Regional Adult Trauma Master Deck Flashcards
Cautions with cervical spine fractures?
Potentially dangerous unstable fractures that may be missed in the unconscious/confused patient; this can leads to spinal cord injury
Low threshold for C-spine immobilisation with a hard collar OR blocks on a spinal board in ANY HIGH-ENERGY INJURY or head injury
How is a patient given a clinically clear C-spine following trauma?
- No history of loss of consciousness
- GCS 15 with no alcohol intoxication
- No significant distracting injury
- No neurological symptoms in upper/lower limbs
- No midline tenderness on palpation of the C-spine
- No pain on gentle active neck movement (ask patient to gently flex forward then rotate to each side)
What to do if a patient is not clinically cleared of a C-spine injury?
C-spine must stay in the collar
X-ray (AP and lateral views +/- odontoid peg open mouth view) OR CT scan is required so that the C-spine can be cleared
When are C-spine fractures/dislocations fatal?
At a high level, esp. over C3, they may be fatal (above the phrenic nerve)
Mx of C-spine fractures?
If more stable, they can be treated in a firm cervical collar
Unstable injuries may require a “halo” vest (type of external fixator); some may have surgical stabilisation
Subluxations and dislocations may require traction (for reduction) and halo application OR operative stabilisation
What do thoracolumbar spinal fractures of low energy and in osteoporotic bones tend to be?
“Wedge” insufficiency fractures - symptomatic treatment
What do thoracolumbar spinal fracture of higher energy in younger patients tend to be?
“Burst” fractures
OR
“Chance” flexion-distraction fractures (failure of posterior ligaments) - may be unstable and require operative stabilisation; if more stable, may be treated with a brace to limit flexion or, if more stable, with a plaster jacket
Indications for surgery in thoracolumbar spinal fractures?
- Presence of neurological deficit, esp. if progressive or very unstable injury
- Unstable injury pattern with substantial loss of vertebral height, displacement or inv. of the posterior ligamentous structures
What is spinal shock?
Physiologic response to injury with complete loss of sensation and motor function and loss of reflexes
Signs of spinal shock?
Bulbocavernous reflex is absent; its return signals the end of spinal shock
Reflex contraction of the anal sphincter with either a squeeze of the glans penis, tapping the mons pubis or pulling on a urethral catheter
What is neurogenic shock?
Occurs secondary to temp. shutdown of sympathetic outflow from T1-L2, usually due to cervical/upper thoracic injury
Leads to hypotension and bradycardia (usually resolves within 24-48 hours)
Treatment of neurogenic shock?
Must differentiate from other forms of shock (e.g: hypovolaemic is the most common and responds to fluid replacement)
IV fluid therapy
Types of spinal cord injuries?
- Complete spinal cord injury - no sensory or voluntary motor function below the level of the injury (reflexes should return); prognosis is poor
- Incomplete spinal cord injury (some sensory and/or motor function is present distal to the level of injury); greater the function present, faster the recovery and better the prognosis
How is the level of injury in a complete spinal cord injury determined?
Most distal spinal level with partial function (after spinal shock has resolved) is determined by the presence of dermatomal sensation and myotomal skeletal muscle voluntary contraction
Good signs in incomplete spinal cord injury?
SACRAL SPARING with preservation of:
• Perianal sensation
• Voluntary anal sphincter contraction
• Big toe flexion
Indicates some continuity of corticospinal (motor) and spinothalamic (coarse touch, pain, temp) tracts
What are the dermatomes of the upper limb?
…….
What are the dermatomes of the lower limb?
……….
Myotomes of the upper limb?
C5 - abduction of arm
C5(6) - flexion of elbow
C8 - flexion of digits
T1 - adduction and abduction of digits
Myotomes of the lower limb?
L1, L2 - hip flexion L3, L4 - knee extension L5, S2 - knee flexion S1, S2 - foot plantarflexion L5 - great toe dorsiflexion
Treatment of spinal cord injury?
Aim to prevent further damage and prevent comps of paralysis:
• Appropriate immobilisation
• Traction may be required where an unstable fracture/dislocation exists
Surgery can be used to relieve pressure on the cord or to stabilise unstable injuries
Pressure area can have spinal beds to reduce pressure sore occurrence from paralysis
If loss of intercostal muscle function, use ventilatory support
What is central cord syndrome?
Caused by incomplete cord injury and is the most common injury pattern; tends to occur with hyperextension injury in a cervical spine with OA
Often there is an assoc. fracture or dislocation
Symptoms and signs of central cord syndrome?
Paralysis of the arms more than legs
Sacral sparing is typical
Describe anterior cord syndrome
Results in loss of motor function as well as loss of coarse touch, pain and temp sensation
Proprioception, vibration sense and light touch are preserved
Causes of pelvic fractures?
In younger patients, due to high energy injuries
Older patients have osteoporosis and can sustain pubic rami fracture from low energy injuries
Describe the pelvic ring
If pelvic ring is disrupted in one place, there is invariably a further disruption in the ring, e.g: fracture or ligamentous injury with the SI joint
Complications of pelvic ring fractures?
