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Orthopedic Surgery Ultimate > Treatment of Fractures > Flashcards

Treatment of Fractures Flashcards

1
Q

BONE:

  1. Skeleton provides what? 3
  2. Cells that are involved in bone structure? 4
  3. Organic component is primarly what type of collagen?
    - What does it provide? 2
  4. What is the key to fracture healing?
  5. Fractures cause what which trigger the healing process?
A
  1. Skeleton provides
    - strength,
    - stiffness
    - rigidity
  2. Cells:
    - osteoblasts,
    - osteocytes,
    - osteoclasts,
    - marrow elements
  3. Organic component is primarily type 1 collagen
    - Provides tensile strength and resiliency
  4. Periosteum provides the vascular supply, key to Fx healing
  5. Fractures cause bleeding which triggers the healing process
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2
Q

What are the phases of fracture healing? 3

A
  1. Reactive phase
  2. Reparative phase
  3. Remodeling phase
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3
Q

Describe the steps in the following phases:

  1. Reactive phase? 4
  2. Reparative phase? 4
  3. Remodeling phase? 2
A
  1. Reactive phase
    - Fracture and inflammatory phase
    - Granulation tissue formation
    - vessels contract, hematoma
    - fibroblasts take over
  2. Reparative phase
    - Cartilage callus formation
    - Lamellar bone deposition
    - periosteal cells - - > chondroblasts
    - form fracture callus
  3. Remodeling phase
    - Remodeling to original contour
    - Trabecular bone is replaced with compact bone
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4
Q

Healing rates:

  1. Effected by what? 3
  2. Common conditions that impair healing? 4
  3. Substance use that impairs healing? 2
  4. Meds that impair healing? 3
A
  1. Effected by
    - thyroid and
    - growth hormone levels,
    - calcitonin
  2. Common conditions that impair healing:
    - Diabetes,
    - arteriovascular disease,
    - anemia,
    - vitamin deficiencies (A C)

3.

  • Tobacco use,
  • chronic alcohol abuse
    4. Med’s:
  • NSAIDS,
  • glucocorticoids,
  • Cipro
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5
Q

Evaluation of Fxs: Mechanism of injury – beware of what?

A

high energy injuries

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6
Q

COMMON INJURY PATTERNS: Outstretched hand? 4

A
  1. scaphoid
  2. radial head,
  3. wrist,
  4. proximal humerus
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7
Q

COMMON INJURY PATTERN: Fall off roof? 3

A
  1. os calcis,
  2. tibial plateau,
  3. TL compression Fx
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8
Q

FRACTURE DESCRIPTION…..get your book out before calling ortho 6

A
  1. Name of the injured bone
  2. Location (dorsal, volar – epiphysis, metaphysis, diaphysis)
    - Diaphyseal: proximal, middle, or distal third
  3. Orientation of the fracture (transverse, oblique, spiral)
  4. Also: angulated, comminuted, segmental, intra-articular, displaced, compression, and impaction
  5. Condition of overlying tissues (open or closed) 1 puncture; 2 laceration with mod ST injury 3 grossly contaminated
  6. Some fractures have unique names -Supracondylar, Colles, Boxer’s,
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9
Q

FACTORS THAT EFFECT TREATMENT 6

A
  1. Open or closed injury Nature and severity of the fracture
  2. Energy involved - Stable or unstable
  3. Is the position acceptable
  4. Is the joint involved
  5. Possible neuro-vascular injuries/complications -N/V issues and compartment syndromes
  6. Age, health, demands of the patient
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10
Q

COMPLICATIONS OF FRACTURES 6

A
  1. Pelvic and femoral fractures can have significant blood loss
  2. Injuries to other structures: Nerves/vessels, especially at knee & elbow
  3. Acute compartment syndromes
  4. Increased risk of venous thrombosis with major trauma
  5. Fat embolism syndrome
  6. Complex regional pain syndromes (sympathetic dystrophy)
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11
Q

COMPLICATIONS OF FRACTURES: Late signs? 3

A

Late:

  • osteomyelitis,
  • non/mal-union,
  • post-traumatic arthritis
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12
Q

PRINCIPLES OF TREATMENT Acute stabilization? 4

A

Acute stabilization

  1. Evaluate the patient
  2. Immobilize the Fx – usually splinting
  3. Provide analgesia: ice, elevation, immobilization, pain meds
  4. Decide on definitive treatment
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13
Q

Treatment options

  1. Reassurance or minimal treatment? 4
  2. Immobilization with cast, splint, or brace: works well for who?
    - Down side is what? 3
  3. Fracture reduction closed or open
    - Maintain with what? 2
  4. Surgical fixation: for what? 4
  5. Complications: surgical? 2
A

1.

