Trauma

Question 1

What is the clinical presentation of fractures?

Answer 1

1. Post-Injury
2. Pain and tenderness
3. Associated symptoms
   
   1. Swelling
   2. Deformity
   3. Loss of function
4. Complications
   
   1. Neurovascular compromise

Question 2

What is the etiology of fractures?

Answer 2

1. Trauma
2. Stress fractures (Normal bone, abnormal stress)
3. Pathological fractures (Abnormal bone, normal stress)
   
   1. Osteoporosis
   2. Metabolic bone disease
   3. Infection
   4. Tumor

Question 3

What investigations would you do for fractures?

Answer 3

X-Rays

• 2 views: Orthogonal views, AP and lateral
• 2 joints: Joints above and below
• 2 times: before and after reduction

MRI: soft tissue injury, occult fractures

CT: Complicated fractures

Question 4

How do you describe a fracture X-ray?

Answer 4

1. Describe the radiograph
2. What type of fracture?
   
   1. Complete
      
      1. Transverse – generally stable
      2. Oblique – Unstable
      3. Spiral - Unstable
      4. Comminuted – Unstable
      5. Avulsion – Unstable
   2. Incomplete
      
      1. Bowing – Stable
      2. Buckle – Stable
      3. Greenstick – Stable
   3. Salter-Harris
3. Where is the fracture?
   
   1. Diaphysis
   2. Metaphysis
   3. Epiphysis
4. Displacement
   
   1. Angulation
   2. Translation
   3. Rotation
   4. Impaction/distraction
5. Something else going on?
   
   1. Joint involvement
   2. Another fracture?

Question 5

What are the stages of fracture healing?

Answer 5

1. 0h: Hematoma formation
2. 8h: Inflammation and cellular proliferation under periosteum
3. 3-12 weeks: Callus formation
   
   1. Soft callus (Cartilage)
   2. Hard callus (Calcified cartilage) – forms woven bone
4. 6-12 months: Consolidation
   
   1. Woven bone replaced by lamellar bone
5. 1-2 years: normal architecture achieved through remodeling.

Question 6

What are the complications of fractures?

Answer 6

1. Local
   
   1. Early
      
      1. Soft tissue injury
         
         1. Nerve injury
         2. Vascular injury
      2. Swelling related
         
         1. Compartment syndrome
      3. Infection
         
         1. Gas gangrene
         2. Osteomyelitis
   2. Late
      
      1. Union-related
         
         1. Delayed union
         2. Non-union: Atrophic, hypertrophic, infected
         3. Malunion
      2. Avascular necrosis
      3. Joint related
         
         1. Joint instability
         2. Osteoarthritis
         3. Joint stiffness
2. Systemic
   
   1. Fat embolism syndrome (long bones)
   2. Hemorrhagic shock
   3. ARDS
   4. DVT

Question 7

What is the management of closed fractures?

Answer 7

Initial Management:

• Stabilize patient
• Neurovascular status of the limb
• Ensure not open fracrture

Principles: FRIAR

• First Aid
• Reduction
• Immobilization
• Active Rehabilitation

Question 8

What are the options for reduction?

What are the indications for open reduction?

Answer 8

Reduction: Adequate apposition and normal alignment (CI in little/no displacement or reduction unlikely to succeed.)

1. Closed Reduction
2. Open Reduction (NOCAST)
   
   1. Non-union
   2. Open fracture
   3. Neurovascular compromise
   4. Intra-articular fracture
   5. Salter Harris 345
   6. Trauma (polytrauma)

Question 9

What are the options for stabilization? Please give some examples of each.

Answer 9

1. External Stabilization
   
   1. Splints/Tape
   2. Casts – functional bracing, hard casts
   3. Traction
   4. External fixator
2. Internal Stabilization (Avoid fixation in smoking, diabetes)
   
   1. Percutaneous pinning (Kirshner/K-wires)
   2. Extramedullary fixation (Screw, plates, wires)
   3. Intramedullary fixation (rods)
   4. Complications
      
      1. Surgical: Blood loss, infection, neurovascular compromise
      2. GA-related: cardiovascular, allergy, paralysis, AMI, stroke
      3. Prosthesis-related: peri-prosthetic fracture

Question 10

What forms of nerve injury are there?

