context week 6 Flashcards
1
Q
why are the terms “buckle fracture” and “greenstick fracture” associated with children #
A
children’s bones tend to buckle/partially fracture/splinter with some degree of continuity of some “fibres” of bone (like breaking a green stick from a tree) rather than break completely.
2
Q
why do childrens # heal quicker than adults?
A
thicker periosteum which is a rich source of osteoblasts.
3
Q
what does the periosteum do?
A
serves to increase the width/circumference of growing long bones
4
Q
what are the differences in periosteum in children and adults
A
in kids is much thicker and tends to remain intact which can help stability and can assist reduction if required.
5
Q
what do children bones have a greater potential for?
A
remodelling
6
Q
why do childrens bone have a greater remodelling potential
A
because they grow with bone being formed along the line of stress and children can correct angulation up to 10° per year of growth remaining in that bone.
7
Q
are kids # treatment in comparison to adults
A
less likely to need surgery with greater degrees of displacement or angulation can be accepted.
If the fracture position is unaccepatable, manipulation and casting may be all that is required accepting a degree of residual angulation or displacement.
8
Q
when are childs # treated like adults
A
puberty [12-14]
9
Q
around where has the potential to disturb growth
A
physis (growth plate)
10
Q
what happens if physis is disturbed by #
A
shortened limb or an angular deformity if one side of the physis is affected by growth arrest.
11
Q
what classification is used for paediatric physeal #’s?
A
Salter-Harris classification of physeal fractures
12
Q
what is salter-harris I #
A
pure physeal separation.
best prognosis and is least likely to result in growth arrest.
13
Q
what is salter-harris 2 #
A
similar to 1 but has a small metaphyseal fragment attached to the physis and epiphysis.
growth disturbance risk is low.
commonest physeal #.
14
Q
Salter‐Harris III and IV #’s
A
’s reduced and stabilized to ensure a congruent articular surface and minimize growth disturbance.
intra‐articular and with the fracture splitting the physis
greater potential for growth arrest
15
Q
Salter‐Harris V injury
A
compression injury to the physis with subsequent growth arrest.
cannot be diagnosed on initial x‐rays; only detected once angular deformity has occurred.
16
Q
Non accidental injury (NAI) risk factors
A
poverty,
children with special needs or disability.
parents who are substance abusers.
17
Q
what raises concern of child abuse/NAI
A
Multiple fractures of varying ages (with varying amounts of callus or healing)
multiple trips to A&E with different injuries
18
Q
other features that raise suspicion of NAI
A
Inconsistent / changing history of events
Discrepancy of history between parents / carers
History not consistent with injury
Injuries not consistent with age of child eg non walking child
Multiple bruises of varying ages
Atypical injuries eg cigarette burns, genital injuries, torn frenulum, dental injuries, lower limb
and trunk burns
Rib fractures
Metaphyseal fractures in infants
19
Q
what should occur in NAI suspected case
A
paediatrics involved ASAP and admitted for saftey.
Full exam and history taking performed
20
Q
examples of common paediatric fractures
A
distal radius, forearm, supracondylar of elbow, femoral shaft, tibial #’s
21
Q
what are some examples of paediatric distal radius #’s
A
buckle, greenstick, salter-harris II
22
Q
Buckle fractures (how stable? treatment?)
A
stable
require only 3‐4 weeks of splintage.
23
Q
Greenstick fractures (describe variation + treatment)
A
may be angulated
may require manipulation + casting if significant deformity (particularly in the older child)
24
Q
Salter‐Harris II fractures. (where, problems and treatment)
A
distal radial physis (occurs in older children)Angulation with deformity requires manipulation. Growth problems are highly unlikely (as with most Salter Harris II fractures).
25
Complete distal radius fractures
may displace as well as angulate with dorsal displacement and angulation more common than volar.
The dorsal periosteum usually remains intact which prevents overcorrection of the deformity and aids stability.
26
treatment of Complete distal radius fractures
If the fracture is fairly stable, casting may suffice.
If a complete fracture is very unstable after reduction, wire stabilization or plate fixation may be employed.
27
forearm #'s
Monteggia and Galeazzi fracture‐dislocations
28
treating forearm #'s in kids
These injuries go against the usual principles of children’s fractures, in that anatomic reduction and rigid fixation with plates and screws is typically used to treat these injuries. There is a high rate of re‐dislocation of the radial head or distal radio-ulnar joint (DRUJ) if only manipulation and casting is used.
29
fractures of both bones of the forearm (types and treatment)
angulated fractures → have an intact periosteum and the instability may only be in one plane → controlled with a cast after manipulation.
Displaced fractures → unstable and flexible → intramedullary nail
30
what are Supracondylar fractures of the elbow common
relatively weak point in the growing upper limb
31
two types of Supracondylar fractures
extension - more common and occur due to a heavy fall onto the outstretched hand
flexion - a fall onto the point of the flexed elbow.
32
treatment of supracondylar #'s
Undisplaced fractures → stable → splint.
Angulated, rotated or displaced # → closed reduction and pinning with wires → prevent deformity
also severely displaced / off‐ended fractures (see later card)
33
severely displace/off-ended supracondylar # problems
brachialis muscle may be tethered in the fracture site
With off‐ended extension type fractures the distal fragment displaces posteriorly with stretch and pressure on the brachial artery and median nerve (predominantly its anterior interosseous branch – the patient is unable to make the “OK” sign due to loss of FPL and FDP to the index).
34
supracondylar Displaced fractures treatment
reduced fairly soon to avoid swelling which can make reduction more difficult.
radial pulse is absent or reduced in volume then emergency surgery ASAP [Closed reduction may be performed with wiring and the pulse may return if the artery is no longer under stretch. if hand remains pulseless after reduction, open surgical exploration is required.]
nerve injury then surgery urgently. majority are neurapraxias and occasionally axonotmesis [normally improve]. neuralgic pain or no improvement may indicate entrapment of the nerve. do surgical release
35
why do Femoral shaft fractures occur?
children due to a fall onto a flexed knee or by indirect bending or rotational forces.
36
what can occur in femoral shaft fracture healing process in kids
overgrowth tends to occur after fracture healing and therefore some shortening can be accepted (more with younger children).
37
femoral shaft # In children less than 2 years old [cause and treatment]
more than half of femoral shaft fractures are due to NAI .
Gallows traction and early hip spica cast
38
femur shaft # in children aged between 2 and 6 treatment
Thomas splint or a hip spica cast.
39
femur shaft # in children between 6 and 12 treatment
femur is large enough to accommodate flexible intramedullary nails which obviate the need for traction or cast.
