Case 24- Pathology 2

Question 1

Journey of a patient in a major road traffic accident

Answer 1

• Would be brough in by ambulance to a major trauma unit at A&E
• Trauma team is alerted and they go through the primary survey before the fracture is dealt with
• Cervical spine immobilisation

Question 2

Journey of a patient with a minor accident

Answer 2

• Would self present to a minor injuries unit at A&E

* Assessed by a triage nurse then a nurse practitioner or doctor

Question 3

Management of open fractures

Answer 3

• Intravenous antibiotics to be administered as soon as possible
• Assessment and documentation of neurovascular status
• Re align and splint the limb, wound debridement (clean the wound) and stabilisation of the fracture
• Tetanus toxoid status should be checked and administered if required

Question 4

Types of fractures

Answer 4

Comminuted fracture- when the bone splits into lots of different pieces, there are multiple segments
Simple fracture- when the bone splits into two pieces
Segmental fracture- when its fractured at two different places and becomes completely detatched.
Children fracture- the periosteum is very strong so the bone can fracture and the periosteum keeps it in place

Question 5

Incomplete and complete fracture

Answer 5

A complete fracture is when the two ends of the bone completely break off and an incomplete fracture is when one part off the bone breaks but the other is still intact or the thick periosteum can hold it in. Incomplete fractures are common in children who may get a buckle fracture where the bone buckles but the periosteum is still intact and only part of the bone breaks

Question 6

Causes of different types of fractures

Answer 6

Spinal and oblique fractures- when the break is at an angle, normally because the arm has been twisted.
Transverse fracture- due to direct trauma, normally a knife wound
Segmental fracture- due to multiple breaks often due to a high impact trauma

Question 7

Intra-articular fracture and pathological fracture

Answer 7

An intra-articular fracture involves the joint and is more worrying then an extra-articular fracture. If it affects the joint it can lead to arthritis and stiffness.
Pathological fracture- fracture caused without an injury i.e. in osteoarthritis or bone cancer

Question 8

Structures in the soft tissue

Answer 8

Skin
Subcutaneous tissue- fat
Muscle
Tendon
Ligaments
Nerve
Blood vessels

Question 9

Anatomy of the soft tissue

Answer 9

Skin- epidermis, dermis
Subcutaneous tissue- fat deep to the skin
Fascia- deep to the fat, overlies the muscles

Question 10

3 steps of wound healing

Answer 10

1) Inflammation
2) Proliferation
3) Remodelling

Question 11

Wound healing- Proliferative phase

Answer 11

Epithelialisation
Formation of granulation tissue
Wound contraction
Angiogenesis

Question 12

Types of soft tissue injuroes

Answer 12

1) Open
2) Penetrating- incised wound, laceration
3) Blunt- Burst laceration, Crush, De-gloving injury, Avulsion, Amputation

Question 13

Laceration/Incised wound treatment

Answer 13

1) Wound debridement
2) Wound washout
3) Repair damaged structures
4) Wound closure

Question 14

Skin loss

Answer 14

Burn, Abrasian, De-gloving injury, Skin necrosis

Question 15

Effects of skin loss

Answer 15

Superficial- Adnexal structures intact, good healing potential
Full-thickness= could heal by secondary intention, may need skin graft or flap
Associated infection/contamination

Question 16

Complex tissue injury

Answer 16

1) Skin and soft tissue loss
2) Exposed structures- muscle/tendon/nerve
3) Exposed bone/fracture
4) Amputation

Question 17

Management of tissue loss

Answer 17

1) Reconstructive ladder/elevator
2) Laceration/incised wound- primary closure
3) Skin loss- secondary intention, skin graft
4) Involvement muscle/tendon/bones- skin graft, flap

Question 18

Skin grafts and flap

Answer 18

Graft- tissue moved from one site to another. Is separated from its blood supply and picks up a new blood supply from the recipient site. Requires a vascularised bed
Fap- tissue moved from one site to another. Brings its blood supply with it. Used to cover non-vascularised tissue i.e. bone, tendon

