Management of specific fractures

Question 1

What is the difference between orthopedics and trauma?

Answer 1

1st assessment at orthopedics:
Look
Feel
Move
XRay

If trauma is detected, treat:
- Reduce
- Hold:
* Plaster
* External fixator
* Internal fixation
- Rehabilitate:
* Normally six weeks later

Question 2

When assessing and managing trauma resulting in a fracture what should you deal with first?

Answer 2

• The fracture is usually the least important bit
• Keep the patient alive first – ATLS (advanced trauma life support)
• Airway
• Breathing
• Circulation
• Disability (ie neurology)
• Treat as part of ‘C’ occasionally or in secondary survey

Question 3

What features of a fracture should you assess for?

Answer 3

• Pain
• Swelling
• Crepitus (a popping, clicking or crackling sound in a joint)
• Deformity
• “Collateral damage”
• Nerve
• Vessel

Question 4

What investigations are used to assess fractures?

Answer 4

• XR (in most cases)
• CT sometimes indicated:
  To make diagnosis
  To assess pattern
• MRI if unsure

Question 5

What should you mention when describing a fracture radiograph?

Answer 5

Location: which bone and which part of bone?
Pieces: simple/multifragmentary?
Pattern:
- transverse (when your bone is broken perpendicular to its length)
- oblique (bone is broken at an angle)
Displaced/undisplaced
Translated/ lateral (bones remain aligned but moves away from each other) or angulated/ valgus/ varus (one bone slanted/ at the angle to the other)
X/Y/Z plane

Question 6

What are the 2 types of angulation you can have?

Answer 6

Valgus (bends inwards/ an excessive inward angulation)
Varus (bends outwards/ an excessive outward angulation)

Question 7

What is impaction in terms of fractures?

Answer 7

Impaction fractures happen when a bone is compressed. This puts pressure on the area, therefore causing parts of the bone to crumble under the weight of the compression

Question 8

What are the types of fracture healing you can have?

Answer 8

1. Direct fracture healing:
   “ the bony fragments are fixed together with compression- The bony ends are joined and healed by osteoclast and osteoblast activity”
   - Anatomical reduction
   - Absolute stability/compression
   - No callus
2. Indirect fracture healing:
   “consists of both endochondral and intramembranous bone healing”
   - Sufficient reduction
   - Micromovement
   - Callus

Question 9

Describe the process of indirect fracture healing

Answer 9

1. INFLAMMATION:
   - Haematoma formation
   - Release of Cytokines
   - Granulation tissue and blood vessel formation
2. REPAIR:
   - Soft Callus formation
   (Type II Collagen - Cartilage)
   - Converted to hard callus
   (Type I Collagen - Bone)
3. REMODELLING:
   - Callus responds to activity, external forces, functional demands and growth
   - Excess bone is removed

Question 10

What is “Wolff’s Law”?

Answer 10

Wolff’s Law: Bone Grows and Remodels in response to the forces that are placed on it

Question 11

What is the time it takes for a fracture to heal?

Answer 11

Actually 3-12 Weeks depending on site & patient

Signs of healing visible on XR from 7-10 days

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

Question 12

How are fractures managed?

Answer 12

1. Reduce:
   - closed
   - open
2. Hold:
   - Plaster/splint
   - External fixation
   - Internal fixation
3. Rehabilitate:
   - Early / late
   - Weight bearing
   - Physiotherapy

Question 13

How is an open fracture reduced?

Answer 13

Either:
- Mini incision
- Full exposure

Question 14

How is a closed fracture reduced?

Answer 14

Either:
1. Manipulation
2. Traction:
* skin
* Skeletal (pins in bone)

Question 15

Why types of fixation can you have?

Answer 15

• Internal
• External
• Medullary
• Mono/mupltiplanar

Question 16

What complications can be caused from a fracture?

Answer 16

General (early or late):
- Fat embolus
- DVT
- Infection
- Prolonged immobility (UTI, chest infections, sores)
Specific
- Neurovascular injury
- Muscle/tendon injury
- Non union/mal union
- Local infection
- Degenerative change (intraarticular)
- Reflex sympathetic dystrophy

Question 17

What factors affect fracture healing?

Answer 17

Mechanical environment:
- Movement
- Forces
Biological environment:
- Blood supply
- Immune function
- infection
- nutrition

Question 18

What are the causes of a fractured neck of femur?

Answer 18

Causes:
Osteoporosis (older)
Trauma (younger)
Combination

Question 19

What needs to be explored in a history for a fractured neck of femur?

