basis of fracture management

Question 1

Rx depends on

Answer 1

stability of #
patient factors: fitness, other injuries
open vs closed

Question 2

complete stability

Answer 2

transverse

Question 3

no stability to shortening

Answer 3

spiral
comminuted
oblique

Question 4

potential stability

Answer 4

oblique <45degrees

Question 5

open fracture

Answer 5

direct communication between external environment and

usually through break in skin but not always

Question 6

open fracture Rx

Answer 6

prophylaxis tetanus and antib
surgical emergency (all within 24hrs)
early + thorough wound excision and toilet
photograph, cover and stabilise limb

Question 7

open fracture Gustilo grade I

Answer 7

low energy

wound <1cm

Question 8

open fracture Gustilo grade II

Answer 8

moderate soft tissue damage

wound 1-10cm

Question 9

open fracture Gustilo grade III

Answer 9

high energy, wound >10cm

A: soft tissue damage ++++
B: periosteal stripping
C: neurovascular complication

Question 10

initial # Rx

Answer 10

immobilisation

pain relief

Question 11

assessment

Answer 11

clinical: open vs closed, fracture, neurological, circulation

radiological

Question 12

definitive Rx

Answer 12

no reduction required
reduction require - local vs general anaesthetic

maintenance of position: conservative, operative

Question 13

conservative Rx: no initial immobilisation or reduction needed

Answer 13

no support

support: brace, elastic bandage, strapping

Question 14

conservative Rx: initial immobilisation +/- reduction

Answer 14

cast
functional brace
traction

Question 15

cast principles

Answer 15

3 point loading
hydraulics: circumferential restraint and longitudinal force - soft tissue wont buldge out and reduces shortening

rotation control by including joint above and below

Question 16

functional bracing

Answer 16

for long bones e.g. femur, humerus
in cast until bone becomes sticky and then brace: bones will no longer shorten
joints free to move

Question 17

traction

Answer 17

axial force
pulls along line of limb
tightens soft tissue sleeve and so aligns bone

closed reduction
initial reduction
maintenance of reduction

Question 18

skin traction

Answer 18

applied via adhesive or non-adhesive tape
blistering and sloughing where traction slides off
compartment syndrome due to elevation and compression

Question 19

skeletal traction

Answer 19

traction via bone: pin, wire
allows greater force, weight
common sites: femur, tibia

Question 20

operative Rx options

Answer 20

internal fixation: intramedullary nailing, screws, plates

external fixation

Question 21

external fixation

Answer 21

fixation from outside

pins/wires passed through skin and bone and fixed to external frame

Question 22

external fixation indication

Answer 22

w poor soft tissue conditions
where distraction through fixator may help w fragment reduction
emergency pelvic stabilisation for haemorrhagic control
limb reconstruction

Question 23

external fixator types

Answer 23

unilateral
multilateral
circular

Question 24

external fixation complications

Answer 24

neurovascular injury
pin tract infection
loss of # alignment

Question 25

additional wires

Answer 25

wires not attached to frames

may be used to pin fragments together

Question 26

intramedullary nailing indications

Answer 26

long bone diaphysis e.g. femoral, tibia

Question 27

IM nailing technique

Answer 27

reduction - check on x-ray
entry point - small incision, x-ray guided
canal reamed - wire passed down, hole made in medulla
nail passed
bone locked onto plate

Question 28

IM nailing advantages

Answer 28

incision remote from # - less chance contamination
minimal #exposure
joints free to move

Question 29

internal fixation - screws and plates

Answer 29

usually incision over and exposure of #

accurate # reduction
allows early joint mobilisation
access for bone grafting

Question 30

internal fixation - screws and plates: risks

Answer 30

devascularisation - slow to heal
wound problems
infection

Question 31

screws

Answer 31

different types for cortical and cancellous
different sizes

fix 2 pieces bone together; compress or fix in position

Question 32

plate fixation

Answer 32

fixed to outside of bone with screws
load sharing between plate and bone
bone needs to heal before plate fails (repeated bending)

Question 33

types of plates

Answer 33

compression: squeeze bone together
neutralisation: resist rotational forces, spiral #
buttress: stop collapse
strut/bridging: no opening of #