Question 18

Skin grafts and flap

Answer 18

Graft- tissue moved from one site to another. Is separated from its blood supply and picks up a new blood supply from the recipient site. Requires a vascularised bed
Fap- tissue moved from one site to another. Brings its blood supply with it. Used to cover non-vascularised tissue i.e. bone, tendon

Question 19

Split thickness skin graft

Answer 19

Sheet- laid on as sheet tissue
Meshed- lots of small holes in the graft. Allows graft to be stretched to increase area covered. Allows blood to drain from underneath
Full thickness- full thickness skin taken. Need to stitch up donor site

Question 20

Classifying flaps

Answer 20

Based on:

1) Blood supply- random pattern, axial
2) Constituents- cutaneous, fasciocutaneous, muscle, musculocutenous, osseous, osseocutaneous
3) Method of movement- transposition, advancement, rotation, pedicled, free flap
4) Location to defect- local, regional, distant- free tissue transfer

Question 21

Compartment syndrome

Answer 21

Increased pressure within a muscle compartment
Causes- fractures, crush injury, reperfusion injury
Bleeding
Swelling
Pain- beyond that expected for injury, on stretching muscles
Pulseless, Pallor, Paraesthesia
Treatment- open up leg

Question 21

Compartment syndrome

Answer 21

Increased pressure within a muscle compartment
Causes- fractures, crush injury, reperfusion injury
Bleeding
Swelling
Pain- beyond that expected for injury, on stretching muscles
Pulseless, Pallor, Paraesthesia
Treatment- open up leg

Question 22

Tendon injury

Answer 22

Open- sharp division tendon
Closed- Rupture- tendon snaps mid substance
Closed- Avulsion- tendon avulsed from insertion

Question 23

Tendon injury- Division

Answer 23

1) Open injury 2) Sharp object 3) Most commonly knife or glass 4) Most commonly see in the forearm and hand- Falls, DIY, Cooking, Deliberate self harm

Question 24

Terminology- Upper limb

Answer 24

``` Radial= thumb side (lateral) Ulnar= little finger side (medial) Palm= Palmar= Volar= Flexor Dorsal= extensor Active movement- movement achieved by the muscle action of the patient Passive movement- movement achieved ```

Question 25

Different types of tendons

Answer 25

Extensor tendon- dorsal aspect of forearm and hand | Flexor tendons- volar aspect forearm and hand

Question 26

Assessment of tendon injury

Answer 26

``` Posture of hand Cascade- normal resting position fingers Active movement Pain on movement Posture of hand Extensor lag- no active movement, can passively extend ```

Question 27

Tendon rapair

Answer 27

1) Skin marketing 2) Protect other structures 3) Sound repair 4) Post-operative rehabilitation 5) Modified Kessler 6) Adelaide repair 7) Tendon repair- epitendinous suture

Question 28

Post-operative rehabilitation Tendon injury

Answer 28

1) Splint 2) Physiotherapy 3) Controlled mobilisation

Question 29

Tendon injury- rupture

Answer 29

1) Closed injury 2) Tendon ruptures mid substance 3) Associated with fractures 4) Associated with arthritis

Question 30

EPL rupture

Answer 30

1) Extensor pollicis longus 2) 3rd dorsal compartment 3) Distal radius fracture

Question 31

Tendoachilles

Answer 31

1) Plantarflexes ankle 2) Sports injury- sudden dorsiflexion of foot when the calf muscles are tensed, direct impact 3) Elderly 4) Treatment- Quinolone antibiotics, steroid injections 5) Sudden pain, difficulty walking, snapping sound 6) Loss of plantarfexion, unable to stand on toes

Question 32

Management of tendoachilles

Answer 32

Non-operative management- cast | Surgery- tendon repair, better outcomes. Increased risk of complications

Question 33

Tendon injury- avulsion

Answer 33

1) Tendon pulled away from bone due to sudden force 2) Most commonly seen sports injury 3) Commonly seen in the hand at lower limbs

Question 34

Soft- tissue mallet

Answer 34

1) Extensor tendon avulsed base distal phalanx 2) Extensor lag- unable to extend DIP joint 3) May be associated with fracture- bony mallet 4) Management- splintage

Question 35

FDP avulsion

Answer 35

1) Jersey finger- rugby injury 2) Unable flex DIP joint 3) May be associated with fracture 4) Management- surgical repair

