T&O - NOF and Radius and Ulna Midshaft Fractures Flashcards
Patterns of fracture breakage - describe these
INSERT PICTURE
- Transverse: a
- Oblique: b
- Spiral: c
- Multifragmentary: d
- Compression/crush: when cancellous bone is crumped (e)
- Stress fractures: repeated stresses that cause bone to fatigue
- Greenstick: in children, bones are softer and more pliable and bend rather than break (f)
- Avulsion
Displacement of fractures - describe these
INSERT PICTURE
- Undisplaced
- Impaction: fragments driven into one another, causing shortening (b)
- angulation: one fragment left angulated relative to other, can lead to deformity of limb (described in degrees) (c)
- Lateral displacement (d) and rotation (e) - note mismatch between widths of the proximal and distal fragments
What is the difference between dislocation and subluxation?
- Dislocation: loss of congruity between articulating surfaces of joint (damage to capsule and surrounding soft tissues)
- Subluxation: partial loss of congruity between two joint surfaces
NOF: demographics and normal findings
• Mainly in elderly females with osteoporotic bone
◦ Have high mortality (20-40% in first year)
• Normal finding: leg externally rotated and shortened (iliopsoas attaches to lesser trochanter of femur and pulls in that direction) + all movements painful + can’t weight bear
NOF: important clerking points for assessment
premorbid mobility
mini mental test score
premorbid independence
comorbidities
NOF: describe the blood supply to the femur
mainly from medial and lateral femoral circumflex branches (travel under capsule along neck) + intramedullary vessels + small contribution from ligamentum teres.
Where can you get fractures on the NOF?
Where does the capsule attach?
Capsule attaches to intertrochanteric line anteriorly and intertrochanteric crest posteriorly
INSERT PICTURE
Describe the garden classification for NOF fractures
INSERT PICTURE
Intracapsular fractures:
- which fractures are intracapsular
- Rx based on displaced vs undisplaced
• Subcaputal or transcervical: grouped into Garden classification I-IV
◦ Undisplaced: often impacted and would unite alone but usually fixed with screws
◦ Displaced: need reduction b/c disrupted blood supply often fixed with either hemi or half hip replacement (elderly)
*young pts: consider long term outcome and try internal fixation with screws, if they develop AVN, could be considered for total hip replacement at later
What are the rules of thumb for treatment of NOFs
Options being: leave, fix and replace
• Intracapsular:
◦ Garden 1-2: ORIF with cannulated screws
◦ Garden 3-4:
‣ <55: canulated screws (can do full replacement if get AVN- more fit so will survive two GAs + want the limb to last longer)
‣ 55-75: total hip replacement if good/fit pt
‣ >75: hemiarthroplasty
• Extracapsular:
◦ Old/unfit patient: ORIF with DHS
◦ Young/fit patient: ORIF with DHS
Run through protocol of Rx for a pt with NOF fracture
Admit pt and assess using ABCDE approach - treat life threatening emergencies/bleeds first
• Good Hx and social status
• Cannula + bloods (U&E, FBC and G&S)
• Get ECG, CXR and pelvis XR + affected limb
• Mark affected limb for theatre
• Surgeon obtain informed consent
• Ensure DVT prophylaxis (TED, foot pumps, LMWH and early mobilisation)
What are the main complications of a total hip replacement?
- Dislocation (more likely to dislocate than hemis), DVT, deep infection, nerve damage (sciatic nerve- can lead to foot drop), leg length discrepancy)
- AVN of femoral head
- OA
What is the prognosis for a pt with NOF?
- 30% mortality in 1 year
- 50% never regain pre-morbid functioning
- > 10% unable to return to premorbid residence
- Majority will have residual pain/disability
Which fractures are classified as Extracapsular?
• basicervical, intertrochanteric or subtrochanteric (do not carry same risk of AVN)
Important principle to remember when thinking about radius and ulna midshaft fractures
Isolated fractures of the shafts is uncommon: should always suspect associated dislocation/fracture at either prox/distal end
