Fractures

Question 1

Definition of Fracture

Answer 1

A break in the structural integrity of a bone because it is unable to support the energy placed on it. Average citizen of a developed country will experience 2 in their lifetime

Question 2

Types of Fracture

Answer 2

Open, if skin is broken, or Closed if skin is not. Complete - transverse( perpendicular forces), oblique(parrallel forces), spiral, longitudinal, comminuted/ segmental (more than 2 pieces), impacted. Incomplete - greenstick, torus (buckling of the cortex), bow, hairline (common in children)

Question 3

Deformity secondary to fractures

Answer 3

Displacement/apposition, Angulation, Rotation or Shortening
–> consider the direction and degree of change from normal
Fractures are usually described by the relationship of the distal fragment to the proximal

Question 4

Fracture Healing (Primary)

Answer 4

Occurs when the edges are touching exactly - direct cortical re-establishment without a fracture callus developing

Question 5

Fracture Healing (Secondary)

Answer 5

i) Haematoma: tissue damage causing bone end death. ii) Inflammation: inflammatory cells invade. iii) Callus(cartilage+osteoid): Form osteoblasts/clasts, (6-12wks). iv) Consolidation: lammellar bone replaces woven bone, v) Remodelling: normal structure restored
Clinical union 3-4 months, remodeling 6-12 months

Question 6

Diagnosing a Fracture - History - 3,3,1

Answer 6

When, where and how did the injury occur
Was there loss of consciousness?
Site and severity of pain
Neurovascular loss

Question 7

Diagnosing a Fracture - Examination

Answer 7

ABC and primary survey to exclude life-threatening injury
General secondary survey —> Specific secondary survey
Look, feel and move

Question 8

Diagnosing a Fracture - Investigations

Answer 8

Radiological –> X-rays (orthogonal), CTs, USSs, MRI
Bloods —> FBC, U+E, LFT, etc,
Poss – radioisotope bone scan

Question 9

Treatments of fractures (3 ‘R’s)

Answer 9

Reduce, Retain reduction and Rehabilitation

Question 10

When Reducing a Fracture you must consider?

Answer 10

Is it open or closed?

Does it require analgesia or anaesthesia?

Question 11

In order to retain the reduction consider?

Answer 11

If Closed: traction or splintage
If open: Intramedullary or extramedullary fixation
Internal or external fixater (Ilizarov/taylor spatial frame)

Question 12

When planning the rehabilitation consider?

Answer 12

Starts with reassurance of the patient
Require support from physiotherapists and occupational therapists
Requires hard work from the patient

Question 13

How to classify complications of Fractures

Answer 13

Early and late

Local and general

Question 14

Early local fracture complications

Answer 14

Fracture - loss of positioning and infection
Soft tissue - infection, wound breakdown & skin loss, peripheral nerve injuries (PNI) and vascular damage, damage to viscera,

Question 15

Late local complications

Answer 15

Fracture - loss of reduction, delayed union/mal-union/non-union, osteoarthritis, joint stiffness and contracture,
Soft tissues - wound infection or breakdown, PNI and vascular damage

Question 16

General fracture Complications

Answer 16

CNS:Confusion, CVA or fat embolism (1-2days post injury)
CVS:MI, DVT or PE, hypovolemic shock, RS:Pneumonia
GI:Haemorrhage, ileus, UGS:UTI or retention, Endo:unstable diabetes

Question 17

Causes of Fractures

Answer 17

Depends on the energy of the event and the strength of the bone (normal or pathological eg osteoporosis)
High energy events - car crashes, or low energy - stress fractures

Question 18

Greenstick Fractures

Answer 18

A break in young soft bone where there is a bend and partial break in the cortex. a type of incomplete fracture

Question 19

Spiral Fractures

Answer 19

A fracture where the line of breakage is in a spiral. caused by a torque applied along the long axis of the bone

Question 20

Avulsion Fractures

Answer 20

Occurs when a piece of bone is pulled away from the main mass of the bone due to physical trauma. This can occur with a ligament due to external force or at the site of a tendon insertion due to powerful muscular contraction

Question 21

Burst Fractures

Answer 21

A type of traumatic fracture of the vertebra when placed under high energy axial load - this causes its to fracture and burst outwards and this can cause significant damage to surrounding structures

