Trauma Orthopaedic Flashcards
General management - treatment - includes
• accurately and concisely prescribe & document treatment • joint mobilisation • swelling management • pain management • weight-bearing (WB) status • walking aids • exercises • fitting of orthoses
General management - plan/further management- includes
• short term goals (while inpatient)
• further reassessment/ treatment • frequency/progression of treatments • discharge criteria • equipment • home programs • referrals
pre operative management is important if able
- what are some of the complications associated
respiratory complications
circulatory complications
surgical delays
give some examples of when pre operative management can’t be performed
time of arrival on the ward, direct admission from theatre, or they are in an
unstable condition
average age of #NOF
80
F v M #NOF
4:1
Mortality rate associated with #NOF
8-10% within 30 days, 21-29% 1 year
§ Regional
Queensland 24.9% (Chia, 2013)
What percentage end up with decreased mobility #NOF
50%
what fraction regain premorbid function #NOF
1/3`
List some associated perioperative complications with #NOFs
pre-op hypoxia, postop
delirium, anaemia, representation within 30days, CHF, acute
renal impairment, MI
Hip fracture causes
simple fall
trip and fall
spontaneous
traumatic fall
simple fall
common in the elderly
land on the hip (direct blow)
trip and fall
common in the elderly catches foot (rotational force)
Spontaneous
pathological
eg. osteoporosis
traumatic fall
eg. MVA, skiiing, etc
Clinical features of a displaced hip fracture
pain
limb shortened/ext rot
unable to WB
Clinical features of undisplaced hip fracture
pain
no change in limb orientation
can sometimes WB
sometimes difficult to pick up on Xray - MRI/CT or bone scan for diagnosis
Possible complications at the time of hip fracture in the elderly
pre-exitsting co-morbidities (physical/mental)- additional fractures - pain - delayed assistance (cold, lying on hard surface, etc.) - haematoma / damage to soft tissues - hospitalisation / change in environment - surgery / anaesthetic
Hip fracture complications
§ Avascular necrosis § Non-union / mal-union § Dislocation § Shortening of leg § Infection § Non-healing of wound § Penetration of metal-ware § Metal-ware loosening § 2° osteoarthritis
Classification of hip fracture
subcapital /intracapsular fracture
intertrochanteric/extracapsular fracture
subtrochanteric fracture
Slide 14
Garden classification system is for what
intracapsular fractures
Type 1 garden classification fracture
Type I fractures have the best outcome. The
bone ends are impacted into one another, which
facilitates vascular re-growth.
Type II Garden classification fracture
Type II fractures are not impacted and are thus
less stable. However there is minimal
displacement of the bones from the anatomically
normal position, and this is beneficial.
Type III Garden classification fracture
Type III fractures are complete but there is only partial displacement (<50%).
Type IV Garden classification fracture
Type IV fractures are complete with total
displacement (>50%). The two ends of bone are
completely separated.
Surgical management for Garden I &II
§ Cannulated screws
§ Dynamic hip screw (DHS)
surgical management for intertrochanteric
§ DHS § Richards compression screw (RCS) § Compression hip screw (CHS)
surgical management for Garden III &IV
§ Hemiarthroplasty
§ THJR
surgical management for subtrochanteric
§ DHS, CHS
§ Extramedullary fixation
(pin & plate)
§ IM Reconstruction nail
general WB guidelines
slide 19
Physiotherapy management for # NOF
§ Mobilise usually day 1 à mobility ax
§ Often easily fatigued à concentrate on functional activities only
§ Co-ordinate with nursing staff
§ Can generally WBAT, except if fixation stability = fragile or it is a
relatively young patient, (about < 65 yrs ), in which case they are
usually TWB or NWB only
Physiotherapy managment for #SOF
§ Usually rodded / nailed
§ Usually mobilise TWB, Day 1. Will be NWB if pin & plate
§ Need to work on knee flexion and quads. Promote regular
independent active work
§ Patient advised to rest with leg in elevation+++ for 10 days post-op.
