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What is the principle of external fixation?
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What is the principle of external fixation?
Bone is transfixed above and below the fracture with screws, pins, or tensioned wires clamped to a frame.
What types of fractures can external fixation be applied to?
It can be used for long bones, pelvis, and almost any part of the skeleton.
What are the key components of a general examination?
Consciousness, position of the patient, breathing, attachments, and observation of skin/deformity.
What is the initial conservative treatment for shoulder dislocation?
Reduction under sedation or GA followed by immobilization in a chest arm bandage for 3 weeks.
What is meant by fracture displacement?
Displaced means the broken end moves out of place.
What are the benefits of external fixation?
It permits adjustment of length and angulation and allows reduction of the fracture in all three planes.
What vital signs are typically assessed during an examination?
Pulse Rate (PR), Blood Pressure (BP), Respiratory Rate (RR), and Temperature.
What indicates the need for open reduction in shoulder dislocation treatment?
Failed closed reduction, soft tissue interposition, greater tuberosity fracture, displacement >1cm after reduction, or large glenoid rim fracture.
What are the three reasons for fracture displacement?
What type of fracture may occur from a fall on the hand that twists the humerus?
Spiral fracture.
What are the indications for using external fixation?
Severe soft-tissue damage, open fractures, severe comminuted & unstable fractures, pelvic fractures, fractures with nerve & vessel damage, and ununited fractures.
What does the 'LOOK' aspect of a local examination include?
Gait, obvious external fixation, swelling, skin integrity, skin color, limb posture, and limb shortening.
What is a common complication of shoulder dislocation, particularly in the early phase?
Axillary nerve injury resulting in paralysis of the deltoid and anesthesia over the lateral aspect of the shoulder.
What does translation refer to in fracture displacement?
Translation refers to a shift where the fragment is displaced and loses its surface contact.
What kind of fracture is caused by a fall on the elbow with the arm abducted?
Oblique or transverse fracture.
What complications can arise from external fixation?
Damage to soft tissue structures, over distraction, and pin-track infection.
What does the 'FEEL' aspect of a local examination assess?
Temperature, tenderness, crepitation, bony irregularity, measurement of lower limbs, sensation, and vascular assessment.
What are common late complications following a shoulder dislocation?
Recurrent dislocation, unreduced dislocation, and traumatic osteoarthritis (OA).
What indicates a successful reduction of a fracture?
What is alignment in the context of fracture displacement?
Alignment refers to the fragment being tilted or angulated.
What is a common presentation of bicep tendon lesion in middle-aged or elderly individuals?
Degeneration and disruption often associated with rotator cuff problems.
What is the Empty Can Test used to assess?
Supraspinatus function.
What causes a transverse or comminuted fracture of the humerus?
A direct blow to the arm.
What types of X-rays should be taken in trauma cases?
Chest, pelvic, cervical, and concerned parts with 2 views (AP and lateral).
What is the aim of splinting in fracture management?
What should be done if a pin-track infection occurs?
Immediate care of the pin-site and administration of antibiotics.
What is the position of the head in inferior glenohumeral dislocation?
The head lies in the subglenoid position.
What is the first step in the fracture healing process?
Tissue destruction and haematoma formation.
What might be involved in the impingement syndrome related to the bicep tendon?
Bicep tendon lesions, including tendinitis and torn long head of the bicep.
What does rotation indicate in fracture displacement?
Rotation indicates that the bone looks straight but the limb has torsion deformity.
What does the Belly Press Test evaluate?
Subscapularis function.
What is the primary treatment method for fractured humeral shaft?
Immobilization with an external cast.
What is the first step in urgent wound and fracture debridement?
Maintain traction on injured limbs while replacing any dressing with a sterile pad and cleaning the surrounding skin.
What are non-operative methods for managing fractures with intact soft tissues?
What is the importance of the rule of 2 in X-ray assessment?
To take additional views for difficult-to-detect fractures, particularly in severe force injuries.
What method is used for traction and counter traction in shoulder dislocation?
Hippocrates method.
What is the commonest type of fracture in children?
Supracondylar humerus fracture.
What occurs at the fracture site during the first step?
Tissue damage and bleeding, leading to haematoma formation.
