Treatment of Fxs Flashcards
(35 cards)
1
Q
What part of the bone is the key to fx healing?
A
- periosteum: provides the vascular supply
2
Q
Biology of fx healing - diff phases?
A
- reactive phase: fx and inflammatory phase (vessels contract, hematoma), granulation tissue formation (fibroblasts take over)
- reparative phase: cartilage callus formation (periosteal cells - turn to chondroblasts), lamellar bone deposition (form fx callus)
- remodeling phase: remodeling to original contour, trabecular bone is replaced w/ compact bone
3
Q
Healing rates depend on what?
A
- vary w/ age, comorbidities, nutritional status
- effected by thyroid and GH levels, calcitonin
- common conditions that impair healing:
diabetes, arteriovascular disease, anemia, vitamin deficiencies (A and C), tobacco use, chronic alcohol use, meds: NSAIDs, glucocorticoids, cipro
4
Q
Eval of fx pt?
A
- vital signs and mental status
- MOI: beware of high energy injuries
- neurovascular status of extremity (elbow and knees): record it for posterity
- where is deformity? beware of knee and elbow injuries
- open or closed?
- check jts above and below fx
- min of 2 xray views of injured pt
5
Q
Common injury patterns of FOOSH?
A
- scaphoid radial head, wrist, proximal humerus
6
Q
Common injury patterns - falling off roof?
A
- os calcis, tibial plateau, TL compression fx
7
Q
How do you describe fx?
A
- name of injured bone
- location (dorsal, volar: epiphysis, metaphysis, diaphysis - proximal, middle, distal third)
- orientation of fx: transverse, oblique, spiral, angulated, comminuted, segmental, intra-articular, displaced, compression and impaction
- condition of overlying tissues (open or closed): 1 puncture, 2 laceration w/ mod ST injury, 3 grossly contaminated
8
Q
What factors effect tx?
A
- open or closed injury
- nature and severity of fx:
energy involved: stable or unstable
is position acceptable, is jt involved? - possible neuro-vascular injuries/complications: N/V issues and compartment syndromes
- age, health, demands of pt
9
Q
Complications of fxs?
A
- pelvic and femoral fxs can have significant blood loss
- injuries to other structures: nerves/vessels, esp at knee and elbow
- acute compartment syndromes
- increased risk of venous thrombosis w/ major trauma
- Fat emboism syndrome: femur fx
- complex regional pain syndromes (sympathetic dystrophy)
- late: osteomyelitis, non/mal-union, post-traumatic arthritis
10
Q
Principles of tx?
A
acute stabilization:
- eval the pt
- immobilize fx: usually splinting
- provide analgesia: ice, elevation, immobilization, pain meds
- decide on definitive tx
- create conditions where the body will heal the fx while pt is as fxnl as possible:
allow for jt motion when possible, pts need est of when they can return to work/sports
11
Q
Tx options for fxs?
A
- reassurance or min. tx: rib fxs, torus fxs, metacarpal fxs, toe fxs
- immobilization w/ cast, splint or brace: works well for stable, well aligned fx, down side: prolonged immobilization, loss of reduction, fxnl limits
- traction: better options than this now
- fx reduction closed or open: maintain w/ cast, hardware or both
- surgical fixation:
displaced, unstable fx, early mobilization, often the best option: quick return to fxn, displaced intra-articular fxs, down side is cost, complications including infection
12
Q
Casting is TOC for what? Types of casts/splints?
A
- Rx of choice for undisplaced, stable, and some reduced fxs
- plaster of paris or fiberglass:
plaster easier to mold,
fiberglass more durable - may splint initially - safer than a cast in acute setting: volar splint forearm and wrist, sugar tong splint for ankle
- diaphyseal fxs: include jts above and below fx
- complications of casting: pressure sores, N/V compromise, compartment syndrome, disuse atrophy, jt stiffness
13
Q
Surgical options for fxs?
A
- pins and wires: reduction of fx, pin fixaion, and cast, cerclage and tension band wiring
- plates and screws: initially thick and unbending, now contoured to specific bones and locking plates
- external fixators: for unstable injuries and contaminated fxs
- intramedullary devices: for long bone fxs, options for cross locking screws, gamma nails for unstable hip fxs
- replacements: hip, shoulder, radial head
14
Q
Common fxs in kids? Salter Harris classification?
A
- usually heal much faster than adults - potential for remodeling
- unique fxs due to nature of young bone:
buckle (torus), greenstick, plastic deformation, growth plate injury, apophyseal avulsion - Salter:
1 undisplaced
2 physis + metaphysis
3 physis + epiphysis
4 across physis
5 crush injury
15
Q
Tx for clavicular fxs?
A
- most (70%) are mid shaft: stable: sling or figure of 8, if displaced, angulated or over riding fx may need surgery
- in kids: 90% in middle 3rd, if younger than 10: majority are non displaced, if older than 10 than majority are displaced
- distal 3rd: behave like AC separations, if undisplaced: conservative tx, otherwise may need surgical repair
- prox 3rd: rare, beware of internal injuries - high energy injury (think about internal injuries as well)
16
Q
How common are adult shoudler fxs? Tx?
A
- 5% of all fxs and increases w/ advancing age:
often due to falling from standing ht, may be simple 2 part fx or 3 or 4 part fx w/ tuberosity involvement - gross deformity suggests anterior or posterior dislocation: need axillary or transthoracic xrays as well as AP films, fx alone can cause sig swelling and ecchymosis
- 80% are impacted or non-displaced: conservative rx -
basic tx is sling, limitation of activities, pain meds, mobilize as comfort permits, PT/OT of benefit, sleep in recliner initially - refer anatomic neck, complex fxs and dislocations
17
Q
Tx for distal forearm fxs in kis?