Prone to injury:
• Branches of the internal iliac arterial system and the pre-sacral venous plexus (risk of hypovolaemia)
• Nerve roots and branches of the lumbosacral plexus
3 main patterns of injury in the pelvis?
Lateral compression fracture - occurs with side impact, e.g: RTA, and 1/2 of the pelvis is medially displaced
Vertical shear fracture - occurs due to axial force on 1 hemipelvis, e.g: fall from height, and the affected side is displaced superiorly
Anteroposterior compression injury - can cause wide disruption of pubis symphisis (open-book pelvic fracture)
Complications with lateral compression fractures?
Fractures through the pubic rami or ischium are accompanied by a sacral compression fracture or SI joint disruption
Complications with a vertical shear fracture?
Sacral nerve roots and lumbosacral plexus are at high risk of injury (major haemorrhage can occur)
Sign of vertical shear fracture?
Leg on affected side appears shorter
Complications of anteroposterior compression injury?
Bleeding from torn vessels with increase in pelvic volume (due to displacement); wide displacement can cause pelvis to contain the entire circulating volume before tamponade and clotting can occur
Treatment of open book pelvic fractures?
Promptly reduce displacement and minimise pelvic volume to allow tamponade of bleeding to occur:
• Apply tied sheet or pelvic binder around outside of pelvis (temp reduction)
• External fixator provides more secure initial stabilisation
Mx if there is ongoing haemodynamic stability despite temporary pelvic reduction?
Angiogram and embolisation OR open packing of the pelvis (if laparotomy is required for coexisting intra-abdominal injuries)
Treatment of bladder and urethral injuries in a pelvic fracture?
Urinary catheterisation may risk furhter injury
Urological assessment and intervention
Why is a PR exam mandatory with pelvic injury?
Assess sacral nerve root function and for presence of blood (indicates rectal tear so the injury is an open fracture and there is a higher risk of mortality)
Main type of pelvic fracture that occurs in low energy injuries of elderly? Treatment?
Tend to be minimally displaced lateral compression injuries (with sacral fracture or SI joint disruption posteriorly)
Settle with conservative Mx
Causes of acetabular fractures?
Usually in young patients with high-energy injuries but may be low-energy in older patients
Injury assoc. with a posterior acetabular wall fracture?
Assoc. with hip dislocation
Posterior wall is fractures as the head of the femur is pushed out the back of the joint, e.g: driver’s knee collides with the dashboard in an RTA
Ix of acetabular fractures?
X-ray (oblique views may help) and CT scans
Treatment of acetabular fractures?
Undisplaced/small wall fractures - conservative Mx
Intra-articular, unstable or displaced fractures - anatomic reduction and rigid fixation in the young patient (reduce risk of post-traumatic OA); older patient may need THR
Cause of humeral neck fractures?
Common and usually low-energy injuries of osteoporotic bone, due to FOOSH (fall on outstretched hand) or falling directly onto the shoulder
Most common fracture pattern in humeral neck fractures?
Fracture of the surgical neck with medial displacement of the humeral shaft, due to pull of the pectoralis major muscle, is MOST COMMON
Greater and lesser tuberosities may also be avulsed
Isolated fractures of the greater tuberosity and head-splitting intra-articular fractures may also occur
Treatment of humeral neck fractures?
Minimally displaced proximal humerus fractures - conservative with a sling and gradual mobilisation
Displaced fractures - position tends to improve once muscle spasm settles; if persistently displaced, treat with internal fixation
3/4 part comminuted fractures - conservative and operative Mx is disappointing
Head-splitting fractures - shoulder replacement (unless younger patient with good bone quality)
Complications of internal fixation?
Part. in elderly patients:
• Stiffness
• Chronic pain
• Failure of fixation
Complications of 3/4 part comminuted fractures of the humeral neck?
AVN of the humeral head resulting in chronic pain
Bone fragments can be thin and of poor quality, so screws and wires can “cut out” - failure of fixation
With shoulder replacement, there is difficulty reattaching tuberosities so rotator cuff dysfunction occurs and range of motion is limited
Most common type of shoulder (GH joint) dislocation?
Anterior dislocation
Causes of anterior shoulder dislocation?
Excessive EXTERNAL ROTATION
Fall onto back of the shoulder
Seizures (may cause bilateral dislocations)
Complications of anterior shoulder dislocation?
Often causes detachment of the ANTERIOR GLENOID LABRUM and capsule (AKA Bankart lesion)
Posterior humeral head can impact on anterior glenoid, producing an impaction fracture of the posterior head (AKA Hill-Sachs lesion)
Axillary nerve may be stretched as it passes through the quadrilateral space (other nerves of the brachial plexus and the axillary artery can also be stretched)
In older patient, rotator cuff tears are very common
Symptoms and signs of anterior shoulder dislocation?
