MANAGEMENT OF SPECIFIC FRACTURES

Question 1

What are the clinical signs of a fracture?

Answer 1

Pain
Swelling
Crepitus
Deformity
Adjacent structural injury (nerves/vessels/ligaments/tendons)

Question 2

List the imaging techniques that can be done to investigate fractures

Answer 2

Radiograph/Xray
CT scan
MRI
Bone scan

Question 3

What are the 5 details when describing a fracture radiograph?

Answer 3

Location
Pieces: simple/multifragmentary
Pattern: transverse/oblique/spiral
Displacement: (translated/angulated)/undisplaced
Plane: XYZ

Question 4

What is translational displacement and it what planes can it occur?

Answer 4

Lateral straight line displacement

Proximal/distal (Y plane)
Anterior/posterior (Z plane)
Medial/lateral (X plane)

Question 5

What is angulational displacement and it what planes does it occur?

Answer 5

Internal/external rotation (Y plane)
Dorsal/volar (Z plane)
Varus/valgus (X plane)

Question 6

What are the 4 steps in fracture healing and what cells do they involve ?

Answer 6

Bleeding
Inflammation (neutrophils, macrophages)
New tissue formation/repair (-blasts)
Remodelling (macrophages, osteoclasts, -blasts)

Question 7

Describe what occurs in the inflammation step of fracture healing

Answer 7

Haematoma formation
Cytokine release
Granulation tissue and blood vessel formation

Question 8

Describe what occurs in the repair step of fracture healing

Answer 8

Soft callus formation (type II collagen - cartilage)

Converted to hard callus (type I collagen - bone)

Question 9

Describe what occurs in the remodelling step of fracture healing

Answer 9

Callus responds to activity, external forces, functional demands and growth (Wolff’s law)
Excess bone is removed

Question 10

What is primary bone healing?

Answer 10

When the fragments are close together allowing for intramembranous healing and absolute stability with mesenchymal stem cells forming woven bone directly

Question 11

What is secondary bone healing?

Answer 11

When the fragments aren’t completely together causing endochondral healing and relative stability. Done by endochondral ossification which results in more callus

Question 12

How long does it take for a fracture to heal?

Answer 12

3-12 weeks depending on site

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

Question 13

What are the general principles to help heal fractures?

Answer 13

Reduce (open and closed)
Hold (closed and fixation)
Rehabilitate (use, move, strengthen, physiotherapy)

Question 14

What are the different options for reduction of a fracture?

Answer 14

Closed:

• manipulation
• traction (skin or skeletal - pins in bones)

Open:

• mini-incision
• full exposure

Question 15

What are the different options for holding of a fracture?

Answer 15

Closed:

• Plaster
• Traction (skin or skeletal)

Fixation (many options)

Question 16

What are the options of fixation of a fracture?

Answer 16

Internal:

• Intramedullary (pins or nails)
• Extramedullary (plates/screws or pins)

External:

• Monoplanar
• Multiplanar

Question 17

What are some general complications of fractures?

Answer 17

Fat embolus
DVT
Infection
Prolonged immobility

Question 18

What are some specific complications of fractures?

Answer 18

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

Question 19

What are some factors affecting tissue healing?

Answer 19

Mechanical environment:

• Movement
• Forces

Biological environment:

• Blood supply
• Immune function
• Infection
• Nutrition

Question 20

What are the causes for a fractured neck of femur?

Answer 20

Osteoporosis
Trauma
Combination

Question 21

Are the femoral head and femoral neck considered intra or extra capsular?

Answer 21

Intracapsular

Question 22

Are the less trochanter and greater trochanter of the femur considered intra or extra capsular?

Answer 22

Extracapsular

Question 23

Why is an intracapsular fracture of the femur considered more dangerous?

Answer 23

Blood supply is more likely to be compromised leading to a higher risk of avascular necrosis

Question 24

How would you treat an extracapsular fracture to the femur?

Answer 24

Fix with plate and screws due to low risk of avascular necrosis

Question 25

How would you treat an undisplaced intracapsular fracture to the femur?

Answer 25

Fix with screws due to less risk to blood supply

Question 26

How would you treat an displaced intracapsular fracture to the femur?

Answer 26

Replace in a > 55 yrs patient and fix if young patient 25-30% of avascular necrosis

Question 27

What would a fit and mobile patient > 55 yrs who fractured their neck of femur have as treatment?

Answer 27

Total hip replacement

Question 28

What would a less fit and mobile patient > 55 yrs who fractured their neck of femur have as treatment?

Answer 28

Hemiarthroplasty

Question 29

How does a shoulder dislocation present?

Answer 29

Variable history but often direct trauma Pain Restricted movement Loss of normal shoulder contour

Question 30

What can be done to investigate a patient with a shoulder dislocation?

Answer 30

X-ray prior any manipulation to identify fracture | Scapular y view

Question 31

How is a shoulder dislocation managed?

Answer 31

``` Reduce dislocated shoulder Traction-counter traction +/- gentle internal rotation to disimpact humeral head (safest method) Patient relaxation (entonox, benzodiazepines) ``` Avoid vigorous/twisting manipulation to avoid fractures

Question 32

What are some complications of shoulder dislocation?

Answer 32

Hills-Sachs defect | Bankart lesion

Question 33

What is a Hills-Sachs defect?

Answer 33

When humerus dislocates it collides with the glenoid and causes a dent in the posterior humeral head

Question 34

What does management of a distal radius fracture involve?

Answer 34

Cast/Splint - temporary until definitive fixation or definitive if minimally displaced and extra-articular Mua and K-wire - extra-articular but have instability particularly in children ORIF (open reduction and internal fixation) - displaced, unstable fractures

Question 35

What is most likely fractured if a patient falls over and complains of wrist pain?

Answer 35

Scaphoid bone

Question 36

What is a lipohaemarthrosis?

Answer 36

Presence of intra-capsular floating fat in a joint cavity seen via imaging. It is indicative of a a intra-articular fracture

Question 37

How is a tibial plateau fracture managed?

Answer 37

Non-operative - only truly undisplaced fractures with good joint line congruency assessed on imaging Operative - restoration of articular surface using plates and screws. Bone graft/cement may be necessary to prevent further depression after fixation

Question 38

What is the management for an ankle fracture?

Answer 38

Non-operative: - Below knee cast (6-8 weeks) then walking boot then physiotherapy - Weber A if stable and Weber B if no evidence of instability Operative: - Patients need strict elevation as injury swells considerably - Open reduction internal fixation +/- syndesmosis repair using either screw or tightrope - Syndesmosis screw can be left or removed at later date - Weber B/C