Fracture Evaluation

Question 1

what is the difference between a primary and secondary trauma survey?

Answer 1

1. primary → imaging initially administered in ED to screen and prioritize injuries
2. secondary → f/u imaging necessary once pt is clinically stable

Question 2

what types of radiographic procedures would be performed following high velocity injuries?

Answer 2

1. cross-table lateral of the c-spine
2. AP chest
3. AP pelvis
4. potential additions
   
   1. focused abdominal ultrasound for trauma (FAST)
   2. CT of head
   3. CT of C-spine
   4. CT of thorax, abdomen, pelvis
   5. Lateral T/L spine radiograph
   6. Extremity radiographs

Question 3

what are important considerations for imaging following trauma to the extremities?

Answer 3

1. >/= 2 views that are 90 deg from each other
2. AP and lateral views when possible
3. include joints adjacent to bones (given heightened concern for remote injury)

Question 4

what to include when describing a fracture

Answer 4

1. open vs. closed
2. anatomic site and extent
3. type: complete vs. incomplete
4. alignment of fragments
5. direction of fracture lines
6. special features
7. associated abnormalities (dislocation, subluxation, soft tissue injury)
8. special types (stress frx, pathological frx, bone graft frx)

Question 5

describe a fracture: anatomic site and extent

Answer 5

1. long bones divided into proximal, middle, distal thirds
2. ends further divided → intra-articular vs extra-articular

Question 6

describing a fracture: type

Answer 6

• Complete vs incomplete
  
  • complete = all cortices disrupted
  • incomplete
    
    • mostly in short bones and children
    • generally stable w/o subsequent stresses
  • comminuted = >2 fragments

Question 7

describing a fracture: alignment

Answer 7

• description of distal segment in relation to proximal
• position → relationship to normal anatomic location
• displaced vs non-displaced
  
  • direction of displacement
  • amount of displacement
  • distraction, overriding, rotation
• in alignment vs angulation
  
  • longitudinal relationships of fragments

Question 8

describing a fracture: direction of frx lines

Answer 8

in reference to longitudinal axis

transverse, longitudinal, oblique, or spiral

comminuted → can be classified as minimal, moderate or severe

Question 9

describing a fracture: special features

what is impaction? Avulsion?

Answer 9

1. impaction → compression w/axial load
   
   1. depression and compression
2. avulsion → tensile loading of fragment and main body of bone
   
   1. muscle contraction or passive loading

Question 10

list and describe several types of unique pediatric fractures (not involving the growth plate)

Answer 10

1. greenstick
   
   1. fracture on side of tensile loading
   2. angular displacement common
2. torus
   
   1. impaction fracture side of compressive loading
3. plastic bowing
   
   1. longitudinal compression forces exerted, capacity for elastic recoil exceeded
   2. likely a component of all pediatric fractures

Question 11

Briefly list and describe the types of Pediatric Physeal Fractures (Salter-Harris classifications)

Answer 11

1. Type I → growth plate only
2. Type II → physis and metaphysis
3. Type III → physis and epiphysis
4. Type IV → epiphysis, physis, and metaphysis
5. Type V → crush injury of physis

(Slipped, Above, Lower, Through/Transverse, Rammed/Ruined)

Question 12

Briefly list and describe Rang’s and Ogden’s fractures

Answer 12

these are also types of pediatric physeal fractures

1. Type VI (Rang’s) → involves perichondral ring or associated periosteum of physis
2. Types VII-IX (Ogden’s) → do not directly involve physis, though may disrupt blood supply
   
   1. VII → osteochondral fracture of epiphysis
   2. VII → fracture of metaphysis
   3. IX → avulsion of periosteum

Question 13

describe healing of pediatric physeal fracture and relevant concerns

is the remodeling phase more or less extensive?

Answer 13

1. remodeling phase more extensive
2. remodeling and potential for subsequent deformity
   
   • skeletal age
     
     • time to remodel vs time for deformity to develop
   • distance of fracture from growth plate
   • severity of displacement of fragments
3. Concerns
   
   1. limb length
   2. angulation
      
      1. altered joint reaction forces
      2. biomechanical stresses

Question 14

list indications for open reduction of a fracture

Answer 14

1. risk w/bed confinement secondary to trial of conservative interventions prohibitive
2. decreased likelihood of success specific to fracture type
3. fracture/displacement of articular surfaces
4. associated arterial injury
5. multiple injuries
6. cost of treatment
7. failed closed reduction attempts
8. pathological frx secondary to metastasis

Question 15

what are the goals and types of fixation?

Answer 15

1. Goals
   
   1. avoid subsequent soft tissue injury
   2. maintain bone length
   3. maintain alignment
2. Types
   
   1. internal
   2. external
3. Open reduction Internal fixation (ORIF)

Question 16

briefly describe fracture healing

Answer 16

1. General phases
   
   1. inflammatory
   2. reparative
   3. remodeling
2. mechanisms can differ
   
   1. cortical bone → callus formation
   2. cancellous bone → more direct osteoblastic activity
   3. surgically compressed bone → more direct osteoblastic activity

Question 17

what is the common immobilization/protection timeline for bone healing? For adults and then for children.

Answer 17

6-8 weeks for adults

4-6 weeks for children

Question 18

early excessive loading following a fracture may increase the risk for what?

Answer 18

pseudoarthrosis

Question 19

list factors that affect healing and prognosis of bone injuries

Answer 19

1. age
2. degree of local trauma
3. extent of bone loss
4. immobilization
5. type of bone (cortical vs trabecular)
6. size of bone (diameter)
7. concomitant health conditions
8. hormones
9. approximation
10. blood supply