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Y6 Senior Surgery > Ortho fractures > Flashcards

Ortho fractures Flashcards

1
Q

What are the ottawa rules

A

used to determine need for X ray

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2
Q

What are ottawa rules used for

A

knee and ankle

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3
Q

what are the ottawa knee rules

A

radiograph the knee if PAIN +:

  • >55yo
  • point tendrnss at fibular heead
  • point tendrness at patella
  • inability to flex knee at 90 degrees
  • inability to bear weight
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4
Q

What are the ottawa ankle rules

A

Ankle PAIN +

  • inability to weight bear
  • point tenderness at posterior edge or lateral / medial malleolus

MIDFOOT PAIN +

  • inability to weight bear
  • point tenderness at navicular
  • point tenderness at 5th metatarsal
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5
Q

What are bones made up of

A

cells (osteoblasts, osteoclasts, osteocytes, OPC)
matrix (osteoid 40%, inorganic 60%)

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6
Q

what are the two types of bone?

A

WOVEN: disorganised bone that forms embryonic skeleton and fracture callus

LAMELLAR bone: mature bone. either cortical or cancellous

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7
Q

What are types of bone formation

A

intramembranous ossifiication (during embryonic development)

endochondral ossification (mesenchyme > cartilage > bone)

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8
Q

what types of fracture can you have

A

Traumatic
Stress
Pathological

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9
Q

What is a stress fracture due to

A

bone fatigue due to repetitive strain

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10
Q

give a common example of stress fracture

A

foot fracture in marathon runner (2nd metatarsal)

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11
Q

what are pathological fractures due to

A

weakened bone- normal forces on diseased bone can cause a fracture

  • local (tumours)
  • general (osteoporosis, cushing’s, paget’s)
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12
Q

what radiographs do you need to get if suspecting a fracture

A

AP and lateral
Need image of joint above and joint below

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13
Q

What pattern of fracture can you have

A

COMPLETE
Transverse
Oblique
Spiral
Comminuted

INCOMPLETE
Grenstick
Buckle

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14
Q

What is a transverse fracture

A

fracture perpendicular to long axis of bone

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15
Q

What is an oblique fracture

A

fracture oblique (approx 45 degrees) to long axis of bone

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16
Q

what is a spiral fracture

A

helical fracture path in diaphysis of long bone

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17
Q

what is a comminuted fracture

A

bone is fractured in MORE THAN TWO parts

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18
Q

What ia greenstick fracture

A

cortex is broken on one side only

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19
Q

what is a buckle fracture and where does it usually happen

A

Cortex is buckled
usually in distal radius

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20
Q

What are the three stages of fracture healing

A
  1. Reactive phase (<48hours): bleeding into fracture site > haematoma > inflammation
  2. Reparative phase ( 2 days - 2 weeks): proliferation of osteoblasts and fibroblasts > callous formation. Consolidation of woven bone into lamellar bone
  3. Remodelling (may take years): according to wolff’s law
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21
Q

What is the outline to describe a fracture

A

PAIDS

Pattern, pieces

Anatomical location

Intraarticular / extraartic

Displacement

Soft tissues

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22
Q

what do you ned to say for displacement

A

TARI:
Translation
Angulation
Rotation
Impaction

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23
Q

What can you say for translation=?

A

DIRECTION: of distal part relative to proximal (anterior/post, lateral/medial, proximal/distal)

AMOUNT: measurement or percentage widthg

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24
Q

what can you say for angulatioon

A

the angulation of the distal part relative to proximal
(anterior/posterior tilt, varus/valgus)

in DEGREES

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25
Q

what can you say for rotation

A

Rotation (internal, external)

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26
Q

what can you say for impaction

A

if any shortening has opccurred

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27
Q

what can you say for soft tissues

A

Open/closed
Neurovascular status
Compartment synndrome

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28
Q

What are the 4 Rs of fracture management

A

resuscitation
reduction
restriction
rehabilitation

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29
Q

What do you need to do for resuscitation

A

ATLS trauma assessed in primary survey; secondary survey addresses fractures
Assess NEUROVASCULAR STATUS, look for dilocation
Stabilise BEFORE imagig (reduce and splint, address pain,)

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30
Q

What are the 6As for ope n fractures

A

Analgesia
Assess NEUROVSC status, soft tissues
Alignment (align fracture and splint)
Antisepsis (wound swab, irrigate, betadine)
Antitetanus
Antibioticss

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31
Q

What classification and guidelines can you use for open fractures?

