Trauma

Question 1

what is resuscitation?

Answer 1

the process of correcting physiological disorders in an acutely unwell or injured patient

Question 2

what does resuscitation involve?

Answer 2

all trauma patients get high flow oxygen
before ABCDE get general impression
major trauma - blood is normally fluid of choice

Question 3

what are the mechanisms of injury likely to result in resuscitation?

Answer 3

road traffic collisions - account for 1/3 of all major trauma presentations
falls
interpersonal violence
suicide
work place accidents
trauma most common in young men 18-40
vital organ failure can result in cardio-respiratory arrest

Question 4

What are the aims of treatment in high energy injuries?

Answer 4

e.g. road traffic accidents (RTA) or falling from heights
save life
prevent serious systemic complications

secondary aims (not as important)
preventing pain and loss of function from fractures and dislocations

Question 5

what can quick medical and surgical treatment in the golden hour prevent death from?

Answer 5

airway compromise 
severe head injuries 
severe chest injuries 
internal organ rupture 
fractures associated with significant blood loss (pelvis and femur)

Question 6

Airway assessment in trauma

Answer 6

sound of breathing can indicate blockage
ability to speak indicates clear airway
need to protect the C-spine

Question 7

Breathing and ventilation assessment in trauma

Answer 7

high flow O2 and tight fitting mask for all major trauma patients
pulse oximetry
need to rule out pneumothorax (including tension)
haemothorax
pulmonary contusion
flail chest

Question 8

Circulation and bleeding control in trauma

Answer 8

pulse and ECG to assess
urinary output for fluid balance (minimum 30ml/hr)
do they look well perfused
all major trauma patients given 2 litres of IV crystalloid initially
get access - bilateral large bore peripheral venous access

Question 9

Potential circulation issues in trauma

Answer 9

hypovolaemic shock - tachycardia, reduced BP, confusion/lethargy, fluid resuscitation
exsanguinating haemothorax - may need thoracotomy
blunt penetrating abdominal trauma - check for internal bleeding
pelvic fracture - can cause substantial blood loss
obvious external bleeding
major peripheral arterial/venous bleeding - temporary tourniquet
haemorrhagic shock - can be concealed in older people and children
often visible site of injury

Question 10

Disability assessment in trauma

Answer 10

Glasgow trauma score
15 - best score
3 - worst score
assesses motor response, verbal response and eye opening with a score from 1 to 5
used to prevent secondary brain injury, get early neurosurgical intervention

Question 11

Exposure in trauma

Answer 11

make sure no injuries are missed - keep warm to avoid hypothermia
warmed IV fluids should be given

Question 12

what tests are done in major trauma after the primary survey?

Answer 12

trauma series of x-rays 
log roll patient 
look for signs of spinal fracture 
PR exam 
check c-spine injury 
urinary catheter 
NG tube 
blood tests

Question 13

what is the secondary survey?

Answer 13

done after the primary survey and when the patient is stable
any deterioration in the clinical condition requires a return to the start of the primary survey - ABCDE
2ndry survey - head-to-toe examination to detect other injuries, may want a whole body CT scan
get more thorough history, PMH and fasting status

Question 14

What is polytrauma

Answer 14

where more than 1 major long bone is injured or where a major fracture is associated with significant chest/abdominal trauma
need early stabilisation of the long bones - either external fixtures or intramedullary nails needed to avoid SIRS, ARDS and hypovolaemia
all of these issues can lead to MODS (multi-organ dysfunction syndrome) and potential death

Question 15

what is a fracture?

Answer 15

a break in the bone

can be because of direct trauma (direct blow) but normally indirect trauma e.g. twisting/bending forces

Question 16

What are the 2 types of fracture?

Answer 16

partial/incomplete e.g. unicortical stress fracture

complete breaks

Question 17

what kind of mechanisms of injury cause high and low energy fractures?