- Arm held in an adducted position, supported by the patients’s other arm
- Loss of symmetry
- Loss of roundness of the shoulder
- Loss of sensation in the regimental badge patch area (if there is axillary nerve injury)
- Difficult to assess deltoid contraction in the acute phase
Ix for anterior shoulder dislocations?
X-ray confirms injury (2 views); repeated after reduction for confirmation
Mx of anterior shoulder dislocation?
Closed reduction under sedation/anaesthetic (NV assessment before and after); sling for 2-3 weeks to allow healing of detached capsule
Followed by rehab and physio
If delayed presentation, may require open reduction
If assoc. fracture of the greater tuberosity, usually reduced to acceptable position with reduction of the shoulder but ORIF is usually required if it remains displaced
Risk of recurrent dislocation?
If <20 years, 80% chance of re-dislocation:
• Advise stabilisation surgery after 1st time dislocation
If >30 years, 20% risk of re-dislocation:
• Physiotherapy
Treatment of recurrent dislocations of the shoulder?
Bankart repair (reattachment of the torn labrum and capsule by arthroscopic or open means)
Causes of marked ligamentous laxity?
- Idiopathic generalised ligamentous laxity/hypermobility
* Connective tissue disease, e.g: Ehlers-Danlos syndrome, Marfan’s syndrome
Describe dislocation in patients with marked ligamentous laxity
Tend to have atraumatic multi-directional dislocation
Some patients can voluntarily dislocate
Surgery for marked ligamentous laxity as a cause of shoulder dislocation?
Less predictable outcomes:
• Open tightening of the shoulder capsule (AKA capsular shift) can improve stability but tightened capsule may stretch again
• Physiotherapy to strengthen the rotatory cuff muscles, which are secondary restraints to dislocation (MAINSTAY TREATMENT)
Cause of posterior shoulder dislocations?
Posterior force on an adducted/internally rotated arm
Signs and Ix of posterior shoulder dislocations?
Humeral head may be palpated posteriorly
X-ray findings are less obvious (main finding is light bulb sign - excessively internally rotated humeral head looking like this on an AP view); lateral views help
Treatment of posterior shoulder dislocations?
Closed reduction and a period of immobilisation followed by physiotherapy
Cause of AC joint injuries?
Usually occur after a fall onto the point of the shoulder (common sporting injury)
Types of injuries of the AC joint?
- Sprained
- Subluxed (assoc. with AC ligaments rupture)
- Dislocated (assoc. with coracoclavicular ligament, conoid and trapezoid, disruption)
Treatment of AC joint injuries?
Mostly conservative (sling for a few weeks followed by physio)
Surgery (reconstruction of coracoclavicular ligaments) is reserved for chronic pain
Cause of humeral shaft fractures?
Direct trauma, e.g: RTA, causing transverse or comminuted fracture
Fall with/without twisting injury causing oblique or spiral fractures
Accepted angulation of humeral shaft fractures
Union rates are high and, due to mobility of ball and socket shoulder joint proximally and the elbow joint distally, up to 30 degrees of angulation accepted
Assoc. injury with a humeral shaft fracture?
Radial in the spiral groove is susceptible to injury (presents with WRIST DROP and loss of sensation in the 1st dorsal web space)
Treatment of humeral shaft fractures?
Mostly non-operative:
• Functional humeral brace (compresses fragments into acceptable alignment and provides stability)
Surgical:
• Internal fixation with IM nail OR plate and screws (quicker recovery)
• Non-unions require plating and bone grafting
Types of elbow injuries?
- Supracondylar fracture (usually in children)
- Intra-articular distal humerus fracture
- Olecranon fracture (usually due to fall onto the point of the elbow with contraction of the triceps muscle)
- Radial head and neck fractures
- Elbow dislocation and fracture dislocation
Treatment of olecranon fractures?
Majority have ORIF to restore triceps function and articular surface
Simple transverse avulsion fracture can be fixed with tension band wiring (compresses tension side of fractures)
Comminuted fractures do not have a fulcrum for the tension band so require ORIF with plate and screws
Structure of the forearm?
Radius and ulna are proximally and distally connected by strong ligaments around the proximal and distal radio-ulnar joints (where supination and pronation occur)
Forearm acts as a ring (if one bone fractures, there is usually a fracture/dislocation inv. the other bone)
What is a nightstick fracture?
Isolated fracture of the ulnar shaft after a direct blow, e.g: defensive fracture
Ensure there is no assoc. Monteggia fracture
Treatment of nightstick fractures?
Conservative Mx (mostly)
ORIF (earlier return to function and reduced risk of non-union)
Treatment when both bones of the forearm have been fractured?
In adults, usually ORIF with plates and screws as they are highly unstable
In children, minimally angulated fractures treated with plaster (small degree of angulation remodels as the child grows)
Substantially angulated/ displaced fractures with an intact periosteum are only unstable in one direction and can be treated with MUA and plaster
If the fracture is very unstable after reduction, flexible IM nails can be used.
What is a Monteggia fracture dislocation?
Fracture of the ulnar + dislocation of the radial head at the elbow
Ix for Monteggia fracture dislocations?
