Ortho unit 5 Flashcards
Periosteum
membrane which covers the outside of bones- has a nerve supply
Immediate consequences of breaking a bone
Pain (nerve supply), blood loss- early management of fracture must minimise both of these consequences. Blood supply must be reestablished for bone to heal.
What helps surgeon decide appropriate treatment
Condition of blood vessels
Clinical aspects of history after trauma
What happened, how did it happen, where and when, what was the injured person like before it happened- full history, who is the person- social history
Medico-legal aspects- keep meticulous notes
Signs of a fracture
Pain
Deformity- position of distal fragment determined by gravity, proximal part determined by attachment of the muscles
Tenderness
Swelling- injured part elevated to reduce swelling
Discolouration or bruising- can age injury
Loss of function
Crepitus- grating feeling when examining an injury
Investigating fractures
X rays- usually 2 views- sagittal and coronal planes
Tomogram- view of slice through part of the body - useful where an area is difficult to distinguish die to overlapping structures
CAT scanner- computerised axial tomography
Ultrasound- can show accumulation of fluid
Radioisotope scanning-
Radioisotope scanning
injecting radioactive substance into the bloodstream of an injured person- attaches to phosphate molecules which are actively taken up by bone- radioactive substance therefore ends up in bones. X ray plate is exposed to affected part of body and radiograph of bone is obtained. More metabolically active the bone is, the faster it takes up the radioactive substance. Sites of unusual metabolic activity can clearly be seen on the radiograph
Helpful in determining if a bone is fractured or not, if there is clinical doubt. More useful in non acute situations. Highly sensitive but doesn’t tell us anything about the fracture other than the fact that its there.
What suspected fracture is radioisotope scanning useful for
scaphoid bone fracture
Describing fractures
Which bone is broken and on which side
Open or closed fracture
Where on the bone is it broken (intra articular, mid shaft, proximal etc)
What shape is the fracture- spiral, oblique, transverse
How many fragments- simple, butterfly, comminuted
Position of the distal fragment- position of distal fragment described relative to the proximal one-
Displacement, angulation, rotation
Could it be a pathological fracture
What causes spiral fractures
Twisting, little soft tissue damage so the blood supply to the bone is preserved
what causes oblique and transverse fractures
bucking or direct injury to the bone
Displacement
anterior, posterior, medial or lateral
Angulation
anterior, posterior, varus or valgus
Rotation
internal or external
Immediate management of fracture
Pain relief-
Pain killing drugs- injections of morphine or pethidine
Splintage- splint should encompass the joint above and below an injury. Alternative to splint is traction- may be used in early treatment to relieve muscle spasm - particularly useful in fractures of femoral neck
Blood loss
significant in major long bone fractures, particularly the femur. Major pelvic fractures, particularly if unstable, are associated with major venous bleeding from the pelvic plexuses- blood loss can be considerable- amounting to 6 units or so. In general, all patients with major long bone injuries should be cross matched for blood and a good size venous line for blood transfusion should be established ASAP. For pelvic fractures, 2 lines may be needed and a central venous line should be established to ensure transfusion is keeping up with loss
Open fractures
Skin is broken. More violent injuries and result in bone being contaminated by bacteria from the environment. Treatment strategy is to clean out fracture and remove all dead tissue to prevent a contamination becoming an infection.
Open fracture
surgical emergency- patient should be taken to the operating theatre ASAP- wound extended surgically and all debris and suspected dead tissue removed- exploration down to bone. Wounds either left open if theres any doubt that closure can be achieved without tension on the skin. This means that the vast majority of woulds should be left opened and closed either as a secondary procedure after a few days or left to heal spontaneously. Patient s all need supplementary broad spectrum antibiotics and some form of tetanus protection
Definitive management of fractures
functional requirements vary from individual to individual
Reduction
restoration of fracture to normal position
Closed reduction may be achieved by traction on the distal fragment and then a relocation of the distal part back onto the proximal fragment by manipulation. Adequate analgesia necessary to achieve a reduction
Open reduction may be required whereby the fracture site is opened surgically and the fragments are relocated directly under vision
Holding
Once fracture is realigned - it myst be held in the desired position until the bone has become strong enough to support itself (united) and then protected until it is strong enough to bear load (consolidated)
How can fractures be held in place
Casting
External fixation- external bar outside the body attached to pins sited in the broken bones
Internal fixation- holding bones together using plates and screws inside the body
Traction- pulling on broken limb to realign the bones
Casting
Hold limb in plaster of paris cast until union- fracture must be held in the correct position by the cast and it must be maintained at the proper length. Cast must immobilise the joints above and below the fracture site, as joint movement may result in distortion in one or more dimensions. Cast acts as a splint- pressure is exerted at 3 points holding the bone in the correct position until it heals.
Disadvantages of casts
Many- heavy and immobilise the joints.
Clinicians can’t examine the covered part or use X ray
Immobility results in muscle wasting and limited mobility due to joint stiffness
Functional brace
Frees the joint. Necessary to support the cast at the joints by a combination of accurate moulding and the provision of hinges, which permit motion in one direction, usually flexion and extension, in order to maintain 3D control of the fracture
Braces are highly dependent on a very accurate fit and so tend to be used after a few weeks, when pain and swelling have settled
modern casting materials
Plaster of paris- brittle, hard to apply, heavy and awkward, takes up to 3 days to dry. New materials- based on glass fibre and polyurethane resin combinations- make ideal cast braces
External fixation
High energy fractures- associated with extensive soft tissue damage, which often results in breaching of the skin or even loss of soft tissue. In such cases, because the blood supply is severely damaged, its important to have an initial phase of soft tissue healing. Plaster splits are unsuitable. Internal fixation is hazardous because of ischaemia and wound contamination increases the risk of infection being introduced during surgery. Compromise- device which is fixed to the bones by pins and which stabilises the limb by means of an external scaffold.. It provides stability of the bones and allows access to the soft tissues for dressings and secondary surgery such as skin grafting.
Internal fixation
Used where a high degree of accuracy is required, or other methods fail. Involves holding of the fractured bone with devices such as screws, nails or plates.
Ways to achieve internal fixation
Apposition
Inter fragmentary compression
Inter fragmentary compression plus only device
Inlay device
Apposition
Once fractures are realigned they may only need to be held in apposition (together in alignment) for healing to proceed. Particularly true in children- semi flexible K or Kirschner wires- hold position without producing immobility so healing occurs by natural callus formation. Can be left standing proud of the bone and so can easily be pulled out once union is established
