Fractures

Question 1

Describe primary bone healing

Answer 1

Minimal gap, bone able to fill gap. E.g. hairline fracture, fixation with plate & screws

Question 2

Describe secondary bone healing

Answer 2

Fracture gap fills with granulation tissue, then cartilage (soft callus), then bone (endochondral ossification, hard callus), eg. colles fracture & POP, IM nail, ex-fix

Question 3

What is the fracture healing process?

Answer 3

Haematoma-soft callus-hard callus-remodelling

Question 4

What does communition mean in relation to fractures?

Answer 4

Bone breaks down into fragments- high energy impacts (watch soft tissus, compartment syndrome) or poor quality bone

Question 5

What are some non operative holding management strategies?

Answer 5

Cast (POP, lightweight), functional bracing, traction

Question 6

What are some internal fixations?

Answer 6

K-wires, cerclage wires, onlay devices-plates, screws, inlay devices- IM (intramedullary) nails

Question 7

What are some external fixations?

Answer 7

Temporary, definitive. Can be lateral rod only, or ring shaped round limb

Question 8

What is a possible management strategy for some intra or periarticular fractures?

Answer 8

Replacement

Question 9

What is the general management if simple minimally displaced extra-articular fracture in acceptable alignment and stable?

Answer 9

Conservative management, splint

Question 10

What is the general management if position unacceptable of fracture?

Answer 10

Reduction

Question 11

What is the general management if fracture unstable and patient is fit?

Answer 11

Operative stabilisation

Question 12

What is the general management if fracture caused by high energy, or substantial soft tissue swelling?

Answer 12

Avoid ORIF, wait until tissues settle, may opt for indirect techniques- nailing, ex-fix

Question 13

What is the general management if undisplaced intra-articular fractures?

Answer 13

May be stable and treated non-operativey

Question 14

What is the general management if displaced intra-articular fractures?

Answer 14

Reduction and rigid internal fixation to prevent post trauma OA

Question 15

What is the general management of peri-articular fractures which risk non-union or AVN?

Answer 15

Joint replacement

Question 16

What is the general management of open fractures?

Answer 16

ABx, tetanus, early debridement and operative stabilisation

Question 17

What is the general management compartment syndrome in complicated fracture?

Answer 17

Fasciotomy & operative stabilisation

Question 18

What is the general management if vascular injury has occurred in complicated fracture?

Answer 18

Reduction, stabilisation and reassess circulation. May need revascularisation procedure (stent etc)

Question 19

What is the general management of nerve injury in a complicated fracture?

Answer 19

If open > explore, closed > reduce fracture & hold, recheck and observe

Question 20

Describe a femoral shaft fracture

Answer 20

Usually high energy (unless pathological). Approx 1l blood loss, associated with other injuries, risk fat embolism, ARDS.

Question 21

How are femoral shaft fractures commonly treated?

Answer 21

Resuscitation, analgesia- femoral nerve block, splintage- Thomas splint. If unstable- IM nailing

Question 22

Describe the treatment of extra articular distal femur fractures?

Answer 22

Unstable- thomas splint. If not too distal can nail, if distal - plating.

Question 23

Describe the treatment of intra-articular distal femur fractures?

Answer 23

Anatomical reduction, rigid fixation, plate & screws

Question 24

Describe proximal tibial fractures

Answer 24

High energy young, low in old usually. Usually valgus stress- lateral tibial plateau fracture with disruption at articular surface.

Question 25

What temporary treatment may a high energy proximal tibial fracture with substantial soft tissue damage need?

Answer 25

Temporary spanning with ex-fix

Question 26

How is the personality of a proximal tibial fracture determined?

Answer 26

CT

Question 27

What is the management of proximal tibial fractures?

Answer 27

Reduction, rigid fixation. Elevation-depressed articular fragments & bone grant. High proportion get post trauma arthritis

Question 28

Describe fractures of the tibial shaft

Answer 28

Low or high energy. Risk of compartment syndrome. Open fracture common. Internal rotation poorly tolerated. 16 wks time to union, >1yr non-union. Conserative-plaster, operative-IM nailing, plating, ex fix

Question 29

What is an intra articular distal tibial #?

Answer 29

Pilon #

Question 30

What are some associated injuries of distal tibial #?

Answer 30

Spine, pelvis, calcaneus

Question 31

What are the concerns in distal tibial #?

Answer 31

Significant soft tissue injury, surgical emergency > urgent bridging ex-fix.

Question 32

What is the management of a distal tibial #?

Answer 32

Internal fixation once soft tissues settle

Question 33

Are isolated distal fibular and minimally displaced medial malleolus # stable or unstable?

Answer 33

Stable- may be treated conservatively

Question 34

What shift occurs in unstable bimalleolar fractures?

Answer 34

Talar shift

Question 35

What is 1st degree nerve injury?

Answer 35

Neurapraxia- temporary conduction block/demyelination. Should resolve within 28d

Question 36

What is 2nd degree nerve injury?

Answer 36

Axonotmesis- nerve cell axon dies distally from point of injury=wallerian degeneration. Structure of nerve (endoneurial tubes) intract, regenerates at 1mm per day

Question 37

What is 3rd degree nerve injury?

Answer 37

Neurotmesis- nerve transected-rare with # or dislocation. Needs surgery

Question 38

What are the indications for exploration of nerve injury?

Answer 38

Open #, penetrating injury, neuralgic pain> ongoing compression

Question 39

What should be done if no function returns after #, indicating nerve injury?

Answer 39

NCS, nerve grafting, tendon transfers

Question 40

What are some early systemic complications of #?

Answer 40

``` Hypovolaemia Fat embolism Acute Respiratory Distress Syndrome Systemic Inflammatory Response Syndrome Multi-Organ Dysfunction Syndrome ```

Question 41

What are some late local complications of #?

Answer 41

``` Stiffness, loss of function, “fracture disease” Post-traumatic arthritis Non-union Atrophic non union Hypertrophic non-union Malunion Volkmann’s ischaemic contracture Chronic Regional Pain Syndrome Osteomyelitis Avascular necrosis DVT ```

Question 42

What is malunion in fracture healing?

Answer 42

Fracture has healed in a non -anatomic position sufficient to cause symptoms-pain, stiffness, loss of function, deformity

Question 43

What fractures require XR to confirm union?

Answer 43

Only diaphyseal fractures of major long bones

Question 44

What are some signs of fracture healing?

Answer 44

Pain improvement, no tenderness, no movement at fracture site, no swelling or oedema

Question 45

What are some causes of atrophic non-union?

Answer 45

Poor blood supply to fracture site, fracture gap too big and no movement, systemic disease, smoking, medicines e.g. steroinds, NSAIDs, bisphosphonates. Infetion