General Trauma Master Deck

Question 1

Different classifications of fractures?

Answer 1

Direct trauma, e.g: direct blow, OR indirect trauma (majority), e.g: twisting/bending forces

Partial/incomplete OR complete

High-energy OR low-energy

Question 2

Describe primary bone healing and when it occurs

Answer 2

Occurs where there is minimal fracture gap (< 1mm), e.g: hairline fractures and when fractures are fixed with compression screws and plates

Bone bridges the gap with new bone

Question 3

Describe secondary bone healing and when it occurs

Answer 3

Majority of fractures have a gap that needs to be temp. filled to act as a scaffold for new bone

Inv. an inflammatory response with recruitment of pluripotential stem cells, which differentiate

Question 4

Fracture process of secondary bone healing?

Answer 4

• Fracture occurs and haematoma forms, with inflammation from damaged tissues
• Macrophages and osteoclasts remove debris and resorb the bone ends
• Granulation tissue forms from fibroblasts and new blood vessels
• Chondroblasts form cartilage (soft callus) and osteoblasts lay down bone matrix (collagen type 1)– enchondral ossification
• Calcium mineralisation produces immature woven bone (hard callus)
• Remodelling occurs with organization along lines of stress into lamellar bone

Question 5

Time period in which soft and hard callus appear?

Answer 5

Soft callus usually forms by 2nd-3rd week

Hard callus takes approx. 6-12 weeks

Question 6

Requirements for secondary bone healing?

Answer 6

Good blood supply for oxygen, nutrients and stem cells

A little movement/stress (compression or tension)

Question 7

What factors may result in atrophic non-union?

Answer 7

Lack of blood supply

No movement (internal fixation with fracture gap)

Too large a fracture gap

Tissue trapped in the fracture gap

Smoking may severely impair fracture healing due to vasospasm; vascular disease, chronic ill health and malnutrition also impair fracture healing

Question 8

Cause of hypertrophic non-union?

Answer 8

Occurs due to excessive movement at the fracture site; there is abundant hard callus formation too much movement gives the fracture no chance to bridge the gap

Question 9

5 fracture patterns?

Answer 9

1. Transverse fractures
2. Oblique fractures
3. Spiral fractures
4. Comminuted fractures
5. Segmental fractures

Question 10

Describe a transverse fracture

Answer 10

Occur with PURE BENDING force (cortex on one side fails in compression and the cortex on the other side in tension)

May not shorten (unless completely displaced) but may angulate or result in rotational malalignment

Question 11

Describe an oblique fracture

Answer 11

Occurs with a SHEARING force, e.g: fall from height, deceleration; they tend to shorten and may angulate

They can be fixed with an interfragmentary scews

Question 12

Describe a spiral fracture

Answer 12

Occurs due to TORSIONAL forces; they are most unstable to rotational forces but they can also angulate

Interfragmentary screws can be used

Question 13

Describe a comminuted fracture

Answer 13

Fracture with 3/more fragments and tend to occur with HIGH-ENERGY injuries (or POOR BONE quality); very unstable and tend to be surgically stabilised

There may be soft tissue damage and periosteal damage with reduced blood supply to the fracture site which may impair healing

Question 14

How to describe a fracture of long bone?

Answer 14

According to the site of the bone inv.:
• Proximal, middle or distal 1/3rd
OR
• Diaphyseal (shaft), metaphyseal or epiphyseal

Question 15

How to describe a fracture at the end of a long bone (metaphyseal/epiphyseal)?

Answer 15

Can be:
• Intra-articular - greater risk of stiffness, pain and post-traumatic OA, part. if there is residual displacement resulting in an uneven articular surface

• Extra-articular

Question 16

What is displacement?

Answer 16

Direction of translation of the distal fragment; described as:
• Anteriorly or posteriorly displaced (in the forearm and hand, volar/palmar and dorsal
• Medially or laterally displaced (ulnar and radial)

Can be estimated with reference to the width of the bone, e.g: 25%; 100% displacement means “off-ended” bone

Question 17

What is angulation?