X-ray may not show incongruence of the radiocapitellar joint (with isolated ulna fractures, perform elbow X-rays)
Treatment of Monteggia fracture dislocations?
ORIF of the ulna fracture (even in children) to reduce radiocapitellar joint
Why is manipulation not used for Monteggia fracture dislocations?
Risks re-dislocation due to the unstable nature of the injury
What is a Galeazzi fracture dislocation?
Fracture of radius + dislocation of ulna at the distal radioulnar joint
Ix for Galeazzi fracture dislocation?
X-rays may not clearly show dislocation (with any isolated radial shaft fracture, lateral X-ray of the wrist is mandatory)
ORIF of the radius is required (allows DRUJ to reduce)
Cause of distal radius fractures?
Common due to FOOSH injury
Types of distal radius fractures?
- Colles fracture
- Smith’s fracture
- Barton’s fracture
- Comminuted intra-articular distal radius fracture
What is a Colles fracture?
Extra-articular fracture of the distal radius within an inch of the articular surface AND with dorsal displacement/angulation
Occurs due to a FOOSH with the wrist extended
Treatment of a Colles fracture?
Depends on the degree of displacement/angulation, the presence of dorsal communition and functional demand of the patient:
• Minimally displaced/angulated fractures - splintage alone
• Any angulation past neutral - manipulation
Fracture may be held with plaster cast alone
OR
Percutaneous wiring OR ORIF with plate and screws if:
• Fracture has dorsal comminution
• Part. unstable after reduction
Complications of Colles fractures?
Median nerve compression from stretch of the nerve
Bleed into the carpal tunnell
Treatment of carpal tunnel syndrome secondary to a Colles fractre?
Reduction of the fracture may relieve pressure on the nerve; fracture is usually stabilised with fixation
Carpal tunnel may need surgical decompression
What is a Smith’s fracture?
Volarly displaceed/angulated extra-articular fracture of the distal radius which usually occurs after a falling onto the back of a flexed wrist
Treatment of Smith’s fractures?
ALL should have ORIF using a plate and screws (highly unstable injuries)
Complications of Smith’s fractures?
Grip strength and wrist extension greatly reduced if there is a malunion with excessive volar angulation
What is a Barton’s fracture?
Intra-articular fractures of the distal radius inv. dorsal/volar rim (where the carpal bones of the wrist joint sublux with the displaced rim fragment)
Classifications of Barton’s fractures?
- Volar Barton’s fracture (intra-articular Smith’s fracture)
* Dorsal Barton’s fracture (intra-articular Colles’ fracture)
Treatment of Barton’s fractures?
As intra-articular, require ORIF
Describe a communited intra-articular distal radius fracture
Distal radius fracture that is so comminuted, e.g: due to high-energy injury or poor bone quality, that stable fixation of the joint fragments is impossivble
Treatment of comminuted intra-articular distal radius fractures?
To restore shortening and hold wrist in reasonable alignment (limit functional deficit), external fixation is sited across the wrist joint
Supplementary wires can be used to pin larger fragments in place
Presentation of Scaphoid fractures?
Usually occur after a FOOSH
Clinical symptoms and signs:
• Tenderness in the anatomic snuff bow
• Pain on compression of the thumb metacarpal
Ix of scaphoid fractures?
X-rays (4 views if scaphoid fracture is suspected, i.e: AP, lateral and 2 oblique views)
Some are not visible on the initial X-ray but can show up on radiographs 2 weeks later (once resorption of the fracture ends as the 1st stage of fracture healing); if clinical suspicion but X-ray normal, splint the wrist and assess after 2 weeks with an X-ray (AKA clinical scaphoid fracture)
Treatment of scaphoid fracture?
- Undisplaced fractures - plaster cast for 6-12 weeks
- Displaced fractures - compression screw sunk into the bone (avoids non-union)
- Non-union is treated with screw fixation and bone grafting
- AVN is difficult to treat but, if patients are symptomatic, partial/total wrist fusion may be required
Complications of scaphoid fractures?
Non-union (synovial fluid inhibits fracture healing); use CT scan to ensure union
AVN of the proximal pole (blood supply distally from a branch of the radial artery)
What is a peri-lunate dislocation?
Dislocation of one of the carpal bones around the lunate; it is uncommon but can occur with severe high-energy wrist injuries resulting from hyperdorsiflexion
Treatment of peri-lunate dislocation?
Emergency - closed reduction and percutaneous pinning OR open reduction
Ligament repairs if necessary
Risk with different types of penetrating hand injuries?
- Volar injuries risk damage to the flexor tendons, digital nerves and digital arteries
- Dorsal injuries risk damage to the extensor tendons
Treatment of penetrating hand injuries?
Low threshold for surgical exploration (tendon may see to functional normally but some can rupture later)
Complete/significant tendon injuries - surgical repair:
Digital nerve injuries proximal to the DIPJ require repair (sensation to the thumb, index and little fingers important)
Injuries to both digital arteries requires microsurgical repair to restore circulation (if only one digital artery is injure, circulation may be fine)
Assoc. injuries with arterial injury to a digit?
