Flashcards in Trauma and Fractures Deck (90):
name that refers to 100% translation in a fracture?
what is Baynert's apposition?
displacement in a fracture with 100% translation + shortening
how can the distal fragment be described relative to the proximal fragment in a displaced fracture?
distraction- fragments separated as occurs via tendon pulling
translation- no longer in line with 1 another
offended- 100% translation
Baynert's apposition- 100% translation and shortening
what name is given to fractures of the physes (epiphyseal growth plates)?
what is the Salter-Harris classification of physis fractures?
type 1= fracture just through physis
2= fracture through physis + through the metaphysis
3= fracture of physis which exits through the epiphysis
4= fracture passes through the physis, and the metaphysis and epiphysis
5= impaction injury in which physis is not displaced, but is damaged by direct compression, with scar tissue formation and subsequent stopping of bone growth.
increasing number= worsening prognosis, as increasing risk of growth arrest
importance of a lateral view radiograph in knee trauma?
allows identification of knee joint effusions and lipohaemarthrosis= fat and blood in joint
3 parts to management of fractures?
reduction- direct (open- with plates and screws) or indirect (closed)
stabilisation- internal, external or combined
rehabilitation- preserve joint function by exercising and weight bearing
Garden classification of intracapsular (NOF) hip fractures?
I - Incomplete or impacted bone injury with valgus angulation of the distal component
II - Complete (across whole neck) - undisplaced
III - Complete - partially displaced
IV - Complete - totally displaced
NICE surgery for displaced intracapsular hip fracture?
hemiarthroplasty or THR
features of ptnt with displaced intracapsular hip fracture to be offered a THR?
were able to walk independently out of doors with no more than the use of a stick and
are not cognitively impaired and
are medically fit for anaesthesia and the procedure. (so no more than 1 co-morbidity really?)
what is used in preference to an intramedullary nail in ptnts with trochanteric fractures above and including lesser trochanter?
extramedullary implant e.g. sliding hip screw (DHS)
NICE tment for subtrochanteric fracture (extracapsular)?
NICE tment of undisplaced intracapsular hip fracture?
internal fixation with screws, arthroplasty considered in those less fit
3 situations where immediate reduction of a fracture is unnecessary?
displacement doesn't initially matter e.g. in some clavicle fractures
reduction unlikely to succeed e.g. with compression fractures of vertebrae
3 steps in closed reduction?
distal part of limb pulled in line of bone
fragments repositioned by reversing original direction of force applied
alignment adjusted in each plane
characteristics on radiograph of displacement in NOF#?
disruption of Shenton's line
disruption of trabeculae
what is a DHS?
dynamic hip screw
function of sustained traction?
exert continuous pull in long axis of bone so as to reduce and hold the reduced fracture
why is skeletal traction used mainly for LL injuries?
can withstand a much greater force
what does skeletal traction involve?
stiff wire or pin inserted e.g. through calcaneus, and cords are attached to apply traction
benefits of skeletal traction over cast splintage?
can view the skin of the limb directly to check for signs of inadequate vascular supply or infection or necrosis
less risk of compartment syndrome
problems with sustained traction?
in children espec. can restrict circulation
older people- may predispose to peroneal nerve injury and cause foot drop
risk of infection at pin sites in skeletal traction
bone may not be able to hold pin if fragile and OP
what is MRI useful for in suspected hip fracture?
looking for soft tissue oedema
how is a fractured clavicle X-rayed?
30 degrees cephalad, AP **
how can a CT be used to look at fractures?
look at extent and size of fragments
where is the midline going through the foot?
through the middle of the 2nd toe
what are extracapsular fractures of the hip more associated with?
what should be looked out for on anankle radiograph in suspected ankle fracture, in terms of the talus?
talar shift- so mortise disrupted
describe tension-band plating
a form of internal fixation in which the plate is applied to the tensile surface of the bone, so compression can be applied to the biomechanically more advantageous side of the fracture
figure of 8- with tension-band wiring, wires looped around the 2 bone fragments and tightened to compress them together, but musn't loop around and trap nerves/vessels.
can't really be used if comminuted fracture*
why do fractures happen?
trauma/injury- direct force, and indirect force- fracture at distant site to where force applied
repetitive stress- repeated stress from high loads causes small deformations and remodelling, reabsorption occurs faster than replacement so fracture risk increased. steroids and MTX have same effect
abnormal bone weakening-pathological- occur with normal loading/stress on weakened bone
differences between contact and gap healing in primary bone healing?
contact- fractures ends in direct contact, so healing with lamellar bone begins immediately
4 main stages of secondary (indirect) bone healing?
