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5thyr > Trauma > Flashcards

Trauma Flashcards

1
Q

What are the 2 types of femoral fractures?

A

Shaft and distal (supracondylar)

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2
Q

How are femoral shaft fractures caused?

What are the types of femoral shaft fractures?

A

-Femoral shaft fractures are caused by HIGH-ENERGY injury e.g. Falls, crushing injury or high speed RTC

Types:

  • transverse (horizontal)
  • linear (vertical)
  • oblique (diagonal)
  • spiral (due to twisting force)
  • comminuted (>2 bone pieces)
  • greenstick (bends and cracks)
  • compound or open (penetrates through skin)
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3
Q

Clinical presentation of femoral shaft fracture?

A

Clinical presentation of femoral shaft fracture

  • Severe pain
  • Unable to WB
  • tense and swollen upper thigh
  • Hip EXTERNALLY ROTATED and SHORTENED (but abducted unlike NOFF)
  • Often very clear deformity
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4
Q

Investigations of femoral shaft fracture?

A 
Investigations of femoral shaft fracture
Bedside
-Examination 
-(look feel move) of hip and knee joint 
-assess sensation and pulses  
-Thomas splint – prevent deformity and ↓haemarthrosis

Bloods
-FBC and crossmatch

Xray of femur (AP and lateral views of)

  • femur (determine type and severity)
  • knee and hip to exclue NOFF
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5
Q

Management of femoral shaft fracture?

A

Management of femoral shaft fracture

  1. Femoral-nerve block (Analgesia) – useful
  2. Open (surgery) or Closed reduction to put back in place
  3. Fixation –internal (most common is intramedullary nail) or external (big metal cage outside skin)
  4. Immobilise – Plaster (back slab) or Thomas splint
  5. X-Ray femur – verify alignment of femur + monitor healing
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6
Q

How long does a femoral shaft fracture take to heal?

A

femoral shaft fracture takes 4-6 months completely healed – open fracture takes longer

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7
Q

Complications of femoral shaft fracture? (8)

A

Complications of femoral shaft fracture

  • Neurovascular damage – from sharp bone ends
  • Acute compartment syndrome – high risk
  • Large haematoma (subtle in closed fractures, as it involves large volumes of blood loss before swelling is obvious)
  • Infection –high risk in open fractures
  • Delayed union (keep cast on for longer)
  • Non union (surgery)
  • Fat embolism, DVT (PE)
  • Shortening, angular, misalignment
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8
Q

Differentials for femoral shaft fracture?

A

Differentials for femoral shaft fracture

  • Hip fracture (NOFF)
  • Supracondylar fracture
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9
Q

What is a supracondylar fracture?

What TYPE of fracture are common with supracondylar fracture?

A

-supracondyl fracture is fracture to the distal 1/3 of femur
(typically weaker metaphyseal bone)

-Commonly COMMINUTED and intra-articular → damage to knee joint

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10
Q

How do supracondylar fractures most commonly occur?

What can supracondyl fractures cause damage to?

A

Supracondylar fractures common causes:

  • Direct violent trauma in adolescent and young adults
  • Osteoporosis with low energy trauma in elderly

-Supracondyl fractures can cause damage to the popliteal artery (because the distal fragment of femur pulls backward)

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11
Q

How do supracondylar fractures present?

A

Supracondylar fractures

  • Pain
  • Deformity
  • Weakness
  • History of falls (elderly)
  • High impact injury (young adults)
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12
Q

Investigations for supracondylar fracture?

A

Bedside

  • Examination
  • (look feel move) of hip and knee joint
  • assess sensation and pulses
  • Thomas splint – prevent deformity and ↓haemarthrosis

Bloods
-FBC and crossmatch

Xray of femur (AP and lateral views of)

  • femur (Categorise as extra-articular, partial articular or complete articular)
  • knee Xray is essential
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13
Q

What is Flexor Tenosynovitis? What is the most common cause?

