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Fractures 4

The document provides information on the presentation, investigation and management of bone fractures. It discusses the types of fractures such as transverse, oblique, spiral and comminuted fractures. It describes how fractures can be presented including symptoms of pain, swelling and deformity. Investigations for fractures include x-rays, CT scans and MRI. Fractures need to be properly described including location, type, displacement and any additional details like open wounds.

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Presentation, investigation and management of fractures William Beedham [1] Broken Bone (Fracture) Symptoms, Types, Causes, Treatment & Healing [Internet]. EMedicineHealth. 2019 [cited 8 September 2019]. A https://www.emedicinehealth.com/bone_fracture_broken_bone/article_em.htm [1]
Learning outcomes and rationale By the end of this session, you should be able to: 1. Describe the presentation of bone fractures. 2. Choose appropriate investigations for bone fractures and interpret the results of these investigations. 3. Demonstrate an understanding of the management principles of bone fractures. *Warning of material*
[1] Humeral Shaft Fractures - Trauma - Orthobullets [Internet]. Orthobullets.com. 2019 [cited 18 September 2019]. Available from: https://www.orthobullets.com/trauma/1016/humeral-shaft-fractures [1]
[2] Ankle Fracture Associated with Tibia Shaft Fractures [Internet]. Synapse.koreamed.org. 2019 [cited 18 September 2019]. Available from: https://synapse.koreamed.org/search.php?where=aview&id=10.12671/jkfs.2014.27.2.136&code=0104JKFS&vmode=PUBREADER [2]
What is a fracture • Simply – a broken bone [1]. • Bones are rigid, with some elasticity. • External force can cause breaking of bone. [1] Luqmani R, Robb J, Porter D, Keating J. Textbook of Orthopaedics, Trauma and Rheumatology. London: Elsevier; 2008. [2] 10 Facts You Must Know about Bone Fractures [Internet]. Ortho Atlanta - Orthopaedics and Sports Medicine. 2019 [cited 16 September 2019]. Available from: https://www.orthoatlanta.com/media/10-facts-you-must-know-about- bone-fractures [2]
Presentation of a fracture [4] Swollen Ankle and Leg Causes, Treatments, and More [Internet]. Healthline. 2019 [cited 17 September 2019]. Available from: https://www.healthline.com/health/swollen-ankle-and-leg [3] Ankle Fracture | Dr. David Geier - Sports Medicine Simplified [Internet]. Dr. David Geier - Sports Medicine Simplified. 2019 [cited 17 September 2019]. Available from: https://www.drdavidgeier.com/ankle- fractures/ [2] 9 of the Worst Injuries in the History of World Football [Internet]. 90min.com. 2019 [cited 17 September 2019]. Available from: https://www.90min.com/posts/3477820-9-of-the-worst-injuries-in-the- history-of-world-football [1] Open fracture [Internet]. Academic Dictionaries and Encyclopedias. 2019 [cited 17 September 2019]. Available from: https://medicine.academic.ru/5841/Open_fracture [1] [2][3][4]
How can we describe a fracture? 1. Type of fracture 2. Location – be specific 3. Displacement 4. Additional info – open? Additional fractures?
Type of Fracture [2] • Incomplete fractures: • Greenstick/Buckle • Fissure • Depression • Complete • Transverse • Oblique • Spiral • Comminuted • Multiple • Impaction • Compression Fractures - OrthoInfo - AAOS [Internet]. OrthoInfo. 2019 [cited 16 September 2019]. Available from: https://orthoinfo.aaos.org/en/diseases--conditions/fractures-broken-bones/ Everything You Need To Know About Your Femur Bone [Internet]. Osteoporosis institute. 2019 [cited 12 September 2019]. Available from: https://www.osteoporosisinstitute.org/femur/ [1]
Greenstick/Buckle fracture • Greenstick: • Convex surface structural integrity overcome • Concave surface in tact. • Buckle/Torus: • Convex in tact • Concave over-come • Angulated longitudinal force • Perpendicular force [3] Greenstick fracture [Internet]. En.wikipedia.org. 2019 [cited 17 September 2019]. Available from: https://en.wikipedia.org/wiki/Greenstick_fracture [2] Mechanism of Injury | Bone Fractures [Internet]. Fractures.thecommonvein.net. 2019 [cited 17 September 2019]. Available from: https://fractures.thecommonvein.net/17-2/ [1] Types of Fractures [Internet]. The Orthopedic Institute at Southwest Health. 2019 [cited 17 September 2019]. Available from: http://orthopedic-institute.org/fracture- care/types-of-fractures/ [4] Weerakkody Y. Torus fracture | Radiology Reference Article | Radiopaedia.org [Internet]. Radiopaedia.org. 2019 [cited 17 September 2019]. Available from: [1] [2] [3] [4]
Fissure fracture • Hairline fracture [2] • Repetitive injury Welck M, Hayes T, Pastides P, Khan w, Rudge B. Stress fractures of the foot and ankle. Injury [Internet]. 2017 [cited 10 September 2019];48(8):1722-1726. Available from: https://www.injuryjournal.com/article/S0020-1383(15)00343-5/fullte Stress Fractures of the Foot and Ankle - AAOS [Internet]. Orthoinfo. 2019 [cited 8 September 2019]. Available from: https://orthoinfo.aaos.org/en/diseases--conditions/stress-fractures-of-the-foot-and-ankle/ [1] • Athletes and osteoporotic patients • Small crack or severe bruising of the bone
Depressed fracture • Area of skull vault displaced inwards • Most commonly in frontoparietal region [1] • High energy impact to the skull [1] Demetriades D, Kobayashi L. Skull fractures - Symptoms, diagnosis and treatment | BMJ Best Practice [Internet]. Bestpractice.bmj.com. 2019 [cited 16 September 2019]. Available from: https://bestpractice.bmj.com/topics/en-gb/398 [2] Bickle I. Depressed skull fracture | Radiology Reference Article | Radiopaedia.org [Internet]. Radiopaedia.org. 2019 [cited 17 September 2019]. Available from: https://radiopaedia.org/articles/depressed-skull-fracture [2] [2]
Transverse fracture • Complete fracture • Go across bone perpendicular to the bone axis • Strong force applied perpendicular to bone [1] • Commonly in long bones • Risk of displacement [1] Jones J. Transverse fracture | Radiology Reference Article | Radiopaedia [Internet]. Radiopaedia.org. 2019 [cited 16 September 2019]. Available from: https://radiopaedia.org/articles/transverse-fracture?lang=gb [2] Jones J. Tibial fracture: transverse diaphyseal | Radiology Case | Radiopaedia.org [Internet]. Radiopaedia.org. 2019 [cited 17 September 2019]. Available from: https://radiopaedia.org/cases/tibial-fracture-transverse-diaphyseal [2]