Answer 17

high energy - RTA, GSW, blast, fall from height
low energy - trip, fall, sports injury
low energy fractures are usually pathological fractures due to an underlying weakness of the bone

Question 18

Primary bone healing?

Answer 18

occurs when there is a minimal fracture gap (less than 1mm)
bone bridges the gap with new bone formed by osteoblasts
this happens in the healing of hairline fractures and when the fractures are fixed with compression screws and plates

Question 19

Secondary bone healing?

Answer 19

majority of fractures
gap at the fracture site more than 1mm which needs to be filled temporarily to act as a scaffold for new bone to be laid down
involves an inflammatory response - recruitment of pluropotential stem cells (can differentiate into any cell)

Question 20

what is the process of secondary bone healing?

Answer 20

Fracture occurs
haematoma occurs with inflammation from damaged tissue
macrophages and osteoclasts remove debris and reabsorb the bone ends
fibroblasts and new blood vessels cause the formation of granulation tissue
chondroblasts form cartilage (soft callus, formed by the 2nd/3rd week)
osteoblasts lay down bone matrix (type 1 collagen) - endochondral ossification
immature woven bone (hard callus, takes 6-12 weeks to appear) is formed by calcium mineralisation
remodelling, organisation along lines of stress into lamellar bone

Question 21

Secondary bone healing needs…

Answer 21

good blood supply for oxygen
nutrients and stem cells
requires little movement or stress (compression or tension)

Question 22

What causes atrophic non-union to occur?

Answer 22

lack of blood supply
no movement - internal fixation with fracture gap
fracture gap is too big
tissue is trapped in the fracture gap

Question 23

hypertrophic non-union occurs when

Answer 23

excessive movement (no chance for fracture to bridge the gap)
abundant hard callus formation

Question 24

things that impair fracture healing?

Answer 24

smoking (causes vasospasm)
vascular disease
chronic ill health and malnutrition

Question 25

what is a transverse fracture?

Answer 25

due to bending force - may angulate or cause rotational malalignment

Question 26

what is an oblique fracture?

Answer 26

due to sheer force - fall from height, deacceleration can be fixed by internal fragmentary screws tends to shorten may angulate

Question 27

What is a spiral fracture?

Answer 27

due to torsional (twisting) forces can be fixed with interfragmentary screws mostly unstable to rotational forces can also angulate

Question 28

what is a comminuted fracture?

Answer 28

fractures with 3 or more fragments generally due to high energy injury or poor bone quality may be substantial soft tissue swelling and periosteal damage with reduced blood supply to the fracture site which impairs healing very unstable tend to be surgically stabilised

Question 29

what is a segmental fracture?

Answer 29

bone is fractured into 2 separate places very unstable needs stabilised with long rods or plates

Question 30

what does valgus and varus mean?

Answer 30

valgus - anything which goes away from the midline | varus - anything which goes towards the midline

Question 31

FOOSH

Answer 31

falling on outstretched hand - ask about hand dominance X-ray - look for rough edges, cortex break fracture can appear more white (bone on bone) or darker (space)

Question 32

limb fracture management?

Answer 32

reduce - get as close to original position as possible retain - keep it there rehabilitate - restore function

Question 33

Operative options for fracture (least - most invasive)

Answer 33

plaster cast - after reducing it fixation - K-wire open reduction and internal fixation - plate and screw Application of an external fixator - only if infection or too swollen eventually remove K-wires - leave plates and screws in

Question 34

intra-articular fracture

Answer 34

look for any reduced joint space (impaction) may need bone graft

Question 35

why do you want to get fractures involving the joint surface as they were

Answer 35

to avoid OA

Question 36

BOAST guidelines for open fractures

Answer 36

- limb should be realigned and splinted - remove gross contamination, dress with saline-soaked gauze and cover with occlusive film - combined orthoplastic response - debridement - definitive soft tissue closure/ coverage within 72 hrs of injury if it can't be performed at time of the debridement

Question 37

what is the initial management of a long bone fracture?

