Management of Specific Fractures

Question 1

What are the main principles of Trauma?

Answer 1

• advanced trauma life support
• reduce the fracture
• hold the fracture
• rehabilitate after healing

Question 2

What are the main principles of Orthopaedics?

Answer 2

(LT, chronic issues)

• history
• examinations
• look/feel/move
• investigations

Question 3

What are the clinical signs of a fracture?

Answer 3

• pain
• swelling
• crepitus
• deformity
• adjacent structural injury (nerves/vessels/ligaments/tendons)

Question 4

What investigations can be done if a fracture is suspected?

Answer 4

• radiograph
• CT
• MRI
• Bone

Question 5

How do you describe a fracture?

Answer 5

• location
• pieces
• pattern
• displaced/undisplaced
• translated/angulated
• X/Y/Z plane
• epiphysis present?

Question 6

What are the different fracture patterns?

Answer 6

• open
• simple
• transverse
• comminuted
• spiral

Question 7

What are the different forms of displacement?

Answer 7

• translation

- angulation

Question 8

How would you describe translation with the X/Y/Z planes?

Answer 8

X - medial/lateral
Y - proximal/distal
Z - anterior/posterior

Question 9

How would you describe angulation with the X/Y/Z planes?

Answer 9

X - dorsal/volar
Y - internal/external
Z - varus/valgus

Question 10

What do the X/Y/Z planes mean with translation?

Answer 10

X - in reference to the midline (facing on)
Y - foot up from the femur
Z - from the side

Question 11

What do the X/Y/Z planes mean with translation?

Answer 11

X - coronal plane (away from midline)
Y - axial plane
Z - sagittal plane

Question 12

How do fractures heal?

Answer 12

• bleeding
• inflammation
• new tissue formation
• modelling

Question 13

What happens in inflammation when a fracture is healing?

Answer 13

• haematoma formation
• cytokine release
• granulation tissue and blood vessel formation

Question 14

What happens during new tissue formation when a fracture is healing?

Answer 14

• Soft Callus formation (T2 collagen - cartilage)

- Converted to Hard Callus (T1 collagen - bone)

Question 15

What is involved in remodelling when a fracture is healing?

Answer 15

macrophages
osteoclasts
- BLASTS

Question 16

What are the different types of ossification?

Answer 16

• endochondral ossification

- intramembranous ossification

Question 17

What happens once the bone is formed?

Answer 17

callus that will remodel according to the stressors put onto it

Question 18

What is involved in inflammation when a fracture is healing?

Answer 18

• neutrophils

- macrophages

Question 19

What is involved during new tissue formation when a fracture is healing?

Answer 19

-BLASTS
fibro - 
osteo - 
chondro - 
(forming collagen)

Question 20

What happens in remodelling when a fracture is healing?

Answer 20

• Callus responds to activity, external forces, functional demand and growth
• excess bone is removed

Question 21

What is Wolff’s law?

Answer 21

bone grows and remodels in response to the forces that it is placed under

Question 22

What stability is provided with intramembranous healing?

Answer 22

absolute

Question 23

What stability is provided with endochondral healing?

Answer 23

relative

Question 24

What is primary bone healing?

Answer 24

• intramembranous healing
• absolute stability
• direct to woven bone

Question 25

What is secondary bone healing?

Answer 25

- endochondral healing - involves responses in the periosteum and external soft tissues - relative stability - endochondral ossification: more callus

Question 26

When are the signs of healing visible on a XR?

Answer 26

7-10 days

Question 27

What are the general principles of fracture management?

Answer 27

- reduce - hold - rehabilitate

Question 28

What are the different types of reduction?

Answer 28

- open | - closed

Question 29

What are the different types of closed reduction?

Answer 29

- manipulation | - traction (skin, skeletal (pins in the bone)

Question 30

What are the different types of open reduction?

Answer 30

- mini-incision | - full exposure

Question 31

What are the different types of hold?

Answer 31

- closed | - fixation

Question 32

What are the different types of closed hold?

Answer 32

- plaster | - traction (skin, skeletal)

Question 33

What are the different types of fixation?

Answer 33

- internal | - external

Question 34

What are the different types of internal fixation?