  • Rib fractures,
  • torus fractures,
  • metacarpal fractures,
  • toe fractures
    2. Works well for stable, well-aligned fractures
  • prolonged immobilization, loss of reduction, functional limits
    3. cast, hardware, or both

4.

  • Displaced, unstable fracture
  • Early mobilization
  • Often the best option – quick return to function
  • Displaced intra-articular fractures
    5. Down side is
  • cost,
  • complications including infection
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14
Q
  1. Casting is the tx of choice for what? 3
  2. What kinds? and what are their advantages?
  3. May splint initially: use what for forearm and wrist? What for ankle?
  4. What are diaphyseal Fxs?
  5. Complications? 5
A
  1. Rx of choice for undisplaced, stable, and some reduced Fx’s
  2. Plaster of Paris or fiberglass
    - Plaster easier to mold
    - Fiberglass more durable
  3. May splint initially – safer than a cast in acute setting
    - Volar splint forearm and wrist
    - Sugar tong splint for ankle
  4. Diaphyseal Fx’s: include joints above and below the fracture
  5. Complications include:
    - pressure sores,
    - N/V compromise,
    - compartment syndrome,
    - disuse atrophy,
    - joint stiffness
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15
Q

Surgical options for Fractures

  1. What are pins and wires for?
  2. Use what?
  3. What are plates and screws used for?
  4. External fixators for?
  5. Intramedullary devices for?
  6. What are for unstable hip fractures?
  7. Replacements for what? 3
A

Pins and wires

  1. Reduction of fracture, pin fixation, and cast
  2. Cerclage and tension band wiring

Plates and screws

  1. Initially thick and unbending

External fixators

  1. For unstable injuries and contaminated fractures

Intramedullary devices

  1. For long bone Fx’s, options for cross locking screws
  2. Gamma nails for unstable hip fractures
  3. Replacements
    - Hip,
    - shoulder,
    - radial head
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16
Q

What is this?

A

CERCLAGE

WIRES

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17
Q

What are these?

A

TENSION BAND WIRING

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18
Q

What are these?

A

EXTERNAL
FIXATORS

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19
Q

What are these?

A

INTRAMEDULLARY DEVICES

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20
Q
  1. Advantage that children have over adults in fractures?
  2. Unique fractures due to nature of young bone? 5
  3. Salter Harris Classification of growth plate fractures? 5
A
21
Q

Clavicular fractures

  1. Most are where?
  2. What kind of splint?
  3. Which fractures may need surgery? 3
  4. In which ages are the majority of fractures displaced?
A
  1. Most (70%) are mid-shaft fractures
  2. Stable injuries… sling or figure of 8 splint

3.

  • Displaced,
  • angulated
  • over riding fracture may need surgery
    3. In children, 90% in the middle third
  • less than age 10, majority are non-displaced,
  • > age 10, majority are displaced
22
Q

CLAVICULAR FRACTURES

  1. Distal third behave how?
  2. Tx for undisplaced?
  3. Otherwise?
  4. Proximal third beware of what?
  5. Commonly caused by?
A
  1. Distal third – behave like AC separations

2.

  • Undisplaced, conservative treatment
    3. Otherwise, may need surgical repair
    4. Proximal third – rare, beware internal injuries
    5. High energy injury
23
Q

ADULT SHOULDER FRACTURES

  1. 5% of all fractures and increases with what?
  2. Often due to?
  3. Describe how serious they could be?
  4. Gross deformity suggests what?
  5. Dx?
  6. Fracture alone can cause what? 2
A
  1. 5% of all fractures and increases with advancing age
  2. Often due to falling from standing height
  3. May be simple 2 part Fx or 3 or 4 part Fx with tuberosity involvement
  4. Gross deformity suggests anterior or posterior dislocation
  5. Need axillary or transthoracic X-rays as well as AP films
  6. Fracture alone can cause
    - significant swelling and
    - ecchymosis
24
Q

ADULT SHOULDER FRACTURES

  1. 80% are impacted or non-displaced….tx?
  2. Basic treatment is? 3
    - Mobilize as comfort permits, PT/OT of benefit
  3. Sleep how initially?
  4. Refer which types? 3
A
  1. conservative Rx

2.

  • sling,
  • limitation of activities,
  • pain meds
    3. in recliner initially

4.