Oblique fracture • Complete fracture in a plane oblique to the axis of the bone • Sharp, angled force to the bone. • Risk of displacement. [1] Jones J. Oblique tibial fracture | Radiology Case | Radiopaedia [Internet]. Radiopaedia.org. 2019 [cited 16 September 2019]. Available from: https://radiopaedia.org/cases/oblique-tibial-fracture?lang=us [1]
Spiral fracture • Complete fracture of long bones, in a spiral appearance • Due to a high energy rotational force • Often associated with displacement [1] Figure 1 - Medical Cases. Spiral Fracture [Internet]. 2019 [cited 16 September 2019]. Available from: https://app.figure1.com/rd/images/56d4e8d6db2008a0795fdc76 [1]
Comminuted fracture • Heterogenous term • 2+ bone fragments are created • Smashed/fragmented appearance • Severe traumatic force – common in RTA [1] Tibial Shaft Fractures - Trauma - Orthobullets [Internet]. Orthobullets. 2019 [cited 16 September 2019]. Available from: https://www.orthobullets.com/trauma/1045/tibial-shaft-fractures [1]
Multiple/Segmented fracture • Similar to comminuted • 2+ fractures at different places within the bone • Difficult management [1] Rohmer T. Multiple fracture of forearm bones treated with closed nailing technique [Internet]. Kolhe Hospital. 2019 [cited 16 September 2019]. Available from: http://kolhehospital.com/ph/?f=Multiple+fracture+of+forearm+bones+treated+with+closed+nailing+technique [1]
Impaction fracture • Force pushes the 2 ends of the fractured bone into each other – axial force [3] • Common in medial femoral condyle fracture [3] Luqmani R, Robb J, Porter D, Keating J. Textbook of Orthopaedics, Trauma and Rheumatology. London: Elsevier; 2008. [2] Hip Fractures [Internet]. Orthoinfo.aaos.org. 2019 [cited 16 September 2019]. Available from: https://orthoinfo.aaos.org/en/diseases--conditions/hip-fractures [1] Willems N, Langenbach G, Everts V, Zentner A. The microstructural and biomechanical development of the condylar bone: a review. The European Journal of Orthodontics [Internet]. 2013 [cited 7 September 2019];36(4):479-485. Available from: https://www.researchgate.net/publication/259491973_The_microstructural_and_biomechanical_development_of_th e_condylar_bone_A_review [2] [1]
Compression fracture • Used almost exclusively for vertebrae • Usually secondary to osteoporosis • Due to the weight bearing force on the bone. [2] Ledford J. Non-Neoplastic Diseases of Bones and Joints: Atlas of Non-tumour Pathology. American Journal of Roentgenology [Internet]. 2012 [cited 4 September 2019];199(6):W778-W778. Available from: https://www.cambridge.org/core/books/silverbergs-principles-and-practice-of-surgical-pathology-and- cytopathology/nonneoplastic-diseases-of-bones-and-joints/B20AF43D409FEBFBFE08C78A306B56BF [1] Vertebral Compression Fractures - Injuries; Poisoning - MSD Manual Professional Edition [Internet]. MSD Manual Professional Edition. 2019 [cited 17 September 2019]. Available from: https://www.msdmanuals.com/professional/injuries-poisoning/fractures/vertebral- compression-fractures [1] [2]
Open fracture • Fracture of the bone with a direct communication to the external environment. • High energy trauma – commonly RTA. • In-to-out, or out-to-in. • Risks include [3]: [2] Alexandra Ortego M. Open Fractures [Internet]. Core EM. 2019 [cited 17 September 2019]. Available from: https://coreem.net/core/open-fractures/ [1] GmbH D. Open fracture - DocCheck Pictures [Internet]. DocCheck Pictures. 2019 [cited 17 September 2019]. Available from: https://pictures.doccheck.com/com/photo/6234-open-fracture [3] National Institute for Health and Care Excellence (NICE), Fractures (complex): assessment and management: NICE Guideline [NG37]. 2016. Available from: https://www.nice.org.uk/guidance/ng37/ifp/chapter/Open-fractures#first-steps-in-treatment [cited 15 September 2019]. [1] [2]
Open fracture • Fracture of the bone with a direct communication to the external environment. • High energy trauma – commonly RTA. • In-to-out, or out-to-in. • Risks include [3]: [2] Alexandra Ortego M. Open Fractures [Internet]. Core EM. 2019 [cited 17 September 2019]. Available from: https://coreem.net/core/open-fractures/ [1] GmbH D. Open fracture - DocCheck Pictures [Internet]. DocCheck Pictures. 2019 [cited 17 September 2019]. Available from: https://pictures.doccheck.com/com/photo/6234-open-fracture [3] National Institute for Health and Care Excellence (NICE), Fractures (complex): assessment and management: NICE Guideline [NG37]. 2016. Available from: https://www.nice.org.uk/guidance/ng37/ifp/chapter/Open-fractures#first-steps-in-treatment [cited 15 September 2019]. [1] [2] Skin damage Soft tissue damage – Gustilo classification. Neurovascular damage Infection
How can we describe a fracture? 1. Type of fracture 2. Location – be specific 3. Displacement 4. Additional info – open? Additional fractures?
Location location location 1. Bone 2. Location within the bone 3. Anatomical name for the part of the bone (if commonly used) [1] Easy Notes On Bones of the Hands [Internet]. Earth's Lab. 2019 [cited 17 September 2019]. Available from: https://www.earthslab.com/anatomy/bones-of-the-hand-carpals-metacarpals-and- phalanges/ [2] 6.3 Bone Structure – Anatomy and Physiology [Internet]. Opentextbc.ca. 2019 [cited 17 September 2019]. Available from: https://opentextbc.ca/anatomyandphysiology/chapter/6-3-bone-structure/ [1] [2]
How can we describe a fracture? 1. Type of fracture 2. Location – be specific 3. Displacement 4. Additional info – open? Additional fractures?
Displacement • TRIAD [2] • Translation = sideways motion • Rotation = rotational displacement • Impaction = 2 ends of fracture pushed into each other • Angulation = one end of the fracture is not aligned with the axis of the bone - can be valgus or varus. • Distraction = increased overall bone length [2] Introduction to Trauma X-ray - Fracture displacement [Internet]. Radiologymasterclass. 2019 [cited 16 September 2019]. Available from: https://www.radiologymasterclass.co.uk/tutorials/musculoskeletal/trauma/trauma_x-ray_page3 [1] Melbourne T. Fracture Education : Evaluation [Internet]. Royal Children's Hospital Melbourne. 2019 [cited 17 September 2019]. Available from: https://www.rch.org.au/fracture-education/evaluation/Evaluation_/ [1]
How can we describe a fracture? 1. Type of fracture 2. Location – be specific 3. Displacement 4. Additional info – open? Additional fractures?