High chance of concurrent injury to the adjacent digital nerve
Treatment of extensor tendon injuries?
If divided by 50%/more - surgical repair with splintage in extension for 6 weeks (any flexion may cause failure of repair)
What is mallet finger?
Avulsion of the extensor tendon from its insertion into the terminal phalanx; caused by forced flexion of the extended DIPJ, often from a ball at sport
May be purely tendinous avulsion OR may have a bony fragment
Presentation of mallet finger?
Pain, drooped DIPJ of the affected finger and inability to extend DIPJ
Treatment of mallet finger?
Mallet splint holding the DIPJ extended (worn continuously for at least 4 weeks)
Problems with flexor tendon injuries?
Tendons must run smoothly within the tendon sheath and under the pulelts
Digital nerves are arteries that run adjacent to the tendons in their sheaths are at risk of injury
Injury to:
• Superficial tendon (FDS)
• Deep tendon (FDP) if the injury is distal to the insertion of the FDS
• Both
Treatment of flexor tendon injuries?
Partial divisions with a flap of tendon - smoothed
Significant partial lacerations or complete tendon divisions - repair; fingers are splinted in a flexed position, often with elastic traction (allow early active gentle extension and passive flexion, preventing stiffness and adhesions within the tendon sheath)
Describe why repair of flexor tendons must be done carefully
Preservation of the pulleys to avoid “bowstringing” of the tendon
Treatment of metacarpal fractures?
3rd, 4th and 5th MCP fractures are treated conservatively
Cause of fracture of the 5th MCP?
AKA Boxer’s fracture (often occurs with a punching injury)
Treatment of a 5th MCP fracture?
Up to 45 degrees of angulation can be tolerated without affecting hand function
Neighbour strapping affected digit to adjacent finger; early motion helps maintain function
Check rotational alignment to avoid problems with grip; any overlapping of fingers when making a fist should be corrected by manipulation with neighbour strapping or k‐wire stabilization
Describe a “fight bite” injury
Laceration sustained to puncher’s hand from the punchee’s tooth; could penetrate MCPJ and/or disrupt extensor tendon
Intra-oral organisms can cause infection, leading to septic arthritis
Treatment of “fight bite” injury?
Should NOT be sutured closed; first, explored and thoroughly washed out in theatre
Treatment of phalangeal fractures?
Neighbour strapping or splintage
If significantly displaced/angulated - MUA or digital nerve block
Unstable or intra-articular fractures - k-wiring or fixation with small screws
Occurrence of hip and proximal femur fractures?
Most patients are >80 years and most are FEMALE
Generally osteoporosis related in the elderly population
Most patients have significant co-morbidities:
• CV insufficiency, cardiac arrhythmias, postural hypotension so contribute to their risk of falling
Treatment of hip fractures?
Nearly all patient undergo surgery within the 1st 24 hours; exceptions are:
• Very high risk patients who are expected to die very soon after injury
Why is conservative Mx not really an option in hip fractures?
High risk of problems with recumbency (pressure sores, chest infections)
Muscular atrophy with bed rest so subsequent rehab is difficult
Arterial supply to the femoral head?
Comes from a ring anastomosis of the circumflex femoral arteries at the insertion of the hip capsule at the base of the femoral neck
Medial and lateral circumflex femoral arteries are branches of the profunda femoral artery; arteries from the ring anastomosis travel up the femoral neck and into the femoral head
Classifications of hip and promixal femoral fractures?
- Intracapsular hip fractures (AKA sub-capital) - occur at the level of the neck and the head of the femur, and are generally within the capsule; this is also the type of fracture if it occurs ON the intertrochanteric line
- Extracapsular hip fractures (AKA intertrochanteric) - occurs between neck of the femur and the lesser trochanter
- Subtrochanteric proximal femoral fractures (also extracapsular) - occurs below the lesser trochanter, in the region between the lesser trochanter and an area approx. 2 1/2 inches below
Risks of intracapsular hip fractures?
Disruption of the arterial supply to the femoral head can cause:
• AVN
• Non-union
Treatment of intracapsular hip fractures?
Replacement of the femoral head either with:
• Hemiarthroplasty (replace femoral head alone)
• THR (replaces acetabulum and femoral head)
Preferred treatment of intracapsular hip fractures?
THR has better functional outcome but higher risk of dislocation (for those with higher-functioning hip fracture)
Hemiarthroplasty for those with restricted mobility and cognitively impaired patient `
What are not risks in extracapsular hip fractures?
Should not cause AVN and have a high union rate
Treatment of extracapsular hip fractures?
Internal fixation with the patient’s own natural hip joint:
• Can inc. compression or DYNAMIC HIP SCREW (as the patient weight bears, screw slides in the barrel of the plate and compression of the fracture site occurs, promoting healing)
This fracture tends to heal in a shortened position
Occurrence of subtrochanteric fractures?