Answer 17

Direction in which the distal fragment points towards and the degree of this deformity:
• Medial or lateral (radial or ulnar; in the lower limb, varus and valgus are used)
• Anterior or posterior (volar or dorsal)

Question 18

Clinical signs of a fracture?

Answer 18

• Localised bony tenderness that is marked (not diffuse mild tenderness)
• Swelling
• Deformity
• Crepitus (bone ends grate in an unstable fracture)

Question 19

Useful rule when deciding whether to X-ray the lower limb for a fracture?

Answer 19

Inability to weight-bear

Question 20

Steps in the assessment of an injured limb?

Answer 20

1. Open/closed
2. Distal neurovascular status (pulses, CRT, temp, colour, sensation, motor power)
3. Check for compartment syndrome
4. Assess the status of the skin and soft tissue envelope

Question 21

Methods of Ix for a fracture?

Answer 21

X‐ray (must have 2 views) - usually an AP and lateral view; oblique views can be useful for complex shaped bones (e.g: scaphoid, acetabulum, tibial plateau)

Tomogram (historic)

CT scan - for complex bones and for assessment of articular damage

MRI - for occult fractures that are suspected despite a normal X-ray

Technetium bone scans - to detect stress fractures that may not show up on X-ray until a hard callus forms

Question 22

Initial Mx of a long bone fracture?

Answer 22

Analgesia (IV morphine), splintage/immobilisation of the limb and Ix (X-rays)

Reduction is performed before X-ray if:
• Fracture is obviously grossly displaced
• Obvious fracture-dislocation
• Risk of skin necrosis from excessive pressure

Question 23

What does splintage or immobilisation involve?

Answer 23

• Temporary plaster slab (AKA backslab)
• Sling
• Orthosis
• Thomas splint (for femoral shaft fractures)

Question 24

Definitive fracture Mx for different types of fractures?

Answer 24

Undisplaced, minimally displaced and minimally angulated fractures that are stable:
• Non-operative Mx with a period of splintage/immobilisation followed by rehab

Displaced OR angulated fractures where the position is unacceptable:
• Reduction under anaesthetic; closed reduction and cast application can be used with serial X-rays to ensure no loss of position
• Unstable injuries can have surgical stabilisation

Question 25

Tools used for surgical stabilisation of an unstable injury?

Answer 25

* Small percutaneous wires (K-wires) for small fragments * Screws OR plates and screws * IM nails * External fixation

Question 26

Definitive Mx of an extra-articular diaphyseal fracture?

Answer 26

Open reduction and internal fixation (ORIF) using plates and screws Aim is primary bone healing

Question 27

When should ORIF be avoided?

Answer 27

* Too much soft tissue swelling * Blood supply to the fracture site is tenuous (high-energy) * If ORIF may cause extensive blood loss, e.g: femoral shaft * Where plate fixation may be prominent, e.g: tibia

Question 28

Alternative to ORIF?

Answer 28

Closed reduction and indirect internal fixation, with an IM nail; aim is functional reduction and stable fixation allowing micromotion required for secondary bone healing Another alternative is external fixation; aim is secondary bone healing

Question 29

Risks of external fixation?

Answer 29

Pin site infection and loosening

Question 30

Definitive Mx of a displaced intra-articular fracture?

Answer 30

Anatomic reduction with rigid fixation with ORIF Fractures of a joint with a predictable poor outcome can undergo joint replacement or arthroidesis

Question 31

Problems with treatment of fractures in elderly patient?

Answer 31

May have co-morbidities, osteoporosis and dementia; they have a higher risk of surgical complications, failure of fixation and failure to rehab satisfactorily Tend not to have as high a functional demand and so more likely to be treated non-operatively

Question 32

Early local complications of fractures?

Answer 32

* Compartment syndrome * Vascular injury with ischaemia * Nerve compression/injury * Skin necrosis

Question 33

Early systemic complications of fractures?