Investigations • Imaging: • X-ray • CT • Three phase bone scan (TPBS) • MRI • FBC + blood typing + crossmatch [3] • Compartment pressure testing • ABPI • US/duplex scanning • Angiography [3] Cohen P. Long bone fracture - Symptoms, diagnosis and treatment [Internet]. BMJ Best Practice. 2019 [cited 16 September 2019]. Available from: https://bestpractice.bmj.com/topics/en-gb/386/investigations [2] Kaewlai R, Avery L, Asrani A, Abujudeh H, Sacknoff R, Novelline R. Multidetector CT of Carpal Injuries: Anatomy, Fractures, and Fracture-Dislocations. RadioGraphics [Internet]. 2008 [cited 6 September 2019];28(6):1771-1784. Available from: https://pubs.rsna.org/doi/pdf/10.1148/rg.286085511 [1] Standing CT vs. MRI for Advanced Visualization of Knee Cartilage and Meniscus - CurveBeam [Internet]. CurveBeam. 2019 [cited 17 September 2019]. Available from: https://www.curvebeam.com/blog/standing-ct-vs-mri-for-advanced- visualization-of-knee-cartilage-and-meniscus/ [1] [2]
Interpreting investigations Radiograph interpretation (4 step approach): 1. Describe radiograph – who? what? why? when? where? 2. Type of fracture? 3. Location? – be specific 4. Displacement?
Presentation and investigations quiz – Case 1 28 YO M pt. Says that they were drunk last and in a fit of anger, kicked a lamp-post [1] Sorrentino S. Tibial midshaft fracture - Radiology Case [Internet]. Radiopaedia.org. 2019 [cited 17 September 2019]. Available from: https://radiopaedia.org/cases/tibial-midshaft-fracture?lang=gb [1]
Presentation and investigations quiz – Case 1 28 YO M pt. Says that they were drunk last and in a fit of anger, kicked a lamp-post X ray of 28YOM patient [1] Sorrentino S. Tibial midshaft fracture - Radiology Case [Internet]. Radiopaedia.org. 2019 [cited 17 September 2019]. Available from: https://radiopaedia.org/cases/tibial-midshaft-fracture?lang=gb [1] PA and Lateral views of the right leg Transverse fracture Of the right tibial midshaft With a translation – proximal fragment is posterior and medial
Presentation and investigation quiz – Case 2 32 YO M comes in with pain and swelling of the hand. His friend got hurt kicking a lamp post, so he decided to punch the lamp post in retaliation. [1] Boxer's fracture [Internet]. En.wikipedia.org. 2019 [cited 17 September 2019]. Available from: https://en.wikipedia.org/wiki/Boxer%27s_fracture [1]
Presentation and investigation quiz – Case 2 32 YO M comes in with pain and swelling of the hand. His friend got hurt kicking a lamp post, so he decided to punch the lamp post in retaliation. X ray of 32YOM patient Boxer’s fracture [1] Boxer's fracture [Internet]. En.wikipedia.org. 2019 [cited 17 September 2019]. Available from: https://en.wikipedia.org/wiki/Boxer%27s_fracture [1] PA view of the right hand Transverse fracture Of the right 5th metacarpal head. With a translation and ?angulation
Presentation and investigation – Case 3 65 YOF arrives in A+E with husband. Says that she tripped and fell forwards in the kitchen. Managed to put her hand out in front of her to break her fall. [1] Colles' fracture [Internet]. En.wikipedia.org. 2019 [cited 17 September 2019]. Available from: https://en.wikipedia.org/wiki/Colles%27_fracture[1]
Presentation and investigation – Case 3 65 YOF arrives in A+E with husband. Says that she tripped and fell forwards in the kitchen. Managed to put her hand out in front of her to break her fall. X ray of 65YOF patient [1] Colles' fracture [Internet]. En.wikipedia.org. 2019 [cited 17 September 2019]. Available from: https://en.wikipedia.org/wiki/Colles%27_fracture[1] PA + lateral view of the L wrist Transverse fracture Of the radial metaphysis With a translation and ?angulation
Management Principles ABCDE 1. Reduce – Required for displaced fractures. 2. Hold – The reduction must be maintained whilst the fracture heals. 3. Rehabilitate – Optimise the long-term functional outcomes. 4. Arthroplasty 5. Special cases Luqmani R, Robb J, Porter D, Keating J. Textbook of Orthopaedics, Trauma and Rheumatology. London: Elsevier; 2008.
Management Quiz
Case 1 • 46 YO male came into A+E after falling off his bike onto his flexed hand. • He is in a lot of pain, which you manage. • You order an X-ray in 2 planes: • How would you manage this? [1] Smith's fracture [Internet]. En.wikipedia.org. 2019 [cited 18 September 2019]. Available from: https://en.wikipedia.org/wiki/Smith%27s_fracture [1]
Case 2 • 72 year old female is brought in by ambulance after being found on the kitchen floor by a neighbour. • Her right leg appears to be slightly shorter and externally rotated. • She is in a lot of pain, which you manage. • An X-ray is ordered: • How would you manage this? [1] Femoral Neck Fractures - Trauma - Orthobullets [Internet]. Orthobullets.com. 2019 [cited 18 September 2019]. Available from: https://www.orthobullets.com/trauma/1037/femoral-neck-fractures [1]
Case 3 • An unconscious patient is brought in by air ambulance following a severe RTA. The patient has been stabilised by paramedics. There is however a high energy fracture of their tibia, with the medial fracture end piercing the skin of the anterior leg. • X ray is taken of the patient: • How would you manage this? [1] healing? H. How to tell if my leg fracture is healing? [Internet]. Medical Sciences Stack Exchange. 2019 [cited 18 September 2019]. Available from: https://medicalsciences.stackexchange.com/questions/3500/how-to-tell-if-my-leg-fracture-is-healing [1]
Role-play – patient notes task • Divide into 2 groups – each group is an on-call doctor • Will be presented with a clinical case • 10 minutes - Within your group you must write in the patient’s notes with the following information: • Patient demographics • How the patient presented? • What the X-ray shows? • What further investigations are appropriate • What would the management plan be?
