Long bone fractures Flashcards by Robyn Baxter

Define the terms diaphysis, metaphysis, epiphysis and physis

Diaphysis - shaft of long bone
Metaphysis - between the diaphysis and epiphysis
Epiphysis - end of long bone
Physis - growth plate

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List the main long bones of the body

Tibia &amp; fibula
Femur
Radius &amp; ulna
Humerus 
Metatarsals, metacarpals and phalanges
Clavicle

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What is primary bone healing?

Healing where the gap between two ends of bone is minimal

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What type of fracture will heal by primary bone healing?

Hairline (after fixation with plate and screws)

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What is secondary bone healing?

There is a gap between the two ends of the bone which fills with granulation tissue > soft callus > hard callus/bone

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Which is more common primary or secondary bone healing?

Secondary

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What is the sequence of fracture healing?

Haematoma >
Soft callus >
Chondral ossification >
Hard callus >
Bone remodelling

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What are the important steps in an assessment of a fracture?

Closed vs open
Neurovascular status
Soft tissue injury
Compartment syndrome

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What can and should be immediately given for a fracture?

Analgesia

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What is a comminuted fracture?

A fracture with more than two segments

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When do comminuted fractures tend to happen?

High energy injuries

Poor quality bone

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How can fractures be managed non-operatively?

Cast (plaster of paris, lightweight)
Functional bracing
Traction

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Which age groups typically get traction?

Young

Elderly

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What are the different types of internal fixation?

K-wires
Cerclage wires
Onlay devices (plates & screws)
Inlay devices (intramedullary nail)

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What are the different types of external fixation

Monolateral

Circular

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What does ORIF stand for?

Open reduction internal fixation

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How might certain intra/periarticular fractures be managed?

Joint replacement

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High energy fractures +/- soft tissue swelling should be treated with ORIF. T/F

False - healing poor and non-union rates high, either way until soft tissues settle or use other techniques

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How should a stable, minimally displaced, extra-articular fracture be managed?

Conservatively - splint

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When is reduction used?

When fracture position is unacceptable

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An unstable fracture should be operatively managed under which circumstance?

When the patient is fit and able to undergo operation

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When might intra-articular fractures be managed non-operatively?

When they are stable and non-displaced

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How should displaced intra-articular fractures be managed? Why?

Operatively with internal fixation

Prevent post-traumatic osteoarthritis

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When might joint replacement be used in a peri-articular fracture?

When non-union risk or avascular necrosis risk is high

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How should open fractures be managed?

Antibiotics Tetanus Ig if not vaccinated Debridement Operative stabilisation

How should compartment syndrome be managed?

Fasciotomy and operative stabilisation

How should vascular injury be managed?

Reduction, stabilisation, reassess +/- revascularisation

How should nerve injury be managed?

Open - explore | Closed - reduce, stabilise, reassess and monitor

When should metronidazole be given (in addition to other antibiotics) with an open fracture?

If it has visible dirt in the fracture wound

Which antibiotics should be prescribed for an open fracture?

Gentamicin and flucloxacillin/co-trimoxazole

Is a femoral shaft fracture usually low or high energy? What is the exception to this?

High. Pathological fracture

What are the risks with femoral shaft fracture?

Hypovolaemia (fluid replacement, blood transfusion) Fat embolism Acute respiratory distress syndrome

What type of analgesia is given in a femoral shaft fracture?

Femoral nerve block

How is a femoral shaft fracture treated?

Stable - Thomas splint | Unstable - Intramedullary nailing

Are extra-articular distal femur fractures stable or unstable? Why?

Unstable. The muscles cause flexion

How is an extra-articular distal femur fracture managed?

Thomas splint Intermedullary nail if more proximal Plate and screw if very distal

How are intra-articular distal femur fractures managed?

Reduction and rigid fixation with plate and screws

Is a proximal tibial fracture high or low energy?

High energy in the young | Low energy in the old

What kind of force is usually responsible for proximal tibial fractures? What pattern of fracture does this cause?

Valgus | Lateral tibial plateau fracture with articular disruption

How is a proximal tibial fracture managed?

Temporary external fixation if high energy with substantial swelling Anatomical reduction with rigid fixation +/- bone graft

What is a common complication of proximal tibial fractures?

Post traumatic osteoarthritis

How is a proximal tibial fracture assessed?

CT scan

Are tibial shaft fractures high or low energy?

Either

What is a common complication that tibial shaft fractures must be monitored for?

Compartment syndrome

How well is 1) angulation and 2) internal rotation tolerated in a tibial shaft fracture?

1 - well tolerated within 5 degrees | 2 - poorly tolerated

How long does a tibial shaft fracture take to heal and over which time frame indicates non-union?

4 months. 1 year

How is a tibial shaft fracture managed?

Conservative - plaster | Surgical - intermedullary nailing, plate, ex-fix

How is compartment syndrome diagnosed?