FC callus formation
bony callus formation
cell which eventually breaks down haematoma?
cytokines involved in haematoma formation?
location of bone remodelled to compact bone?
law which refers to the fact that bone remodelling is affected by mechanical stressors on the bone?
wolff's law- bone remodels and adapts to loads placed on it
all bone morphogenic proteins belong to which family?
transforming growth factor beta (TGF-beta) , except BMP-1
where are BMPs found?
deminersaliased bone matrix
function of BMPs?
promote differetiation of fibroblast like cells into preosteoblasts, then into osteoblasts which form new bone (osteoinduction)
key function of BMP-3?
induction of intramembranous ossification
key function of BMP-2 and -7?
induce endochondral ossification in segemetnal defects
how doe BMP-1 regulate EC matrix production?
has enzymatic activity, cleaves C terminal sequence of procollagen I, II and III
how do fibroblast GFs enhance callus formation?
promote proliferation of chondrocytes and osteoblasts needed for callus formation
FGF-2 also has role in promoting angiogenesis
peak of cytokine production in bone fractures?
24 hrs after bone injury/fracture
then peaks again in bone remodelling
why might post menopausal women be prone to pathological bone fractures?
reduced oestrogen levels- oestrogen normally reduces IL-1 and -6 synthesis, which stimulate bone resorption, so with less oestrogen, there is more IL-1 and-6 to stimulate bone breakdown, promoting osteoporosis and hence increasing risk of pathological fracture
mediators of bone healing?
factors that interrupt bone healing?
surrounding soft tissue injury
ptnt factors- poor general health e.g. Vit D deficiency, smoking, malnutrition, drug therapy-corticosteroids, DM- too high glucose leads to defective collagen production, and can disrupt b.supply?
indications for anatomical and functional reductions?
anatomical if joint fracture
functional if metaphyseal or diaphyseal fracture e.g. in diaphyseal fracture, length, alignment and rotational axis of bone restored, so functional anatomy restored, and load-bearing axis is restored.
aims in reduction of closed fractures?
for adequate apposition and alignment of bone fragments as greater contact favours bone healing, and if articular surface, need precise reduction to maintain joint function
when is closed reduction suitable?
minimally displaced fractures
fractures in children
fractures which are likely to be stable after reduction
done under anaesthesia and muscle relaxation
why might femoral shaft fractures be difficult to reduce by manipulation?
countering forces from strong muscles, so may reduce then support with mechanical traction to hold fragments until they unite
indications for open reduction of fractures?
failed closed reduction e.g. due to unstable fragments or soft tissue interposition between them
large articular fragments that need accurate positioning
assoc. injuries e.g. artery damage
why is fixation performed?
prevent fragmetn displacement
allow soft tissue healing
allow movement of unaffected joints
indications for internal fixation?
fractures that cannot be reduced without op.
unstable fractures prone to re-displacement after reduction
poorly uniting fractures, and those that unite slowly e.g. NOF#
pathological fractures, bone disease may prevent healing
multiple fractures-where early fixation reduces risk of general comp.s
indications for external fixation?
fractures assoc with severe soft-tissue damage
severely comminuted and unstable fractures
multiple, severe fractures- EF can be easily applied if ptnt not yet ready for longer surgery
ununited fractures requiring bone reconstruction
fractures assoc. with major vessel damage
fractures involving fragile, OP bone that internal plates and screws won't be held??*
4 essentials in tment of open fractures?
prompt wound debridement
early definitive wound cover
what type of stabilisation is a wrist sling an example of?
sustained traction -traction by gravity- weight of arm provides continual traction to humerus
where is wire/pin inserted in skeletal traction for hip, knee or thigh injuries?
why is cast splintage good for tibial fractures?
ptnt can bear weight on cast
tment of pressure sores in ptnts with cast splintage?
cut out windows in cast over areas of pain
if diffuse pain in ptnt with cast splintage, what should be done?
cast should be opened if pain does not subside in an hr
how is absolute stability achieved e.g. for fractures involving articular surfaces?
interfragmentary compression e.g. lag screws, compression plates, tension band
primary bone healing takes place
tment of infection with internal fixation?
may need replacement of implants with external fixation
objectives of rehabilitation?
restore joint movement
restore muscle power
introduce ptnt back to normal activity
initial management of open (compound) fracture?
emergency treatment= 7As: A to E assessment, assess-NV status, soft tissue injury, photograph wound, antisepsis-irrigate and dress-1L saline, alignment-and splint, anti-tetanus, Abx-co-amoxiclav or clindamycin if pen allergic, analgesia
cover with sterile dressing
address life threat. conditions
tetanus prophylaxis- toxoid if prev. given, human antiserum if not
Abx once OF diagnosis made
-Co-amoxiclav or cefuroxime
-Clindamycin if patient has penicillin allergy
remove gross contamination
Gustilo's classification of open fractures?
type 1- low-energy, small, clean wound, little soft tissue damage
how can lateral malleolus fractures be classified?
