management of specific fractures

Question 1

What is the difference trauma vs orthopaedics?

Answer 1

Orthopaedics- look, feel, move, Xray
Trauma- Reduce, hold (plaster, internal fixation, external fixation), rehabilitate (usually 6 weeks later

Question 2

What are the main principles of assessing and managing trauma?

Answer 2

Fracture is usually the least important bit

Keep the patient alive first- ATLS
Airway
Breathing
Circulation
Disability

Fracture is sometimes treated as part of C or in secondary survey (Reduce, hold, rehabilitate)

Question 3

What are the clinical signs of a fracture?

Answer 3

Pain
Swelling
Crepitus
Deformity
Collateral damage- nerves, vessels, tendons, ligaments

Question 4

How do we investigate a fracture

Answer 4

Xray (in most cases)
CT is sometimes indicated- to make diagnosis/ to assess pattern
MRI if unsure
Bone scan

Question 5

What features of a fracture do we discuss when describing a radiograph?

Answer 5

Location- which bone and where in that bone is the fracture located
Pieces- simple, multi fragmentary
Pattern- transverse/ oblique/ spiral
Displacement- displaced/ undisplaced/ minimally displaced
Translated/ angulated
X/Y/Z plane

Question 6

What are translations in fractures?

Answer 6

Straight line movements

Anterior or posterior
lateral or medial
proximal or distal

Question 7

What are angulations in fractures

Answer 7

varus/ valgus- coronal plane (away from midline)
dorsal/ volar -sagittal plane
internal rotation/ external rotation

Question 8

What are the two ways in which a fracture can heal

Answer 8

Direct fracture healing- there is anatomical reduction, absolute compression and stability, no callus forms

Indirect fracture healing- sufficient reduction, micro movement, callus forms

Question 9

What are the broad steps in healing?

Answer 9

Bleeding
Inflammation
Repair
Remodelling

Question 10

What happens during the inflammation stage of healing?

Answer 10

Haematoma formation
Cytokine release
Granulation tissue and new blood vessel formation

Question 11

What happens during the repair stage of healing?

Answer 11

Soft callus formation (type II collagen- cartilage)
Converted to hard callus (type I collagen- bone)

Question 12

What happens during the remodelling stage of healing?

Answer 12

Callus responds to external forces, activity, functional demands and growth
excess bone is removed

Question 13

What is Wolff’s law?

Answer 13

Bone grows and remodels in response to the forces that are placed on it

Question 14

How long does it take bone to heal?

Answer 14

6 weeks
3-12 weeks depending on the patient

Question 15

When are signs of healing visible on Xray?

Answer 15

7-10 days

Question 16

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

Answer 16

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

Question 17

What are the 2 methods of fracture reduction? Give examples.

Answer 17

Question 18

Name 3 methods of holding a fracture

Answer 18

Plaster/ splint
Internal fixation- intramedullary, extramedullary
External fixation- monoplanar, multiplanar

Question 19

What are general complications of fractures?

Answer 19

Fat embolus (hours)
DVT (days- weeks)
PE
Infection
Prolonged immobility- UTI, chest infection, bed sores

Question 20

Name some specific complications of fractures

Answer 20

Neurovascular injury
Muscle/ tendon injury
Non-union/ Mal-union
Local infection
Degenerative changes (intraarticular)
Reflex sympathetic dystrophy

Question 21

What factors affect fracture healing?

Answer 21

Mechanical environment- movement, forces
Biological environment- blood supply, nutrition, infection, immune function

Question 22

What causes NoF fractures?

Answer 22

Osteoporosis (older)
Trauma (younger)
Combination

Question 23

What would you want to know from the history of a person with a NoF fracture?

Answer 23

Age
Comorbidities (cardiovascular, respiratory, diabetes, cancer)
Preinjury mobility (were they independent? shopping? walking? sports?)
Social hx (relatives? stairs at home? EtOH?)

Question 24

Look at this picture of NoF anatomy son.

Answer 24

red dotted line is the attachment of the capsule along the intertrochanteric line on the front line
- On the back of the femur the capsule goes halfway up NOF
- Anything above dotted line is intracapsular and everything below it is extracapsular (there’s a half zone on the back where it’s extracapsular there but around the front it’s intracapsular)

Question 25

What types of NoF fractures are there by location?

Answer 25

Supcapital (intracapsular) Transcervical (extra capsular) Basicervical (extra capsular) Subtrochanteric Intratrochanteric

Question 26

What complications can arise from intracapsular fractures?

