Specific fracture management Flashcards
whats the difference between trauma and orthopaedics (not important)
trauma - advanced trauma life support, reduce hold rehabilitate
orthopaedics - history, examination ,look feel move and investigations
presentation of a fracture
pain swelling crepitus deformity adjacent structural injury - nerves, vessels, ligaments, tendons
investigations for a fracture?
gold standard X ray/radiograph
CT scan
bone scan
MRI scan
how to describe a fracture X ray
location - bone and part of bone pieces - simple/comminuted pattern - transverse/oblique/spiral displaced/undisplaced translated/angulated XYZ plane - varus valgus
what is fracture translation?
lateral movement of bones
proximal/distal
anterior/posterior
medial/lateral
types of angulation of fractures?
internal/external rotation
dorsal/volar (Z plane)
varus/valgus (X plane)
when is a fracture classified as varus or valgus?
varus - distal part of bone more medial
valgus - distal part of bone more lateral
what is the broad process of healing?
bleeding
inflammation
new tissue formation
remodelling
what happens in the inflammatory stage of healing?
haematoma formation
release of cytokines
granulation tissue and blood vessel formation
what happens in the repair stage of healing?
1 - soft callus formation (type ii collagen - cartilage)
2 - hard callus transformation (type i collagen - bone)
what is wolffs law?
bone grows/remodels according to stresses put on it
what is intramembranous ossification for fracture healing? aka primary bone healing
mesenchymal cell - osteoblast produces woven bone straight away
results in stable fractures
when bone ends are still together
what is endochondral ossification in fracture healing? aka secondary bone healing
chondral precursor then bone cells migrate to location and produce woven bone
therefore means more callus and less stability than intramembranous
when is healing visible on an x ray?
7-10 days
what are the concepts of general fracture management?
reduce
hold/fixate
rehabilitate
choices for fracture reduction?
closed - manipulation or traction (skin/skeletal traction)
open - full exposure or mini incision
choices for fracture holding?
closed - plaster, traction (skin/skeletal)
fixation
choices for fracture fixation?
internal - intramedullary (pins nails) or extramedullary (plates pins)
external - monoplanar or multiplanar (all way round)
what are the concepts of fracture rehabilitation?
use
move
strengthen
weight bear
general complications of fractures
fat embolus
deep vein thrombosis
infection
prolonged immobility (UTI, chest infections, sores)
fracture - specific complications
neurovascular injury muscle/tendon injury non union/malunion local infection degenerative change reflex sympathetic dystrophy
biological factors affecting fracture healing
blood supply
immune function
infection
nutrition
mechanical factors affecting healing
stresse
environment
causes of neck of femur fracture NOF#
osteoporosis
trauma
combination
location of NOF# classification
subcapital(intracapsular) transcervical (extracapsular) intertrochanteric (extracapsular) subtrochanteric 3 part intertrochanteric
what type of neck of femur fracture is more likely to cause avascular necrosis?
displaced intracapsular fracture
management of an extracapsular neck of femur fracture
fix with plate and screws (dynamic hip screw)
Management of intra-capsular NOF undisplaced
Fix with screws
Management of intra capsular NOF displaced
30% risk of AVN. replace in older patients, fix if young (under 55)
Replacement of undisplaced NOF fracture in over-65 year olds
fit and mobile - totla hip replacement
less fit - Hemi-arthroplasty
Presentation of shoulder dislocation
Variable HX - often direct trauma
pain
restricted movement
loss of normal shoulder contour
clinical examination for shoulder dislocation
assess neurovascular status of auxiliary nerve
Investigation for shoulder dislocation
X-ray prior to manipulation: scapular Y-view in addition to AP
Reducing shoulder dislocation
Avoid vigorous manipulation or twisting. Safest methdo is traction / counter-traction and gentle internal rotation
Ensure adequate patient relaxation. Could use Stimson method
Complication of shoulder dislocation
Hill-Sachs - ball of humerus chipped off (bankart lesion) may lead to re-dislocation
Management of distal radius fracture for minimally displaced extra-articular
reduction of fracture and placement into cast until definite fixation
Distal radius fracture management - extra-arcticular and unstable
MUA in theatre with K-wire fixation.
Wires removed clinic post-op
Distal radius fracture management displaced + unstable
not suitable for K-wires
Open reduction / internal fixation with plate and screws
What is a lipohaemarthrosis
Fat moves when sat down, creating a straight line above tibia
tells you that there is a fracture in the joint
non-operative management of tibial plateau fracture indications
undisplaced fractures with good joint line congruency assessed on CT (rare)
Operative management of tibial plateau fracture
Restoration of articular surface using plates and screws
maybe bone graft or cement to prevent further depression
Mechanism of injury for tibial-plateau fracture
Key weight-bearing surface
Any extreme valgus/varus force or axial loading across the knee
Impaction of femoral condyles causing comparatively soft bone of tibial plateau or depress or split
Additional ligumentus or miniscal injury possible
Non operative management of ankle fracture (Weber A and B stable)
Non-weight bearing below-knee cast 6-8 weeks
then walking boot
then physiotherapy
What is Weber A ankle fracture
simple fracture to bottom part of fibular
What is Weber B ankle fracture
Fracture to fibular- unstable fractures with Tellar shift / medial or posterior malleoli
What is Weber C ankle fracture?
Fibular fracture above level of syndersmosis therefore unstable
Operative management of ankle fracture (Weber B unstable or Weber C)
Open reduction with internal fixation +/- syndersmosis repair using screw or tightrope technique
What is operative ankle fracture management dependent upon?
Pateint’s soft tissues
patients need strict elevation as injury swells significantly
Broad mechanisms of fracture
trauma
stress
pathalogical / insufficiency
Causes behind pathological fractures
Osteoporosis Malignancy - primary / bone mets Vitamin D deficiency osteamyelitis Osteogenesis imperfecta Pagets
Urgent complications of fractures
Local visceral injury vascular injury nerve injury compartment syndrome Haemarthrosis Infection Gas gangrene
