Trauma Flashcards
Are the majority of fractures due to direct or indirect trauma?
indirect e.g. twisting/bending forces
What is primary bone healing?
There is a minimal fracture gap, and bone simply bridges gap with new bone from osteoblasts
When does primary bone healing occur?
healing of hairline fractures
when fractures are fixed with compression screws and plates
What is secondary bone healing?
there is a gap at the fracture site, needs to be filled temporarily to act as scaffold for new bone
What does secondary bone healing involve?
inflammatory response with recruitment of pluropotential stem cells, which differentiate into different cells during healing process
Describe the process of secondary bone healing.
- fracture occurs
- haematoma with inflammation
- macrophages and osteoclasts remove debris and resorb bone ends
- granulation tissue forms from fibroblasts and new vessels
- chrondroblasts form cartilage
- osteoblasts lay down bone matrix (collagen type 1 - endorchondral ossification)
- calcium mineralization produces immature woven bone (hard callus)
- remodeling occurs with organization along lines of stress into lamellar bone
Give the 4 main steps of secondary bone healing.
inflammation
soft callus
hard callus
remodelling
When is the soft callus usually formed?
by 2nd to 3rd week
When is hard callus usually formed??
6-12 weeks
What may result in atrophic non union?
lack of blood supply, no movement e.g. internal fixation with fracture gap, too big a fracture gap or tissue trapped in gap
What can smoking do to fracture healing?
severely impair it due to vasospasm
Why do hypertrophis non unions occur?
too much movement
List the 5 basic fracture patterns.
transverse, oblique, spiral, comminuted, segmental
Describe transverse fractures.
pure bending force causes one side to fail in compression and the other to fail in tension
Describe oblique fractures.
shearing force e.g. fall from height causes oblique fracture pattern
What are oblique fractures able to be fixed with?
interfragmentary screw
Do oblique fractures tend to shorten~??
yes
Describe spiral fractures.
occur due to torsional forces (twisting)
What are communuted fractures?
fractures with 3 or more fragments
suggests higher energy injury, very unstable
What is a segmental fracture?
bone is fracture in two different places. very unstable - need rods or plates
What is displacement?
direction of translation of distal fragment (e.g. can be anteriorly or posteriorly displaced and medially or laterally displaced)
What does angulation describe?
direction which the distal fragment points towards
What is different about children’s fractures?
periosteum in children is much thicker, tends to remain intact
Fractures heal more quickly
Can remodel more easily
Tend to buckle/partially fracture or splinter
At what age does a child’s fractures tend to be treated as an adult’s?
12-14 start of puberty
Fractures where have the ability to disturb growth?
fractures around physis (growth plate)
What is the Salter Harris classification of physeal fractures?
Salter Harris 1 = pure physeal separation
Salter Harris 2 = small metaphyseal fragment attached to physis and epiphysis
Salter Harris 3 and 4 = intra articular and with the fracture splitting the physis, more potential for growth arrest
Salter Harris 5 = compression injury to the physis with subsequent growth arrest - CANNOT BE DETECTED ON X RAY, only once angular deformity is present
Which Salter Harris type is most common type of physeal fractures?
2
Which features should raise suspicious of Non accidental injury?
inconsistent history discrepancy between parents history not consistent with injury multiple bruises atypical injuries eg cigarette burns rib fractures metaphyseal fractures in infants
Give 4 clinical signs of a fracture.
localized bony tenderness
swelling
deformity
crepitus (from bone ends grating)
Do all MSK injuries require X ray to exclude a fracture?
no
What is a useful rule for doing an X ray?
if patient cannot weight bear on lower limb, x ray should be requested
What should be used to investigate a fracture?
X ray (lateral and AP - always both) Oblique views for complex shaped bones eg scaphoid, acetabulum, tibial plateau
What is a tomogram?
moving X ray to take images of complex bones
What may be needed to assess fractures of complex bone and determine degree of articular damage?
CT
What may MRI be used to detect?
occult fractures
What are technetium bone scans used for?
stress fractures, as these may fail to show up on x ray
What is the main late systemic complication of a fracture?