Answer 37

``` clinical assessment of injured limb analgesia (usually IV morphine) splintage/immobilisation of the limb investigation - X ray if fracture is grossly displaced, obvious dislocation or skin damage because of excessive pressure - do reduction of the fracture before waiting for an X-ray ```

Question 38

definitive management for undisplaced, minimally displaced and minimally angulated fractures which are considered to be stable long bone fractures

Answer 38

non-operative with splintage/immobilisation then rehab

Question 39

definitive management for displaced or angulated long bone fractures

Answer 39

reduce under anaesthetic - closed reduction and cast, serial X rays

Question 40

definitive management for unstable injuries

Answer 40

``` surgical stabilisation K-wires plates and screws intermedullary nails external fixation ```

Question 41

definitive management for unstable extra-articular diaphyseal fractures

Answer 41

open reduction and internal fixation (ORIF) - using plates or screws ORIF should be avoided when soft tissues are swollen, blood supply to fracture site is weak or where ORIF may cause extensive blood loss or plate fixation may be prominent e.g. tibia Do a closed reduction and internal fixation with intramedullary nail or extenal fixation which aims for 2ndry bone healing - risk of infection and loosening

Question 42

definitive management for displaced intra-articular fractures

Answer 42

ORIF using wires, screws and plates | may need joint replacement or arthrodesis

Question 43

definitive management of long bone fractures in elderly people with osteoporosis and dementia

Answer 43

higher risk of complications of surgery failure of fixation failure to rehabilitate satisfactorily - elderly patients also tend to have a high functional demand so surgery is usually avoided

Question 44

early local complications of fractures

Answer 44

compartment syndrome vascular injury with ischaemia nerve compression/ injury skin necrosis

Question 45

early systemic complications of fractures

Answer 45

``` hypovolaemia fat embolism shock ARDS acute renal failure SIRS MODS death ```

Question 46

late local complications of fractures

Answer 46

``` stiffness loss of function CRPS (chronic regional pain syndrome) infection non-union mal-union Volkmann's ischaemic contracture post-traumatic OA DVT ```

Question 47

late systemic complications

Answer 47

PE

Question 48

what is compartment syndrome?

Answer 48

a serious complication and surgical emergency | groups of muscles are bound in tight fascial compartments with limited capacity for swelling

Question 49

pathology of compartment syndrome

Answer 49

rising pressure compresses the venous system causing congestion within the muscle and secondary ischaemia as oxygenated arterial blood can't supply the congested muscle

Question 50

what are the symptoms and signs of compartment syndrome

Answer 50

severe pain parasthesiae sensory loss increased pain on passive stretching of the involved muscle severe pain outwith the anticipated severity of the clinical context limb will be tensely swollen and the muscle tender to touch

Question 51

What does loss of pulses mean in compartment syndrome?

Answer 51

end-stage ischaemia - diagnosed too late

Question 52

what is the treatment for compartment syndrome?

Answer 52

removal of any tight bandages for temporary relief emergency fasciotomies involving incisions through skin and fascia to relieve contraction open wound is left for a few days before 2ndry closure

Question 53

what happens if compartment syndrome is left untreated?

Answer 53

ischaemic muscle will necrose causing fibrotic contracture (Volkmann's ischaemic contracture) poor function

Question 54

what are the nerve injuries associated with a fracture?

Answer 54

neurapraxia | axonotmesis

Question 55

what is neurotmesis?

Answer 55

complete transection of a nerve requiring surgical repair for any chance of recovery of function

Question 56

what is neurapraxia?

Answer 56

temporary conduction defect from compression/ stretch | resolves over time with full recovery (can take up to 28 days)

Question 57

what is axantmesis?

