Principles of Fracture Management

Question 1

What is the important adage for fractures

Answer 1

Reduce, Hold, Rehabilitate

Question 2

Define reduction (3)

Answer 2

1 restoration of anatomical alignment 2 of fracture or dislocation 3 of an affected limb

Question 3

How reduction benefits fracture site (2)

Answer 3

1 tamponade of bleeding 2 reduced traction on soft tissues

Question 4

Effects of swelling at wound site (2)

Answer 4

1 increased risk of complication 2 which can delay surgery

Question 5

Advantage of reduction for nerves (2)

Answer 5

Reduced traction reduces: 1 risk of neuropraxia 2 risk of nerve damage

Question 6

Advantage of reduction of vascular system (2)

Answer 6

1 reduced pressure in local blood vessels 2 which restores any affected blood supply

Question 7

Main principle in reduction

Answer 7

Correct deforming forces that resulted in injury

Question 8

Ways reduction may be performed (3)

Answer 8

1 closed 2 open 3 intra-operatively

Question 9

Why reduction requires anaesthesia

Answer 9

Painful

Question 10

Means of anaesthesia in reduction (2)

Answer 10

1 local/regional blockade 2 conscious sedation

Question 11

Requirements for conscious sedation

Answer 11

1 anaesthetic agents 2 airway adjuncts 3 monitoring

Question 12

Why reduction requires two people

Answer 12

1 one for reduction manoeuvre 2 another for counter traction

Question 13

Define ‘hold’ of a fracture

Answer 13

Immobilising a fracture

Question 14

When is traction required

Answer 14

Pull of soft tissues makes fracture unstable

Question 15

Examples of fractures which require traction in hold (3)

Answer 15

1 Subtrochanteric 2 femoral shaft 3 displaced acetabular fractures

Question 16

Methods of holding fractures (4)

Answer 16

1 casting 2 internal fixation 3 external fixation 4 locking plates

Question 17

Why back slabs used in initial holding (2)

Answer 17

1 Allow fracture to swell 2 without causing compartment syndrome

Question 18

Advantages of casting (4)

Answer 18

1 simplest and 2 cheapest method 3 quick pain relief 4 lowest infection risk

Question 19

Complications with casting (3)

Answer 19

1 pressure sores 2 loosening/breakdown 3 thromboembolism

Question 20

Indications for internal fixation (7)

Answer 20

1 unstable fractures 2 intra-articular fractures 3 neurovascular damage 4 polytrauma 5 elderly patients (lower limb) 6 long bone fractures 7 failure of conservative management

Question 21

Why internally fixate an intra-articular fracture

Answer 21

Decrease risk of OA (NoF)

Question 22

Need for internal fixation in fractures with neurovascular damage

Answer 22

Stability prevents repaired structures being damaged by fragments

Question 23

Advantage of internal fixation in polytrauma (2)

Answer 23

1 Allows early mobilisation and 2 facilitates nursing care

Question 24

Advantage of internal fixation in lower limb fractures of elderly patients

Answer 24

Long periods of immobilisation poorly tolerated

Question 25

Define ‘failure of conservative treatment’ in fractures

Answer 25

Loss of acceptable alignment

Question 26

Methods of internal fixation (4)

Answer 26

1 compression plate and screws 2 k wires 3 locking plate and screws 4 tension band wiring

Question 27

Complications of internal fixation (5)

Answer 27

1 infection 2 neurovascular injury 3 non union 4 implant failure leading to 5 further fracture on removal

Question 28

Indications for external fixation (5)

Answer 28

1 Open with ++soft tissue damage 2 highly comminuted or unstable 3 initial stabilisation for damage control 4 periarticular (tibial plateau/pilon) 5 salvage in mal/non union

Question 29

Most common method of external fixation

Answer 29

pin and rod construct

Question 30

Complications of external fixation (3)

Answer 30

1 pin site infection 2 soft tissue/neurovascular injury 3 over-distraction leading to non union

Question 31

What is locking plate fixation (2)

Answer 31

1 thread screw heads which 2 engage and lock plate in place

Question 32

Transmission of forces in locking plate (3)

Answer 32

1 bone 2 to screw 3 to plate

Question 33

Why are locking plates stronger than normal plates (2)

Answer 33

1 provide angular stability 2 all screws act in unison

Question 34

Advantages of locking plates

Answer 34

1 no compression of periosteum 2 don’t require contouring 3 can be placed percutaneously (avoids soft tissue stripping)

Question 35

What is ‘rehabilitation’ in fracture management

Answer 35

Extensive period of physiotherapy

Question 36

Why fractures are rehabilitated following management (2)

Answer 36

1 prevent stiffness 2 allowing recovery from injury

Question 37

Social implication of frailty, immobility and non-weight bearing following fractures

Answer 37

Inability to cope at home

Question 38

Important rehabilitation consideration in fractures involving frailty

Answer 38

Home adaptations to facilitate recovery