Answer 33

* Hypovolaemia and shock * Fat embolism * Acute renal failure * ARDS, SIRS and MODS

Question 34

Late local complications of fractures?

Answer 34

* Stiffness and loss of function * Chronic Regional Pain Syndrome (CRPS) * Infection * Non-union * Malunion * Volkmann's ischaemia contracture * Post-traumatic OA * DVT

Question 35

Late systemic complications of fractures?

Answer 35

PE (tends to occur several days-weeks after injury but may occur within a day)

Question 36

Describe compartment syndrome

Answer 36

Groups of muscles are bound in tight fascial compartment with limited capacity for swelling Bleeding and inflammatory exudate cause pressure rise and compression of the venous system, resulting in congestion within the muscle; secondary ischaemia occurs as arterial blood cannot supply the congested muscle, so muscle ischaemia occurs

Question 37

Symptoms and signs of compartment syndrome?

Answer 37

Pressure can compress nerves, causing paraesthesiae and sensory loss Cardinal clinical signs: 1. Increased pain on passive stretching of the inv. muscle 2. Severe pain outwith the anticipated severity in the clinical context (disproportionate) Limb is tensely swollen and muscle is tender to touch Loss of pulses is a feature of end-stage ischaemia (late diagnosis)

Question 38

Treatment of compartment syndrome?

Answer 38

Removal of any tight bandages can cause temporary relief Emergency fasciotomy; the open wound is left for a few days before secondary closure (may require split skin grafting)

Question 39

Complications of untreated ischaemic muscle in compartment syndrome?

Answer 39

Necrosis occurs, resulting in fibrotic contracture (AKA Volkmann's ischaemia contracture) and poor function

Question 40

Types of nerve injury?

Answer 40

* Neurapraxia * Axonotmesis * Neurotmesis

Question 41

What is neurapraxia?

Answer 41

Nerve has a temporary conduction defect from compression/stretch and resolve over time with full recovery (up to 28 days)

Question 42

What is axonotmesis?

Answer 42

Occurs due to a sustained compression or stretch or from a higher degree of force Nerve remains in continuity and the internal structure (endoneurial tubes) remains intact, the long nerve cell axons distal to the point of injury (AKA Wallerian degeneration); longer peripheral nerve thus take longer to recover

Question 43

Ix and prognosis of axonotmesis?

Answer 43

Recovery is variable and full power/sensation may not be achieved; it can be predicted by nerve conduction studies (from around a month from the time of injury)

Question 44

What is neurotmesis?

Answer 44

Complete transection of a nerve (rare in closed injuries but may occur in penetrating injuries) No recovery occurs unless the affected nerve is surgically repaired

Question 45

General rule with nerve injuries assoc. with fracture (or dislocation)?

Answer 45

Usually resolve with time and they do not indicate surgical exploration, unless there is evidence of nerve entrapment within the fracture, causing severe neuralgic pain If a nerve injury occurs after fracture manipulation, assume that the nerve is trapped in the fracture site

Question 46

Treatment option for poor recovery from axonotmesis or neurotmesis?

Answer 46

Nerve grafting, using an expendable cutaneous nerve can help Tendon transfers to recruit muscles with intact nerve supply and altering their mechanics, by changing their insertion can improve function

Question 47

Injuries that are characteristically assoc. with particular nerve injuries?

Answer 47

Colles fracture - acute median nerve compression/carpal tunnel syndrome Anterior dislocation of the shoulder - axillary nerve palsy Humeral shaft fracture - radial nerve palsy (in spiral groove) Supracondylar fracture of the elbow - median nerve injury (usually anterior interosseous branch) Posterior dislocation of the hip - sciatic nerve injury "Bumper" injury to lateral knee - common peroneal nerve palsy

Question 48

Complications of vascular injuries?

Answer 48

Distal limb ischaemia risks subsequent amputation Haemorrhage from arterial/venous injury may result in hypovolaemic shock Certain injuries have a higher risk of concomitant vascular injury

Question 49

Risks assoc. of different types of fracture?

