Treatment of Fractures Flashcards
What does the skeleton provide for the body?
Strength
Stiffness
Rigidity
Types of Cells within Bones
Osteoblasts
Osteocytes
Osteoclasts
Marrow elements
What does type 1 collagen provide for the bone?
Tensile strength
Resiliency
What does the periosteum provide for healing of fractures?
Vascular supply
What triggers the healing process in bone fractures?
Bleeding
3 Phases of Fracture Healing
Reactive phase
Reparative phase
Remodeling phase
What is part of the reactive phase of fracture healing?
Fracture & inflammatory phase Formation of granulation tissue formation Vessels contrac Hematoma Fibroblasts take over
Parts of the Reparative Phase of Fracture Healing
Cartilage callus formation
Lamellar bone deposition
Periosteal cells -> chondroblasts
Form fracture callus
Parts of the Remodeling Phase of Fracture Healing
Remodeling to original contour
Trabecular bone replaced with compact bone
Factors Affecting Healing Rates
Age Comorbidities Nutritional Status Thyroid & GH levels Calcitonin
Common Conditions that Impair Healing
DM Arteriovascular disease Anemia Vitamin A, C deficiencies Tobacco use Chronic alcohol abuse
Medications that Impair Healing
NSAIDs
Glucocorticoids
Cipro
Evaluation of the Fracture Patient
Vitals Mental status Mechanism of injury Neurovascular status of the extremity Where is the deformity? Open or closed? Check joints above and below Minimum of 2 X-ray views
Common Fractures when Landing on an Outstretched Hand
Scaphoid
Radial head
Wrist
Proximal humerus
Common Fractures When Falling off of a Roof
Os calcis
Tibial plateau
TL compression fracture
Describing Fractures
Name of bone Location Orientation of fracture Condition of overlying tissues (open vs. closed) Unique fracture names
Location of Fractures
Dorsal Volar Epiphysis Metaphysis Diaphysis (proximal, middle, or distal third)
Orientation of Fractures
Transverse Oblique Spiral Angulated Comminuted Segmental Intra-articular Displaced Compression Impaction
Unique Names of Fractures
Supracondylar
Colles
Boxer’s
Factors that Effect Treatment
Open vs. closed Nature & severity of fracture Possible neuro-vascular injuries/complications Age Health Demands of patient
Complications of Fractures
Pelvic & femoral: severe bleeding Injuries to other structures Acute compartment syndrome Increased risk of venous thrombosis with major trauma Fat embolism syndrome Complex regional pain syndromes Osteomyelitis Non/mal-union, post-traumatic arthritis
Principles of Fracture Treatment
Acute stabilization
Definitive treatment
Possible Options when Stabilizing a Fracture
Splinting
Provide analgesia: ice, elevation, pain meds
Decide on definitive treatment
Definitive Treatment of Fractures
Create conditions where body will heal the fracture while keeping the patient as functional as possible
Treatment Options for Fractures
Reassurance Immobilization: cast, sprint, brace Traction: more historical Reduction: cast, hardware, both Surgical fixation
When is surgical fixation warranted?
Displaced,unstable fractures Early mobilization Quick return to function Displaced intra-articular fractures Down side: cost, complications
When are casts the prescription of choice for fractures?
Undisplaced
Stable
Some reduced fractures
How do you cast a diaphyseal fracture?
Include joints above & below
Complications of Casting
Pressure sores Neurovascular compromise Compartment syndrome Disuse atrophy Joint stiffness
Surgical Options for Fractures
Pins & wires Plates & screws External fixtures Intramedullary devices Replacements
Unique Fractures in Children
Buckle (torus) Growth plate injury Greenstick Plastic deformation Apophyseal avulsion
Salter Harris Classification of Fractures in Children
1: undisplaced
2: physis + metaphysis
3: physis + epiphysis
4: across the physics
5: crush injury
Treatment of Stable Mid-Shaft Clavicular Fractures
Sling
Figure 8 splint
Treatment of Displaced, Angulated, or Over Riding Clavicular fracture
Surgery
Treatment of Distal Third Clavicular Fractures
Undisplaced: conservative
Others: surgery
Treatment of Proximal Third Clavicular Fractures
High energy injury
Rare
Watch for internal injuries
When do shoulder fractures generally occur?