PE
What happens in compartment syndrome?
groups of muscles are bound in tigh fascial compartments with limited capacity for swelling
pressure rises, ischaemia occurs
SEVERE PAIN, PARAESTHESIAE, SWELLING
What is the cardinal clinical sign of compartment syndrome?
increased pain on passive stretching of muscle
If left untreated, what can compartment syndrome lead to?
necrosis of muscle resulting in fibrotic contracture known as Volkmann’s ischaemic contracture and poor function
Are vascular injuries common in trauma?
no, but consequences can be significant
Which fracture risks brachial artery injury?
paediatric supracondylar fracture of elbow
What can result in axillary artery compromise?
shoulder trauma
What may help localize the site of arterial occlusion urgently in theatre?
angiography
How can ongoing haemorrhage from arterial injury in the pelvis be controlled?
angiographic embolization
What are two types of open fractures?
due to fractured bone puncturing skin (inside out) or laceration of skin from penetrating injury (outside in)
Which classification system exists for open wounds to describe the degree of contamination, size of wound and whether t he wound will be able to be closed or require plastic surgery?
Gustilo
What is initial management for open fractures in A and E?
IV anti bs, normally flucloxicillin, gentamicin and metronidazole
How are open fractures usually stabilized?
internal or external fixation providing an early and thorough debridement
In a situation where a fracture is causing a lot of pressure on the skin, as shown by blanching what should happen?
fracture should be reduced as emergency to avoid necrosis
What can a shearing force on the skin result in?
avulsion of skin from underlying blood vessels, known as DEGLOVING
If excessive soft tissue swellings and contusions are present, what are more appropriate treatment, external or internal fixators?
external
What is one of the slowest healing bones in the body?
tibia
What is fracture disease?
stiffness and weakness due to fracture
What type of fractures, metaphyseal or cortical, tend to heal more quickly?
metaphyseal
Give a cause of delayed union.
infection
What causes hypertrophic non union, and what causes atrophic non union?
hypertrophic non union: instability and excess motion
atrophic non union: rigid fixation with fracture gap/lack of blood supply
What can mal-union cause?
cosmetic deformity, risks OA
What can malunited colles fracture result in?
weakness, stiffness and chronic pain
Which fractures are prone to developing AVN?
femoral neck, scaphoid and talus
What are characteristics of CRPS?
constant burning, throbbing, sensitivity to stimuli, painful movement and skin colour change
For what should you use a Thomas splint?
femoral shaft fractures
What type of fractures are treated non surgically with splintage or immobilization?
undisplaced, minimally displaced and minimally angulated
considered stable
When is reduction under anaesthetic performed?
in displaced or angulated fractures
position deemed unacceptable
How can unstable injuries be treated?
surgical stabilization, which involves pins, cerclage wires, screws, plates, intramedullary nails, external fixation etc
How should unstable extra articular diaphyseal fractures be fixed?
open reduction and internal fixation (ORIF) using plates and screws
In which cases of extra articular diaphyseal fractures should ORIF be avoided?
soft tissue swelling too large
blood supply in tenuous
femoral shaft
tibia
What should be done if extra articular diaphyseal fractures cannot be treated by ORIF?
external fixation
What does ORIF aim for, primary or secondary bone healing?
secondary
Fractures involving a joint with predictable poor outcome should be treated how?
arthrodesis or joint replacement
Who are more likely to be treated non operatively?
elderly
Give 4 signs of fracture healing.
resolution of pain and function
absence of point tenderness
no local oedema
resolution of movement at fracture site
Give 3 signs of non union.
ongoing pain
ongoing oedema
movement at fracture site
What may be seen on X ray in non union?
bridging callus
How are dislocations treated?
reduction by closed manipulation
With regard to dislocations, what increases the risk of needing an open reduction and recurrent instability?
delayed presentation
In whom may dislocations occur with seemingly innocuous trauma?
Ehlers Danlos
Marfans
Describe the grading of ligament tears.
