General Trauma (cortex) Flashcards
(110 cards)
1
Q
Trauma care may involve many different medical and surgical specialties
A
T
2
Q
the specialty of orthopaedics is involved in the management of fractures, dislocations, lacerations and penetrating injuries
A
T
3
Q
What are the priorities in high energy injuries?
A
- save life
- prevent serious sytemic complications
- preventing pain
- loss of function
4
Q
What do the principles of ATLS involve? (Advanced Trauma Life Support)
A
initial primary survey (ABCDE- correct any problems)
secondary survey involving a head to toe survey
5
Q
Very low injury fractures are usually due to?
A
an underlying weakness of the bone resulting in a pathologic fracture
6
Q
Terms to decribe fracture
A
direct trauma / indirect trauma (twistin or bending)
partial/complete
high energy (gun, fall from height)/ low energy (trip, sports, fall)
7
Q
When does primary bone healing occur?
A
Minimal fracture gap <1mm
Occurs in hairline fractures and when fractyres are fixed with compression screws and plates
8
Q
How does primary bone healing occur?
A
bone simply bridges the gap with new bone from osteoblasts
9
Q
How does secondary bone healing occur?
A
Haematoma,
granulation tissue
soft cartilegnous callus (chondroblasts)
endochonral ossification - osteoblasts lay down collagen type 1
Caclium mineralisation - immature woven bone (hard callus)
Remodelling
10
Q
How long does it take for soft callus and hard callus to appear?
A
2nd to 3rd week, 6-12 weeks
11
Q
What can stop secondary bone healing?
A
Lack of blood supply too big a fracture gap tissue trapped in fracture Smoking (vasospasm) malnutrition Excessive movement
12
Q
What causes transverse fractures ?
A
pure bending force
13
Q
What causes Oblique fractures?
A
shearing force (eg fall from height, deceleration)
14
Q
What causes spiral fractures?
A
torsional forces
15
Q
What are comminuted fractures?
A
fractures with 3 or more fragments
reflection of a higher energy injury or poor bone quality
periosteal damage with reduced blood supply
16
Q
What are segmental fractures?
A
bone is fractured in two separate places.
injuries are very unstable and require stabilization with long rods or plates
17
Q
Transverse fractures may result in?
A
angulation or rotational malalignment
18
Q
What is shortening?
A
Proximal migration of the distal fracture resulting in shortening of bone length
19
Q
Which fractures are readily shortened?
A
Oblique fractures
20
Q
How are oblique fractures usually managed?
A
interfragmentary screw
21
Q
How are spiral fractures usually managed?
A
interfragmentary screw
22
Q
Which types of fractures are relative unstable ?
A
spiral> comminuted and segmental
23
Q
How do you describe fractures?
A
proximal, middle or distal third
diaphyseal (shaft), metaphyseal or epiphyseal
intra‐articular (extending into the joint) or extra‐articular
displaced? anteriorly or posteriorly? Degree?( relative to bone i.e. 100%, 75%)
Angulation? Medial, lateral, ant, post?
24
Q
What are the clinical signs of a fracture?
A
Localised bony (marked) tenderness – not diffuse mild tenderness
Swelling
Deformity
Crepitus – from bone ends grating with an unstable fracture
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fracture can be excluded on clinical grounds avoiding unnecessary radiographs
T
26
if a patient cannot weight bear on an injured lower limb, X‐ray of the painful area should be requested.
T
27
Which factors should be assessed in an injured limb?
open or closed
distal neurovascular status (pulses, capillary refill, temperature, colour, sensation, motor power)
Compartment syndrome?
status of skin and soft tissue
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Oblique view x rays can also be useful for complex shaped bones
T
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two views of X ray (AP and perpendicular) are always required
T
30
What is used to diagnose mandibular fractures/?
tomogram
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What form of investigation can help with surgical planning for complex intra‐articular fractures
CT
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Which investigation can be used for "hidden" fractures that dont readily appear on X ray?
MRI
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Which investigation is used for stress frcatures?
Technetium bone scans
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undisplaced, minimally displaced and minimally angulated fractures which are considered to be - are usually treated with?
stable, non‐operatively with a period of splintage or immobilization and then rehabilitation
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Displaced or angulated fractures require?