Advancing age
Fall from standing height
Treatment of Impacted or Non-Displaced Shoulder Fractures
Sling Limitation of activities Pain meds Mobilize as tolerated PT/OT Sleep in recliner initially
What shoulder fractures should be referred to a specialist?
Anatomic neck
Complex fractures
Dislocations
What distal forearm fractures in children need to be referred?
Neurovascular compromise
Open fractures
Gross deformity
Displaced Salter fracture
Treatment of Stable Distal Forearm Fractures in Children
Cast
Brace
Depends on patient/parent preference
Describe a Colle’s Fracture
Dorsal displacement/angulation of distal radius
Increased risk with age
Treatment of a Colle’s Fracture
Splint
Pinning
Plating
What does treatment of metacarpal fractures depend on?
Displacement
Angulation
Rotation
What determines treatment with a base of thumb fracture?
Stability of thumb joint
How do vertebral compression fractures occur?
With/without trauma
Osteoporosis
Treatment of Vertebral Compression Fractures
Pain relief
Correction of osteoporosis
Bracing
Surgery
What does bracing provide for a compression fracture?
Pain relief
Increased activity
When is surgery performed for a compression fracture?
Neuro compromised
Unresponsive patient
Caution with Pelvic Fractures in Children
Major trauma
Blood loss
Injuries to other organs
Pelvic Fractures in the Elderly
See pubic rami or sacral fractures with minimal trauma
Risks for Pelvic Fractures in the Elderly
Osteoporosis Low body weight Smoking Steroids Limited activity
When should we be suspicious for a pelvic fracture in the elderly?
Vague pelvic pain
Pain with leg motion
Inability to bear weight
Diagnosing a Pelvic Fracture in the Elderly
X-rays
MRI
Treatment of Pelvic Fractures in the Elderly
Pain control
Early, protected ambulation
What is a significant source of morbidity & mortality in the elderly?
Hip fractures
Could be pathologic fractures
Treatment of Hip Fractures
Surgery: either pinning or total hip if previous arthritis
Diagnosis of Femoral Neck Fractures
Shortening & external rotation of leg
Groin pain
Treatment of Femoral Neck Fractures
Replacement > pinning
Treatment of Intertrochanteric Hip Fractures
Surgery: plate & screws
Major concern with Intertrochanteric Hip Fractures
Blood loss
Type & screen prior to surgery
Subtrochanteric Hip Fractures
Unstable
Intramedullary device
Significant blood loss
Location of Low Energy Tibial Shaft Fractures
Distal metaphysis
What type of tibial fractures are caused by rotational injuries?
Spiral
Oblique
Distal fractures
Location of High Energy Tibial Fractures
Mid-shaft fracture
Treatment of Tibial Shaft Fractures
Orthopedist
Conservative (stable)
Most: surgery
When do adults usually obtain ankle fractures?
Twisting injuries of the foot/ankle
Physical Exam Findings in Ankle Fractures in Adults
Neurovascular status
Medial & lateral tenderness
Treatment of Stable Ankle Fractures in Adults
Conservatively
Treatment of Unstable Ankle Fractures in Adults
Surgery
When is surgery mandatory for ankle fractures?
Ankle joint diastasis
LOOK AT MORTICE
Conservative Treatment of Forefoot Fractures
Short leg walking cast
Walking boot
Stable toe fracture: buddy tape
Displaced or unstable toe fracture: pinning
Treatment of Metastatic Fractures
Stabilize fracture
Remove tumor
Early lesion (pre-fracture): radiotherapy
Diagnosing a Stress Fracture
X-ray: often not seen
MRI or bone scan
Treatment of Stress Fractures
Most: decreased activity, immobilization
Fractures & Child Abuse Signs
Injuries inconsistent with history
Metaphyseal corner fracture
Rib, sternum, scapula, spinous processes fractures
Multiple fractures in different stages of healing
Bilateral long-bone fractures
Skull fractures in children less than 18 months
When to Refer Fractures to Ortho
Open injuries Neurovascular compromise High energy injuries Excessive pain Significantly angulated or displaced fracture Hip fractures Scaphoid fractures Displaced long bone fractures Patient or parent concerns