Role-play group 1 • You are doctor working on A+E. • Nurse calls you over to see a 53 YO F patient who fell from her mountain bike yesterday onto her left arm. • The patient is in significant pain and the nurse suspects a fracture. • Describe this presentation? • What investigations would you do to confirm this diagnosis? [1] Bruising on a woman's arm due to fractured humerus [Internet]. Science Photo Library. 2019 [cited 8 September 2019]. Available from: https://www.sciencephoto.com/media/264187/view/bruising-on-a-woman-s-arm-due-to-fractured-humerus [1]
Role-play group 2 • You are on A+E. • 32 YO M is brought in by ambulance, after his left leg got trapped under his motorcycle. • He has been stabilised, but is complaining of terrible pain. • The paramedics ask you to see the patient, as they think there may be a fracture • Describe this presentation? • What investigation would you like to do to confirm this diagnosis? [1] Swollen Ankle and Leg Causes, Treatments, and More [Internet]. Healthline. 2019 [cited 17 September 2019]. Available from: https://www.healthline.com/health/swollen- [1]
Group 1 Group 2 1. Patient demographics 2. How patient presented? 3. What the X-ray shows? 4. What further investigations are appropriate 5. What would the management plan be? Patient demographics [1] Humeral Shaft Fractures - Trauma - Orthobullets [Internet]. Orthobullets.com. 2019 [cited 18 September 2019]. Available from: https://www.orthobullets.com/trauma/1016/humeral-shaft-fractures [1] [2] Ankle Fracture Associated with Tibia Shaft Fractures [Internet]. Synapse.koreamed.org. 2019 [cited 18 September 2019]. Available from: [2]
Questions? Further clarification? 1. What is it called when bone alignment is lost following a fracture? 2. What is the first step in fracture management? 3. What is normal compartment pressure? 4. What are the risks following an open fracture?
Thank you for listening!

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Fractures 4

  • 1.
    Presentation, investigation and managementof fractures William Beedham [1] Broken Bone (Fracture) Symptoms, Types, Causes, Treatment & Healing [Internet]. EMedicineHealth. 2019 [cited 8 September 2019]. A https://www.emedicinehealth.com/bone_fracture_broken_bone/article_em.htm [1]
  • 2.
    Learning outcomes andrationale By the end of this session, you should be able to: 1. Describe the presentation of bone fractures. 2. Choose appropriate investigations for bone fractures and interpret the results of these investigations. 3. Demonstrate an understanding of the management principles of bone fractures. *Warning of material*
  • 3.
    [1] Humeral ShaftFractures - Trauma - Orthobullets [Internet]. Orthobullets.com. 2019 [cited 18 September 2019]. Available from: https://www.orthobullets.com/trauma/1016/humeral-shaft-fractures [1]
  • 4.
    [2] Ankle FractureAssociated with Tibia Shaft Fractures [Internet]. Synapse.koreamed.org. 2019 [cited 18 September 2019]. Available from: https://synapse.koreamed.org/search.php?where=aview&id=10.12671/jkfs.2014.27.2.136&code=0104JKFS&vmode=PUBREADER [2]
  • 5.
    What is afracture • Simply – a broken bone [1]. • Bones are rigid, with some elasticity. • External force can cause breaking of bone. [1] Luqmani R, Robb J, Porter D, Keating J. Textbook of Orthopaedics, Trauma and Rheumatology. London: Elsevier; 2008. [2] 10 Facts You Must Know about Bone Fractures [Internet]. Ortho Atlanta - Orthopaedics and Sports Medicine. 2019 [cited 16 September 2019]. Available from: https://www.orthoatlanta.com/media/10-facts-you-must-know-about- bone-fractures [2]
  • 6.
    Presentation of afracture [4] Swollen Ankle and Leg Causes, Treatments, and More [Internet]. Healthline. 2019 [cited 17 September 2019]. Available from: https://www.healthline.com/health/swollen-ankle-and-leg [3] Ankle Fracture | Dr. David Geier - Sports Medicine Simplified [Internet]. Dr. David Geier - Sports Medicine Simplified. 2019 [cited 17 September 2019]. Available from: https://www.drdavidgeier.com/ankle- fractures/ [2] 9 of the Worst Injuries in the History of World Football [Internet]. 90min.com. 2019 [cited 17 September 2019]. Available from: https://www.90min.com/posts/3477820-9-of-the-worst-injuries-in-the- history-of-world-football [1] Open fracture [Internet]. Academic Dictionaries and Encyclopedias. 2019 [cited 17 September 2019]. Available from: https://medicine.academic.ru/5841/Open_fracture [1] [2][3][4]
  • 7.
    How can wedescribe a fracture? 1. Type of fracture 2. Location – be specific 3. Displacement 4. Additional info – open? Additional fractures?
  • 8.
    Type of Fracture[2] • Incomplete fractures: • Greenstick/Buckle • Fissure • Depression • Complete • Transverse • Oblique • Spiral • Comminuted • Multiple • Impaction • Compression Fractures - OrthoInfo - AAOS [Internet]. OrthoInfo. 2019 [cited 16 September 2019]. Available from: https://orthoinfo.aaos.org/en/diseases--conditions/fractures-broken-bones/ Everything You Need To Know About Your Femur Bone [Internet]. Osteoporosis institute. 2019 [cited 12 September 2019]. Available from: https://www.osteoporosisinstitute.org/femur/ [1]
  • 9.
    Greenstick/Buckle fracture • Greenstick: •Convex surface structural integrity overcome • Concave surface in tact. • Buckle/Torus: • Convex in tact • Concave over-come • Angulated longitudinal force • Perpendicular force [3] Greenstick fracture [Internet]. En.wikipedia.org. 2019 [cited 17 September 2019]. Available from: https://en.wikipedia.org/wiki/Greenstick_fracture [2] Mechanism of Injury | Bone Fractures [Internet]. Fractures.thecommonvein.net. 2019 [cited 17 September 2019]. Available from: https://fractures.thecommonvein.net/17-2/ [1] Types of Fractures [Internet]. The Orthopedic Institute at Southwest Health. 2019 [cited 17 September 2019]. Available from: http://orthopedic-institute.org/fracture- care/types-of-fractures/ [4] Weerakkody Y. Torus fracture | Radiology Reference Article | Radiopaedia.org [Internet]. Radiopaedia.org. 2019 [cited 17 September 2019]. Available from: [1] [2] [3] [4]
  • 10.
    Fissure fracture • Hairlinefracture [2] • Repetitive injury Welck M, Hayes T, Pastides P, Khan w, Rudge B. Stress fractures of the foot and ankle. Injury [Internet]. 2017 [cited 10 September 2019];48(8):1722-1726. Available from: https://www.injuryjournal.com/article/S0020-1383(15)00343-5/fullte Stress Fractures of the Foot and Ankle - AAOS [Internet]. Orthoinfo. 2019 [cited 8 September 2019]. Available from: https://orthoinfo.aaos.org/en/diseases--conditions/stress-fractures-of-the-foot-and-ankle/ [1] • Athletes and osteoporotic patients • Small crack or severe bruising of the bone
  • 11.
    Depressed fracture • Areaof skull vault displaced inwards • Most commonly in frontoparietal region [1] • High energy impact to the skull [1] Demetriades D, Kobayashi L. Skull fractures - Symptoms, diagnosis and treatment | BMJ Best Practice [Internet]. Bestpractice.bmj.com. 2019 [cited 16 September 2019]. Available from: https://bestpractice.bmj.com/topics/en-gb/398 [2] Bickle I. Depressed skull fracture | Radiology Reference Article | Radiopaedia.org [Internet]. Radiopaedia.org. 2019 [cited 17 September 2019]. Available from: https://radiopaedia.org/articles/depressed-skull-fracture [2] [2]
  • 12.