Post op delirium
§ Early detection is key to management
§ Poorly recognized, misdiagnosed as dementia
or depression
§ Generally reversible, but poor prognosis
§ Develops quickly, fluctuates during day
Risk factors for post op delirium
dementia, anticholinergic drugs, prev delirium,
indoor falls, prev stroke, depression, impaired hearing or vision
causes of post op delirium
anaemia, CHF, severe hypotension, pulmonary
complications, increase in cortisol levels, UTI, fevers, feeding issues
(Lundstrom, 2004)
polypharmacy, hypoglycamia, hypoxaemia, metabolic encephalopathy
early aims of #NOF treatment
literature supports what
- early mobilisation (Day 1-2 post-op)
- encourage ambulation WBAT/TWB
- encourage maximal functional
independence - ensure adequate pain relief
- provide appropriate walking aid/s
- ensure patient safety at all times
- discourage prolonged bed rest, but
ensure adequate rest periods
Function outcomes - physio role
§ Level of assistance required for lying ↔ sitting ↔ standing § Balance § Willingness to weight-bear through # leg § Distance walked § Frame → crutches § ↑ and ↓ steps / ramp
Physio intervention - physio role
Early mobilization § Consider analgesia prior to mobilizing § Provide walking aids § Mobility status, ward function § Assess transfers § Falls prevention program § Exercises § Chest Physiotherapy § Circulation exercises § Hip precautions (if indicated)
EBP guidelines
Daily evaluation by geriatricians and orthopaedic
specialists
§ Early mobilisation
§ Transfer to a rehabilitation unit or home by Day 3
post-op.
§ Dedicated team with orthopaedic and geriatric
leadership has lead to improved efficiency and quality
of care for patients
§ Exercises: bridging (for Hemi), IRQ, hip and knee
flexion, knee abduction
general fracture management guidelines for #tibial plateua /supracondylar knee #
- usually ORIF’d with plates and screws +/- bone graft, or nailed
- usually to be fitted with IROM brace with open range 0°- 90°
- usually mobilise NWB, Day 1
- need to work on knee ROM and quads. Promote regular
independent active work - patient advised to rest with leg in elevation+++ for 10 days post-op.
general fracture guidelines # patella and ORIF with tension band wiring
- sometimes go into an IROM brace locked in extension or limited
ROM - sometimes go into knee brace which is to be removed for showering
& gentle flexion exercises - usually mobilise WBAT, Day1
- provide with lifting strap for self-assistance of injured leg
General fracture guidelines #Tibia/fibula (shafts)
- usually rodded / nailed → mobilise TWB, Day 1
- also can be ORIFd with plate and screws or fixed with an
external fixateur → mobilise NWB - need to work on knee flexion, dorsiflexion and quads.
Promote regular independent active work (SQ, IRQ, SLR, hip
+knee flexion, hip abd/add) - will often be given a BKPOP or aircast walker for 2 weeks for
comfort and to avoid foot-drop - patient advised to rest with leg in elevation+++ for 10 days
post-op.
ankle general fracture guidelines
- usually ORIFd with plates and screws
- usually mobilise NWB in BKPOP backslab, Day 1 (unless
swelling is an issue) - patient advised to rest with leg in elevation+++ for 10 days
post-op. - Exercises: IRQ, SLR, hip and knee flexion, hip abd/add
humerus general fracture guidelines
- usually mobilise day 1
- Op arm rests in sling
- Wrist, hand, elbow, grip strengthening op
arm, PROM/AAROM shoulder flexion/
abduction, pendulum ex as per surgeon - D/C Day 1/2/3 if mobile and safe home
environment
pelvis (pubic rami) general fracture guidelines
- usually mobilise WBAT as soon as patient is
able to move independently across the bed - if more than one ramus is #d, progression of
mobility is usually slower due to pain
When do you suspect a spinal injury
- Think about mechanism of injury → fall/heavy load/bending/
impact/RTA - Suspect in all unconscious patients → they can’t tell you if they
have any spinal pain - Presence of any neurological red flags
- Any spine pain or tenderness → however if no pain you can’t
necessarily rule out injury - Don’t forget other injuries – beware the “distracting injury”
1) Immobilise on rigid board – start spinal rules
2) Apply rigid collar
Protection is priority, Detection is secondary
Canadian C spine rules
- Highly sensitive, reliable
- Alert, stable, recent trauma - ?X-Ray
- Not applicable in unstable patient, acute paralysis,
known vertebral disease, prev CSp surgery,
