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Fractures II (Pelvic fractures (Lateral compression fracture (Side impact,…
Fractures II
Pelvic fractures
High energy in young
Low energy in elderly
Almost always involves >1 fracture
Risk of haemorrhage to internal iliac arterial system
Mandatory rectal exam
Blood indicates open fracture
Loss of anal sphincter tone = sacral nerve root damage
Lateral compression fracture
Side impact
Medial hemipelvic displacement
Accompanying SI joint/ pubic rami fracture
Anteroposterior compression fracture
Open book fracture
High chance of significant haemorrhage
Acetabular fracture
Fracture of posterior wall
Reduction/ internal fixation in young
Total hip replacement in elderly
Hip fractures
Majority osteoporosis related
Associated with risk of falling
Risk of surgery as high as risk of not operating
Intracapsular
Arterial supply of femoral head can be disrupted
Risk of avascular necrosis and non-union
Hemiarthroplasty/ total hip replacement
Extracapsular
Low risk of avascular necrosis
Internal fixation
With dynamic sliding screw
Subtrochanteric proximal femoral
Fall onto side
Thomas splinting
Intramedullary nail
Femoral shaft
High energy
Osteoporotic crush fractures in elderly
High risk of haemorrhage/thrombosis/lipoembolism
Requires immediate Thomas splinting
Definitive treatment with intramedullary nail
Acromioclavicular joint
Subluxation
Usually with ligament rupture
Dislocation
Usually with coracoid ligament rupture
Sprain
Conservative management with sling
Humeral shaft fractures
Direct trauma
Tranverse fracture
Comminuted fracture
Fall onto outstretched hand
Oblique fracture
Spiral fracture
Risk of radial nerve injury
Wrist drop
High union rate with bracing
Forearm fracture
Ulnar shaft
Nightstick fracture
Usually direct blow
Conservative treatment
Monteggia fracture-dislocation
Ulnar fracture with radial dislocation
ORIF
Galeazzi fracture-dislocation
Radial fracture with ulnar dislocation
ORIF
Distal radius
Colles fracture
Extra-articular <1" of articular surface
Dorsal displacement
Concomitant fracture of ulnar styloid
Fall onto outstretched hand
Treatment
Minimally displaced = splintage
Percutaneous wiring
ORIF
Risk of median nerve injury
Smith's fracture
Volar displacement
Fall onto back of flexed wrist
ORIF
Barton's fracture
Intra-articular fracture
Subluxation of carpal bones
ORIF
Hand fracture
Scaphoid
Fall onto outstretched hand
Tenderness over anatomical snuffbox
Plaster cast/ splintage
Risk of avascular necrosis
Penetrating hand injuries
Dorsal = extensor tendons
Volar = flexor tendons
Surgical exploration and tendon repair required
Mallet finger
Avulsion fracture of extensor tendon from distal phalanx
Often from ball sports
Presents with flexion of DIP
Splintage
Phalangeal/ metacarpal fractures treated conservatively
Knee
Distal femoral fracture
Osteoporotic patients
Fall onto flexed knee
Presents with unretractable flexed knee
ORIF
Knee dislocation
Sporting/ high energy injuries
Hyperextension/ twisting
High risk of vascular/nervous injury and compartment syndrome
Immediate reduction
Immediate neurovascular assessment
Ligament reconstruction
Patellar dislocation
Almost always lateral
Most common in adolescent females
Presents with pain over patellofemoral ligament and haemarthrosis
Risk of osteochondral fracture
Physiotherapy
Proximal tibial plateau fracture
High energy
Intra-articular
Car-bumper fracture= medial fracture
Risk of common peroneal nerve injury
Foot drop
Fibular head fracture
Plates and screws
Often requires TKR later on
Tibial shaft fractures
Slowest healing bone in body
Usually open fracture
Commonest cause of compartment syndrome
Treatment
Non-operative
<50% displacement
<5 degrees angulation
Frequent X-rays and cast alteration
Operative
Open fractures
Comminuted fractures
Internal fixation
Intramedullary nail
Spinal fractures
Cervical spine
Occurs in high energy injuries
Must be immobilised with collar
Criteria for clearing
No loss of consciousness
GCS 15
No distracting injuries
No neurological injury
No midline tenderness on palpation
No pain on gentle movement
Treatment involves collar/ halo vest
Thoracocolumbar
Usually from RTAs
Osteoporotic crush fracture in elderly
Stable
No displacement
Bracing
Plaster jacket
Unstable
Surgery
Neurological injury
Loss of height
Posterior ligament involvement
Displacement
Spinal cord injury
Complete
No motor/ sensory function below fracture
No recovery
Reflexes intact
Incomplete
Partial functioning
Sacral sparing indicates continuity of spinal tract
Central cord syndrome
Most common
Occurs with hyperextension
Paralysis of upper limbs with sacral/ lower limb sparing
Anterior cord syndrome
Paralysis with loss of pain and temperature sensation
Maintenance of proprioception and touch
Posterior cord syndrome
Loss of proprioception and touch
Brown-Sequard syndrome
Ipsilateral paralysis with contralateral loss of sensation
Spinal shock
Physiologic response
Loss of function/sensation/reflexes below level of spinal injury
Lasts 24 hours
End can be determined by return of bulbocavernous reflex
Neurogenic shock
Temporary loss of sympathetic drive from T1-S2
Hypotension
Bradycardia
Resolves within 24-48 hours
Treated with IV fluids
Shoulder
Usually sporting injuries
Humeral neck
Most commonly osteoporotic fall onto outstretched hand
Occurs in surgical neck
Medial displacement of humeral shaft
Avulsion of rotator cuff tendons common
Treated with sling + mobilisation
Internal fixation only if significant displacement
Dislocations
Anterior > posterior
Excessive external rotation
Bankart lesion = anterior detachment of labrum
Hill-Sachs lesion = compaction fracture of posterior head
Risk of damage to axillary nerve
Loss of sensation in regimental badge patch
Loss of roundness
Arm held in adducted position
Posterior dislocation = lightbulb sign on X-ray
Ankle injuries
Inversion/ rotation on planted foot
Sprain
Pain/bruising/tenderness over lateral ligaments
Fracture
Stable
Isolated distal fibular
Intact deltoid ligament
Cast 6 weeks
Unstable
Distal fibular fracture with rupture of deltoid
Medial tenderness/haematoma
ORIF/ rigid internal fixation
1mm gap can result in osteoarthritis
Bimalleolar fractures
Foot injuries
Calcaneal fracture
Fall from height
Can involve subtalar joint
Risk of compartment syndrome
ORIF in young patients
Arthrodesis in older/ co-morbidities
Talus fracture
Rapid deceleration with forced dorsiflexion
ORIF
Risk of avascular necrosis
Midfoot fracture-dislocation
Lisfranc fracture
Fracture of 2nd metatarsal with dislocation of 2nd/lateral metatarsals
Gross swelling and bruising
ORIF
Distal tibial
Extra-articular
Conservative management
Intra-articular
Pilon fractures
Displacement of talus
Emergency ORIF