Usually occur in the elderly patient with osteoporosis due to a fall onto the side
Risks with subtrochanteric fractures?
Subtrochanteric bone has a fairly poor blood supply and this area is under bending stress so:
• Fractures take some time to heal
• Non-union occurs fairly frequently
Treatment of subtrochanteric fractures?
Pre-operative pain relief and stabilisation can be helped with a Thomas splint (not in some with a hip replacement due to high dislocation rates)
IM nail is recommended - strong indirect fixation without disrupting the blood supply
Occurrence of femoral shaft fractures?
High-energy injuries (high risk of concomitant fracture elsewhere)
Stress fractures of the femoral shaft may also occur in:
• Osteoporotic bone
• Metastatic disease
• Paget’s disease
• Paradoxically with long-term bisphosphonate use (for osteoporosis)
Risks with femoral shaft fractures?
With displaced femoral shaft fractures:
• Substantial blood loss (1.5 l)
• Fat embolism (confusion, hypoxia, ARDS)
Initial Mx of a femoral shaft fracture?
Initial resuscitation (must also optimise analgesia with a femoral nerve block)
Thomas splint (stabilises fracture and reduces blood loss and risk of fat embolism)
Definitive Mx of a femoral shaft fracture?
IM nails allows closed reduction and stabilisation (usually)
However, minimally invasive plate fixation with minimal disruption to the fracture site blood supply may also be used
What is the knee?
Articulation between the distal end of the femur and proximal tibia
It is a hinge joint (main planes of movement are flexion and extension but there is also a small degree of rotation)
Soft tissues of the knee?
Not as stable as the hip joint so it relies on soft tissue structure for stability:
• Medial and lateral collateral ligaments (resist valgus and varus stresses respectively)
• Anterior and posterior cruciate ligaments (stabilise the tibia in the sagittal and rotational planes)
Occurrence of distal femoral fractures (knee)?
Usually occur in osteoporotic bone, with a fall onto the FLEXED KNEE
Classification of distal femoral fractures?
- Extra-articular (supracondylar)
2. Intra-articular (intercondylar)
Signs of distal femoral fractures?
Distal fracture usually adopts a flexed position (due to pull of the gastrocnemii muscles)
Treatment of distal femoral fracture?
Usually fixed with plate and screws (fracture position is difficult to maintain in a cast) unless:
• Patient is very frail and not fit for surgery
Occurrence of true knee dislocations?
Uncommon but may occur in:
• High-energy injuries
• Severe hyperextension and/or rotational forces with a sporting injury
Risks with true knee dislocation?
Surgical emergency with a high incidence of:
• Vascular injury (intimal tears, vascular occlusion, complete transection)
• Nerve injury
• Compartment syndrome
• Tearing of multiple ligaments
Treatment of true knee dislocations?
Reduced urgently, if obvious, with a thorough NV assessment
Vascular surgery referral and revascularisation as required
If knee is very unstable - external fixation
Multi-ligament reconsruction is usually required
Caution with true knee dislocation?
Pay attention to NV status as knee injuries that present with evidence of gross instability (part. PCL & LCL injuries from hyperxtension & varus) may have been momentary true knee dislocations with spontaneous reduction
Occurrence of patellar dislocation?
Relatively common, part. in adolescents (esp. females) and predisposed to by:
• Generalised ligamentous laxity
• Valgus alignment of the knee
• Rotational malalignment (inc. femoral neck anteversion)
• Shallow trochlear groove
Causes of patellar dislocation?
Most are lateral dislocation due to:
• Direct dislocation (e.g: clash of knees at sport)
• Contraction of the quadriceps with a rotation force with the patella not engaged in the trochlea (<30 degree flexion)
Symptoms and signs of patellar dislocation?
Tenderness over the medial retinaculum (medial patellofemoral ligament is torn here)
May have haemarthrosis (impaction of the medial patellar facet on the outer aspect of the lateral femoral condyle)
Assoc. injuries with patellar dislocation and treatment?
Osteochondral fracture can occur with sheared off/detached fragments
May require retrieval or fixation, depending on size and amount of bone on the detached fragment
Treatment of patellar dislocation?
Manipulation for reduction
More commonly, spontaneous reduction may occur when the knee is straightened
Redislocation of patella?
Around 10% of all 1st time patellar dislocation patients experience a further dislocation; 50% of these will have multiple recurrent dislocations
Prevention and treatment of further patellar dislocation?
Temporary splintage followed by physio (strengthen the vastus medialis) can help prevent further dislocations and many adolescent patients stabilize as they get older
Occasionally surgical stabilization with either a bony procedure for malalignment or a soft tissue (MPFL) reconstruction is required
Injuries that mimic patellar dislocation?
Subluxations can occur without frank dislocation of the patella
What are proximal tibial plateau fracture?
Intra‐articular fractures with either a split in the bone, a depression of the articular surface or a combination of both
Classified according to the Schatzker system
Occurrence of proximal tibial plateau fractures?
High-energy injuries
Assoc. injuries with proximal tibial plateau fractures?
