Week 5 - E - General Trauma (3) - Assessing, investigating and managing a long bone fracture

Question 1

The assessment of an injured limb should include assessment of whether the injury is open or closed, What does open or closed mean?

Answer 1

In a closed fracture, the broken bone doesn’t break your skin.

An open fracture is also called a compound fracture.

In an open fracture, the ends of the broken bone tear your skin

Question 2

Which between and open and closed fracture is at a higher risk of infection?

Answer 2

Open fractures are at higher risk of infection

Question 3

What is always essential to carry out in open fractures?

Answer 3

Debdridement as the risk of infection is high

Question 4

an assessment of the distal neurovascular status, whether there is a compartment syndrome present and an assessment of the status of the skin and soft tissue envelope should also be carried out after debridement

How is the distal neurovascular status checked?

Answer 4

pulses, capillary refill, temperature, colour, sensation, motor power

Question 5

What is the first symptom of compartment syndrome?

Answer 5

Pain out of proportion is the first symptoms

Question 6

What are the symptoms of compartment syndrome?

Answer 6

Pain out of proportion

Pallor,

paraesthesia paralysis,

pulselessness (late finding)

Question 7

What does the intracompartmental pressure have to be in compartment syndrome?

Answer 7

intracompartmental pressure greater than 30mmHg is diagnostic

Question 8

What imaging is used to diagnose the majority of fractures with usually an AP and lateral view required to assess ?

Answer 8

This would be an X-ray

Question 9

Some fractures may not be obvious on one view but readily seen on the orthogonal (perpendicular) view hence two views are always required. Oblique views can also be useful for complex shaped bones

What type of bones are oblique vies required for?

Answer 9

Scaphoid, acetabulum and tibial plateau

Question 10

A tomogram is a moving X‐ray to take images of complex bones. Their use is largely historic but what are they still used to diagnose?

Answer 10

Mandibular fractures

Question 11

CT (computerized tomography) can be used to assess fractures of complex bones (vertebrae, pelvis, calcaneus, scapular glenoid) and can help determine the degree of articular damage and help surgical planning for complex intra‐articular fractures (eg. tibial plateau, distal tibia).

What can be used to detect stress fractures as they may fail to show up on xray until the hard callus forms?

Answer 11

Technetium bone can be used to diagnose these

Question 12

How long does a hard callus take to form and where are metatarsal stress fractures most commonly seen?

Answer 12

Hard callus takes approx 6-12 weeks to form

Metatarsal stress fractures are commonly seen in the 2nd and 3rd metatarsal heads in runners, dancer, marchers

Question 13

What is used to treat metatarsal stress fractures?

Answer 13

6-12 weeks in a rigid soled boot

Question 14

What can be used to detect occult fractures where there is clinical suspicion but a normal X‐ray (eg. hip, scaphoid)?

Answer 14

MRI scans

Question 15

What is used to assess mandibular fractures and stress fractures?

Answer 15

Mandibular fracture - can use xray or tomogram

Stress fracture - use technetium scan

Question 16

Initial fracture management involves clinical assessment of the injured limb, analgesia (usually iv morphine), splintage / immobilization of the limb and investigation (usually X‐rays).

What will splintage and immobilzation of the limb involve?

Answer 16

Splintage or immobilization may involve the application of a temporary plaster slab (known as a backslab), a sling, an orthosis or a Thomas splint

Question 17

What are thomas splints used in for immobilisation?

Answer 17

They are used for femoral shaft fractures (stable ones)

Question 18

After the initial management of the long bone fracture has taken place (splintage,analgesics, immbolization, xrays), the definite management occurs where the fracture may need to be reduced

In general terms undisplaced, minimally displaced and minimally angulated fractures which are considered to be stable are usually treated how?

Answer 18

Usually treated non-operatively with a period of splintage or immobilization and then rehabilitation

Question 19

What types of fractures are generally treated non-operatively, with splintage or immobilzation then rehabilitation?

Answer 19

This would be un/minimally displaced, minimally angulated fractures which are considered to be stable

Question 20

Displaced or angulated fractures where the position is deemed unacceptable require reduction under anaesthetic What are the types of anaesthetic that may be given?

Answer 20

General anaesthetic

Spinal anaesthetic.

Bier’s block - (local anaesthetic injected IV)

Question 21

Unstable injuries may be treated with surgical stabilisation =

What may this stabilisation involve the use of if there are small fragments in the fracture present?

Answer 21

May involve the use of small percutaneous pins known as K wiring for small fragments

Question 22

UNstable injuries can undergo internal or external fixation What is the difference?

Answer 22

Internal fixation is under the skin with the plates and screws

External fixation is where the plates and screws attach to something externally

Question 23

Unstable extra‐articular diaphyseal fractures can be fixed with Open reduction and Internal Fixation (ORIF) using plates and screws What type of healing does this anatomic reduction and fixed healing lead to?

Answer 23

This will lead to the bone undergoing primary healing

Question 24

In occasions where ORIF would cause extensive blood loss or plate fixation may be prominent, it should be avoided Where may there be extensive blood loss if ORIF is used?

Answer 24

ORIF may cause extensive blood loss (eg femoral shaft) or plate fixation may be prominent (eg tibia)

Question 25

Another alternative for extra‐articular diaphyseal fractures is what? has a risk of pin site infection and lossening

Answer 25

This would be external fixation

Question 26

What type of healing does the bone undergo when external fixation is used?

Answer 26

external fixation which again aims for secondary bone healing however carries the risk of pin site infection and loosening.

Question 27

How are displaced intra-articular fractures treated?

Answer 27

They are treated using open reduction and internal fixation (ORIF) - using plates and screws

Question 28

Fractures involving a joint with predictable poor outcome may be treated with what?

Answer 28

Joint replacement or arthrodesis