A

Gustilo classification
BOAST guidelines

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32
Q

What do you need to know for reduction of fractures

A

ALL displaced fractures need to be reduced
unlless there is no effect onn the outcome (e.g. ribs)

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33
Q

How do you reduce fractureqs

A

CLOSED (manipulation or traction)

OPEN

consider LA / GA

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34
Q

How do you restrict a fracture

A

Non-operative: non rigid sling, bracing
Operative:
- external fixation (fragments helld topgether via pins / wires connected to external frame)
- internal fix (intra/extramedullary - pins, plates, screw, IM nails)

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35
Q

what are indications for external fixation

A
  • open fractures
  • soft tissue loss
  • burns
  • complex periarticular fractures
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36
Q

what is the biggest risk of externall fixation

A

risk of pinsite infections

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37
Q

why is rehabilitation important

A
  • immobility reduces muscle and bone mass, causes joint stiffness
  • need to maximise mobility of uninjured imbs
  • reduces risk of further morbidity
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38
Q

what are methods of rehav

A
  • physio
  • OT
  • social services (meals on wheels, home help)
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39
Q

how can you classify general complications to fracture surgery

A 
anaesthetic (anaphylaxis, damage to teeth/tarynx, aspiration) 
intraop (bleeding, damage to local structures, treatment failure) 
early postop (infection SSI; other infection e.g. UTI, VTE) 
late postop (scarring, loss of function/degeneration, neuropathy/pain)
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40
Q

what are complications specific to fractyures

A

intraop: neurovascualr / visceral damage

early postop: infection (esp with InFix), compartment syndrome, ARDS

late postop: nonunion, avasciular necrosis, growth disturbnce, post-traumatic arthritis, complex regional pain syndrome

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41
Q

what are neurological complications and what is the classification used

A

SEDDON’S classification

  • neuropraxia
  • axonotomesis
  • neurotmesis
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42
Q

what is neuropraxia

A

axon is preserved, but itnerruption of conduction

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43
Q

what is axonotomesis

A

axon disrupted, interruption of connduction

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44
Q

what is neurotmesis

A

axon transected, surgery required

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45
Q

what nerve palsy does anterior shoulder sìdislocation / humeral surgica neck fracture cause?

A

AXILLARY NERVE PALSY > numb regimental patch, weak abduction

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46
Q

what palsy does humeral shaft fracture cause?

A

RADIAL NERVE > waiter tip

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47
Q

what palsy does elbow dislocation causee

A

ULNAR NERVE > claw hand

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48
Q

what palsy does hip dislocation cause

A

SCIATIC NERVE > foot drop

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49
Q

what palsy does fibula neck fracture / knee dislocation cause

A

PERONEAL NERVE > foot drop

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50
Q

what is the pathophysiology behind compartment syndrome

A

oedema from fracture > increased pressure > reduced venous drainage > increaased pressure > ischaemia

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51
Q

what are S/S of compartment syndrome

A

pain from passive stretching
warm, eruythematous, swollen
weak / absent pulses
raised CRP