- NV injury
- Compartment syndrome
Valgus stress injury to the knee may cause:
• Lateral plateau fracture with failure of the MCL and possibly ACL with increasing force
Direct blow from a car bumper may also cause:
• Proximal fibular fracture
• Injury to the common peroneal nerve with foot-drop (due to loss of power to tibialis anterior)
Varus injury may result in:
• Medial plateau fracture (less common) with potential for LCL rupture and stretch injury to the common peroneal nerve
Treatment of proximal tibial plateau fractures?
Reduction and rigid fixation with plates and screws; once a depressed fracture has been elevated, a void in the bone is left (requires bone grafting to provide support)
High-energy fractures often have assoc. substantial soft tissue swelling and temporary external fixation spanning the joint may be required for initial stability and to allow the swelling to resolve (before ORIF)
Results are often disappointing and many subsequently require TKR
Why is early motion required following ORIF?
Reduces risk of stiffness and post-traumatic OA
Occurrence of tibial shaft fractures?
Usually occur with indirect force and either:
• Bending (transverse fracture) OR rotation energy (spiral fracture)
• Compressive force from deceleration (oblique fracture)
• Combination of these forces or from high-energy injuries (comminuted fractures)
Open fractures are not uncommon as the tibial shaft is subcutaneous
Tibial shaft fractures are the commonest cause of what?
Most common cause of COMPARTMENT SYNDROME (part. of the anterior leg compartment)
Non-operative treatment of tibial shaft fractures?
Up to 50% displacement and 5 degree angulation in any plane can be accepted:
• Conservative Mx in an above knee cast
Any internal rotation of the distal fragment is poorly tolerated:
• Position may be difficult to control in a cast (frequent cast changes and check X-rays required)
If the fibula is not fractured, the tibia often drifts into varus whilst if the fibula is also fractured valgus alignment is more common
How does the fibula affect alignment of the tibia following a tibial shaft fracture?
If the fibula is not fractured, tibia often drifts into varus whilst if the fibula is also fractured valgus alignment is more common
Operative Mx of tibial shaft fractures?
Internal fixation controls fracture position
Comminuted fractures require surgical stabilisation as do open fractures (also require adequate skin coverage) - IM nailing is used for stabilisation
ORIF with plate and screws gives rigid stability but does reduce periosteal blood supply (increased non-union risk)
Benefits of internal fixation?
Removes the need for a cast
Early joint motion
Potentially faster rehab
Complications of IM nail use for surgical stabilisation of a tibial shaft fracture?
Inserted behind the patellar tendon and 1/4 of patient suffer significant anterior knee pain (must be discussed pre-operatively, esp. to those who kneel a lot)
Treatment of non-union of tibial shaft fractures?
Bone grafting or special circular frames (can be adjusted to alter angulation, rotation or length and can give compression at the fracture site to promote healing and formation of new bone - distraction osteogenesis)
What is a Pilon fracture?
INTRA-ARTICULAR fracture of the distal tibia are Pilon fractures, generally caused by high-energy fractures of the distal tibia, e.g: fall from a height or rapid deceleration
With a Pilon (AKA pestle) fracture, talus acts as a pestle and is driven into the distal tibial articular surface, i.e: mortar, causing substantial disruption comminution or impaction of the articular surface
Treatment of Pilon fractures?
Early ORIF, if the soft tissue envelope is satisfactory; in most cases though, there is temp. external fixation with delayed internal fixation once swelling settles
Treatment of extra-articular distal tibial fractures?
If in an acceptable position, treat with either:
• Conservative Mx
• Surgical stabilisation with early motion
If fracture is not too distal, an IM nail can be used; if too distal, plating is preferred
Assoc. problems with Pilon fractures?
Substantial soft tissue swelling
High incidence of other injuries
Post-traumatic OA (may require ankle arthrodesis)
Most common causes of ankle injuries?
Inversion injury and/or rotation force on a planted foot
Soft tissue sprains of the ankle?
Sprains of the lateral ankle ligaments are common:
• Anterior and posterior talofibular ligaments
• Calcaneofibular ligaments
Symptoms of soft tissue sprains of the ankle?
Pain, bruising and mild-moderate tenderness over the inv. ligaments
With higher force/energy OR in osteoporotic bone, fractures can occur
Ottawa criteria for A&E assessment of an ankle fracture?
Used to identify a suspected ankle fracture and which ones require X-ray:
• Any severe localized tenderness (AKA bony tenderness) of the distal tibia or fibular
• Inability to weight bear for 4 steps merits an X-ray
Which ankle fractures are stable and which are unstable?
Stable - isolated distal fibular fractures with no medial fracture or rupture of the deltoid ligament
Unstable - distal fibular fracture with rupture of the deltoid ligament
Rupture of the deltoid ligament is suspected with bruising and medial tenderness
Risks with ankle fracture?
Talar shift can occur, where there is asymmetric increased space around the talus within the ankle mortise (a rectangular recess, like in a mortise lock)
Talar tilt, where the talus and tibial plafond (ceiling) are non-parallel
If either of these is present, then, by definition, the deltoid ligament must be ruptures
Ix for talar shift?