Grade I (sprain), Grade 2 (partial tear), Grade 3 (complete tear)
What is the mainstay of treatment for most soft tissue injuries?
RICE - but some complete ligament ruptures may need repair, tightening or graft reconstruction
What tendon injuries are particularly common, usually requiring surgical repair?
flexor and extensor tendon injuries in hand
Why do pelvic fractures occur in young patients?
due to high energy
Why are older patients likely to get pelvic fractures from low energy injuries?
osteoporosis
What forms the pelvic ring?
sacrum, ilium, ischium and pubic bones
If pelvic ring is disrupted in one place, is it likely there will be any further disruption?
yes - either fracture or ligament injury at SI joint
Which arteries and veins in pelvis are prone to injury, with risk of serious hypovolaemia?
internal iliac arterial system
pre-sacral venous plexus
What is mandatory to asses sacral nerve root function and to look for presence of blood in bladder and urethral injuries?
PR exam
What type of injuries do low energy pubic rami fractures in eldery tend to be?
minimally displaced lateral compression injuries
What are the more common fractures at the shoulder?
proximal humerus fracture
Why do most proximal humerus fractures occur?
low energy injuries in osteoporotic bone due to fall on outstretched hand or directly onto shoulder
What is the most common pattern in proximal humerus fracture, fracture of surgical or anatomic neck? Displacement of what occurs?
surgical neck
medial displacement of humeral shaft (due to pull of pectoralis muscle)
What is the most common type of shoulder dislocation?
anterior
Why does anterior shoulder dislocation occur?
due to excessive external rotation, for fall onto back of shoulder
What can also cause a shoulder dislocation?
seizure
What is seen in a shoulder dislocation(anterior)?
loss of symmetry
loss of roundness
arm held in adducted position supported by patients other arm
What type of fractures are caused in the humeral shaft by:
a) direct trauma
b) fall with or without twist
direct trauma - transverse or comminuted
fall - oblique or spiral
Why are union rates in humeral shaft fracture high?
mobility of ball and socket shoulder joint and of elbow joint
How are most cases of humeral shaft fracture treated?
non operatively with humeral brace
Who get supracondylar fractures?
mostly children
Are olecranon fractures common?
yes, with fall onto elbow
What is a fracture of ulnar shaft also known as?
nightstick fracture
What is a monteggia fracture dislocation?
fracture of ulna occurs with dislocation of radial head at elbow
What is a galeazzi fracture dislocation?
fracture of radius with dislocation of ulna
Is colles fracture intra or extra articular?
extra articular fracture
Why does a colles fracture occur?
FOOSH (fall on outstretched hand) with the wrist extended
What can accompany a colles fracture?
median nerve compression
bleed into carpal tunnel
What is a specific late local complication of a colles fracture?
rupture of extensor pollicis longus tendon
When does a smith’s fracture occur?
falling onto back of flexed wrist
Which fracture is of the distal radius involving the dorsal or volar rim where carpal bones of the wrist joint sublux with the displaced rim fragment?
Barton’s fracture - ORIF
What should be done to treat comminuted intra articular distal radius fracture?
external fixation across wrist joint
When do scaphoid fractures usually occur?
after a FOOSH
What is the shape of the scaphoid?
kidney bean shaped
How should undisplaced scaphoid fractures be treated?
plaster cast
Are penetrating hand injuries common?
Yes
Injuries to both digital arteries in a digit require what?
microsurgical repair to restore circulation
What is the condition where avulsion of the extensor tendon from its insertion into the terminal phalanx occurs, caused by forced flexion of the extended DIPJ, and what can cause this?
mallet finger
a ball at sport
Why do flexor tendon injuries pose a particular problem?
tendons need to run smoothly within the tendon sheath and under the pulleys
The tendon sheath requires careful repair with preservation of the pulleys to avoid what of the tendon?
bowstringing
In whom are hip fractures common?
elderly
How can hip fractures be broadly classified?
intracapsular
extracapsular
Which type of hip fractures can interfere with the arterial supply of the femoral head, risking AVN and non union?
intracapsular
How should intracapsular hip fractures be treated?
replacement of femoral head
Which type of hip replacement, total or hemi, has a higher risk of dislocation?
total
How should extracapsular hip fractures be fixed?
dynamic hip screw
How do femoral shaft fractures normally occur?
high energy injuries
Long term use of which drug can have risk of femoral shaft fracture?
bisphonates
What can occur with displaced femoral shaft fractures?
substantial blood loss, fat embolism, hypoxia, risk of ARDS
Treatment of Femoral shaft fracture?
