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Ortho > Treatment of Fxs > Flashcards

Treatment of Fxs Flashcards

1
Q

What part of the bone is the key to fx healing?

A
  • periosteum: provides the vascular supply
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2
Q

Biology of fx healing - diff phases?

A
  • reactive phase: fx and inflammatory phase (vessels contract, hematoma), granulation tissue formation (fibroblasts take over)
  • reparative phase: cartilage callus formation (periosteal cells - turn to chondroblasts), lamellar bone deposition (form fx callus)
  • remodeling phase: remodeling to original contour, trabecular bone is replaced w/ compact bone
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3
Q

Healing rates depend on what?

A
  • vary w/ age, comorbidities, nutritional status
  • effected by thyroid and GH levels, calcitonin
  • common conditions that impair healing:
    diabetes, arteriovascular disease, anemia, vitamin deficiencies (A and C), tobacco use, chronic alcohol use, meds: NSAIDs, glucocorticoids, cipro
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4
Q

Eval of fx pt?

A
  • vital signs and mental status
  • MOI: beware of high energy injuries
  • neurovascular status of extremity (elbow and knees): record it for posterity
  • where is deformity? beware of knee and elbow injuries
  • open or closed?
  • check jts above and below fx
  • min of 2 xray views of injured pt
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5
Q

Common injury patterns of FOOSH?

A
  • scaphoid radial head, wrist, proximal humerus
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6
Q

Common injury patterns - falling off roof?

A
  • os calcis, tibial plateau, TL compression fx
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7
Q

How do you describe fx?

A
  • name of injured bone
  • location (dorsal, volar: epiphysis, metaphysis, diaphysis - proximal, middle, distal third)
  • orientation of fx: transverse, oblique, spiral, angulated, comminuted, segmental, intra-articular, displaced, compression and impaction
  • condition of overlying tissues (open or closed): 1 puncture, 2 laceration w/ mod ST injury, 3 grossly contaminated
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8
Q

What factors effect tx?

A
  • open or closed injury
  • nature and severity of fx:
    energy involved: stable or unstable
    is position acceptable, is jt involved?
  • possible neuro-vascular injuries/complications: N/V issues and compartment syndromes
  • age, health, demands of pt
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9
Q

Complications of fxs?

A
  • pelvic and femoral fxs can have significant blood loss
  • injuries to other structures: nerves/vessels, esp at knee and elbow
  • acute compartment syndromes
  • increased risk of venous thrombosis w/ major trauma
  • Fat emboism syndrome: femur fx
  • complex regional pain syndromes (sympathetic dystrophy)
  • late: osteomyelitis, non/mal-union, post-traumatic arthritis
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10
Q

Principles of tx?

A

acute stabilization:
- eval the pt
- immobilize fx: usually splinting
- provide analgesia: ice, elevation, immobilization, pain meds
- decide on definitive tx
- create conditions where the body will heal the fx while pt is as fxnl as possible:
allow for jt motion when possible, pts need est of when they can return to work/sports

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11
Q

Tx options for fxs?

A
  • reassurance or min. tx: rib fxs, torus fxs, metacarpal fxs, toe fxs
  • immobilization w/ cast, splint or brace: works well for stable, well aligned fx, down side: prolonged immobilization, loss of reduction, fxnl limits
  • traction: better options than this now
  • fx reduction closed or open: maintain w/ cast, hardware or both
  • surgical fixation:
    displaced, unstable fx, early mobilization, often the best option: quick return to fxn, displaced intra-articular fxs, down side is cost, complications including infection
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12
Q

Casting is TOC for what? Types of casts/splints?

A
  • Rx of choice for undisplaced, stable, and some reduced fxs
  • plaster of paris or fiberglass:
    plaster easier to mold,
    fiberglass more durable
  • may splint initially - safer than a cast in acute setting: volar splint forearm and wrist, sugar tong splint for ankle
  • diaphyseal fxs: include jts above and below fx
  • complications of casting: pressure sores, N/V compromise, compartment syndrome, disuse atrophy, jt stiffness
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13
Q

Surgical options for fxs?