What are the four signs of flexor tenosynovitis?

A

Flexor Tenosynovitis is an infection of finger flexor tendon sheath (surrounds tendon) following PENETRATING INJURY (common)

Kanaval’s 4 signs

  1. Fixed flexion of digit – “trigger finger”
  2. Symmetrical fusiform swelling of digit (sausage finger)
  3. Excruciating tenderness over flexor sheath
  4. EXTREME pain on passive extension
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14
Q

What is the treatment of flexor tenosynovitis?

What is a complication of flexor tenosynovitis?

A

Treatment of flexor tenosynovitis
1. Urgent incision, drainage and irrigation of flexor tendon sheath
2. Tendon sheath release
3. URGENT broad IV Abx (commonly staph infection) –
Co-amox (animal bite), narrow Abx following cultures

Complication: significant sheath scaring → compromise finger function

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15
Q

What is a felon? What is the most common cause?

A
  • Felon is a subcutaneous abscess over the pulp of distal phalanx or thumb
  • Due to penetrating injury
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16
Q

What is the treatment of felon?

A

Treatment of felon

  1. Urgent incision, drainage and irrigation of absess
  2. Warm antiseptic soaks
  3. Oral Abx (IV if septic)
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17
Q

What is Paronychia?

What 2 pathogens can cause this and whats the difference in presentations between them?

A

Paronychia
-Infection of nail fold adjacent to nail

Pathogens

  • Bacteria (S aureas most common): sudden onset and painful
  • Candida: slow and chronic
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18
Q

Treatment of paronychia?

Treatment of paronychia with absess?

A

Treatment of paronychia

  • Flucoxacillin if cellulitis (curative in early stages)
  • Fungal/chronic: topical antifungals

-If abscess/pus develops> urgent incision, drainage and irrigation under LA digital block with oral AB

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19
Q

What are the 3 types of humerus fractures?

Where does the radial nerve run?

A

Humeral fractures: proximal (5%), shaft, distal

Radial nerve runs posterior at middle 1/3rd of shaft in spiral groove

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20
Q

What features may indicated PATHOLOGICAL FRACTURE?

A

PATHOLOGICAL FRACTURE

  • Bone pain preceeding fracture
  • Limb swelling preceeding fracture or large post fracture swelling
  • Cystic abnormality on Xray
  • History of malignancy
  • Pagets disease of the bone
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21
Q

What is the most common site of proximal humorous fracture?

A

Surgical neck (below tuberosities) is most common place for proximal humorous fracture

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22
Q

What is a common mechanism of injury for proximal humerus fracture? (what other signs may they have)

A
  • Proximal humorous fracture often caused by FOOSH

- May also have posterior shoulder dislocation

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23
Q

Presentation of proximal humorous fracture?

A

Presentation of proximal humorous fracture

  • Tenderness or swelling of proximal humerus
  • ↓RoM at shoulder (due to pain)
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24
Q

Investigations for proximal humeral fracture?

A

BEDSIDE
MSK and neuro exam
-shoulder and elbow
Axillary nerve – sensation of regimental badge over deltoid + assess UL power
Brachial plexus – distal PNS exam of UL
Peripheral pulses

IMAGING
-AP and lateral of scapular and axillary

Special tests (NEER CLASSIFICATION)
-based on 4 usual cleavage lines (head, LT, GT, surgical neck/shaft), therefore either 2, 3 or 4-part fractures
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25
Q

Management of proximal humeral fracture?

A
  1. Immobilise joint + Analgesia
  2. Collar and Cuff support – 85% treated non-operatively

If more complex or if displaced

  1. Surgery
    - closed reduction and percutaneous fixation
    - open reduction and internal fixation
    - proximal head replacement
  2. Physiotherapy
  3. Follow- up
26
Q

Complications of proximal humeral fractures?