Answer 10

1. Neuropraxia – compression of the neurons
2. Axonotmesis – damage of the axons
3. Neurotmesis – Transection of the nerve

Question 11

Describe the classification of open fractures

Answer 11

• Type 1: Wound length <1cm
• Type 2: Wound >1cm
• Type 3A: Extensive soft tissue damage
• Type 3B: Inadequate soft tissue damage
• Type 3C: Arterial damage requiring repair

Question 12

What is your management of an open fracture?

Answer 12

1. Resuscitate according to ATLS principles
2. Call senior
3. Medications
   
   1. Broad spectrum antibiotics
   2. Analgesia
   3. Tetanus toxoid
4. Wound Management
   
   1. Irrigate
   2. Take picture and cover
   3. Immobilize
5. EOT within 6 hours
   
   1. Irrigation and debridement
   2. Repair vascular injury
   3. Reduce and stabilize
   4. Wound cultures

Question 13

What is the clinical presentation of a hip fracture?

Answer 13

Symptoms:

1. Hip Pain
2. Swelling
3. Ecchymosis
4. Unable to walk

Signs:

1. Shorterned and externally rotated leg
2. Trochanteric tenderness

Question 14

What are the etiologies of hip fractures?

Answer 14

• Trauma
• Weak bones
  
  • Osteoporosis
  • Pathological Fracture

Question 15

What are the complications of hip fractures?

Answer 15

1. Infection
2. Immobility
   
   1. Pneumonia
   2. Pressure sores
   3. UTI
   4. Thromboembolism
3. AVN and joint destruction
4. Atrophic non-union

Question 16

What are the investigations you would do in a hip fracture?

Answer 16

Diagnosis:

• X-Rays
  
  • Anterior-posterior view
  • Lateral view
• Etiology
  
  • BMD
  • Calcium
• Pre-Op (GXM, PT/PTT, FBC, RP)

Question 17

How do you classify hip fractures?

Answer 17

Hip fractures can be classified generally into NOF or intertrochanteric fractures.

• NOF
  
  • Intracapsular:
  • Extracapsular
• Intertrochanteric

Question 18

What is the classification for NOF fractures?

Answer 18

It is divided into 5 stages

• Gardens 1: Incomplete and impacted
• Gardens 2: Complete but non-displaced
• Gardens 3: Complete with moderate displacement
• Gardens 4: Complex and severe displacement

Question 19

What is the management of hip fractures? (Before surgery)

Answer 19

Initial Management:

1. Pain
   
   1. Analgesia
   2. Traction
2. Prevention of complications:
   
   1. DVT prophylaxis
   2. Prevention of pressure sores
   3. Prophylactic antibiotics
3. Pre-op management
   
   1. Pre-op optimization
   2. Pre-op risk stratification
   3. Pre-op investigations

Question 20

What is the definitive management of hip fractures?

Answer 20

Must be operated on within 48 hours (lower mortality)

1. Surgical Fixation (Open reduction internal fixation)
   
   1. Indications: Young people, older people with gardens 1 and 2 (non-displaced)
   2. Intramedullary nail (antirotation proximal femoral nail) - unstable fractures (currently gold standard)
   3. Extramedullary screws (dynamic hip screws) – generally IT fractures
   4. 3 Cancellous screws
2. Hip replacement
   
   1. Indications: High risk of AVN with surgical reduction and fixation of the fracture, intracapsular fractures, displaced fractures
      
      1. Older person Gardens 3 and 4

Question 21

What are the complications of surgical fixation of the hip?

Answer 21

1. Intra-op
   
   1. GA risks
2. Early
   
   1. Bleeding, infection
3. Intermediate
   
   1. Dislocation (cannot adduct)
   2. Non-union
   3. Avascular necrosis (periodic radiographs for 3 years for development of AVN)
4. Late
   
   1. Posttraumatic arthiritic changes

Question 22

What are the risks of hip replacement?

Answer 22

Hip Replacement:

1. Intra-op (Fracture, neurovascular damage)
2. Early (Infection, dislocation, limb length difference, DVT)
3. Late (Loosening, prosthetic infection)