Ortho Fx Flashcards
Fracture Definition
A break or disruption in the continuity of the bone
Results from compressive forces, tension or torsion
Skin integrity
Closed / simple
Open / Compound
Closed fx
Does not penetrate through the skin
Open fx
Fx that penetrates through the skin
Nondisplaced
Fx fragments anatomically align
Displaced
Fx fragments no longer in usual alignment
Alignment
Rotational or angular position
Angulated
Fx fragments malaligned
Apposition
Amount of end-to-end contract of the fx
Bayonetted
Distal fx fragment longitudinally overlaps proximal fragment
Distracted
Distal and proximal fragments separated by a gap
Types of fx displacement
Nondisplaced vs. displaced Alignment Angulated Apposition Bayonetted Distracted
Types of fx and orientation of fx line
Transverse Oblique Spiral Comminuted Segmental Intra-articular Torus Greenstick Avulsion Impacted Compression Depression
Transverse
Fx perpendicular to shaft of the bone
Oblique
Angulated fx line
Spiral
Multiplanar & complex fx line
Comminuted
Fx with multiple fragments (>2)
Segmental
Comminuted fx in which a completely separate segment of bone is bordered by fx lines
Intra-articular
Fx that includes the joint surface
Torus
“buckle” fx caused by compression of cortex
Typically in distal radius and children
Greenstick
Incomplete fx
- fx of one cortex with bending of opposite cortex
Generally occurs in children
Avulsion
“chip” generally near the joint and with tendon or ligament attached
Impacted
Fx whose ends are driven into each other
Compression
Impaction fx occurring in the vertebrae
Results in depression of end plates
Depression
Impactions fx that occurs in knee when femoral condyle strikes softer tibial plateau
Can also occur in the skull
Pathologic
Fx that occurs b/c bone is weakened due to some abnormal condition
Stress
Fx that occurs when weak bone is stressed normally (insufficiency) or normal bone is stressed excessively (fatigue)
Usually only seen in weight bearing bones
Dislocation
Disruption in the continuity of the joint
Fx-Dislocation
Complete dislocation of joint occurring with a fx
Subluxation
Partial disruption in the continuity of the joint
Pseudarthosis
Failure of bone healing causing a “false joint” consisting of soft tissue
Hx
MOI - often trauma, but not always - make sure the MOI matches up with injury Pain - with or w/o weight-bearing Swelling Decreased function Visible deformity Numbness & tingling
PE
Bone and joints above and below the injury Inspection - Swelling - Ecchymosis - Deformity -Skin integrity - lacerations & abrasions Palpate - Tenderness - Crepitus - Compartment tightness - Neurologic & vascular status
Traumatic nerve injuries
Contusions
Crus
Transection
Contusion
Neuropraxic
Recover 2-3 months (except in knee dislocations)
Crush
Recover slowly (2cm/month)
2 common sites
- Radial N. (spiral fx to humerus –> wrist drop)
- Peroneal N. (fx to the fibular neck –> foot drop)
Imaging
Plain radiographs often good enough
CT for bone
MRI for soft tissue and stress fx
X-ray rule of 2’s
2 views taken at 90° angles - may need oblique
2 joints (one above and one below) - proximal fx most often missed
2 weeks
2 limbs (esp. children)
Ultimate Goals of fx tx
- Alignment of bones in both angular and rotational planes
- Restoration of proper length
- Restoration of apposition of the bone ends
- Adequate immobilization
Fracture tx - initial (in general)
Splinting
Cast
Sling
Splinting
Often initial step in fx care
Allows for swelling to avoid circulatory and neuro problems
Can be done “in the field”
Trauma splints are temporary; remove and replace with padded splint if definitive tx delayed
Can be loosened or tightened with elastic bandage
Significant angular or rotational deformity should be corrected ASAP
Cast
Low-impact fx with minimal swelling
Sling
Tx in humeral head, clavicle fx
Non-sx tx
Splinting followed by casting
- fx that don’t require reduction or sx intervention (non-displaced wrist fx, torus fx)
- splinting done initially in ER to allow for swelling
- F/u scheduled with ortho for definitive tx with casting
Sx tx
ORIF or CRIF
Continuous traction followed by cast immobilization
Closed reduction with external fixation
Closed reduction followed by casting
Disadvantage of splinting over cast
Allow more movement at fx site
Types of splints
Sugar-tong
Posterior
Ulnar gutter
3 purposes of casts
Immobilize ends of fx
Allow ambulation
Hold position of the reduction
Fiberglass / synthetic material
Light weight Strong Short shelf-life More expensive Can get wet, but padding cannot (need special lining)
Plaster
Easy to mainipulate Long shelf-life Low-cost Cannot get wet Heavier than fiberglass
Why CRIF
Prevents devascularization
Decreases risk of infection
Why ORIF
Displaced joint fx (esp. weight bearing joints)
