Orthopaedics unit 5 Common fractures - deck 3

Question 1

What is the essential strategy of long-term fracture management

Answer 1

To return the injured person to their pre-injury level of function by the safest means possible.

Question 2

What are the 3 main factors which will determine the tactics used to achieve the aim of long-term fracture management ‘‘to return the injured person to their pre-injury level of function by the safest means possible.’’

Answer 2

1. The injured person
2. The injury
3. The surgeon.

Question 3

Define what is meant by the term ‘definitive management’

Answer 3

This is defined as the technique used (after bleeding and pain have been controlled) to restore normal function to the injured part of the body (usually a limb), after a fracture

Question 4

What are the main factors which determine the functional requirements of the individual and what you need to aim to achieve in terms of restoring function for that individual ?

Answer 4

• Age
• Physical health
• Occupation

Question 5

Describe why in older individuals the clinician may opt for a less than perfect result in the management of their fracture, as long as it doesn’t affect their daily acitivities

Answer 5

Older people may have poor bone quality due to osteoporosis, and may have medical problems such as heart disease or diabetes. The benefit must outwiegh the risk when providing treatment and in some of these scenarios the benefit to these individuals may not out-weigh the risk ==> opting for a less than perfect management strategy

e.g. how fractures of the wrist are treated in the elderly. The fracture may be treated under local anaesthesia in A&E. Although this might not achieve the perfect result, the injured person can then be discharged home to an environment where they may function satisfactorily without further extensive treatment, which could lead to unnecessary complications such as bedsores, pneumonia or urinary infections.

Question 6

Why may on the other hand a young fit, right-handed craftsman or woman who injures his/her right wrist joint may be prepared to spend many months undergoing treatment to ensure a perfect result?

Answer 6

Because that is what is required for his/her long-term health and employment security.

Question 7

What is the key thing to remember when deciding on a treatment strategy ?

Answer 7

The benefits must out-weigh the risks

Question 8

Appreciate this:

A young and well person will tolerate long-term treatment and surgery with no physical detriment, but in the older patient, perfect function may sometimes only be achieved at the expense of the risk of complications.

Question 9

When managing someones injury what should not be underestimated ?

Answer 9

They psychological effects caused by the injury

Question 10

In order to achieve acceptable function following a fraction, what must be done ?

Answer 10

The anatomy of a fracture should be returned to as near normal as is safely and practically possible

Question 11

What is the difference in margin for error for restoring the normal anatomy of a fracture which passes into a joint compared to a fracture which occurs through the shaft of a long-bone?

Answer 11

• If a fracture passes into a joint then the anatomy needs to be restored very accurately to normal in order to achieve acceptable function
• Whereas if a fracture occurs in the shaft of a long bone then the margin for error is much greater and something less than perfect is acceptable

Question 12

Is it possible to achieve restoration of normal function in all fractures ?

Answer 12

No some injuries are so severe that normal restoration is impossible.

Question 13

How is restoration of a fracture to a normal position is achieved?

Answer 13

Reduction:

The fracture must be reduced to the normal position and then held there until the bone heals naturally.

Question 14

How is closed reduction of a fracture achieved ?

Answer 14

By traction on the distal fragment and then a relocation of that distal part back onto the proximal fragment by manipulation

Question 15

What is necessary to ensure the patient is provided in order to achieve a reduction of a fracture ?

Answer 15

Adequate analgesia - general or regional anaesthesia may be used.

Question 16

What does manipulation of the distal part of the fracture usually involve ?

Answer 16

Usually involves reversing the direction of the deforming force

Question 17

If closed reduction of a fracture is unsuccessful what can be done to reduce the fracture?

Answer 17

Open reduction - the fracture site is opened surgically and the fragments are relocated directly under vision.

Question 18

What must be done once a fracture has be adequately realigned via reduction ?

Answer 18

It must 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 some load (consolidated).

Question 19

What are the 4 main ways in which a fracture can be held in place and describe them

Answer 19

1. Casting - surrounding the broken limb with a hard ‘coat’ which holds the fracture steady.
2. Internal fixation - holding broken bones together using screws and plates inside the body.
3. External fixation - an external ‘bar’ outside the body attached to pins sited in the broken bones.
4. Traction - pulling on a broken limb to align the bones.

Question 20

Once the fracture is manipulated, the holding exercise may simply involve placing the limb in a plaster of Paris cast until when?

Answer 20

Union

Question 21

What 2 things must a cast ensure correct healing of a fracture ?

Answer 21

Fracture must be held in the correct position by the cast and it must be maintained at the proper length

Question 22

If a cast holds the fracture fragments too far away from each other what may happen?

Answer 22

Delayed union of the fragments

Question 23

In order to ensure complete control of all dimensions of the fracture the cast must what?

Answer 23

Immobilise the joints above and below the fracture site, as joint movement may result in distortion in one or more dimensions.