Reduction under anaesthetic
Closed reduction and cast application
Serial x‐rays
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Unstable injuries may be treated with ?
surgical stabilisation - involve use of percutaneous pins wires, screws etc
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What is Open reduction and Internal Fixation (ORIF)?
anatomic reduction and rigid fixation leading to primary bone healing
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In which types of fractures is it better to avoid Open reduction and Internal Fixation (ORIF)?
soft tissues swollen
little blood supply
ORIF may cause extensive blood loss (i.e. in the femur)
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What are the alternatives to orif?
Closed reduction and indirect internal fixation (nail distant to fracture site)
allows micromotion required for secondary bone healing
for Extra articular diaphyseal frcatures
external fixation (nails and rod outside going in) aiming for secondary bone healing
risk of pin site infection and loosening
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Displaced intra‐articular fractures require
ORIF :anatomic reduction and rigid fixation using wires,screws and plates
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Fractures involving a joint with predictable poor outcome may be treated with
joint replacement or arthrodesis
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Elderly patients tend not to have as high a functional demand and therefore older patients may be more likely to be treated non‐operatively.
T
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What are Early local complications?
compartment syndrome, vascular injury with ischaemia, nerve compression or injury, and skin necrosis.
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What are Early systemic complications?
hypovolaemia, fat embolism, shock, Acute Respiratory Distress Syndrome, acute renal failure, Systemic Inflammatory Response Syndrome, Multi‐Organ Dysfunction Syndrome and death
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What are Late local complications?
stiffness, loss of function, Chronic Regional Pain Syndrome, infection, non‐union, mal‐union, Volkmann’s ischaemic contracture, post traumatic osteoarthritis and deep vein thrombosis.
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What are main late systemic complication?
pulmonary embolism - can be quick or take a while
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What can increase pressure in fracture?
blood
| inflammatory exudate
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What are the conseq. of inc pressure?
compression venous system
congestion muscle - secondary ischaemia as arterial blood cant supply
severe pain
nerves - parastheisa and sensory loss
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What are the CARDINAL clinical signs of compartment syndorme?
(1) increased pain on passive stretching of the involved muscle
(2) severe pain outwith the anticipated severity in the clinical context
also: tensely, tender, swollen muscle, loss pulses
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Once compartment syndrome has been clinically suspected you should?
remove tight bandages
emergency fasciotomy
open wound left for few days
secondary closure (may require skin graft)
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What is Volkmann’s ischaemic contractur
untreated compartment syndrome w/ ischaemic muscle necrosis resulting in fibrotic contracture
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Partial tears affecting the arterial intima can?
thrombose resulting in arterial occlusion
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Knee dislocation risks - artery injury
popliteal
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paediatric supracondylar fracture of the elbow risks -
| artery injury
brachial
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shoulder trauma can result in - artery compromise
axillary
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Pelvic fractures can be associated with life threatening haemorrhage from arterial or venous bleeding.
T
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Any signs of reduced distal circulation mandates urgent vascular surgery review
T
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Temporary restoration of circulation can be achieved with use of?
vascular shunt or vascular repair with either a bypass graft or endoluminal stent
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Urgent - in theatre may help localize the site of arterial occlusion.
angiography
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Pelvic fractures can be associated with life threatening haemorrhage from arterial or venous bleeding.
T
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How can ongoing haemorrhage from arterial injury in the pelvis be managed?
angiographic embolisation
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A protruding spike of bone or tension on the skin from deformity can lead to?
necrosis and skin break down
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How does excessive pressure on the skin manifest?
tenting (when you pinch skin and "tent" remains - loss elasticity) and blanching
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Pressure on skin due to fracture is an emergency
T
| reduction should be done under analgesia/sedation to avoid necrosis
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What is de-gloving?
Shearing force on the skin
it is forcibly detached
removal from underlying blood vessels
= ischaemia and necrosis
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What are the signs of degloving?
skin will not blanch under pressure
| lack of sensation
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The de‐gloved area of skin may take a few days to demarcate
T
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The amount of soft tissue swelling and bruising (contusion) is usually a reflection of the energy of the injury involved
T
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Why do fracture blisters occur?
