Week 5 - E - General Trauma (3) - Assessing, investigating and managing a long bone fracture Flashcards
The assessment of an injured limb should include assessment of whether the injury is open or closed, What does open or closed mean?
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
Which between and open and closed fracture is at a higher risk of infection?
Open fractures are at higher risk of infection
What is always essential to carry out in open fractures?
Debdridement as the risk of infection is high
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?
pulses, capillary refill, temperature, colour, sensation, motor power
What is the first symptom of compartment syndrome?
Pain out of proportion is the first symptoms
What are the symptoms of compartment syndrome?
Pain out of proportion
Pallor,
paraesthesia paralysis,
pulselessness (late finding)
What does the intracompartmental pressure have to be in compartment syndrome?
intracompartmental pressure greater than 30mmHg is diagnostic
What imaging is used to diagnose the majority of fractures with usually an AP and lateral view required to assess ?
This would be an X-ray
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?
Scaphoid, acetabulum and tibial plateau
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?
Mandibular fractures
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?
Technetium bone can be used to diagnose these
How long does a hard callus take to form and where are metatarsal stress fractures most commonly seen?
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
What is used to treat metatarsal stress fractures?
6-12 weeks in a rigid soled boot
What can be used to detect occult fractures where there is clinical suspicion but a normal X‐ray (eg. hip, scaphoid)?
MRI scans
What is used to assess mandibular fractures and stress fractures?
Mandibular fracture - can use xray or tomogram
Stress fracture - use technetium scan
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?
Splintage or immobilization may involve the application of a temporary plaster slab (known as a backslab), a sling, an orthosis or a Thomas splint
What are thomas splints used in for immobilisation?
They are used for femoral shaft fractures (stable ones)
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?
Usually treated non-operatively with a period of splintage or immobilization and then rehabilitation
What types of fractures are generally treated non-operatively, with splintage or immobilzation then rehabilitation?
This would be un/minimally displaced, minimally angulated fractures which are considered to be stable
Displaced or angulated fractures where the position is deemed unacceptable require reduction under anaesthetic What are the types of anaesthetic that may be given?
General anaesthetic
Spinal anaesthetic.
Bier’s block - (local anaesthetic injected IV)
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?
May involve the use of small percutaneous pins known as K wiring for small fragments
UNstable injuries can undergo internal or external fixation What is the difference?
Internal fixation is under the skin with the plates and screws
External fixation is where the plates and screws attach to something externally
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?
This will lead to the bone undergoing primary healing
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?
ORIF may cause extensive blood loss (eg femoral shaft) or plate fixation may be prominent (eg tibia)