Answer 34

- intramedullary (pins, nails) | - extramedullary (plates/screws, pins)

Question 35

What are the different types of external fixation?

Answer 35

- monoplanar | - multiplanar

Question 36

What are the different types of rehabilitation?

Answer 36

- use (pain relief, retrain) - move - strengthen - weight bear

Question 37

What are the different classes of complications?

Answer 37

- general | - specifc

Question 38

What are some examples of general complications?

Answer 38

- fat embolus - DVT - infection - prolonged immobility (UTI, chest infections, sores)

Question 39

What are some examples of specific complications?

Answer 39

- neurovascular injury - muscle/tendon injury - non-union/mal-union - local infection - degenerative change (intraarticular) - reflex sympathetic dystrophy

Question 40

What factors in the mechanical environment affect tissue healing?

Answer 40

- movement | - forces

Question 41

What factors in the biological environment affect tissue healing?

Answer 41

- blood supply - immune function - infection - nutrition

Question 42

What are the possible causes of a fractured neck of femur?

Answer 42

- osteoporosis - trauma - combination

Question 43

What Hx should be taken when the patient has a fractured neck of femur?

Answer 43

- age - co-morbidities - preinjury mobility (?independent) - social Hx (?stairs)

Question 44

What is a concern when there is an intra-capsular neck of femur fracture?

Answer 44

- blood supply is more likely to be compromised

Question 45

What determines whether a neck of the femur fracture should be fixed or displaced?

Answer 45

- location (intra- or extracapsular) - displacement - age of patient

Question 46

What would be the options in a displaced, intracapsular neck of the femur fracture in a patient above 55 years old?

Answer 46

if fit and mobile: - total hip replacement less fit: - hemiarthroplasty

Question 47

What is the management of an extracapsular neck of femur fracture?

Answer 47

internal fixation (plates and screws, nails)

Question 48

What would be the management in a displaced, intracapsular neck of the femur fracture in a patient less than 55 years old?

Answer 48

- reduce | - fixation with screws

Question 49

What would be the management in an undisplaced, intracapsular neck of the femur fracture?

Answer 49

fixation with screws

Question 50

How do shoulder dislocations present?

Answer 50

- variable Hx but often direct trauma - pain - restricted movement - loss of normal shoulder controur

Question 51

What clinical examinations should be done for a suspected shoulder dislocation?

Answer 51

assess neurovascular status, axillary nerve

Question 52

What investigations should be done for a suspected shoulder dislocation?

Answer 52

- XR prior to manipulation | - scapular Y view/modified axillary in addition to AP

Question 53

What management is done for a shoulder dislocation?

Answer 53

- reduce the dislocation - avoid vigorous/twisting manipulation - traction-counter traction recommended

Question 54

What are the possible complications associated with a shoulder dislocation?

Answer 54

Hill-Sachs defect with a Bankart lesion (improper or rough reduction)

Question 55

When is a cast/split used in a distal radius fracture?

Answer 55

- temporary treatment for any distal radius fracture - reduction of fracture and placed into a cast until definitive fixation - definitive if minimally displaced, extra articular fracture

Question 56

When is a MUA and k-wire used in a distal radius fracture?

Answer 56

for fractures that are extra-articular but are instable (esp in children)

Question 57

When is an open reduction with internal fixation used in a distal radius fracture?

Answer 57

- in displaced, unstable fractures not suitable for K wires or with intra-articular involvement

Question 58

What are common complications associated with a tibial plateau fracture?

Answer 58

concomitant ligamentous or meniscal injury

Question 59

When is non-operative management of a tibial plateau fracture considered?

Answer 59

undisplaced fractures with a good joint line

Question 60

What. is the operative management of a tibial plateau fracture?

Answer 60

- restoration of articular surface using combination of plate and screws - bone graft or cement may be necessary to prevent further depression after fixation

Question 61

What is the non-operative management of an ankle fracture?

Answer 61

- non-weight bearing knee cast for 6-8 weeks - transfer to a walking boot - physiotherapy to improve ROM/stiffness

Question 62

What is the operative management of an ankle fracture?

Answer 62

- soft tissue dependent (elevation necessary) | - open reduction internal fixation +/- syndesmosis repair using either screw or tightrope technique