Mortise AP view X-ray
Consequences of talar shift?
Ankle joint contact pressure greatly increase with even 1mm of talar shift, i.e: risk of post-traumatic OA
Treatment of stable ankle fractures?
Walking cast or splint for around 6 weeks
Treatment of unstable ankle fractures)
Distal fibular fractures - ORIF (with plate and screws)
Bimalleolar fractures (to both medial and lateral malleoli) - ORIF
Ankle fractures can be associated with substantial soft tissue swelling and fracture blisters, so ORIF may be delayed 1‐2 weeks to allow soft tissues to settle and to reduce the risk of wound healing problems and infection
Treatment of talar shift?
Anatomic reduction and rigid fixation to minimise risk with any talar shift
Organisation of the foot?
Forefoot, midfoot and hindfoot
Occurrence of calcaneal fractures?
Fall from a height onto the heel, e.g: from a ladder, jumping out a window
Other injuries assoc. with falling from a height should be excluded
Types of calcaneal fracture?
Can be extra-articular or may involve the subtalar joint
Prognosis is dependant on the extent of involvement of the subtalar joint and the degree of comminution
Assoc. problems with calcaneal fractures?
- Substantial soft tissue swelling
- Compartment syndrome
- Heel tends to drift into a valgus position, with a widened heel causing impingement of the lateral ankle tendons
Treatment of calcaneal fractures?
ORIF in a younger patient to restore articular surface (risk of wound healing problems; if wound breakdown occurs, it can be difficult to achieve skin coverage without footwear problems)
For those who develop chronic pain due to subtalar joint damage or OA, subtalar arthrodesis is an option
Factors that increase the risk of poor wound healing and infection?
Heavy smoking, vascular disease, diabetes, poor surgical technique and increasing age
Occurrence of talar fractures?
Fractures of the talar neck usually occur with forced dorsiflexion from rapid deceleration, e.g: RTA, aircraft crach
Types of talar fractures?
- Undisplaced
* Displaced with subluxation of the subtalar joint
Risks with talar fractures?
With displacement of the fracture of subluxation/dislocation of the talus, high risk of AVN of the talar body (blood supply is distal, with anastamoses around and vessels traversing the talar neck)
Assoc. injuries with talar fractures?
Higher energy injuries may also result in dislocation of the:
• Body of the talus from the ankle joint
• Head of the talus from the talonavicular joint
Treatment of talar fractures?
Displaced fractures - closed or open reduction and screw fixation
AVN of the talus is not always symptomatic but secondary symptomatic OA may require ankle fusion
What is the Lisfranc joint?
Articulation between the metatarsal and tarsal bones
Describe a Lisfranc fracture
Uncommon but often missed
Fracture of the base of the 2nd metatarsal asspc. with dislocation of the base of the 2nd metatarsal with/without dislocation of the other metatarsals (at the tarso-metatarsal joints); ligament form the medial cuneiform to the base of the 2nd metatarsal no longer holds the metatarsal in joint
Ix for Lisfranc fracture?
X-ray - fracture may only be a small flake fracture, which is easily missed, and dislocations are difficult to see (be very wary of a normal X-ray)
If in doubt, CT scan
Symptoms of Lisfranc fracture?
Grossly swollen, bruised foot
Cannot weight bear on that side
Consequences of untreated Lisfranc fracture?
Fairly high risk of pain and disability
Treatment of Lisfranc fractures?
Closed or open reduction with fixation (using screws)
Occurrence of metatarsal fractures?
Fractures of the base of the 5th metatarsal are common; occur due to inversion injury with an avulsion fracture at the insertion of the peroneus brevis tendon
Treatment of 5th metatarsal fractures?
Walking cast, supportive bandage or wearing of a stout boot for 4-6 weeks
Even with those who fail to achieve bony union, many have a stable fibrous non-union (usually asymptomatic)
Treatment of 1st metatarsal fractures?
Uncommonly fractured (due to thickness and strength)
If fractured, usually fixed
Treatment of lesser metatarsal fractures?
Common, often with multiple fractures
Minimal displacement - conservative Mx with a cast
Multiple displaced fractures - stabilised with k-wires to reduce risk of chronic pain
Causes of 2nd metatarsal fractures?
Common site for stress fractures
Can occur spontaneously or after a period of increased exercise/activity
Ix for 2nd metatarsal fractures?
May not be visible on plain X-ray until a healing/callus response has started (can take several weeks)
Bone scan may aid in diagnosis
Treatment of 2nd metatarsal fractures?
Cast until pain subsides
Treatment of toe fractures?
Rarely require anything other than protection in a stout boot
Intra-articular fracture of the base of the proximal phalanx of the hallux may benefit from reduction and fixation (if the fragment(s) are sizeable)
Open fractures require debridement and may be stabilised with wires
Treatment of toe dislocations?
Closed reduction and either neighbour strapping or wiring
