Trauma Flashcards
Definition of compartment syndrome?
- Increased osteofascial compartment pressure to a level that decreases perfusion
- Due to decreased compartment size, or increased compartment content
Risk factors for compartment syndrome?
- Blunt trauma
- Crush injury/prolonged limb compression
- Haemorrhage into compartment
- Fracture
- Burns
Presentation of compartment syndrome?
Symptoms
- Severe pain out of proportion with clinical situation
Signs
- Pain with passive stretch
- Tense/woody compartment
- Late = paraesthesia, absent pulses
Complications of compartment syndrome?
Volkman’s ischaemic contracture
Amputation
Management in compartment syndrome?
CALL SENIOR
Investigations (clinical diagnosis)
- Bloods work up for surgery: FBC, UEs, LFTs, CRP, Clotting, G&S
- ECG
- Nil by mouth
General
- Release/remove cast and dressings down to level of skin
- Elevate limb to the level of the heart
- Give analgesia and reverse any hypotension/coagulopathy present
Surgical
- Refer to orthopaedics
- Will require surgical fasciotomy to relieve pressure
- May require skin graft to close fasciotomy
Where you need to palpate for Ottowa Ankle Rules?
What views do you need for X-ray?
- Posterior tip of lateral malleolus
- Posterior tip of medial malleolus
- Base of 5th metatarsal
- Navicular
- INABILITY TO WEIGHT BEAR IMMEDIATELY AND IN ED
AP, lateral and mortise view
Grading of ankle sprains? Where and how do they most occur?
85% are lateral ankle sprains, due to inversion of plantar flexed foot
- Grade 1 – ligament stretched with microscopic tear, patient can weight bear partially
- Grade 2 – partial tearing, mod-severe swelling. Difficulty weight bearing
- Grade 3 – ruptured ligament, swelling immediate and severe, cannot weight bear. Instability of joint present.
Management of ankle sprain?
POLICE
- Protect
- Optimal loading (rest but use muscles to prevent loss of strength)
- Ice (10-30 mins)
- Compression (bandage)
- Elevation
Simple analgesia, gentle exercise as soon as pain allows.
Severe sprains with rupture (grade 3) may require surgical repair. They should be immobilised for a short period to increase recovery time (below knee cast/brace)
What is this?
Colle’s Fracture
Fracture of distal radius with dorsal displacement of fragments
What is this?
Smith’s fracture
Distal radius fracture with volar (anterior) displacement of fracture fragments
History of Colle’s fracture?
- Fall on outstretch hand (FOOSH)
- Pain, swelling, bruising, deformity, loss of function, instability
- Check mechanism of injury – if mild force then consider osteoporosis
Dinner fork deformity - with deviation backwards and laterally
Complications of Colle’s fracture?
- Median/ulnar nerve damage with acute carpal tunnel syndrome
- Compartment syndrome
- Deformity leading to loss of mobility and function
- Chronic pain, mal/non-union, arthritis, complex regional pain syndrome
Definitions of…
- Simple
- Compound
- Comminuted
- Greenstick
- Simple: Fracture that is not displaced, no break in skin
- Compound: Fracture with overlaying break in the skin, even if bone not protruding
- Comminuted: Fracture with 3+ fragments of bone
- Greenstick: In young person, bone bends and then breaks
Management of Colle’s fracture?
- Reduction of fracture with appropriate analgesia
- Move forwards and medially
- Apply back slab and repeat X ray to assess reduction, repeat if unsatisfactory
- Healing = 6 weeks, give appropriate analgesia
Surgical reduction if intra-articular fracture
Risk factors for # femur?
High impact injury (RTA)
Elderly, female
Osteoporosis
Pathological (metastatic disease)
Presentation of # femur?
Symptoms
- Severe pain with supporting hx of injury
- Tense, swollen tender thigh
- Inability to weight bear
Signs
- Deformity and shortening on affected side
- Assess neurovascular status of limb
- Open wound (trauma cases)
Complications of # femur?
Early
- Major blood loss (1500ml), especially if not obvious in closed fracture
- Acute compartment syndrome
- High risk of infection in open fracture
Late
- Fat embolism (more common in closed, 24-72 hours after injury with SOB, petechial rash, high temp, drowsiness and oliguria)
- DVT, PE, infection, malalignment, non-union
Investigations in # femur?
General
- Monitor observations to check for blood loss/other complications
Bloods
- FBC, UEs, LFTs, CRP, Clotting, G&S/X-match
Imaging
- X Ray of affected limb – AP, lateral, Oblique
- Also ipsilateral knee and hip to rule out co-existing NoF fracture
- Consider CT in mid-shaft fractures
Management of severe # femur?
- Resuscitation - ATLS - PRC/fluid replacement
-
Reduction - restore the anatomy, relieve pressure on surrounding nerves, vessels, muscle
- Thomas’ splint to immobilise
- Stabilisation - hold the reduced fracture
- Rehabilitation - restore function
Surgical
- Intramedullary nail – rod into bone marrow of femur and fixed with nails
- Early mobilisation and treatment to reduce risk of complications – physiotherapy involvement and mobilisation recommended day after surgery
What this ting?
