Trauma and orthopaedics: Fracture Flashcards
3 types of fracture
compound
stable
pathological
compound fracture
open fracture
is when the skin is broken and the broken bone is exposed to the air. The broken bone can puncture through the skin.
stable fracture
refers to when the sections of bone remain in alignment at the fracture.
pathological fracture
refers to when a bone breaks due to an abnormality within the bone (see below).
e.g. tumour
osteoporos
pagets disease
presentation: may occur with only minor trauma or spontaneously
common sites
- femur
- vertebral bodies
The main cancers that metastasise to the bones are (mnemonic: PoRTaBLe):
- Po – Prostate
- R – Renal
- Ta – Thyroid
- B – Breast
- Le – Lung
terms used to describe the way a bone breaks
- Transverse
- Oblique
- Spiral
- Segmental
- Comminuted (breaking into multiple fragments)
- Compression fractures (affecting the vertebrae in the spine)
- Greenstick
- Buckle (torus)
- Salter-Harris (growth plate fracture)
which fractures happen in children rather than adults
can only occur in children (adults do not have growth plates)
- Salter-harris
typically
- greenstick
- buckle
Salter-harris fracture
is a fracture that involves the epiphyseal plate or growth plate of a bone, specifically the zone of provisional calcification
imaging for fractures
initial: X-ray
* AP and lateral
if inconclusive or further information needed e.g. comminuted fracture: CT scan
principles of fracture management (simple fracture without the need for surgery)
REDUCE HOLD REHABILITATE
principles of reduction
for mechanical alignment of the fracture. Can be done either by
- Closed reduction via manipulation of the limb
- Open reduction via surgery (ORIF)
reduction allows for
- tamponade of bleeding at fracture site
- reduces swelling of soft tissue
- reduces risk of neurovascular damage
how is fracture reduction typically performed
The specific manoeuvre used invariably requires two people (one to perform the reduction manoeuvre and one to provide counter-traction). A third person is typically needed to apply the plaster.
typically performed closed in the emergency setting.
or
reduced open (by directly visualising the fracture and reducing it with instruments)
or
intra-operatively (ORIF)
analgesia during reduction
- regional or local blockade
- local anaesthetic
- regional block
- conscious sedation
hold
to provide stability
This can be done by fixing the bone in the correct position while it heals. There are various ways the bone can be fixed in position:
- External casts (e.g., plaster cast)/ splints
- K wires
- Intramedullary wires
- Intramedullary nails
- Screws
- Plate and screws
traction
it is important to consider whether traction is needed (this is most commonly employed for subtrochanteric neck of femur fractures, femoral shaft fractures, displaced acetabular fractures, and some pelvic fractures), whereby the muscular pull across the fracture site is strong and the fracture is inherently unstable.
important principles to remeber with plaster casts
-
For 2 weeks plasters should not be circumferential (must have area only covered by overlying dressing
- allows fracture to swell, reduce risk of compartment syndrome
- If there is axial instability(whereby the fracture is able to rotate along its long axis), such as combined tibia/fibula metaphyseal fractures or combined radius/ulna metaphyseal fractures, the plaster should cross both the joint above and below.
- These are usually termed ‘above knee’ or ‘above elbow’ plasters, respectively, preventing the limb to rotate on its long axis.
- For most other fractures, the plaster need only cross the joint immediately distal to it.
patient arrives at A&E with fracture outline initial management
- ATLS
- Patients presenting to A&E will be investigated with x-rays to establish the diagnosis.
- Patients with fractures require appropriate pain management.
- Straightforward fractures may be managed in A&E (e.g., a Colle’s fracture in a young adult). They may require closed reduction if the bones are out of alignment. A plaster cast may be applied, and the patient can be discharged with a follow-up appointment in the fracture clinic.
