Management of Specific Fractures

Question 1

What are the clinical signs of a fracture?

Answer 1

Pain, Swelling, Crepitus, Deformity, Adjacent structural injury to nerves/vessels/ligaments/tendons

DCAPS

Question 2

How are fractures investigated?

Answer 2

MRI scan, CT scan, Radiograph, Bone scan

Question 3

What needs to be included when describing a fracture radiograph?

Answer 3

Location (diaphysis, metaphysis, epiphysis)
Pieces: simple/multifragmentary
Pattern: transverse/oblique/spiral
Displaced/undisplaced?
Translated/angulated?
X/Y/Z plane

Question 4

What are the forms of displacement?

Answer 4

Translation involves bone movement in the mediolateral plane on X axis, proximal distal in Y plane and anterioposterior in Z plane. Angulation can occur in internal and external rotation in Y plane, varus/valgus in X plane and dorsal, volar in Z plane.

Question 5

What are the main principles of fracture healing?

Answer 5

Bleeding (blood), Inflammation (neutrophils and macrophages), New tissue formation (-blasts), Remodelling (osteoclasts, osteoblasts)

Question 6

What occurs in the inflammation stage?

Answer 6

Haematoma formation, prostaglandin/cytokine release, granulation tissue and blood vessel formation (growth factors increase local blood flow and periosteal supply takes over).

Question 7

What occurs in the repair stage?

Answer 7

Soft callus formation - occurs with type 2 collagen with cartilage. This is converted to hard callus with type 1 collagen, laying down osteoid.

Question 8

What happens in the remodelling stage?

Answer 8

Callus responds to activity, external forces, functional demands and growth. Excess bone is removed. Wolff’s Law states that bone grows and remodels in response to the forces placed on it.

Question 9

Contrast primary bone healing with secondary

Answer 9

Primary Bone Healing: Intramembranous healing, Absolute stability, Direct to woven bone

Secondary bone healing: Endochondral healing, Involves responses in the periosteum and external soft tissues, Relative stability, Endochondral ossification: more callus

Question 10

Describe average fracture healing times at various sites

Answer 10

Phalanges: 3 weeks
Metacarpals: 4-6 weeks
Distal radius: 4-6 weeks
Forearm: 8-10 weeks
Tibia: 10 weeks
Femur: 12 weeks

Question 11

What are the general principles of fracture treatment?

Answer 11

Reduce (can be closed or open), Hold (with metal or without), Rehabilitate (move, physiotherapy, use)

Question 12

What does reduction involve?

Answer 12

Closed reduction involves manipulation or traction (can be skeletal with pins in bone or skin). Open reduction can involve full exposure or mini-incision.

Question 13

What does hold involve?

Answer 13

Can be fixation or closed with plaster or traction (skin or skeletal).

Question 14

What are the types of fixation?

Answer 14

External can be monoplanar or multiplanar. Internal can be intramedullary or extramedullary. Intramedullary can use pins and nails while extramedullary uses plate/screws and pins.

Question 15

What does rehabilitate involve?

Answer 15

Use bone with pain relief and retraining. Move, strengthen and weight bear.

Question 16

What are general fracture complications?

Answer 16

Fat embolus
DVT
Infection
Prolonged immobility (UTI, chest infections, sores)

Question 17

What are specific fracture complications?

Answer 17

Neurovascular injury
Muscle/tendon injury
Non union/mal union
Local infection
Degenerative change (intraarticular)
Reflex sympathetic dystrophy

Question 18

What factors affect fracture healing?

Answer 18

Mechanical environment (movement and forces). Biological environment: blood supply, immune function, infection and nutrition.

Question 19

What are causes of a fractured neck of femur?

Answer 19

Osteoporosis (older)
Trauma (younger)
Combination

Question 20

What does a typical history for someone with a fractured neck of femur look like?

Answer 20

Age
Comorbidity: respiratory/cardiovascular/diabetes/cancer
Preinjury mobility: independent/shopping/walking/sports
Social hx: relatives, stairs, etoh

Question 21

What are different types of neck of femur fractures?

Answer 21

Subcapital (intracapsular), Transcervical (extracapsular), Intertrochanteric (extracapsular) and subtrochanteric

Question 22

What is a problem with neck of femur fracture?