Thomas’ splint
Risk factors for tibula/fibula fracture?
- Direct blow or falls onto tibial shaft
- High energy injury
- Violent twisting injury (contact sports)
- Motorcycle accidents
Usually presents as tib/fib fracture - isolated tibial fracture rare.
Complications of tib/fib fracture?
- Neurovascular compromise (especially popliteal artery injury)
- Compartment syndrome
- Peroneal nerve injury (in fibular neck fracture), infection
- Non-union
What is this?
Maisonneuve fracture
- Spiral fracture of upper fibula, with ankle tibia fracture
- Requires internal fixation
Management of tib/fib fracture?
Un-displaced
- Analgesia and immobilisation in long leg back slab
- Spiral and oblique fractures = unstable
- Refer to orthopaedic team
Displaced
- Analgesia, immobilise in back slab, refer orthopaedics
- May require manipulation under anaesthesia or IM nail
- Urgent orthopaedic referral if ?vascular injury, sensory deficit or gross swelling
Compound
- Irrigate wound with saline, cover with sterile dressing
- IV antibiotics, tetanus
- Refer orthopaedics for urgent cleaning, debridement and fixation with IM nail or external fixation
What is shenton’s line?
An imaginary curved line drawn along the inferior border of the superior pubic ramus (superior border of the obturator foramen) and along the inferomedial border of the neck of femur.
This line should be continuous and smooth.
Disruption indicates a #NOF
Two main types of hip fracture?
- Intracapsular: proximal to greater trochanter (above insertion of the capsule)
- Extracapsular: Intratrochanteric or subtrochanteric
Independent risk factors for hip fracture?
- Increasing age
- Female
- Low BMI
- Maternal hx of hip fracture
- Impaired vision
- Physical inactivity
- Smoking
- Benzos
Presentation of hip fracture?
Fall or blow to greater trochanter
- May occur on weight bearing e.g. standing from a chair if bone is severely osteopenic
Affected side = shortened and externally rotated due to unopposed rotation by the iliopsoas and gravity.
Complications of hip fracture?
- High rate of morbidity and mortality
- 1/10 mortality within 1 month
- 1/3 mortality in 3 months
- Avascular necrosis in 1/3 of displaced fractures – need replacement
- Non-union of fracture in 1/3
- Osteoarthritis
What is Gardner’s classification?
- Stage I - Incomplete fracture of the neck
- Stage II - Complete fracture without displacement
- Stage III - Complete with partial displacement, malalignment of the femoral trabeculae
- Stage IV – Complete fracture with full displacement, proximal fragment is free
What will X ray show in #NOF?
Transcervical or subcapital fracture line - with or without displacement
Management of hip fractures?
Surgery must be performed within 24 hours of admission.
Treat correctable co-morbities e.g. anaemia, coagulopathy, electrolyte imbalance, fluid depletion, cardiac arrhythmia etc.
Surgery
- Arthroplasty = intracapsular, displaced
- Dynamic Hip Screw = intertrochanteric/ transtrochanteric
- IM Nailing = subtrochanteric
VTE Prophylaxis
- Mechanical: stockings until patient no longer has reduced mobility
- Pharmacological: fondaparinux 6 hours after surgical closure (if no bleeding risk), continue for 28-35 days.
Indications for total/hemi arthroplasty in hip fracture?
- Total: able to walk out doors with only a stick, no cognitive impairment, medically fit for anaesthesia and procedure
- Hemi: all others who do not meet these criteria
What are these signs? What do they indicate?
- Haemotympanum
- Battle’s sign
- Panda eyes
Basal skull fracture
Indications for CT head within 1 hour in head injury?
- GCS <13 on initial assessment in ED
- GCS <15 at 2 hours after injury on assessment in ED
- Suspected open or depressed skull fracture
- Post-traumatic seizure
- Any sign of basal skull fracture
- Focal neurological deficit
- >1 episode of vomiting
Indications for CT head within 8 hours in head injury?
- Current warfarin treatment
- ≥65 yrs old
- >30 mins retrograde amnesia of events immediately before head injury
- Any history of bleeding/clotting disorders
- Dangerous mechanism of injury
Things to ask in head injury history?
- Mechanism of injury
- Time of injury
- Loss of consciousness, seizures
- Memory (before, during and after)
- Blood/fluid from nose or ears
- Vomiting
- Weakness/numbness/tingling in limbs
- Time of last meal
- Dizziness
- Visual changes
- Headache
Causes of hand sepsis? Risk factors?
- Staph (60%), strep (10-15%), coliforms, pasteurella, clostridia, pseudomonas
- Rarely: virus, fungi, mycobacteria
Usually mixed bacterial and secondary to penetrating injury
- Bites (human, dog, cat)
- IVDU
- Occupation
- Immuno-suppression
- Trauma (penetrating injury)
Examining hand sepsis?
Document with drawings and photos
- Active and passive ROM
- Signs of acute inflammation: tenderness, erythema, heat etc
- Signs of regional and systemic spread (tracking, sepsis)
Investigations in hand sepsis?
