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Clin Med II - Ortho > Ortho Fx > Flashcards

Ortho Fx Flashcards

1
Q

Fracture Definition

A

A break or disruption in the continuity of the bone

Results from compressive forces, tension or torsion

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2
Q

Skin integrity

A

Closed / simple

Open / Compound

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3
Q

Closed fx

A

Does not penetrate through the skin

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4
Q

Open fx

A

Fx that penetrates through the skin

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5
Q

Nondisplaced

A

Fx fragments anatomically align

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6
Q

Displaced

A

Fx fragments no longer in usual alignment

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7
Q

Alignment

A

Rotational or angular position

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8
Q

Angulated

A

Fx fragments malaligned

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9
Q

Apposition

A

Amount of end-to-end contract of the fx

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10
Q

Bayonetted

A

Distal fx fragment longitudinally overlaps proximal fragment

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11
Q

Distracted

A

Distal and proximal fragments separated by a gap

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12
Q

Types of fx displacement

A 
Nondisplaced vs. displaced
Alignment
Angulated
Apposition
Bayonetted
Distracted
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13
Q

Types of fx and orientation of fx line

A 
Transverse
Oblique
Spiral
Comminuted
Segmental
Intra-articular
Torus
Greenstick
Avulsion
Impacted
Compression
Depression
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14
Q

Transverse

A

Fx perpendicular to shaft of the bone

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15
Q

Oblique

A

Angulated fx line

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16
Q

Spiral

A

Multiplanar & complex fx line

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17
Q

Comminuted

A

Fx with multiple fragments (>2)

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18
Q

Segmental

A

Comminuted fx in which a completely separate segment of bone is bordered by fx lines

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19
Q

Intra-articular

A

Fx that includes the joint surface

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20
Q

Torus

A

“buckle” fx caused by compression of cortex

Typically in distal radius and children

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21
Q

Greenstick

A

Incomplete fx
- fx of one cortex with bending of opposite cortex

Generally occurs in children

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22
Q

Avulsion

A

“chip” generally near the joint and with tendon or ligament attached

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23
Q

Impacted

A

Fx whose ends are driven into each other

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24
Q

Compression

A

Impaction fx occurring in the vertebrae

Results in depression of end plates

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25
Q

Depression

A

Impactions fx that occurs in knee when femoral condyle strikes softer tibial plateau

Can also occur in the skull

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26
Q

Pathologic

A

Fx that occurs b/c bone is weakened due to some abnormal condition

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27
Q

Stress

A

Fx that occurs when weak bone is stressed normally (insufficiency) or normal bone is stressed excessively (fatigue)

Usually only seen in weight bearing bones

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28
Q

Dislocation

A

Disruption in the continuity of the joint

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29
Q

Fx-Dislocation

A

Complete dislocation of joint occurring with a fx

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30
Q

Subluxation

A

Partial disruption in the continuity of the joint

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31
Q

Pseudarthosis

A

Failure of bone healing causing a “false joint” consisting of soft tissue

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32
Q

Hx

A 
MOI
- often trauma, but not always
- make sure the MOI matches up with injury
Pain - with or w/o weight-bearing
Swelling
Decreased function
Visible deformity
Numbness & tingling
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33
Q

PE

A 
Bone and joints above and below the injury
Inspection
- Swelling
- Ecchymosis
- Deformity
-Skin integrity - lacerations & abrasions
Palpate
- Tenderness
- Crepitus
- Compartment tightness
- Neurologic & vascular status
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34
Q

Traumatic nerve injuries

A

Contusions
Crus
Transection

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35
Q

Contusion

A

Neuropraxic

Recover 2-3 months (except in knee dislocations)

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36
Q

Crush

A

Recover slowly (2cm/month)

2 common sites

  • Radial N. (spiral fx to humerus –> wrist drop)
  • Peroneal N. (fx to the fibular neck –> foot drop)
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37
Q

Imaging

A

Plain radiographs often good enough

CT for bone

MRI for soft tissue and stress fx

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38
Q

X-ray rule of 2’s

A

2 views taken at 90° angles - may need oblique
2 joints (one above and one below) - proximal fx most often missed
2 weeks
2 limbs (esp. children)

