Orthopaedics unit 5 Common fractures - deck 1

Question 1

Why are the immediate effects of breaking a bone (a fracture) serve pain and blood loss ?

Answer 1

Because bones have a very rich blood supply and a periosteum

Question 2

Define what is meant by the term a fracture

Answer 2

This is the breaking of a bone

Question 3

Describe what the periosteum is

Answer 3

This is the membrane which covers the outside of bones, it has a nerve supply

Question 4

What must the early management of a fracture focus on ?

Answer 4

Minimising the effects of blood loss and reducing the pain

i.e. conteracting the immediate effects of fractures

Question 5

In the long-term management of a fracture what must be re-established ?

Answer 5

• The rich blood supply to the bone
• Therefore, the condition of the soft tissues containing the blood vessels will be considered by the surgeon when choosing the most appropriate treatment

Question 6

Why may fractures not be the surgeons first concern when treating someone ?

Answer 6

Other injuries received in the same incident (head, chest and abdominal injuries) may be more serious.

Question 7

After trauma a careful history must be taken, what are the 2 priniciple reasons for taking a careful history ?

Answer 7

To ascertain the clinical and medico-legal information

Question 8

What are the 5 questions that you must ask about the clinical aspects of a persons fracture ?

Answer 8

1. What happened?
2. How did it happen?
3. Where and when?
4. What was the injured person like before it happened
5. Who is the person?

Question 9

Why is it important to ask what happened to cause the trauma ?

Answer 9

• Becuase fractures at a particular site can look the same. The appearance of a fracture on a radiograph may not give much of a clue to the severity of an injury.
• There is a world of difference, however, between gaining a fracture from slipping off a step and from being hit by a car. In these two extreme examples the first involves little energy transfer to the affected part of the body and the second usually involves quite a lot. The amount of energy transferred to the body in an accident determines not only the injury to the bone, but also the soft tissue damage and the extent to which the blood supply is disrupted.

Question 10

Why is it important to ask how did it happen with regards to a trauma incident?

Answer 10

Finding out how the accident happened can also help because it helps predict the injuries which may have occurred ==> reducing the chances of missing something

e.g. a pedestrian hit by a car tends to receive leg injuries from the bumper, pelvic and abdominal injuries from the bonnet and head injuries from the door pillar.

Question 11

Why is it important to ask where and when the trauma occured?

Answer 11

As a long delay between injury and treatment may limit the options for treatment.

Question 12

Why is it important to ask what was the injured person like before the trauma happened ?

Answer 12

• It is important to establish as much information as possible about the injured person’s previous general medical state. Often, medical conditions may be associated with an injury. For example, the injured person may have had a fit or may have collapsed with a hypoglycaemic attack because she/he is diabetic. In the elderly in particular, a fracture may have occurred as a result of a fall during a heart attack or a stroke.
• Many patients with fractures may need an anaesthetic and so the condition of the cardiovascular and respiratory system must be established. The last time the injured person ate or drank must be ascertained so that surgery can be delayed, if possible, until the stomach is empty to reduce the risk of breathing in vomit.

Question 13

Why is it important to ask who is the person who has experienced the trauma ?

Answer 13

A social history is important. The status of the injured person before the injury must be established. Where do they live and with whom? Do they have stairs to climb into the house or flat or within the home? Can the older injured person go to relatives after any hospital stay to rehabilitate?

The planning of recovery starts with admission to hospital and not as an afterthought just before discharge

Question 14

What are some of the consequences of an accident ?

Answer 14

• They will affect the victims personally, and their families.
• They will also, depending on the circumstances, have effects relating to insurance and litigation.

Question 15

Why is it important to keep meticulous, legiable and complete notes and to make them at the time of examination and treatment, or as soon afterwards as possible?

Answer 15

It is often months or even years before a doctor may be called to give an account of an accident.

Question 16

What are the 7 main signs of a fracture ?

Answer 16

1. Pain
2. Deformity
3. Tenderness
4. Swelling
5. Discolouration or burising
6. Loss of function
7. Crepitus

Think - some people bite the lolly, creepy demons

Question 17

What should nerve be done to a limb with a suspected fracture ?

Answer 17

It should never be moved suddenly and never without support from a splint

Question 18

For someone experiencing pain from a potential fracture what should the doctor ensure to provide ?

Answer 18

Adequate pain relief

Question 19

How can a fracture result in deformity ?

Answer 19

The position of the distal fragment of a fractured bone is determined by gravity, the position of the proximal fragment is determined by the muscles ==> this difference can result in deformity.

Sometimes the deformity is influenced by the direction of the force which caused the fracture.

