management of specific fractures

Question 1

What are clinical signs of a fracture?

Answer 1

Pain, swelling, crepitus, deformity, adjacent structural injury (nerves, vessels, ligament, tendon)

Question 2

What are different investigations used for fractures?

Answer 2

Radiograph, bone scan, CT, MRI

Question 3

How to describe a fracture radiograph?

Answer 3

1. Location (which bone & which part of it)
2. pieces (simple/multifragmentary).
3. pattern (transverse/oblique/spiral)
4. displaced/undisplaced -> translated/angulated

Question 4

How do we describe displacement (translation & angulation)?

Answer 4

• Translation is lateral displacement (anterior/posterior, medial/lateral, proximal/distal).
• Angulation - if distal part more lateral valgus, if distal part more medial varus. + internal/external rotation, dorsal/volar, varus/valgus

Question 5

How do fractures heal?

Answer 5

1. inflammation: Bleeding brings cells & inflammatory mediators to site (inflammation - neutrophils, macrophages) that form granulation tissue & blood vessel formation.
2. repair: Fibroblasts/osteoblasts/chondroblasts make new tissue. Initially get soft callus (type II collagen - manly cartilage) which is then converted to hard callus (type I - bone).
3. remodelling: Callus remodels by responding to activity & forces applied to it.

Question 6

What is primary bone healing?

Answer 6

When bones are close together (stable fracture) we get intramembranous healing when mesenchymal stem cell goes straight to osteoblast and we get woven bone.

Question 7

What is secondary bone healing?

Answer 7

When bones more displaced and not as stable we get endochondral healing with mesenchymal stem cell going to chondral precursor which will then produce bone cells. More callus produced.

Question 8

What are the general rules on fracture healing times, how long does it generally take?

Answer 8

Generally upper limbs heal quicker than lower limbs. Generally take 3-12 weeks to heal.

Question 9

How quickly can you see signs of healing on x-ray?

Answer 9

From 7-10 days

Question 10

How long does it take for phalanges, metacarpals, distal radius, forearm, tibia, femur to heal?

Answer 10

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

Question 11

What do fracture healing times vary with?

Answer 11

Vary with age, biology and comorbidities

Question 12

How can you reduce a fracture?

Answer 12

1. closed - manipulation or traction (pulling on skin, or skeletal - putting pins in bone and pulling)
2. open - mini incision or full exposure

Question 13

How can you hold a fracture?

Answer 13

1. closed - plaster or continued traction over weeks (skin/skeletal)
2. fixation (putting metals in or around bone) - 1. internal - intramedullary (pins & nails) or extramedullary (plate, screws, pins), 2. external - monoplanar or multiplanar

Question 14

How do you rehabilitate a fracture?

Answer 14

Use (pain relief, retrain), move, strengthen, if lower limbs weight bear

Question 15

What are some general and specific fracture complications?

Answer 15

• General: fat embolus, DVT, infection, prolonged immobility (UTI, chest infection, sores).
• Specific: neurovascular injury, muscle/tendon injury, non-union/malunion, local infection, degenerative change (intra-articular), reflex sympathetic dystrophy

Question 16

What are factors affecting tissue healing?

Answer 16

• Mechanical environment - movement, forces.

- Biology - blood supply, immune function, infection, nutrition

Question 17

What are causes of fractured neck of femur?

Answer 17

Osteoporosis (older), trauma (younger) or combination

Question 18

What do you have to consider in fractured neck of femur history?

Answer 18

Age, comorbidities, pre-injury mobility, social history (home history included)

Question 19

What is the anatomy of the neck of femur? Where does the blood supply come from? What is the intratrochanteric line and what does it define?

Answer 19

• Femoral head and neck below. Capsule below. Lesser trochanter medially, greater trochanter above and laterally.
• Blood supply comes from capsular vessels.
• Intratrochanteric line joins lesser and greater trochanters. Anything above this line is intracapsular and anything below extracapsular

Question 20

When is there risk of avascular necrosis in neck of femur fractures?

Answer 20

When intracapsular more likely blood supply is compromised causing avascular necrosis, if displaced even higher risk

Question 21

What is treatment for each type of neck of femur fracture and why?

