Specific fracture management Flashcards
Function of bones
See BRS I
What are the different types of bones?
Flat bones Long bones Irregular bones Short bones See BRS I
What are the three parts of the bone?
Epiphysis
Metaphysis
Diaphysis
What is the role of the periosteum?
Provides blood supply and nutrition to the bone
What are the two types of bone?
Woven
Lamellar
What comprises the extracellular matrix of bone?
Collagen (90% Type I) (Type V)
Mineral salts
What comprised the cellular components of bone?
Osteoblasts
Osteocytes
Osteoblasts
What are osteocytes?
As osteoid mineralises
Osteoblasts are entombed between lamellae
What is special about osteocytes?
The are multinucleated
What happens once bones are formed?
Constant state of remodlling
What do osteoblasts have receptors for?
PTH
Prostaglandins
Vitamin D
Cytokines
What is a fracture?
Discontinuity of the bone
How do you describe fractures?
Orientation
Location
Displacement
Skin penetration
What is the AO/OTA classification?
Number for a specific bone e.g. humerus 1
Number for location e.g. proximal end 11
Subgroup relating to type of fracture
What are the features of primary bone healing?
Direct bone healing
Generally intermembraneous healing
Small gap and no movement
Key is that this is a very slow process and that achieving no movement is very difficult
What are the features of secondary bone healing?
Stage III
Neovascularisation
Calcified matrix is deposit as osteoblasts is brought in by the new blood vessels
What is an expected timeline of healing for a fracture?
6 months
6 weeks for callus formation
1 year for full remodelling
Lower limb twice as long as upper limb
Children half as long adults
Give an example of Wolff’s law
If the femur heals bent
Bone will remodel so new cells are formed on the concave side
Reabsorption on the other side
Straightens the bone out
What are the two categories of fracture healing complications?
Non-union
Union
What is Malunion?
Bone healing occurs outside of the normal parameters of alignment
What is non-union?
Failure of bone healing within an expected time frame
Atrophic- healing completely stopped with no XR changes often physiological
Hypertrophic - too much movement causing too much callus healing. Bone does not unite and form a callus
What are examples of hypertrophic non-union?
Elephant’s foot
Horse’s foot
What is pseudoarthritis?
fibrous callous formation that forms like a joint
becomes mobile at that site but is not stable
What are the steps of fracture management?
Resuscitate
Reduce - bring the bone back together in an acceptable alignment, can allow for pain relief and prevent any further blood loss.
Rest- hold the fracture in a position to prevent distortion or movement
Rehabilitate- get function back and avoid stiffness
What must you think about with regards to a period of immobility?
Functional limitations and support needed
wider MDT (catherisation, nutrition etc.)
VTE prophylaxis
Physio
Occupational therapist
What is the conservative approach to fracture management?
Try in this order until happy with managment
Rest
Ice
Elevation
Plaster/Fibreglass cast or Splint
Traction - skin/bone
Pulls on the leg until the bone ends are reconstituted - provides almost immediate relief
Hummerus - tend to use collar and shaft which utlises gravity
Why is a backslap cast used in A&E as opposed to a circumferential cast?
Acute injuries - tendency to swell
If a circumferetial cast is used the blood flow will be limited
Can create compartment syndrome?
What is an example of internal fixation?
K wire - reduces with patient under anaesthetic, useful for children as they have thick periosteum’s that prevent the fracture from holding in position
What os ORIF?
Open reduction
Internal Fixation
What are IM nails?
Intramedullary nails
Useful for long bone fractures - insufficient soft tissue coverage for extramedullary methods
Can be very dangerous since you can disrupt the physiology of a patient
What are examples of external fixators?
Mono/biplanar
Sits within one or two planes
Goes in from outside the skin - apply rods on the outside and build a construct that allows for stability of the fracture pattern
Used often in open fractures where there is poor soft tissue coverage
What are examples of external fixators?
Mono/biplanar
Sits within one or two planes
Goes in from outside the skin - apply rods on the outside and build a construct that allows for stability of the fracture pattern
Used often in open fractures where there is poor soft tissue coverage
After the soft tissue injury has been dealt with other internal fixation methods can be used
Quick an easy
When would you used a ring fixator?
When other methods have been used and there is still non-union
Patient is non-compliant with intramedullary methods
Use computer tomography to say where to place the pins
Multiplanar construct thats more stable
How do approach orthopaedic X-rays?
