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What's Included

🏥 General Surgery — Introduction (6 SAQs + 2 LAQs)

🦴 Orthopaedics — Fractures (5 SAQs + 2 LAQs)

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🦴 PRINCIPLES OF FRACTURE MANAGEMENT — MADE EASY

The Golden Rule: Every fracture management follows 3 Rs:

Recognise → Reduce → Rehabilitate

(Some books say: Reduce → Rest/Fix → Rehabilitate)

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STEP 1 — RECOGNISE (Assess the Fracture)

🔍 How to Describe Any Fracture (Systematic Approach)

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📐 Fracture Patterns — Simple Visual Memory

TRANSVERSE    OBLIQUE     SPIRAL        COMMINUTED    GREENSTICK
   ───           /           S              ╳╳╳          |  <-- kids only
(direct hit)  (angular   (twisting       (crush /      (bone bends,
              force)      force)         high energy)  doesn't fully break)

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🩻 Investigations

• Always 2 views at 90° (AP + lateral)
• Include the joint above AND below the fracture
• Compare with opposite limb in children

• CT scan → Complex fractures (pelvis, spine, intra-articular)
• MRI → Stress fractures, occult (hidden) fractures, physis (growth plate) injuries
• Doppler USS → Suspected vascular injury

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STEP 2 — REDUCE (Put It Back in Place)

When do you NEED to reduce?

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2 Ways to Reduce

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STEP 3 — REST/HOLD (Immobilise / Fix)

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🗂️ The 5 Methods of Fracture Fixation

1️⃣ Conservative (No Surgery)

• Used for: undisplaced or minimally displaced fractures, fractures in children
• Examples: Colles fracture → below-elbow backslab; clavicle fracture → broad arm sling; undisplaced NOF → cannulated screws (borderline conservative)
• ⚠️ Must watch for: compartment syndrome under tight cast — check the 6 P's!

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2️⃣ Traction

• Skin traction (tape/bandage): light, temporary (e.g., pre-op femur fracture in elderly)
• Skeletal traction (pin through bone): heavier forces (e.g., Steinmann pin through tibial tubercle for femoral shaft fracture)
• Used when: awaiting surgery, paediatric femoral fractures (Thomas splint)
• Rarely definitive in adults today (replaced by nailing)

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3️⃣ External Fixation

  Bone ──●──────────────●── Bone
         |    BAR/FRAME |
  Pins go through skin → external bar outside the body

• Used for: Open fractures (Grade III), damage control in polytrauma, infected non-union, spanning a joint temporarily
• Advantage: Keeps bone aligned without hardware near contaminated wound
• Types: Monolateral fixator, Ring/circular fixator (Ilizarov frame — for limb lengthening too)

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4️⃣ Internal Fixation (ORIF — Open Reduction Internal Fixation)

NOF fracture
    ↓
Is it INTRACAPSULAR?
    ├── Undisplaced (Garden I/II) → Cannulated screws
    └── Displaced (Garden III/IV) → Hemiarthroplasty (or THR if young/active)

Is it EXTRACAPSULAR?
    ├── Intertrochanteric → Dynamic Hip Screw (DHS)
    └── Subtrochanteric → Intramedullary Nail (IMN)

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5️⃣ Arthroplasty (Joint Replacement)

• Used when: bone too damaged/comminuted to fix, blood supply lost (AVN risk), elderly patients with poor bone stock
• Examples:
  • Displaced intracapsular NOF (Garden III/IV) → Hemiarthroplasty
  • Young + active + displaced NOF → Total Hip Replacement (THR)
  • Severely comminuted proximal humerus → Reverse shoulder arthroplasty

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⚡ Quick Decision Guide: Which fixation method?

Fracture
│
├── Undisplaced → CONSERVATIVE (cast/splint)
│
├── Open fracture → EXTERNAL FIXATOR (contaminated → no internal hardware)
│
├── Long bone shaft (femur/tibia) → INTRAMEDULLARY NAIL
│
├── Intra-articular → ORIF (plates/screws) — must restore joint surface
│
├── Intertrochanteric NOF → DYNAMIC HIP SCREW
│
├── Subtrochanteric NOF → IMN
│
├── Displaced intracapsular NOF (elderly) → HEMIARTHROPLASTY
│
└── Polytrauma (unstable patient) → DAMAGE CONTROL ORTHOPAEDICS
       → Temporary external fixation first, then definitive fixation later

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STEP 4 — REHABILITATE

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COMPLICATIONS — THE BIG 3 (High Yield)

1. Compartment Syndrome (Early — Hours)

Raised pressure in closed fascial compartment → ischaemia → necrosis

• Pain (disproportionate — passive stretch worsens it → most sensitive early sign)
• Pressure (tense compartment)
• Paraesthesia (tingling — early nerve ischaemia)
• Paralysis (late — muscle death)
• Pallor
• Pulselessness (very late — do NOT wait for this!)