How can altered length affect a fracture?
Altered length can result in shortening of the bone due to muscle spasm.
What is a common fracture affecting all age groups?
Fracture of the clavicle.
What is the Painful Arc Test used for?
To identify rotator cuff tear, particularly between 60-120 degrees of abduction.
What are two special tests used to diagnose bicep tendon issues?
Speed test and Yergason test.
What is usually the main complaint in a fracture history?
Pain, often followed by a history of trauma.
What is the recommended irrigation method for a wound?
Irrigate thoroughly using copious amounts of warm normal saline, potentially needing 6-12 liters for long bone injuries.
What additional investigations are used for complex fractures?
CT/MRI and radioisotope imaging.
What should be checked before and after MRI for anterior dislocation management?
Check for axillary nerve intactness and sensation at the deltoid.
What is a common cause of a supracondylar humerus fracture?
Fall on an outstretched hand or direct fall on the elbow.
What is the purpose of a full blood count in fracture management?
To check for hemoglobin (Hb) and evaluate overall blood health.
What is the principle behind fixed traction?
Same principle as balanced traction, but without counter-traction.
How does the energy of the fracture impact soft tissue damage?
Low energy fractures cause moderate soft tissue damage, while high energy fractures cause severe damage.
What position is required for the Supraspinatus Test?
Seated or standing with arm abducted to 90 degrees and brought forward by 30 degrees.
What is the primary mechanism of injury for a clavicle fracture?
Fall on the point of the shoulder.
What is the typical symptom sharp localization in bicep tendon lesion?
Pain and tenderness over the bicipital groove.
What should be determined first in the mechanism of injury?
How the injury happened.
What antibiotics are used for prophylaxis in contaminated wounds?
Benzylpenicillin + Flucloxacillin or a second-generation cephalosporin, given every 6 hours for 48 hours.
What should be avoided during the movement examination?
Never move a broken bone; only relevant joints should be moved, especially in unconscious patients.
What is a common cause of elbow dislocation?
Fall on the outstretched hand.
Which direction is the displacement most likely in a supracondylar humerus fracture?
Posterior displacement is greater than anterior displacement.
What does the coagulation profile assess?
It assesses the blood's ability to clot, which is crucial before surgery.
Give an example of a low energy fracture.
A closed spiral fracture.
What are the weight guidelines for skin traction?
No more than 4-5 kg.
What is the first step in the cast application process?
Clean skin and apply dressing if there is a wound.
What type of cast is used for middle and upper shaft humeral fractures?
U-slab.
What percentage of clavicle fractures result from falls on the shoulder?
91%.
In the Infraspinatus and Teres Minor Test, how is the patient's arm positioned?
Arms at the sides with elbows flexed to 90 degrees.
What can help relieve pain in cases of bicep tendinitis?
Rest, local heat, and deep transverse frictions.
What are operative methods for fractures with severe soft tissue damage?
What factors influence the method of fixation for fractures?
Degree of contamination, length of time from injury to operation, and amount of soft tissue damage.
What factors regarding the injury's nature should be taken into account?
Velocity of injury, safety measures, and treatment received in A&E.
What happens within 8 hours of a fracture?
Inflammatory cells appear in the haematoma.
What percentage of elbow dislocations result in the forearm bones being pushed backwards?
90%.
What are some clinical features of a posteriorly displaced supracondylar humerus fracture?
Swelling, S-shaped deformity, distal humeral tenderness, and unusual posterior prominence at olecranon.
What is a common cause of acromioclavicular joint injury?
Fall on the outer prominence of the shoulder.
What is another name for subacute tendinitis in the context of rotator cuff syndrome?
Painful arc syndrome.
What is the primary aim of reduction in closed fractures?
To achieve adequate apposition and normal alignment of bone fragments.
What are examples of high energy fractures?
Segmental and comminuted fractures, either open or closed.
How many layers of padding/ortho bandage should be applied during cast preparation?
At least 2 layers with 50% overlap.
What complications can arise from skin traction?
Vascular compression.
What is the primary material used in a conventional cast?
Plaster of Paris (calcium sulfate, Gypsum).
When should ORIF (Open Reduction and Internal Fixation) be performed?