Projection Patient details Technical adequacy Obvious abnormality Systematic review of X-ray Summarise
What is projection?
At least two views
What is important when checking patient details?
NHS number
2 people may have the same name
How might shoulder dislocation present?
Variable Hx but often direct trauma
Pain
Restricted movement
Loss of normal shoulder contour
What must be assessed prior to internvention?
Assess neurovascular status
Axillary nerve
Sensation of regimental patch
What are the types of shoulder dislocation?
Anterior
Posterior
Inferior
What are the features of anterior shoulder dislocation?
Commonest type 90%
Bimodal distribution
Humeral head not overlying glenoid
What are the features of posterior shoulder dislocation?
Rare (around 6%)
Associated with seizures/shock
Lightbulb sign on Xray
What is the safest method of shoulder dislocation management?
Traction-counter traction
Gentle internal rotation
What is Hills-Sachs defect?
During injury or reduction
Catch humeral head on glenoid or other bony strucure
What is a Bankart lesion?
During injury or reduction
Lesion to the glenoid
What is the consequences of Hills-Sachs or Bankart defects?
Can cause instability or impingement
What is a typical presentation of proximal humerus fracture?
Fall onto outstretched hand
Typically in the elderly or those with osteoporosis
How can proximal humerus fractures be classified?
Neer classification
When would you opt for conservative management for proximal humerus fracture?
Collar and Cuff
2-part fracture, minimally displaced
High surgical risk
What is a Colles fracture?
Distal radius fracture
Dorsal angulation
Extra articular
What is Smith fracture?
Distal radius fracture
Volar angualtion
Extra articular
What is a Barton fracture?
Distal radius fracture
Dorsal angualtion
Intra articular
What is a Reverse barton fracture?
Distal radius fracture
Volar angualtion
Intra articular
How to scaphoid fractures present typically?
Commonest carpal bone injury, usually in young patients
Typically a fall backwards onto their hand
How is a scaphoid fracture examined?
Anyone with FOOSH or with distal radius fracture should have a scaphoid exam
Palpation of anatomical snuffbox
What is Perilunate instability?
Spectrum of disorders around the lunate
What is a perilunate dislocation?
Remainder of your carpal bones do not line up and not articulate with the radius
But the lunate does
What is lunate dislocation?
All carpal bones BUT Lunate articulate
How do pelvic fractures typically present?
Usually as as result of high energy trauma
Patients can become very unstable - lots of visceral organs and vasculature are adherent to the pelvis
How to manage pelvic fractures?
ABCDE principles
Hypovolaemia is common
Pelvic binders are used as a tamponade device but need to placed accurately
Ongoing instability should suggest surgical intervention
What line indicates disruption to the femoral head?
Shenton’s line
What are the features of neck of femur fractures?
Makes up 25% of all fractures seen in hospital
Pathological fracture, often as a result of osteoporosis and minimal trauma in the elderly
What is common signs of neck of femur fracture in the history?
Minor fall
May report groin, thigh or buttock pain
Want to ask about preceding symptoms
What is the clinical examination for neck of femur fracture?
Look
Feel
Move
Thorough secondary survey to look for other injuries
What is the protocol for neck of femur fracture management?
Rule out other pathology that could cause fall
Involve orthogeriatricians/medical team early
Pain relief
Catheterise
Blood tests
ECGs/CXR
Pre-op optimisation
How do you classify neck of femur fractures?
Intracapsular:
Subcapital
Transcervical Basicervical
Extracapsular:
Intertrochanteric Subtrochanteric
Reverse Oblique
What are the mangement option for intracapsular NOF fractures?
Total hip arthroplasty
Hemiarthroplasty
Cannulate screws
What is the criteria for total hip arthroplasty?
Mobile with <1 walking stick outdoors No cognitive impairment Medically suitable for procedure and anaesthetic
What are the management options for extracapsular NOF fracture?
Dynamic hip screws
Intramedullary nails
What is the criteria for hemiarthroplasty?
Mobile with >1 walking stick outdoors Reduced AMTS Comorbidities or reduced baseline not benefiting from THR
What is key in post-op management?
Prevent leading causes of death – hospital acquired infections, DVTs/PEs by early
mobilisation