40
children aged 12 and above femur shaft # treatment
adult type intramedullary nail is typically used.
41
what to remember to check in femur fractures
femur is a common site for benign and malignant bone tumors and the fracture may be pathological with osteolysis and cortical thinning
(also if young then NAI)
42
undisplayed tibial #'s occur in what age group and are treated with what
Undisplaced spiral fractures of the tibial shaft are common in toddler’s (the injury is known as a “toddler’s fracture”)
require a short time in cast.
43
treating tibial #s
mainly cast for majority.
compartment syndrome risk less than adult.
up to 10 degrees angulation allowed or manipulated
serial x-rays to check doesn't drift into excessive angulation. shortening or malrotation also unaccepted
44
very unstable or open tibial #s
stabilise = flexible intramedullary nails, plates and screws or external fixation.
Adolescents with a closed proximal tibial physis give adult intramedullary nail.
45
C-spine #
high energy injuries (RTA, fall from height) + associated with head injury.
Potentially dangerous unstable fractures may be missed in the unconscious or confused patient which may result in spinal cord injury. therefore C‐spine immobilization with a hard collar and sand bags or blocks on a spinal board
46
how to clinically clear C-spine injury
No history of loss of consciousness
GCS 15 with no alcohol intoxication
No significant distracting injury (such as head injury, chest trauma or other fractures including more distal spinal fractures)
No neurological symptoms in the upper or lower limbs
No midline tenderness on palpation of the c-spine
No pain on gentle active neck movement (ask the patient to gently flexed forward, then rotate to each side)
47
what to do if c-spine cannot be clinically cleared
collar must stay in situ.
Further imaging in the form of X‐Rays (AP & lateral views +/‐ odontoid peg open mouth view) or CT scan of the c‐spine is required so that a c-spine injury can be radologically cleared
48
what to do in any suspected c-spine injury
full trauma assessment (ABCD) and a full neurological examination including:
```
peripheral motor function
coarse touch sensation
upper & lower limb reflexes
cranial nerve evaluation
rectal examination, and
assessment of bulbocavernous reflex.
```
49
what height are c-spine dislocations/'s especially fatal
c3 or above (as phrenic nerve suppling diaphragm is C3,4,5.)
50
treatment of stable c-spine injuries
firm cervical collar
51
treatment of unstable injuries of c-spine
immbolise in "halo vest" (external fixation)
surigcal stabilisation with fusion/wiring/internal fixation
52
c-spine Subluxations and dislocations treament
traction for reduction and halo application or operative stabilization
53
burst fracture with neurological deficits treatment
traction to decompress spinal cord
54
why do thoracolumbar spine fractures occur
- motor vehicle accidents or falls from a height. give burst fractures or chance fracture-dislocation
- elderly with osteoporosis osteoporotic “wedge” insufficiency fractures ( do not require anything other than symptomatic treatment.)
55
what does any thoracolumbar injury require?
full trauma evaluation and neurological assessment
56
treatment of thoracolumbar injury
stable of throacic spine= brace to limit flexion/kyphosis
stable lumbar spine = plaster jacket for presrve lordosis.
57
examination of thoracolumbar spinal fractures
posterior bony or ligamentous involvement detected by local tenderness, swelling and palpable defect on exam
58
indication for surgery of thoracolumbar #
Presence of neurological deficit (especially if progressive or very unstable injury)
Unstable injury pattern with substantial loss of vertebral height, displacement or involvement of the posterior ligamentous structures.
59
what might surgery of thoracolumbar # involve
Surgery may involve stabilization with pedicle screws and rods, spinal fusion and decompression.
60
what can cause spinal cord injuries?
contusion, compression, stretch or laceration.
61
what does vascular disruption and oedema cause in spinal cord injuries?
further ischaemic damage and hypotension, hypoxia and inflammatory responses may also result in secondary damage.
62
what is Spinal shock
physiologic response to injury with complete loss of sensation and motor function and loss of reflexes below the level of the injury. Spinal shock usually resolves in 24 hours with return of reflexes and the severity of a spinal cord injury may not be determined until after spinal shock has resolved
63
what reflexes can be asessed in spinal shock?
The bulbocavernous reflex
contraction of the anal sphincter with either a squeeze of the glans penis, tapping the mons pubis or pulling on a urethral catheter. The bulbocavernous reflex is absent in spinal shock and its return signals the end of spinal shock.
64
what is Neurogenic shock
occurs secondary to temporary shutdown of sympathetic outflow from the cord from T1 to L2, usually due to injury in the cervical or upper thoracic cord leading to hypotension and bradycardia which usually resolves within 24‐48 hours.
65
what can occur in neurogenic shock
Priapism (prolonged erection), due to unopposed parasympathetic stimulation
66
treating neurogenic shock
Neurogenic shock is treated with IV fluid therapy.
Neurogenic shock must be differentiated from other forms of shock (e.g.: hypovolemic shock also responds to fluid replacement )
67
two classifications of spinal cord injury
complete or incomplete
68
Complete spinal cord injury
- results in no sensory or voluntary motor function below the level of the injury (reflexes should return).
- The level of the injury is determined by the most distal spinal level with partial function (after spinal shock has resolved) as determined by the presence of dermatomal sensation and myotomal skeletal muscle voluntary contraction.
- The prognosis for recovery from complete cord injuries is poor.
69
incomplete spinal cord injuries,
- some neurologic function (sensory and/or motor) is present distal to the level of injury.
- In general, the greater the function present, the faster the recovery is and the better the prognosis.
- Sacral sparing with preservation of perianal sensation, voluntary anal sphincter contraction and big toe flexion (FHL muscle, S1/2) indicates some continuity of the corticospinal (motor) and spinothalamic (course touch, pain, temperature) tracts. The presence of sacral sparing indicates an incomplete cord injury with a better prognosis than a complete injury.
70
treatment of spinal cord injury
Full ATLS primary survey with resuscitation and protection of the cervical and thoracolumbar spine is mandatory.
appropriate immobilisation, traction, surgery, ventilation support, multi-disiplanry approach
71
name the 4 types of incomplete spinal cord injuries
central, anterior, posterior cord syndromes and brown-swquard syndromes
72
Central cord syndrome signs
commoonest, hyperextension injury in C-spine with OA.
often no associated fracture or dislocation. paralysis or arms more than legs. (as central in cord is upper motor neurones mainly) sacral sparing typical .