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2. Fat Embolism Syndrome (Early — 24–72 hrs)

Fat droplets from marrow enter circulation after long bone fractures

• 🫁 Respiratory → hypoxia, tachypnoea, ARDS
• 🧠 Neurological → confusion, coma
• 🔴 Skin → petechiae on chest, axillae (pathognomonic)

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3. Non-Union (Late — Months)

Fracture fails to heal

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📌 MEMORY SUMMARY — ONE PAGE

ASSESS      → History + Exam + X-ray (2 views, 2 joints)
DESCRIBE    → Open/Closed | Bone | Location | Pattern | Displacement | Angulation
REDUCE      → Closed (MUA) or Open (Surgery/ORIF)
IMMOBILISE  → Cast | Traction | External fix | Internal fix (nail/plate/screw) | Arthroplasty
REHABILITATE→ Physio + DVT prophylaxis + Analgesia + Nutrition

WATCH FOR   → Compartment syndrome (early) | Fat embolism | Non-union (late)
              Malunion | AVN | Osteomyelitis (open fractures) | CRPS

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🦴 PRINCIPLES OF FRACTURE MANAGEMENT

Exam-Ready Flowing Points

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DEFINITION

• A fracture is a break in the continuity of bone, either complete or incomplete.
• Management follows the universal principle of 3 Rs — Reduce, Retain (immobilise), Rehabilitate.

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I. ASSESSMENT & RECOGNITION

History

• Note the mechanism of injury — high energy (RTA, fall from height) suggests severe fracture with associated injuries.
• Ask about time of injury — critical for open fractures (6-hour rule for debridement).
• Ask about pre-existing bone disease — malignancy, osteoporosis, Paget's disease suggest pathological fracture.
• Note medications — steroids, anticoagulants, bisphosphonates affect management.
• Assess tetanus immunisation status in open fractures.

Examination

• Look — deformity, shortening, swelling, bruising, open wound, skin integrity.
• Feel — localised tenderness at fracture site; assess distal neurovascular status.
• Move — assess joints above and below fracture for associated injuries.
• Always document neurovascular status before and after any manipulation.
• Check distal pulse, capillary refill, sensation, and motor power.

Investigations

• X-ray is the first-line investigation — always obtain two views at 90° (AP + lateral).
• Include the joint above and below the fracture in every X-ray.
• CT scan — for complex, intra-articular, pelvic, or spinal fractures.
• MRI — for stress fractures, occult fractures, and growth plate injuries in children.
• Doppler USS — when vascular injury is suspected.
• Bloods — FBC, U&E, G&S/cross-match for major fractures (femur, pelvis).

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II. FRACTURE DESCRIPTION (Systematic)

• Always describe using: bone → side → open/closed → location → pattern → displacement → angulation → rotation.
• Closed fracture — overlying skin is intact.
• Open (compound) fracture — fracture communicates with external environment; treated as a time-dependent orthopaedic emergency due to risk of osteomyelitis.
• Location described as proximal, middle, or distal third of the bone.
• Intra-articular extension must always be noted — requires anatomic restoration to prevent post-traumatic arthritis.

Fracture Patterns

• Transverse — perpendicular to long axis; caused by direct blow.
• Oblique — diagonal line; caused by angular force.
• Spiral — encircles shaft; caused by rotational/torsional force; raises suspicion of non-accidental injury in children.
• Comminuted — more than two fragments; caused by high-energy trauma.
• Greenstick — incomplete fracture; one cortex intact; seen only in children due to pliable bone.
• Stress fracture — repetitive loading without single traumatic event; common in runners and military recruits.
• Pathological fracture — occurs through diseased bone (metastasis, osteoporosis, Paget's) with minimal or trivial trauma.
• Avulsion fracture — bone fragment pulled off by forceful muscle contraction or ligament resistance.
• Impacted fracture — fragments driven into each other; telescoping appearance; common in proximal humerus.

Displacement & Angulation

• Displacement — movement of distal fragment relative to proximal; described as undisplaced, minimally, or severely displaced.
• Angulation — deviation of longitudinal axis; direction named by apex of the angle formed.
• Valgus — apex points toward midline.
• Varus — apex points away from midline.
• Rotation — rotational deformity of distal fragment relative to proximal; described as internal or external.

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III. REDUCTION

• Reduction is the restoration of fracture fragments to their normal anatomical position.
• Required for: displaced fractures, angulated fractures, intra-articular fractures, and open fractures.
• Not required for undisplaced or minimally displaced fractures — immobilise as they lie.

Closed Reduction (Non-surgical)

• Performed as manipulation under anaesthesia (MUA).
• Technique: apply longitudinal traction first, then reverse the mechanism of injury.
• Confirmed by image intensifier (fluoroscopy) intraoperatively.
• Indicated for most simple fractures — Colles fracture, ankle fracture, greenstick fractures.

