Soft tissue injuries and compartment syndrome Flashcards
(38 cards)
what types of injuries can result in visceral organ injuries?
rib fracture and pneumothorax
pelvic fractures and bladder and urethra damage
These injuries require emergency treatment before fracture is dealt with.
how can vascular injury occur from trauma?
vessels may be torn, compressed or cut by bone fragments.
the vessel may become thrombosed, intima may become detached or may go into spasm
what are the effects of vessel injury?
ischaemia, tissue death
peripheral gangrene.
How long does ischaemia have to last for in order to result in limb loss?
4-6 hours
what are the clinical features that would suggest vascular damage after trauma?
cold, pale/cyanosed limb
weak/absent pulse.
How could you investigate vascular damage after trauma?
pulses, capillary refil
pale/cold limb
based on Xray does the injury look like it could damage an artery.
Angiography
how can we treat vascular damage after trauma?
temporary shunt across damaged zone to re-establish circulation
vessel repair by vascular surgeon
What artery is at risk of damage from a:
a) first rib fracture b) supracondylar fracture c) shoulder dislocation d) elbow dislocation
a) subclavian artery
b) brachial artery
c) axillary artery
d) brachial artery
What artery is at risk of damage from a:
a) pelvic fracture
b) femoral supracondylar fracture
c) knee dislocation
d) proximal tibial dislocation
a) internal iliac
b) femoral artery
c) popliteal artery
d) popliteal artery
what organisms cause gas gangrene?
clostridium perfringens
E.coli, pseudomonas aeruginosa, klebsiella pneumonia , proteus
usually causes by multiple bugs at the same time
what is clostridium perfringens?
gram positive obligate anaerobe
grows in dirty wound, dead muscle and inadequate debridement (complication of open fracture)
produces alpha toxin (exotoxin) which causes muscle necrosis and vessel thrombosis which can cause haemolysis and shock.
ferments glucose to produce CO2
what are the clinical features of gas gangrene?
intense swelling and pain around the wound brownish discharge gas formation increased pulse rate smell pyrexia (sometimes none at all)
what investigations would you want to do if you suspect gas gangrene?
Bloods - raised LDH, WBC, ABG (acidosis) and U&Es
Xray
histology and gram staining
what would you expect to find on xray in someone with gas gangrene?
linear streaks of gas in soft tissue
what is a histological hallmark of gas gangrene?
absence of neutrophils due to lack of acute inflammatory response
how is gas gangrene treated?
non operative:
- IV fluids
- IV Abx - first line is penicillin G and clindamycin (alternative = erythromycin and tetracycline)
- hyperbaric O2 - to limit spread of gangrene
operative:
- decompress wound and remove all dead material (debridement)
- amputation if advanced
what are the complications of gas gangrene?
shock
renal failure
what are the differentials for gas gangrene?
necrotising fasciitis
anaerobic cellulitis - superficial gas formation but not as toxic as gas gangrene.
what is necrotising fasciitis?
rapidly spreading bacterial infection spreading along tissue planes resulting in necrosis of soft tissue.
often caused by a multitude of different organisms
what are the risk factors for developing necrotising fasciitis?
immune suppression - diabetes, AIDs, cancer
bacterial introduction - IV drug use, insect bites, skin abrasions, abdo surgery
obesity
what are the signs and symptoms of necrotising fasciitis ?
severe pain tender slight erythema and swelling pyrexia discolouration bruising haemorrhagic blisters necrosis of skin
toxic shock may develop
how do you test for necrotising fasciitis?
sweep test: make an incision and if fascia comes away = positive test
bloods: high WCC, CRP, disturbed U&Es, acidosis and hypoxaemic.
need to get blood and tissue cultures.
oedema extending along fascial planes on CT/MRI/Xray
how is necrotising fasciitis treated?
radical debridement with broad spec Abx
haemodynamic monitoring and resus - sepsis 6
operative when life threatening - often amputation required.
how do you distinguish gas gangrene from aerobic cellulitis?
Muscle swelling and severe pain are prominent features of gas gangrene. The pain is often out of proportion to physical findings