73
anterior cord syndrome signs
loss of motor function, coarse touch, pain, temp sensation below injury height.
proprioception, vibration sense and light touch preserved
74
posterior cord syndrome signs
loss of dorsal column function is rare (vibration sense, proprioception, light touch)
75
Brown‐Sequard syndrome signs
results from hemisection of the cord usually from penetrating injury eg stab wound. Ipsilateral paralysis and loss of dorsal column sensation occurs with contralateral loss of pain, temperature and coarse touch sensation. This is due to nerve fibres of the spinothalamic tracts crossing to the other side of the cord one or two levels above their entry into the cord whilst the nerve fibres of the other tracts cross higher up in the medulla
76
pelvic #
young=high energy
old= low energy possible due to osteoporosis
if pelvic ring disputed then always > 1 place (polo mint)
77
what forms the pelvic ring?
sacrum, ilium, ischium and pubic bones with strong supporting ligaments.
78
pelvis # complications
Branches of the internal iliac arterial system and the pre‐sacral venous plexus are prone to injury with risk of serious hypovolaemia.
Nerve roots and branches of the lumbo‐sacral plexus are prone to injury.
79
what are the three main patterns of injury in pelvis?
lateral compression #, vertical shear #, anteroposterior compression injury
80
lateral compression fracture
occurs with a side impact (eg RTA) where one half of the pelvis (hemipelvis) is displaced medially. Fractures through the pubic rami or ischium are accompanied by a sacral compression fracture or SI joint disruption.
81
vertical shear fracture
occurs due to axial force on one hemipelvis (eg fall from height, rapid deceleration) where the affected hemipelvis is displaced superiorly. The sacral nerve roots and lumbosacral plexus are at high risk of injury and major haemorrhage may occur. The leg on the affected side will appear shorter.
82
anteroposterior compression injury
may result in wide disruption of the pubic symphysis the pelvis opening up like the pages of a book – the so‐called open book pelvic fracture. Substantial bleeding from torn vessels occurs and as the pelvic volume increases exponentially with the degree of displacement, with widely displaced injuries the pelvis can contain several litres of blood (ie the entire circulating volume) before tamponade and clotting will occur.
83
high-energy pelvic # treatment
associated with other injuries
blood loss treat
with open book pelvic # promptly reduce the displacement and minimise pelvic volume to allow tamponade of bleeding to occur. Application of a tied sheet or a special pelvic binder around the outside of the pelvis will hold the reduction temporarily and allow clotting of the vessels. An external fixator will provide more secure initial stabilization.
Ongoing haemodynamic instability despite these measures may require angiogram and embolization or open packing of the pelvis if laparotomy is required for co‐existing intra‐abdominal injuries.
Bladder and urethral injuries (blood at the urethral meatus) may also occur and urinary catheterization may risk further injury. Urological assessment and intervention may be required. A PR exam is mandatory to assess sacral nerve root function and to look for the presence of blood. The presence of blood indicates a rectal tear rendering the injury an open fracture and carries a higher risk of mortality. General surgical review is mandatory and defunctioning colostomy may be required.
84
treating low energy pelvic #'s
Low energy pubic rami fractures in the elderly tend to be minimally displaced lateral compression injuries (with sacral fracture or SI joint disruption posteriorly) and settle with conservative management over time.
85
acetabulum #'s
Acetabular fractures are usually high energy injuries in the younger patient but can be low energy in the older patient.
Posterior wall fractures may be associated with a hip dislocation. In these cases, the posterior wall is fractured as the head of the femur is pushed out the back of the joint. (RTA)
The pattern of the fracture can be difficult to determine on plain X‐rays (oblique views may help) and CT scans help to determine the pattern of the fracture and are essential for surgical planning.
86
treatment of acetabulum #'a
Undisplaced fractures or small wall fractures may be treated conservatively. As with most intra‐ articular fractures, unstable or displaced fractures require anatomic reduction and rigid fixation in the younger patient to reduce the risk of post traumatic OA. Older patients may be treated with total hip replacement – either early (with an uncemented cup and screws) or delayed.
87
examples of shoulder trauma
humeral neck #, shoulder (gleno-humeral) dislocations, ACJ (Acromioclavicular joint) injuries
88
humeral neck #'s common cause
Proximal humerus fractures are common with the majority being low energy injuries in osteoprotic bone due to a fall onto the outstretched hand or directly onto the shoulder.
89
humeral neck # pattern of #
The most common pattern is a fracture of the surgical neck (rather than the anatomic neck) with medial displacement of the humeral shaft due to pull of the pectoralis major muscle. The greater and lesser tuberosities may also be avulsed with the attachments of Supraspinatus, Infraspinatus and teres minor for the greater tuberosity and subscapularis for the lesser tuberosity. Isolated fractures of the greater tuberosity and head‐splitting intra‐articular fractures can also occur.
90
treatment of humeral neck #
Many minimally displaced proximal humerus fractures are treated conservatively with a sling and gradual return to mobilization
displaced= the position often improves once muscle spasm settles.
permanametly displaced = internal fixation (plate, screws, wires or intramedullary nail) but stiffness, chronic pain and failure of fixation can occur particularly in the older patient.
91
consequences of humeral head #
pain and/or loss of motion. AVN of humeral head causing chronic pain. bone fragments may need cut out or fixed as leads to failure, shoulder replacement can be used. (Head splitting fractures usually require shoulder replacement unless the patient is younger with very good bone quality.)
92
gleno-humeral dislocation which type is more common?
Anterior shoulder dislocation is much more common than posterior dislocation (the latter contributing only 2‐5% of all shoulder dislocations).
93
Traumatic anterior shoulder dislocation occurs due to what?
excessive external rotation force or a fall onto the back of the shoulder. also seizure (watch for bilateral dislocations)
94
what is the pathophysiology of a Anterior shoulder dislocation
often detachment of the anterior glenoid labrum and capsule known as a Bankart lesion whilst the posterior humeral head can impact on the anterior glenoid producing an impaction fracture of the posterior head (Hill‐Sachs lesion)
95
what can be compromised in Anterior shoulder dislocation
auxillary nerve can be stretched as it passed through quadrilateral space witle axially artery and other bracial plexus nerves can be affected.
96
finding on clinical assessment of anterior shoulder dislocation
Loss of symmetry is seen with loss of roundness of the shoulder and the arm held in an adducted position supported by the patients other arm. The principle sign of axillary nerve injury is loss of sensation in the regimental badge area. It may be difficult to determine deltoid contraction in the acute phase. Full distal neurovascular assessment should be carried out. In older patients, tears of the rotator cuff are very common but again these can be difficult to assess in the acute setting.
