fractures Flashcards by Susannah Welch

bones with vulnerable blood supplies where a fracture can lead to AVN, non-union..

scaphoid
femoral head
humeral head

certain foot bones - talus, navicular, 5th metatarsal in foot

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main cancers that metastasise to the bone

(PoRTaBLe)

Prostate
Renal
Thyroid
Breast
Lung

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treatment to reduce fragility fractures

calcium + vit D
biphosphonates (alendronic acid)

denosumab where bisphosphonates contraindicated/not tolerated

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bisphosphonates side effects

reflux, oesophageal erosion - need to be taken on an empty stomach + sit upright for 30mins
osteonecrosis of jaw
osteonecrosis of external auditory canal
atypical fractures

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bisphosphonates MoA

reduce osteoclast activity - preventing reabsorption of bone

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methods of stabilising fractures

(stability to allow to heal)

external cast - plaster cast
K wires
intramedullary

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early fracture complications

>damage to local tendons, muscles, nerves etc
>haemorrhage leading to shock + death
>compartment syndrome
>fat embolism
>venous thromboembolism

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fat embolism post fracture

can cause systemic inflammatory response - fat embolism syndrome

presents ysyally 24-72hrs post fracture

pres = stress, petechial rash, cerebral involvement

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longer-term fracture complications

>delayed union
> malunion - pain,stiffness, loss of function, deformity
>non-union
>AVN
> infection (osteomyelitis)
>joint instability/stiffness
>contractures (tightening of soft tissue)
>arthritis
>complex regional pain syndrome

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reasons why non-union may occur post fracture

poor bloody supply to fracture
gap too big
systemic disease
**smoking**
steroids
NSAIDs
bisphosphonates

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neurapraxia

occurs when the nerve has a temporary conduction defect from compression or stretch + resolve over time with full recovery

(can take up to 28days)

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axonotmesis

nerve injury sustained due to compression or stretch from a higher degree of force with death of the long nerve cell axons distal to the point of injury

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neurotmesis

complete transection of a nerve requiring surgical repair for any chance of recovery of function

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prognosis in Salter-Harris fractures

fracture prognosis is poorer as the classification progresses

(children’s fractures around the physis aka growth plate)

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chronic regional pain syndrome presentation

constant burning or throbbing
sensitivity to stimuli not normally painful
swelling, stiffness
painful/restricted movement
skin colour changes

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metatarsal stress fractures

commonest - 2nd or 3rd metatarsal

runners, soldiers on prolonged marches, dancers, long walks in people not used to them

xrays may not demonstrate until 3 weeks

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when is surgery offered for hallux valgus?

for pain + restriction of function

cosmetic reasons won’t be happy

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This 50 year old lady complains of left 1st MTPJ pain on walking, particularly when wearing thin, non-supportive shoes. She cannot wear high heels because of the pain and stiffness in the joint. On examination, active and passive range of movement of the joint is reduced (and quite tender at the end range of movement) and grind test is positive.

hallux rigidus

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classification used in ankle fractures

Weber classification

Type A - below ankle joint, syndesmosis intact
Type B - at level of joint, syndesmosis intact or partially torn
Type C - above joint, syndesmosis disrupted

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management of ankle fractures

assessmnet of stability determines posible management - if fracture disrupts syndesmosis, surgery is more likely

conservative = cast or moon boot
surgical = open reduction internal fixation (ORIF)

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what are people with tibial shaft fractures more at risk of?

compartment syndrome - particularly anterior compartment

–> open fractures common, v slow healing

management of tibial shaft fractures

conservative (up to 50% displacement + 5degrees angulation)
= above knee cast

surgical = IM nail, ORIF

associated risk in tibial plateau fractures

neurovascular injury - popliteal structures, common peroneal nerve
compartment syndrome

often associated soft tissue injuries eg ACL

management of tibial plateau fractures

conservative = above knee cast

surgical (more common, high energy injury)