A

Complications of proximal humeral fractures

  1. AXILARY NERVE DAMAGE
    - loss of sensation to regimental badge (appears flat)
    - suprascapular nerve and radial artery can also happen
  2. AVASCULAR NECROSIS
    -common in complex fractures with multiple fragments
    Neurovascular injury (1/3rd )
27
Q

What are the common mechanisms for shaft of humerus fracture?

A

Shaft of humerus fracture

  • direct blunt trauma>transverse
  • torsion injury> spiral fracture
  • FOOSH when abducted
28
Q

Management of humeral shaft fracture?

A

A) Non-operatively

  • Hanging arm cast or Coaptation splint (extends from axilla → nape of neck w/ stirrup around elbow)
  • Then Functional arm brace (looks like a robot arm)
  • Physiotherapy

B) Operatively

  • Closed reduction + long arm splint – if mildly displaced (repeat X-ray post-reduction)
  • Open reduction + surgical fixation – if comminuted or vascular compromise
29
Q

What is a complication of a humeral shaft fracture?

What is the prognosis?

How could you tell?

A

Complication of a humeral shaft fracture?
RADIAL NERVE INJURY (12%)
-more common with transverse/spiral fractures
-should recover (70%) with conservative treatment

Signs of radial nerve injury

  • wrist drop (when elbow flexed and pronated)
  • sensory loss (dorsal 3 ½ fingers webspace) (plantar lateral 1/2 thumb)
  • moto loss: cant thumbs up
30
Q

List the nerves that can be affected in humeral fractures (proximal, shaft and distal)

What are the signs?

A

Proximal fracture: AXILLARY
-loss sensation to regimental badge, appears flat

Shaft fracture:RADIAL

  • wrist drop
  • LOS dorsal 3 & 1/2 fingers
  • LOS plantar lateral 1/2 thumb
Distal fracture: RADIAL (18%), MEDIAL, ULNAR 
RADIAL 
-wrist drop 
-LOS dorsal 3 & 1/2 fingers 
-LOS plantar lateral 1/2 thumb

MEDIAL

  • inability to flex index finger and thumb
  • LOS medial 1/2 thenar eminence

ULNAR

  • Froments paper sign shows flexing of thumb
  • inability to cross fingers ‘good luck sign’
  • claw hand
31
Q

How do distal humerus (elbow) fractures present?

A

Distal humerus (elbow) fractures presentation
-S shaped fracture
-significant rapid swelling
-nerve damage:
> radial nerve (18%)
>median nerve (inability to flex index finger and thumb with LOS medial 1/2 thenar eminence
>ulnar nerve (Froments paper sign shows flexing of thumb, inability to cross fingers ‘good luck sign’

32
Q

Management of distal humerus fracture?

A

Distal humerus fracture
-Immobilise elbow (posterior long arm splint, elbow at 90o to forearm in neutral position)

Surgical repair – for displaced or open fractures (most common is open reduction and internal fixation)

33
Q

What is a hip fracture and what are the 3 types?

A

Hip fracture is a fracture of the PROXIMAL femur (proximal to 5cm below lesser trochanter)

3 types:

  1. Intracapsular NOFF
  2. Extracapsular inter-trochanteric
  3. Extracapsular sub-trochanteric
34
Q

Define intra capsular NOFF

How does it normal happen?

A

Intracapsular NOFF
-between edge of femoral head and intertrochanteric line

-typically follows a fall onto hip or bum

35
Q

What is the clinical presentation of intracapsular NOFF

A

Intracapsular NOFF

  • leg appears SHORTENED + EXTERNALLY rotated (and adducted)
  • TENDERNESS over hip ± greater trochanter particularly on rotation
  • may have referred knee pain
  • inability to weight-bear (although some may be able to)
36
Q

Investigations for intracapsular NOFF?