97
investigations of anterior shoulder dislocation
x-rays to confirm.
| also surgical neck and greater tuberoity # can occur with shoulder dislocation
98
Management of ant shoulder dislocation
Closed reduction (under sedation or anaesthetic) is the mainstay of treatment with neurovascular assessment before and after reduction. Radiographs are repeated to confirm reduction. The patient is placed in a sling for 2‐3 weeks to allow the detached capsule to heal then rehabilitation with physiotherapy is commenced. Delayed presentation dislocations (eg alcoholics) may be difficult to reduce by closed means and may require open reduction..
associated fracture of the greater tuberosity, this usually reduces to an acceptable position with reduction of the shoulder however ORIF is usually required if it remains displaced. Fracture‐dislocations involving the surgical neck usually require surgery.
99
risk of shoulder redislocation
The risk of recurrent dislocation is predicted by the age of the patient at the time of initial dislocation.
Patients less than 20 have an 80% chance of re‐dislocation and many surgeons advocate stabilization surgery after first time dislocation in this age group. Patients over 30 have only a 20% risk of further dislocation and the re‐dislocation rate reduced further with increasing age. Recurrent dislocations can be stabilized by a Bankart repair with reattachment of the torn labrum and capsule by arthroscopic or open means.
100
Some shoulder dislocations occur in patients with marked ligamentous laxity (who and treatment)
EDS/marfan's causes this. atraumatic multi-directional dislocation (which may be painful), open tightening gf shoulder capsule possible + physic to strengthen RC is treatment
101
causes of Posterior shoulder dislocations
posterior force on the adducted and internally rotated arm
102
investigating Posterior shoulder dislocations
The humeral head may be palpated posteriorly. They are often missed as the radiographic findings are much less obvious than anterior dislocation. The main Xray finding is the “light bulb” sign where the excessively internally rotated humeral head looks symmetrical like a light bulb on an AP view. Special lateral xray views assist in the diagnosis.
103
treatment of Posterior shoulder dislocations
Closed reduction and a period of immobilization followed by physiotherapy are again the mainstay of treatment.
104
why do ACJ injuries occur?
Injuries of the acromioclavicular joint usually occur after a fall onto the point of the shoulder. They are a fairly common sporting injury.
105
classification of ACJ injuries
sprained, subluxed (the acromioclavicular ligaments are ruptured) or dislocated. ( the coracoclavicular ligaments (conoid and trapezoid ligaments) are also disrupted )
106
treatment of ACJ injuries
Most injuries are treated with conservative management wearing a sling for a few weeks followed by physiotherapy.
surgery (reconstruction of the coracoclavicular ligaments) is reserved for those with chronic pain (although some surgeons advocate early reconstruction for younger athletes with dislocation – controversial).
107
what causes a humeral shaft #
direct rauama (RTA) results in transverse or comminuted #.
fall +/- twisting injury resulting in oblique or spiral #.
108
recovery from humeral shaft #
Union rates are high (90%) and due to the mobility of the ball and socket shoulder joint proximally and the elbow joint distally, up to 30° of angulation can be accepted.
109
complications of humeral shaft #
The radial nerve in the spiral groove is susceptible to injury which present with a wrist drop and loss of sensation in the first dorsal web space.
110
treatment of humeral shaft #
Most cases are treated non-operatively with a functional humeral brace which compresses the fragments into acceptable alignment and provides some stability.
Internal fixation with an intramedullary nail or plate and screws may afford a quicker recovery and intramedullary nailing may be used in polytrauma. Non unions require plating and bone grafting.
111
common elbow injuries
supracondylar # (paediartic )
intra-articular distal humerus #
olecranon #
radial head and neck #
elbow dislocation and fracture dislocation
112
Intra‐articular distal humerus fractures treatment
As with most intra‐articular fractures, these require open reduction, internal fixation (ORIF) with anatomic reduction and rigid fixation to minimize loss of function. Special plates are available to follow the complex contours of the distal humerus. Elbow replacement can be considered in highly comminuted fractures in the elderly.
113
Olecranon fracture
common, due to fall onto pint of elbow with contraction of tricep. mostly ORIF to restore tricep function and articular surface.
114
Olecranon fracture treatment
A simple transverse avulsion fracture can be fixed with tension band wiring which compresses the tension side of the fractures. Comminuted fractures don’t have a fulcrum for the tension band and require ORIF with a plate and screws.
115
Radial head & neck fractures due to what?
Radial head and neck fractures usually occur due to a fall onto the outstretched arm.
116
investigating radial head and neck #s
Some undisplaced fractures may not show up on x‐ray other than a fat pad sign on the lateral x‐ray (a triangle like a sail anterior to the distal humerus) with lateral elbow pain on supination / pronation.
117
treating Radial head & neck fractures
Undisplaced or minimally displaced fractures are treated conservatively with a sling for comfort followed by early elbow exercises to minimize stiffness. Patients often lose 10‐15° of terminal extension. Displaced intra‐articular radial head fractures may require surgery if the displaced fragment causes a mechanical block to full extension. Aspitation of the haemarthrosis and injection of local anaesthetic may help to exclude those with restricted ROM due to pain. ORIF is performed if the fragment is large enough or excision if not amenable to fixation.
118
elbow dislocation
Most elbow dislocations occur in the posterior direction after a fall onto the outstretched hand. They may be associated with neurovascular injury. Uncomplicated dislocations require closed reduction under sedation assessing neurovascular status pre‐ and post‐reduction. A short period in sling (1‐3 weeks) followed by elbow exercises is typically required.
119
In elbow fracture-dislocation, what are the common # that occur with elbow dislocation
Associated fractures of the radial head, humeral epicondyles or coronoid process of the ulna.
120
treating elbow fracture dislocation
Surgery may be required if entrapped bony fragments prevent reduction or block motion. Radial neck or head fractures may require ORIF or excision and replacement with a prosthetic radial head to maintain stability.
Epicondyle fractures are fixed with a screw. Large coronoid fractures may need ORIF with small screws to prevent recurrent dislocation. Some cases with recurrent instability may be helped with lateral elbow ligament reconstruction.
