Ortho fractures Flashcards
What are the ottawa rules
used to determine need for X ray
What are ottawa rules used for
knee and ankle
what are the ottawa knee rules
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
What are the ottawa ankle rules
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
What are bones made up of
cells (osteoblasts, osteoclasts, osteocytes, OPC)
matrix (osteoid 40%, inorganic 60%)
what are the two types of bone?
WOVEN: disorganised bone that forms embryonic skeleton and fracture callus
LAMELLAR bone: mature bone. either cortical or cancellous
What are types of bone formation
intramembranous ossifiication (during embryonic development)
endochondral ossification (mesenchyme > cartilage > bone)
what types of fracture can you have
Traumatic
Stress
Pathological
What is a stress fracture due to
bone fatigue due to repetitive strain
give a common example of stress fracture
foot fracture in marathon runner (2nd metatarsal)
what are pathological fractures due to
weakened bone- normal forces on diseased bone can cause a fracture
- local (tumours)
- general (osteoporosis, cushing’s, paget’s)
what radiographs do you need to get if suspecting a fracture
AP and lateral
Need image of joint above and joint below
What pattern of fracture can you have
COMPLETE
Transverse
Oblique
Spiral
Comminuted
INCOMPLETE
Grenstick
Buckle
What is a transverse fracture
fracture perpendicular to long axis of bone
What is an oblique fracture
fracture oblique (approx 45 degrees) to long axis of bone
what is a spiral fracture
helical fracture path in diaphysis of long bone
what is a comminuted fracture
bone is fractured in MORE THAN TWO parts
What ia greenstick fracture
cortex is broken on one side only
what is a buckle fracture and where does it usually happen
Cortex is buckled
usually in distal radius
What are the three stages of fracture healing
- Reactive phase (<48hours): bleeding into fracture site > haematoma > inflammation
- Reparative phase ( 2 days - 2 weeks): proliferation of osteoblasts and fibroblasts > callous formation. Consolidation of woven bone into lamellar bone
- Remodelling (may take years): according to wolff’s law
What is the outline to describe a fracture
PAIDS
Pattern, pieces
Anatomical location
Intraarticular / extraartic
Displacement
Soft tissues
what do you ned to say for displacement
TARI:
Translation
Angulation
Rotation
Impaction
What can you say for translation=?
DIRECTION: of distal part relative to proximal (anterior/post, lateral/medial, proximal/distal)
AMOUNT: measurement or percentage widthg
what can you say for angulatioon
the angulation of the distal part relative to proximal
(anterior/posterior tilt, varus/valgus)
in DEGREES
what can you say for rotation
Rotation (internal, external)
what can you say for impaction
if any shortening has opccurred
what can you say for soft tissues
Open/closed
Neurovascular status
Compartment synndrome
What are the 4 Rs of fracture management
resuscitation
reduction
restriction
rehabilitation
What do you need to do for resuscitation
ATLS trauma assessed in primary survey; secondary survey addresses fractures
Assess NEUROVASCULAR STATUS, look for dilocation
Stabilise BEFORE imagig (reduce and splint, address pain,)
What are the 6As for ope n fractures
Analgesia
Assess NEUROVSC status, soft tissues
Alignment (align fracture and splint)
Antisepsis (wound swab, irrigate, betadine)
Antitetanus
Antibioticss
What classification and guidelines can you use for open fractures?
Gustilo classification
BOAST guidelines
What do you need to know for reduction of fractures
ALL displaced fractures need to be reduced
unlless there is no effect onn the outcome (e.g. ribs)
How do you reduce fractureqs
CLOSED (manipulation or traction)
OPEN
consider LA / GA
How do you restrict a fracture
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)
what are indications for external fixation
- open fractures
- soft tissue loss
- burns
- complex periarticular fractures
what is the biggest risk of externall fixation
risk of pinsite infections
why is rehabilitation important
- immobility reduces muscle and bone mass, causes joint stiffness
- need to maximise mobility of uninjured imbs
- reduces risk of further morbidity
what are methods of rehav
- physio
- OT
- social services (meals on wheels, home help)
how can you classify general complications to fracture surgery
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)
what are complications specific to fractyures
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
what are neurological complications and what is the classification used
SEDDON’S classification
- neuropraxia
- axonotomesis
- neurotmesis
what is neuropraxia
axon is preserved, but itnerruption of conduction
what is axonotomesis
axon disrupted, interruption of connduction
what is neurotmesis
axon transected, surgery required
what nerve palsy does anterior shoulder sìdislocation / humeral surgica neck fracture cause?
AXILLARY NERVE PALSY > numb regimental patch, weak abduction
what palsy does humeral shaft fracture cause?