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52
Q

how do you manage compartment syndrome

A

elevate limb
remove all bandages / split
fasciotomy

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53
Q

what are complications of compartment syndrome

A

rhabdomyolysis
Volkmann’s contractures

54
Q

what are causes on non-union

A

5 Is

  • ischaemia
  • infection
  • interfragmentary strain increased
  • intercurrent disease (e.g. malignancy)
  • interposition of tissues between fragments
55
Q

how do you mannage non-union

A 
optimise biology (nutrition, tx infection) 
optimise mechanics (maximise stabilisation with brace ) 
bone stimulator (electical / electromagnetic field, bone growth factor)
56
Q

what are common bones affected by non union and why

A
  • distal tibia and scaphoid

due to poor blood supply

57
Q

what is avascular necrosis

A

loss of blood supply to bone, causing necrosis

58
Q

what are sites of avascular necrosis

A

femoral head
scaphoid
talus

59
Q

what are consequences of avascular necrosis

A

bone is soft and deformed > pain, stiffness, OA

60
Q

what is myositis ossificanas

A

ossification of musce at site of haematoma formation
leads to restricted and painful movement

61
Q

how does presentation of a fat emboolus differ from a PE

A

NEURO signs: confusion, agitation,r retinal haemorrhage

may also have dermatological presentation (red/brown petechial rash)

62
Q

summarise salter harris cllassification

A

for paediatric fractures that affect the growth plaltes of long bones
SALT-C:
- Straight across
- Above
- Lower
- Through (above to below)
- Crush

63
Q

what are risk factors for a NoF fractures?

A

OSTEOPOROSIS + SHATTERED:
Steroids
Hyperthyroid / hyperparathyroid
Alcohol / smoking
Thin
Testosterone low
Early menopause
Renal / liver failure
Erosive or inflammatory bone disease
Dietary calcium low

64
Q

how does a NoF fracture present

A

shortened externally rotated limb

65
Q

what does a short and INTERNALLY rotated limb indicate

A

posterior dislocation

66
Q

what are you looking for in NoF x ray

A

Shenton’s line non-continuous

67
Q

what is the anatomical difference between intracapsular vs extracapsular fractures

A

intracapsular: proximal to intertrochanteric line
extracapsular: intertrochanteric line, up to 5 cm distal to lesser trochanter

68
Q

what is the risk with intracapsular fractures and why

A

avascular necrosis of head of femur

because the blood supply to femooral head comes frrom the MEDIAL CIRCUMFLEX FEMORAL ARTERY that wraps around the femorall neck intracapsularly

so trauma in that region could distrupt the blood supply

69
Q

what are the three types of intracapsular fracture q

A

subcapital (most common)
transcervical
basicervical

70
Q

how can you classify extracapsular fracture

A

intertrochanteric (most common)
subtrochanteric

71
Q

How do you prep a NoF fracture for theatre

A

A>G
Anaesthetist - inform and book theatre
Bloods: FBC, UE, clotting, Xmatch 2u
CXR
DVT prophylaxis (TED, LMWH)
ECG
Films (X rays)
Get consent

72
Q

How do you manage an extracapsular fracture

A

ORIF with Dynamic Hip Screw (intertrochanteric)

IM nail (subtrochanteric)

73
Q

How do you manage an intracapsular fracture

A

depends on displacement, as undisplaced has lower risk to blood supply but displaced has HIGH risk to blood supply

  • UNDISPLACED (Garden 1-2): ORIF with screws
  • DISPLACED (Garden 3-4) has a 30% risk AVN
  • —- <55: ORIF with cancellous/cannulated screws
  • —–55-75 Total Hip Replacement
  • —– >75: hemiarthroplasty (as less fit and less likley to be suitable for THR)
74
Q

common complications NOF Fractures

A

Avascular necrosis 30%
Malunion/nonunion 10-30%
Infection
OA

75
Q

prognosis NOF fracture

A

30% mortality
50% never regain pre-morbid motility

76
Q

What are risk factors for osteonecrosis (avascular necrosis) of hip?

A

TRANSCERIVCAL (INTRACAPSULAR) fracture

direct

  • irradiation
  • trauma
  • haem disease (leukaemia)

Indirect

  • alcohol
  • hypercoag state
  • steroids
  • SLE
  • transplant / immunosuppressed
77
Q

What are symptoms of osteonecrosis of hip

A

anterior hip pain on climbing stairs
insidous onset

78
Q

what are investigations for osteonecrosis of hip

A

XR AP, frog leg, contralateral

MRI (couble density appearance)
Bone scan

79
Q

What artery is disrupted by osteonecrosis?