A

Investigations for intracapsular NOFF
1. X ray -Shenton’s line disrupted (medial edge of femoral head and inferior edge of superior pubic ramus)

  1. Garden classification – used for Intracapsular NOFF
    I - INCOMPLETE undisplaced fracture with the inferior cortex intact
    II - COMPLETE undisplaced fracture through the neck
    III - Complete neck fracture with PARTIAL displacement
    IV - Complete neck fracture thats FULLY displaced
37
Q

Initial managment of NOFF?

A

Managment of NOFF

ABCD(hypothermia) E assessment

IV access

  • Bloods - FBC, U+Es (AKI), CK (could be lying for ages), glucose, crossmatch to prepare for surgery
  • IV fluids if hypotension/dehydrated
  • IV morphine (titrate up) + antiemetic
  • ECG (look for arrhythmias/MI, may explain fall)

Additional

  • Femoral nerve block (women in AndE)
  • Lateral hip X-ray (repeats/MRI may be needed if cant see)
  • Refer to orthopaedic surgery
  • May need to realign or apply splint in the mean time
38
Q

Treatment on INTRAcapsular NOF?

A

Intracapsular NOFF
-General rule is that intracapsular gets replaced and extracapsular gets fixed

However, UNdisplaced (garden 1 and 2)

  • open reduction and internal fixation (ORIF) with cannulated hip screws
  • comorbid and old=hemi

DISplaced (garden 3 and 4)
<55 ORIF with cannulated hip screws (unless AVN>arthroplasty)
In between: Total hip replacement (active or arthritis)
>75 Hemiarthroplasty

39
Q

What is a complication of intracapsular neck of femur fractures?

A

Complications of NOFF
-Mortality (10% at 6 weeks; 30% mortality at 1 year (MAD)

-Avascular necrosis -disruption of blood supply to femoral head → whole joint needs replacing

40
Q

What is the managment of extracapsular NOF?

usual vs exception

A

Extracapsular
-General rule is OPEN REPAIR WITH INTERNAL FIXATION ORIF (with DHS)

UNLESS:

  1. SUB TROCHANERIC (shaft) fracture (do IM nail)
    - fracture within 5cm below the lesser trochanter (less risk of AVN (outside capsule)
  2. Four part intertrochanteric fractures
  3. oblique or transverse

DO IM NAIL INSTEAD>UNSTABLE

41
Q

Whats the difference between THR and Hemi hip replacement? When would you be more inclined to do a THR?

A

Total hip replacement-all and socket (active patient, independant) (risk of dislocation)
Hemi hip replacemnt- just the ball (more frail)

42
Q

Describe the presentation of fat embolism?

Treatment?

A

Post op a fat embolism can occur at any 3 sites:
Brain (stroke)
Fat (rash)
Lungs (PE)

Treatment: supportive care, ITU if breathless

43
Q

Whats is less likely to cause AVN (dynamic hip screw or IM nail)?

A

DHS is good because its less likely to cause AVN

44
Q

Explain compartment syndrome

Where can you get compartment syndrome (and where is most common)?

A

Compartment syndrome
swelling of tissue in anatomical compartment>increase pressure>occludes vasculature>hypoxia> acute ischemia and oedema>necrosis

  • TIBEA is most common (Commonly lower and upper limb)
  • also can get in abdomen, gluteal region
45
Q

What are the causes of compartment syndrome?

A

Causes of compartment syndrome

  • trauma (fractures, crush injury)
  • burns
  • infection
  • vascular (haemorrhage, reperfusion injury)
  • muscle hypertrophy (athletes)
46
Q

What are some INITIAL signs of acute compartment syndrome? (within 48 hours)

A 
INITIAL signs of acute compartment syndrome (within 48 hours)
PAIN PAIN PAIN PAIN PAIN PAIN 
-on passive stretch 
-out of proportion 
-getting worse 
-on palpation of compartments 
-despite immobilisation 
-despite analgesia

May also get sensory deficit in distribution of nerves of compartment

47
Q

What are some LATE signs of acute compartment syndrome? (within 48 hours)

A 
Late signs  
Tissue ischaemia (the other 5) – pallor, pulselessness, cold, paraestheia, paralysis (can cause abnormal flexing)
48
Q

What are the investigations of acute compartment syndrome?

