Musculoskeletal trauma

Question 1

Order of steps in aim of extremity bleeding control

Answer 1

Pressure to wound
Pressure dressing
Compression of artery proximal to injury
Tourniquet

Question 2

Potentially life threatening extremity injuries

Answer 2

Major arterial haemorrhage
Bilateral femur fractures
Crush syndrome
Pelvic disruption

Question 3

Management of life threatening extremity injuries

Answer 3

Traction splint fractures
Fluid resuscitation
Direct pressure to open wounds
Reduce joint dislocations when possible

Question 4

Aim of splinting fractured extremities

Answer 4

Prevent bone movement which:
- Decreases blood loss
- Decreases pain
- Helps preserve distal perfusion

Question 5

Management of open fractures

Answer 5

Reduce the fracture
(pull bone ends back into wound if needed)

Clean wound

Sterile saline soaked pressure dressing over wound

Abx

Question 6

Indication for tourniquet

Answer 6

Traumatic amputations - high risk with major arterial haemorrhage

Question 7

Sign of interrupted arterial blood supply

Answer 7

Cold, pale pulseless extremity

Question 8

Sign of significant vascular injury

Answer 8

Rapidly expanding haematoma

Question 9

Indication for arteriography and other diagnostic tools

Answer 9

Patients with no haemodynamic compromise only

Question 10

Indication for urgent surgery for extremity injuries

Answer 10

Clear vascular injuries

Question 11

When to consider trial of deflating tourniquet

Answer 11

If time to surgery is > 1 hour

One attempt only - life over limb

Question 12

Another name for crush syndrome

Answer 12

Traumatic rhabdomyolysis

Question 13

Crush syndrome

Answer 13

Direct muscle injury
Muscle ischaemia
Cell death and release of myoglobin
Acute renal failure and death

Question 14

When is crush syndrome and highest risk

Answer 14

Compression injury to significant muscle mass

Eg thigh or calf

Question 15

Assessment if suspected crush syndrome

Answer 15

Myoglobin assay

OR

Amber coloured urine with Creatinine Kinase > 10,000

Question 16

Management of crush syndrome

Answer 16

Aggressive fluid therapy
Intravascular fluid expansion

Question 17

When to check neurovascular status of a limb

Answer 17

Before and after manipulation / splint

Question 18

Management of joint dislocations

Answer 18

Reduce and immobilise in anatomical position

If unable to reduce, splint in position it was found to control bleeding and pain

Question 19

Deformities seen with anterior shoulder dislocation

Answer 19

Squared off

Question 20

Deformities seen with posterior shoulder dislocation

Answer 20

Locked in internal rotation

Question 21

Deformities seen with posterior elbow dislocation

Answer 21

Olecranon prominent posteriorly

Question 22

Deformities seen with anterior hip dislocation

Answer 22

Extended, abducted and externally rotated

Question 23

Deformities seen with posterior hip dislocation

Answer 23

Flexed, adducted and internally rotated

Question 24

Deformities seen with anteroposterior knee dislocation

Answer 24

Loss of normal contour
Extended

May spontaneously reduce prior to evaluation

Question 25

Deformities seen with lateral ankle dislocation

Answer 25

Externally rotated Prominent medial malleolus Lateral dislocation most common

Question 26

Deformities seen with lateral subtalar joint dislocation

Answer 26

Laterally displaced os calcis (calcaneous) Lateral dislocation most common

Question 27

Deformities seen with lateral subtalar joint dislocation

Answer 27

Laterally displaced os calcis (calcaneus) Lateral dislocation most common

Question 28

When to treat an injury to the extremity prior to X ray

Answer 28

Presence of vascular compromise Impending skin breakdown

Question 29

Open fracture definition

Answer 29

Open wound on same limb segment as associated fracture

Question 30

Open joint injury definition

Answer 30

Open wound over / near joint Confirm with CT or saline / dye injection Needs Orthopaedic consult

Question 31

Antibiotics used for open fractures

Answer 31

First generation cephalosporins IV (Eg cefazolin) Clindamycin if anaphylactic penicillin allergy Weight based dosing

Question 32

Management of vascular injury to extremity

Answer 32

Operative revascularisation Within 6 hours

Question 33

Compartment syndrome definition

Answer 33

Increased pressure within musculofascial compartment Results in ischaemia and necrosis

Question 34

Causes of compartment syndrome

Answer 34

Increase in compartment contents - Eg bleeding Decrease in compartment size - Eg restrictive dressing

Question 35

Common areas of compartment syndrome occurrence

Answer 35

Lower leg Forearm

Question 36

Signs of compartment syndrome

Answer 36

Disproportionate pain Pain in passive stretch of affected muscle Tense compartment swelling Paraesthesia / altered sensation distal to affected compartment

Question 37

Management of compartment syndrome

Answer 37

Release all restrictive dressings / casts / splints Fasciotomy

Question 38

Method for splint application

Answer 38

Inline traction Immobilise joint above and below the fracture Assess neurovascular status before and after

Question 39

Management of lacerations

Answer 39

Debride and close Consider tetanus immunisation

Question 40

Management of contusions to extremities

Answer 40

Limit extremity function Cold packs

Question 41

Management of crushing or degloving injuries

Answer 41

Suspect based on mechanism if injury Palpate component involved Consider surgical consult for drainage / debridement

Question 42

When to splint fractures when transferring patients

Answer 42

Prior to transfer

Question 43

Immobilisation guidelines for femoral fractures

Answer 43

Traction splint Do NOT apply traction when have ipsilateral tibial shaft fractures as can cause neurovascular damage

Question 44

Immobilisation guidelines for femoral fractures + tibial shaft fractures

Answer 44

Use long leg posterior splint for the lower leg

Question 45

Immobilisation guidelines for knee injuries

Answer 45

Immobilise knee with 10 degree flexion Commercial knee immobiliser OR Posterior long leg plaster splint

Question 46

Immobilisation guidelines for tibial fractures

Answer 46

Plaster splints

Question 47

Immobilisation guidelines for ankle fractures

Answer 47

Well padded plaster splint

Question 48

Immobilisation guidelines for forearm / wrist fractures

Answer 48

Padded or pillow splint Splint wrist and fingers in functional position where possible

Question 49

Immobilisation guidelines for elbow injuries

Answer 49

Partially flexed position Padded splints

Question 50

Immobilisation guidelines for upper arm injuries

Answer 50

Sling and swath device +/- thoracobrachial bandage

Question 51

Immobilisation guidelines for shoulder injuries

Answer 51

Sling and swathe device

Question 52

Immobilisation guidelines for hand injuries

Answer 52

Short arm splint

Question 53

Hand position for immobilisation of hand injuries

Answer 53

Slight dorsiflexion Fingers flexed 45 degrees at metacarpophalangeal joints

Question 54

Injuries associated with calcaneus fractures

Answer 54

Spinal injuries / fractures