Question 24

How does a cast work?

Answer 24

A cast acts as a splint.

By controlling joint movement and position it may be used to control posture. The plaster cast is moulded so that the pressure is exerted at three points, holding the fractured bone in the correct position until it has healed.

Question 25

What are the main disadvantages of casts ?

Answer 25

• They are heavy and they immobilise the joints.
• Clinicians cannot examine the covered part, or use investigative techniques such as Xray
• Cost and inconvenience in having to remove them during treatment to assess progress
• The immobility imposed on a limb results in muscle wasting and limited mobility due to joint stiffness.

Question 26

What can be used to overcome the disadvantages of regular plaster cast ?

Answer 26

By freeing the joints and using functional braces

Question 27

In order to maintain three-dimensional control of the fracture when using a functional brace what is it necessary to do?

Answer 27

It is necessary to support the cast at the joints by a combination of accurate moulding and the provision of hinges

Question 28

What directions of motion are usually permitted by the hinges in a functional cast brace?

Answer 28

Motion in one direction, usually flexion and extension.

Question 29

Why do functional cast braces tend to be used after a few weeks ?

Answer 29

Because they are highly dependent on a very accurate fit, so used when pain and swelling have settled

Question 30

Why were new materials developed for making casts

Answer 30

Because Plaster of Paris is relatively brittle, is messy and is very difficult to apply well. It is heavy and awkward particularly for an elderly person and, as it takes up to three days to dry, it can be very inconvenient.

For these reasons stronger and lighter new materials have been developed.

Question 31

What are the new materials used for casts ?

Answer 31

Glass fibre and polyurethane resin combinations.

Question 32

When are the new materials used for casts and why?

Answer 32

They are used used as secondary casts a week or two after the injury, once swelling has settled. Because they are not as versatile as the Plaster of Paris casts

Question 33

What are the new materials for casts ideal for making ?

Answer 33

Cast braces (functional cast braces)

Question 34

Injury to what are high energy fractures often associated with ?

Answer 34

Extensive soft-tissue damage, which often results in breaching of the skin or even loss of soft tissue.

Question 35

In terms of healing what is it important to initially have for high energy fractures which has caused extensive soft-tissue damage

Answer 35

Because the blood supply is severely damaged, it is important to have an initial phase of soft tissue healing

Question 36

Why are plaster splints and internal fixation highly unsuitable for high-energy fractures with extensive soft-tissue damage ?

Answer 36

Plaster splints are highly unsuitable because the wounds become inaccessible.

Internal fixation is hazardous because of ischaemia (lack of blood), and wound contamination increases the risk of an infection being introduced during surgery.

Question 37

Define ischaemia

Answer 37

This is the lack of blood supply to an organ or part of the body

Question 38

What device can be used to allow an initial phase of soft tissue healing in high-energy fractures with extensive soft tissue damage?

Answer 38

External fixators

Question 39

Describe what an external fixator is and how it works

Answer 39

It is a 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.

Question 40

When were external fixators initially designed to be removed ?

Answer 40

Once the soft tissues healed, fracture treatment continued by other means

Question 41

Is it possible now to once the soft tissues have healed to definitively treat the fracture with an external fixator ?

Answer 41

Yes - particularly if the fixator can be adjusted in the later stages to permit some movement (dynamisation) at the fracture site.

Question 42

What is the main problem associated with external fixators ?

Answer 42

Infection - the pin sites which are an easy route for infection

Question 43

When is internal fixation used in the treatment of fractures ?

Answer 43

Where a high degree of accuracy is required, or other methods fail

Question 44

What does internal fixation of a fracture involve

Answer 44

This involves the holding of the fractured bone with devices such as screws, nails or plates.

Question 45

Why arent all fractures treated using internal fixation ?

Answer 45

1. It is very technically demanding
2. Has many complications
3. It prevents natural healing.

Question 46

What are the 4 main ways in which internal fixation of a fracture can be achieved ?

Answer 46

1. Apposition.
2. Interfragmentary compression.
3. Interfragmentary compression plus onlay device.
4. Inlay device.

Question 47

Define what apposition means

Answer 47

Together in aligement

Question 48

If internal fixation is to be used once a fracture has been realigned what may the fragments only need to be held in for satisfactory healing?

Answer 48

They may only need to be held apposition (together in alignment)

Question 49

When internal fixation is to be used who often only needs a fracture to be held in apposition for satisfactory healing to occur ?

Answer 49

Children

Question 50

What device can apposition of a fracture be achieved with?

Answer 50

By using semi-flexible wires known as K or Kirschner wires

Question 51

How do k-wires work?

Answer 51

They hold position without producing immobility and so healing occurs by natural callus formation.

They can be left standing proud of the bone and so can easily be pulled out once union is established and before consolidation.