Management of Specific Fractures Flashcards
What methods are used to investigate a bone fracture (3)?
- XRay (in most cases)
-
CT sometimes indicated
- To make diagnosis
- To assess pattern
- MRI if unsure
What is used when describing a fracture radiograph (4)?
-
Location:
- Which bone and which part of bone?
-
Pieces:
- Simple / Multifragmentary
-
Pattern:
- Transverse / Oblique / Spiral
-
Displaced / Undisplaced:
- Translated / Angulated
- X / Y / Z plane
What kind of fracture pattern is this?
Transverse
What kind of fracture pattern is this?
Oblique
What kind of fracture pattern is this?
Spiral
What kind of fracture pattern is this?
Comminuted
What kind of displacement is this?
Translation
What kind of displacement is this?
Angulation
What kind of displacement is this?
Rotation
What kind of displacement is this?
Impication
What is an impacted fracture?
- One fracture is driven into the other as a result of compression
What is a greenstick fracture?
- Partial fracture in which one side of the bone is broken
What is an open fracture?
- A fracture in which at least one end of the bone penetrates the skin - presenting a potential risk of infection
What is a closed fracture?
- A fracture in which the skin remains intact
What is the universal fracture classification?
- OTA classification
OTA: Orthopaedic Trauma Association
What is primary bone healing?
-
Intermembranous healing is associated with absolute stability
- Osteoblasts move into fracture → In primary bone healing, the bone ends are in contact therefore the osteoblasts can traverse across and bone formation is accelerated, membrane forms
- Membrane formation behaves as a conduit for osteoblasts to pass
- Haversian remodelling occurs in circumstances that there is a little or no gap < 500mm
- Slow process using a cutter cone concept
- Osteoblasts move into fracture → In primary bone healing, the bone ends are in contact therefore the osteoblasts can traverse across and bone formation is accelerated, membrane forms
What are the 3 phases of primary bone healing?
- Inflammatory phase (Neutrophils , Macrophages) (Duration: Hours-Days)
- Reparative phase (Fibroblasts, Osteoblasts, Chondroblasts) (Duration: Days-weeks)
- Remodelling phase (Macrophages, Osteoclasts, Osteoblasts) (Duration: Months-years)
What happens during the inflammatory phase?
- Haematoma formation
- Release of cytokines, growth factors & prostaglandins
- Fracture haematoma becomes organised & infiltrated by fibrovascular tissues → Forms matrix for bone formation & primary callus
What is the Wolff’s Law?
- States that bone grows and remodels in response to the forces that are exerted onto it
- Placing stress in specific directions stimulate osteocyte activity
What are the 4 steps to managing a bone fracture?
4 Rs
-
Resuscitate
- Save the patients life, then worry about the fracture
-
Reduce
- Bring the bone back together in an acceptable alignment
-
Rest / Hold
- Hold the fracture in position to prevent distortion or movement
-
Rehabilitate
- Get function back and avoid stiffness
What are the possible ways to reduce a fracture (3C / 2O)?
- Closed:
- Manipulation
- Skin traction
- Skeletal traction
- Open:
- Mini-incision
- Full explore
What are the possible ways to rest a fracture (3C / 4IF / 2EF)?
- Closed:
- Plaster
- Skin traction
- Skeletal traction
- Fixation:
- Internal:
- Intramedullary pins
- Intramedullary nails
- Extramedullary plate / screws
- Extramedullary pins
- External:
- Monoplanar
- Multiplanar
- Internal:
What are the possible ways to rehabilitate a fracture (4)?
- Use
- Move
- Strengthen
- Weight bearing
What are the possible systemic fracture complications (12)?
- General:
- Fat embolus
- DVT
- Infection
- Prolonged immobility:
- UTI
- Chest infection
- Sores
- Specific:
- Neurovascular injury
- Muscle / tendon injury
- Non union / malunion
- Local infection
- Degenerative charge (intraarticular)
- Reflex sympatheti dystrophy
What factors are affecting fracture healing (6)?
What is Type 1 NoF Fracture?
Specific fracture: NoF Fracture
Subcapital (intracapsular)
What is Type 2 NoF Fracture?
Specific fracture: NoF Fracture
Transcervical (extracapsular)
What is Type 3 NoF Fracture?
Specific fracture: NoF Fracture
Basicervical (extracapsular)
What is Type 4 NoF Fracture (left & right)?
Specific fracture: NoF Fracture
Subtrochanteric (left) / 3 Part intertrochanteric (right)
What factors determine the management of an NoF fracture?