  • anatomic neck,
  • complex fractures
  • dislocations
25
Q

DISTAL FOREARM FRACTURES IN CHILDREN

  1. Need ortho referral if? 4
  2. Stable tx with?
A
  1. Need orthopedic referral if there is
    - N/V compromise,
    - open fracture,
    - gross deformity
    - displaced Salter Fx
  2. Stable Fx’s may be treated with casts or braces
26
Q

COLLE’S FRACTURES

  1. Incidence increases with?
  2. Where is displacement and angulation?
  3. Injured how?
  4. Tx?
A
27
Q

Metacarpal fractures

  1. Usually due to?
  2. Tx depends on? 3
  3. Usually what is injured and how is it treated?
A
  1. Usually due to direct trauma (punching a wall)…..happens all the time!
  2. Treatment depends on
    - displacement,
    - angulation,
    - rotation
  3. Can accept significant angulation of 5th metacarpal (Boxer’s)
    - Can be treated with off the shelf brace or taping of fingers
28
Q

For base of thumb fx what do you need to test?

A

Need to test stability – determines treatment

29
Q

VERTEBRAL COMPRESSION FRACTURES

  1. Traumatic fx: What do you need to ask about?
  2. Which are often asymptomatic? What will you see on Xray?
  3. Can occur in the absense of?
  4. Tx?
A
  1. Traumatic Fx – has there been posterior compromise?
  2. Osteoporotic often are asymptomatic – Dowager’s hump
  3. Can occur in the absence of trauma
  4. Treatment: pain relief and correction of osteoporosis
30
Q

VERTEBRAL COMPRESSION FRACTURES

  1. Bracing helps with? 2
  2. Surgery for who? 2
  3. What kind?
A
  1. Bracing can provide
    - pain relief
    - increased activity
  2. Surgery for
    - neuro compromise
    - unresponsive pain
  3. Vertebroplasty – correction and cement
31
Q

PELVIC FRACTURES

  1. Prognosis?
  2. Beware of what?
A
32
Q

PELVIC FRACTURES IN THE ELDERLY

  1. Can see what with minimal trauma? 2
  2. Seen in the who?
  3. Risk factors? 4
  4. Be suspicious with what? 3
  5. Dx with what? 2
  6. tx?
A
  1. pubic rami or sacral fractures
  2. osteoporotic

3.

  • Low body weight,
  • smoking,
  • steroids,
  • limited activity

4.

  • vague pelvic pain,
  • pain with leg motion,
  • inability to bear weight on the leg
    5. X-rays, may need MRI
    6. Pain control and early, protected ambulation
33
Q

Hip Fractures

Significant source of morbidity and mortality in the elderly

  1. 1/3 die within how long?
  2. Fracture may occur when?
  3. Unless severely debilitated, Rx of choice is what?
  4. Advantages for surgery? 3
  5. May need total hip if there is what?
A
  1. 6 months
  2. before the fall (pathologic fx)
  3. surgery

4.

  • Decreases morbidity,
  • relieves pain,
  • allows for function
    5. preexisting arthritis
34
Q

FEMORAL NECK FRACTURES

  1. Positioning of the leg?
  2. Pain where?
  3. high complications rate why?
  4. Whats usually better: pinning or replacement?
A
  1. Shortening and external rotation of leg –
  2. groin pain
  3. Interrupt blood supply, high complication rate
  4. Replacement often better than pinning
35
Q

INTERTROCHANTERIC HIP FRACTURES

  1. Do well with what?
  2. Can lose what?
  3. What do you have to do before surgery?
A
36
Q

SUBTROCHANTERIC HIP FRACTURES

  1. Usually treated how?
  2. Complication?
A
  1. Unstable injury best treated with intramedullary device
  2. Also can have significant blood loss
37
Q

TIBIAL SHAFT FRACTURES

  1. Low energy fxs usually seen where?
  2. Rotational injuries cause? 3
  3. Mid shaft Fx usually due to ?
    - be on the alert for what?
  4. Need to be treated how?
A
  1. Low energy Fx’s usually seen in distal metaphysis
  2. Rotational injuries cause
    - spiral,
    - oblique, or
    - distal Fx’s
  3. Mid shaft Fx’s usually due to high energy injuries – MVA
    - BE ON THE ALERT FOR COMPARTMENT SYNDROME
  4. Need to be treated by an orthopedist
    - May be able to treat stable injuries conservatively
    - Many injuries will require surgery
38
Q