    Transverse fracture • Completefracture • Go across bone perpendicular to the bone axis • Strong force applied perpendicular to bone [1] • Commonly in long bones • Risk of displacement [1] Jones J. Transverse fracture | Radiology Reference Article | Radiopaedia [Internet]. Radiopaedia.org. 2019 [cited 16 September 2019]. Available from: https://radiopaedia.org/articles/transverse-fracture?lang=gb [2] Jones J. Tibial fracture: transverse diaphyseal | Radiology Case | Radiopaedia.org [Internet]. Radiopaedia.org. 2019 [cited 17 September 2019]. Available from: https://radiopaedia.org/cases/tibial-fracture-transverse-diaphyseal [2]
  • 13.
    Oblique fracture • Completefracture in a plane oblique to the axis of the bone • Sharp, angled force to the bone. • Risk of displacement. [1] Jones J. Oblique tibial fracture | Radiology Case | Radiopaedia [Internet]. Radiopaedia.org. 2019 [cited 16 September 2019]. Available from: https://radiopaedia.org/cases/oblique-tibial-fracture?lang=us [1]
  • 14.
    Spiral fracture • Completefracture of long bones, in a spiral appearance • Due to a high energy rotational force • Often associated with displacement [1] Figure 1 - Medical Cases. Spiral Fracture [Internet]. 2019 [cited 16 September 2019]. Available from: https://app.figure1.com/rd/images/56d4e8d6db2008a0795fdc76 [1]
  • 15.
    Comminuted fracture • Heterogenousterm • 2+ bone fragments are created • Smashed/fragmented appearance • Severe traumatic force – common in RTA [1] Tibial Shaft Fractures - Trauma - Orthobullets [Internet]. Orthobullets. 2019 [cited 16 September 2019]. Available from: https://www.orthobullets.com/trauma/1045/tibial-shaft-fractures [1]
  • 16.
    Multiple/Segmented fracture • Similarto comminuted • 2+ fractures at different places within the bone • Difficult management [1] Rohmer T. Multiple fracture of forearm bones treated with closed nailing technique [Internet]. Kolhe Hospital. 2019 [cited 16 September 2019]. Available from: http://kolhehospital.com/ph/?f=Multiple+fracture+of+forearm+bones+treated+with+closed+nailing+technique [1]
  • 17.
    Impaction fracture • Forcepushes the 2 ends of the fractured bone into each other – axial force [3] • Common in medial femoral condyle fracture [3] Luqmani R, Robb J, Porter D, Keating J. Textbook of Orthopaedics, Trauma and Rheumatology. London: Elsevier; 2008. [2] Hip Fractures [Internet]. Orthoinfo.aaos.org. 2019 [cited 16 September 2019]. Available from: https://orthoinfo.aaos.org/en/diseases--conditions/hip-fractures [1] Willems N, Langenbach G, Everts V, Zentner A. The microstructural and biomechanical development of the condylar bone: a review. The European Journal of Orthodontics [Internet]. 2013 [cited 7 September 2019];36(4):479-485. Available from: https://www.researchgate.net/publication/259491973_The_microstructural_and_biomechanical_development_of_th e_condylar_bone_A_review [2] [1]
  • 18.
    Compression fracture • Usedalmost exclusively for vertebrae • Usually secondary to osteoporosis • Due to the weight bearing force on the bone. [2] Ledford J. Non-Neoplastic Diseases of Bones and Joints: Atlas of Non-tumour Pathology. American Journal of Roentgenology [Internet]. 2012 [cited 4 September 2019];199(6):W778-W778. Available from: https://www.cambridge.org/core/books/silverbergs-principles-and-practice-of-surgical-pathology-and- cytopathology/nonneoplastic-diseases-of-bones-and-joints/B20AF43D409FEBFBFE08C78A306B56BF [1] Vertebral Compression Fractures - Injuries; Poisoning - MSD Manual Professional Edition [Internet]. MSD Manual Professional Edition. 2019 [cited 17 September 2019]. Available from: https://www.msdmanuals.com/professional/injuries-poisoning/fractures/vertebral- compression-fractures [1] [2]
  • 19.
    Open fracture • Fractureof the bone with a direct communication to the external environment. • High energy trauma – commonly RTA. • In-to-out, or out-to-in. • Risks include [3]: [2] Alexandra Ortego M. Open Fractures [Internet]. Core EM. 2019 [cited 17 September 2019]. Available from: https://coreem.net/core/open-fractures/ [1] GmbH D. Open fracture - DocCheck Pictures [Internet]. DocCheck Pictures. 2019 [cited 17 September 2019]. Available from: https://pictures.doccheck.com/com/photo/6234-open-fracture [3] National Institute for Health and Care Excellence (NICE), Fractures (complex): assessment and management: NICE Guideline [NG37]. 2016. Available from: https://www.nice.org.uk/guidance/ng37/ifp/chapter/Open-fractures#first-steps-in-treatment [cited 15 September 2019]. [1] [2]
  • 20.
    Open fracture • Fractureof the bone with a direct communication to the external environment. • High energy trauma – commonly RTA. • In-to-out, or out-to-in. • Risks include [3]: [2] Alexandra Ortego M. Open Fractures [Internet]. Core EM. 2019 [cited 17 September 2019]. Available from: https://coreem.net/core/open-fractures/ [1] GmbH D. Open fracture - DocCheck Pictures [Internet]. DocCheck Pictures. 2019 [cited 17 September 2019]. Available from: https://pictures.doccheck.com/com/photo/6234-open-fracture [3] National Institute for Health and Care Excellence (NICE), Fractures (complex): assessment and management: NICE Guideline [NG37]. 2016. Available from: https://www.nice.org.uk/guidance/ng37/ifp/chapter/Open-fractures#first-steps-in-treatment [cited 15 September 2019]. [1] [2] Skin damage Soft tissue damage – Gustilo classification. Neurovascular damage Infection
  • 21.
    How can wedescribe a fracture? 1. Type of fracture 2. Location – be specific 3. Displacement 4. Additional info – open? Additional fractures?
  • 22.
    Location location location 1.Bone 2. Location within the bone 3. Anatomical name for the part of the bone (if commonly used) [1] Easy Notes On Bones of the Hands [Internet]. Earth's Lab. 2019 [cited 17 September 2019]. Available from: https://www.earthslab.com/anatomy/bones-of-the-hand-carpals-metacarpals-and- phalanges/ [2] 6.3 Bone Structure – Anatomy and Physiology [Internet]. Opentextbc.ca. 2019 [cited 17 September 2019]. Available from: https://opentextbc.ca/anatomyandphysiology/chapter/6-3-bone-structure/ [1] [2]
  • 23.