Question 36

Nerve injury

Answer 36

Open- incised wound/laceration. Nerve division | Closed- traction, compression

Question 37

Nerve injury- division

Answer 37

1) Open injury 2) Incised or penetrating wound 3) Most commonly in the hand and forearm 4) Primary repair

Question 37

Nerve injury- division

Answer 37

1) Open injury 2) Incised or penetrating wound 3) Most commonly in the hand and forearm 4) Primary repair

Question 38

Nerve anatomy of the hand

Answer 38

``` Normal anatomy- median nerve, ulnar nerve, radial nerve Danger sites (superficial nerves)- Superficial radial nerve, digital nerve (radial and ulnar) ```

Question 39

Assessment of nerve injury

Answer 39

Sensation- radial (extensor pollicis longus), median (abductor pollicis brevis), ulnar (abductor digiti minimi) Compare with normal- out of 10 Biro= 2-point discrimination

Question 40

Nerve injury- traction injury

Answer 40

Nerve stretched- sudden high velocity force. High speed road traffic accidents, associated with fractures or dislocation Rupture- axons, fascicles, nerve Nerve avulsed spinal cord

Question 41

Classification of nerve injuries

Answer 41

Seddon Neuropraxia- concussion Axonotmesis- sheath intact, axons cut Neurotmesis- sheath and axons cut

Question 42

Nerve injury- compression

Answer 42

Soft tissue swelling- compartment syndrome Fractures or dislocations Long-lie= Saturday night palsy Usually neurapraxia Longer duration or greater compression recovery depends on the extent of nerve damage

Question 43

Management of nerve compression

Answer 43

``` Watch and wait Repeated clinical examination Neurophysiology Nerve grafts Nerve transfers ```

Question 44

Nerve injury and compression= acute/ chronic

Answer 44

Acute- Laceration, Penetrating wounds, fracture, haematoma | Chronic- Meralgia paraesthesia, Tarsal tunnel syndrome

Question 45

Injury to the Femoral nerve

Answer 45

1) Posterior dislocation hip 2) Hip surgery 3) Laceration- stab wound, penetrating injury

Question 46

Femoral nerve sensation

Answer 46

1) Anterior thigh 2) Medial leg via saphenous nerve 3) Motor- knee extension

Question 47

Sciatic nerve injury

Answer 47

1) Posterior dislocation hip 2) Hip surgery 3) Laceration- stab wound, penetrating injury

Question 48

Sciatic nerve sensation

Answer 48

Sensation- no sensory branches in the thigh Hip extension/knee flexion (motor)- Semimembranosus, Semitendinosus, Biceps femoralis (long head), Branch to adductor magnus

Question 49

Tibial nerve injury

Answer 49

``` Fractures Dislocation knee Dislocation ankle Compression Baker's cyst Tarsal tunnel ```

Question 50

Tibial nerve sensation

Answer 50

Motor Ankle plantar flexion Toe flexion Sensory- sole of the foot

Question 51

Injury to the common peroneal nerve

Answer 51

Fracture of the fibula head Lacerations Compression- Casts/braces. Habitual knee flexion 'Strawberry pickers' palsy' Divides into a deep and superficial nerve

Question 52

Superficial peroneal nerve sensory

Answer 52

Sensation- two thirds lateral leg, dorsum foot except 1st webspace Motor- Ankle eversion (Peroneus longus, Peroneus brevis, Peroneus tertius)

Question 53

Deep peroneal nerve sensory

Answer 53

Sensation- dorsum foot 1st webspace Motor- Ankle dorsiflexion (anterior tibialis), Toe extension (Extensor hallucis longus, Extensor digitorum brevis) Results- stub toe, Footdrop

Question 54

Nerve compression syndromes

Answer 54

1) Meralgia parasthesia | 2) Tarsal tunnel syndrome

Question 55

Lateral cutaneous nerve thigh

Answer 55

Meralgia paraesthesia Compression- Idiopathic, External i.e. seat belt/tool belt, Pregnancy, Obesity Injury- Iatrogenic (Hip surgery, Inguinal hernia repair) Sensation= Anterior-lateral thigh