ANKLE FRACTURES IN ADULTS

  1. Commonly seen in what?
  2. PE?
  3. Which xrays? 3
  4. Stable injuries can be treated conservatively. What are considered stable?
A
  1. Common injury seen with twisting injuries of the foot/ankle
  2. Physical exam: N/V status – medial and lateral tenderness
  3. Need AP, lateral and oblique x-rays
  4. Stable injuries can be treated conservatively
    - Undisplaced malleolar Fx without ligamentous injury
39
Q

ANKLE FRACTURES IN ADULTS

  1. Unstable injuries do better with?
  2. Which are these? 2
  3. Surgery is mandatory when?
  4. Always look where?
A
  1. Unstable injuries do better with surgery

2.

  • Bimalleolar Fx’s or
  • malleolar Fx with ligament injury
    3. Surgery mandatory if there is ankle joint diastasis
    4. ALWAYS LOOK AT THE MORTICE
40
Q

FOOT FRACTURES

  1. Need what Xrays? 3
  2. Beware of mid and hind foot fractures. Why?
  3. Palpate what? why?
  4. Most forefoot fractures can be treated conservatively. With? 4
A
  1. Need AP, lateral, and oblique x-rays
  2. Beware of mid and hind foot fractures: Severity of injury can be hard to see on x-rays
  3. Palpate tarsal-metatarsal joints, occult injuries
  4. Most forefoot fractures can be treated conservatively
    - Short leg walking cast or walking boot
    - First metatarsal Fx’s require extra vigilance
    - Stable toe Fx can be simply taped
    - Displaced, unstable toe Fx’s may need pinning
41
Q

METASTATIC FRACTURES

  1. 17-50% of patients with what will experience new spinal fractures each year? 2
  2. Up to 41% of patients receiving what to treat bone metastasis experience bone fractures?
  3. New spinal fractures are reported to occur in 15-30% of patients with what annually?
  4. What is present more than half the time, among myeloma patients with bone pain in the back?
A
  1. breast Ca and bone metastasis
  2. radiation
  3. multiple myeloma
  4. Vertebral fracture
42
Q

METASTATIC FRACTURES

  1. Tx? 3
  2. What may respond to radiotherapy?
A

1.

  • Need to stabilize fracture,
  • remove tumor
  • Bone cement
    2. Early lesion (pre fracture) may respond to radiotherapy
43
Q

STRESS FRACTURES

  1. Occur why?
  2. Present how?
  3. Starts how? Progresses to?
  4. Will have what over the fracture site?
  5. Often seen how?
A
  1. Occur because of repetitive stresses applied to a bone
    - Rate of resorption exceeds that of deposition
  2. Can start as dull ache and build to sharp pain
  3. Stress reaction progresses to frank fracture
  4. Will have point tenderness over the fracture site
  5. Often not seen on X-ray…..MRI or bone scan if suspicious
44
Q

Stress Fractures

  1. Most respond to what?
  2. Beware stress fractures where? 3
  3. What in an endurance athlete must be fully evaluated?
A
  1. decreased activity and immobilization
  2. in
    - spine,
    - hip
    - tarsal navicular
  3. Aching groin pain
45
Q

FRACTURES AND CHILD ABUSE

  1. Fracture patterns suggestive of inflicted trauma? 5
  2. What would you do to find occult lesions? 2
  3. What are you required to do?
A
  1. Fracture patterns suggestive of inflicted trauma
    - Metaphyseal corner fractures
    - Fractures of ribs, sternum, scapula, spinous processes
    - Multiple fractures in various stages of healing
    - Bilateral acute long-bone fractures
    - Skull fractures in children younger than 18 months
  2. Skeletal survey or bone scan to find occult lesions
  3. Legally required to notify child protective services
46
Q

What is this?

What is it indicative of?

A

1.

METAPHSEAL CORNER FX’s

  1. Child abuse
47
Q

What does this show?

A

FRESH CONDYLAR FX

OLD RADIAL FX’s

Child abuse

48
Q

When to refer for fractures?

7

A
  1. Any open injury
  2. When there is neurovascular compromise: Beware spine, knee, and elbow fractures
  3. High energy injuries
  4. Excessive pain….. possible compartment syndrome
  5. Fracture that is significantly angulated or displaced: If it is deformed clinically, usually needs to be reduced
  6. Fractures with known bad outcomes
    - Hip fractures
    - Scaphoid fractures
    - Displaced long bone fractures
  7. Whenever patient or parent has concerns

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