Flashcards in 10.3. - Fractures - Seminar Deck (24):
What is a Fracture?
A Break in Structural Continuity of Bone (Crack, Break, Split, Crumpling, Buckle)
Why do Bones fail?
1. High Energy Transfer in normal Bones
2. Repetitive Stress in Normal Bones (Stress Fracture)
3. Low Energy Transfer in Abnormal Bones (Osteoporosis, Osteomalacia, Metastatic Tumour etc.)
What are the Key points in the Description of a Fracture?
1. Mechanism & Energy of Injury
2. Skin & Soft-Tisue Issues
7. Associated Injuries
What are the aims of treating a Fracture?
1. Relieving Pain
2. Restoring Function
(3. Saving Life?)
What is the Management plan of an Injured Patient?
1. Advanced Trauma Life Support (ATLS)
2. Emergency Orthopaedic Management (Day 1)
3. Monitoring of Fracture (Days-Weeks)
4. Rehabilitation + Treatment of Complications (Weeks-Months)
What is included in Emergency Orthopaedic Management?
1. Life Saving:
1. a) Reducing a Pelvic Fracture in Haemodynamically Unstable Patients
1. b) Applying Pressure to reduce Haemorrhage from an Open Fracture
2. Complication Saving:
2. a) Early &Complete Diagnosis of the Extent of Injuries
2. b) Diagnosing &Treating the Soft-Tissue Injuries
What Soft-Tissue Injuries can occur during a Fracture?
1. Skin - Degloving Injuries . Ischaemic Necrosis
2. Muscles - Crush Injury & Compartment Syndromes
3. Blood Vessels - Vasospasm & Arterial Laceration
4. Nerves - Neurapraxias, Axonotmesis, Neurotmesis
5. Ligaments - Joint Instability & Dislocation
Note - All require urgent treatment, as they will delay healing
What does the choice of treatment depend on?
1. The type of Fracture
2. The Bone which has been Fractures
3. Soft-Tissue Injury
4. Patient details
5. Facilities / Abilities of the Surgeon
What is the difference of healing pattens between:
1. Soft Tissue?
1. Soft Tissue heals by replacing the injured tissue with a fibrous Scar
2. Bone heals by Regeneration of Normal Bone Anatomy (forming a Callus) - Very Vascular, a broken bone will always bleed
What are the 3 phases of Bone Healing?
1. Inflammatory Phase
2. Reparative Phase
3. Remodelling Phase
How do Fractures Heal in Nature?
1. Regeneration vs Repair
2. Phases of Healing by Callus
3. Rapid Process, but Rehabilitation is Slow (Low Risk)
How do Fractures Heal with Surgery?
If Rigid - ORIF + Compression:
1. Primary Bone Healing
2. Slow Process but Rehabilitation is Rapid (High Risk)
If Stable - Nailing or External Fixation:
1. Healing by Callus
2. Rapid Process, and Rehabilitation Rapid (Lesser Risk)
How is Fracture Healing measured?
1. Clinical Examination:
1.a) Adult - Upper Limb = 6-8 wk; Lower Limb = 12-16 wk
1.b) Child - Upper Limb = 3-4 wk; Lower Limb = 6-8 wk
2. Radiologically (Bridging Callus Formation / Remodelling)
3. Biomechanically (Stiffness)
When is a fracture healed?
1. When the patient can bear weight
2. When the X-Rays says so
3. When remodelling is complete
What are the Local Problems of a Fracture?
1. Neurovascular Damage
2. Skin / Wound Problems
3. Compartment Syndrome
1. Delayed Union / Nonunion
2. Avascular Necrosis
What are the Local Complications of a Fracture?
2. CRPS Type 1
3. Implant Failure
4. Joint Stiffness
What are the Systemic Problems of a Fracture?
2. Crush Syndrome
3. Fat embolism + ARDS
Late: Psychological & Social Aspects
What are the Systemic Complications of a Fracture?
1. Bed Rest Complications (including DVT / PE)
What factors influence Fracture repair?
1. Host - nutritional & hormonal status / drugs / CNS injury
2. Local Factors - Soft Tissue Injury / Bone Loss / Radiation / Tumour / Distraction / Tissue Interposition / Blood Supply / Infection / Type of Bone / Synovial Fluid
3. Treatment Method - Mobility at fracture site (Stable vs Rigid Fixation)
What are the Bony Problems of Fracture Healing?
1. Delayed Union (healing taking longer than average)
2. Non-Union (no further progress towards union)
3. Mal-Union (healed but not in a correct position)
4. Avascular Necrosis (loss of blood supply)
What are the 2 types of Non-Union?
1. Atrophic - Gap at the Fracture Site (infection)
2. Hypertrophic - attempt at healing but the fracture is too mobile
What are the Treatment Options?
1. Active Early Movement + Protection
2. Rest + Elevation / Gravity
3. Immobilisation by Semi-Rigid Splintage
4. Functional Brace
5. Skin / Skeletal Traction
6. External Fixation
7. Percutaneous K-Wire Fixation +/- ORIF
8. ORIF + Tension Band Wiring / Screws / Plate
9. Internal Fixation + Sliding or Intramedullary Nail / Rod / Screw / Plate
10. Spinal Rods
11. Excision of Fracture Fragment +/- Replacement
What are the problems with treatment (Conservative vs Operative) of Delayed / Non-Union Fractures?
1. Inadequate Immobilisation
2. Distraction of Fracture by Fixation Device / Traction
3. Repeated Manipulations
4. Periosteal Stripping & Soft-Tissue Damage at Operation
5. Anatomical Vascular Susceptibility