Ortho Med Unit 5 Flashcards
What questions should be be asked when taking a trauma history?
- What happened?
- (different amount of energy between low impact fracture from a slip, or a RTA - radiograph may look the same)
- Determines the likelihood of injury to soft tissues and blood supply disruption - How did it happen? (look for injury pattern)
- Where and when? (how long since injury)
- What were they like before it happened? (PMH)
- Who is the person (social history)
Why is it important to keep detailed notes as soon as possible after managing an incident?
May be important relating to insurance or litigation
May not be months of years until asked to give an account of the incident
What are the 6 signs of a fracture?
Deformity Tenderness Swelling Discolouration/bruising Loss of function Crepitus
What other tissues may be damaged in an injury causing fracture?
Skin Fat Muscle Blood vessels Nerves
How can bruising be used to age an injury?
Dark at first; loss of deoxygenated blood into soft tissues
Green-yellow; haemoglobin in the RBCs broken down + carried to liver (by scavenger cells)
What information may be given but he deformed appearance of a fracture?
The direction of injury
How are fractures investigated?
X-ray; coronal + sagittal plane
CT scan; if hidden by shadows on X-ray
USS; show resulting blood accumulation
Radioisotope scanning; for a suspected fracture that is a couple of weeks old and can’t be seen on X-ray
How does radioisotope scanning work?
Inject a small amount of radioactive substance into the blood stream, binds to phosphorus which is uptaken by bones - the more uptaken, the more metabolically active
Will identify a site of unusual metabolic activity (ie fracture)
Especially useful for scaphoid fractures
How should a fracture be described?
Bone
Side
Open/closed
Where on bone (prox/dist/mid-shaft/intra-articular)
Shape (spiral, oblique, transverse)
How many fragments (simple, butterfly, comminuted)
Position of distal fragment
- displacement (ant/post/med/lat)
- angulation (ant/post/varus/valgus)
- rotation (internal/external)
Could it be pathological (if seems out of proportion to the violence of the injury)
What type of injury causes a spiral vs oblique/transverse fracture?
Spiral: through twisting (low energy mode of injury)
- assoc with little soft tissue damage
- blood supply is preserved and healing unlikely to be a problem
Oblique/transverse: buckling or direct injury (high energy mode of injury)
- results in soft tissue stripping + damage to blood supply
- usually takes longer to heal
What is the difference between a simple, butterfly and comminuted fracture?
Simple: 2 fragments
Butterfly: 3 fragments
Comminuted: multiple fragments (shattered)
What is the immediate management of a fracture?
Pain relief - analgesia/splintage
Control of blood loss (may need to replace blood)
If open = immediate surgery (surgical emergency)
How does splintage/traction help in the immediate management of pain from a fracture?
Helps to relieve muscle spasm, a major component of post fracture pain
(should include the joint above/below a fracture)
Arm to chest, bind legs together
How much blood is lost in different fractures?
Upper limb + peripheral lower limb; very minimal (even tolerated by the elderly)
Femur; 2-3pints
Tibia; 1unit (only serious if combined with other injuries)
Pelvic; 6units (due to venous plexus disruption - very serious)
What should be done for an open fracture?
Surgery
- extend the fracture and remove all debris (otherwise will miss contaminants - bits of clothing)
- clean wound + remove all dead tissue
- broad spec Abx + tetanus protection
What is the definitive management of a fracture?
Reduction + holding
What are the aims of reduction? How is reduction of a fracture done?
Aim to restore as close to a normal position as possible (joint should be very accurate whereas mid shaft is more margin for error)
Closed reduction; traction + manipulation (general or regional anaesthetic required)
Open reduction; surgically open + relocated under vision
What are the different methods of holding a fracture?
Casting
Internal fixation
External fixation
Traction
How does casting work and what are the advantages/disadvantages?
Acts as a splint to apply 3 point pressure and hold the position of the fracture until healed. Should also immobile joints above/below so that movement doesn’t disrupt the reduction
Adv:
- cheap + easy
Disadv:
- heavy
- immobile joints as well (jt stiffness)
- result in muscle wasting
- can’t examine the part in the cast (or do an X-ray)
What are the 2 types of cast and when are they used?
Plaster of Paris: used for first couple of weeks
- brittle, messy + difficult to apply,
- takes up to 3 days to fully dry
- Heavy/awkward for elderly
Fibreglass/polyurethane resin combo: secondary cast
- stronger + lighter
- not so versatile
What is the advantage of a functional brace?
