Cortex - general trauma 4 (this is the more important stuff from this section)

Question 1

What are some of the ways in which skin and soft tissue problems can arise following a fracture ?

Answer 1

• A protruding spike of bone or tension on the skin from deformity can lead to devitalisation and necrosis with skin breakdown
• A shearing force on the skin can result in avulsion of the skin from its underlying blood vessels known as de‐gloving which can result in skin ischaemia and necrosis
• Fracture blisters can occur due to inflammatory exudates causing lifting of the epidermis of the skin (much like a burn).

Question 2

What are the signs/symptoms of good normal fracture healing ?

Answer 2

• Resolution of pain and function
• Absence of point tenderness
• No local oedema
• Resolution of movement at fracture site

Question 3

What are the signs/symptoms of non-union?

Answer 3

• Ongoing pain
• Ongoing oedema
• Movement at the fracture site
• Bridging callus may be seen on X‐ray however in cases where doubt exists over bony union, CT scans may confirm or exclude bridging callus.

Question 4

What are some of the different ways in which there can be problems with fracture union ?

Answer 4

• Delayed union
• Non-union

Question 5

Define what delayed union in terms of fracture healing is

Answer 5

A delayed union is a fracture that has not healed within the expected time.

Question 6

What is meant by non-union in terms of fracture healing ?

Answer 6

Two types:

1. Hypertrophic non-union which can occur due to instability and excessive motion at the fracture site
2. Atrophic non‐unioncan occur due to rigid fixation with a fracture gap, lack of blood supply to the fracture site, chronic disease or soft tissue interposition

Question 7

What are some of the typical fractures which are prone to non-union due to poor blood supply ?

Answer 7

• Scaphoid waist fractures
• Fractures of the distal clavicle
• Subtrochanteric fractures of the femur
• And a Jones fracture of the fifth metatarsal.

Question 8

Why may a patient develop a DVT following a fracture ?

Answer 8

This can occur esp in pelvic and lower limb fractures due to a period of immobility - at risk patients are given LMWH

Question 9

What does the term fracture disease mean ?

Answer 9

Stiffness and weakness due to the fracture

Question 10

What is complex regional pain syndrome ?

Answer 10

A heightened chronic pain response following injury.

Characteristics include - constant burning or throbbing, sensitivity to stimuli not normally painful (allodynia) including cold or light touch, chronic swelling, stiffness, painful movement and skin colour changes.

Question 11

What are the two main mechanisms resulting in open fractures ?

Answer 11

1. Inside-out injury: a spike of fractured bone from within puncturing the skin
2. Outside-in injury: laceration of the skin from tearing or penetrating injury

Question 12

Describe the treatment of open fractures

Answer 12

• IV antibiotics in A&E
• Prompt surgical debridement
• Stabilized with internal or external fixation

Question 13

What are fracture-dislocations and how are they treated?

Answer 13

A fracture which occurs with a dislocation

• Closed reduction
• However ORIF may be required if reduction cannot be achieved, if a bony fragment prevents congruent reduction or if the joint is very unstable.

Question 14

How are ligament ruptures graded?

Answer 14

Grade 1-3

• Grade I = sprain
• Grade II = tear
• Grade III = complete tear

Question 15

What is the mainstay for most soft tissue injuries (ones that are not that bad)?

Answer 15

RICE - rest, ice, compression and elevation

Question 16

What is the typical presenting features of septic arthritis ?

Answer 16

Severely painful red, hot, swollen and tender joint with severe pain on any movement

Question 17

Who is most at risk of developing septic arthritis ?

Answer 17

Similar to osteomyelitis the young, elderly, IVDUs and immunocompromised patients are most prone to infection.

Question 18

What are the bacteria found to most commonly cause septic arthritis ?

Answer 18

• Staphylococcus aureus ‐ the most common cause in adults
• Streptococci ‐ the second most common cause
• Haemophilus influenzae ‐ was the most common cause in children but is now uncommon in areas where Haemophilus vaccination is practiced
• Neisseria gonorrhoea ‐ in young adults (now thought rare in Western Europe)
• Escherichia coli ‐ in the elderly, IV drug users and the seriously ill

Question 19

How does septic arthritis arise ?

Answer 19

• Usually pathogen spreads from infection of adjacent tissues
• Sometimes there will be a history of direct penetration of a joint with a sharp object (eg a “fight bite” wound from a punching injury and penetration of a tooth or a rose thorn injury from gardening).

Question 20

How is septic arthritis diagnosed and when should this be done ?

Answer 20

Diagnosed by aspirating the joint (frank pus should be seen) this is done before antibiotics are given

Question 21

What is the treatment of septic arthritis ?

Answer 21

• Surgical washouteither via open surgery or using arthroscopic techniques
• IV antibiotics - Flucloxacillin