paediatrics, pregnant
slides 32/33
cervical fracture
- Usually the result of high energy trauma
- 80% 18-25yr old, Male to Female 4:1
- Suspected injury? Assume & immobilise until cleared
- May be associated with head injury
- Blunt head injury – suspect C1-3 involvement
- Needs neuro examination
- Paeds = C2/3, Adult = C5/6/7
- 5-10% unconscious MVA/Fall patients – CSp #
Thoracolumbar fracture
- Usually the result of high energy trauma
- 40% MVA, 20% falls, 40% GSW/sport/occupational
- Pathological fractures
- Suspected injury? Assume & immobilise until cleared
- Mod-severe pain, worse with movement
- Needs neuro examination
- May have additional other injuries à abdo
- Tx/Lx # + SCI involvement = 10-38% of #, 50-60% of #/
Dislocation
fracture patterns
- Flexion fracture pattern
* Compression fracture
* Burst fracture - Extension fracture pattern
* Flexion/distraction - Rotation Fracture pattern
* Fracture dislocation
* Transverse process fracture
types of spinal fractures
compression
burst
flexion/distraction (chance #)
Fracture dislocation
minor fractures
spinous process fractures
compression spinal fracture
- Common in OP
- Sudden force on spine
- Anterior wedgeing
burst spinal fracture
- Due to severe trauma
- Usually comminuted #
- Risk of SCI
- Vertebra loses height ant & post
Flexion/distraction (chance#) spinal fracture
- Common with flexion+impact
(MVA) - Usually # in posterior & middle
column
Fracture dislocation spinal fractures
* Any of the above with significant vertebral mvt * Normally involves 3 columns à unstable * Frequently involve SCI
Minor fractures transverse process fractures
- Unlikely to affect stability
- Results from rotation or extreme
lateral bending
Spinous process fracture
- “Clay-Shovelers fracture”
- Stable injury
- Direct trauma or sudden musc/lig
pull - MVA/sports/occupation
Overview of spinal fractures is on
slide 40
treatment of spinal fractures
- Chest PT, ASIA Ax
- Surgery
- Unstable fractures
- Spinal cord compromise
- Internal fixation
- External fixation - HALO
- Spinal Braces 6-12wk
- Stable fractures
- No intervention
Halo brace
C0-1, C1-2, C6-T5
LERMANN minerva
C3-T5
Miami -J
C3-6
Cash/Jewett
T7-L3
Miami JTO
C6-T5
TLSO
T7-L4
Philadelphia collar
C3-6
stable/minor compression # of Lx - management
- usually mobilised WBAT +/- elastic L-S support / brace, Day 1
- lying ↔ standing through side lying and perching is
recommended - Educate re: injury & expectations, avoid heavy lifting,/
jumping/sustained flexion for 6 weeks
unstable/moderate spinal # (with no significant neurology) management
- usually fitted with a brace or surgically stabilised
- usually mobilise the day of brace application or Day 1 post-op
- lying ↔ standing through side lying and perching is
recommended - Educate to avoid heavy lifting/jumping/sustained flexion for 6
weeks
simple acute discectomy (no fusion) mgmt
- usually mobilised WBAT, Day 1
- lying ↔ standing through side lying and perching, is
recommended - encourage gentle functional activities++ within
tolerance level but avoid heavy lifting for 6 weeks - ?referral to OP physio
Why are fractures missed?
• Poor history and examination
• Not linking radiology with clinical findings
• Failure to examine all views
• Poor methodical approach
• Failure to order special views
“One view is one view too few – Geoff Connor, 2016”
• Failure to identify need for a comparison view
• Failure to get a second opinion
Commonly missed, high risk injuries
DOH abbreviation
Dislocations
Occult fractures
Half of injuries missed (second fracture)
Wrist dislocations
Scapholunate DS
Perilunate DL
Lunate DL
Wrist occult fractures
Scaphoid #
Triquetrium #C
Wrist Half of injuries missed
Galeazzi #
Distal radius # +
carpal injury
Elbow dislocations
Radial head DL
Elbow occult fractures
Radial Head #
Elbow half of injuries missed
Monteggia #
Pelvis/hip dislocations
Hip DL
Pelvis / hip occult fractures
NOF #
Sacrum #
Acetabulum #
Hip/pelvis Half of injuries missed
Another pelvis ring
fracture
Knee Dislocations
Knee DL
Knee occult fracture
Tibial Plateau #
Segond #
Patella #
Knee Half of injuries missed
Maisonneuve #
Foot dislocations
Lisfranc injury
Foot occult fracture
Calcaneus #
Talus #
Foot half of injuries missed
Thoracolumbar +
calcaneus #
reading an MSK x-ray - guidelines
- Use a systematic approach
- Check patients name, date of X-Ray, side of body (should be a marker)
- Consider clinical information why do you require an X-Ray?