Answer 57

nerve injury sustained due to compression/ stretch or from a higher degree of force with death of the long nerve cell axons distal to the point of injury die

Question 58

what nerve injury is associated with a colles fracture

Answer 58

acute medial nerve compression (carpal tunnel syndrome)

Question 59

anterior dislocation of the shoulder

Answer 59

axillary nerve palsy

Question 60

humeral shaft fracture

Answer 60

radial nerve palsy (in spiral groove)

Question 61

supracondylar fracture of the elbow

Answer 61

median nerve injury (usually anterior interosseous branch)

Question 62

posterior dislocation of the hip

Answer 62

sciatic nerve injury

Question 63

'bumper' injury to lateral knee

Answer 63

common peroneal (fibular) nerve palsy

Question 64

what are the vascular injuries which can be associated with fractures

Answer 64

uncommon but with significant causes can happen with both blunt and penetrating trauma vessels can be transected, torn, stretched or compressed partial tears affecting the arterial intima - can thrombose forming arterial occlusion haemorrhage from arterial/venous injury causing hypovolaemic shock

Question 65

potential management of a vascular injury caused by a fracture

Answer 65

may need an urgent angiography emergency can make temporary restoration of circulation with vascular shunt/repair with bypass graft or endoluminal stent need to do skeletal stabilisation with internal/external fixation to protect repair from shearing force

Question 66

vascular risk with knee dislocation

Answer 66

risk of popliteal artery injury

Question 67

vascular risk with paediatric supracondylar fracture of the elbow

Answer 67

risk of brachial artery injury

Question 68

vascular risk with shoulder trauma

Answer 68

risk of axillary artery injury

Question 69

vascular risk with pelvic fractures

Answer 69

risk of life-threatening haemorrhage from arterial/ venous bleeding ongoing haemorrhage can be controlled by angiographic embolisation performed by interventional radiologists

Question 70

skin and soft tissue problems which can be caused by skin and soft tissue problems

Answer 70

especially affected by high energy injuries and if skin is fragile protruding spike of bone/tension can cause devitalisation and necrosis with skin breakdown if fracture is causing excessive pressure on skin may see tenting of the skin and blanching - fracture should be reduced - emergency to avoid necrosis shear force - can cause degloving, can result in skin ischaemia, no blanching under pressure and can be insensate - skin graft/flap may be needed high energy injury - more soft tissue swelling and bruising (contusion) inflammatory exudates causing lifting of the epidermis can cause fracture blisters surgical wound is not recommended

Question 71

how do you describe a fracture of the long bone?

Answer 71

the site of the bone - proximal, middle, distal 3rd | type of bone involved - diaphyseal (shaft), metaphyseal, epiphyseal

Question 72

intra-articular fracture

Answer 72

fracture at the end of the long bone (metaphyseal/epiphyseal) which extends into the joint greater risk of stiffness, pain and post-traumatic OA esp. if residual displacement resulting in an uneven articular surface or extra-articular

Question 73

translation fracture displacement

Answer 73

of the distal fragment can be described as anteriorly or posteriorly (volar/palmar or dorsal in the forearm and hand) medially or laterally (ulnar and radial in the forearm) can be estimated in relation to the width of the bone 25% etc 100% displaced - an off-ended fracture

Question 74

angulation fracture displacement

Answer 74

direction in which the distal fragment points towards and the degree of deformity can be described as anteriorly or posteriorly or medially or laterally measures in degrees from the longitudinal axis of the diaphysis of the long bone gives info of the direction of forces involved in the injury and info about the reversed direction of forces required to reduce a fracture residual displacement and angulation can cause deformity - loss of function and abnormal pressure leads to post-traumatic OA minor degrees of displacement/ angulation may be alright depending on the bone involved and the site of fracture

Question 75

rotation displacement of fracture

Answer 75

of distal fragment relative to the proximal fragment clinically important rotational malalignment is poorly tolerated and needs to be corrected fracture is more unstable

Question 76

what is optimum fracture management dependent on?