Fx that cannot be held by closed methods
Fx of the LE in elderly to promote early mobilization
Certain epiphyseal fx that could result in growth disturbance if not accurately reduced
Joint fx in which early motion would be helpful to prevent stiffness
Closed Reduction with external skeletal fixation
External fx tx that uses several pins placed above and below the fx site
Elements of Closed Reduction
Sx
Closed reduction followed by casting
Periosteum forms a hinge that can help guide a displaced fx back into place
Different methods include “pushing” it back or traction with manipulation
Anesthesia for closed reduction
Local by direct infiltration of the fx hematoma
Regional
Digital block
General
What is an adequate reduction
- Rotational deformity is completely corrected regardless of age
- In adults, angular deformity should also be completely corrected, esp. in fx of the fingers, forearm and lower extremities
- In peds, some angular deformity (15-20°) that is close to a joint and in the same plane of motion as that joint will correct itself if sufficient growth remains
- Perfect apposition is not always necessary for normal healing
- Fx involving the weight-bearing joints require exact reduction
- Slight shortening in the upper extremity is often acceptable, but proper length in the lower extremity is preferable
Aftercare
Elevate extremity Apply ice 48-72h Move all joints not immobilized - Well result in fewer vasomotor disturbances, less swelling and faster recovery Keep clean and dry Itching is common Ecchymosis in different stages is common Keep pt informed of entire tx plan
Top ten principles
- Comparison x-rays
- X-ray in at least 2 planes
- Look for an injury to the other bone or for dislocation
- Correct both rotational and angular misalignment
- Take stress x-rays when necessary
- Do not be satisfied with one dx
- Reduce the fx ASAP
- In avulsion fx, eval for joint stability and tendon function
- The measure of success is the usefulness of the extremity.
- Irreducibility may signify soft tissue interposition
Fx healing
A complex biologic cascade mediated by a variety of cells and proteins
Determined by both clinical and radiographical evidence
Fx healing - clinically
Absence of tenderness and motion at fx site
Fx healing - radiographically
Amount of bridging callus or obliteration of fx line
Phases of fx healing
3 overlapping phases
Inflammation
Repair
Remodeling
Potential Complications of fx healing
Impaired fx healing Joint stiffness Contractures Osteonecrosis / avascular necrosis Infection / osteomyelitis Compartment syndrome Volkmann's ischemic contracture Pressure ulcers
Volkmann’s ischemic contracture
Acute ischemia and necrosis of the muscle fibers of the flexor group of muscles of the forearm, esp. FDP and FPL.
The muscles become fibrotic and shortened
Impaired fx healing - in general
Malunion
Delayed union / Delayed healing
Non-Union
Malunion
Inadequately aligned union
Delayed Union / Delayed Healing
Fx not healed after 16-20 weeks
Non-union
Fx not healed after 6mo of tx or absence of radiographic evidence of progression of callus formation over a 3 month period
Causes of non-union fx
Inadequate stability
Inadequate biological conditions
Infection
Inadequate reduction
Fibrous non-union
Clinically healed w/o radiographic evidence
Risks of nonunion
Smoking Infection Inadequate Immobilization NSAID Malnutrition Poor blood supply Significant soft-tissue injury
Keys to fx healing
Keep bone ends in apposition
Maintain blood supply
Keep fragments adequately immobilized
Osteonecrosis
fx that results in compromised blood supply to bone and ultimately results in bone death
Fx to these bones require diligent identification and possibly more aggressive tx
Bone at increased risk for osteonecrosis
Talus
Scaphoid
Femoral head
Compartment syndrome
Condition that develops when perfusion of nerve and muscle decreases to the point where it is unable to sustain viability
Progression of Compartment Syndrome
Pressure in fascial compartments rise second to fx bleeding (creates pressure on capillaries and nerves)
Compartment pressure exceeds BP and capillaries collapse
Obstruction of venous outflow
Increase in tissue pressure and necrosis
Acute Compartment Syndrome
Medical Emergency
W/o tx, it can lead to paralysis, loss of limb or death
Chronic Compartment Syndrome
Often occurs with exercise and improves with rest
Not an emergency
Suspect Compartment Syndrome if
- Pain on passive stretching of the muscles of the affected compartment
- Parethesias or sensory loss
- Tenderness of the involved compartment
- Paralysis may occur
7 P’s of Compartment Syndrome
Pain!!! Pallor Paresthesias Paralysis Pressure Pulslessness Poikilothermia
Compartment Syndrome - Hx & PE
Excessive pain may be the only early clue!
