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Fracture Flashcards

1
Q

Traumatic fractures

A

Direct: e.g. Assault/RTA
Indirect: fall on outstretched hand -> clavicle #
Avulsion

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2
Q

Stress fracture

A

Bone fatigue due to repetitive strain

E.g. In marathon runners

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3
Q

Pathological fractures

A

Normal forces in diseased bone -> #
Local: tumour
General: osteoporosis, Cushing’s, paget’s

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4
Q

Fracture patterns

A 
Transverse
Oblique
Spiral 
Multifragmentary aka comminuted
Crush
Greenstick
Avulsion
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5
Q

Fracture deformity

A

Translation
Angulation or tilt
Rotation
Impaction

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6
Q

Soft tissue issues to consider in fracture

A

Open or closed?
Compartment syndrome
Neuro vascular status

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7
Q

Primary survey

A

C-spine
Chest
Pelvis

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8
Q

Fracture assessment in secondary survey

A

Assess neurovascular status
Check for dislocations
? Reduction and splinting prior to imaging:
reduces bleeding, pain, risk of neurovasc injury
X-ray once stable

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9
Q

6 As of open fracture

A 
Analgesia: M+M
Assess: soft tissues, nv status
Antisepsis: irrigate, swab, cover
Alignment: reduce # + splint
Anti-tetanus: check last tetanus jab
Antibiotics: fluclox 500mg IV/IM + benpen 600mg IV/IM
Or augmentin 1.2g IV
Debride and fixate in theatre
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10
Q

Most dangerous complication of open #

A

Clostridium Perfringens
Wound infection + gas gangrene
+- shock + renal failure
Rx debride, benpen, clindamycin

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11
Q

Gustillo classification of open #s

A
  1. Wound <1cm
  2. Wound >1cm, minimal soft tissue damage
  3. Extensive soft tissue damage
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12
Q

reduction

A

If displaced -> reduce unless no effect on outcome e.g. Ribs
Aim = anatomical reduction
Alignment > opposition

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13
Q

Methods of reduction

A

Closed reduction: under local/regional/general anaesthetic
traction to disimpact, manipulation to align
Traction: only used to overcome contraction of large muscles e.g.femur mostly seen in paeds
Open reduction + internal fixation

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14
Q

Indications for internal fixation

A

Intra articular #
Open #
2 # in one limb
Failure of conservative management

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15
Q

Principles of restriction

A 
Fixation:
reduces strain -> bone formation
reduces pain
increases stability
increases function
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16
Q

Methods of restriction

A

Non rigid: slings, elastic support
Plaster: first 24 hrs back slab/split cask, risk compartment synd
Functional brace: joint free to move, bone shaft supported in cast
Continuous traction: collar + cuff
External fixation: pins, wires + ext frame
Internal fixation: pins, plates, screws, nails

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17
Q

Rehab

A

Immobility -> reduced bone/muscle mass + joint stiffness
Maximise mobility of uninjured limb
Quick return to function reduces morbidity later
Physio
OT
Social services

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18
Q

General # complications

A

Tissue damage: haemorrhage, infection, rhabdomyolysis
Anaesthesia: anaphylaxis, teeth, aspiration
Prolonged bed rest: UTI/chest infection, pressure ulcer, muscle wasting, DVT/PE, reduced BMD

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19
Q

Specific # complications

A

Immed: NV damage, visceral damage
Early: compartment synd, infection, fat embolisation -> ARDS
Late: AVN, union issues, growth disturbance, post traumatic OA, complex regional pain synd, myositis ossificans

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20
Q

complications: neurological

A

Seddon classification
Neuropraxia: temporary interruption of conduction w/o loss of axon continuity
Axonotmesis: axon disruption-> distal Wallerian degeneration
connective tissue preserved, regeneration and recovery possible
Neurotmesis: entire nerve fibre disrupted, req surgery, recovery not complete

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21
Q

Common # associated palsies

A

Axillary N: numb chevron, weak abduction
ant shoulder dislocation/ humeral surgical neck #
Radial N: waiter’s tip, humeral shaft #
Ulnar N: claw hand, elbow dislocation
Sciatic N: foot drop, hip dislocation
Fibular N: foot drop, # neck of fibula, knee dislocation

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22
Q

Compartment syndrome

A 
Fascia divide groups of muscles, nerves and vessels in limbs into discrete compartments
Fascia do not stretch or expand easily
# -> oedema -> incr compartment P -> decr venous drainage -> incr P
Compartment P > capillary P = ischaemia
Muscle infarction: rhabdo + ATN, fibrosis -> Volkman's isch.contracture
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23
Q

Compartment syndrome presentation

A

Pain in passive stretching of muscles
Warm erythematous swollen limb
^ CRT
Weak/ absent peripheral pulses