A

the retinacular artery from the medial circumflex femoral artery

80
Q

what is management of osteonecrosis

A

non-operative: biphosphonates
operative: cord decompression + bone grafting, rotational ostetomy…

81
Q

what is a big risk with osteonecrosis

A

risk of femoral head collapse
based on modified Kerboul angle

82
Q

How do yuou manage a femoral shaft fracture

A

Traction (skeletal traction to temporarily relieve pain and bleeding)
IM nailing (antegrade from hip or retrograde from knee)
ORIF if IM nail unsuitable

83
Q

what are RF for proximal humeral fractures

A

Elderly / with osteoporosis

84
Q

When should you get a CT for proximal humeral fractures

A

if suspicion of articular involvement or comminution

85
Q

How can you manage a proximal humeral fractures

A
  1. Collar and cuff (if 2 parts, minimally displaced, high surgical risk)
  2. ORIF plate and screws (if displaced, >=2 parts but not highly comminuted)
  3. Arthroplasty (humeral head fracture with large displacmeent and risk of non-union
  4. Reverse arthroplasty (unrepairable rotator cuff with prior unsuccessful replacement)
86
Q

Who is a supracondylar humeral fracture common in

A

children
following fall on outstretched hand

87
Q

what is a possible complication of supracondylar humeral fracture

A

injury to the brachial artery
as the proxifractured humerus has a sharp edge

88
Q

how can you identify a supracondylar humeral fracture on X ray

A

look at lateral X ray
Anterior humeral line should intersect the middle third of capitellum

89
Q

How do you manage a supracondylar humeral fracture

A

no displacement: collar/cuff for 3 weeks with fully flexed arm
displacement: MUA + K wire fixation > collar/cuff for 3 weeks with fully flexed arm w

90
Q

what does valgus mean

A

that distal part points AWAY

91
Q

What is the commonest way of breaking radius or ulna

A

FOOSH (flexed or extended wrist)

92
Q

How can you tell radius and ulna apart at the wrist

A

Radius is LARGER at the wrist
Ulna is under (inferior) + medial

93
Q

How do you cause a Colles fracture

A

by falling onto OUTSTRETCHED extended hand

94
Q

What is a colles fracture

A

DORSAL displacmeent and angulation of distal radius fragment

95
Q

What is a smith’s fracture

A

VOLAR / anterior displacement and angulation of distal radius fragment

96
Q

How do you cause a smiths fracture

A

falling onto flexed wrist

97
Q

what is a monteggia fracture

A

proximal 3rd of ulna shaft + dislocated proximal head of radius

MANCHESTER UNITED = MONTEGGIA ULNA

98
Q

what is a galeazzi fracture

A

fracture of distal 3rd of radial shaft + dislocation of distal radio-ulnar joint

GALAXY RANGER = GALEAZZI RADIUS

99
Q

what are the carpal bones

A

some lovers try positions
that they can’s handle

(starting lateroproximally)
scaphoid
lunate
triquetrium
pisiform
trapezium
trapezioid
capitate
hamate

100
Q

what are the commonest mechanisms of injury for the scaphoid bone
in what age group

A

FOOSH or contact sports
avg ager 22

101
Q

what are signs of a scaphoid fracture

A

pain in anatomical snuffbox
wrist joint effusion
pain in telescoping thumb
tenderness in scaphoid tubercle
pain on ulnar deviation of wrist

102
Q

what are investigations of scaphoid fracture

A

XR scaphoid view, AP and lateral (may only become apparent after 10 days)

if not visible in XR but clinical conviction, consider CT / MRI

103
Q

management of scaphoid fracture

A

Futuro splint / below-elbow backslab (before X Ray)
Cast / orif based on displacement