Question 22

X rays to assess a fracture

Answer 22

Require images in two planes (orthogonal)

If in a limb can also require imaging of the joints above and below

Question 23

A complicated Fracture

Answer 23

Where there is important soft tissue damage, particularly neurological or vascular

Question 24

Open or compound fracture

Answer 24

Where there is some communication with the outside usually through a break in the skin - infection is a serious possiblity

Question 25

Hangman's Fracture

Answer 25

Fracture of the bilateral pedicle or lamina or the second vertebra - causes immediate death due to transection of the spinal cord

Question 26

Impacted Fracture

Answer 26

When the bone fragments are forced together by the impact | Usually stable

Question 27

Stability of Fractures

Answer 27

How likely the fracture is to move and become displaced Particularly important in the spinal column Stable '#'s: transverse, short oblique Unstable '#'s: spiral, long oblique

Question 28

Salter-harris classification (Classification of injuries in children involving the growth plates)

Answer 28

I - transverse # through the physis (5%) II - a # through the physis with a piece of proximal bone (metaphysis) (75%). III - as type II but with a piece of distal bone (epiphysis) (8%) IV - a # through all three elements (10%) V - compaction of the physis (~1%) The last 2 as associated with growth deformity

Question 29

SALTER mnemonic (Imagine the bone as a long bone with a joint and growth plate at the bottom)