Answer 49

* Knee dislocations risk popliteal artery injury * Paediatric supracondylar fracture of the elbow risks brachial artery injury whilst shoulder trauma can result in axillary artery compromise * Pelvic fractures can be assoc. with life-threatening haemorrhage, from arterial/venous bleeding

Question 50

Signs of reduced distal circulation?

Answer 50

* Reduced or absent pulses * Pallor * Delayed capillary refill * Cold to touch Mandates urgent vascular surgery review and surgical Mx

Question 51

Ix and treatment vascular injury?

Answer 51

Urgent angiography may help localise the site of arterial occlusion Temporary restoration of circulation using a vascular shunt or repair (bypass graft or stent) Skeletal stabilisation with internal/external fixation should be performed to protect the repair from shearing force Ongoing haemorrhage from arterial injury in the pelvis can be controlled angiographic embolisation

Question 52

Causes of skin and soft tissue problems with fractures?

Answer 52

With higher energy injuries or with fragile skin, e.g: due to age, steroids, rheumatoid arthritis Injury may jeopardise the viability of the overlying skin; a protruding spike of bone/ tension on the skin from deformity can lead to devitalisation and necrosis with skin breakdown

Question 53

Signs and symptoms of skin and soft tissue problems?

Answer 53

Tenting of the skin and "blanching" (fracture causes excessive pressure on the skin)

Question 54

Treatment of fractures with skin and soft tissue problems?

Answer 54

Reduced as an emergency (under analgesia +/- sedation) to avoid necrosis

Question 55

Describe de-gloving

Answer 55

Shearing force on the skin can result in avulsion of the skin from its underlying blood vessels Underlying haematoma may also increase pressure on the skin occluding capillaries

Question 56

Symptoms and signs of de-gloving?

Answer 56

Skin will not "blanch" on pressure and may be insensate

Question 57

Describe fracture blisters

Answer 57

Occur due to inflammatory exudates causing lifting of the epidermis of the skin (much like a burn)

Question 58

Treatment of skin and soft tissue complications of fractures?

Answer 58

Surgical wound through swollen and contused skin and soft tissue is not advisable as the wound may not be closed (leaving a route for potential infection) OR Excessive tension on the wound may lead to necrosis and wound breakdown Indirect methods of stabilisation may be appropriate

Question 59

Ix for assessing fracture union?

Answer 59

Bridging callus may be seen on X-ray but, if there is doubt, CT scans can confirm Not all fractures need to have radiographic evidence of fracture union; many fractures, part. extra-articular cancellous bone fracture, are expected to heal and do not routinely require follow-up X-rays

Question 60

Symptoms and signs of fracture healing?

Answer 60

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

Question 61

Clinical signs of non-union?

Answer 61

* Ongoing pain and oedema | * Movement at the fracture site

Question 62

Slowest healing bones in the body?

Answer 62

Tibia typically takes ~16 weeks and sometimes over a year to unite Femoral shaft fractures also take 3-4 months to heal

Question 63

Which fractures heal faster: metaphyseal or cortical?

Answer 63

Metaphyseal fractures tend to heal more quickly

Question 64

What is a delayed union and potential causes?

Answer 64

Delayed union is a fracture that has not healed within the expected time Infection can result in delayed union and, if diagnosed, healing can occur; however, if the infection is suppressed with antibiotics, the fracture may go on to an infected non-union

Question 65

Types of non-union and their causes?

Answer 65

Hypertrophic non-union can occur due to: • Instability and excessive motion at the fracture site ``` Atrophic non-union can occur due to: • Rigid fixation with a fracture gap • Lack of blood supply to the fracture site • Chronic disease • Soft tissue interposition ``` Both types may also be caused by infection

Question 66

Which fractures are part. prone to problems with healing due to poor blood supply?