Question 20

What is meant when saying one of the signs of a fracture is tenderness

Answer 20

As well as being painful, the area around a suspected fracture is tender - it hurts when touched or pressed

Question 21

Swelling is a normal reaction to injury, what does excessive swelling result in ?

Answer 21

Pain and makes recovery more difficult

Question 22

How may swelling in the injured part be reduced, explain specifically how this would be done for a fracture in the arm and also in the leg?

Answer 22

To reduce swelling, the injured part can be elevated

• An injured arm should be raised above the level of the heart as this will help fluid to drain.
• In the case of an injured leg, the injured person should be lying down with the leg raised above chest level

Question 23

No single act is more important than… in the first aid treatment of fractures ?

Answer 23

The reduction of swelling

Question 24

What sign can loss of blood and swelling cause on the skin of a fracture site?

Answer 24

Discolouration and bruising

Question 25

It is possible to age an injury according to the discolouration (change in colour) present - T or F?

Answer 25

True

Question 26

Describe discolouration present as time progresses in a bruise

Answer 26

• At first it is dark because of the deoxygenated blood loss into the soft tissues.
• Then, as the haemoglobin in the red blood cells is broken down and carried away to the liver by scavenger cells, the colour changes to green and then to yellow.

Question 27

How may crepitus be perceived as when examining an injury and potentially suggesting a fracture ?

Answer 27

A grating feeling

Question 28

During clinical examination, as well as looking for signs of a fracture, what should the clinician be also making an assessment of injury to ?

Answer 28

The clinician makes an assessment of the injury to other body tissues such as: the skin, the fat, the muscle, the blood vessels, and the nerves.

Question 29

If a fracture is suspected from history and examination what it be confirmed with ?

Answer 29

Investigative techniques e.g. X-ray, U/S etc

Question 30

What are the 5 common investigative techniques which can be done to aid in diagnosis of management of a fracture ?

Answer 30

1. X-rays
2. Tomograms e.g. computerised tomograph (CT)
3. Computerised Axial Tomography - CAT scan
4. Ultrasound
5. Radioisotope scanning

Question 31

What technique is the mainstay for investigating suspected fractures ?

Answer 31

X-ray

Question 32

Define what a radiograph is

Answer 32

This is an x-ray picture

Question 33

What is the use of a radiograph

Answer 33

It confirms/excludes diagnosis of a fracture and aids in management

Question 34

What are the 2 standard views of radiographs taken of an area suspected to have a fracture and why are 2 views taken?

Answer 34

• One in the sagittal and one in the coronal plane
• 2 views are taken to reduce the chances of missing any injury

Question 35

What is a tomogram

Answer 35

It is a view of “slice” through a part of the body

Question 36

What is the difference between earlier and modern tomograms now ?

Answer 36

• The earliest tomograms were obtained using a narrow beam of X-rays which were moved, with the X-ray film, round the part of the body to be investigated, this technique did not produce very clear pictures, and gave the injured person an undesirably large dose of X-rays.
• Modern tomographic X-ray machines use electronic detectors in place of Xray film

Question 37

What are modern tomographic X-ray machines e.g. CT very useful for ?

Answer 37

Where an area is difficult to distinguish because of many structures overlapping. For instance the axis bone in the cervical region of the spine is often difficult to see on a radiograph amongst confusing shadows at the base of the skull and from the jaw and teeth.

Question 38

Describe what Computerised Axial Tomography is

Answer 38

Using modern tomographic techniques, computers can be used to generate tomograms on a video screen, and to print out the results on paper.

Question 39

What can ultrasound be used to show when investigating a fracture ?

Answer 39

The resulting accumulation of fluid (especially blood).

Question 40

Describe how radioisotope scanning works

Answer 40

1. This technique involves injecting a very small quantity of a radioactive substance into the bloodstream of the injured person.
2. The radioactive substance attaches to phosphate molecules which are actively taken up by bone.
3. The radioactive substance therefore ends up in the bones. An X-ray plate is then exposed under the affected part of the body and a radiograph of the bone is obtained.
4. The more metabolically active the bone is, the faster it takes up the radioactive substance. The sites of unusual metabolic activity (i.e. at the site of the fracture) can be clearly seen on the radiograph.

Question 41

When can radioisotope scanning be useful ?

Answer 41

When there is clinical doubt, it can help in determining if there is a fracture or not

Question 42

Is radioisotope scanning useful in acute situations ?

Answer 42

No - it is more useful in non-acute situations at about two weeks from the time of injury.

Question 43

Radioisotope scanning is a highly sensitive test but what does it not tell us ?

Answer 43

It does not tell us anything about the fracture except it is there

Question 44

When what specific fracture is suspected is radioisotope scanning used ?

Answer 44

When a scaphoid (a bone in the wrist) fracture is suspected, as this is not easily seen on a first X-ray.