If the fracture is unstable, the patient is obese, or there is prolonged discomfort.
What does the Neer’s Sign test for?
Impingement of subacromial structures.
What are common clinical features of a clavicle fracture?
Pain, swelling, deformity, crepitus, and inability to raise the shoulder.
What deformity may occur due to bicep tendon rupture?
Popeye deformity.
What is the principle of sustained traction?
Traction is applied to the distal limb of the fracture, exerting a continuous pull along the long axis of the bone.
How should uncontaminated wound types I and II be treated?
Sutured within a few hours of injury after debridement and incision.
What are common symptoms to assess in a fracture?
Pain, swelling, bruising, obvious deformity, and loss of function.
What is formed during step 3 of the fracture healing process?
Soft callus from cells changing into osteoblasts and osteoclasts.
What are the special features of an elbow dislocation?
Deformity, pain, and swelling.
What is a potential early complication of a supracondylar humerus fracture?
Injury to the brachial artery or median and radial nerves.
What may result from acromioclavicular joint injury?
Partial or complete rupture of the acromioclavicular or coraco-clavicular ligaments.
What is the characteristic pain location for a rotator cuff tear?
Anterior shoulder pain.
When is reduction considered unnecessary?
When there is little or no displacement of the fracture.
What should you do to the plaster before application?
Soak plaster in water at room temperature until air bubbles cease.
What is the weight guideline for skeletal traction?
20% of body weight.
What are the advantages of using fiberglass for casts?
Strong, lighter, comfortable, cool, water-resistant, and radiolucent.
What are some potential complications of a humeral shaft fracture?
Nerve injury (e.g., radial nerve palsy) and non-union.
How do the outer and inner fragments displace in a clavicle fracture?
Outer fragment displaces medially and downward; inner fragment displaces upwards.
What indicates a positive test in the Hawkins Sign?
Pain when the arm is flexed to 90 degrees and internally rotated.
What history is often associated with SLAP lesions in the bicep tendon?
A fall followed by pain in the shoulder.
In which type of fractures is sustained traction particularly useful?
Spiral fractures of long bone shafts, such as the femur and tibia.
What indicates the need for plastic surgery in wound treatment?
Wound type III requiring more than one debridement and extensive skin loss over the fracture.
What can indicate nerve involvement in a fracture?
Numbness, movement, and sensation of the distal part.
What is one advantage of internal fixation?
Precise reduction and immediate stability.
What type of bone is formed during callus formation?
Immature bone, also known as woven bone.
What must be examined in the hand during an elbow dislocation assessment?
Signs of vascular or nerve damage.
What are common symptoms of acromioclavicular joint injury?
Pain and swelling localized to the acromioclavicular joint.
What is a late complication of a supracondylar humerus fracture?
Malunion leading to gunstock deformity.
What activity might lead to the development of anterior shoulder pain?
Competitive swimming or a weekend of house decorating.
What is the main challenge during the first 12 hours post-fracture?
Swelling of soft tissues, which can complicate reduction.
In which direction should the plaster bandage be applied?
From distal to proximal.
What are the disadvantages of Plaster of Paris?
Heavy, fragile when in contact with water, and radio-opaque.
What are some complications associated with skeletal traction?
Pin infection, nerve, and vascular injury.
What clinical features indicate a humeral shaft fracture?
History of trauma followed by pain, gradually increasing in severity, and limited movement.
What are the classifications of clavicle fractures based on the site?
Group I (middle 1/3), Group II (lateral 1/3), Group III (medial 1/3).
What are the signs of a torn long head of the bicep during a physical examination?
Elbow flexion leads to a prominent lump, and bruising may appear over the front of the arm.
What are the advantages of sustained traction?
Can move joints, allowing for muscle exercise, and is safe if not excessive.
What is the purpose of the Sugar-Tong splint?
Used for the acute management of distal radial and ulnar fractures.
What are the signs of dead muscles?
Purplish color, failure to contract, and failure to bleed when cut.
What signs may indicate vascular involvement?
Skin colour changes, temperature variation, pulse presence, and collagenosity.
What is a common disadvantage of internal fixation?
Sepsis.
What imaging technique is used to confirm an elbow dislocation?
X-ray.