A

Investigations of acute compartment syndrome
clinical diagnosis

  1. Bloods
    FBC/CK (increased)/UsEs (can cause renal failure)
  2. Intra-compartmental pressure monitoring is diagnostic if unclear
    - Wick catheter and needle
49
Q

Explain the results of the intra-compartmental pressure monitoring

A
  • Difference of > 30mmHg between diastolic BP and compartment pressure = ↑risk of compartment syndrome → surgical decompression + fasciotomy
  • If absolute compartment pressure > 40mmHg with clinical symptoms →DIAGNOSTIC → surgical decompression + fasciotomy
50
Q

Acute MANAGEMENT of compartment syndrome? (5 steps)

A

Compartment syndrome

  1. RELEASE any circumferential cast + dressing (↓pressure by 90%)!!! + ELEVATE limb to heart level
  2. Monitor and control BP
  3. Urgent surgical DECOMPRESSION (within 1hr) – if symptoms persist FasciOTOMY
  4. Excise necrotic tissue – FasciECTOMY
  5. Re-exploration – ALL PATIENTs at ~ 48hours
51
Q

When should you surgically re-explore a patient after treatment for compartment syndrome?

A

All patients should get re explored at 48 hours

52
Q

Complications of compartment syndrome? (3)

A

Complications of compartment syndrome
1. Tissue necrosis – within 6-12 hours
2. Muscle necrosis → fibrosis + ischaemic contracture (Volkmann’s)
3. Renal failure – rhabdomyolysis from necrosis → ↑CK
(IV Fluids + Acidosis Mx)

53
Q

Who normally gets Chronic/Exertional compartment syndrome?

How does it present?

A

Chronic (Exertional compartment syndrome)
-young athletes (football, cycling)

Presentation

  • usually both legs
  • severe pain/tightness
  • rigid legs
  • sensory change – numb, tingling
  • weakness
  • abnormal gait

*worse with exercise and stretch (resolves with rest)

54
Q

What are investigations for exertion compartment syndrome? What would you expect to see?

Whats the managment?

A
  1. Intra-compartmental pressure monitoring (gold standard) – measure before and after exercise
    Large difference in pressure confirms

Management

  • Limit or stop activity causing pain
  • Fasciotomy – for athletes unwilling to modify sport
55
Q

Differentials of acute and chronic compartment syndrome?

A

Differential Diagnosis
Acute
-DVT

Chronic

  • Stress fracture
  • Shin splints
56
Q

What sling do you need for an acromioclavicular joint injury?

A

Acromioclavicular joint injury=broad arm sling (shove arm up to reduce the space)

57
Q

Managment of anterior shoulder disclocation?

What if there is a fracture?

A

Anterior shoulder dislocation

  • MUA to muscle relax (midazolam +/- propofol)
  • Re Xray
  • Physio
  • Immoblisation (broad arm sling)

**if fracture: ORIF!

58
Q

How do you test for scafoid fracture?

A

Scafoid fracture

  • anatomical snuffbox pain and pain on thumb telescoping
  • cast in beer glass position (future splint)

Bring back for CT!

59
Q

What is the scoring system for fibula fractures?

A

Webers scoring for fibula fractures
A-below the ligament >cast and send home
B-at the level of ligament
C-above ligament>surgery

60
Q

What is a Galeazzi fracture?

A

Galeazzi fracture

  • a distal radial fracture with an associated dislocation of the distal radioulnar joint
  • direct blow

Radial shaft fracture with associated dislocation of the distal radioulnar joint
Direct blow

61
Q

What is a Monteggia fracture?

A

Monteggia fracture

-fracture of the proximal ulna, with an associated dislocation of the proximal radioulnar joint.

5thyr (18 decks)

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