ORIF
external fixator
delayed total knee replacement

causes of femoral shaft fractures

high energy injury - major trauma, pobs with other injuries metastatic disease, Paget's, long term bisphophonate use for osteoporsis substantial blood loss can occur in displaced fractures - up to 1.5L

management of femoral shaft fractures

initially = Thomas splint - temp stabilisation, minimises blood loss + fat embolism definitive = IM nail, plate fixation or ORIF

most common pelvic fragility fracture in elderly?

pubic ramus Low energy pubic rami fractures in elderly tend to be minimally displaced lateral compression injuries + settle with conservative management over time

risk in pelvic fractures

often leads to significant intra-abdominal bleeding - emboli - shock + death

3 main patterns of pelvic fractures

1. Lateral compression - side impact (RTA) 2. Anteroposterior compression - torn pubic symphysis, open book pelvic fracture 3. Vertical shear force - fall from height + rapid deceleration, sacral + lumbosacral roots at high risk of injury

mandatory investigation in pelvic fractures

PR exam assess sacral nerve root function + look for blood blood = open fracture

pelvic fracture management

initial = pelvic binder conservative = rest, physio, analgesia, occu surgical = open reduction internal fixation (ORIF)

cause + presentation of scaphoid fractures

caused by FOOSH tenderness in anatomical snuffbox pain on compressing thumb metacarpal

treatment + complication of scaphoid fractures

plaster cast 6-12weeks avascular necrosis* non-union

types of distal radius fractures

Colles fracture - FOOSH, dinner fork deformity Smith fracture - fall onto back of flexed wrist, ORIF Barton fracture - intra-articular involvinf dorsal or volar rim, ORIF

Colles fractures

FOOSH, dinner fork deformity distal radius - causes distal portion to displace posteriorly (upwards)

complications of Colles fractures

ulnar styloid fracture median nerve compression from stretch of nerve bleed into carpal tunnel long term = rupture of extensor pollicis longus tendon - requires tendon transfer

management of Colles fracture

(distal radius) cast, splint ORIF, manipulation under anesthesia (MUA), K wires external fixation if in lots of bits (comminuted)

why is the forearm prone to multiple injuries?

radius + ulnar connected with proximal + distal radioulnar joints = forms ring fracture of one bone - usually injury in another

cause + treatment of isolated ulnar fractures (nightstick)

result from direct blow - classic defensive fracture (nightstick) conservative or ORIF *make sure no dislocation of radial head at elbow (Monteggia)

what is a Monteggia injury?

fracture of ulnar shaft + dislocation of radial head at elbow management = ORIF

what is a Galeazzi injury?

fracture of distal part of radius + dislocation of distal radioulnar joint (ulnar intact) management = ORIF

cause + presentation of olecranon fracture

fall onto elbow insertion of triceps tendon - extension of elbow

management of olecranon fracture

conservative = cast surgical = tension band wiring, ORIF, plate fixation

causes of humeral shaft fracture

fall resulting in transverse or comminuted direct trauma resulting in oblique or spiral

biggest risk in humeral shaft fractures

neurovascular injury - esp RADIAL nerve (sits in humeral groove) presentation = wrist drop + loss of sensation in first dorsal web space

management of humeral shaft fractures

high union rate (90%) - most conservative conserv = humeral brace / U-slab cast surgical = IM nail, ORIF plate fixation

what nerves are at risk of damage in shaft vs proximal humeral fractures?

shaft = radial (humeral groove) - wrist drop proximal = axillary - regimental patch test

cause + management of proximal humeral head fractures

common low energy or osteoporotic bone ``` conservative = collar + cuff surgical = ORIF, replacement ``` **damage to axillary nerve - regimental patch test

malunion of a fracture of the distal radius may result in impaired grip strength, is this impairment associated with loss of extension or flexion at the wrist joint post injury?

wrist extension is associated with poor grip strength ost distal radial fracture

which types of salter-harris fractures are intra-articular?

III + IV - fracture splits the physis

which nerve is most at risk in a Colles fracture?

median nerve

Fractures have the potential to remodel over time. That is that they change shape with 'bone laid down along areas of stress'. What is the eponymous name given the the physics principle being described and applied here?

Wolff's law