    How can wedescribe a fracture? 1. Type of fracture 2. Location – be specific 3. Displacement 4. Additional info – open? Additional fractures?
  • 24.
    Displacement • TRIAD [2] •Translation = sideways motion • Rotation = rotational displacement • Impaction = 2 ends of fracture pushed into each other • Angulation = one end of the fracture is not aligned with the axis of the bone - can be valgus or varus. • Distraction = increased overall bone length [2] Introduction to Trauma X-ray - Fracture displacement [Internet]. Radiologymasterclass. 2019 [cited 16 September 2019]. Available from: https://www.radiologymasterclass.co.uk/tutorials/musculoskeletal/trauma/trauma_x-ray_page3 [1] Melbourne T. Fracture Education : Evaluation [Internet]. Royal Children's Hospital Melbourne. 2019 [cited 17 September 2019]. Available from: https://www.rch.org.au/fracture-education/evaluation/Evaluation_/ [1]
  • 25.
    How can wedescribe a fracture? 1. Type of fracture 2. Location – be specific 3. Displacement 4. Additional info – open? Additional fractures?
  • 26.
    Investigations • Imaging: • X-ray •CT • Three phase bone scan (TPBS) • MRI • FBC + blood typing + crossmatch [3] • Compartment pressure testing • ABPI • US/duplex scanning • Angiography [3] Cohen P. Long bone fracture - Symptoms, diagnosis and treatment [Internet]. BMJ Best Practice. 2019 [cited 16 September 2019]. Available from: https://bestpractice.bmj.com/topics/en-gb/386/investigations [2] Kaewlai R, Avery L, Asrani A, Abujudeh H, Sacknoff R, Novelline R. Multidetector CT of Carpal Injuries: Anatomy, Fractures, and Fracture-Dislocations. RadioGraphics [Internet]. 2008 [cited 6 September 2019];28(6):1771-1784. Available from: https://pubs.rsna.org/doi/pdf/10.1148/rg.286085511 [1] Standing CT vs. MRI for Advanced Visualization of Knee Cartilage and Meniscus - CurveBeam [Internet]. CurveBeam. 2019 [cited 17 September 2019]. Available from: https://www.curvebeam.com/blog/standing-ct-vs-mri-for-advanced- visualization-of-knee-cartilage-and-meniscus/ [1] [2]
  • 27.
    Interpreting investigations Radiograph interpretation(4 step approach): 1. Describe radiograph – who? what? why? when? where? 2. Type of fracture? 3. Location? – be specific 4. Displacement?
  • 28.
    Presentation and investigationsquiz – Case 1 28 YO M pt. Says that they were drunk last and in a fit of anger, kicked a lamp-post [1] Sorrentino S. Tibial midshaft fracture - Radiology Case [Internet]. Radiopaedia.org. 2019 [cited 17 September 2019]. Available from: https://radiopaedia.org/cases/tibial-midshaft-fracture?lang=gb [1]
  • 29.
    Presentation and investigationsquiz – Case 1 28 YO M pt. Says that they were drunk last and in a fit of anger, kicked a lamp-post X ray of 28YOM patient [1] Sorrentino S. Tibial midshaft fracture - Radiology Case [Internet]. Radiopaedia.org. 2019 [cited 17 September 2019]. Available from: https://radiopaedia.org/cases/tibial-midshaft-fracture?lang=gb [1] PA and Lateral views of the right leg Transverse fracture Of the right tibial midshaft With a translation – proximal fragment is posterior and medial
  • 30.
    Presentation and investigationquiz – Case 2 32 YO M comes in with pain and swelling of the hand. His friend got hurt kicking a lamp post, so he decided to punch the lamp post in retaliation. [1] Boxer's fracture [Internet]. En.wikipedia.org. 2019 [cited 17 September 2019]. Available from: https://en.wikipedia.org/wiki/Boxer%27s_fracture [1]
  • 31.
    Presentation and investigationquiz – Case 2 32 YO M comes in with pain and swelling of the hand. His friend got hurt kicking a lamp post, so he decided to punch the lamp post in retaliation. X ray of 32YOM patient Boxer’s fracture [1] Boxer's fracture [Internet]. En.wikipedia.org. 2019 [cited 17 September 2019]. Available from: https://en.wikipedia.org/wiki/Boxer%27s_fracture [1] PA view of the right hand Transverse fracture Of the right 5th metacarpal head. With a translation and ?angulation
  • 32.
    Presentation and investigation– Case 3 65 YOF arrives in A+E with husband. Says that she tripped and fell forwards in the kitchen. Managed to put her hand out in front of her to break her fall. [1] Colles' fracture [Internet]. En.wikipedia.org. 2019 [cited 17 September 2019]. Available from: https://en.wikipedia.org/wiki/Colles%27_fracture[1]
  • 33.
    Presentation and investigation– Case 3 65 YOF arrives in A+E with husband. Says that she tripped and fell forwards in the kitchen. Managed to put her hand out in front of her to break her fall. X ray of 65YOF patient [1] Colles' fracture [Internet]. En.wikipedia.org. 2019 [cited 17 September 2019]. Available from: https://en.wikipedia.org/wiki/Colles%27_fracture[1] PA + lateral view of the L wrist Transverse fracture Of the radial metaphysis With a translation and ?angulation
  • 34.
    Management Principles ABCDE 1. Reduce– Required for displaced fractures. 2. Hold – The reduction must be maintained whilst the fracture heals. 3. Rehabilitate – Optimise the long-term functional outcomes. 4. Arthroplasty 5. Special cases Luqmani R, Robb J, Porter D, Keating J. Textbook of Orthopaedics, Trauma and Rheumatology. London: Elsevier; 2008.
  • 35.
  • 36.
    Case 1 • 46YO male came into A+E after falling off his bike onto his flexed hand. • He is in a lot of pain, which you manage. • You order an X-ray in 2 planes: • How would you manage this? [1] Smith's fracture [Internet]. En.wikipedia.org. 2019 [cited 18 September 2019]. Available from: https://en.wikipedia.org/wiki/Smith%27s_fracture [1]
  • 37.
    Case 2 • 72year old female is brought in by ambulance after being found on the kitchen floor by a neighbour. • Her right leg appears to be slightly shorter and externally rotated. • She is in a lot of pain, which you manage. • An X-ray is ordered: • How would you manage this? [1] Femoral Neck Fractures - Trauma - Orthobullets [Internet]. Orthobullets.com. 2019 [cited 18 September 2019]. Available from: https://www.orthobullets.com/trauma/1037/femoral-neck-fractures [1]
  • 38.