What happens in step 4 of the healing process?
Consolidation occurs, transforming woven bone into lamellar bone.
What does an X-ray show in acromioclavicular joint injuries?
Subluxation or dislocation at the affected site.
What causes a fracture of the lateral condyle?
Falls on the hand with elbow extended and forced into varus.
What happens to tenderness during arm flexion in subacute tendinitis?
Tenderness disappears.
What are the two methods of reduction?
Closed reduction and open reduction.
How should the plaster be molded during application?
Evenly, rapidly, and without intervention using the palm, not fingers.
When should a splint be used instead of a cast?
For soft tissue injuries, acute management awaiting orthopedic intervention, or selected types of fractures.
What are the two types of traction pins mentioned?
Thin wire and Steinman pin.
What differential diagnoses should be considered for stiffness after a humeral shaft fracture?
Post-traumatic stiffness, disuse stiffness, regional pain syndrome, and arthritis.
What are early complications of a clavicle fracture?
Injury to subclavian vessel or medial cord of brachial plexus.
What is a potential complication of prolonged bed rest due to sustained traction?
Thromboembolism, respiratory problems, and general weakness.
How should the Humeral Shaft Coaptation splint be applied?
Medially splint ends in axilla and must be well padded to avoid skin breakdown.
What should be done post-operatively if a wound is left open?
Inspect again after 2-3 days; if there's significant skin loss, consider plastic surgery.
What systemic reviews should be performed after a fracture?
CNS, CVS/RS, GIT, and GUT assessments.
What factors influence the risk of infection in internal fixation?
Patient condition, doctor's skill, and facility standards.
What is the final step in fracture healing?
Remodelling of the newly formed bone to resemble normal structure.
What is the treatment for Grade I acromioclavicular joint injury?
Rest in a triangular sling and analgesics.
What is the first step in treating an uncomplicated elbow dislocation?
Patient should be fully relaxed under anaesthesia.
What is the recommended management for mild to moderate rotator cuff issues?
NSAIDs or aspirin.
What are the clinical features of a lateral condyle fracture?
Swollen and deformed elbow, tenderness over the lateral condyle, painful passive wrist flexion.
What should be assessed after the cast application?
Pulse and capillary refill.
What is required for successful closed reduction?
Anaesthesia, muscle relaxation, and X-rays before and after the procedure.
What is an advantage of a smooth Steinman pin?
Stronger but can slide if angled.
What are the rules for applying a Plaster of Paris cast?
Length from one joint above to one joint below, specific number of layers for upper and lower limbs, and specific width measurements.
What is the primary objective of exercise in fracture management?
To reduce oedema (swelling) and preserve joint movement.
What treatment is ideal for an undisplaced clavicle fracture?
Conservative treatment with a cuff and triangular sling.
What are the benefits of fracture bracing?
Allows for early functional range of motion and weight bearing, while relieving soft tissues and maintaining alignment.
What past medical history should be considered?
Previous anaesthesia, operations, injuries, and other musculoskeletal abnormalities.
When is internal fixation indicated?
For fractures that cannot be reduced non-operatively or are inherently unstable.
What proteins drive the process of callus formation?
Fibroblast growth factors, transforming growth factors, and bone morphogenic protein.
What is a common cause of glenohumeral dislocation?
A fall on an outstretched hand with the shoulder abducted and externally rotated.
What should be done after the reduction of an elbow dislocation?
Put the elbow through the full range of movement to check stability.
What procedure can help diagnose a rotator cuff tear?
Injecting local anesthetic into the subacromial space.
What is the treatment for a displaced supracondylar humerus fracture?
Open reduction and internal fixation (ORIF).
Who is most commonly affected by proximal humerus fractures?
Osteoporotic individuals after middle age.
What should a patient do immediately if they experience numbness, tingling, or increased pain after cast application?
Come immediately for assessment.
What indicates the need for open reduction?
If closed reduction fails or when the fracture involves large articular fragments.
What functional positions should the elbow and wrist be in when applying a cast?
Elbow in 90° flexion and wrist in 25° extension.
What is the typical diameter of a pin for adults?
5-6 mm.
What are the suggested activities for managing fractures?