121
forearm # principles
forearm consists of radius nd ulna bone connected proximally and distally by strong ligaments around the respective radio-ulnar joints (where supination/pronation occurs).
because of strong ligaments forearm acts as a ring (so ifone bone #/dislocated then other is likely to be as well)
122
Fracture of ulnar shaft is know as?
nightstick #
123
what can cause an ulnar shaft #
direct blow (nightstick because used to b after hit by truncheon/nightstick)
check there is no associated Monteggia injury.
many
124
treatment of ulnar shaft #/nightstick #
conservative management
ORIF if need earlier return of function/reduced risk of non-union
125
treatment for # of both bones of forearm
diaphysial fracture of both bone in adults needs ORID with plates and screws as is highly unstable and needed to prevent dislocation and maximise function.
children can do cast if minimally angulated # as angulation corrects with age
substantially angulated # or displace # with intact periostem are only unstable in one direction so plaster (+/-MUA)
if fracture is very unstable after reduction then flexible intramedullary screws used
126
MUA means?
manipluation under anathesisa
127
what is a Monteggia Fracture dislocation
fracture of the ulna occurs with dislocation of the radial head at the elbow
128
Monteggia Fracture dislocation investigation
forearms X-rays may not be easy to see
therefore do elbow X-rays too
129
Monteggia Fracture dislocation treatment
ORIF of ulna fracture (even in kids). which should result in reduction of RCJ [manipulation alone risks re-dislocation due to unstable nature or injury]
130
what is Galeazzi fracture dislocation
fracture of the radius with dislocation of the ulna at the distal radioulnar joint.
131
Galeazzi fracture dislocation investigation
forearms X-rays may not be easy to see
therefore lateral X-ray of wrist is mandatory
132
Galeazzi fracture dislocation treatment
ORIF of radius which should allow the DRUJ to reduced
133
what are some common Distal Radial #s
colles#, Smith's#, Barton's#, comminuted IA distal #
134
distal radial # common cause?
due to FOOSH (falling into an outstretched hand)
135
what is a Colles #
extra‐articular fracture of the distal radius within an inch of the articular surface and with dorsal displacement or angulation.
(there is often associated # of ulnar styloid)
136
why does Colles # occur
FOOSH with wrist extended.
137
treatment of Colles #
minimal angulation/shortening = splintage alone
any angulation past neutral = manipulation.
may be held with plaster cast alone or if has dorsal comminution or is felt unstable after reduction then percutaneous wires or ORIF with plate + screws.
138
what accompanies a Colles #
assocaited # of ulnar styloid.
median nerve compression from nerve stretch or a bleed into carpal tunnel.
[Reduction may relive the pressure on the nerve and the fracture is usually stabilized with fixation. The carpal tunnel may need surgically decompressed.]
139
what is a specific late local complication of a Colles #
Extensor Polligus Longus tendon rupture (require tendon transfer)
140
what is Smith's #
volarly displaced or angulated extra‐articular fracture of the distal radius which usually occurs after falling onto the back of a flexed wrist.
141
treatment for Smith's #
ORIF using plate and screws as are highly unstable.
142
examining Smith's #
grip strength and wrist extension are greatly reduced if there is a malunion with excessive volar angulation.
143
what is Barton's #
intra‐articular fractures of the distal radius involving the dorsal or volar rim, where the carpal bones of the wrist joint sublux with the displaced rim fragment.
144
how can Barton's # be classified
They can be classified as volar Barton's fractures (an intra-articular Smith's fracture) or a dorsal Barton's fracture (an intra-articular Colles' fracture)
145
Barton's # treatment
require ORIF (as with most IA injuries)
146
why does a Comminuted intra‐articular distal radius fracture occur?
when the distal radius fractures are so comminuted (due to high energy or poor bone quality) that stable fixation of the joint fragments is not possible.
147
what is treatment for Comminuted intra‐articular distal radius fracture?
external fixture across wrist joint (restore the shortening and hold the wrist in reasonable alignment and therefore limit functional deficit). supplementary wires can be used to pin larger fragments
148
scaphoid # PC
after FOOSH.
tenderness in anatomical snuff box and pain on compressing thumb metatarsal
149
investigating scaphoid #
AP, lateral and 2 oblique views taken due to kindness shaped bone makes it difficult to detect #. Some aren't visible initially but can bee seen 2 weeks later after reabsorption of fracture ends.
150
what to do if scaphoid # is suspected but X-rays fail to show #
wrist is splinted and further assessment in 2 weeks time.
called "clinical scaphoid #"
151
treatment for scaphoid #
Undisplaced # are usually treated with plaster cast for 6‐12 weeks.
Displaced # = compression screw to prevent non-union.
152
complications of scaphoid #
non-union problems due to SF inhibitng # healing. CT helpful to see if union has occurred.
AVN of proximal pole.
153
how are non-union scaphoid # treated
CT scan shows non-union
screw fixation and bone grafting.
154
how is AVN of scaphoid # treated
difficult, once has established usually symptomatic partial or total wrist fusion
155
what is a peri-lunate dislocation
dislocation of one of the carpal bones around the lunate (another carpal bone)
uncommon, classic “missed diagnosis” with up to 25% of cases being missed on initial presentation.
156
peri-lunate dislocation PC
severe high energy wrist injury resulting in hyperdorsiflexion
157
investigation of peri-lunate dislocation
x-ray: not obvious. demonstrate lose of alignment of the capitate and lunate with the concave lunate fossa being empty
exam: median nerve injury/acute carpal tunnel syndrome may be present
158
treatment of peri-lunate dislocation
emergency - closed reduction + percutaneous pinning/open reduction. carpal tunnel decompression may be required.
159
what is a lunate dislocation
high energy injury where the lunate dislocates (usually volarly) whilst the remainder of the carpal bones remain enlocated.
160
investigating lunate dislocation
X-raysplit cup sign.
exam: acute carpal tunnel syndrome common.
161
treatment of lunate dislocation
emergency closed/open reduction and pinning
162
why does a Scapho‐lunate dissociation occur?
occurs when the scapho‐lunate ligaments ruptures.
163
what is seen on Xray in Scapho‐lunate dissociation
increased gap between the scaphoid and lunate on AP X-ray.
164
what happens if Scapho‐lunate dissociation is left untreated
abnormal forces on wrist and carpus causing early OA
165
treatment of Scapho‐lunate dissociation
surgical with closed reduciotn and K-wiring +/-scapholunate ligament repair.
166
how are chronic cases of Scapho‐lunate dissociation without OA treated?
soft tissue tethering to the distal pole of the scaphoid to prevent hyperflexion (dorsal capsulodesis)
167
how are chronic cases of Scapho‐lunate dissociation with OA treated?
partial or total wrist fusion (to improve symptoms)
168
name some common hand injuries
penetrating injury, extensor tendon injuries, mallet finger, flexor tendon injuries, metacarpal #, phalangeal #
169
what do volar injuries risk damage (palm side)
flexor tendons, digital nerves, digital arteries
170
what do dorsal injuries risk damage (back of hand side)
extensor tendons
171
investigating hand penetrating injury
assessment of neurovascular and tendon function.