    Case 3 • Anunconscious patient is brought in by air ambulance following a severe RTA. The patient has been stabilised by paramedics. There is however a high energy fracture of their tibia, with the medial fracture end piercing the skin of the anterior leg. • X ray is taken of the patient: • How would you manage this? [1] healing? H. How to tell if my leg fracture is healing? [Internet]. Medical Sciences Stack Exchange. 2019 [cited 18 September 2019]. Available from: https://medicalsciences.stackexchange.com/questions/3500/how-to-tell-if-my-leg-fracture-is-healing [1]
  • 39.
    Role-play – patientnotes task • Divide into 2 groups – each group is an on-call doctor • Will be presented with a clinical case • 10 minutes - Within your group you must write in the patient’s notes with the following information: • Patient demographics • How the patient presented? • What the X-ray shows? • What further investigations are appropriate • What would the management plan be?
  • 40.
    Role-play group 1 •You are doctor working on A+E. • Nurse calls you over to see a 53 YO F patient who fell from her mountain bike yesterday onto her left arm. • The patient is in significant pain and the nurse suspects a fracture. • Describe this presentation? • What investigations would you do to confirm this diagnosis? [1] Bruising on a woman's arm due to fractured humerus [Internet]. Science Photo Library. 2019 [cited 8 September 2019]. Available from: https://www.sciencephoto.com/media/264187/view/bruising-on-a-woman-s-arm-due-to-fractured-humerus [1]
  • 41.
    Role-play group 2 •You are on A+E. • 32 YO M is brought in by ambulance, after his left leg got trapped under his motorcycle. • He has been stabilised, but is complaining of terrible pain. • The paramedics ask you to see the patient, as they think there may be a fracture • Describe this presentation? • What investigation would you like to do to confirm this diagnosis? [1] Swollen Ankle and Leg Causes, Treatments, and More [Internet]. Healthline. 2019 [cited 17 September 2019]. Available from: https://www.healthline.com/health/swollen- [1]
  • 42.
    Group 1 Group2 1. Patient demographics 2. How patient presented? 3. What the X-ray shows? 4. What further investigations are appropriate 5. What would the management plan be? Patient demographics [1] Humeral Shaft Fractures - Trauma - Orthobullets [Internet]. Orthobullets.com. 2019 [cited 18 September 2019]. Available from: https://www.orthobullets.com/trauma/1016/humeral-shaft-fractures [1] [2] Ankle Fracture Associated with Tibia Shaft Fractures [Internet]. Synapse.koreamed.org. 2019 [cited 18 September 2019]. Available from: [2]
  • 43.
    Questions? Further clarification? 1.What is it called when bone alignment is lost following a fracture? 2. What is the first step in fracture management? 3. What is normal compartment pressure? 4. What are the risks following an open fracture?
  • 44.
    Thank you forlistening!

Editor's Notes

  • #3 Describe the presentation of pathological bone fractures, including red flags. Choose appropriate investigations for pathological bone fractures and interpret the results of these investigations. Demonstrate an understanding of the management principles of pathological bone fractures. – this will involve you being able to formulate a management plan following the presentation of a pathological fracture.
  • #6 More official definition – a fracture is the loss of continuity of bone and is most frequently due to trauma.
  • #7 Red flags of fracture
  • #8 Describing a fracture is very useful and is directly transferable to describing an X-ray
  • #10 Lateral longitudinal = FOOSH Perpendicular force = trauma. These fractures are common in children due to the softer bones due to less mature mineralisation. The greenstick and Buckle fractures are the 2 fractures that occur when one side of the bone is in tact and the other side is overcome – they are opposites Buckle is more common. Torus is the word used for the base of a Greek Column and represents the donut ring appearance of a bone that has undergone this fracture type. Occurs due to “bending of the bone” that can come from an angulated longitudinal force or a perpendicular force.
  • #11 Hairline fractures are very small cracks that appear in the bones Often due to repetitive low energy trauma to the bone such as running on hard surfaces. Osteoporotic patients are also particularly at risk due to their diminished bone density. As you can see it is very difficult to detect these fractures on a plain radiograph – therefore there is a special type of investigation that we will discuss later for these fractures.
  • #12 A depressed fracture normally occurs in flat bones such as the skull This occurs when a fragment of the bone is punched out or pushed through the plane of the bone e.g. depressed skull fracture. The fronto-parietal region – this is an area where the coronal suture is present and also where the pterion occurs on the side, which is the weakest area of the skull due to the meeting of the three bones and the relatively low thickness. Normally caused by a high energy impact with a blunt or penetrating object. Often the depression does not cause complete fracture of the bone and therefore it is considered an incomplete fracture.
  • #13 A transverse fracture occurs when there is a complete fracture of the bone from one side of the bone to the other. This occurs due to a high energy force being applied perpendicular to the bone. More common in long bones due to the relative instability within the diaphysis. Because there is complete transection of the bone there are effectively 2 fracture fragments that are able to move independently – therefore there is possibility of moving.
  • #14 This is a form of complete fracture where the fracture is in the plane that is oblique to the axis of the bone. There must be a sharp angled force to the bone There is a high risk of displacement – This is because of the plane of the bone, means that there is weight bearing instability and high risk of displacement. Because of the shape the fracture shape it is likely that this will be an angulation fracture. Furthermore due to the sharp fracture fragments that are created there is increased risk of soft tissue injury – e.g. nerve, blood vessel of muscle damage.
  • #15 Spiral fractures are due to a high energy rotational force = Torsion – this is often due to the foot being planted with the body remaining in motion – seen often in sports players who wear studs for example. This can also be due to a combined loading = compression with torsion for example. Highly associated with displacement – the high energy and subsequent instability of the fracture fragments.
  • #16 Effectively this term is used when in a fracture there are more fracture components or fragments than the main proximal and distal Often display a smashed or fragmented appearance This is often due to very high energy impacts such as RTA
  • #17 The same bone has been broken at 2 distinct sites, differentiating it from the comminuted fracture. Fractures are difficult to manage, especially without open surgical intervention Very often there is significant displacement or open aspects
  • #18 There is axial force – force acting within the axis of the bone - this causes a compression of the bone that leads to fracture as the bone breaks. Specifically a fragment of cortical bone is pushed into cancellous bone. (hard into spongy) Common in medial femoral condyle fracture due to the weight bearing in this region which causes a lot of axial force.
  • #19 Compression fracture is similar to impaction and is caused by axial force being applied. However in this case it is used to describe when cancellous bone collapses in on itself rather than being impacted by cortical bone – this is most commonly seen in the vertebral column.
  • #20 Gustilo classification: This is a classification that is done according to the size, extent of soft tissue damage, and neurovascular compromise. 1, 2, 3a, 3b, 3c This helps to decide the course of management – anything 3b or above require a flap rather than just soft tissue coverage. Out to in or in to out = there may be an external sharp force that has caused the open wound to the bone fracture or it may be the bone fragment that has caused the perforation of the skin.