RADIAL NERVE > waiter tip
what palsy does elbow dislocation causee
ULNAR NERVE > claw hand
what palsy does hip dislocation cause
SCIATIC NERVE > foot drop
what palsy does fibula neck fracture / knee dislocation cause
PERONEAL NERVE > foot drop
what is the pathophysiology behind compartment syndrome
oedema from fracture > increased pressure > reduced venous drainage > increaased pressure > ischaemia
what are S/S of compartment syndrome
pain from passive stretching
warm, eruythematous, swollen
weak / absent pulses
raised CRP
how do you manage compartment syndrome
elevate limb
remove all bandages / split
fasciotomy
what are complications of compartment syndrome
rhabdomyolysis
Volkmann’s contractures
what are causes on non-union
5 Is
- ischaemia
- infection
- interfragmentary strain increased
- intercurrent disease (e.g. malignancy)
- interposition of tissues between fragments
how do you mannage non-union
optimise biology (nutrition, tx infection) optimise mechanics (maximise stabilisation with brace ) bone stimulator (electical / electromagnetic field, bone growth factor)
what are common bones affected by non union and why
- distal tibia and scaphoid
due to poor blood supply
what is avascular necrosis
loss of blood supply to bone, causing necrosis
what are sites of avascular necrosis
femoral head
scaphoid
talus
what are consequences of avascular necrosis
bone is soft and deformed > pain, stiffness, OA
what is myositis ossificanas
ossification of musce at site of haematoma formation
leads to restricted and painful movement
how does presentation of a fat emboolus differ from a PE
NEURO signs: confusion, agitation,r retinal haemorrhage
may also have dermatological presentation (red/brown petechial rash)
summarise salter harris cllassification
for paediatric fractures that affect the growth plaltes of long bones
SALT-C:
- Straight across
- Above
- Lower
- Through (above to below)
- Crush
what are risk factors for a NoF fractures?
OSTEOPOROSIS + SHATTERED:
Steroids
Hyperthyroid / hyperparathyroid
Alcohol / smoking
Thin
Testosterone low
Early menopause
Renal / liver failure
Erosive or inflammatory bone disease
Dietary calcium low
how does a NoF fracture present
shortened externally rotated limb
what does a short and INTERNALLY rotated limb indicate
posterior dislocation
what are you looking for in NoF x ray
Shenton’s line non-continuous
what is the anatomical difference between intracapsular vs extracapsular fractures
intracapsular: proximal to intertrochanteric line
extracapsular: intertrochanteric line, up to 5 cm distal to lesser trochanter
what is the risk with intracapsular fractures and why
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
what are the three types of intracapsular fracture q
subcapital (most common)
transcervical
basicervical
how can you classify extracapsular fracture
intertrochanteric (most common)
subtrochanteric
How do you prep a NoF fracture for theatre
A>G
Anaesthetist - inform and book theatre
Bloods: FBC, UE, clotting, Xmatch 2u
CXR
DVT prophylaxis (TED, LMWH)
ECG
Films (X rays)
Get consent
How do you manage an extracapsular fracture
ORIF with Dynamic Hip Screw (intertrochanteric)
IM nail (subtrochanteric)
How do you manage an intracapsular fracture
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)
common complications NOF Fractures
Avascular necrosis 30%
Malunion/nonunion 10-30%
Infection
OA
prognosis NOF fracture
30% mortality
50% never regain pre-morbid motility
What are risk factors for osteonecrosis (avascular necrosis) of hip?
TRANSCERIVCAL (INTRACAPSULAR) fracture
direct
- irradiation
- trauma
- haem disease (leukaemia)
Indirect
- alcohol
- hypercoag state
- steroids
- SLE
- transplant / immunosuppressed
What are symptoms of osteonecrosis of hip
anterior hip pain on climbing stairs
insidous onset
what are investigations for osteonecrosis of hip
XR AP, frog leg, contralateral
MRI (couble density appearance)
Bone scan
What artery is disrupted by osteonecrosis?