Answer 66

Scaphoid waist fractures Fractures of distal clavicle Subtrochanteric fractures of the femur Jone fracture of the 5th metatarsal Some intra-articular fractures may not unite due to synovial fluid inhibition of healing if a fracture gap exists, e.g intracapsular hip fractures, scaphoid fractures

Question 67

Prophylaxis of DVT?

Answer 67

Usually, LMWH is given to all "at-risk" patients Suspected DVT require requires duplex scanning and anti-coagulation

Question 68

What is fracture disease?

Answer 68

Stiffness and weakness due to the fracture and subsequent splintage in cast

Question 69

Treatment of fracture disease?

Answer 69

Most cases resolve with time and may be helped with physio

Question 70

Fractures prone to AVN?

Answer 70

Fractures of the femoral neck, scaphoid and talus

Question 71

Treatment of AVN?

Answer 71

Surgical Mx in the form of: • THR for the hip or arthroidesis • Arthrodesis

Question 72

Causes of post-traumatic OA?

Answer 72

Intra-articular fracture, ligamentous instability or fracture malunion

Question 73

Treatment of post-traumatic OA?

Answer 73

Analgesia, bracing/splinting, arthrodesis or joint replacement

Question 74

What is complex regional pain syndrome (CRPS)?

Answer 74

Heightened chronic pain response after injury; it can be caused by a peripheral nerve injury (type 2 CRPS) or not (type 1 CRPS)

Question 75

Characteristics of CRPS?

Answer 75

* Constant burning or throbbing * Sensitivity to stimuli not normally painful (allodynia), inc. cold or light touch * Chronic swelling * Stiffness * Painful movement * Skin colour changes

Question 76

Mx of CRPS?

Answer 76

Analgesica, anti-depressants (amitriptyline), anti-convulsants (gabapentin) and steroids TENS machines Physio Lidocaine patches Sympathetic nerve blocking injections

Question 77

Fixation methods of an infected fracture?

Answer 77

Can still unite if the infection is suppressed; for acute infections: • Antibiotic therapy with/without surgical washout may be adequate For infections present >few weeks: • Antibiotic suppression but the metalwork will need later removal If the infection cannot be suppressed and becomes too problematic (sepsis, discharging sinus): • Surgery is required with removal of all implants and debridement of infected bone For medullary infection, from an infected IM nail, the medullary canal can be reamed out and a new nail implanted; alternatively, an external fixator can be applied to give stability (also approp. for infected non‐union of a plate and screw fixation)

Question 78

Causes of open fractures and types?

Answer 78

Inside-out injury - either due to a spike of fractured bone from within puncturing the skin Outside-in injury - laceration of the skin from tearing/penetrating injury

Question 79

Factors that increase the risk of infection of an open fracture?

Answer 79

Higher-energy injury Amount of contamination Delay in appropriate treatment Problems with wound closure

Question 80

Classification system for open fractures?

