Emergency MSK Flashcards by Molly Harby

What is an open fracture?

Fracture with communication with the outside world

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What system is used to classify open fractures?

Gustilo classification

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What is a type I Gustilo fracture?

Wound <1cm, low energy, no contamination, simple fracture

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What is a type II Gustilo fracture?

wound is 1-10cm, moderate energy, mild contamination, mild comminution

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What is a type IIIa Gustilo fracture?

Wound >10cm, high energy, enough tissue for coverage, contamination
PLUS any wounds with comminuted fractures and ALL farm injuries

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What is a type IIIb Gustilo fracture?

Extensive peritoneal stripping and requires a free tissue transfer

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What is a type IIIc Gustilo fracture?

Vascular injury requiring vascular repair

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What antibiotics are recommended for a Gustilo I or II open fracture?

Cephalosporin (eg. Cefazolin)

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What antibiotics are recommended for a Gustilo III open fracture?

Cephalosporin and an Aminoglycoside

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What antibiotics are given additionally in an open wound contaminated with bowel contents or occuring on a farm?

Penicillin (for C.diff coverage)

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In tetanus prophylaxis, what toxoid dose should be given in open fractures regardless of age?

0.5mL

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How is an open fracture managed in A&E?

Antibiotics
Tetanus prophylaxis
Control bleeding
Assess soft tissue damage and neurovascular supply
Remove debris from wound
Splint the fracture to decrease pain and reduce risk of further damage

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How are open fractures managed surgically?

Debridement and irrigation with saline
Fracture stabilisation
Early soft tissue coverage or wound closure
Bone gap reconstruction

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How much saline is needed to debride a:

a. Type I Gustilo open fracture
b. Type II Gustilo open fracture
c. Type III Gustilo open fracture

a. 3L
b. 6L
c. 9L

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What is compartment syndrome?

A condition where an osteofascial compartment pressure rises to a level that restricts blood flow to the distal limb.

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Give 5 causes of compartment syndrome

BEST BAE
Burns 
Extravasation of IV infusion 
Swelling (post-ischaemia) 
Trauma- fractures/crush injury/gunshot wound/contusions 
Bleeding disorders
Arterial injury 
External casts/dressings/wrappings

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What are the symptoms of compartment syndrome?

5Ps: pulselessness, pain, pallor, paresthesia, paralysis

Pain will be out of proportion to injury, pain will occur on passive stretching, the leg will swell

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How is compartment syndrome treated?

Observation
Remove/loosen cast or dressing
Hyperbaric oxygen therapy
Emergency fasciotomy

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What is the major complication of compartment syndrome?

Permanent injury to muscle and nerves due to ischaemia

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What is cauda equina syndrome?

Terminal spinal nerve root compression in the lumbosacral region. It is a medical emergency.

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Give 4 symptoms of cauda equina syndrome

Bilateral leg pain 
Urinary retention 
Urinary overflow incontinence 
Saddle anaesthesia
Sensorimotor changes 
Impotence
Bowel dysfunction 
Decreased rectal tone

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Give 3 potential causes of cauda equina

Disc herniation 
Spinal stenosis
Tumour 
Trauma 
Spinal epidural haematoma 
Epidural abscess

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How is cauda equina treated?

Urgent surgical decompression within 48hrs

Discectomy or laminectomy

Give 3 potential complications of cauda equina

Sexual dysfunction
Urinary dysfunction
Chronic pain
Persistent leg weakness

What is septic arthritis?

Infection of the joint space which can lead to profound, extensive cartilage damage within hours

Where is the most common place affected by septic arthritis?

Knee (50% of cases)

Give 4 risk factors of septic arthritis

``` >80 years old Diabetes RA Cirrhosis HIV Endocarditis IV drug user Recent joint surgery ```

Give the 3 potential ways a joint can become infected

Bacteraemia --> spread of infection through the blood Direct inoculation --> from trauma or surgery Contiguous spread --> from adjacent osteomyelitis

What is the most common bacteria responsible for septic arthritis?

Staphylococcus aureus

Give 2 symptoms of septic arthritis

``` Pain in joint Fever Erythematous joint Swollen joint Warm and tender to touch Inability to bear weight on joint ```

What can be seen on an x-ray of septic arthritis?

Joint space widening Effusion Periarticular osteopenia

What is the gold standard diagnostic test for septic arthritis?

Joint fluid aspirate analysis

How is septic arthritis managed?

IV antibiotics | Drainage of the joint

What is necrotising fasciitis?

Life-threatening infection which spreads along soft tissue planes

Give 4 risk factors for necrotising fasciitis

``` Diabetes AIDS Cancer IV drug use Skin abrasions Obesity Abdominal surgery ```

What is Type I necrotising fasciitis?

Most common (80-90%) Polymicrobial cause Seen in immunosuppressed and post-op patients

What is Type II necrotising fasciitis?

Monomicrobial- usually group A beta-haemolytic streptococci

What is Type IV necrotising fasciitis?

Caused by MRSA

What are the early signs of necrotising fasciitis?

``` Localised abscess Rapid progression Mild swelling No trauma No discolouration ```

What are the late signs of necrotising fasciitis?

``` Severe pain High fever Chills Rigor Tachycardia ```

What is found on examination of necrotising fasciitis?

Skin bullae, cutaneous gangrene, ischaemic patches, swelling, oedema, erythema, subcutaneous emphysema

What score can be used to assess diagnosis of necrotising fasciitis?

LRINEC score | Looks at CRP, leukocytes, haemoglobin, sodium, creatinine and glucose

How is necrotising fasciitis treated?

Emergency radical debridement | Broad spectrum IV antibiotics

During the operation to fix necrotising fasciitis, what may be found?

Liquified subcutaneous fat Dishwater pus Muscle necrosis Venous thrombosis

Which empirical antibiotics are given in necrotising fasciitis?

Penicillin Clindamycin Metronidazole Aminoglycoside

If MRSA is confirmed in necrotising fasciitis, what antibiotics should be given?

Vancomycin

What is osteomyelitis?

Infection of the bone characterised by progressive inflammatory destruction and apposition of new bone

Give 4 risk factors for osteomyelitis

``` Recent trauma Recent surgery Immunocompromised IV drug use Poor vascular supply Diabetes Sickle cell disease Peripheral neuropathy ```

Why are antibiotics less efficient at treating osteomyelitis

Bacteria produce a biofilm layer which covers necrotic bone and stops antibiotics from penetrating the bone

What is the most common infecting organism in adults with osteomyelitis?

Staphylococcus aureus

What can be seen on an x-ray of osteomyelitis?

Lytic region surrounded by sclerosis May look like neoplastic changes Sequestrum New bone around bone necrosis

How is osteomyelitis treated?

``` IV antibiotics Hyperbaric oxygen therapy Surgical irrigation and debridement Vascularised bone grafts Stabilisation of bone ```

What is gas gangrene?

Rapidly spreading gangrene which affects injured tissue infected by clostridium bacteria.

What are the pathological effects of gas gangrene?

``` Muscle necrosis Vessel thrombosis Haemolysis Shock Foul-smelling odour (glucose breakdown) ```

Give 4 risk factors for gas gangrene

``` Car accidents Crush injuries Gunshot wounds Burns Frostbite IV drug abuse Bowel resection Biliary surgery Colon cancer Neutropenia ```

Give 2 symptoms which precede evidence of gas gangrene

Feeling of impending doom Sudden progressive pain out of proportion of what is expected Tachycardia

How is gas gangrene managed?

IV antibiotics Hyperbaric oxygen therapy Radical surgical debridement with fasciotomy