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39
Q

Ultimate Goals of fx tx

A
  1. Alignment of bones in both angular and rotational planes
  2. Restoration of proper length
  3. Restoration of apposition of the bone ends
  4. Adequate immobilization
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40
Q

Fracture tx - initial (in general)

A

Splinting
Cast
Sling

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41
Q

Splinting

A

Often initial step in fx care
Allows for swelling to avoid circulatory and neuro problems
Can be done “in the field”
Trauma splints are temporary; remove and replace with padded splint if definitive tx delayed
Can be loosened or tightened with elastic bandage
Significant angular or rotational deformity should be corrected ASAP

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42
Q

Cast

A

Low-impact fx with minimal swelling

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43
Q

Sling

A

Tx in humeral head, clavicle fx

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44
Q

Non-sx tx

A

Splinting followed by casting

  • fx that don’t require reduction or sx intervention (non-displaced wrist fx, torus fx)
  • splinting done initially in ER to allow for swelling
  • F/u scheduled with ortho for definitive tx with casting
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45
Q

Sx tx

A

ORIF or CRIF
Continuous traction followed by cast immobilization
Closed reduction with external fixation
Closed reduction followed by casting

46
Q

Disadvantage of splinting over cast

A

Allow more movement at fx site

47
Q

Types of splints

A

Sugar-tong
Posterior
Ulnar gutter

48
Q

3 purposes of casts

A

Immobilize ends of fx
Allow ambulation
Hold position of the reduction

49
Q

Fiberglass / synthetic material

A 
Light weight
Strong
Short shelf-life
More expensive
Can get wet, but padding cannot (need special lining)
50
Q

Plaster

A 
Easy to mainipulate
Long shelf-life
Low-cost
Cannot get wet
Heavier than fiberglass
51
Q

Why CRIF

A

Prevents devascularization

Decreases risk of infection

52
Q

Why ORIF

A

Displaced joint fx (esp. weight bearing joints)
Fx that cannot be held by closed methods
Fx of the LE in elderly to promote early mobilization
Certain epiphyseal fx that could result in growth disturbance if not accurately reduced
Joint fx in which early motion would be helpful to prevent stiffness

53
Q

Closed Reduction with external skeletal fixation

A

External fx tx that uses several pins placed above and below the fx site

54
Q

Elements of Closed Reduction

A

Sx
Closed reduction followed by casting
Periosteum forms a hinge that can help guide a displaced fx back into place
Different methods include “pushing” it back or traction with manipulation

55
Q

Anesthesia for closed reduction

A

Local by direct infiltration of the fx hematoma
Regional
Digital block
General

56
Q

What is an adequate reduction

A
  1. Rotational deformity is completely corrected regardless of age
  2. In adults, angular deformity should also be completely corrected, esp. in fx of the fingers, forearm and lower extremities
  3. In peds, some angular deformity (15-20°) that is close to a joint and in the same plane of motion as that joint will correct itself if sufficient growth remains
  4. Perfect apposition is not always necessary for normal healing
  5. Fx involving the weight-bearing joints require exact reduction
  6. Slight shortening in the upper extremity is often acceptable, but proper length in the lower extremity is preferable
57
Q

Aftercare

A 
Elevate extremity
Apply ice 48-72h
Move all joints not immobilized - Well result in fewer vasomotor disturbances, less swelling and faster recovery
Keep clean and dry
Itching is common
Ecchymosis in different stages is common
Keep pt informed of entire tx plan
58
Q

Top ten principles

A
  1. Comparison x-rays
  2. X-ray in at least 2 planes
  3. Look for an injury to the other bone or for dislocation
  4. Correct both rotational and angular misalignment
  5. Take stress x-rays when necessary
  6. Do not be satisfied with one dx
  7. Reduce the fx ASAP
  8. In avulsion fx, eval for joint stability and tendon function
  9. The measure of success is the usefulness of the extremity.
  10. Irreducibility may signify soft tissue interposition
59
Q

Fx healing

A

A complex biologic cascade mediated by a variety of cells and proteins

Determined by both clinical and radiographical evidence

60
Q

Fx healing - clinically

A

Absence of tenderness and motion at fx site

61
Q

Fx healing - radiographically

A

Amount of bridging callus or obliteration of fx line

62
Q

Phases of fx healing

A

3 overlapping phases

Inflammation
Repair
Remodeling

63
Q

Potential Complications of fx healing

A 
Impaired fx healing
Joint stiffness
Contractures
Osteonecrosis / avascular necrosis
Infection / osteomyelitis
Compartment syndrome
Volkmann's ischemic contracture
Pressure ulcers
64
Q

Volkmann’s ischemic contracture

A

Acute ischemia and necrosis of the muscle fibers of the flexor group of muscles of the forearm, esp. FDP and FPL.

