Lecture 1 - Orthopedic Trauma

Question 1

How fractures happen

Answer 1

• single traumatic event
• Stress fracture: repetitive stress on normal bone
• Pathological fracture: physiological stress in abnormal bone
• Direct fgorce: bone breaks at point of impact
• Indirect force; bone breaks at a distance from where force is applied

Question 2

Mechanism of injury

Answer 2

• spiral = torsion
• butterfly = bending
• short oblique = compression
• Transverse = tension

Question 3

Comminuted fracture

Answer 3

More than two fragments

Question 4

Greenstick fracture

Answer 4

Bone incompletely divided and periosteum intact

Question 5

How fractures are displaced

Answer 5

• translation/shift
• alignment/angulation
• rotation/twist
• length

Question 6

5 steps of bone healing

Answer 6

• Hematoma formation
• inflammation/ cellular proliferation
• Callus
• Consolidation
• Remodelling

Question 7

Direct vs indirect healing

Answer 7

• indirect hearling - callus forms in response to movement at the fracture site and serves to stabilise the fragments
• Direct healing: if fracture is absolutely immobile- no need for callus - fracture healing occurs directly between fragments

Question 8

Systemic approach to examining a fracture

Answer 8

• Examine injured part
• Examine for vascular and neurological injuries at presentation and after any intervention
• Examine the associated injuries in region
• Examine the associated injuries in distal part

Question 9

X ray of fracture - rule of 2s

Answer 9

• 2 views: anteroposterior and lateral
• 2 joints: above and below the fracture
• 2 limbs
• 2 injuries
• 2 occasions

Question 10

Advanced imaging for fractures undetectable by Xray

Answer 10

• Technetium bone scan: relies on osteoblastic response, may result in false negatives
• CT scan for complex or intra-articular fractures
• MRI scan useful for assessment of associated structures

Question 11

Management principles of fractures

Answer 11

• treat the patient not just the fracture
• Reduction/ fixation/ rehabilitation
• preserve normal muscle and joint activity

Question 12

Reduction

Answer 12

• complicated by soft tissue swelling
• urgency dictated by presence of neurovascular compromise of joint dislocation
• unecessary if minimal displacement
• two methods: open or closed

Question 13

Closed reduction

Answer 13

• performed under appropriate anesthesia and muscle relaxation
• used for most fractures in children, for fractures that are stable after reduction, or for unstable fractures prior to external or internal fixation

Question 14

Open reduction

Answer 14

• when closed reduction fails
• articular ractures where anatomical reduction is required
• where internal fixation is required

Question 15

Fracture immobilisation methods

Answer 15

• Continuous traction: not commonly used anymore, but still for certain injuries
• cast splintage: plaster of paris. Immobilise joint above and bellow
• functional bracing
• internal fixation: wires, plate and screws, intramedullary nails
• external fixation

Question 16

Cast splintage

Answer 16

• use plenty of padding, especially over bony prominences
• as swelling subsides, cast may become loose
• beware tight cast: pain, parasthesia

Question 17

Indications for internal fixation

Answer 17

• Failed treatment by closed means
• Inherently unstable fractures
• fractures known to unite poorly and slowly
• pathological fractures
• Multiple injuries
• nursing difficulties

Question 18

Indications for external fixation

Answer 18

• Fractures associated with severe soft tissue damage
• Fractures associated with nerve or vessel injury
• Fractures treates with dynamic techniques
• Fractures in the presence of infection
• Rapid stabilisation

Question 19

Principles of treatment for open fractures

Answer 19

• wound debridement
• antibiotic prophylaxis
• stabilisation of fracture
• early soft tissue coverage

Question 20

• EarlyFracture complication

Answer 20

• vascular injury
• nere injury
• compartment syndrome
• infection
• fracture blisters

Question 21

Late fracture complication

Answer 21

Delayed union and non union
Malunion
Avascular necrosis
Growth disturbance
Joint impairment
Pain syndromes

Question 22

Common nerve injuries

• shoulder dislocation
• humerus shaft fracture
• humerus supracondylar fracture
• hip dislocation
• knee dislocatin

Answer 22

• axillary nerve
• radial nerve
• radial or median nerves
• sciatic nerve
• peroneal nerve

Question 23

Compartment syndrome

Answer 23

• bleeding, oedema or inflammation can increase pressure in compartment
• can result in muscle ischemia
• vicious circle resultin in necrosis of muscle and nerves
• treatment is urgent fasciotomy
• recognize by: pain out of proportion, pain on passive stretch

Question 24

Physeal injury

Answer 24

• 10 % of fractures in children

- most common is type 2: runs through hypertrophic or calcified layer -> little effect on longitudinal growth

Question 25

Delayed union and non union

Answer 25

• delayed union: prolonged time to fracture union
• non union - failure of bones to unite
• Caused by: soft tissue interposition, poor blood supply, infection, smoking, nutrition, NSAIDs
• Hypertrophic vs atrophic non union