- Look at all images available
- Bone & Joint alignment
- Bone cortex and cortical outline
- Joint spacing
- Soft tissue structures
ABCS abbreviation
for reading an x ray
Alignment
Bone
Cartilage
Soft tissue
always check patient details
Name DOB UR Date and time side series
fracture causes
• Traumatic # -caused by abnormal trauma e.g. fall,
sport, car accident
• Pathological # - fracture in bone weakened by disease
• Periprosthetic # - fracture at point of mechanical
weakness of an implant
• Avulsion # - tendon or ligament remains intact but
pulls off bone fragment
classification of fractures
• Classified by type of fracture, relationship to skin, extent, location • Some fractures may be classified by specific name Relationship to the Environment Open vs. Closed Extent Complete vs. Incomplete Site/Location Intra-articular, location of bone Epiphyseal/growth plate (Salter-Harris) Location along long bone (head, base, shaft, neck)
classification of fractures continued
Relationship of the Fragments Displaced vs. Undisplaced Involvement of dislocation Angulated, impacted, compression • Configuration
Fracture classification : location
– shaft (proximal, middle, distal) of long bones
– medial, lateral (e.g. in ankle)
– head, base (e.g. in phalanges)
– intra-articular / extra-articular (e.g. tibial plateau)
– epiphyseal (proximal, distal)
– subcapital / intertrocanteric / subtrocanteric (e.g. in hip)
– supracondylar / intercondylar (e.g. in knee or elbow)
– periprosthetic (joint replacements or previous ORIF)
bone alignment
• Crucial in determining management of
fracture
• Loss of alignment can be accompanied by
change in bone length, angulation or rotation
Scaphoid fracture
• Most common type of carpal bone fracture • Pain at base of thumb – ASB tenderness • FOOSH • Men 20-30yr, adolescents/ young adults • Needs specific scaphoid view • 10% distal, 70-80% waist, 20% proximal pole
colles fracture = distal radius
- Transverse + partially comminuted fracture of distal radius
- Distal component dorsally displaced and angulated
- Associate transverse fracture of Ulna styloid
- Also called a “dinner fork” or “bayonet” due to shape of forearm
- Often from FOOSH
- Common in osteoporotic bones, middle age elderly
Weber A ankle fracture
• Fracture of the lateral malleolus distal to the syndesmosis • Below level of ankle joint/mortise • Tib/fib syndesmosis intact • Deltoid lig intact • Medial malleolus often fractured • Usually stable but can require ORIF occasionally
Weber B ankle fracture
• Fracture at the level of the syndesmosis • At level of ankle joint, extending superiorly and laterally up fibula • Tib/fib syndesmosis intact or only partially torn • Deltoid lig may be torn • Medial malleolus often fractured • Variable stability
Weber C ankle fracture
• Fracture proximal to the syndesmosis • Above level of ankle joint • Tib/fib syndesmosis disrupted • Deltoid lig injury or medial malleolus fracture present • Unstable – requires ORIF
Lisfanc injury
• Crush injury, foot run over by car, land on foot from
fall from height, sudden rotational force on plantar
flexed forefoot
• Gap between base of 1st and 2nd proximal MT heads
• Disruption of ligament complex, fracture, +/- DL
Jones fracture
- Can be mistaken for a sprain
- AP/Oblique/Lateral with foot fully dorsiflexed
- # diaphysis fifth metatarsal
Patella fracture
- Hard blow to front of knee
* Surgical vs. conservative management
Ottawa ankle rules
An ankle x-ray series is required if there is pain
in the malleolar zone and any of the following:
• Bony tenderness over posterior edge of lateral
malleolus (distal 6cm)
or / and
• Bony tenderness over posterior edge of medial
malleolus (distal 6cm)
or / and
• Inability to weight bear (immediately and in ED)
Ottawa ankle/foot rules
A foot x-ray series is required if there is pain in
the midfoot zone and any of the following:
• Bony tenderness over base of 5th metatarsal
or / and
• Bony tenderness over the navicular
or / and
• Inability to weightbear (immediately and in ED)
Ottawa knee rules
• A patient with knee pain qualifies for an X-Ray if: • 55 years or older • Unable to flex knee to 90* • Inability to bear weight (4 steps) • Point tenderness at proximal fibular head • Isolated point tenderness of patella High sensitivity and specificity
