Treatment of Fxs Flashcards
1
Q
What part of the bone is the key to fx healing?
A
- periosteum: provides the vascular supply
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
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
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
5
Q
Common injury patterns of FOOSH?
A
- scaphoid radial head, wrist, proximal humerus
6
Q
Common injury patterns - falling off roof?
A
- os calcis, tibial plateau, TL compression fx
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
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
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
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
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
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
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
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
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)
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