the retinacular artery from the medial circumflex femoral artery
what is management of osteonecrosis
non-operative: biphosphonates
operative: cord decompression + bone grafting, rotational ostetomy…
what is a big risk with osteonecrosis
risk of femoral head collapse
based on modified Kerboul angle
How do yuou manage a femoral shaft fracture
Traction (skeletal traction to temporarily relieve pain and bleeding)
IM nailing (antegrade from hip or retrograde from knee)
ORIF if IM nail unsuitable
what are RF for proximal humeral fractures
Elderly / with osteoporosis
When should you get a CT for proximal humeral fractures
if suspicion of articular involvement or comminution
How can you manage a proximal humeral fractures
- Collar and cuff (if 2 parts, minimally displaced, high surgical risk)
- ORIF plate and screws (if displaced, >=2 parts but not highly comminuted)
- Arthroplasty (humeral head fracture with large displacmeent and risk of non-union
- Reverse arthroplasty (unrepairable rotator cuff with prior unsuccessful replacement)
Who is a supracondylar humeral fracture common in
children
following fall on outstretched hand
what is a possible complication of supracondylar humeral fracture
injury to the brachial artery
as the proxifractured humerus has a sharp edge
how can you identify a supracondylar humeral fracture on X ray
look at lateral X ray
Anterior humeral line should intersect the middle third of capitellum
How do you manage a supracondylar humeral fracture
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
what does valgus mean
that distal part points AWAY
What is the commonest way of breaking radius or ulna
FOOSH (flexed or extended wrist)
How can you tell radius and ulna apart at the wrist
Radius is LARGER at the wrist
Ulna is under (inferior) + medial
How do you cause a Colles fracture
by falling onto OUTSTRETCHED extended hand
What is a colles fracture
DORSAL displacmeent and angulation of distal radius fragment
What is a smith’s fracture
VOLAR / anterior displacement and angulation of distal radius fragment
How do you cause a smiths fracture
falling onto flexed wrist
what is a monteggia fracture
proximal 3rd of ulna shaft + dislocated proximal head of radius
MANCHESTER UNITED = MONTEGGIA ULNA
what is a galeazzi fracture
fracture of distal 3rd of radial shaft + dislocation of distal radio-ulnar joint
GALAXY RANGER = GALEAZZI RADIUS
what are the carpal bones
some lovers try positions
that they can’s handle
(starting lateroproximally)
scaphoid
lunate
triquetrium
pisiform
trapezium
trapezioid
capitate
hamate
what are the commonest mechanisms of injury for the scaphoid bone
in what age group
FOOSH or contact sports
avg ager 22
what are signs of a scaphoid fracture
pain in anatomical snuffbox
wrist joint effusion
pain in telescoping thumb
tenderness in scaphoid tubercle
pain on ulnar deviation of wrist
what are investigations of scaphoid fracture
XR scaphoid view, AP and lateral (may only become apparent after 10 days)
if not visible in XR but clinical conviction, consider CT / MRI
management of scaphoid fracture
Futuro splint / below-elbow backslab (before X Ray)
Cast / orif based on displacement
complication of scaphoid fracture
avascular necrosis of scaphoid > early osteoarthritis
what causes a tibial plateau fracture
extreme axial loading or varus/valgus forces
impaction of the femoral condyles cause comparatively soft bone of tibial plateau to split
what concomitant injueries can occur with tibial plateau fracture
ligamentous / menisceal injury
management for tibial plateau fracture
non-operative if non-displaced on CT (needs to be high fidelity)
operative (screws, plates, bone graft)
what is a pott’s fracture
bimalleolar fracture
what is a cotton’s fracture
trimalleolar fracture
what is a Pilon fracture
fracture of distal tibia involving articular surface
due to excessive loading forces through feet e.g. falls from great height
what is a maissonneuve fracture
high twisting injury that disrupts the syndodesmosis
caused by high twisting injury, leading to high fibular fracture
what are syndodesmotic ligaments
ligaments that stabilise the distal tibial-fibular joint
provide ankle stability
summarise the four possible types of ankle fractures
Pott’s fracture (bimalleolar)
Cotton’s fracture (trimalleolar)
Pilon: distal tibia + articular suface
Maisonneuve: dysruption of syndodesmosis (high fibular fracture)
How do you classify lateral malleolus fractures
Weber calssification
- Weber A: below syndesmosis, transverse
- weber B: across syndesmosis, spiral
- weber C: above syndesmosis
How do you manage ankle fractures
non-displaced: boot
displaced/above syndesmosis: Orif + syndesmosis repair
Which foot bone is most llikely to fracture
calcaneus
what is a Lisfranc injury
tarsometatarsal fracture dislocation characterized by traumatic disruption between the articulation of the medial cuneiform and base of the second metatarsal.
what are symptoms of a Lisfranc injury
medial plantar bruising
unable to weightberar
gross midfoot swelling
severe midfoot pain
which metatarsal is most commonly fractured in adults and why
the 5th metatarsal
in crush injuries
what is compartment syndrome
raised pressure qwithin a closed anatomical state
the raised pressure eventually compromises tissue perfusion and results in necrosis
causes of compartment syndrome
supracondylar fractures & tibial shaft fractures
ischaemia reperfusion injury in vascular patients
burns
crush
tourniquet/constrictive dressing
what are signs of compartment syndrome
pain (esp on movement, even if passive)
excessive use of analgesia
parasthesia, pallor, paralysis
how do you investigate compartment syndrome
manometer readings (manometer measures intercompartimental prssure)
how much will pressure be in compartment syndrome
absolute pressuire >30mmHg
Delta pressure <30mmHg
(normal pressure should be 0-10mmHg)
how do you manage compartment syndrome
Ensure normotension with fluid resus (as hypoperfusion accellerates tissue injury)
Remove circumferential bandages and casts
maintain limb at heart level
OPERATIVE: fasciotomh
what are complications of compartment syndrome
Volkmann’s contractures (in UL)
Claw toe (in LL)
weak dorsiflexors
sensory loss
chronic pain
amputation
what is Volkmann’s contractures
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)
when can you use DHS for fractured NOF
use DYNAMIC HIP SCREWS only if. EXTRACAPSULAR
what does a buckle fracture look like
bulging of cortex
with no visible fracture line
how long after hip repair can you be fully weight bearing
IMMEDIATELY