Answer 29

``` S - Straight across A - Above the physis L - Lower than the physis TE - Through Everything R - Rammed ```

Question 30

Dislocation

Answer 30

Loss of joint integrity | Subluxation is the partial loss of joint surface integrity

Question 31

Healing time for a type II salter-harris #?

Answer 31

2-3 weeks

Question 32

Signs of a Fracture?

Answer 32

Pain and tenderness (increased temp) Swelling and deformity (haematoma or haemoarthrosis) Abnormal movement and creptitus, loss of function

Question 33

Orthopaedic Emergencies (9)

Answer 33

Amputations, Open fractures, Pentrating injures, Major bleeding or vascular injury, pelvic fractures/open book, Major joint dislocations, Compartment sydrome, spinal injury, multiply injured patient

Question 34

Vascular injury

Answer 34

Clock starts at time of injury --> after 6hrs there is irreversible damage (blood loss--> ischaemia--> compartment syndrome-->tissue necrosis)

Question 35

Classification of Open fractures

Answer 35

Gustilo classification - 1976 - based on mechanism of injury, severity of bone and soft tissue damage and level of contamination Type I, II, IIIA/IIIB/IIIC

Question 36

Gustilo type I

Answer 36

skin wound is <1cm, minimal contamination with a simple fracture Infection risk - 0-4%

Question 37

Gustilo type II

Answer 37

Skin wound is >1cm with moderate crush damage or moderate comminution or moderate contamination Infection risk - 2-6%

Question 38

Gustilo type IIIA

Answer 38

Laceration of >5cm with comminution and contamination | Consider delayed primary closure (DPC) or Split thickness skin grafting (STSG) Infection risk - 5-12%

Question 39

Gustilo type IIIB

Answer 39

Bone is Exposed after debridement and requires local or free flap for coverage - Massive contamination Infection risk - 16-45%

Question 40

Gustilo type IIIC

Answer 40

Vascular injury - must repair or amputate the limb

Question 41

Management of major open fractures

Answer 41

Examine and sterilise --> may have to extend wound and remove dead muscle/bone and foreign material/bacteria Stabilise and give antibiotics/Tobramycin beads

Question 42

Signs of compartment syndrome (six 'P's)

Answer 42

Pain, Pallor, Paresthesia, Pulselessness, Paralysis, pretty damn cold Particularly pain which is out of proportion with injury Most common in arms and legs

Question 43

Treatment of Compartment syndrome

Answer 43

Fasciotomy when --> worsening clinical picture, when tissue pressure approaches 20-30mmHg below diastolic, signs of significant tissue injury, if there was significant ischaemia (>6hrs) when perfusion was restored

Question 44

General Management of Fractures

Answer 44

In open #s minimise infection risk In closed #s reduction (may need manipulation, traction or an open reduction) - depending on site and articular involvement may not want to reduce - Must maintain reduction with fixation

Question 45

How long does it take for fractures to heal?

Answer 45

Depends on the method of fixation Long bones - 12wks Cancellous ends of long bones/short bones 6-8wks Children 2-3wks Will heal to the point of being painless in 2-3wks

Question 46

Sudek's Atrophy (Reflex sympathetic Dystrophy or Complex regional pain syndrome)

Answer 46

A condition which can occur post traumatic injury in up to 5% of cases where there is sympathetic damage resulting in burning pain, skin changes, excessive perspiration --> this can lead to immbolisation and general atrophy of the body part

Question 47

Nerve damage during fractures

Answer 47

Distal neurovascular assessment is a crucial part of 2ary survey In closed fractures nerve injury is usually grade 1 or neuropraxia which will recover on its own - in open fractures nerves may be transected - should always explore and if poss repair

Question 48

Neuropraxia

Answer 48

Loss of function in peripheral nerves lasting 6-8wks usually due to blockage of nerve conduction for a variety of reasons Can occur in closed bone fractures

Question 49

Vascular Injury during fractures

Answer 49

If tissue is still pink with good capillary refill even if pulses are weak or lost they will likely return once fracture is reduced If tissue is white and do not have good capillary refill then good chance will need vascular repair even once fracture is reduced

Question 50

Volkmann contracture of the forearm

Answer 50

Occurs when the brachial artery is blocked by supracondylar # or compartment syndrome causing ischaemic necrosis of the flexor muscles with ulnar and median damage and an absent radial pulse --- most common in children

Question 51

Myositis ossificans

Answer 51

The calcification of muscle post traumatic injury - there is a rare autosomal dominant hereditary form Treatment is usually conservative but surgical intervention may be required

Question 52

Delayed Union

Answer 52

The bone takes longer to heal than normal but it will occur eventually with or without augmentation

Question 53

Non union

Answer 53

There is a complete cessation of bone healing which will not improve without an augmentation procedure such as bone grafting

Question 54

Mal Union

Answer 54

The fracture unites but with the fragments in unacceptable positions leading to deformity

Question 55

Plaster Sores

Answer 55

A constant diffuse pain under a cast - should not be ignored and any complaint of unrelenting pain or a digging sensation should be examined.

Question 56

Colle's Fracture

Answer 56

Fracture of the distal radius with dorsal augulation - fall on the outstretched hand

Question 57

Smith's Fracture

Answer 57

Fracture of the distal radius with palmar augulation - fall on the flexed hand

Question 58

Jones' Fracture

Answer 58

Fracture of the base of the 5th metatarsal - can be an avulsion fracture due to the pull of the peroneus brevis tendon

Question 59

Boxer's Fracture

Answer 59

Fracture of the head of the 5th metacarpal with palmar augulation - most commonly after someone punches a wall or person

Question 60

Easily missed fractures in children

Answer 60

Buckle # of radius/ulna - heal quickly Supracondylar # - common Radial head # - common

Question 61

Easily missed fractures in adults

Answer 61

Scaphoid # cause pain in anatomical snuffbox - can cause AVN Posterior dislocation of the shoulder - requires multiple plan view to exclude Hip #'s --> Can be very subtle and require bone scans to detect, particularly in people with weak bones

Question 62

Osteomyelitis

Answer 62

infection of the bone, once infected always infected, horrible infection - treat with antibiotics and debridement and may require bone grafting

Question 63

Bone sites at risk of AVN

Answer 63

Head of femur Proximal scaphoid Body of the talus

Question 64

Grades of Ligament injury

Answer 64

I - few torn fibres but structurally intact II - Incomplete tear without pathological laxity III - complete tear causing pathological laxity

Question 65

Indication for Austin-Moore hemiarthroplasty

Answer 65

High chance of avascular necrosis of femur head, eg intracapsular fracture of NoF

Question 66

Indication for dynamic hip screw

Answer 66

Intertrochanteric fractures

Question 67

Indication for cannulated screws

Answer 67

Intracapsular fracture where there is a chance to save the femoral head

Question 68

Initial management of hip and thigh injuries

Answer 68

Thomas splint

Question 69

Indication for intramedullary nails

Answer 69

Infratrochanteric femoral fractures (load bearing devices)