The muscles become fibrotic and shortened

65
Q

Impaired fx healing - in general

A

Malunion
Delayed union / Delayed healing
Non-Union

66
Q

Malunion

A

Inadequately aligned union

67
Q

Delayed Union / Delayed Healing

A

Fx not healed after 16-20 weeks

68
Q

Non-union

A

Fx not healed after 6mo of tx or absence of radiographic evidence of progression of callus formation over a 3 month period

69
Q

Causes of non-union fx

A

Inadequate stability
Inadequate biological conditions
Infection
Inadequate reduction

70
Q

Fibrous non-union

A

Clinically healed w/o radiographic evidence

71
Q

Risks of nonunion

A 
Smoking
Infection
Inadequate Immobilization
NSAID
Malnutrition
Poor blood supply
Significant soft-tissue injury
72
Q

Keys to fx healing

A

Keep bone ends in apposition
Maintain blood supply
Keep fragments adequately immobilized

73
Q

Osteonecrosis

A

fx that results in compromised blood supply to bone and ultimately results in bone death

Fx to these bones require diligent identification and possibly more aggressive tx

74
Q

Bone at increased risk for osteonecrosis

A

Talus
Scaphoid
Femoral head

75
Q

Compartment syndrome

A

Condition that develops when perfusion of nerve and muscle decreases to the point where it is unable to sustain viability

76
Q

Progression of Compartment Syndrome

A

Pressure in fascial compartments rise second to fx bleeding (creates pressure on capillaries and nerves)
Compartment pressure exceeds BP and capillaries collapse
Obstruction of venous outflow
Increase in tissue pressure and necrosis

77
Q

Acute Compartment Syndrome

A

Medical Emergency

W/o tx, it can lead to paralysis, loss of limb or death

78
Q

Chronic Compartment Syndrome

A

Often occurs with exercise and improves with rest

Not an emergency

79
Q

Suspect Compartment Syndrome if

A
  1. Pain on passive stretching of the muscles of the affected compartment
  2. Parethesias or sensory loss
  3. Tenderness of the involved compartment
  4. Paralysis may occur
80
Q

7 P’s of Compartment Syndrome

A 
Pain!!!
Pallor
Paresthesias
Paralysis
Pressure
Pulslessness
Poikilothermia
81
Q

Compartment Syndrome - Hx & PE

A

Excessive pain may be the only early clue!
Assess for circulatory compromise
- may need to split cast and/or cotton and spread to allow for swelling
- if pain persists may need to remove cast
- if severe may need fasciotomy
Palpate compartments
Assess passive motion, motor and sensory function of peripheral nerves

82
Q

Measuring pressures of Compartment Syndrome

A

Direct measurement of compartment pressures

Diastolic pressure - the intracompartmental pressure is = to 30mmHg

83
Q

Compartment Syndrome - Tx and prevention

A

Fasciotomy

Pt education - elevation

84
Q

Volkmann’s ischemic contracture

A

Considered a sx emergency!!!
Rare complication!!!
Results from untx arterial injury or compartment syndrome secondary to swelling in a tight cast
Causes ischemia and injury to muscles of affected area

85
Q

When does Volkmann’s ischemic contracture often occur?

A

After trauma

Crush injury or fx

86
Q

Areas where Volkmann’s ischemic contracture is most commonly seen

A

Severe elbow injuries
High tibial fxs
metatarsal fxs

87
Q

Progression of Volkmann’s ischemic contracture

A

Trauma
Leads to swelling
Compresses blood vessels which can decrease blood flow to affected area
Prolonged decrease in blood flow
Ischemia
Injures nerves and muscles
Nerves and muscles shorten and become stiff (scarred)
Pull on joint at end of muscle
Joint stiff, remains bent and cannot straighten out
Results in contractures and severe muscle loss
Deformity persists despite prolonged attempts at reconstructive sx and therapy