Inflammatory exudate resulting in the lifting of epidermis (ike a burn)
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WHy is a surgical incision not advised through swollen and bruised skin?
wound may not be able to be closed (infection risk)
| Excessive tension when closing wound may lead to necrosis and wound breakdown
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Which type of fractures are expected to heal and do not need serial follow up with X rays?
extra articular cancellous bone fractures
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What are the symptoms/signs of fracture healing?
Resolution of pain and function
Absence of point tenderness
No local oedema
Resolution of movement at fracture site
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What are the clinical signs of non-union?
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.
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Healing is dependent on ?
energy of injury
age of patient
health status
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Which boen is the slowest healing bone in the body?
the tibia
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Metaphyseal fractures tend to heal more quickly than cortical fractures.
T
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What can cause a delayed union in a fracture?
infection
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Hypertrophic non union can occur due to?
Instability and excessive motion , infection
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Atrophic non union can occur due to?
```
rigid fixation with a fracture gap
lack of blood supply
chronic disease
soft tissue interposition
infection
```
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Intraarticular fractures may not unite due to?
Synovial fluid inhibiting healing
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For DVT prophylaxis should be given to all at risk patients
T
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Suspected DVT requires?
duplex scanning and anticoagulation
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Deep vein thrombosis can occur particularly after ?
pelvic or major lower limb fractures with a period of immobility
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What is fracture disease?
stiffness and weakness due to the fracture and subsequent splintage in cast
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How do you resolve fracture disease?
time and may be helped with physiotherapy
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Avascular necrosis is always symptomatic
F
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How is post traumatic OA managed?
analgesia
bracing/splinting
arthrodesis
joint replacement
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What can cause postraumatic OA?
intra‐articular fracture, ligamentous instability or fracture malunion
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What is Complex Regional Pain Syndrome (CRPS)?
heightened chronic pain response after injury
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What are symptoms of Complex Regional Pain Syndrome?
constant burning or throbbing
sensitivity to stimuli not normally painful (allodynia),
chronic swelling, stiffness,
painful movement and skin colour changes
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Which type of nerve injury is Complex Regional Pain Syndrome usually caused by?
Neuropraxia - T1
| can be caused by Axonometesis T2
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Management of Complex Regional Pain Syndrome is complicated and requires specialist pain services as well as analgesics, antidepressants (amitriptyline), anticonvulsants (gabapentin) and steroids
T
93
Fractures can still unite if the infection is suppressed
T
94
For infections present for longer than a few weeks, fracture healing may still be accomplished with antibiotic suppression but ???
metal work will need to be removed i.e.
| intra‐medullary nail, the medullary canal can be reamed out (cored out with a flexible drill) and a new nail implanted.
95
What are the typical presenting features of septic arthritis?
Acute onset of a severely painful red, hot, swollen and tender joint with severe pain on any movement
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Bacterial infections can irreversibly damage hyaline articular cartilage within days
T
97
In septic arthritis Staphylococcus aureous is most commonly found in?
adults
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In septic arthritis Haemophilus influenzae is most commonly found in?
children
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In septic arthritis neisseria gonorrhea is most commonly found in?
young adults
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In septic arthritis escherichia coli is most commonly found in?
elderly, IV drug users and seriously ill
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What is the most common pathogen found in adults?
streptococci
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If a joint is suspected to be septic then...
aspiration (before antibiotics are given)
surgical washout via open surgery or arhtroscopic technique
IV antibiotics instead of washout in children
103
people with hypermobility may sustain a dislocation with a seemingly innocuous injury
T
104
How are ligament ruptures graded?
grade I (sprain), grade 2 (partial tear) and grade 3 (complete tear).
105
what is the treatment for most soft tissue injuries
RICE – Rest, Ice, Compression, Elevation
| early movement to prevent stiffness
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What is the initial management of fractures in A&E?
Broad spec antibiotics
Sterile dressing
debridement of contaminated/dead tissue
Fixate and stabilise
107
Which antibiotic covers gram +ve organisms?
flucloxacillin
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Which antibiotic covers gram -ve organisms?
gentamicin
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Which antibiotic covers anaerobic organisms?
metronidzole - esp soil contamination
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In open fractures, what should you do if theres doubt over the viability of soft tissues?
safer to leave the wound open then further debridement