Clinically

What is an intra-articular distal tibial fracture called?

Pilon fracture

Is an intra-articular tibial fracture high or low energy?

High

What are the associated injuries of a distal tibial fracture?

Spine, pelvis, calcaneous

How is a distal tibial fracture managed?

Urgent external fixation +/- limited internal fixation > Soft tissues settle > Internal fixation

How are distal tibial fractures assessed?

CT scan

When may ankle fractures be treated conservatively?

Isolated distal fibular fracture | Minimally displaced medial malleolus

What are the two causes of talar shift?

``` Bimalleolar fractures (unstable) Distal fibular fracture with ruptured deltoid ligament ```

How at risk of post-traumatic OA are ankle fractures?

Most are high risk

How is talar shift managed? Why?

ORIF. Change in joint force causes massive increase in OA risk

What is the main cause of proximal humerus fractures and in which type of patient?

Osteoporosis. Elderly

What are the risks of proximal humerus fractures?

Brachial plexus injury | Axillary artery injury

What are the risk in comminuted proximal humerus fractures?

Avascular necrosis | Non-union

How are proximal humerus fractures managed?

Elderly - conservative Head splitting/comminuted fracture - arthroplasty Young and displaced - internal fixation

What are the benefits of arthroplasty in proximal humerus fractures? The drawbacks?

Pain relief. Poor range of movement

Why is surgery not chosen for proximal humerus fractures in the elderly?

Stiffness and rotator cuff dysfunction causes poor healing

What is the risk with humeral shaft injuries?

Radial nerve injury (neurapraxia)

Can angulation be tolerated with humeral shaft injuries?

Yes

How is humeral shaft fracture managed?

Bracing

When might humeral shaft fractures be managed surgically?

``` Non-union Pathological Polytrauma Open fracture High energy Not tolerating brace ```

How is a distal humerus fracture managed?

Intra-articular - ORIF | Elderly - arthroplasty

Most olcranon fractures are avulsion. T/F

True - due to quadriceps contraction

How are olcranon fractures managed?

Internal fixation unless elderly with low demand

Which fracture often occurs in conjunction with an elbow dislocation?

Radial head fracture

How are radial head fractures managed?

Minimally displaced - conservative Fragment blocking movement/displaced with large fragments - fixation Comminuted - excise +/- replacement

What is a Galeazzi fracture dislocation?

Isolated radial fracture and distal radio-ulnar joint disocation

What is a Monteggia fracture dislocation?

Isolated ulnar fracture and dislocation of radial head

How is a forearm fracture of both the radius and ulna managed?

ORIF

How is a Galeazzi or Monteggia fracture managed?

ORIF (dislocation should reduce)

What is a nightstick fracture? How is it managed?

Isolated fracture of the ulna. Conservatively

How does a nightstick fracture occur?

Direct blow to the ulna

What is a Colle's fracture?

Extra-articular, dorsal angulation and dorsal displacement of the distal radius

How is a Colle's fracture managed?

Stabled/minimally displaced - Plaster of paris Simple displacement - manipulation under anaesthetic Displaced comminution - manipulation under anaesthetic & k-wires or ORIF

What are the complications of Colle's fracture?

Median nerve compression EPL rupture Chronic regional pain syndrome Loss of grip strength

What is the typical mechanism by which a Colle's fracture occurs?

Fall onto an outstretched hand

What type of fracture can result in a dinner fork deformity?

Colle's fracture

What is the typical mechanism by which a Smiths fracture occurs?

Fall onto the back of the hand

What is a Smith's fracture?

Extra-articular, volar displacement and angulation of the distal radius

How is a Smith's fracture managed?

ORIF

What is a Barton's fracture?

Intra-articular, volar or dorsal on lateral +/- carpal subluxation of the distal radius

How is a Barton's fracture managed?

ORIF

How is a comminuted intra-articular fracture of the distal radius managed?

External fixation +/- k-wires

How many x-ray views does a scaphoid fracture required? What else must be done?

4. Must be x-rayed a number of days after to confirm

How is a perilunate dislocation of the wrist managed?

Urgent reduction

How is polytrauma defined?

More than one major fracture (long bones/pelvis)

What are the two worst fractures in terms of blood loss/fat embolism?

Pelvic and femoral shaft fracture

What is the risk in terms of inflammatory cascades during polytrauma?

Systemic inflammatory response syndrome Adult respiratory distress syndrome Multiple organ dysfunction syndrome

What is the lethal triad in relation to blood loss and polytrauma?

Hypothermia, acidosis and coagulopathy

How is a pelvic fracture managed?

Pelvic binder

What is consumption coagulopathy?

Bleeding uses up all clotting factors

What are the most pressing injuries to treat in polytrauma?

Pelvic, tibial or femoral fracture Vascular compromise Open fractures Compartment syndrome