidly fixed (e.g. by plaster / immobilisation) —> all bones will heal if given long enough time
2. Indirect healing
   - axial realignment (in terms of length, rotation, alignment)
   - less rigid fixation
   - ***callus formation (in 2-3 months) in response to motion —> bone grow across fracture (natural healing)

Question 5

Principles of fracture treatment

Answer 5

1. Reduction (if necessary, some bones not require reduction e.g. toe fracture)
   - Open vs Closed
2. Immobilisation of fracture (NOT patient!)
   - Traction (past)
   - Plaster (Circumferential) / Bracing (aka Splint, not circumferential)
   - Internal fixation (plate (e.g. DHS) (good for more complex fractures) / intramedullary nail (good for long bone, shaft fracture))
   - External fixation (for open wound / quick stabilisation in unstable joint)
3. Rehabilitation always (Physiotherapy, Prosthetics)
   - ROM
   - Power

A fracture might not need to be fixed in order to heal, but need to ensure
1. Union takes place in proper anatomical position
2. Alleviate pain

Extra-articular / Diaphyseal (Shaft):
1. Good reduction (length, rotation, alignment) (NB: young kids can grow out of bone displacements)
2. Stable fixation / splinting

Intra-articular / Joint:
1. Anatomical reduction
2. **Rigid / Stable fixation (otherwise become unstable —> degeneration very quickly (in 1-2 years))
3. **Early joint motion

Goal:
1. Early **functional recovery with **uncomplicated fracture healing in ***good position
2. Importance of rehabilitation

Question 6

Indications for Internal fixation

Answer 6

1. Non-operative treatment likely to fail (e.g. in malunion, non-union etc.)
2. Fractures involving a joint (∵ need very good opposition of joints —> ORIF to prevent degeneration)
3. Pathological fractures (∵ bone may not heal due to the pathology)
4. Multiple fractures
5. Early function is desirable + beneficial (e.g. elderly hip fracture)

Question 7

Ankle fracture

Answer 7

• Reconstruct joint anatomically
• Early mobilisation

Question 8

Indications for External fixation

Answer 8

• Can be seen outside the limb
• Must be removed

Indications:
- Open fracture
- Multiple fractures (for quick stabilisation in unstable joint)