Principles of Fracture Management / repair

Question 1

What should the first assessment be?

Answer 1

Airway patency +/- oxygen
Breathing - chest trauma, airway trauma - thoracocentesis
Circulatory - iv cath & fluids
Disabilities - ortho/neuro exam, analysis, imaging

Question 2

What is your minium database?

Answer 2

• PCV
• TS
• BG
• BUN
• USG

Question 3

What other analysis might we want to do ?

Answer 3

• haem
• biochem
• urinalysis
• POCUS
• Radiography

Question 4

First line management for fracture?

Answer 4

• Oxygen
• Fluid therapy
• Analgesia -> opioids, NSAIds, LA, others
• ABs

Question 5

What to assess about our fracture?

Answer 5

• Bruising
• Swelling
• Open wounds -> extent of trauma, debris, neuro vasc damage

Question 6

Management of soft tissue injuries in fract?

Answer 6

OPEN WOUNDS
- Sterile cover
-Wide clipping
- Remove debris
- Lavage
- Debride

CLOSED -> splint lower limbs

Question 7

How should we plan to Xray fract?

Answer 7

• 2 orthogonal views
• Whole bone (inc joint above and below )
• Contralat bone

-> Magnification & lateralisation marker

Question 8

Fracture classification?

Answer 8

• Location (bone & part of it)
• type/shape/N° lines
• Reducibility
• Open/closed
• stability after anatomic reconstruction

Question 9

Classification of open fracts?

Answer 9

Question 10

Classification of Physeal fractures?

Answer 10

Question 11

What is involved in planning & decision making

Answer 11

• Biological factors
• Mechanical factors
• Client / patient factors

Question 12

Biological factors?

Answer 12

• Age
• Weight
• Concurrent injuries
• Overall health
• Fracture location
• Soft tissue injuries
• Soft tissue coverage

Question 13

Mechanical factors?

Answer 13

• Fracture configuration
• Reconstruction possible?
• Other MSK injuries or abnormalities?

Question 14

Client/ patient factors?

Answer 14

• Patient’s activity level
• Work?
• Ability of postoperative care
• Client compliance

Question 15

What factors affect return to full function?

Answer 15

• Prolonged surgery time
• Soft tissue trauma
• Technical errors
• High complication rate

Question 16

Adv / disadv or Open repair?

Answer 16

ADV -> Anatomical reconstruction, share weightbearing load
DISADV -> iatrogenic contamination, add ST trauma, imparement blood supply

Question 17

ADV/ DISADV of closed repair?

Answer 17

ADV: Preserves soft tissues & BS, decrase iatrogenic contamination
DISADV -> Fracture fragments not seen ; cortical pposition not acheived, no shearing WB load

Question 18

Patient prep for fracture repair?

Answer 18

Fasting prior to anaesthesia
Clip hair & vacuum
Foot covered sterily & hunged
Cleansing – antiseptic
Patient positioning
Appropriate attire

Question 19

What different implants might we use ?

Answer 19

Screws & plates
External fixators
Pins & Kirschner wires
External fixators
Interlocking nails
Cerclage wire

Question 20

Detail use of screws?

Answer 20

<40% diameter
Self tapping vs non self-tapping
Cortical vs cancellous vs shaft
Locking vs non-locking

Question 21

What different screws can we use?

Answer 21

• Lag screw
• Positional screw
• Plate screw

Question 22

What are some different plates ?

Answer 22

• Dynamic compression plate (DCP)
• Limited contact dynamic compression plate
• Veterinary cuttable plates
• Reconstruction plates
• Locking plates

Question 23

What different plate application modes?

Answer 23

• Compression
• Neutralisation
• Buttress
• Bridging (Plate Rod)

Question 24

How do interlocking nails work/when to use ?

Answer 24

• Medullary cavity + locking bolts
• High resistance bending stresses
  + axial & rotational forces
• Bones -> humerus, femur, tibia
• Bridging mode

Question 25

Describe steinmann pins?

Answer 25

* Intramedullary cavity – 2.0-5.0mm * Resist bending forces * Do not resist: compression or rotation * Adjuct implant – not alone

Question 26

Describe Kirschner wires?

Answer 26

* Pins 0.8-2.0mm * Maintain position * Physeal – growing patients

Question 27

What can be sued in external skeletal fixators?

Answer 27

-> Pins -> smooth vs traded ; positive vs negative threads ; end-threaded or centrally threaded -> Clamps ->Conecting bars

Question 28

Describe HOW we use External skeletal fixators

Answer 28

Below elbow/ stifle Closed application Use of soft tissue corridors ≥ 2 pins/fragment Pin ≤ % bone diameter Threaded > smooth

Question 29

Detail use fo orthopaedic wire?

Answer 29

Malleable 316L Stainless steel Close contact to bone Temporary or supplementary

Question 30

What applications for orthopaedic wire?

Answer 30

Cerclage wire Hemicerclage or interfragmentary Tension band wire

Question 31

What to look for in postop appraisal ?

Answer 31

ALIGNEMENT APPOSITION APPARATUS ACTIVITY

Question 32

Post op care?

Answer 32

Elizabethan collar – protect surgical site Rest at home – small room or crate Avoid: jumping/running/stairs Modified exercise: 5-10min on-lead walks

Question 33

Complications?

Answer 33

Delayed unions Nonunion Malunion Osteomyelitis & surgical site infection Implant failure