104
Q

complication of scaphoid fracture

A

avascular necrosis of scaphoid > early osteoarthritis

105
Q

what causes a tibial plateau fracture

A

extreme axial loading or varus/valgus forces
impaction of the femoral condyles cause comparatively soft bone of tibial plateau to split

106
Q

what concomitant injueries can occur with tibial plateau fracture

A

ligamentous / menisceal injury

107
Q

management for tibial plateau fracture

A

non-operative if non-displaced on CT (needs to be high fidelity)

operative (screws, plates, bone graft)

108
Q

what is a pott’s fracture

A

bimalleolar fracture

109
Q

what is a cotton’s fracture

A

trimalleolar fracture

110
Q

what is a Pilon fracture

A

fracture of distal tibia involving articular surface
due to excessive loading forces through feet e.g. falls from great height

111
Q

what is a maissonneuve fracture

A

high twisting injury that disrupts the syndodesmosis

caused by high twisting injury, leading to high fibular fracture

112
Q

what are syndodesmotic ligaments

A

ligaments that stabilise the distal tibial-fibular joint
provide ankle stability

113
Q

summarise the four possible types of ankle fractures

A

Pott’s fracture (bimalleolar)
Cotton’s fracture (trimalleolar)
Pilon: distal tibia + articular suface
Maisonneuve: dysruption of syndodesmosis (high fibular fracture)

114
Q

How do you classify lateral malleolus fractures

A

Weber calssification

  • Weber A: below syndesmosis, transverse
  • weber B: across syndesmosis, spiral
  • weber C: above syndesmosis
115
Q

How do you manage ankle fractures

A

non-displaced: boot
displaced/above syndesmosis: Orif + syndesmosis repair

116
Q

Which foot bone is most llikely to fracture

A

calcaneus

117
Q

what is a Lisfranc injury

A

tarsometatarsal fracture dislocation characterized by traumatic disruption between the articulation of the medial cuneiform and base of the second metatarsal.

118
Q

what are symptoms of a Lisfranc injury

A

medial plantar bruising
unable to weightberar
gross midfoot swelling
severe midfoot pain

119
Q

which metatarsal is most commonly fractured in adults and why

A

the 5th metatarsal
in crush injuries

120
Q

what is compartment syndrome

A

raised pressure qwithin a closed anatomical state

the raised pressure eventually compromises tissue perfusion and results in necrosis

121
Q

causes of compartment syndrome

A

supracondylar fractures & tibial shaft fractures
ischaemia reperfusion injury in vascular patients
burns
crush
tourniquet/constrictive dressing

122
Q

what are signs of compartment syndrome

A

pain (esp on movement, even if passive)
excessive use of analgesia
parasthesia, pallor, paralysis

123
Q

how do you investigate compartment syndrome

A

manometer readings (manometer measures intercompartimental prssure)

124
Q

how much will pressure be in compartment syndrome

A

absolute pressuire >30mmHg
Delta pressure <30mmHg
(normal pressure should be 0-10mmHg)

125
Q

how do you manage compartment syndrome

A

Ensure normotension with fluid resus (as hypoperfusion accellerates tissue injury)

Remove circumferential bandages and casts

maintain limb at heart level

OPERATIVE: fasciotomh

126
Q

what are complications of compartment syndrome

A

Volkmann’s contractures (in UL)
Claw toe (in LL)
weak dorsiflexors
sensory loss
chronic pain
amputation

127
Q

what is Volkmann’s contractures

A

permanent deformituy of hand, finger, wrist
caused by supracondylar fracture of humerus, crush injuries, compartment syndrome >insufficient circulation > fibrosis of muscle > shortening of muscle (mainly affecting flexor muscles of forearm)

128
Q

when can you use DHS for fractured NOF

A

use DYNAMIC HIP SCREWS only if. EXTRACAPSULAR

129
Q

what does a buckle fracture look like

A

bulging of cortex

with no visible fracture line

130
Q

how long after hip repair can you be fully weight bearing

A

IMMEDIATELY

Y6 Senior Surgery (10 decks)

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