- Complex fractures and those requiring surgery (e.g., hip fractures) are referred to the on-call trauma and orthopaedics team. They are admitted and made nil by mouth if they may need an operation. They are discussed at the trauma meeting the following day (typically, this starts at 7.45 am), then seen on the morning ward round. A plan will be made for further management at this stage.
with fractures always assess (2)
the joint above and below
neurovascular supply before and after any procedure
Possible early complications of fracture include:
- Damage to local structures (e.g., tendons, muscles, arteries, nerves, skin and lung)
- Haemorrhage leading to shock and potentially death
- Compartment syndrome
- Fat embolism (see below)
- Venous thromboembolism (DVTs and PEs) due to immobility
rehabilitate
intensive period of physiotherpay following fracture management
Possible longer-term complications include:
to do with the bone coming together
- Delayed union (slow healing)
- Malunion (misaligned healing)
- Non-union (failure to heal)
other complications
- Avascular necrosis (death of the bone)
- Infection (osteomyelitis)
- Osteoarthritis
- Chronic pain
fat embolism
occurs after fracture of a long bone e.g. femur
Fat globules are released into the circulation following a fracture (possibly from the bone marrow). These globules may become lodged in blood vessels (e.g., pulmonary arteries) and cause blood flow obstruction.
what can occurs secondary to fat embolism
fat embolism syndrome
systemic inflammatory response,
criteria for fat embolism syndrome
Gurds criteria
major criteria
- Respiratory distress
- Petechial rash
- Cerebral involvement
how to prevent risk of fat embolism syndrome
operate early
common wrist fractures
- Colles
- Scaphoid
Colles fracture summary
- transverse fracture of distal radius
- causes distal portion to displace posteriorly (upwards)
- ‘dinner fork deformity’
- RF
- female
- osteoporosis
- steroids
- smoking
- menopause
- mechanism: FOOSH
- management
- closed reduction in A&E (appropriate anaesthetics)
- below-elbow backslab cast (allows for swelling)
- re-Xray after a week
- physiotherapy
Colles’ - Dorsally Displaced Distal radius → Dinner fork Deformity
ankle fracture summary
- Involve the lateral malleolus (distal fibula) or the medial malleolus (distal tibia).
-
Weber classification describes fractures of lateral malleolus
- fracture in relation to distal syndesmosis
- A- below
- B- at level
- C- above (worse)
- fracture in relation to distal syndesmosis
-
Management
- All ankle fractures should be promptly reduced to remove pressure on the overlying skin and subsequent necrosis
- Young patients, with unstable, high velocity or proximal injuries will usually require surgical repair. Often using a compression plate.
- Elderly patients, even with potentially unstable injuries usually fare better with attempts at conservative management as their thin bone does not hold metalwork well.
pelvic ring fractures summary
The pelvis forms a ring. When one part of the pelvic ring fractures, another part will also fracture (similar to fracturing a polo mint).
Pelvic fractures often lead to significant intra-abdominal bleeding, either due to vascular injury or from the cancellous bone of the pelvis. This can lead to shock and death, so needs emergency resuscitation and trauma management.
fragility fractures
occur due to weakness in the bone, usually due to osteoporosis. They often occur without the appropriate trauma that is typically required to break a bone. For example, a patient may present with a fractured femur after a minor fall.
which tool is used to predict risk of fragility fracture
A patient’s risk of a fragility fracture over the next 10 years can be predicted using the FRAX tool.
bone mineral density can be measured using
DEXA scan
bisphosponates e.g. alendronic acid
work by interfering with osteoclasts and reducing their activity, preventing the reabsorption of bone. There are a few key side effects to remember:
- Reflux and oesophageal erosions (oral bisphosphonates are taken on an empty stomach sitting upright for 30 minutes before moving or eating to prevent this)
- Atypical fractures (e.g. atypical femoral fractures)
- Osteonecrosis of the jaw
- Osteonecrosis of the external auditory canal
if bisphosphantes contraindicated, not tolerated or not effective
Denosumab is a monoclonal antibody that works by blocking the activity of osteoclasts. It is an alternative to bisphosphonates where they are contraindicated, not tolerated or not effective.
management of hip fractures is dependent on if it is
- intracapsular (subcapital): from the edge of the femoral head to the insertion of the capsule of the hip joint
- extracapsular: these can either be trochanteric or subtrochanteric (the lesser trochanter is the dividing line)
classification of hip fracture
Garden classification
management of undisplaced intracapsular fracture
internal fixation, or hemiarthroplasty if unfit.
