T&O - Fractures Flashcards
Principles of Fracture Management
Reduce
Immobilise (Hold)
Rehabilitate
1.) Reduce - restore anatomical alignment
- usually requires reduction and counter traction
- ↓swelling, ↓nerve damage, restores blood supply
- local anaesthetic or conscious sedation needed
2.) Immobilise - simple splints or plaster casts
- plasters are not circumferential in first 2 weeks to allow the fracture to swell, preventing compartment syndrome
- if axial instability, plaster should cross the joint above and below e.g. ‘above knee/elbow’ plasters
- need thromboprophylaxis if unable to weight bear
- safety net for compartment syndrome
3.) Rehabilitate
- intensive period of physiotherapy
- patients should move unaffected joints
Open Fractures
Clinical Features
Investigations
Management
Rehabilitation
Outcomes/Complications of an Open Fracture x4
1.) Clinical Features
- pain, swelling, deformity, overlying wound/punctum
- check neurovascular status and overlying skin
- skin loss: plastic surgery input identified early
2.) Investigations
- routine bloods: inc clotting and G/S
- neuro examination should be repeated multiple times
- photograph, X-ray, CT (complex fractures)
3.) Management
- resuscitation, analgesia, anti-emetics
- realignment, wound dressings, and splinting
- IV antibiotic cover and tetanus vaccine (if needed)
- surgical debridement and fracture irrigation in theatre
- external fixation is used in widespread soft tissue damage whilst you wait for the skin and fracture to heal
- internal fixation once fracture has healed sufficiently
- soft tissue coverage must be obtained within 72hrs
4.) Rehabilitation
- after internal fixation: immobilised in splint/sling until fracture heals
- antibiotics to prevent infection
- healing time is variable and physio is needed
5.) Outcomes/Complications of an Open Fracture
- infection, neurovascular compromise, non-union
- compartment syndrome
- fat embolism (long bone fractures): up to 3 days post-trauma, fever, SOB, retinal haemorrhages, confusion, petechial rash
Classification and Severity Scores for Open Fractures
Gustilo-Anderson Classification x3(5)
Mangled Extremity Severity Score
1.) Gustilo-Anderson Classification - wound size
- 1: <1cm + clean, 2: 1-10cm + clean
- 3A: >10cm, high energy, good soft tissue coverage, OR farm injury
- 3B: >10cm , high energy, bad soft tissue coverage
- 3C: any injury with vascular injury
- 3A ortho only, 3B need plastics, 3C needs vascular
2.) Mangled Extremity Severity Score - used to predict necessity of amputation after lower extremity trauma
- skeletal/soft tissue injury: low energy (1-4) vs high energy
- limb ischaemia: no ischaemia (0-3) severe (no CRT)
- shock: stable (0-2) persistent hypotension
- age: <30 (0-2) >50
- score >7/11 predictive of amputation
Pathophysiology of Compartment Syndrome
Increase in Intra-Compartmental Pressure (ICP)
Increase in Hydrostatic Pressure
Compression of Traversing Nerves
Ischaemia
1.) Increase in Intra-Compartmental Pressure (ICP)
- due to fluid being deposited in fascial compartments which are closed and cannot be distended
2.) Increase in Hydrostatic Pressure
- due to venous compression because of ↑ICP
- causes fluid to move out of veins which increases intra-compartmental pressure even further
3.) Compression of Traversing Nerves
- causes a sensory +/- motor deficit distally
- means paraesthesia is a common symptom
4.) Ischaemia - when arterial inflow is compromised
- occurs when ICP reaches diastolic BP
- late sign of missed compartment syndrome
- acute arterial insufficiency (6Ps): pain, paraesthesia, pallor, perishingly cold, paralysis, pulselessness
Compartment Syndrome
Mechanism x3
Clinical Features
Investigations
Initial Management
Definitive Management
1.) Mechanism - main 3: high energy trauma, crush injuries, fractures causing vascular injury
- others: iatrogenic vascular injury, tight casts/splints, DVT, post-reperfusion swelling
2.) Clinical Features - within hrs or up to 4hrs post-injury
- severe pain, disproportionate to the injury (excessive use of analgesia)
- not improved with initial measures
- pain worsened by passive stretching of the muscle bellies of the area
- distal paraesthesia w/ evolving neurology
- tense fascial compartment (minimally distensible)
- 5Ps: if compartment syndrome is missed
3.) Investigations - clinical diagnosis
- elevated/rising CK may aid diagnosis
- intra-compartmental pressure monitor is only used in clinical uncertainty or if the patient is unconscious/intubated: >20 mmHg is abnormal whilst >40mmHg is diagnostic
- no visible pathology on an X-ray
4.) Initial Management
- aggressive IV fluids (AKI risk), high flow oxygen, IV analgesia
- keep limb at neutral level (DO NOT elevate or lower)
- remove all dressing/splints/casts
5.) Definitive Management - urgent fasciotomy
- skin incisions left open for 24-48hrs to assess for any dead tissue which will need to be debrided, wound is closed once remaining tissue are healthy
- monitor renal function due to the potential effects of rhabdomyolysis or reperfusion injury or myoglobinuria after a fasciotomy