Answer 19

• Age
• Comorbidity respiratory/ cardiovascular/ diabetes/ cancer
• Preinjury mobility independent/ shopping/ walking/ sports
• Social history: relatives, stairs, alcohol intake

Question 20

What are the types of neck of femur fractures by location?

Answer 20

1. Subcapital (The fracture line extends through the junction of the head and neck of femur- below the femoral head)
2. Transcervical (across the mid-femoral neck)
3. Basicervical (across the base of the femoral neck)
4. subtrochanteric (fractures of the proximal femur that occur within 5 cm of the lesser trochanter)
5. part intertrochanteric (Intertrochanteric fractures are defined as extracapsular fractures of the proximal femur that occur between the greater and lesser trochanter)

Question 21

How are neck of femur fractures managed?

Answer 21

• Extracapsular fractures - fix with screws or nails
• Intracapsular fractures
• A bit more complex
  (replace in some cases)

Question 22

Do you fix or replace a fracture?

Answer 22

depends on location/displacement and age

Question 23

How would you fix a extracapsular neck of femur fracture?

Answer 23

Internal fixation (plate and screws or nail)

Question 24

How would you fix an intracapsular displaced neck of femur fracture?

Answer 24

• Less than 55yrs: reduce and fixation with screws
• > 65 yrs replace:
• Fit and mobile: total hip replacement
• Less fit: hemiarthroplasty

Question 25

How would you fix an intracapsular undisplaced neck of femur fracture?

Answer 25

- Fixation with screws

Question 26

How does a shoulder dislocation present?

Answer 26

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

Question 27

What clinical examination is used to assess a dislocated shoulder?

Answer 27

- Assess neurovascular status- axillary nerve

Question 28

What investigations are used to monitor shoulder dislocation?

Answer 28

- X-ray prior to any manipulation- identify fracture e.g, humeral neck, greater tuberosity avulsion or glenoid - Scapular- Y view/ modified axillary in addiction to AP

Question 29

How is a dislocated shoulder managed?

Answer 29

- 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 +/- gentle internal rotation to disimpact humeral head - Ensure adequate patient relaxation- Entonox; benzodiazepines - If alone could use Stimson method - Undertake in safe environment, especially e.g. resus, ask for senior/ anesthetic support early on if necessary

Question 30

What complications can occur from a shoulder dislocation?

Answer 30

1. Hill- Sachs defect: - injury that occurs secondary to an anterior shoulder dislocation. - The humeral head 'collides' with the anterior part of the glenoid, causing a lesion, bone loss, defect and deformity of the humeral head. - This may cause a change loss of range of motion, feelings of instability and pain 2. Bankart lesion: - a type of shoulder injury that occurs following a dislocated shoulder. - It is an injury of the anterior (inferior) glenoid labrum of the shoulder. - When this happens, a pocket at the front of the glenoid forms that allows the humeral head to dislocate into it

Question 31

What is a distal- radius fracture?

Answer 31

The radius is one of two forearm bones and is located on the thumb side. The part of the radius connected to the wrist joint is called the distal radius. When the radius breaks near the wrist, it is called a distal radius fracture.

Question 32

How is a distal radius fracture managed?

Answer 32

1. cast/ splint: - Temporary treatment for any distal radius fracture- reduction of fracture and placement into cast until definitive fixation - Definitive if minimally displaced, extra articular fracture 2. MUA & K-WIRE: - 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 3. ORIF: - 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 33

What is a scaphoid fracture?

Answer 33

A scaphoid (navicular) fracture is a break in one of the small bones of the wrist. This type of fracture occurs most often after a fall onto an outstretched hand. Symptoms of a scaphoid fracture typically include pain and tenderness in the area just below the base of the thumb.

Question 34

What is a Tibial plateau fracture?

Answer 34

- The proximal tibia comprises a key weight bearing surface as part of your knee joint, articulating with the distal femur - Tibial joint surface is relatively flat and comprises of both medial and lateral plateaus with a central tibial spine acting as an insertion point for ligaments. - 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

Question 35

How is a tibial plateau fracture managed?

Answer 35

Non-operative: - only truly undisplaced fractures with good joint line congruency assessed on CT or high fidelity imaging Operative: - Predominance of treatment will be operative - Restoration of articular surface using combination of plane and screws - Bone graft or cement may be necessary to prevent further depression after fixation

Question 36

What is a trimalleolar fracture?

Answer 36

Trimalleolar fractures happen when you break the lower leg sections that form your ankle joint and help you move your foot and ankle

Question 37

How are ankle fractures managed?

Answer 37

Non- operative: - Non- weight bearing 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) Operative: - Soft tissue dependent- patients need strict elevation as injuries often well 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 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