management of a displaced intracapsular fracture
Displaced Fracture:
- Total hip replacement or hemiarthroplasty to all patients with a displaced intracapsular hip fracture
- total hip replacement is favoured to hemiarthroplasty if patients:
- were able to walk independently out of doors with no more than the use of a stick and
- are not cognitively impaired and
- are medically fit for anaesthesia and the procedure.
management of extracapsular fracture
Management
- stable intertrochanteric fractures: dynamic hip screw (a)
- subtrochanteric fractures: intramedullary hip screw (b)
ATLS
advanced trauma life support
- Treat the greatest threat to life first.
- Definitive diagnosis is not immediately important.
- Time matters (“golden hour” emphasizes urgency).
- Do no further harm.
- Assess, intervene, reassess. Did the intervention work? Is the patient’s physiology returning to or staying normal?
- A-E
open fracture
fracture is ‘open’ when there is a direct communication between the fracture site and the external environment. This is most often through the skin – however, pelvic fractures may be internally open, having penetrated in to the vagina or rectum.
classification of open
‘in to out’
‘out to in’
“in-to-out”
injury, whereby the sharp bone ends penetrate the skin from beneath,
‘Out-to-in’
whereby a high energy injury (e.g. ballistic injury or a direct blow) penetrates the skin, traumatising the subtending soft tissues and bone.
most common open fractures
tibial, phalangeal, forearm, ankle, metacarpal
what needs to be considered with open fractures
- skin- will be need plastics
- soft tissue- muscle/tendon/ligament loss
- neurovascular injury
- infection
causes of open fracture
some type of high-energy event—such as a gunshot or motor vehicle accident.
investigation for open fracture
- blood tests
- clotting screen
- group an sae
- X-ray (PA and lateral)
- CT for comminuted or complex fracture
Classification of Open Fractures
The Gustilo-Anderson classification can be used to classify open fractures
- Type 1: <1cm wound and clean
- Type 2: 1-10cm wound and clean
- Type 3A: >10cm wound and high-energy, but with adequate soft tissue coverage
- Type 3B: >10cm wound and high-energy, but with inadequate soft tissue coverage
- Type 3C: All injuries with vascular injury
A simple summary in how this can help to guide management is: 3A can be managed by orthopaedics alone, 3B requires plastics input, and 3C requires vascular input
initial management of open fracture
- ATLS
- initial resuscitation and suitable management in cases of major trauma (often a polytrauma due to high energy injury)
- Analgesia
- Neurovascular status
- Evidence of contamination should be assessed for and documented (marine, agricultural and sewage of highest importance)
following resus and stabilisation of patient with open fracture
- urgent realginement and splinting
- re-assess and document neurovascular status following any realignment or reduction
- broad spectrum antibiotics + tetanus vaccine if not up to date
- out-of theatre washout is not indicated (wound should be dressed with saline-soaked gauze)
- photograph the wound and remove gross debris
definitive management of open fracture
- debridement of wound and fracture site (should happen immediately if contaminated with marine, agricultural or sewage material, or <12-24 if clean)
- remove devitalised tissue
- wash wound out with copious volume sof saline
- ensure definitive skeletal stabilisation
- soft tissue coverage by pladtics
- if vascular compromise- vascular surgeon
Fracture healing
(1) Haematoma- tissue damage and bleeding at the fracture site; the bone ends die back for a few mm
(2) Inflammatory reaction- inflammatory cells appears in the haematoma
(3) Callus- the cell population changes to osteoblasts and osteoclasts; dead bone is mopped ip and woven bone appears in the fracture callus
(4) Consolidation- woven bone is replaced by lamellar bone- fracture is united
5) Remodelling- newly formed bone is remodelled to resemble the normal structure
he is cool cat rapping
US in influencing bone healing
EXOGEN accelerates the healing of indicated* fresh fractures by 38%.
smoking and fracture healing
smokers take longer to heal from fractures. In recent research, smokers who broke their leg took 62% more time to heal than non-smokers