- death of muscle groups may occur within 4-6 hours
- consider debridement and amputation if there are necrotic muscle groups at fasciotomy
Tibial Shaft Fractures
Mechanism
Clinical Features
Investigations
Management
Surgical Management
1.) Mechanism - vulnerable to both direct (fall, direct blow) or indirect injuries (twisting, bending)
- ↑risk of open fractures and compartment syndrome due to lack of significant soft tissue envelope
2.) Clinical Features
- severe pain w/ inability to weight bear
- may be a clear deformity and swelling and bruising
- full neuro exam needed, check skin for open fracture
3.) Investigations
- urgent bloods: inc clotting and G/S
- X-ray (AP+lateral) of tibia and fibula inc knee+ankle
- CT: intra-articular extension, spiral fracture of distal tibia, fracture of posterior malleolus
4.) Management
- reduction: MUA, re-X-ray, reassess neuro
- immobilise: above knee back slab, elevate
- non-operative: Sarmiento cast in closed stable tibial fractures can be an alternative to operation
5.) Surgical Management - required most of the time
- intramedullary (IM) nailing most commonly used for fixation, patients usually full weight bear immediately
- ORIF: may be needed for intra-articular extension
- temporary external fixation (for multiple injuries)
- fibula usually heals alone once tibia is stabilised
- can take 15-30 weeks (4-8mths) for union of the fracture
Neck of Femur Fracture (#NOF)
Mechanism
Avascular Necrosis
Clinical Features
Investigations
Post-Op Management
1.) Mechanism
- low energy fall in frail older patients
- high energy injury e.g. RTC or fall from height
2.) Avascular Necrosis - of the femoral head in a displaced intracapsular #NOF
- due to retrograde blood supply from MCFA
3.) Clinical Features
- pain in the hip or referred pain to the groin, thigh, or knee
- difficulty/no weight-bearing
- leg is shortened and externally rotated (gluteus medius)
- tenderness on palpation of the greater trochanter
- limited straight leg raise
- distal neurovascular deficits are rare (but must be assessed)
4.) Investigations
- X-ray: hip (AP and lateral), pelvis (AP), femur, can draw Shenton’s line to assess whether neck of femur fracture
- routine bloods: inc lactate, clotting, G/S, CK
- urine dip, CXR, ECG, AMTS esp for elderly
5.) Post-Op Management
- immediate post-operative weight bearing
- LMWH 6-12hrs after surgery for 28 days or 10 days followed by aspirin for further 28 days
- repeat bloods, X-ray, analgesia, IV fluids
- early rehab w/ physios and occupational therapists
Classification and Scoring Systems for #NOF
Garden Classification
Nottingham Hip Fracture Score
Mortality Figures
1.) Garden Classification - for intracapsular fractures
- I: incomplete #NOF, II: complete # but non-displaced
- III: complete #, partial displacement
- IV: complete # and fully displaced
2.) Nottingham Hip Fracture Score - 30 day mortality risk using:
- age, gender, AMTS, Hb on admission, where they live
- co-morbidities, active malignancy last 20 yrs
- raised serum lactate also indicator of ↑mortality
3.) Mortality Figures
- mortality: 10% in 1mth, 20% in 3 mths, 30% in 1 yr
Surgical Management of #NOF
Displaced Intracapsular
Non-Displaced Intracapsular
Inter-Trochanteric
Sub-Trochanteric
1.) Displaced Intracapsular - cemented hemiarthroplasty
- replace femoral head and neck
- total hip replacement (inc acetabulum) for patients who walk independently and not cognitively impaired
- can have aseptic loosening of a total hip replacement needing revision, presents with hip/groin pain radiating to the knee
2.) Non-Displaced Intracapsular - INTERNAL FIXATION with cannulated hip screws (for younger patients to prevent having prosthesis)
- three parallel screws in inverted triangle formation
- can consider hemiarthroplasty if unfit
3.) Inter-Trochanteric - dynamic hip screw (DHS)
- for fixation, dynamic lag screw provides compression and primary healing of the bone
4.) Sub-Trochanteric: intramedullary femoral nail
- titanium rod through medullary cavity for stabilisation
- also reduces pain
Types of Distal Radius Fractures
Pathophysiology
Colles Fracture
Smith’s Fracture
Barton’s Fracture
1.) Pathophysiology
- FOOSH causes forced supination or pronation of the carpus, increasing impaction load of the distal radius
- ↑risk w/ age/osteoporosis, children 5-15 also prone
1.) Colles Fracture - extra-articular fracture of the distal radius w/ dorsal angulation and displacement
- body load forces the wrist into supination
- typically occurs as fragility fracture in osteoporosis
- most common wrist fracture (90%)
- leads to dinner-fork deformity
- complications: median nerve injury (most common), compartment syndrome, malunion, vascular compromise, rupture of EPL tendon
- late complications: OA, complex regional pain syndrome
2.) Smith’s Fracture - extra-articular fracture of the distal radius w/ volar/palmar angulation +/- displacement
- falling backwards causing forced pronation
- leads to garden-spade deformity