- X Ray: to check for radio-opaque splinters
- Blood cultures if sign of systemic infection
- Urine dip (diabetes)
- Wound swab – before abx
Management of hand sepsis?
If septic – follow ABCDE and BUFALO (broad spec abx according to local guidelines)
- Wound MC&S and Blood cultures before antibiotics
- Surgical drainage + removal of infected tissue
- Surgery recommended if
- Presentation >48 hours after onset of symptoms, immunocompromised, throbbing pain at night, localised tenderness for >2 days, induration
FOLLOW UP ESSENTIAL - within 24 hours of treatment
What to examine in facial injury?
- Examine pupils, eye movements
- Do full ENT examination
- Complete cranial nerve exam
Complications of facial injury?
Immediate
- Airway compromise, aspiration, haemorrhage, infection
Longer-term
- Scars and permanent facial deformity
- Chronic sinusitis
- Nerve damage leading to loss of facial sensation, movement, smell, taste or vision
- Malocclusion
- Non-union/mal-union of fractures
- Malnutrition and weight loss
Causes of shoulder fracture? Where do they most commonly occur?
- FOOSH, occur after direct blow to clavicle, common in cyclists
- Most common in middle third, proximal fragment pulled superiorly by sternocleidomastoid
Complications of clavicle/shoulder fracture?
neurovascular injury to brachial plexus, pneumothorax
Usual management of clavicle fracture?
- Broad arm sling with follow up XRay at 6 weeks to ensure union
Rarely need fixation - unless comminuted distal clavicle fracture (ORIF)
Management of clavicle fracture?
Investigations
- CXR, neurovascular exam
- Reduction - realignment of fracture fragments
- Stabilise - by cast or surgical fixation
- Maintain - make sure neurovascular supply not compromised
- Rehab - encourage early rehab
What is this?
Acute paronychia
- Cellulitis around fingernail
- Rx = abx, may need drainage
What is an emergency hand infection?
Infective flexor tendonitis
- Bacterial infection of flexor tendon sheath: surgical emergency due to risk of spread to forearm via carpal tunnel
Kanavels 4 signs:
- Symmetrical swollen fingers
- Tenderness over flexor sheath
- Pain on passive extension
- Preference to hold finger in flexion
Urgent abx IV and repeated drainage in theatre
Presentations of flexor tendon injuries?
- Failure to flex DIP against resistance = flexor digitorum profundus division
- Failure to flex IP of thumb = flexor pollicus longus
Treat with intensive hand physio and potential tendon graft
What is this?
Finkelstein’s Test
- Grasp the thumb and ulnar deviates the hand sharply, as shown in the image.
- If sharp pain occurs along the distal radius (top of forearm, close to wrist; see image), de Quervain’s tenosynovitis is likely
What is Weber classification and how is each managed?
Above/at level of/below the syndesmosis (fibrous part of joint which joins tib and fib)
Weber A/B = Stable
- Treat non-operatively with cast
Weber C/displaced = unstable
- Surgical repair
Presentation and management of patellar fracture?
- Usually lateral, twisting of lower leg
- Knee flexed with lateral deformity
- Reduction = firm medial pressure and extending knee
Do X ray to rule out patellar #
Collateral ligament injury?
- Common in sport
- Medial CL = Blow to lateral aspect of knee with fixed foot
- Effusion and tenderness over affected area
- Rest and then firm support
ACL injury?
- Twisting injury with fixed foot
- Positive anterior draw test
- Sudden effusion, unable to continue playing, haem-arthrosis
- If young/instability = graft
PCl injury?
- Car crash as knee strikes dash board
- Do posterior draw test
- Most treated conservatively
Meniscal tear injuries?
- Medial = bucket handle, twsits to flexed knee
- Lateral = Adduction and internal rotation
- Sx knee locking, tender joint line, positive McMurrays.
MRI to show if able to repair (preserve meniscus)
Unhappy triad of knee injury?
ACL + MCL + medial meniscus following valgus stress with rotation of knee
General soft tissue injury management|?
POLICE
- Protection from further injury
- Optimal Loading
- Ice
- Compression
- Elevation
Common foot/ankle fractures?
Maisonneuves
- Proximal fibular #and syndesmosis rupture, and medial malleolu fracture.
- Surgical mx as # unstable
Lisfranc fracture dislocation
- Commonly missed in multi-trauma, may cause compartment syndrome of medial foot
- Look for widening of gap between medial cuniform and base of 2nd metatarsal
- Surgical screw fixation
Fractured neck of talus
- Forced dorsiflexion, may lead to AVN of talus body
- If displaced, ORIF (open reduction internal fixation – surgical)
Calcaneus
- Bilateral, after serious falls. Many left disabled
5th Metatarsal #
- Proximal avulsion # assoc with ankle inversion, treat conservatively
- Jones transverse #, surgical intervention due to risk of non-union.
Salter Harris Classification?
Paediatric fractures involving growth plate (physis)
What is this?
Ilizarov Frame
Used to lengthen or reshape bones or to treat complex mal-union or non-union fractures
