Other fractures

Question 1

The pelvic ring is formed by:

Answer 1

• Two innominate bones (ilium, ischium and pubis)
• Sacrum
• Supporting ligaments

Question 2

What is the most common cause of pelvic injury?

Answer 2

High energy blunt trauma, such as road traffic accidents or falls from height

Question 3

Clinical features of a pelvic fracture

Answer 3

• Significant pain and swelling around the pelvis
• Full neurovascular assessment is required, including checking anal tone

Question 4

Pelvic fracture investigations

Answer 4

• 3 plain film radiographs are required to completely assess the pelvic ring
• However in a trauma setting, often a CT scan is performed as part of the patient assessment, which usually negated the need for plain films

Question 5

Initial management of pelvic fracture

Answer 5

• Initial management of a patient with high energy trauma follows the ATLS guidelines and should always begin with a primary survey to identify life threatening injuries
• Pelvic binder to give skeletal stabilisation (required for clot formation)

Question 6

What is the syndesmosis is of the ankle?

Answer 6

The tibia and fibula are joined at the syndesmosis, a very strong fibrous structure comprised of the anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament and the intra-osseous membrane.

Question 7

How can ankle fractures be classified anatomically?

Answer 7

• Isolated lateral maleolar fractures
• Isolated medial malleolar fractures
• Bimalleolar fractures (medial + lateral malleolar fracture)
• Trimalleolar fractures (medial + lateral + posterior malleolar fracture)

Question 8

How are lateral malleolus fractures classified?

Answer 8

• Type A = below the syndesmosis
• Type B = at the level of the syndesmosis
• Type C = above the level of the syndesmosis

(The more proximal the injury, the higher the likelihood of ankle instability)

Question 9

Clinical features of ankle fracture

Answer 9

• Ankle pain following traumatic injury
• May be associated deformity

Question 10

Investigations for ankle fracture

Answer 10

A plain radiograph should be obtained in all suspected cases, with both AP and lateral views. (Ensure ankle is in full dorsiflexion.)

Check joint space for uniformity ensuring there is no talar shift.

Question 11

Management of ankle fracture

Answer 11

• Immediate fracture reduction
• Once reduced, ankle should be placed in a below knee back slab
• Repeat neurovascular examination
• Repeat plain film radiography

Question 12

Which ankle fractures will require surgical management?

Answer 12

Open reduction and internal fixation

• Displace bimalleolar or trimalleolar fractures
• Weber C fractures
• Weber B fractures with Talar shift
• Open fractures

Question 13

What percentage of all fractures do distal radius fractures represent?

What is the most common type of radius fracture?

Answer 13

25% of all fractures seen clinically

Colles’ fracture account for 90% of distal radius fractures

Question 14

Describe a Colles’ fracture

Answer 14

An extra-articular fracture of the distal radius with dorsal angulation and dorsal displacement, within 2cm of the articular surface.

Question 15

How does a Colles’ fracture occur?

Answer 15

It occurs when a person falls forwards and plants their outstretched hand in front of them. The transfer of load as their body fall forces the wrist into supination.

This type of fracture typically occurs as a “fragility fracture” in osteoporotic bone.

Question 16

Clinical features of a distal radius fracture

Examination

Answer 16

• Episode of trauma
• Immediate pain +/- deformity
• Sudden swelling around fracture site

On examination:

• Check for neurovascular compromise

Question 17

Investigations for distal radius fracture

Answer 17

Plain film radiograph

Question 18

Which nerve is at high risk of being damaged in a humeral shaft fracture?

If this nerve is involved what features would this produce?

Prognosis of nerve injury

Answer 18

Radial nerve (10%)

If the radial nerve is involved, the patient may complain of reduced sensation over the dorsal 1st webspace and weakness in wrist extension.

90% will improve within 3 months without any intervention.

Question 19

Clinical features of humeral shaft fracture

Answer 19

• Pain and deformity
• May occur from a fall directly onto the outstretched limb or falling laterally onto an adducted limb

Question 20

In which part of the humerus do the majority of humeral shaft fracture occur?

Answer 20

Middle third of the humerus

Question 21

Humeral shaft fracture investigations

Answer 21

• Plain film radiograph
• AP and lateral views
• Elbow and shoulder should be visible

Question 22

The majority of humeral fractures can be managed conservatively. What is the conservative management of a humeral fracture?

Answer 22

• Realignment of the limb
• Fuctional humeral brace

Question 23

Clinical features of a fractured scaphoid

Answer 23

• High energy trauma
• Sudden onset wrist pain

Examination:

• Tenderness on floor of anatomical snuffbox
• Pain on palpating the scaphoid tubercle
• Pain on telescoping of the thumb

Question 24

Investigations for scaphoid fracture

Answer 24

• Initial plain radiographs: a scaphoid series
• If initial imaging negative but there is significant clinical suspicion, the patient should have wrist immobilisation in a thumb splint and repeat plain radiographs in 10-14 days for further evaluation
• If repeat radiograph imagin is negative, but there remains clinical suspicion, an MRI scan is indicated

Question 25

Complications of scaphoid fracture

Answer 25

• Avascular necrosis
• Mal-union (the bone failing to heal properly)