3.) Barton’s Fracture - intra-articular fracture of the distal radius with dislocation of the radio-carpal joint
- can be volar (more common) or dorsal
Distal Radius Fracture
Clinical Features
Investigations
Management
Surgical Management
Complications x3
1.) Clinical Features
- traumatic episode with immediate pain +/- deformity and sudden swelling around the fracture site
- must assess evidence of neurovascular compromise (CRT, pulses, median/ulnar/radial nerve)
2.) Investigations
- X-ray (gold): radial height <11mm, radial inclination <22°, radial tilt >11°
- CT/MRI: if complex or for operative planning
3.) Management
- reduction: traction and MUA(haematoma/Biers block)
- immobilise: below-elbow backslab cast
- rehabilitation via physiotherapists
4.) Surgical Management - unstable fractures or intra-articular step of the radiocarpal joint >2mm
- ORIF with plating or K-wire fixation
5.) Complications
- malunion: poor realignment –> shortened radius causing ↓ROM, wrist pain, ↓forearm rotation
- MN compression: ↑ in malunion
- osteoarthritis
Classification of Ankle Fractures
Definition
Anatomical Classification
Weber Classification
Lauge-Hansen Classification
1.) Definition - fracture of any malleolus (lateral, medial, posterior) +/- disruption to the syndesmosis
2.) Anatomical
- isolated lateral/medial malleolar fractures
- bimalleolar and trimalleolar (lateral/medial/posterior)
3.) Weber - classifies lateral malleolus fractures
- type A: below syndesmosis, B: level of syndesmosis
- type C: above the level of the syndesmosis
- higher injury –> ↑likelihood of ankle instability
- type C fractures always need surgical fixation
4.) Lauge-Hansen - based on ankle position at time of injury and the deforming force involved
- more widely used and more detailed than Weber’s
Ankle Fracture
Clinical Features
Ottawa Ankle Rules
Investigations
Management
Surgical Management
1.) Clinical Features - traumatic episode followed by:
- ankle pain +/- associated deformity e.g. dislocation
- open fractures may have neurovascular compromise
2.) Ottawa Ankle Rules - X-ray requirements (near 100% sensitivity)
- bony tenderness at posterior edge/tip of LM OR MM
- inability to weight bear for 4 steps
3.) Investigations
- X-ray: mortise view (modified AP, internal rotation by 10-20°) + lateral view, taken in ankle dorsiflexion since the talus can appear translated when plantarflexed
- CT for complex fractures for surgical planning
4.) Management
- reduction: manage open fracture accordingly
- hold: below knee back slab, post-reduction neuro exam, repeat X-ray to ensure reduction is adequate
- conservative: non-displaced MM, Weber A, Weber B w/out talar shift, unfit for surgical intervention
- weight bear as tolerated in a CAM (controlled ankle motion) boot for 6 weeks
5.) Surgical Management - ORIF
- displaced bi/trimalleolar fractures, open fracture
- Weber C fracture, Weber B w/ talar shift
- talar shift is widening of the medial clear space which is suggestive of greater ankle instability
Fracture Healing
Pathophysiology of Fracture Healing
Factors affecting Fracture Healing
Ultrasound Stimulating Fracture Healing (EXOGEN)
1.) Pathophysiology of Fracture Healing - 5 steps
- haematoma –> inflammation –> callus formation –> consolidation –> bone remodelling
2.) Factors affecting Fracture Healing
- local: blood supply, denervation, infection, necrotic tissue, foreign bodies, surgical techniques
- systemic: age, anaemia, hypoxia, hypovolaemia, obesity, diabetes, malignancy, malnutrition, drugs
3.) Ultrasound Stimulating Fracture Healing (EXOGEN)
- stimulates production of GFs and proteins that ↑ the removal of old bone, ↑the production of new bone
- used to treat long bone fracture w/ non-union or delayed healing
- adv: quicker healing, avoid surgery, self-administered
Scaphoid Fracture
Pathophysiology
Clinical Features
Investigations
Management
1.) Pathophysiology - a type of wrist fracture, often due to a FOOSH causing axial compression of the scaphoid with the wrist hyperextended, and radially deviated
- often occurs during contact sports or RTAs
- proximal injuries can cause avascular necrosis due to the retrograde blood supply from the radial artery
2.) Clinical Features
- pain at the base of the thumb
- maximal tenderness over the anatomic snuffbox and tenderness of the scaphoid tubercle
- loss of grip/pinch strength
- wrist joint effusion: less likely if hyperacute or delayed
- pain during ulnar deviation of the wrist
3.) Investigations
- wrist X-Ray: AP, lateral, ‘scaphoid views’. can be missed within the first week of the injury
- MRI: technically first-line but X-Rays still often used
- CT: only to plan operative Mx or fracture union
4.) Management - referral to orthopaedics
- immobilisation w/ a (futuro) splint and X-ray
- another X-ray after 1 week if the first X-ray is normal
- displaced or proximal pole fractures: needs surgical fixation
- undisplaced fractures: below-elbow cast for 6-8 weeks
- complications: avascular necrosis, non-union → pain and early osteoarthritis