(be prepared for surgery as tendon can seem functionally normal but have little continuity/attachment meaning rupture is common)
172
treatment for Complete or significant partial tendon injuries
surgery
173
surgery for Complete or significant partial tendon injuries involves
if both digital arteries injured then microsurgical repair
if pulsated bleeding/arteries injury to digit then higher chance of congruent injury to adjacent digital nerve
Digital nerve injuries proximal to the DIPJ warrant repair with sensation to the thumb, index and little fingers particularly important.
174
Extensor tendon injuries treatment
Extensor tendon divisions of 50% or more usually require surgical repair with splintage in extension for 6 weeks as any flexion within this period may cause failure of the repair.
175
what is mallet finger
Mallet finger is an avulsion of the extensor tendon from its insertion into the terminal phalanx and is caused by forced flexion of the extended DIPJ, often from a ball at sport.
176
PC of mallet finger
due to sport usually, The patient presents with pain, a drooped DIPJ of the affected finger and inability to extend at the DIPJ. The injury may be a purely tendinous avulsion or may have a bony fragment.
177
treatment of mallet finger
mallet splint holding the DIPJ extended which should be worn continuously for a minimum of 4 weeks.
178
what problems do flexor tendon injuries cause?
tendons cannot run smoothly within tendon sheath and under the pulley.
digital nerves and arteries that run adjacent to the tendons can be injured too
injuries to FDS, FDP or both may occur
concomitant injury to the interdigital nerves or arterial system.
179
how to tell difference between FDS and FDP?
FDP has more distal insertion than FDS
180
what are FDS and FDP
FDS = flexor digitorium superficalis
FDP = deep (extends to distal)
181
what is flexor in thumb?
FPB - flexor pollicus brevis
182
how to treat palmar injuries
all need explored
smooth over partial divisions or repair complete divisions. (special suture technique)
183
why does the tendon sheath requires careful repair with preservation of the pulleys?
to avoid bow-stringing of tendon
184
what about rehab post-surgery of flexor tendon injury
splinted in flexed position.
often with elastic traction to allow early active gentle extension and passive flexion
(to prevent stiffness and adhesion in tendon sheath)
185
Penetrating injuries in the volar forearm risk injury to what?
wrist flexors (FCU and FCR)
long flexors to the fingers and thumb
injuries to median and ulnar nerves
injuries to ulnar and radial arteries
186
how are # of 3, 4, 5th metacarpals treated and why?
conservatively (usually)
The 3rd + 4th metacarpals have strong intermetacarpal ligaments proximally and distally. gives stability to # and minimal displacement.
187
why do Fractures of the 5th metacarpal often occur?
punching injury
Esp 5th matacapral neck # (aka: boxer's #).
188
what is tolerate for boxer's #
up to 45 degrees angulation - as don't affect hand function
189
treatement for boxer's #
neighbour strapping
early motion to maintain function.
check rotational alignment/grip problems/overlapping fingers when making a fist
190
how would you fix rotational alignment/grip problems/overlapping fingers when making a fist
mainulaltion + neighbour stapping/k-wire stabilisation
191
what is a "fight bite"?
laceration sustained to the puncher's hand from the punchee's tooth!
192
what complications can "fight bite " cause?
MCPj disruption
extensor tendon rupture
intra-oral organsis cause aggressive infection cause septic arthritis.
193
treatment of fight bite
explored and thoroughly washed out in theatre and certainly not sutured closed in A&E.(due to infection risk)
194
how to treat phalangeal #'s
neighbour strapping/spintage.
if significantly displaced → MUA.
unstable # or IA #→ Kwiring or fixation with small screens.
195
what two things are hip # related to?
falls + osteoporosis
196
outcomes and mortality from hip #
variable some fine, some need walking aids, some wheelchair
Mortality from hip fracture is around 10% at one month, 20% at four months and 30% at one year.
because of significant co-morbidities (MI, ARF, RespF, Chest infections, surgical complication, CVS failure, reduced physiological reserves....)
197
what increase a patient risk of falling?
age, co-morbiditiies (cerebrovascular insufficiency, cardiac arrhythmias, postural hypotension etc.)
198
treatment for hip #
surgery despite risks. (as non-op just as high)
199
non-op management of hip #
prolonged bed rest for several weeks → very sore for toileting and bathing → problems with recumbency (pressure sores, chest infections) + # may not heal. also muscular atrophy making rehab difficult
200
post hip # surgery what is done in 24hrs?
mobilisation (reduces surgical risks and physio time)
201
when would surgery not be indicated for hip #
ery high risk patients who are expected to die very soon after the injury.
202
what are the two types of hip #?
intra and extra capsular
| can also be described as sub capital, intertrochanteric and subtrochanteric [intra, extra, extra]
203
why is it relevant if # is intra/extracapsular?
likelihood of blood supply being interrupted in greater in intra (femoral head AVN and poor healing/non-union)
204
what is the arterial supply of the femoral head?
come from a ring anastomoses of the circumflex femoral artier (at insertion of hip papule at base of femoral neck).
medial and lateral circumflex arteries travel up femoral neck and into the femoral head.
205
medial and lateral circumflex arteries are branches of which artery?
profunda femoral artery
206
intracapsular # problems
femoral head AVN and poor healing/non-union
207
treatment of intracapsular # of hip
replacement femoral head which can either be a hemi‐arthroplasty or THR
208
what is the difference between THR + hemi‐arthroplasty?
hemi‐arthroplasty - replacing the femoral head alone.
THR - replacing the acetabulum as well as the femoral head
209
why choose THR? why choose hemi‐arthroplasty?
THR - better function (given to higher functioning patients)
hemi‐arthroplasty - give to resirtited mobility and cognitively impaired patient. (as THR dislocation risk is high in cognitively impaired)
210
why is internal fixation used for extra-capsular hip #?
bc want to keep natural joint as AVN and non-union rate low bc have good blood supply both sides
211
treatment for extra-capsular hip #?
internal fixation EG; compression or dynamic hip screw (screw slides promoting # healing)
212
why do Subtrochanteric # occur?
elderly patient with osteoporosis with fall onto their side
213
healing of subtrochanteric #
- relatively poor blood supply
- area of bone under considerable bending stress.
-therefore inc time healing and non‐union occurs fairly frequently.