A cast with a hinge at the joint
Allows movement at the joint (in one direction) whilst still immobilising the bone
Useful after a few weeks when the pain + swelling have settled
What is external fixation? When is external fixation used?
Pins into the bone held in position by an external scaffold
If there is soft tissue damage as allows access to the skin for soft tissue dressings (or secondary surgery - skin grafts etc)
The pin sites are an easy route for infection so may be appropriate to switch for a cast when suitable
When is internal fixation used?
When a high degree of accuracy is required or if other methods fail
Very complicated + high risk so should be avoided where possible
Prevents natural healing of the bone
What are the different internal fixation methods? What are the advantages/disadvantages of each?
Apposition = K-wires
- can be easily removed before consolidation
- hold position without causing immobility so have normal callus formation
Interfragmentary compression = screws to hold fragments together
- very good in cancellous bone
Onlay devices = plates (used with screws)
- allows early movement
- inhibits natural healing (by preventing micro movement at the fracture)
- delays complete resolution + full bone loading
Inlay devices = IM nails
- holds correct alignment without disrupting natural bone healing
- not very accurate so not useful around joints
- good in long bone fractures of the lower limb
What are the pros/cons of removing internal fixation devices?
Pros:
- reports of tumours growing around long term implants
- the supported bone becomes weaker because of reduced loading upon it (remodelling) - removal allows it to become stronger
Cons:
- risks associated with surgery at the same site (infection, damage to NVB)
- bone is weaker so there is a higher risk of subsequent fracture
(in a young person they should generally be removed)
What is traction used for? What are the 3 types of traction?
To hold a reduced position
Static
Balanced
Dynamic
Describe the 3 types of traction and their uses
Static: provide pull against another part of the body (ie Thomas splint)
Used for short periods
Balanced: Use a counterweight to hold position to take pressure off the skin
Used when there is a risk of damage to the body from the pressure of static traction
Dynamic: Uses weights on pulleys to permit joint movement while providing pull along the line of the broken bone
Require to stay longer in hospital and care is difficult
Used when traction is required to relieve pain - reduces muscle spasm by changing muscle tone
(if long term use a pin through the bone - challenge to prevent infection)
What are the stages of fracture healing?
1-2 weeks: Swelling 2-6 weeks: callus formation 6-12 weeks: initial bone forming 6-12 months: consolidation of bone 1-2 years: remodelling complete and bone returns to normal
At what angle do bones heal most effectively? Why is this?
Those with a bit of movement at 90º to the fracture
Allows micromovement which stimulates bone healing
(bones held in internal fixation without micromovement will heal much slower and by a different process without a callus)
What different does internal fixation make to bone healing?
Will heal in correct position but much more slowly and won’t be quite as strong
How should pathological fractures be managed?
Fixation - allows for pain relief + early return home
How are fractures involving joints managed?
Usually require internal fixation
If there if fragmentation should be reconstructed
When should internal fixation be used in low energy injuries?
If the risk is low - young/middle aged people
If the benefit is high - elderly (allows early mobilisation + reduces complications of immobility)
What are the early primary complications of fracture?
Blood loss, Infection (if open), Fat embolism, Renal failure Soft tissue injury Compartment syndrome
What are the early secondary complications of fracture (as a result of treatment)?
Plaster disease Renal stones Immobility Infection Compartment syndrome
What are the late primary complications or fracture?
Non-union Delayed union Mal-union Growth arrest Arthritis
What are the later secondary consequences of fracture?
Mal-union
Fracture
How do fat embolus present and how are they managed?
Long bone fractures of men <20yo
2-5 day’s after injury
Shallow rapid breathing + mild confusion
May have a rash on chest and neck (not always)
Treat with high percentage O2 + chest physio
Fatalities do occur
What causes renal failure after a fracture?
Soft tissue injury + ischaemia cause accumulation of myoglobin in the kidneys
How is compartment syndrome diagnosed and managed?
Pain out of proportion to injury
Loss of function of muscles
Extreme pain caused by stretching
Surgical decompression
What is plaster disease?
Muscle wasting, stiffness, skin sores
After how long is delayed/non-union considered? How long do they usually take to heal?
Upper limb: 10 weeks (usually heal in 6 weeks)
Lower limb: 20 weeks (usually heal in 12 weeks)
What are the causes of delayed or non union?
Excess movement
Not enough movement (from rigid internal fixation)
Soft tissue interposition (soft tissue between bone ends)
Poor blood supply
Infection
Excessive traction/splintage too far apart
How is union stimulated after non union?
Remove any underlying cause
Stabilisation + bone graph effective (unsure why - maybe switches on healing mechanism)