A
- need ortho referral if there is N/V compromise, open fx, gross deformity or displaced salter fx
- stable fxs may be tx w/ casts or braces:
depends on pt/parent preference, high five to assess healing
18
Q
What is a colle’s fx? Tx?
A
- incidence increases w/ age
- dorsal displacement/angulation of distal radius
- FOOSH
- tx ranges from splint to pinning to plating
19
Q
Metacarpal fxs usually due to what? Tx?
A
- 30-40% of all hand fxs
- usually due to direct trauma (punching a wall)
- tx depends on displacement, angulation, rotation
- can accept sig angulation of 5th metacarpal (Boxer’s): can be tx w/ off the shelf braces or taping of fingers
20
Q
Tx of base of thum fxs?
A
- stability determines tx
- thumb spica if stable, if not refer to ortho
21
Q
Etiology of vertebral compression fx? Tx?
A
- traumatic fx: has there been posterior compromise?
- osteoporotic often are asx: dowager’s hump - can occur in absence of trauma, tx: pain relief and correction of osteoporosis
- bracing can provide pain relief and increased activity, surgery for neuro compromise or unresponsive pain - vertebroplasty: correction and cement
22
Q
Etiology of pelvic fxs? Tx?
A
- major trauma in young, beware of blood loss and injuries to other organs
- elderly: can see pubic rami or sacral fxs w/ minimal trauma: seen in osteoporotic, low body wt, smoking, steroids, limited activity
- be suspicious w/ vague pelvic pain, pain w/ leg motion, inability to bear wt on leg
- dx w/ xrays, may need MRI
- pain control and early, protected ambulation
23
Q
Hip fxs in the elderly? Tx?
A
- sig source of morbidity and mortality in elderly:
1/3 die w/in 6 months, fx may occur b/f fall (pathologic fx) - unless severely debilitated, Rx of choice is surgery:
decreases morbidity, relieves pain, allows for fxn, may need total hip if there is preexisting arthritis
24
Q
Presentation of femoral neck fxs? Complications? tx?
A
- shortening and external rotation of leg = groin pain
- interrupt blood supply, high complication rate
- replacement often better than pinning
25
Tx of intertrochanteric hip fxs?
- do well w/ plate and screws
| - can lose sig blood: type and screen b/f surgery
26
Tx of subtrochanteric hip fxs?
- unstable injury best tx w/ intramedullary device, also can have significant blood loss
27
Common tibial shaft fxs? Tx?
- low energy fxs usually seen in distal metaphysics
- rotational injuries cause spiral, oblique, or distal fxs
- mid shaft fxs usually due to high energy injuries: MVA - be on alert for compartment syndrome
- need to be tx by an orthopedist:
may be able to tx stable injuries conservatively, many injuries will reqr surgery
28
ankle fxs:
| PE, dx, tx?
- common injury seen w/ twisting injuries of foot/ankle
- PE: N/V status - medial and lateral tenderness
- need AP, lateral, and oblique xrays
- stable injuries can be tx conservatively: undisplaced malleolar fx w/o ligamentous injury
- unstable injuries: do better w/ surgery - bimalleolar fxs or malleolar fx w/ ligament injury
- surgery mandatory if there is ankle jt diastasis: always look at mortice
29
Dx, tx of foot fxs?
- need AP, lateral, and oblique xrays
- beware of mid and hind foot fxs: severity of injury can be hard to see on X-rays, palpate tarsal-metatarsal its, occult injuries
- most forefront fxs can be tx conservatively:
short leg walking cast or walking boot, 1st metatarsal fxs require extra vigilance, stable toe fx can be simply taped, displaced, unstable toe Fxs may need pinning
30
How common are metastatic fxs?
- occur in 10-15% of persons w/ mets bone disease
- 17-50% of pts w/ breast cancer and bone mets will experience new spinal fxs each year
- up to 41% of pts receiving radiation to tx bone mets experience bone fxs
- new spinal fxs are reported to occur in 15-30% of pts w/ multiple myeloma annually
- vertebral fx is present more than half the time, among myeloma pts w/ bone pain in back
31
Tx of met fxs?
- need to stabilize fx, remove tumor: bone cement
| - early lesion (pre fx) may respond to radiotherapy
32
When do stress fxs occur? Presentation?
- occur b/c of repetitive stresses applied to bone: rate of resorption exceeds that of deposition
- can start as dull ache and build to sharp pain: stress rxn progresses to frank fx, will have pt tenderness over fx site
- often not seen on X-ray: MRI or bone scan if suspicious
33
Tx of stress fx?
- most respond to decreased activity and immobilization, beware stress fx in spine, hip and tarsal navicular: aching groin pain in an endurance athlete must be fully eval
34
What are fx patterns suggestive of inflicted trauma?
- injuries inconsistent w/ hx given or changes in hx given: esp in young or special needs pts
Fx patterns suggestive of inflicted trauma:
- metaphyseal corner fxs
- fxs of ribs, sternum, scapula, spinous processes
- mult fxs in various stages of healing
- bilateral acute long bone fxs
- skull fxs in kids younger than 18 months
- skeletal survery or bone scan to find occult lesions
- legally reqd to notify child protective services
35
When should you refer a pt w/ a fx on to ortho?
- any open injury
- when there is neurovascular compromise: beware spine, knee, elbow fxs
- high energy injuries
- excessive pain: possible compartment syndrome
- fx that is sig angulated or displaced: if it is deformed clinically, usually needs to be reduced
- fxs with known bad outcomes:
hip fxs, scaphoid fxs, displaced long bone fxs
- whenever pt or parent has concerns