Answer 22

If intracapsular, blood supply is more likely to be compromised and avascular necrosis possible.

Question 23

How is decision to fix or replace made with neck of femur fracture in those over 65?

Answer 23

If extracapsular: minimal risk to blood supply and AVN: fix with plate and screws (Dynamic hip screw)

Intracapsular:
if undisplaced: less risk to blood supply: fix with screws
If displaced: 25-30% risk AVN: replace in older patients; fix if young

Question 24

What are treatment options for someone with displaced intracapsular fracture above 55 years?

Answer 24

If they walk >mile day, are independent and have minimal comorbidities: Total hip replacement
If they have lower mobility, multiple comorbities: hemiarthroplasty (but metal will rub on socket)

Question 25

Describe typical presentation, examination andinvestigation of shoulder dislocation

Answer 25

Variable history but often direct trauma, pain, restricted movement and loss of normal shoulder contour Examination: assess neurovascular status (axillary nerve) Investigation: x-ray prior to any manipulation and identify fracture (humeral neck, greater tuberosity avulsion or glenoid), Scapular Y view and modified axillary in addition to AP.

Question 26

What are management options for shoulder dislocation?

Answer 26

Numerous techniques for reduction, vigorous manipulation/twisting should be avoided, safest method is traction/counter traction with gentle internal rotation to disimpact humeral head, ensure adequate patient relaxation, could use stimson method when home alone

Question 27

What are complications of a shoulder dislocation?

Answer 27

Hill Sachs defect - a compression fracture or "dent" of the posterosuperolateral humeral head that occurs in association with anterior instability or dislocation of the glenohumeral joint. Bankart lesion - a lesion of the anterior part of the glenoid labrum of the shoulder.

Question 28

How is a distal radius fracture managed?

Answer 28

1. Cast/Splint - temporary treatment. Reduction of fracture and placement into cast until definitive fixation. Definitive if minimally displaced, extra-articular fracture. 2. MUA (manipulation under anaesthetic) and K-wire - used for fractures that are extra-articular but have instability esp in children. MUA in theatre with K-wire fixation can be used. Wires can then be removed in clinic post-op. 3. ORIF (open reduction with internal fixation) - Any displaced, unstable fractures not suitable for K-wires or with intra-articular involvement may benefit from open reduction internal fixation with plate and screws.

Question 29

What is a complication of tibilal plateau fracture?

Answer 29

Lipohaemarthrosis - impact on bone means marrow leaks out leading to fat and aqueous contents floating to surface of joint space.

Question 30

Describe overview of tibial plateau fracture

Answer 30

Proximal tibia is a key weightbearing surface as part of knee joint, articulating with distal femur. Joint surface is relatively flat comprising medial and lateral plateaus with central tibial spine acting as insertion point for ligaments.

Question 31

What can cause a tibial plateau fracture?

Answer 31

Any extreme valgua/varus force or axial loading with impaction across knee. Impaction of femoral condyles cause comparatively soft bone of tibial plateau to depress/split. Concomittant ligamentous or meniscal injury not uncommon.

Question 32

How is tibial plateau fracture managed?

Answer 32

Non operative: Only truly undisplaced fracture with good joint line congruency assessed on CT or high fidelity imaging. Operative: most operative. Restoration of articular surface using combination of plates and screws. Bone graft or cement may be necessary to prevent further depression after fixation.

Question 33

How is a trimalleolar fracture managed non-operatively?

Answer 33

Non-weight bearing below knee cast for 6-8 weeks, can then transfer into walking boot and finally physiotherapy to improve range of motion/stiffness from joint isolation. Weber A - below syndesmosis and therefore stable Weber B - if no evidence of instability (no medial/posterior malleolar fracture or talar shift).

Question 34

How is a trimalleolar fracture managed operatively?

Answer 34

Soft tissue dependent - patient needs strict elevation as injury swells considerably. ORIF + syndemosis repair using either screw or tightrope technique Syndesmosis screws can be left in situ but may break after some time so therefore can be removed at a later date if necessary. Weber B - unstable fractures: talar shift/medial or posterior malleoli fracture Weber C - fibular fracture above level of syndesmosis and hence unstable