A
  • pins and wires: reduction of fx, pin fixaion, and cast, cerclage and tension band wiring
  • plates and screws: initially thick and unbending, now contoured to specific bones and locking plates
  • external fixators: for unstable injuries and contaminated fxs
  • intramedullary devices: for long bone fxs, options for cross locking screws, gamma nails for unstable hip fxs
  • replacements: hip, shoulder, radial head
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14
Q

Common fxs in kids? Salter Harris classification?

A
  • usually heal much faster than adults - potential for remodeling
  • unique fxs due to nature of young bone:
    buckle (torus), greenstick, plastic deformation, growth plate injury, apophyseal avulsion
  • Salter:
    1 undisplaced
    2 physis + metaphysis
    3 physis + epiphysis
    4 across physis
    5 crush injury
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15
Q

Tx for clavicular fxs?

A
  • most (70%) are mid shaft: stable: sling or figure of 8, if displaced, angulated or over riding fx may need surgery
  • in kids: 90% in middle 3rd, if younger than 10: majority are non displaced, if older than 10 than majority are displaced
  • distal 3rd: behave like AC separations, if undisplaced: conservative tx, otherwise may need surgical repair
  • prox 3rd: rare, beware of internal injuries - high energy injury (think about internal injuries as well)
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16
Q

How common are adult shoudler fxs? Tx?

A
  • 5% of all fxs and increases w/ advancing age:
    often due to falling from standing ht, may be simple 2 part fx or 3 or 4 part fx w/ tuberosity involvement
  • gross deformity suggests anterior or posterior dislocation: need axillary or transthoracic xrays as well as AP films, fx alone can cause sig swelling and ecchymosis
  • 80% are impacted or non-displaced: conservative rx -
    basic tx is sling, limitation of activities, pain meds, mobilize as comfort permits, PT/OT of benefit, sleep in recliner initially
  • refer anatomic neck, complex fxs and dislocations
17
Q

Tx for distal forearm fxs in kis?

A
  • need ortho referral if there is N/V compromise, open fx, gross deformity or displaced salter fx
  • stable fxs may be tx w/ casts or braces:
    depends on pt/parent preference, high five to assess healing
18
Q

What is a colle’s fx? Tx?

A
  • incidence increases w/ age
  • dorsal displacement/angulation of distal radius
  • FOOSH
  • tx ranges from splint to pinning to plating
19
Q

Metacarpal fxs usually due to what? Tx?

A
  • 30-40% of all hand fxs
  • usually due to direct trauma (punching a wall)
  • tx depends on displacement, angulation, rotation
  • can accept sig angulation of 5th metacarpal (Boxer’s): can be tx w/ off the shelf braces or taping of fingers
20
Q

Tx of base of thum fxs?

A
  • stability determines tx

- thumb spica if stable, if not refer to ortho

21
Q

Etiology of vertebral compression fx? Tx?

A
  • traumatic fx: has there been posterior compromise?
  • osteoporotic often are asx: dowager’s hump - can occur in absence of trauma, tx: pain relief and correction of osteoporosis
  • bracing can provide pain relief and increased activity, surgery for neuro compromise or unresponsive pain - vertebroplasty: correction and cement
22
Q

Etiology of pelvic fxs? Tx?

A
  • major trauma in young, beware of blood loss and injuries to other organs
  • elderly: can see pubic rami or sacral fxs w/ minimal trauma: seen in osteoporotic, low body wt, smoking, steroids, limited activity
  • be suspicious w/ vague pelvic pain, pain w/ leg motion, inability to bear wt on leg
  • dx w/ xrays, may need MRI
  • pain control and early, protected ambulation
23
Q

Hip fxs in the elderly? Tx?

A
  • sig source of morbidity and mortality in elderly:
    1/3 die w/in 6 months, fx may occur b/f fall (pathologic fx)
  • unless severely debilitated, Rx of choice is surgery:
    decreases morbidity, relieves pain, allows for fxn, may need total hip if there is preexisting arthritis
24
Q

Presentation of femoral neck fxs? Complications? tx?

