chapter 3 - general principles of fractures

Question 1

what is a fracture?

Answer 1

a fracture is an open or closed soft tissue injury of varying severity, accompanied by a break in the continuity of the adjacent or underlying bone

Question 2

what is an open fracture

Answer 2

there is a break in the continuity of the skin overlying the fracture

Question 3

what is a closed fracture

Answer 3

there is no communication between the fracture and the atmosphere

Question 4

why do fractures occur?

Answer 4

interaction between the magnitude of the injuring load or force and the quality and resilience of the bone

Question 5

what is a pathological fracture

Answer 5

fracture occuring through diseased bone which is weak ie metastatic tumours or an area of osteomyelitis

Question 6

what is a stress or fatigue fracture

Answer 6

this occurs to normal bone that is subjected to repetitive loads of stress

Question 7

what is the radiological appearance of a stress fracture

Answer 7

attempts at healing + new areas of fracture

Question 8

what is a direct force and what type of fractures does it commonly cause?

Answer 8

direct trauma to the area of the fracture

transverse or complex fractures

Question 9

what is an indirect force and what type of fractures does it commonly cause

Answer 9

the force was applied at a distance away from where the bone was fractured
oblique and spiral fractures in long bones
compression fractures in the spine

Question 10

name 5 types of typical bone fractures

Answer 10

greenstick
spiral
comminuted
trasnverse
compound
vertebral compression

Question 11

define a simple fracture

Answer 11

single fracture line that may be transverse, oblique or spiral

Question 12

define a segmental fracture and its clinical presentation

Answer 12

2 fracture lines
tubular segments of shaft which has cortex present on its entire circumference
no lateral stability but may be longitudinally stable

Question 13

define a complex (comminuted) fracture and its clinical presentation

Answer 13

multiple fragments
cortex on parts of the circumference
no lateral and no longitudinal stability

Question 14

what us the rule for taking X rays of fractures

hint: 2s

Answer 14

2 views, 2 joints, 2 sides, 2 opinions

Question 15

what is the appropriate early immediate management of a fracture

Answer 15

1. assess neurovascular status of the limb
2. analgesia
3. realign with gentle longitudinal traction
4. sugar tongs splint

Question 16

what could occur if a fracture is not splinted early?

Answer 16

severe oedema –> decreased blood supply –> more oedema

Question 17

name the 6 modalities of displacement

Answer 17

shift
distraction
shortening
impaction
twist
tilt

Question 18

what is acceptable displacement in long bone shaft fractures? ie it does not have to be reduced

Answer 18

shift: 50% of diameter of shaft
shortening: 10mm
twist: 0 degrees
tilt: 10 degrees
impaction: 10mm

Question 19

if the fracture involves the joint surface, which parameters are used and what do they mean?
ie simple split = undisplaced

Answer 19

split/gap: displaced laterally but not vertically
split/step: displaced vertically but not laterally
split/impaction: displaced vertically and compressed

Question 20

acceptable displacement in articular surface fractures

Answer 20

gap up to: 5mm Large joint and 2mm small joint
step up to 2mm/ 1mm
impaction up to: 2mm/ 1mm

Question 21

how is a closed fracture reduced?

Answer 21

direct manipulation

traction

Question 22

how is an open fracture reduced?

Answer 22

surgically

Question 23

4 reasons why fracture reduction may fail

Answer 23

1. inexperience
   2/ inadequate anaesthesia/muscle relaxation
2. inability to obtain a reduction - interposition of soft tissue or bony fragments
   4.inability to maintain the reduction - unstable fracture configuration

Question 24

2 indications for open reduction

Answer 24

failure of reduction

intra articular fractures which need to be reduced accurately

Question 25

why must a fracture be immobilised

Answer 25

to maintain the reduction which has been obtained

Question 26

two types of immobilisation

Answer 26

external fixation = no implant in the soft tissue | internal fixation = surgical implant within the soft tissue or bone

Question 27

examples of external fixation methods

Answer 27

plaster of paris traction bracing or splinting external fixator - transcutaneous fixation with pins anchored to the bone

Question 28

examplesof internal fixation

Answer 28

intramedullary nail plates and screws interfragmentary wires and screws

Question 29

3 indications for internal fixation

Answer 29

1. inability to obtain or maintain fixation externally 2. intraarticular fractures 3. polytrauma

Question 30

all fractures should be reduced and immobilised within X hours

Answer 30

72 hours

Question 31

if the patiet has had a manipulation of a fracture and a plaster cast has been applied when should they be seen? and why

Answer 31

after 24 hours for a circulation check

Question 32

when should the patient be seen immediately after manipulation and fixation of a fracture - 4 warning signs

Answer 32

1. excessive or increasing pain 2. pale, red or blue fingers or toes 3. tingling or pins and needles in fingers and toes 4. swelling in fingers and toes

Question 33

after a fracture has been managed a POP circulation check is done 24 hours later - what is this

Answer 33

check neurovascular status in the limb if concerned: plaster should be split down and loosened until perfusion occurs if no improvement: remove plaster completely if there is still pain, swelling or pins and needles - consider and exclude compartment syndrome

Question 34

follow up visits following fracture management

Answer 34

2 weeks: check that plaster is not loose and do Xray in plaster change plaster if loose to ensure that the correct position is maintained 2-4 week intervals: xray to check for fracture healing - out of plaster assessment of union: clinical = if pain and movement on stressing is present - still requires immobilisation radiological= look for callus

Question 35

F/u after a fracture - what is the assessment of union?

Answer 35

``` clinical = if pain and movement on stressing is present - still requires immobilisation radiological= look for callus ```

Question 36

what are the principles of management of open fractures?

Answer 36

1. orthopedic emergencies 2. basic evaluation as with closed fractures 3. tetanus toxoid 0.5ml sc 4. antibiotic cover 5. cover the wound with a sterile dressing 6. splintage of the fracture - padded kramer wire splint 7. debridement of the wound ( remove foreign matter, excise dead tissue, start at the edge and work through the layers of fascia, muscle and bone) 8. thorough washout with 5 L of warm normal saline 9. test muscle viability - pinch skin with forceps and wait for contraction 10. do not suture original wound closed at first debridement - if the wound was enlarged this extension may be loosely closed 11. apply an external fixator 12. after 48-72 hours the pt is reassessed in theatre and if the wound is clean it can be closed 13. closure with split skin graft or suture 14. if not clean - further debridement in theatre can be repeated until it can be closed 15. once soft tissue has healed the external fixator can be removed and a plaster cast applied