Answer 80

``` Gustilo classification describes the: • Degree of contamination • Size of the wound • Whether the wound will be able to be closed or require plastic surgery • Presence of an assoc. vascular injury ```

Question 81

Initial Mx of open fractures?

Answer 81

IV broad-spectrum antibiotics, typically: • Flucloxacillin - cover gram +ve organisms • Gentamicin - cover gram -ve organisms • Metronidazole - cover anaerobes if there is soil contamination Sterile/antiseptic soak dressing should be applied to the wound to prevent further contamination, before the fracture is splinted

Question 82

Surgical Mx of open fractures?

Answer 82

Prompt surgical debridement and stabilisation with internal/external fixation; wound can be closed primarily if: • No gross contamination and all remaining skin and muscle is viable • Closure can occur with no undue tension on skin edges If doubt over soft tissue viability, or if the wound is heavily contaminated, safer to leave the wound open (allow ongoing infection to drain out) and do further debridement in 48 hours (necrotic tissue will be obvious now)

Question 83

Why is there an infection risk with unstable fractures?

Answer 83

May produce haematoma, which acts as a culture medium for bacteria and can cause additional necrosis

Question 84

Alternatives if a wound cannot be closed primarily?

Answer 84

Either skin grafting, local flap coverage or free flap coverage

Question 85

Tissues that readily accept a skin graft?

Answer 85

Muscle, fascia and granulation tissue, as can paratenon and periosteum

Question 86

Skin graft does not take on?

Answer 86

Bare tendon, bone or any exposed metalwork; may also not take on fat, due to poor vascularisation

Question 87

Treatment of mangled extremiry?

Answer 87

In some cases, may be wiser to do an early amputation to produce a more functional outcome and avoid multiple surgeries

Question 88

Treatment of a dislocation?

Answer 88

REDUCED AS SOON AS POSSIBLE, mostly with closed reduction under sedation and analgesia Delayed presentation, e.g: alcoholics, increases risk of requiring open reduction and recurrent instability

Question 89

Causes of dislocation?

Answer 89

Significant trauma Hypermobility, inc. Ehlers-Danlos syndrome and Marfan's Some can voluntarily dislocate joints

Question 90

Injuries assoc. with dislocation?

Answer 90

Tendon tears Nerve and vascular injury Compartment syndrome

Question 91

Treatment of fracture-dislocations?

Answer 91

Closed reduction ORIF may be used if: • Closed reduction cannot be achieved • Bony fragment prevents congruent reduction • Joint is very unstable

Question 92

Grading of ligament ruptures?

Answer 92

Grade 1 (sprain) Grade 2 (partial tears) Grade 3 (complete tear)

Question 93

Mainstay treatment of most soft tissue injuries?

Answer 93

Rest Ice Compression Elevation Reduces initial swelling; follow this with early movement to prevent movement

Question 94

Treatment of complete ligament ruptures?

Answer 94

May result in joint instability - repair, tightening (Advancement) or graft reconstruction

Question 95

Treatment of complete tearing of tendons that are fundamental for function?

Answer 95

E.g: quadriceps, patellar tendons Surgical repair Some can be treated conservatively, e.g: complete tearing of Achilles tendon, rotator cuff, long head of biceps brachii, distal biceps) but repair can restore function

Question 96

Treatment of divided tendons?

Answer 96

May occur with a penetrating incised wound, e.g: flexor and extensor tendon injuries in the hand and wrist are part. common and usually require surgical repair

Question 97

Typical presenting features of septic arthritis?

Answer 97

Acute onset of severely painful red, hot, swollen and tender joint Severe pain on any movement

Question 98

Causes of septic arthritis?

Answer 98

In most cases, organism spreads via blood or from infection of adjacent tissues May be a Hx of direct, penetration of a joint, e.g: "fight bite" wound from a punching injury and penetration of a tooth OR a rose thorn injury from gardening May occur after intra-articular surgery Septic emboli from endocarditis, part. if >1 joint or bone is inv.

Question 99

Complications of untreated septic arthritis?

Answer 99

Bacteria can irreversibly damage hyaline articular cartilage within day; there can be chronic arthritis damage

Question 100

Groups of people that are most prone to septic arthritis?

Answer 100

Young and elderly PWIDs and immunocompromised patient Neonates and infants have some intra-capsular metaphyses and septic arthritis can evolve from metaphyseal osteomyelitis

Question 101

Most common bacterial causes of septic arthritis?

Answer 101

* Staph. aureus (most common in adults) * Streptococci (2nd most common) * H. influenzae (used to be most common cause in children but reduced due to vaccine) * Neisseria gonorrhea (young adults) * E. coli (elderly, PWIDs and the seriously ill)

Question 102

Ix for septic arthritis?

Answer 102

Aspiration before antibiotics are given (a single dose can cause a falsely -ve gram stain and culture); looking for frank pus aspiration or a +ve gram stain

Question 103

Treatment of septic arthritis?

Answer 103

Surgical washout either via open surgery or using arthroscopic techniques; open washout is best to decrease bacterial load throughout the joint Response to treatment is based on clinical findings and serial CRP