Assess for circulatory compromise
- may need to split cast and/or cotton and spread to allow for swelling
- if pain persists may need to remove cast
- if severe may need fasciotomy
Palpate compartments
Assess passive motion, motor and sensory function of peripheral nerves
Measuring pressures of Compartment Syndrome
Direct measurement of compartment pressures
Diastolic pressure - the intracompartmental pressure is = to 30mmHg
Compartment Syndrome - Tx and prevention
Fasciotomy
Pt education - elevation
Volkmann’s ischemic contracture
Considered a sx emergency!!!
Rare complication!!!
Results from untx arterial injury or compartment syndrome secondary to swelling in a tight cast
Causes ischemia and injury to muscles of affected area
When does Volkmann’s ischemic contracture often occur?
After trauma
Crush injury or fx
Areas where Volkmann’s ischemic contracture is most commonly seen
Severe elbow injuries
High tibial fxs
metatarsal fxs
Progression of Volkmann’s ischemic contracture
Trauma
Leads to swelling
Compresses blood vessels which can decrease blood flow to affected area
Prolonged decrease in blood flow
Ischemia
Injures nerves and muscles
Nerves and muscles shorten and become stiff (scarred)
Pull on joint at end of muscle
Joint stiff, remains bent and cannot straighten out
Results in contractures and severe muscle loss
Deformity persists despite prolonged attempts at reconstructive sx and therapy
Results of Volkmann’s ischemic contracture
Contractures
Severe Muscle Loss
Deformity persists despite prolonged attempts at reconstructive sx and therapy
Reflex sympathetic dystrophy (CRPS) - in general
Common d/o of unknown cause that often follows a relatively minor injury
Usually affects extremity
Early recognition is difficult
Reflex sympathetic dystrophy (CRPS) - pathology
Unclear
Disturbance of the sympathetic nervous system which leads to intense pain and vasomotor symptoms
Reflex sympathetic dystrophy (CRPS) - prevalence
W>M, 4x
Smoking increases risk
30-50yo most likely
Reflex sympathetic dystrophy (CRPS) - clinical features
Staging not always reliable b/c variation is common Joint motion restricted Area becomes cool Atrophy - skin & muscle Skin - dry, shiny, glossy Stiffness and intractable pain Anxiety Depression
Reflex sympathetic dystrophy (CRPS) - Acute phase
Lasts 6-12 weeks Pain out of proportion to injury!!! Allodynia Hyperesthesia Persistent burning pain Hypersensitivity to light touch Initially localized to area of injury but then spreads to remainder of extremity Extremity is swollen, warm and excessive perspiration may occur
Reflex sympathetic dystrophy (CRPS) - Imaging studies
Not dx
Plain x-rays - may reveal patchy osteoporosis
Bone scan - may be positive-regional uptake
Autonomic function testing
Response to sympatholytic oral injectable drugs
Reflex sympathetic dystrophy (CRPS) - DDX
Specific nerve d/o
Factitious syndromes
- Munchausen
- Malingering (hypochondria)
Reflex sympathetic dystrophy (CRPS) - Tx
PREVENTION - Control pain & swelling - Early use of extremity Difficult to tx - REFER Antidepressants Corticosteroids CCB Repeated sympathetic blocks Sx
Reflex sympathetic dystrophy (CRPS) - Prevention
Control pain and swelling
Early use of extremity
Pressure Ulcers - in general
May develop rapidly in a cast over areas of pressure - roll in casting material
Cast needs to be removed and painful area assessed - pain will subside when tissue necrosis has occurred - so assess
Rehab for fx
Begins at time of injury
Control swelling
Move joints not immobilized
Isometric exercises in the cast may prevent excessive atrophy
Rehab for fx after cast removal
Active mobilization of joints immobilized - may take 4-6 weeks to regain strength and motion
Formal PT not always needed
Pathologic fx - in general
Fx that develops b/c of some abnormal local condition that causes the bone to become weakened
Pathologic fx - causes
Tumors that mets to bone (most common)
Infection
Cystic lesions of the bone
Paget’s dz
Pathologic fx - goal
Maintain high level of functioning
Aggressive tx
Stress fx - insufficiency
Normal stress applied to weak bone
Osteoporosis - most common cause
Stress fx - fatigue
Excess stress applied to normal bone
Occur in unconditioned athletes or military personnel (long hikes - “march fx”)
Stress fx - s/s
Local tenderness
Swelling usually present
Stress fx - most common locations
Metatarsals Neck of femur Calcaneus Tibia Fibula Pelvis
Stress fx - imaging
x-ray
Normal early in course
If suspected, tx as fx and repeat x-rays at 2 week intervals
Healing seen 2-4 weeks
Stress fx - tx
Protect bone from stress and eliminate offending agent
Gradually resume activity as pain allows
Bone Stim
Delivery of right amount of voltage and current by electrodes can stimulate osteogenesis
Today used in cases of delayed union or nonunion to help promotes bone healing
- When done in conjunction with fx reduction and adequate immobilization, success rate 60-75%
- Usually 30 min BID, and most ill completely stop working after 9 months