24
Q

Management of compartment syndrome

A

Elevate limb
Remove bandages, split/remove cast
Fasciotomy

25
Causes of delayed/non Union
Ischaemia: poor supply / AVN Infection Incr inter-fragmentary strain Interposition of tissue between fragments Intercurrent disease: malignancy/malnutrition
26
Non-union
Hypertrophy: rounded, dense, sclerotic bone end Atrophy: osteopenic bone Management optimise bio: infection, blood supply, graft, BMP optimise mechanics: ORIF
27
Avascular necrosis
Sites: femoral head, scaphoid, talus -> soft, deformed bone => pain, stiffness, OA X-Ray: sclerosis + deformity
28
Myositis ossificans
Heterotrophic ossification of muscle at sites of haematoma formation -> restricted painful movement Commoner in elbow + quadriceps Can be surgically excised
29
Pellegrini-stieda disease
A form of myositis ossificans | Calcification of the superior attachment of the MCL at the knee following trauma
30
Complex regional pain syndrome type 1
Complex disorder of pain, sensory abnormalities, abnormal blood flow, sweating and trophic changes in superficial or deep tissues with no evidence of nerve injury Assoc with: #s, carpal tunnel release, ops on dupuytron's contracture, HZV, MI, idiopathic
31
Symptoms of complex regional pain syndrome type 1
Wks/maths following injury, area neighbouring traumatised area Lancing pain, hyperalgesia or allodynia Weakness hyper-reflexia, dystonia, contractures Swollen, shiny skin Usually self limiting, can try gabapentin, amitryptiline Refer to pain team
32
Growth disturbance due to fracture
Salter-Harris classification of growth plate injuries 1. Straight across 5% e.g. SUFE 2. Above 75% 3. Lower 10% 4. Through 10% union across physis interferes with growth 5. Crush uncommon physis injury -> growth arrest
33
Osteoporosis RF
``` Age + shattered Steroids Hyper para/thyroidism Alcohol + cigarettes Thin BMI<22 Testosterone low Early menopause Renal/liver failure Erosive/inflammatory bone disease: RA / myeloma Dietary Ca low/ malabsorption ```
34
NOF presentation
``` O/E shortened + externally rotated mechanism RF premorbid mobility premorbid independence comorbidities MMSE ```
35
NOF management
``` Resus: dehydration, hypothermia Analgesia: M + M Assess NV status of limb Imaging: AP + lateral films Prep for theatre ```
36
Prep for theatre
``` Anaesthetist: inform of pt, book theatre Bloods: FBC, U=E, clotting, X-match (2U) CXR DVT prophylaxis: LMWH + TEDS ECG Films: orthogonal X-Rays Get consent ```
37
Imaging
``` AP + lateral films Check Shenton's lines Intra or extra capsular? Displaced or non-displaced? Osteopaenic? ```
38
Classification
Intracapsular: subcapital, transcervical, basicervical Extracapsular: intertrochanteric, sub trochanteric
39
Intracapsular #s - Garden classification
1. incomplete, undisplaced # 2. complete, undisplaced # 3. complete, partially displaced # 4. complete, completely displaced #
40
NOF anatomy
Capsule attaches: proximally to acetabular margin, distally to intertrochanteric line Blood supply to femoral head: retinacular vessels in capsule running distal -> prox (damage = risk of AVN), intramedullary vessels, artery of ligamentum teres
41
Surgical management of intracapsular NOF #
``` Garden 1/2: ORIF with cancellous screws 3/4: <55yrs = ORIF with screws, f/u in OP with arthroplasty if AVN develops (30%) 55-75 yrs = total hip replacement >75 yrs = hemiarthroplasty mobile: cemented Thompson's immobile: uncemented Austin Moore ```
42
Surgical management of extracapsular NOF #
ORIF with DHS - dynamic hip screw
43
Complications specific to NOF #
AVN of femoral head in 30% displaced # non/mal-union 10-30% infection OA
44
Prognosis of NOF #
mortality at 1 yr = 30% 50% never regain pre-morbid function >10% unable to return to permorbid residence
45
Colles #
FOOSH female elderly pop with osteoporosis 'dinner fork' deformity
46
X-ray features of Colles' fracture
distal radius: extra-articular # dorsal displacement + angulation (11 degree volar tilt) of distal fragment decreased radial height + inclination +- ulna styloid avulsion or impaction
47
Management of Colles' fracture
``` NV injury: median nerve + radial artery reduction -> imaging manipulation under anaesthesia # clinic f/u for cast in 48hrs 6wks cast + physio ```
48
Complications specific to Colles' #
``` Medican N injury Frozen shoulder Tendon rupture (EPL) Carpal tunnel syndrome Mal/non-union Sudek's atrophy/CRPS ```
49
Smith's # (aka reverse Colles')
Fall onto back of flexed wrist # of distal radius Volar displacement + angulation of distal fragment Reduction + cast for 6 wks
50
Barton's #
oblique intra-articular # of dorsal distal radius dislocation of radio-carpal joint reverse Barton's = volar aspect of radius
51
Presentation of scaphoid #
FOOSH Tenderness in anatomical snuffbox Tender on telescoping of thumb
52
Specific management of scaphoid #
Request scaphoid x-ray view Treat with suggestive clinical hx even if X-ray normal (scaphoid plaster) +ve X-ray after 10 days (localised decalcification) -> 6 wks plaster -ve but clinically tender -> 2wks plaster
53
Complications specific to scaphoid #
AVN of scaphoid (blood supply distal-> proximal) | = stiffness + pain at wrist
54
Monteggia #
proximal 1/3 of ulna shaft ant dislocation of radial head at capitulum (palsy of deep branch radial N)
55
Galleazzi #
``` # of radial shaft between mid and distal 1/3s dislocation of radio-ulna joint ```
56
Specific management of radial + ulna shaft #s
``` unstable: adults = ORIF, kids = MUA + above elbow plaster plaster in most stable position proximal # = supination distal # = pronation mid-shaft # = neutral ```

Toni's Presentations (121 decks)

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