E1: fractures/splinting & casting

what are the types of fractures?

comminuted

transverse, nondisplaced

oblique, nondisplaced

spiral

segmental

Salter-Harris Fracture Classification

what are the most commonly missed fractures?

scaphoid

talar neck

radial head

tibial plateau

what are complications of fractures?

vascular compromise → cap refill > 2 sec and pulse not normal

nerve injury → contusion, crush, transection

what is a contusion (neuropraxic) associated with?

closed fx, dislocation or blunt trauma

what is axonotmesis (crush) associated with?

closed fx, dislocation or blunt trauma

what is neurotmesis (transection) associated with?

open fx

how long does nerve recovery take?

type 1 = 2-3 months (except knee)

type 2 = 1-2 cm/month → 95% recover by 6 mos

what are common sites of fx complications?

spiral fx humerus → radial nerve injury = wrist drop

tibial plateau fx → peroneal nerve injury = foot drop

what is the initial care (at scene) of a fx?

splint before transporting including joint above & below

always pad splints

elevate extremity

ice to control swelling

when should an orthopedic surgeon be consulted for a fracture?

- any open fx

- displaced intraarticular fx

- large/long bone fx (femur, spine, humerus)

- fx of both tibia and fibula

what factors delay healing of fractures?

smoking

elderly

DM

malnutrition

bleeding disorders

what are the methods of fracture management?

1. open or closed reduction w/ internal fixation

2. continuous traction followed by cast immobilization

3. closed reduction w/ external skeletal fixation

4. closed reduction followed by cast immobilization

is open or closed reduction with internal fixation preferred and why?

closed because it has less infection

what are the types of fracture that benefits from rigid internal fixation?

- a displaced joint fx (esp weight bearing joints)

- fx that can't be reduced or held closed (unstable fx)

- elderly pts w fps (allows for earlier activity)

- epiphyseal fx (salter Harris)

- joint fx (allows for early motion to prevent stiffness)

which method of fracture management is used for lower extremity fractures?

continuous traction → allows alignment & maintain reduction

what is external fixation?

using pins/hardware through the skin to stabilize fx

- hardware is placed above and below fx site

- typically incorporated into a cast

what is the most common form of fracture management?

closed reduction → using a cast to immobilize fx and allow for healing

what is the "periosteal hinge"?

the periosteum on the opposite side of the fx is still intact and is used to correct the fx

closed reduction is done on what type of fractures?

epiphyseal fx → distal portion is pushed back into place

transverse fx → reduced by simple traction

oblique "toggle" fx

how is closed reduction accomplished?

1. traction is applied to distal fragment w counter traction on proximal fragment

2. misalignment is corrected

3. distal fragment is reduced & angular deformity corrected

4. periosteal hinge prevents over reduction

5. cast holds position

how is adequate reduction done in adults vs children?

adults = angular deformities have to be completely corrected

child = angular deformity < 20 degrees that is close to a joint and in same plane of motion corrects itself

why do we cast fractures?

- immobilizes the ends of a fx

- allows for ambulation

- hold position of reduction

what are the 2 types of casts?

plaster and fiberglass

what is appropriate aftercare of an arm cast?

- keep elevated above heart (using a sling)

- watch for compartment syndrome

- watch for complications → Volkmann's ischemic contracture and tissue necrosis

how is itching from a cast treated?

ice, elevation, OTC antihistamines

what is proper casting for the arm?

cast does not extend beyond distal palmar creases

MCPs should be able to completely flex

pt should be able to fan fingers

elbow casts should be 90 degrees

what is the proper casting for a short leg cast?

- foot/ankle at 90 degrees (prevents Achilles tightness)

- always extend under metatarsal heads (support)

- toes exposed (no free pics tho)

- if a kid, can use weight-bearing cast and post-op shoe

should you wait for the swelling to go down before reducing a fracture?

NO!!!

an avulsion fx near a joint may signify?

ligament or tendon damage

does rotational misalignment correct itself in children?

no

what are the most common bones fractured from child abuse?

long bones → shaft (metaphysis) is most common

ribs → posterior, lateral

vertebral body compression fx

what plain film views do you want to do if you suspect child abuse?

AP & lateral (sometimes oblique)

- the more views the better!

what are S&S of senior abuse?

hand fx

unset broken bones

repeat fall injuries