Open Reduction (Surgical)

• Fracture is exposed surgically and reduced under direct vision.
• Followed by internal fixation — called ORIF (Open Reduction Internal Fixation).
• Indicated when:
  • Closed reduction fails or is not maintainable.
  • Intra-articular fracture requires anatomic restoration.
  • Soft tissue (tendon/nerve) is interposed between fragments.
  • Open fracture requires wound debridement.
  • Fracture in a bone where conservative management performs poorly (femoral neck, femoral shaft).

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IV. IMMOBILISATION / FIXATION

1. Conservative (Non-operative)

• Plaster cast or splint holds reduced fracture in correct position until healing.
• Used for undisplaced or minimally displaced fractures, and most paediatric fractures.
• Sling used for clavicle fractures, humeral shaft (hanging cast), and post-operative support.
• Monitor for compartment syndrome under circumferential casts — check 6 P's regularly.
• Cast must be bivalved (split) immediately if signs of compartment syndrome develop.

2. Traction

• Longitudinal pull applied to distal limb to overcome muscle spasm and hold length.
• Skin traction — adhesive tape/bandage; light forces; temporary use only.
• Skeletal traction — pin inserted through bone (e.g., Steinmann pin through tibial tubercle); heavier forces.
• Used as temporary measure while awaiting surgery (e.g., femoral shaft fracture).
• Definitive use mainly in paediatric femoral fractures (Thomas splint).

3. External Fixation

• Metal pins inserted into bone above and below fracture, connected by an external bar or frame.
• Fracture is stabilised without placing hardware within the wound.
• Indications:
  • Open fractures (Grade II/III) — keeps contaminated wound away from implant.
  • Damage control orthopaedics in polytrauma — fast, safe temporary stabilisation.
  • Infected non-union or peri-articular fractures.
  • Temporary joint-spanning for periarticular injuries.
• Ilizarov ring fixator — circular frame; used for complex non-unions and limb lengthening.

4. Internal Fixation (ORIF)

• Hardware is placed inside the body to hold the fracture.

K-wires (Kirschner wires)

• Thin smooth metal wires; temporary fixation.
• Used in children's fractures (supracondylar humerus) and small bone fractures (hand, wrist).

Screws alone

• Provide interfragmentary compression across fracture (lag screw technique).
• Used for simple oblique/spiral fractures and intra-articular fragments.

Plate and screws

• Metal plate applied to outer bone surface; screws anchor it.
• Locking plates — screws lock into plate; ideal for osteoporotic bone.
• Used for: forearm fractures (both-bone forearm), clavicle, periarticular fractures, proximal humerus.

Intramedullary Nail (IMN)

• Long metal rod inserted into the medullary cavity of a long bone.
• Shares load with bone along its entire length — very mechanically strong.
• Allows early weight-bearing.
• Gold standard for: femoral shaft, tibial shaft, humeral shaft fractures.
• Inserted with interlocking screws proximally and distally to prevent rotation and shortening.

Dynamic Hip Screw (DHS)

• Sliding lag screw inserted into femoral head + side plate on femoral shaft.
• Allows controlled collapse at fracture site promoting healing.
• Gold standard for intertrochanteric (extracapsular) NOF fractures.

Cannulated screws

• Three parallel hollow screws inserted in triangular configuration.
• Used for undisplaced intracapsular (Garden I/II) NOF fractures to preserve femoral head.

5. Arthroplasty (Joint Replacement)

• Used when fixation is not possible or not advisable.
• Hemiarthroplasty — replace only the femoral head; used for displaced intracapsular NOF (Garden III/IV) in the elderly.
• Total Hip Replacement (THR) — replace both femoral head and acetabulum; preferred in younger, active patients with displaced intracapsular NOF.
• Reverse shoulder arthroplasty — for severely comminuted proximal humerus fractures in elderly where fixation is not feasible.

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V. FRACTURE HEALING

• Fracture healing occurs by two mechanisms: primary (direct) and secondary (indirect/callus).
• Secondary healing is the most common and occurs in five stages:

Stages of Secondary (Indirect) Healing

1. Haematoma formation — fracture tears periosteum and vessels → haematoma fills gap → fibrin scaffold forms; inflammatory cytokines (IL-1, IL-6, TNF-α) released.
2. Inflammatory phase — macrophages debride devitalized tissue; osteoprogenitor cells recruited from periosteum and endosteum.
3. Soft callus — fibroblasts and chondroblasts form fibrocartilaginous callus bridging fracture; fracture mobile but stabilising.
4. Hard callus (ossification) — enchondral ossification converts soft callus to woven bone; fracture becomes radiographically visible.
5. Remodelling — woven bone replaced by lamellar bone along lines of mechanical stress (Wolff's law); medullary canal re-established; may take months to years.