Specific fracture: NoF Fracture
- Intracapsular / Extracapsular
- Displaced / Undisplaced
- Age
- Fit and Mobile / Not
How does shoulder dislocation present?
Specific fracture: Shoulder dislocation
- Variable hx (mostly direct trauma)
- Pain
- Restricted movement
- Loss of normal shoulder shape / contour
What clinical examination is conducted after a shoulder dislocation?
Specific fracture: Shoulder dislocation
- Assess neurovascular status - axillary nerve
What investigation is conducted after a shoulder dislocation?
Specific fracture: Shoulder dislocation
- X-Ray prior to manipulation
How is shoulder dislocation managed?
Specific fracture: Shoulder dislocation
- Numerous techniques to reduce a dislocated shoulder
- Vigorous manipulation or twisting manipulation should be avoided to avoid fractures
- Safest method is to use traction-counter traction +/- gentle internal rotation to disimpact humeral head
- Ensure adequate patient relaxation - Entonox; benzodiazepines
- If alone could use Stimson method
- Undertake in safe environment, especially in elderly e.g. resus, ask for senior/anaesthetic support early on if necessary
What are the possible complications of shoulder dislocation (2)?
Specific fracture: Shoulder dislocation
How does distal radius fracture present?
Specific fracture: Distal radius fracture
- Variable hx (mostly direct trauma)
- Pain
- Restricted movement
- Gross swelling
What investigation is conducted after a distal radius fracture?
Specific fracture: Distal radius fracture
- X-Ray
When is cast / splint recommended for managing a distal radius fracture?
Specific fracture: Distal radius fracture
- Temporary treatment for any distal radius fracture - reduction of fracture and placement into cast until definitive fixation
- Definitive if minimally displaced, extra articular fracture
When is MUA & K-Wire recommended for managing a distal radius fracture?
Specific fracture: Distal radius fracture
- For fractures that are extra-articular but have instability, particularly in children, MUA in theatre with K-wire fixation can be used. Wires can then be removed in clinic post-op
When is ORIF recommended for managing a distal radius fracture?
ORIF: Open Reduction Internal Fixation
Specific fracture: Distal radius fracture
- 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
How does scaphoid fracture present?
Specific fracture: Scaphoid fracture
- Variabl hx but often direct trauma
- Chronic pain (>1/7)
What investigation is conducted after after a scaphoid fracture?
Specific fracture: Scaphoid fracture
- X-Ray
When is Cast / Splint recommended for managing a scaphoid fracture?
Specific fracture: Scaphoid fracture
- Conservative treatment for any minimal displaced fracture & placed into cast until definitive fixation
When is ORIF recommended for managing a scaphoid fracture?
ORIF: Open Reduction Internal Fixation
Specific fracture: Scaphoid fracture
- 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
How does tibial plateau fracture present?
Specific fracture: Tibial plateau fracture
- Variable hx but often direct trauma
- Any extreme valgus/varus force or axial loading across the knee can cause a tibial plateau fracture, with impaction of the femoral condyles causing the comparatively soft bone of the tibial plateau to depress or split (Concomitant ligamentous or meniscal injury is not uncommon)
- Chronic pain (> 4 / 24)
What investigation is conducted after after a tibial plateau fracture?
Specific fracture: Tibial plateau fracture
- X-Ray
When is non-operative recommended for managing a tibial plateau fracture?
Specific fracture: Tibial plateau fracture
- Only truly undisplaced fractures with good joint line congruency assessed on CT or high fidelity imaging
When is operative recommended for managing a tibial plateau fracture?
Specific fracture: Tibial plateau fracture
- Predominance of treatment will be operative
- Restoration of articular surface using combination of plate and screws
- Bone graft or cement may be necessary to prevent further depression after fixation
How does an ankle fracture present?
Specific fracture: Ankle fracture
- Variable hx but often direct trauma
- Extremelly swollen
- Dislocated
What investigation is conducted after an ankle fracture?
Specific fracture: Ankle fracture
- X-Ray
What is the non-operative management for an ankle fracture?
Specific fracture: Ankle fracture
-
Non-weightbearing below knee cast for 6-8 weeks, can transfer into walking boot and then physiotherapy to improve range of motion/stiffness from joint isolation
- Weber A i.e. below syndesmosis and therefore thought to be stable
- Weber B if no evidence of instability (no medial/posterior malleolus fracture and no talar shift)
What is the non-operative management for an ankle fracture?
Specific fracture: Ankle fracture
- Soft tissue dependent - patients need strict elevation as iniuries often swell considerably
- Open reduction internal fixation +/- syndesmosis 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 fractures)
- Weber C i.e. fibular fracture above the level of the syndesmosis therefore unstable