  • #21 Gustilo classification: This is a classification that is done according to the size, extent of soft tissue damage, and neurovascular compromise. 1, 2, 3a, 3b, 3c This helps to decide the course of management – anything 3b or above require a flap rather than just soft tissue coverage. Out to in or in to out = there may be an external sharp force that has caused the open wound to the bone fracture or it may be the bone fragment that has caused the perforation of the skin.
  • #23 Need to think about 3 lots of location information. Which bone is it within the body – gives gross location – e.g. tibia Where within the bone is the fracture – diaphysis, epiphysis etc. Anatomical used for the bone? – this is for example the shafts, base or heads of the metacarpal bones?
  • #25 Displacement can be described as abnormal position of the distal bone fragment to the proximal one. Displacement can be remembered with the TRIAD mnemonic Translation = sideways motion Rotation = rotationally displaced = what fracture would this be common in? Femoral neck fracture Impaction = the 2 ends are pushed into eachother causing bone shortening. Angulation = one end of the fracture (one of the fracture fragments (proximal or distal)) is not aligned with the axis of the bone. Distraction = increased overall bone length = stretching out.
  • #27 https://casereports.bmj.com/content/2017/bcr-2017-221647 X ray: Useful for finding a fracture Radiolucency – suggests that there is a fracture with a gap in the bone (displacement) Radio-opacity – suggests that there is compression of fragments. CT: These allow better visualisation of the fracture that may not be seen on plain X-ray. Can do 3D construction imaging which aids in the exact fracture anatomy Useful for peri-operative planning. TPBS: Technetium 99 bone scan that is used to look for skeletal mets Also picks up on small stress fractures – there is increased uptake of the radio-active tracer in the areas of bone turnover. Compartment pressure: Important when there is a risk of compartment syndrome. Involves a small needle being inserted into the compartment. Normal pressure is below 8 mmHg Anything above 20 may cause pain 25-30 may cause neurovascular compromise. Symptoms of compartment sy ABPI – way of assessing the blood flow Duplex – way of assessing flow to the limb Angiography – assess patency of blood vessels and can intervene if required. It is very important to assess the blood supply – after 20 minutes without blood there is irreversible damage to limb tissue.
  • #28 I have briefly talked about the other ways that investigations can be useful, but there is not enough time to go through every investigation, and unless you are a specialist, it is unlikely that you will need to do them – however being able to interpret a radiograph is an essential skill. Therefore we will focus on the interpretation of X rays in fracture diagnosis. So the best way to learn this is with some examples that we can work through. There are 3 cases – one person will talk us through each case, and then we will go through them as a group. The cases are also within the handout so you can fill them in – the numbers correspond to the 4 steps of interpreting X-rays.
  • #29 These cases are on page 8 and 9
  • #30 These cases are on page 8 and 9
  • #31 What else would you like to get – another view of the hand to assess the fracture more clearly or a CT.
  • #32 What else would you like to get – another view of the hand to assess the fracture more clearly or a CT.
  • #35 Reducing a fracture is re-establishing the correct alignment of the bone so that there is no longer any displacement. Reduction can be done without surgical intervention using manipulation and traction. Surgical reduction may be required for more complex fractures. May need to exaggerate fracture with degree of distraction Hold – When reduction must be maintained with force. This must be done whilst the fracture heals: Rehabilitate – this optimises the long term functional outcomes of the individual. Arthroplasty – when fracture occurs within a joint – may be easier to just replace the joint. Special cases – special cases that we must consider in fractures are mostly open factures.
  • #37 On pages 12, 13 and 14 of the handout Following the treatment algorithm: Reduce – There is moderate displacement of the fracture there is volar angulation of the distal fragment – the distal fragment is angled towards the palm. Reduction must take place – this can be done externally with the use of manipulation and traction. MUST ENSURE THAT THERE IS SUFFICIENT ANALGESIA or anaesthetic. Hold – In this case there should be a below the elbow back slab applied for 2 weeks to ensure that pressure is allowed to escape. Then a cast should be applied to prevent any distortion of the broken bone. Should be applied for 4-12 weeks. Rehabilitate – following the fracture disuse may lead to atrophy or nervous damage may require rehabilitation of the joints and muscles in that region. Falling onto a flexed hand is the known aetiology of a smith fracture where the distal fracture segment is displaced towards the palm (palmar surface)
  • #38 Reduce: The fracture appears to be translated and partially impacted therefore reduction with potential traction may be required. Hold : in this case fixation is not indicated but a hemi-arthroplasty – the acetabulum appears to be in-tact and therefore only the femoral head requires replacement. This is an example of a sub-capital intracapsular fracture. Rehabilitation – will require significant rehabilitation to be able to walk again. What else is important? Occupational therapy involvement – she is elderly and now has reduced mobility. We will want to do a kidney function test Creatine kinase – she is old – we do not know how long she has been on the floor – there is the chance of rhabdomyolysis. Continued pain management. Neck of femur fractures have v high mortality = 30% at one year – therefore it is highly likely that there will be complicaitons.
  • #39 Reduce: In this case there is more than one fracture. There is also angulation of both tibia and fibula. Therefore there should be surgical reduction of the fracture. Fixation: The fracture is in a weight bearing location. It is also in the diaphyseal region and therefore should be suitable for intramedullary nail fixation The fibula is too narrow for intra-medullary fixation. Rehabilitation: Patient will require significant rehabilitation following the injury. Other: Prophylactic antibiotics for risk of osteomyelitis or superficial infection.
  • #40 Pages 15-18 of the handout
  • #41 Take a concise history and communicate to the patient what you are going to do Give the patient pain medication Assess compartment pressure and neurovascular supply X-ray the patient
  • #43 Case 1 X-ray: Humeral mid-shaft fracture (diaphysis), spiral fracture with slight angulation. Further investigations: Need to check the neurovascular status of the arm – assess the peripheral pulses and also the sensation in all dermatomes. Consider duplex scan. The arm was red and swollen – likely inflammation due to the trauma, but to be safe test the compartment pressure. May also wish to do a clotting screen to assess the patients ability to clot. Management plan: Reduce – realign the bone Hold – in this case may require an intramedullary nail Rehabilitate Case 2 Describe the X-ray: Radiograph of the left leg of this 32 year old male taken on X, due to left leg pain following a fall from his motorcycle Oblique fracture. Mid-shaft of tibia (diaphysis) Appears to be slight angulation There appears to be a fractur in the fibula as well What investigations should you do next? Want a FBC – need to look at the potassium as this is a crush injury Also not sure how long he was there so maybe creatine kinase = look for rhambdomyolysis. Also look at kidneys for kidney damage. Do a clotting screen. What would the likely management plan be for this fracture? Because of the nature of the fracture and the high risk of displacement, it is advised to do an intra-medullary nail in this case. The fibula is also damaged but is quite narrow and so may not be able to fit a nail Therefore the fibula should be fixed with a plate.