Orthopaedics Unit 5 Flashcards
what is the anatomical features of bone
has a very rich blood supply
periosteum is the membrane which covers the outside of the bone
- has a nerve supply
Mx of fracture priorities
early Mx
- minimise effects of blood loss
- reduce pain
Mx
- re-establish blood supply to the bone to allow it to heal
what questions need considered in the history of a fracture
what happened?
how did it happen?
where and when?
what was the injured person like before it happened?
who is the person?
what injuries are a person hit by a car likely to have
leg injuries from the bumper
pelvic and abdominal injuries from the bonnet
head injuries from the door pillar
what are the signs of a fracture
pain deformity tenderness swelling discolouration or bruising loss of function crepitus injury to other tissues
what influences the deformity of the bone after a fracture
position of the distal fragment of a fractured bone is determined by gravity
position of the proximal fragment is determined by the muscles
how can swelling be reduced in a fracture
elevate the part of the body injured
injured arm
- raised about level of the heart
injured leg
- lie patient down, with leg raised above chest level
what causes the colours of bruising
bruise at first is dark
- due to deoxygenated blood loss into soft tissue
bruise then becomes green/yellow
- as haemoglobin in the red blood cells is broken down and carried away to the liver
what 2 x-ray views are taken on a suspected fracture
one in sagittal plane
one in coronal plane
what is radioisotope scanning
when a very small quantity of a radioactive substance is injected into the blood of the injured person
how does radioisotope scanning work
- radioactive substance attaches to phosphate molecules which are actively taken up by bone
- then an x-ray is taken
- more metabolically active the bone is, the faster it takes up the radioactive substance
- sites of unusual metabolic activity (i.e. at the site of the fracture) can be clearly seen
when is radioisotope scanning used
useful in determining whether a bone is fractured or not
often used when a scaphoid [bone of the wrist] fracture is suspected
what questions should be answered when describing a fractured bone
which bone is broken and on which side?
is the fracture open or closed?
where on the bone is the fracture?
- intra-articular [in the joint]
- mid shaft
- proximal, middle or lower third?
what is the shape of the fracture?
- spiral
- oblique
- transverse
how many fragments?
- simple
- butterfly
- comminuted
what is the position of the distal fragment?
- describe distal fragment in relation to proximal one
could it be a pathological fracture?
how do spiral fractures occur
through twisting, low energy injuries
associated with little soft tissue damage = blood supply is preserved and healing should be no problem
when do you see oblique or transverse fractures
caused by buckling or direct injury to the bone
lots of energy involved
associated with soft tissue stripping and damage to the blood supply
require a lot more consideration for choice of Tx and usually take longer to heal
what are the 3 considerations when describing the position of the distal part of a fracture
displacement
- anterior
- posterior
- medial
- lateral
angulation
- anterior
- posterior
- varus
- valgus
rotation
- internal
- external
what are signs of a pathological fracture
fracture seems out of proportion to the violence of the injury
suggests bone is weak = result of osteoporosis or other diseases such as cancer
what are the headings of the immediate management of fractures
pain relief
managing blood loss
managing open fractures
what are the 2 methods of immediate pain relief
pain-killers
- i.e. morphine or pethidine injections
splintage
- hold fracture steady
- should encompass the joint above and below an injury
what is an alternative to splint age
traction
- also used in early Tx to relieve muscle spasm
when is traction particularly useful
fractures of the femoral neck
as splint age is impossible to apply
what type of fractures can lead to significant blood loss
major long bone fracture
i.e. femur
tibial # = 1 unit blood loss
femoral # = 2-3 units
major pelvic # = 6 units [major venous bleeding]
what is the Mx of all patients with major long bone injuries
cross matched for blood
wide bore cannula
- 2 lines if pelvic fracture
what is the Mx of open fractures and why is it important it happens quickly
clean them out and remove all dead tissue
- remove bits of clothing, dirt, wood, metal
prevent infection from bacteria
prevents potenital sepsis
what is the wound management of an open fracture
wounds are better left open if there is any doubt that closure cannot be achieved without any tension on the skin
wounds closed as a secondary procedure after a few days or left to heal spontaneously
Tx of open fractures
broad spectrum antibiotics
tetanus protection
what factors will determine what the long term, definitive management is of a fracture
the injured person
the injury
the surgery
what needs to be considered in the injured person in terms of management of the fracture
age of the patient, physical health and occupation
- older people tend to have a poor bone quality (osteoporosis) and co-existing medical problems [heart disease, diabetes]
how might the treatment of a wrist fracture be different in an elderly person and a young person
elderly
- fracture may be treated under local anaesthesia in the A&E
- not perfect result, but can go home and may have a satisfactory level of function
- surgery would require bed rest which might lead to complications like bedsores, UTI
young
- might be prepared to spend months undergoing Tx to ensure perfect result
- need it for work etc
what is essential to ensure when considering surgery
benefits outweigh the risks
what is the name of the process of returning the bone to its normal position
reduction
[and then holding the bone in place to allow healing]
what is close reduction
achieved by traction on the distal fragment
then relocation of that distal part back onto the proximal fragment by manipulation
need adequate analgesia
what does the manipulation of the fracture usually involve
reversing the direction of the deforming force
what is open reduction
site is open surgically and the fragments are relocated directly under vision
done if closed reduction doesn’t work
why does a bone need to be held in the desired position
bone needs to become strong enough to support itself (united) and then protected until it is strong enough to bear some load (consolidated)
how can a fracture be held in place
Casting
- surrounding the broken limb with a hard ‘coat’ which holds the fracture steady.
External fixation - an external ‘bar’ outside the body attached to pins sited in the broken bones.
Internal fixation - holding broken bones together using screws and plates inside the body.
Traction - pulling on a broken limb to align the bones.
what is casting
place limb in plaster of Paris cast until union
limb must be held in correct position and maintained at proper length [too long/short will delay union]
what must be covered in a plaster of paris cast
must immobilise the joints above and below the fracture site, as joint movement may result in distortion in one or more dimensions.
how does a cast work
acts as a splint
controls joint movement and position to control posture
plaster cast is folded so that pressure is exerted at 3 points
3 holding forces - mimics the direction of the reducing force sufficient to hold the reduction
disadvantages of casts
heavy
immobilise the joint
cannot examine the site
cannot x-ray
after cast is removed:
- muscle wasting
- limited mobility due to joint stiffness
what technique can be used to over come plaster cast
functional brace
- frees the joint
how does a functional brace work
accurate moulding and the provision of hinges, which permit motion in one direction, usually flexion and extension
- maintains 3D control of #
why is a functional brace normally fitted a few weeks after the injury
brace is reliant on a very accurate fit so need to wait for pain and swelling to reduce
what are disadvantages of the plaster of paris in regards to the material and what are alternatives
brittle messy difficult to apply well heavy can take 3 days to dry
glass fibre and polyurethane resin [however, not as versatile]