88
Q

Results of Volkmann’s ischemic contracture

A

Contractures
Severe Muscle Loss
Deformity persists despite prolonged attempts at reconstructive sx and therapy

89
Q

Reflex sympathetic dystrophy (CRPS) - in general

A

Common d/o of unknown cause that often follows a relatively minor injury
Usually affects extremity
Early recognition is difficult

90
Q

Reflex sympathetic dystrophy (CRPS) - pathology

A

Unclear

Disturbance of the sympathetic nervous system which leads to intense pain and vasomotor symptoms

91
Q

Reflex sympathetic dystrophy (CRPS) - prevalence

A

W>M, 4x
Smoking increases risk
30-50yo most likely

92
Q

Reflex sympathetic dystrophy (CRPS) - clinical features

A 
Staging not always reliable b/c variation is common
Joint motion restricted
Area becomes cool
Atrophy - skin & muscle
Skin - dry, shiny, glossy
Stiffness and intractable pain
Anxiety
Depression
93
Q

Reflex sympathetic dystrophy (CRPS) - Acute phase

A 
Lasts 6-12 weeks
Pain out of proportion to injury!!!
Allodynia
Hyperesthesia
Persistent burning pain
Hypersensitivity to light touch
Initially localized to area of injury but then spreads to remainder of extremity
Extremity is swollen, warm and excessive perspiration may occur
94
Q

Reflex sympathetic dystrophy (CRPS) - Imaging studies

A

Not dx
Plain x-rays - may reveal patchy osteoporosis
Bone scan - may be positive-regional uptake
Autonomic function testing
Response to sympatholytic oral injectable drugs

95
Q

Reflex sympathetic dystrophy (CRPS) - DDX

A

Specific nerve d/o
Factitious syndromes
- Munchausen
- Malingering (hypochondria)

96
Q

Reflex sympathetic dystrophy (CRPS) - Tx

A 
PREVENTION
- Control pain & swelling
- Early use of extremity
Difficult to tx - REFER
Antidepressants
Corticosteroids
CCB
Repeated sympathetic blocks
Sx
97
Q

Reflex sympathetic dystrophy (CRPS) - Prevention

A

Control pain and swelling

Early use of extremity

98
Q

Pressure Ulcers - in general

A

May develop rapidly in a cast over areas of pressure - roll in casting material

Cast needs to be removed and painful area assessed - pain will subside when tissue necrosis has occurred - so assess

99
Q

Rehab for fx

A

Begins at time of injury
Control swelling
Move joints not immobilized
Isometric exercises in the cast may prevent excessive atrophy

100
Q

Rehab for fx after cast removal

A

Active mobilization of joints immobilized - may take 4-6 weeks to regain strength and motion

Formal PT not always needed

101
Q

Pathologic fx - in general

A

Fx that develops b/c of some abnormal local condition that causes the bone to become weakened

102
Q

Pathologic fx - causes

A

Tumors that mets to bone (most common)
Infection
Cystic lesions of the bone
Paget’s dz

103
Q

Pathologic fx - goal

A

Maintain high level of functioning

Aggressive tx

104
Q

Stress fx - insufficiency

A

Normal stress applied to weak bone

Osteoporosis - most common cause

105
Q

Stress fx - fatigue

A

Excess stress applied to normal bone

Occur in unconditioned athletes or military personnel (long hikes - “march fx”)

106
Q

Stress fx - s/s

A

Local tenderness

Swelling usually present

107
Q

Stress fx - most common locations

A 
Metatarsals
Neck of femur
Calcaneus
Tibia
Fibula
Pelvis
108
Q

Stress fx - imaging

A

x-ray
Normal early in course
If suspected, tx as fx and repeat x-rays at 2 week intervals
Healing seen 2-4 weeks

109
Q

Stress fx - tx

A

Protect bone from stress and eliminate offending agent

Gradually resume activity as pain allows

110
Q

Bone Stim

A

Delivery of right amount of voltage and current by electrodes can stimulate osteogenesis

Today used in cases of delayed union or nonunion to help promotes bone healing

  • When done in conjunction with fx reduction and adequate immobilization, success rate 60-75%
  • Usually 30 min BID, and most ill completely stop working after 9 months

Clin Med II - Ortho (13 decks)

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