Answer 26

1. Avascular necrosis- due to interruption of blood supply Blood supply to femoral head (mainly from medial and lateral circumflex branches of profunda femoris) goes through capsule, so neck fracture can lead to head necrosis (avascular necrosis) 2. non-union

Question 27

What factors decide whether to fix or replace NoF fracture?

Answer 27

Location/ displacement Age

Question 28

Management of extra capsular NoF

Answer 28

Internal fixation (with plate and screws/ nails)

Question 29

Management of intra capsular undisplaced NoF

Answer 29

Fixation with screws

Question 30

Management of intra capsular displaced NoF where patient is <55 years old

Answer 30

Reduction and fixation with screws

Question 31

Management of intra capsular displaced NoF where patient is >65 years old and fit and mobile

Answer 31

total hip replacement

Question 32

Management of intra capsular displaced NoF where patient is >65 years old and less fit

Answer 32

hemiarthroplasty

Question 33

Dislocated shoulder radiograph

Answer 33

Question 34

How would a dislocated shoulder present?

Answer 34

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

Question 35

What is an important clinical examination performed for patients present with a dislocated shoulder?

Answer 35

Assess neuromuscular status- axillary nerve

Question 36

What investigations are carried out for shoulder dislocation?

Answer 36

Xray prior to any manipulation: identify fracture (e.g. humoral neck, greater trochanter avulsion fracture, glenoid) Scapular Y-view/ modified axillary in addition to AP

Question 37

Management for shoulder dislocations

Answer 37

There are numerous techniques for reducing a dislocated shoulder Vigorous manipulation/ twisting manipulation should be avoided to avoid fractures The safest method is to use traction-counter traction +/- gentle internal rotation to disimpact humeral head If alone, could use Stimson method (using hanging weights) ensure adequate patient relaxation e.g. entonox, benzodiazepines Undertake in a safe environment, especially if elderly e.g. resus, ask for senior/ anaesthetic support early on if necessary.

Question 38

Name a complication of shoulder dislocation and what can this lead to?

Answer 38

Hill-Sachs defect (as humerus comes out, it bangs on glenoid and a fleck of bone comes off, called a Bankart lesion) can lead to recurrent shoulder dislocation

Question 39

What are the three ways in which a distal radius fracture is managed?

Answer 39

Cast and splint- temporary treatment for any distal radius fracture: fracture is reduced and fixed within cast until definitive treatment. this is definitive treatment for minimally displaced, extra-articular fractures MUA and K-wire- for fractures that are extra-articular but have instability, particularly in children. Wires can be removed in clinic post-op. ORIF- any fracture that is displaced, unstable and unsuitable for K-wires or with intra-articular involvement can be treated with open reduction and internal fixation with plate and screws

Question 40

describe how a tibial plateau fracture can occur

Answer 40

The proximal tibia is a key weight-bearing surface and forms part of the knee joint articulating with the distal femur The tibial surface is mostly flat, with medial and distal tibial plateaus and a central tibial spine for ligament attachment. Any excessive varus/ valves force or axial loading across the knee can cause a tibial plateau fracture, with the impaction of the femoral condyles causing the relatively soft tissue of the tibial plateau to depress/ split concomitant ligament/ meniscus injury is not uncommon

Question 41

Non-operative management for tibial plateau fracture

Answer 41

only done for truly undisplayed fractures with good joint line congruency assessed on CT or high fidelity imageing reduce, hold, rehabilitate

Question 42

operative management for tibial plateau fracture

Answer 42

Predominant treatment Articular surface is restored using a combination of plates and screws Bone graft or cement may be necessary to prevent further depression after fixation

Question 43

What fractures make up a trimalleolar fracture?

Answer 43

Oblique (lateral) malleolus fracture- fibula Medial malleolus fracture- tibia Posterior malleolus fracture- tibia

Question 44

What is the most frequently fractured ankle bone

Answer 44

fibula

Question 45

Non-operative ankle fracture management

Answer 45

Non-weightbearing below knee cast for 6-8 weeks, can transfer into walking boot and then physio to improve range of motion/stiffness from joint isolation Weber A and Weber B if no evidence of instability (no posterior/ medial malleolus fracture and no talar shift)

Question 46

Operative ankle fracture management

Answer 46

Soft-tissue dependent- patients need strict elevation as injuries often swell considerably ORIF +/- 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 needed Unstable Weber B and Weber C fractures

Question 47

What is a Weber A fracture

Answer 47

simple fracture to bottom part of fibula (below syndesmosis)

Question 48

What is a Weber B fracture

Answer 48

Fracture of fibula at level where it ligamentally joins to the tibia (syndesmosis)

Question 49

What is a Weber C fracture

Answer 49

Fibular fracture above level of syndersmosis (where tibia and fibula join ligamentously) therefore unstable