Thomas splint
Are knee dislocations common?
no
What is there a risk of with knee dislocations?
vascular injury, nerve injury, compartment syndrome
What may be applied in knee dislocation if the knee is very unstable?
external fixation
What are more common, knee dislocations or patellar dislocations?
patellar (relatively common)
In whom is patellar dislocation or subluxation more common?
teens, particularly females
What do patients have tenderness over in patellar dislocation?
medial retinaculum
In dislocation of what is there likely to be a haemoarthrosis from impact?
patella
What type of injury to the knee may cause a lateral plateau with failure of MCL (and potentially ACL)?
valgus stress injury
What kind of blow could cause proximal fibular fracture?
direct blow from car bumper
What injury occurs with proximal fibular fracture?
injury to common peroneal nerve with footdrop
What may result in medial plateau fracture?
varus injury
What type of fractures can a tibial shaft fracture be?
all but segmental
Are open tibial shaft fractures common?
no - due to tibial shaft being subcutaneous
What are the commonest cause of compartment syndrome after trauma?
tibial fractures
What compartment of the leg do tibial fractures affect?
anterior
What is the commonest method of surgical stabilization of tibial fracture?
intramedullary nails
What are most ankle injuries due to?
inversion injury/rotation on planted foot
What characterize sprains of lateral ankle ligaments?
pain, bruising, tenderness
What merits an X ray of an ankle injury?
inability to weight bear
bony tenderness of distal tibia/fibula
What distinction needs to be made in ankle injuries?
stable or unstable
Treatment of ankle injury?
walking cast or splint
What does a talar shift or a talar tilt mean?
deltoid ligament must be ruptured if there is not medial malleolar fracture
Are bimalleolar fractures stable?
no unstable
Are fractures of the base of the 5th metatarsal common?
Yes
What is it called when the bone fractures in the proximal diaphysis in the foot? Is this good or bad?
Jones fracture - can be bad, as poor blood supply here
Is the first metatarsal commonly fractures?
no
Are the less metatarsals commonly fractured?
yes, often with multiple fractures
What do toe fractures normally just need?
protection in stout boot
Treatment of Buckle fractures?
3-4 weeks of splintage
Where are buckle and greenstick fractures?
distal radius
What type of fractures may be angulated and may require manipulation?
greenstick
Where do Salter-Harris II fractures commonly occur?
around distal radial physis in older children
In ehom can moteggia and galaezzi fractures occur?
children and adults
Name a relatively weak point the growing upper limb.
supracondylar region of distal humerus
Are extensor or flexor injuries of supracondylar region of elbow more common?
extensor
When do extension type fractures of supracondylar region of elbow occur?
heavy FOOSH
When do flexion type fractures of supracondylar region of elbow occur?
fall onto point of flexed elbow
When is a patient unable to make the OK sign?
extension type fractures of supracondylar region of elbow
pressure may occur on brachial artery and median nerve
Why do femoral shaft fractures occur?
fall onto flexed knee
indirect bending/rotational forces
Can shortening be accepted in femoral shaft fractures?
yes
Treatment of femoral shaft fracture in patients aged 2-6?
Thomas splint
Treatment of femoral shaft fracture in patients aged 6-12?
intramedullary nails
Treatment of femoral shaft fracture in patients aged 12+?
intramedullary nail
What is the femur a common site for?
tumors
What type of tibial shaft fractures are common in toddlers?
undisplaced spiral
What is the mainstay of management for children’s tibial fractures?
cast