214
treating Subtrochanteric #
Strong indirect fixation (without further disruption to the blood supply) = intramedullary nail
Thomas split may help relieve pre-op pain and stabilise #
215
why do femoral shaft # occur? (give 5 reasons)
high energy injuries (high risk of concomitant# elsewhere)
[also osteoporotic bone, metatstatic disease, patients with Paget’s disease and paradoxically with long term bisphosphonate use for osteoporosis.]
216
what is main problem with displaced femoral shaft fractures?
- substantial blood loss of up to 1.5L can occur.
| - Fat from the medullary canal → enter venous system → fat embolism → confusion, hypoxia and risk of ARDS.
217
management of femoral shaft #
initially = initial resuscitation (optimizing analgesia [morphine IV/femoral nerve block] + application of a Thomas splint)
Definitive = usually closed reduction and stabilization with an intramedullary nail
(minimally invasive plate fixation with minimal disruption to the fracture site blood supply possible)
218
why is thomas splint used in immediate management of femoral shaft #?
stabilises the fracture minimizing further blood loss and fat embolism.)
219
knee range of movement
mainly flexion and extension
small degree of rotation
220
what is the knee the articulation of?
distal end of the femur and proximal tibia
221
what force of the MCL resist
valgus force
222
what force of the LCL resist
varus force
223
what does the ACL + PCL do?
stabilise the tibia in the sagittal and rotational planes for stability.
224
what do distal femoral # occur?
osteoporotic bone with a fall onto the flexed knee.
| can be extra (supracondylar) or intra articular (intercondylar)
225
treatment of distal femoral #
-surgery with plate and screws (as the fracture position is difficult to maintain in a cast.)
226
when do true knee dislocations occur?
High energy injuries
severe hyperextension and/or rotational forces with a sporting injury.
227
what should you think when you see a knee dislocation
surgical emergency
228
why is knee dislocation a surgical emergency?
high incidence of vascular injury (intimal tears, vascular occlusion, complete transection), nerve injury and compartment syndrome
229
treatment of knee dislocation
reduced urgently → neurovascular assessment
230
what to do if knee dislocation causes abnormal neurovascular assessment
vascular surgery referral if any doubt with further investigation (Doppler, duplex scan or angiogram) and revascularization (endovascular procedures or bypass) as required.
231
what can be done in very unstable knee (post-dislocation)
external fixator
232
what must occur for knee to dislocate?
Multi‐ligament tears/rupture → needs reconstruction
233
why can true knee dislocations be difficult to tell apart from part from partial and how do you do it?
can spontaneuosly reduce back
check neurovasuclar status carefully
234
why do patellar dislocation occur?
- direct blow (clash of knees at sport)
| - contraction of quads with rotation force with patella not engaged in trochlea
235
patellar dislocation treatment (initially)
Manipulation for reduction but more commonly reduce when knee is straightened
236
facts about patellar dislocations (epidimeilology and risk factors)
common, mainly occur in adolecscent females.
lax ligaments, valgus alignment of the knee,
rotational malalignment (including femoral neck anteversion), and
a shallow trochlear groove. = inc risk
Subluxations can also occur without frank dislocation.
237
Examination of patellar dislocation shows what?
- tenderness over the medial retinaculum (where the medial patellofemoral ligament is torn)
- haemarthrosis [from impaction of the medial patellar facet on the outer aspect of the lateral femoral condyle]
- osteochondral # can occur (fix or remove fragments)
238
how many people who have first time patellar dislocation will have another one and how many will have multiple?
10% have another one
50% of those will be recurrent
239
treatment of patellar dislocation
reduction
temporary splinter then physio
occasionally surgical stabilisation (with either bony procedure for malalignment or soft tissue reconstruction is required)
240
what does the physio try to strengthen post-patellar dislocation?
vastus medialis - prevents further dislocations (many adolescent patient stabilise with age).
241
why do Proximal tibia (plateau) #s occur?
high energy in young
osteoporotic bone in old
242
Proximal tibia (plateau) # characterisitics
IA # with either split in bone or depression of the articular surface or both.
243
how are Proximal tibia (plateau) #s classified
Schatzker system (beyond undergrad level)
244
what may Proximal tibia (plateau) # have associated in high energy injuries?
neurovascular injury or compartment syndrome.
245
treatment of Proximal tibia (plateau) #
(as with most IA #s) surgery to reduce articular surface and riding fixation with early motion (combat stiffness and post-trauma OA).
246
what investigations are useful in Proximal tibia (plateau) # surgical planning
CT
247
what can valgus stress to the knee cause?
lateral plateau fracture with failure of the MCL and possibly ACL with increasing force
248
what can a direct blow (car bumper) to the knee cause?
proximal fibular fracture and injury to the common peroneal nerve with foot-drop (due to loss of power to tibialis anterior)
249
what can a varus injury to the knee cause?
medial plateau fracture (less common) with potential for LCL rupture and stretch injury to the common peroneal nerve.
250
what is the treatment for lateral plateau, medical plateau and proximal fibular #?
Plates and screws for fixation.
once depressed # has ben elevated then void in bone filled by bone graft (morsellised packed cancellous autograft from iliac crest) to provide support.
251
what often occurs with high energy #s and what is done about it?
substantial soft tissue swelling
temporary external fixator spanning the joint → initial stability → allows the swelling to resolve → do ORIF (some surgeons use external fixture as definitive management not ORIF)
252
what is prognosis of surgery
Despite efforts to restore the articular surface → results often disappointing → need TKR
253
why do tibial #s occur?
indirect force and either (transverse #) bending or rotational energy (spiral #), compressive force from decelleration (oblique #), or a combination (comminuted #)
254
what is common to occur in tibial shaft #?
open # (as shaft is subcutaneous) and compartment syndrome risk very high (particularly anterior compartment of the leg)
255
treatment of tibial shaft # non-op/conservative
non-op: up to 50% displacement and 5 degrees angulation accepted. above knee cast
internal rotation of the distal fragment is poorly tolerated.
position difficult to control in a cast → frequent cast changes and check X-rays required:
fibula not # → tibia often drifts into varus
fibula is also fractured → valgus alignment common.
256
treatment of tibial shaft # operative
internal fixation controls position and removes need for cast (early mobility and # quicker rehab)
257
how long does tibial shaft # take to heal?
average time to union of around 16 weeks and can take up to a year to heal.
258
what to do in comminuted tibial shaft #?
v unstable needs surgery to stabilise. (open # need plastic surgeon).
compartment syndrome needs fasciotomy.
ORIF with plate/screws give rigid stability. Intramedullary nailing is the commonest method of surgical stabilization - can give pain kneeling
external fixation used sometimes but infection and loosening = problems
259
IA distal tibial # are known as what?
pilon #s
260
how is extra-articular # of distal tibia is it treated?
if in acceptable position either op/non-op with early motion. (intramedullary nail or distal locking screw).
