CCP 220 Orthopedic and Soft Tissue Injuries 🦴

Question 1

the various complications of fractures

Answer 1

1) infection
2) hemorrhage
3) vascular injury
4) nerve injury
5) avascular necrosis
6) compartment syndrome
7) fat emboli

Question 2

Jefferson fracture

Answer 2

boney fracture of the C1 vertebra

Question 3

Hangman’s fracture

Answer 3

boney fracture of the C2 vertebra

Question 4

TILE pelvic fracture staging

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Answer 4

1. The Tile classification of pelvic fractures is the precursor of the more contemporary Young and Burgess classification of pelvic ring fractures.
2. TILE takes into account stability, force direction, and pathoanatomy.
3. The integrity of the posterior arch determines the grade, with the posterior arch referring to all of the pelvis posterior to the acetabulum.
4. Stability is defined as the ‘ability of the pelvis to withstand physiologic force without deformation’ by the original author
5. Tile “A” = Stable (posterior arch intact)
6. Tile “B” = Partially stable (incomplete disruption of the posterior arch)
7. Tile “C” = Unstable (complete disruption of the posterior arch)

Question 5

cauda equina syndrome

Answer 5

Cauda equina syndrome occurs when the nerve roots in the lumbar spine are compressed, cutting off distal sensation and movement

Question 6

potential complications of pelvic injuries

Answer 6

1) Major Hemorrhage
2) Urological injury
3) Neurological injury (cauda equina etc)

Question 7

Pathophysiological pathway of compartment syndrome?

Answer 7

1. High pressure in non-expanding space cuts off vascular blood supply
2. progressive worsening acidosis and necrosis of structures
3. Positive feedback loop whereby venous system compressed first, decrease drainage and increasing pressure

Question 8

the 3 different mechanisms of compartment syndrome

Answer 8

1. Increase contents (bleeding, hematoma)
2. Decrease compartment size (fascia, cysts)
3. External pressure (eschar, cast or splint too tight)

Question 9

clinical diagnosis of compartment syndrome

Answer 9

“The five P’s”

Pain (out of proportion) 
Pallor 
Pulselessness 
Paresthesia 
Paralysis

Question 10

complications arising from compartment syndrome

Answer 10

1. rhabdomyolysis → Hyper-K + Renal Failure (Potassium + Myoglobin release)
2. Infection
3. Contractures (muscle tissue fibrosis → tissue shortening and hardening)
4. Lactic acidosis (anaerobic tissue metabolism → lactic acid release)

Question 11

crush syndrome versus compartment syndrome

Answer 11

crush injury - prolonged, continuous pressure on large muscles resulting in muscle disintegration → tissue destruction/rhabdo (can occur in non-traumatic patients as well; patients who have been immobilized for a long time, such as the “found down” patient)

compartment syndrome - condition in which a structure has been constricted within a space (such as d/t hematoma expansion in an isolated #)

Question 12

pathway to death in crush injury

Answer 12

Hypovolemia (3rd spacing)

Hyper Kalemia (K+ release second to muscle tissue breakdown)

Dysrhythmias (hyper-K + progressive metabolic acidosis)

Question 13

Types of necrotizing fasciitis

Answer 13

Type 1 - polymicrobial
Type 2 - mono microbial (typically due to group A streptococcus or staphylococci including methicillin-resistant strains/MRSA)

Question 14

concerning XR finding in suspected necrotizing fasciitis

Answer 14

Free air in the tissue consistent with bacterial off gassing

Question 15

Penetrating neck injury definition

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Answer 15

trauma to the neck that has breached the platysma muscle

Question 16

3 zones of the neck

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Answer 16

1) Zone 1 - Clavicle to cricoid cartilage
2) Zone 2 - Cricoid to angle of mandible
3) Zone 3 - Angle of mandible to base of skull

Question 17

Transverse fracture

Answer 17

straight across bone

Question 18

Oblique fracture

Answer 18

1. complete fractures that occur at a plane oblique to the long axis of the bone
2. diagonal across bone

Question 19

Comminuted fracture

Answer 19

1. shattered fragments of bone

2. break or splinter of the bone into more than two fragments

Question 20

Spiral fracture

Answer 20

1. occurs when a long bone is broken by a twisting force
2. also known as torsion fracture
3. a type of complete fracture
4. bone has been twisted apart

Question 21

segmental fracture

Answer 21

1. at least two fracture lines that together isolate a segment of bone
2. floating section of broken bone

Question 22

Young and Burgess classification of pelvic ring fractures

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Answer 22

1. The Young and Burgess classification is a modification of the earlier Tile classification
2. It is the recommended and most widely used classification system for pelvic ring fractures.
3. It takes into account force type, severity, and direction, as well as injury instability.
4. Three basic mechanistic descriptions are used, each with degrees of severity.

Anteroposterior compression

1. APC I: stable
2. APC II: rotationally unstable, vertically stable
3. APC III: equates to a complete hemipelvis separation (but without vertical displacement); unstable

Lateral compression (Most common type)

1. LC I: stable
2. LC II: rotationally unstable, vertically stable​
3. LC III: unstable
4. Vertical shear (Most severe and unstable type with a high association of visceral injuries.)

Question 23

Soft tissue risk factors for wound infection (risk factors for infection with soft tissue injuries)

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Answer 23

1. Immunocompromised (diabetic, chemotherapy, steroids, renal failure)
2. Location of wound (less vascular areas are more prone to infection. shitty blood flow to bring in WBC’s to fight infection)
3. Mechanism (blunt/crush are more susceptible for infections vs “clean” wounds like GSW or stab)
4. inappropriate wound closure (not properly irrigated prior to closure)

Question 24

what soft tissue wounds should receive prophylactic ABX

Answer 24

1. cat bites
2. grossly contaminated wounds
3. through and through oral wounds
4. human fight bites
5. burns
6. foot wounds/wounds in a less vascular area
7. open fractures
8. tendons and joints

Question 25

Gustilo-Anderson classification system definition

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Answer 25

the most widely accepted classification system of open (or compound) fractures.

The grading system is used to guide management of compound fractures, with higher grade injuries associated with higher risk of complications.

Soft tissue injury is graded on a combination of:

1. amount of energy dissipated
2. extent of soft-tissue injury
3. degree of contamination

Question 26

Gustilo-Anderson grade 1

Answer 26

1. clean wound <1 cm in length

Question 27

Gustilo-Anderson grade 2

Answer 27

2. wound 1-10 cm in length without extensive soft-tissue damage, flaps or avulsions

Question 28

Gustilo-Anderson grade 3

Answer 28

1. extensive soft-tissue laceration (>10 cm) or tissue loss/damage or an open segmental fracture
2. open fractures caused by farm injuries
3. injuries requiring vascular intervention
4. fractures that have been open for 8 hours prior to treatment

Question 29

Gustilo-Anderson grade 3A

Answer 29

1. adequate periosteal coverage of the fracture bone despite the extensive soft-tissue laceration or damage

Question 30

Gustilo-Anderson grade 3B

Answer 30

1. extensive soft-tissue loss, periosteal stripping and bone damage
2. usually associated with massive contamination
3. will often need further soft-tissue coverage procedure (e.g. free or rotational flap)

Question 31

Gustilo-Anderson grade 3C

Answer 31

1. associated with an arterial injury requiring repair, irrespective of degree of soft-tissue injury