Fractures

Question 1

How are fractures described?

Answer 1

1. Integrity of skin/tissue (closed/open)
2. Location (epiphyseal/ metaphyseal/ diaphyseal/physis)
3. Orientation/fracture pattern
4. Displacement

Question 2

What is an open v closed fracture?

Answer 2

Closed: skin overlying intact
Open: skin overlying lacerated, fracture exposed to external environment

Question 3

Characteristics of a transverse fracture?

Answer 3

Fracture line perpendicular to long axis of bone, direct force, high energy.

Question 4

Characteristics of an oblique fracture?

Answer 4

Angular fracture line, angular or rotational force.

Question 5

What is a spiral fracture?

Answer 5

Complex multi-planar fracture line. Rotational force with high energy.

Question 6

What is a comminuted fracture?

Answer 6

More than 2 fracture segments.

Question 7

What are the indications for open reduction of a fracture?

Answer 7

NO CAST:
N: Non-union
O: Open fracture
C: neurovascular Compromise
A: intra-Articular fracture
S: Salter-Harris 3/4/5
T: polyTrauma

Question 8

How should fractures be managed?

Answer 8

• ABC, 1” and 2” survey
• AMPLE Hx
• Analgesia
• Imaging
• Splint
• Reduction and maintenance
• Rehabilitation

Question 9

What is an AMPLE Hx?

Answer 9

• Allergies
• Medications
• PMHx
• Last meal
• Events surrounding injury.

Question 10

How is a closed reduction conducted?

Answer 10

• Apply traction in long axis of the limb
• Reverse mechanism that produced trauma
• Reduce with IV sedation and muscle relaxation

Question 11

What are the potential complications of open fracture reduction?

Answer 11

• Infection
• Mal-union
• Non-union
• Implant failure
• New fracture

Question 12

Describe normal fracture healing.

Answer 12

W 0-3: Haematoma, M0 surround fracture
W 3-6: osteoclasts remodel sharp edges, callus forms within haematoma
W 6-12: bone forms within callus, bridges fragments
M 6-12: Cortical gap bridged by bone
Y1-2: normal architecture through remodelling

Question 13

What are the early local complications of fracture?

Answer 13

• Compartment syndrome
• Neurovascular injury
• Infection
• Implant failure
• Fracture blisters

Question 14

What are the systemic complications of fracture?

Answer 14

• Sepsis
• DVT/PE
• ARDS (2” to fat embolism)
• Haemorrhagic shock

Question 15

What are the late local complications of fracture?

Answer 15

• Mal/non-union;
• AVN,
• osteomyelitis,
• Heterotopic ossification
• OA, stiffness.

Question 16

What is the emergency management of open fractures?

Answer 16

• Remove obvious foreign material
• Irrigate with normal saline if contaminated
• Cover with sterile dressing
• IV ABx
• Tetanus toxoid/Ig
• Reduce and splint
• NPO and OR prep

Question 17

What are the Xray rules in fracture investigation?

Answer 17

Xray Rule of 2s:

• 2 sides = bilateral
• 2 views = AP + lateral
• 2 joints = above and below
• 2 times = before and after reduction

Question 18

What does displacement refer to?

Answer 18

Distal fragment relative to the proximal fragment

Question 19

What is heterotopic ossification?

Answer 19

Formation of bone in abnormal locations (e.g. in muscle), secondary to pathology.

Question 20

What are the orthopaedic emergencies?

Answer 20

VON CHOP:
V- Vascular compromise
O - Open fracture
N - Neurological compromise
C - Compartment Syndrome
H - Hip Dislocation
O - Osteomyelitis / septic arthritis
P - unstable Pelvic Fracture

Question 21

What is an open fracture?

Answer 21

Fractured bone in communication with the external environment. Increased risk of osteomyelitis.

Question 22

Emergency management of open fracture?

Answer 22

STAND (splint, tetanus prophylaxis, ABx, Neurovascular status, dressings to cover).

• Clean/irrigate/cover
• Immediate IV ABx
• Consider tetanus toxoid / Ig
• Reduce and splint fracture
• NPO and OT prep

Question 23

How are open fractures classified?

Answer 23

Gustilo Classification (I-III) based on length of open wound (10cm).

Question 24

Prophylactic ABx in open fractures?

Answer 24

GUSTILO I: Cefazolin for 3d

GUSTILO II: Cefazolin 3/7 + gentamicin (G-ve cover) 3/7

Question 25

Mechanism of clavicle fracture?

Answer 25

- Fall on shoulder (87%) - Direct trauma to clavicle (7%) - FOOSH (6%)

Question 26

Clinical features of clavicle#?

Answer 26

- Pain and skin tenting | - Arm clasped to chest

Question 27

Mx clavicle fractures?

Answer 27

- Proximal and Middle 1/3: figure of 8 sling 1-2/52 - Distal 1/3: - ->undisplaced = sling 1-2/52. - ->displaced (CC ligament injury): ORIF

Question 28

Complications of clavicle fracture?

Answer 28

(In addition to general # complications) - cosmetic bump - shoulder stiffness/weakness - pneumothorax / neurovascular injury (very rare)

Question 29

Framework for fracture description?

Answer 29

``` SOLARTAT Site Open v closed Length Articular Rotation Translation Alignment / Angulation Type (e.g. Salter Harris etc) ```

Question 30

What is the Gustilo Anderson classification?

Answer 30

Classification of open fractures. i: wound 10cm, coverage available iiib: 10cm, requiring soft tissue coverage procedure iiic: with vascular injury requiring repair

Question 31

Emergency Mx and assessment of vascular injuries?

Answer 31

- Realign limb / apply longitudinal traction and reassess pulses - surgical consult - direct pressure if external bleeding

Question 32

Which structures are at risk in anterior shoulder dislocation?

Answer 32

- Axillary nerve (lateral aspect of shoulder) | - Musculocutaneous nerve (extensor aspect of forearm)

Question 33

What is the mechanism of Colles fracture?

Answer 33

Generally FOOSH

Question 34

Features of Colles fracture?

Answer 34

Dinner fork deformity i) Dorsal tilt ii) Dorsal displacement iii) Ulnar styloid fracture iv) Radial displacement v) Radial tilt vi) Shortening

Question 35

Fractures resulting from FOOSH by age?

Answer 35

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