Active exercise, assisted movement (continuous passive motion), and functional activity (everyday tasks).
What is a late complication of a clavicle fracture in the elderly?
Shoulder stiffness.
What injuries is the Volar/Dorsal forearm splint used for?
Soft tissue injuries to hand and wrist, acute carpal bone fractures (excluding scaphoid/trapezium), and childhood buckle fractures of the distal radius.
Why is social history important in fracture assessment?
To evaluate support systems, lifestyle factors like smoking or alcohol use, and financial status.
What is an interfragmentary screw used for?
Fixating small fragments onto the main bone.
What role do osteoclasts play in the consolidation phase?
They burrow through debris at the fracture site.
Which type of dislocation is more common in the glenohumeral joint?
Anterior dislocation is more common than posterior dislocation.
What is used to support the arm after an elbow reduction?
A light cast with elbow flexed to just above 90 degrees.
What are the symptoms of a complete rotator cuff tear during active abduction?
Active abduction is impossible.
What complication can arise from a fracture of the medial epicondyle?
Recurrent dislocation and stiffness of the elbow.
What commonly causes a rupture of the proximal humerus?
A fall on the outstretched hand.
What local complication can occur due to a tight cast?
Vascular compression, leading to diffuse pain and bluish discoloration of digits.
List the steps in the reduction process.
What is a necessary step before inserting a traction pin?
Create a sterile field with limb exposed.
What is the reason for immobilizing in functional anatomy?
To maintain proper joint function while providing immobilization.
What is the initial management step for an open fracture at the scene of an accident?
Splinting the limb and covering the wound to reduce risk of further contamination.
What is the definition of a fracture?
A break in the structural continuity of bone, which may include cracks, crumpling, splinting, or complete breaks.
What is the purpose of intramedullary nails?
To stabilize long bone fractures, especially in femur and tibia.
What is formed in the medullary cavity during remodelling?
The medullary cavity is reformed.
What is the typical mechanism of injury for posterior dislocation?
A direct force pushing the humerus head out of the glenoid cavity.
What should be done at 3 weeks post elbow dislocation treatment?
Discard the collar and cuff.
What occurs occasionally after a sprain or jerking injury of the shoulder?
A full thickness rotator cuff tear.
What are some special features of proximal humerus fractures?
Pain, large bruise in the upper arm, signs of axillary nerve or brachial plexus injury.
What is a potential systemic complication associated with plaster casts?
Deep vein thrombosis (DVT) leading to pulmonary embolism.
Where should you insert a pin for the distal femur?
Medial to lateral.
What is a disadvantage of using a cast?
Higher risk of complications and more technically difficult to apply.
What should be addressed in the hospital for open fractures?
Any life-threatening conditions and wound inspection.
What are some potential complications of a fracture?
Involvement of surrounding soft tissues, joint issues, local edema, inflammation, severe tissue damage, and vascular impairment.
What is a common complication of poor internal fixation technique?
Iatrogenic infection leading to chronic osteomyelitis.
What additional treatment is needed if associated fractures are present?
Internal fixation.
What classification is used for the location of the humeral head in dislocation?
Preglenoid, subcoracoid, subclavicular for anterior dislocation; subcromial, subglenoid, subspinous for posterior dislocation.
What might indicate the need for surgery in cases of rotator cuff syndrome?
Progressive fibrosis and disruption of the cuff.
What are some complications associated with improper cast application?
Joint stiffness, skin abrasion, and plaster breakage.
How is a proximal humerus fracture diagnosed in elderly patients?
Through x-ray.
Which fractures does the Ulnar gutter splint typically support?
4th and 5th proximal/middle phalangeal shaft fractures and the 1st metacarpal fracture.
What are the different types of open fractures based on wound size?
Type I: Puncture wound (<1cm); Type II: Skin damage (>1cm); Type III: Severe, big wound (>10cm).
What is a common cause of traumatic fractures?
A single highly stressful, traumatic incident causing a break at the point of impact.
What causes non-union in fractures?
Excessive damage to soft tissues, inadequate blood supply, or rigid fixation.
What is a common age range for individuals experiencing rotator cuff issues?
40-50 years old.
What type of fixation may be required for unstable elbows after treatment?
Hinged external fixation.