261
how is an (IA) pilon # treated
emergency - temporary external fixation (as soft tissue swelling) then definitive ORIF to ensure congruent articular surface
(impacted articular fracture fragment need to be removed and any voids filled by bone graft).
(ankle arthrodesis may be required for post-trauma OA)
262
why do pilon # occur?
high energy caused by fall from height or rapid deceleration.
263
what is the pathology of a pilon #?
talus driven into the distal tibial article surface → substantial disruption, comminution or impaction of articular cartilage.
soft tissue swelling/ bruising/blistering.
other injuries common
264
how is pilon # investigated?
CT scan.
265
ankle sprain due to what?
very common, with inversion or rotational injury force on planted foot
266
what are soft tissue sprain in ankle PC
sprains of lateral ankle ligaments are commonplace:
pain, bruising and mild/moderate tenderness in involved ligaments. (higher force causes #s)
267
what criteria is used for ankle injuries to determine if need Xray? what merits Xray?
Ottowa.
Any severe localized tenderness (known as bony tenderness) of the distal tibia or fibula or inability to weight bear for four steps merits an xray
268
what is difference between stable and unstable ankle # and why is this important?
Isolated distal fibular fractures with no medial fracture or rupture of the deltoid ligament are stable and are common and stable.
Distal fibular fractures with rupture of the deltoid ligament (suspected by bruising and tenderness medially) are unstable.
important as treatment differs
269
what is treatment for stable ankle #?
a walking cast or splint for around 6 weeks.
270
what is treatment for unstable ankle #?
ORIF (with plate/screws).
271
what must have occurred if there is talar shift/talar tilt?
definition the deltoid ligament must be ruptured if there is no medial malleolar fracture
272
what is difference between talar shift + talar tilt?
talar shift - asymmetric increased space around the talus within the ankle mortise (on AP X-ray view)
talar tilt - talus and tibial plafond being non parallel
273
why is talar shift important to spot?
Ankle joint contact pressures greatly increase with even 1mm of talar shift with subsequent risk of post traumatic OA
274
treating talar shift
anatomic reduction and rigid internal fixation is required to minimize this risk with any talar shift.
275
what is treatment for bimalleolar #s?(# both medial and lateral malleoli)
unstable so undergo ORIF
276
what are ankle # associated with (soft tissue wise). why is this relevent?
substantial soft tissue swelling and fracture blisters
ORIF may be delayed by 1‐2 weeks to allow the soft tissues to settle and reduced the risk of wound healing problems and infection.
277
when to check for Talar shift? (do AP X-ray for it)
if ottawa criteria suggests Xray (bony tenderness or inability to bear weight)
278
how is the foot anatomically arrangement
forefoot - matatarsal + phlanx
midfoot - the rest (navicular, cuboid, lateral, median and middle cuneiforms)
rearfoot - talus and calcaneus
279
calcaneal # MOI
due to fall from height onto the heel
280
calcaneal # pathology
can bc EA or involve subtalar joint (IA).
substantial soft tissue swelling + compartment syndrome
heel tends to drift into valgus with a widened heel causing impingement of the lateral ankle tendons
281
what is calcaneal # prognosis dependant on?
extent of involvement of the subtalar joint and the degree of comminution.
282
treatment of calcaneal #
controversial. ORIF to restore artilar surface in young.
however, risk of wound healing and breakdown high → difficult to achieve skin coverage without footwear problems. Smoking, vascular disease, inc age = risk factors for healing problems/infection. Also no evidence ORIF improves pain/function long term.
283
what is a complication of cancaneal # involving subtler joint and how is treated?
post-trauam OA →chronic pain → subtalar arthrodesis
284
why do talar # occur?
of talar neck occur with forced dorsiflexion of foot from rapid deceleration (RTA). high energy
285
talar # types
undisplaced or displaced with subluxation of of subtalar joint.
286
why is talus at risk of AVN?
blood supply from distally with anastomoses around and vessels traversing the talar neck.
287
treatment of talar #s?
displaced = closed or open reduction and screw fixation
AVN of the talus is not always symptomatic but secondary symptomatic OA may require ankle fusion.
288
midfoot #/dislocation know as
lisfranc injury
289
what is a lisfranc injury?
base # of the 2nd metatarsal in associated with dislocation of the base of the 2nd metatarsal +/- dislocation of the other metatarsals at the tarso‐metatarsal joints.
290
investigating Lisfranc injury
X-ray (can look normal as # can be small flake # and easy missed) → CT if doubt
291
PC of lisfranc #
swollen, bruised foot, can't bear weight.
292
what happens if lisfranc injury is untreated?
high risk of pain + disability
293
treatment for lisfranc/midfoot #
closed/open reduction with fixation using screws
294
metatarsal injuries: how likely are 5th metatarsal # and why do they occur?
of base of 5th metatarsal are common.
inversion injury with an avulsion fracture at the insertion of the peroneus brevis tendon
295
treatment for 5th metatarsal #
These heal predictably and require a walking cast, supportive bandage or wearing of a stout boot for 4‐6 weeks. Even with those which fail to achieve bony union, many have a stable fibrous non‐union which is usually asymptomatic.
296
what is a jones #?
where the bone fractures in the region of the proximal diaphysis
297
why is Jones # important?
area has poorer blood supply and risk of non-union higher (25%) even in undisplaced #s
298
treatment for jones #?
Fixation if displaced/inactive patient.(usually with single screw).
non-union = bone graft and fixation
299
how common is 1st metatarsal # and what is treatment
uncommon (due to thickness and strength). normally fixed as important
300
how common are the lesser metatarsal #s and what is treatment
commonly fractured, often with multiple fractures.
minimal displacement= conservatively with a cast.
Multiple displaced fractures = K‐wires to reduce the risk of chronic pain.
301
what is a common metatarsal site for a stress #?
2nd metatarsal.
occur spontaneously/after period of inc activity.
302
investigating 2nd metatarsal #
x-ray may not show until callus formation has started.
Bone scan may aid diagnosis
303
treatment for 2nd metatarsal #
cast until pain stops
304
toe # treatment
rarely require anything other than protection in a stout boot.
305
treatment of IA # at base of proximal phalanx of hallus
reduction and fixation if the fragment(s) are sizeable
306
what is treatment of open toes #?
Open fractures require debridement +/- wire stabilising
307
how are toe dislocations treated?
closed reduction + neighbour stepping or wiring.