Answer 21

1. extracapsular: fix with plate and screw (dynamic hip screw) - because minimal risk of AN.
2. intracapsular undisplaced - fix with screws.
3. intracapsular displaced - high risk of AVN - replace in older patients >65, fix if young <55. if more mobile - total hip replacement (acetabulum + head of femur). If less mobile/multiple comboribidities do hemiarthroplasty

Question 22

In which fossa should the humerus be?

Answer 22

Glenoid fossa

Question 23

How do dislocated shoulders present?

Answer 23

Direct trauma, pain, restricted movement, loss of normal shoulder contour

Question 24

What is involved in clinical exam of shoulder dislocation? What imaging is needed?

Answer 24

Assess neurovascular status (axillary nerve, ligaments, tendons). Plain X ray before manipulation to see fractures. Scapular Y view/modified axillary + AP

Question 25

How do you manage a shoulder dislocation?

Answer 25

- For reduction - avoid vigorous manipulation/twisting to avoid fractures. - Safest method is use traction counter traction +/- gentle internal rotation to disimpact humeral head. - For patient relaxation - benzodiazepines, entonox. - If alone use stimson method. - Do in safe environment especially if elderly

Question 26

What is a complication that can occur during reduction of the shoulder dislocation & what can this lead to?

Answer 26

- Humerus as it comes out bangs on glenoid causing bankart lesion on glenoid & hill-sachs on humerus on part that took bone out. - Can lead to recurrent dislocation

Question 27

How do you manage a distal radius fracture? What needs to be considered?

Answer 27

- If bones haven't moved - plaster. Cast/splint temporary, reduce and place in cast until definitive fixation. - If minimally displaced extra-articular fracture definitive fixation. - For extra-articular fractures with instability MUA & K wire fixation (mainly in kids), wires can be removed post-op. - for displaced unstable fractures not suitable for K wires or if have intra-articular involvement do open reduction internal fixation (ORIF) with plate and screws

Question 28

What is a lipohaemarthrosis? What does it indicate?

Answer 28

Fat fluid line. Pathognomonic of fracture within joint

Question 29

What is the structure of the tibial plateau?

Answer 29

Proximal tibia key weight-bearing. Flat and has medial and lateral plateaus with central tibial spine for insertion of ligaments.

Question 30

What can cause a tibial plateau fracture? What concomitant injury can accompany it?

Answer 30

- Any extreme valgus/varus force on axial loading across knee can cause tibial plateau fracture, with impaction of femoral condyles causing soft bone of plateau to depress or splint. - Concomitant ligamentous or meniscal injury not uncommon

Question 31

How do you manage a tibial plateau fracture?

Answer 31

- Non-operative if un-displaced fracture with good joint line congruency assessed on CT or high fidelity imaging. - Operative mostly, restore articular surface with plates and screws, bone graft or cement may be needed to prevent more depression after fixation

Question 32

How do you manage an ankle fracture?

Answer 32

1. non-operative - non-weight bearing below knee cast 7-8wks, then walking boot and physiotherapy, if weber A (stable) or weber B with no evidence of instability (no medial/posterior malleolus fracture and no talar shift) 2. operative - soft tissue dependent so need strict elevation as injuries swell, ORIF (open reduction internal fixation) +/- syndesmosis repair using either screws or tightrope technique. Screws can be left there but may break so need removal. This is for weber B (if unstable - talar shift/medial or posterior malleolus fracture) or weber C (fracture above level of syndesmosis so unstable)

Question 33

What is weber A & what is needed?

Answer 33

Fracture below syndesmosis so syndesmosis intact and usually stable. Knee cast --> walking boot --> physiotherapy

Question 34

What is weber B & what is needed?

Answer 34

Fracture at level of syndesmosis so syndesmosis may be intact or partially torn, so may be stable or unstable. If stable - knee cast, walking boot, then physiotherapy. If unstable - ORIF

Question 35

What is weber C & what is needed?

Answer 35

Fracture above level of syndesmosis so syndesmosis damaged, unstable. ORIF