Weber classification, A B and C
A= fracture distal to ankle joint
B= fracture at level of ankle joint
C= proximal to ankle joint
contraindications to external fixation?
non compliant patient unable to look after pin sites and wires with care
already internal fixation in place so wires and pins unable to be placed properly
bone pathology precluding pin fixation
ptnt with compromised immune system
how can external fixation be used in limb lengthening?
femur cut diagonally, and external fixator apparatus applied on either side of fracture to gradually push the 2 sides apart and bone will gradually grow into gap created
what is a trimalleolar ankle fracture?
fractures of medial and lateral malleoli, AND posterior malleolus= posterior aspect of tibia
why is tetanus prophylaxis required in open fracture?
wound can become infected with clostridium tetani, producing muscle spasms which are life threatening if respiratory muscles involved
why are EC hip fractures more common in ptnts with hip OA?
hip OA results in the intertrochanteric region being an area of greater stress
why is good bony apposition required?
in order to achieve stability and union- adequate healing
importance of correcting angulation in forearm fractures?
allow adequate supination and pronation
importance of correcting angulation in lower limb fractures?
so as not to alter plane of movements which can lead to abnormal joint stresses and subsequent secondary OA
if conservatively treated forearm fractures, why should a broad arm sling and NOT a collar and cuff be used?
muscle wasting with loss of brachialis and brachioradialis bulk leads to plaster slackening and angulatory deformity
best tment for displaced forearm fractures in fit healthy adult?
ORIF, usually by plating both bones through separate incisions- minimises risk of cross-union
closed reduction often difficult and late slipping very common
tment of a greenstick fracture of the clavicle in a child?
no reduction required
must provide support for weight of arm, best done with a broad arm sling
immediate management of NOF# ptnt?
assess risk of pressure sores
hydration and electrolyte balance, set up IV line, take bloods
pain- give analgesia before X-ray
core body temp.
continence- may need urinary catheter
note mental state, prev. mobility and overall function- performance status?
medication- take note e.g. warfarin, may need to give Vit K
in a hip hemiarthroplasty, what are the complications of the stem being uncemented and cemented?
uncemented- higher rate of thigh pain, poorer overall function, higher rate of revision
cemented- intraop hypotension, elevatiomn of pulmonary arterial pressure, longer op?
what lies in the space between the distal end of the ulna and the articular surface of the radius, and why might this not be the case in a radial fracture?
the triangular fibrocartilage
may be ulna dislocation with radial fracture (Galeazzi fracture-dislocation)
tment of radius nonunion?
internal fixation and bone grafting
when should forearm CS diagnosis be considered?
marked pain, exacerbated by passive extension of fingers
reduced sensation in hand or paraesthesia
significant rise in compartment pressure- most useful in unconscious ptnt
why does ulnar styloid avulsion occur in Colle's fracture?
distal radial fragment attached to ulnar styloid by triangular fibrocartilage
characteristics of typical displaced Colle's fracture?
dorsal displacement, (and radial displacement)
anterior angulation (posterior tilt)
sling for Colle's fracture?
collar and cuff
characteristics of a type 2 classification of an open fracture in terms of soft tissue wounding?
skin wound >1cm
simple fracture pattern
no flaps or avulsions
soft-tissue damage not extensive
what is a type 3 open fracture in the Gustilo and Anderson classification?
high energy injury involving extensive soft tissue damage
or multifragmetnary fracture, segmental fractures, or bone loss irrespective of skin wound size
or severe crush injuries
or vascular injury requiring repair
or severe contamination includ. farmyard injuries
how does internal fixation compare with hemi-arthroplasty for NOF fractures?
hemi or THR used in displaced IC hip fractures due to high risk of AN of femoral head
hemi may be used in less fit ptnt if fracture undisplaced rather than internal fixation, maybe as less fit ptnt will have poorer b.supply to femoral head and poorer healing
hemi has lower rates of re-operation than internal fixation