WCS35 Injuries To Bones And Joints

Question 1

How does fracture occur?

Answer 1

1. Trauma
   - High energy in young adults with good bone
   - Low energy in older patients with osteoporosis
2. Stress fracture
   - fatigue induced, repeated submaximal trauma
3. Pathological fractures
   - bone already weakened by pre-existing bone disease e.g. tumour, osteolytic lesions

Question 2

History taking

Answer 2

1. History of trauma
2. How and when?
3. Predisposing factors?
4. Pathological (bone weakened by pre-existing disease)?

Question 3

Stress fractures

Answer 3

• Pain on weight bearing
• More severe with activity
• Occurs in lower limb e.g. metatarsal, tibia, femoral neck
• X-ray: Crack fracture, Sclerosis, Callus formation

Treatment:

• Rest
• Avoid exercises
• Surgical fixation in severe cases

Question 4

Description of fracture

Answer 4

Shape:

1. Transverse
2. Oblique
3. Spiral
4. Segmental
5. Comminuted

Site:

1. Shaft (Proximal, Mid, Distal)
2. Articular (Intra, Extra)

Question 5

Clinical features of fracture

Answer 5

1. Look
   - swelling
   - bruises
   - deformity
   - open wound
2. Feel
   - tenderness
3. Move (seldom of use)
   - crepitus
   - abnormal movement

Question 6

Assessment of fractures

Answer 6

Bony fractures:
- ***X-ray
***Rule of 2
—> 2 views (AP + lateral)
—> 2 occasions (repeat X-ray)
—> 2 joints (joint above + below fracture)
—> 2 limbs (compare with other side)

• CT
• Tomogram (not used anymore)
• MRI (not good for bone)
• Bone scan (not used anymore)
• **Soft tissue injuries:
• Skin: open wound
• Nerve injuries (median, radial, sciatic)
• Vascular injuries

General conditions:

• Multiple trauma
• Haemodynamics

Question 7

Compartment syndrome

Answer 7

Tight fascia
—> ↑ in content
—> ↑ pressure within one of the body’s anatomical compartments
—> Impairment of vascular circulation
—> Insufficient blood supply to tissue within that space

Question 8

Injuries to joint

Answer 8

Dislocated / Subluxed (partial dislocation, part of articular surface still in contact)

Articular surface may also be fractured (i.e. Intra-articular fracture)

Effect to ligament:

1. Laxity: prone to re-dislocation (∵ Ligamentous tear)
2. Stiffness: loss of motion

Question 9

Galeazzi, Monteggia fracture dislocation

Answer 9

Galeazzi: Fracture in Radius (distal) + Dislocation of Ulnar head

Monteggia: Fracture in Ulnar (proximal) + Dislocation of Radius head

Question 10

Treatment of joint injury

Answer 10

1. ***Reduction always (for acute injury)
   - Closed: traction + manipulation
   - Open: screw + wire, internal fixation, intramedullary nail, external fixation (for open fracture)
2. **Immobilisation if necessary
   - **Plaster
   - ***Traction: skin / skeletal, temporary / definitive
3. ***Rehabilitation always
   - range of motion exercise
   - muscle strengthening
   - activities of daily living
   - work training

Question 11

Fracture healing

Answer 11

Direct healing: Fracture rigidly fixed
Indirect healing: Callus forms in response to motion, then bone grows across the fracture (natural healing)

Secondary healing

1. Resorption of bone ends
   - ***Haematoma formation
2. ***Soft callus formation
   - Organisation of haematoma
   - Cartilage formation
   - Early bone formation
3. ***Hard callus formation
   - Persistent cartilage formation
   - Revascularisation of cortical bone
   - Bridging by woven bone

3 phases:

1. Inflammation phase
2. Reparative phase
3. Remodeling phase

Question 12

Complications of fracture

Answer 12

General effects:

• ***Haemorrhage —> Shock
• ***Fat embolism —> ∵ fatty bone marrow formed in haematoma reabsorbed into circulation (esp. femur)
• Chest, urinary, skin complications ∵ immobility (e.g. bed sores)

Local:

• Bone: nonunion, malunion
• ***Soft tissues (including compartment syndrome): nerve damage, blood vessels, muscle and tendon
• Joints: ***osteoarthritis (e.g. in articular fracture), stiffness (if no rehab)

Question 13

Delayed union / Nonunion

Answer 13

Definition: Fracture does not heal by 6 months

Causes:

• Lack of fracture stability
• Lack of blood supply

Question 14

Key points revision: Injuries to bones

Answer 14

How:

• Trauma
• Stress
• Pathological

Shape:

• Transverse
• Oblique
• Spiral
• Comminuted
• Segmental

Displacement:

• Angulation
• Shortening
• Rotation
• Segmental

Healing:
- Haematoma —> Inflammation —> Callus —> Consolidation —> Remodeling

Non-healing:

• Distraction
• ↑ Movement
• ↓ Blood supply

X-ray:
Rule of 2
- 2 views (AP, lateral)
- 2 occasions (repeat)
- 2 joints (joint above + below fracture)
- 2 sides (compare to other side)

Treatment:

• Reduction
• Immobilisation
• Rehabilitation

Complications:

• General
• Local
• Look out for compartment syndrome