T&O at a glance Flashcards
Fractures general principles
Tension results in transverse fracture
Axial compression results in oblique fracture
If bone struck by large rigid object bending force generated resulting in segmental fracture
Twisting/torsion results in spiral fracture
Complexity of fracture pattern and degree of fragmentation is known as comminution. A highly comminuted fracture is at risk for associated visceral injuries, soft tissue injury/compartment syndrome/NV deficit, stripping of periosteum and inc risk of non union
PARTS (Describing a fracture)
Pattern- Transverse, spiral, oblique, comminuted
Displacement (Distal relative to proximal)
Angulation- Varus/Valgus, Ant/post
Rotation- Need to see joint above/below
Translation- Movement of distal fragment anteriorly/posteriorly, laterally or medially
Shortening- Due to pull of muscles
Open fractures
When a fracture occurs a haematoma forms around broken bone ends. If the haematoma communicates with an epithelialised surface it is an open fracture. Can be classified using the gustillo anderson classification.
Early problems with open fractures:
Multisystem injury, compartment syndrome, nerve/vessel injury
Later problems
Infection, Periosteal stripping and non union
Treatment open fractures:
1) ATLS
2) NV assessment before and after any manipulation
3) Remove contamination from wound
4) If fracture grossly displaced restore alignment and splint using backslab
5) Abx and tetanus. Co amoxiclav or cefuroxime and gent
6) X rays of bone inc joints above and below
7) Assess for compartment syndrome
8) Wound debridement (immediate if gross contamination, compartment syndrome, vascular compromise)
9) Primary amputation may be considered if limb avascular for more than 6 hrs, there is segmental muscle or bone loss
Fracture healing (secondary bone healing)
1) Haematoma and inflammation
2) Soft callus within 2 weeks collagen and fibrocartilage bridge fracture site
3) Hard callus- after around 6 weeks the soft callus becomes mineralised. Osteoclasts mineralise the fibrocartilage to produce woven bone
4) Remodelling over months and years. Osteoclasts remove woven bone ad osteoblasts lay down ordered lamellar bone
Some micromovement stimates and is relative stability but excessive causes disruption of soft callus and non union
Primary bone healing occurs when bone ends are absolutely stable with no micromovement and ends in direct apposition with no gap. Needs absolute stability and acheived when fracture is plated and compressed. Osteoclasts drill tunnels across the fracture site and osteoblasts follow layng don layers of strong organised lamellar bone
Fracture treatment options
Reduce, Hold, Rehabilitate
Consider: Site of fracture - if joint surface involved then anatomical reduction must be acheived to prevent arthiritis
Age: Children have huge potential to remodel
Functional demands of patient
Ways of holding fracture:
Rest e.g small avulsion fractures of stress fractures. Patient may be provided splint or crutches
Traction: Application of traction to limb uses gravity to keep limb in alignment
Plaster cast: Provides relative stability allowing secondary fracture healing. Too tight can cause compartment. Firt week backslab
K-wires: Simple fractures that remain unstable despite closed reduction may be held with percutaneous K wires. Wires are left protruding through the skin to be removed after 4 weeks.
ORIF: Open reduction and internal fixation - fracttures that cannot be reduced by manipulation need to be reduced by direct manipulation of fracture fragments. Stability is then maintained by applicaton of plate and screws. This method is suitable for fractures extending into a joint. Allows primary fracture healing
IM nail: Long bone fractures can be stablised by passing metal rod into medullary canal to provide stability
External fixator: If a fracture is highly comminuted such that anatomical reduction cannot be acheived. If open fracture is highly contaminated or soft tissues grossly swollen such that wound healing comprimised an external fixator can be applied
Arthroplasty: If blood supply to fracture has been comprimised or fracture is comminuted and extends into joint, joint replacement can be considered
Upper limb trauma 1
Clavicle fracture
Common after a fall onto the shoulder. Fractures over middle third more common (80%), lateral third (15%), Medial third (5%). Lateral third have high risk of non union and medial third have high risk of brachial plexus/ lung injury
Ix: X ray AP view and 30deg cephalad
Tx: Most cases conservatively managed with collar and cuff for 4-6 weeks and mobilisation as tolerated. Indications for surgery include open fractures, tenting/comprimise of skin/ NV injury. Lateral third fractures can be managed surgically due to high risk of non union expecially if they extend into acromioclavicular joint.
Fractures that are highly comminuted have higher risk of non union
Shoulder dislocation
Anterior most common.
Patient presents with pain restricted movement and loss of normal shoulder contour. Clinical exam should include pulses, brachial plexus and axillary nerve integrity by testing sensation over regimental badge area
Ix: X ray AP and axillary/scapular Y
Mx: Relax patient with sedation. Patient monitored and given oxygen. Hippocratic method. Reduce and place in broad arm sling then x ray
Acute rotator cuff tear
Acute tear presents with new onset weakness and pain. Chronic tear in elderly due to gradual degeneration of the tendons and may be associated with arthiritis
Examine all movements of the cuff looking for focal weakeness. Comparing the opposite side. MRI/ USS confirms diagnosis. Tx is repair of the tendons can be arthroscopically
Proximal humerus fractures
Falling onto an outstretched hand may result in fracture of proximal humerus, especially in elderly with osteoporosis.
Three types of fracture
1) Avulsion of greater tuberosity caused by pulling of supraspinatus
2) Fracture of surgical neck
3) Comminuted fractures in which head and tubersities are separated
Tx:
Isolated tuberostiry fractuers can be managed conservatively in broad arm sling if undisplaced. If displaced then fixed
Minimally displaced surgical neck fractures treated conservatively in a collar and cuff
Comminuted fractures involving the head of the humerus. If head is split or fragments widely displaced high risk of non union/ AVN or late arthiritis. Fracture is then either fixed with plate/screws or whole head is replaced with hemiarthoplasty
Upper limb trauma 2
Humeral shaft fractures