A
  • shortening and external rotation of leg = groin pain
  • interrupt blood supply, high complication rate
  • replacement often better than pinning
25
Q

Tx of intertrochanteric hip fxs?

A
  • do well w/ plate and screws

- can lose sig blood: type and screen b/f surgery

26
Q

Tx of subtrochanteric hip fxs?

A
  • unstable injury best tx w/ intramedullary device, also can have significant blood loss
27
Q

Common tibial shaft fxs? Tx?

A
  • low energy fxs usually seen in distal metaphysics
  • rotational injuries cause spiral, oblique, or distal fxs
  • mid shaft fxs usually due to high energy injuries: MVA - be on alert for compartment syndrome
  • need to be tx by an orthopedist:
    may be able to tx stable injuries conservatively, many injuries will reqr surgery
28
Q

ankle fxs:

PE, dx, tx?

A
  • common injury seen w/ twisting injuries of foot/ankle
  • PE: N/V status - medial and lateral tenderness
  • need AP, lateral, and oblique xrays
  • stable injuries can be tx conservatively: undisplaced malleolar fx w/o ligamentous injury
  • unstable injuries: do better w/ surgery - bimalleolar fxs or malleolar fx w/ ligament injury
  • surgery mandatory if there is ankle jt diastasis: always look at mortice
29
Q

Dx, tx of foot fxs?

A
  • need AP, lateral, and oblique xrays
  • beware of mid and hind foot fxs: severity of injury can be hard to see on X-rays, palpate tarsal-metatarsal its, occult injuries
  • most forefront fxs can be tx conservatively:
    short leg walking cast or walking boot, 1st metatarsal fxs require extra vigilance, stable toe fx can be simply taped, displaced, unstable toe Fxs may need pinning
30
Q

How common are metastatic fxs?

A
  • occur in 10-15% of persons w/ mets bone disease
  • 17-50% of pts w/ breast cancer and bone mets will experience new spinal fxs each year
  • up to 41% of pts receiving radiation to tx bone mets experience bone fxs
  • new spinal fxs are reported to occur in 15-30% of pts w/ multiple myeloma annually
  • vertebral fx is present more than half the time, among myeloma pts w/ bone pain in back
31
Q

Tx of met fxs?

A
  • need to stabilize fx, remove tumor: bone cement

- early lesion (pre fx) may respond to radiotherapy

32
Q

When do stress fxs occur? Presentation?

A
  • occur b/c of repetitive stresses applied to bone: rate of resorption exceeds that of deposition
  • can start as dull ache and build to sharp pain: stress rxn progresses to frank fx, will have pt tenderness over fx site
  • often not seen on X-ray: MRI or bone scan if suspicious
33
Q

Tx of stress fx?

A
  • most respond to decreased activity and immobilization, beware stress fx in spine, hip and tarsal navicular: aching groin pain in an endurance athlete must be fully eval
34
Q

What are fx patterns suggestive of inflicted trauma?

A
  • injuries inconsistent w/ hx given or changes in hx given: esp in young or special needs pts

Fx patterns suggestive of inflicted trauma:

  • metaphyseal corner fxs
  • fxs of ribs, sternum, scapula, spinous processes
  • mult fxs in various stages of healing
  • bilateral acute long bone fxs
  • skull fxs in kids younger than 18 months
  • skeletal survery or bone scan to find occult lesions
  • legally reqd to notify child protective services
35
Q

When should you refer a pt w/ a fx on to ortho?

A
  • any open injury
  • when there is neurovascular compromise: beware spine, knee, elbow fxs
  • high energy injuries
  • excessive pain: possible compartment syndrome
  • fx that is sig angulated or displaced: if it is deformed clinically, usually needs to be reduced
  • fxs with known bad outcomes:
    hip fxs, scaphoid fxs, displaced long bone fxs
  • whenever pt or parent has concerns

Ortho (24 decks)

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