Factors Affecting Healing

• Cancellous bone heals faster than cortical bone.
• Oblique fractures heal faster than transverse (greater surface contact).
• Healing is impaired by: smoking, corticosteroids, diabetes, malnutrition, infection, poor blood supply, excessive movement, NSAIDs (long-term).
• Healing is promoted by: stable fixation, good blood supply, early weight-bearing (stimulates callus ossification).
• Approximate healing times: humerus ~2 months; femur ~4 months.

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VI. COMPLICATIONS OF FRACTURES

Immediate (At time of injury)

• Haemorrhage — femur = 1–2 L blood loss; pelvis = potentially several litres.
• Neurovascular injury — e.g., radial nerve in humeral shaft; brachial artery in supracondylar fracture.
• Visceral injury — e.g., pneumothorax in rib fractures; bladder rupture in pelvic fractures.
• Open wound.

Early (Hours to days)

• Compartment syndrome — raised pressure in fascial compartment → ischaemia.
  • Presents with pain disproportionate to injury, pain on passive stretch (earliest sign), paraesthesia, tense compartment.
  • Treatment: emergency fasciotomy of all four compartments of the leg.
• Fat embolism syndrome — fat droplets from marrow enter circulation after long bone fractures.
  • Classic triad: hypoxia + confusion + petechiae on chest and axillae.
  • Occurs 24–72 hours after injury, especially with femoral and tibial fractures.
• Osteomyelitis — infection of bone; especially feared in open fractures.
• DVT/PE — particularly after lower limb fractures.
• Haemorrhagic shock — major fractures (pelvis, femur).

Late (Weeks to months)

• Malunion — fracture heals in incorrect position → deformity and functional impairment.
• Delayed union — fracture takes longer than expected to heal for that bone.
• Non-union — fracture fails to unite entirely.
  • Hypertrophic non-union — excessive callus, no bridging → cause: inadequate immobilisation.
  • Atrophic non-union — no callus, tapered ends → cause: poor blood supply, avascular bone.
  • May result in pseudarthrosis (false joint).
• Avascular necrosis (AVN) — disruption of blood supply to a fracture fragment.
  • Classical sites: femoral head (intracapsular NOF), scaphoid (proximal pole), talus.
• Post-traumatic osteoarthritis — follows intra-articular fractures with imperfect reduction.
• Growth arrest — in children; physeal (Salter-Harris) injuries can damage the growth plate.
• Chronic osteomyelitis — especially after open or surgically treated fractures.
• Complex Regional Pain Syndrome (CRPS) — disproportionate pain, swelling, vasomotor changes; formerly called Reflex Sympathetic Dystrophy.
• Joint stiffness — from prolonged immobilisation.

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VII. REHABILITATION

• Rehabilitation begins on day 1 post-fixation — early mobilisation is the rule.
• Physiotherapy — active and passive exercises for joints above and below fracture; progressive weight-bearing as permitted by fixation stability.
• DVT prophylaxis — LMWH + TED stockings for all lower limb fractures/surgery; continue for 28 days post-discharge after hip fractures.
• Analgesia — regular paracetamol, short-course NSAIDs (avoid long-term — impair healing), opioids PRN.
• Nutritional support — adequate protein, Vitamin D + Calcium supplementation especially in elderly.
• Occupational therapy — upper limb functional tasks, ADL assessment, home modification.
• Secondary prevention for fragility fractures — bisphosphonates (alendronate/zoledronic acid), DEXA scan, falls prevention programme, Fracture Liaison Service referral.

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OPEN FRACTURES — SPECIAL MANAGEMENT

Gustilo-Anderson Classification

• Grade I — wound <1 cm, clean, minimal soft tissue damage.
• Grade II — wound 1–5 cm, no significant contamination or crush.
• Grade IIIA — wound >5 cm, extensive soft tissue injury but bone still covered.
• Grade IIIB — periosteal stripping; bone exposed; requires soft tissue flap for coverage.
• Grade IIIC — any open fracture with arterial injury requiring vascular repair.

Emergency Management of Open Fractures

• Control haemorrhage with sterile pressure dressing in the field.
• Splint without reduction unless there is vascular compromise.
• Cover wound with saline-soaked sterile dressings — do not push contamination back in.
• IV antibiotics as early as possible:
  • Cefazolin 2g IV q8h for all grades.
  • Add aminoglycoside (gentamicin) for Grade II and III.
  • Add metronidazole or penicillin for farm/faecal contamination.
• Administer tetanus prophylaxis including tetanus immune globulin for large crush wounds.
• Urgent theatre for wound debridement and washout within 6 hours — time-dependent emergency.
• External fixation preferred for Grade III open fractures; avoid internal hardware in contaminated wounds.

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QUICK EXAM SUMMARY

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