Answer 76

site of fracture position stability related to the fracture pattern and degree of initial displacement

Question 77

what are the clinical signs of a fracture?

Answer 77

localised bony (marked) tenderness NOT diffused mild tenderness swelling deformity crepitus (bone ends grating with an unstable fracture)

Question 78

when to x ray a suspected fracture?

Answer 78

if a patient can't weight bear on an injured lower limb then x-ray painful area x-ray if any clinical signs

Question 79

How is a fracture assessed?

Answer 79

radiographs (X-rays) - diagnose majority of fractures - usually an AP and lateral view, 2 views are always required, oblique views can be useful for complex shaped bones Tomogram - moving X-ray, takes images of complex bones not really used anymore except for diagnosing mandibular fractures CT - assess fractures of complex bones can help to determine the degree of articular damage and help surgical planning for complex intra-articular fractures MRI - used to detect occult fractures where there is a clinical suspicion but a normal X-ray Technetium bone scans: used to detect stress fractures, usually fail to show up on an X-ray until a hard callus begins to appear

Question 80

signs a fracture is healing?

Answer 80

resolution of pain/function no point tenderness no local oedema resolution of movement at fracture site

Question 81

signs of fracture non-union?

Answer 81

``` ongoing pain/function ongoing oedema movement at fracture site may see bridging callus on X-ray may need CT to confirm ```

Question 82

what is a delated union?

Answer 82

fracture that has not healed within the expected time many factors affect the rate of healing - tibia is one of the slowest healing bones - femoral shaft fractures take 3-4 months to heal, metaphyseal fractures tend to heal more quickly than cortical fractures infection can delay union antibiotics might help union - might not

Question 83

what is hypertrophic non-union?

Answer 83

due to instability and excessive motion at the fracture site

Question 84

what is atrophic non-union?

Answer 84

due to rigid fixation with a fracture gap, lack of blood supply to the fracture site, chronic disease or soft tissue interposition

Question 85

what can cause fracture non-union?

Answer 85

infection some fractures are prone to problems with healing due to poor blood supply e.g. scaphoid wrist fractures, distal clavicle fractures, subtrochanteric fractures of the femur, Jones fracture of the fifth metatarsal Some intra-articular fractures may not unite due to synovial fluid inhibiting healing if a fracture gap exists (intracapsular hip fracture, scaphoid fracture)

Question 86

who is likely to get a local DVT?

Answer 86

after pelvic/major lower limb fractures with a period of immobility prophylaxis (LMWH) to all at-risk patients suspected DVT needs duplex scanning and anticoagulation

Question 87

what is fracture disease?

Answer 87

Stiffness and weakness due to the fracture and splintage in cast, self-limiting may need physiotherapy

Question 88

where does AVN occur post fracture?

Answer 88

fractures in the femoral neck, scaphoid and talus | not all cases are symptomatic but many cases need surgery (THR if hip, athrodesis)

Question 89

what is post-traumatic OA?

Answer 89

can occur due to intra-articular fracture ligamentous instability or fracture malunion treated with analgesia bracing/splinting arthrodesis joint replacement

Question 90

what is CRPS?

Answer 90

heightened chronic pain response after injury burning/throbbing sensitivity to stimuli that's not usually painful chronic swelling stiffness painful movement skin colour changes Type 1 - caused by a peripheral nerve injury Type 2 - not caused by a peripheral nerve injury, most cases

Question 91

what is the management of CRPS?

Answer 91

``` anlagesics antidepressants anticonvulsants steroids TENS machines physio lidocaine patches sympathetic nerve blocking injections ```

Question 92

how is infected fracture fixation managed?

Answer 92

antibiotics with/without surgical washout | may need surgery to remove implants and for debridement of the infected bone

Question 93

causes of open fractures

Answer 93

spike of fractured bone from within puncturing the skin | laceration of the skin from tearing/penetrating injury

Question 94

why is treatment of an open fracture to avoid infection is so important

Answer 94

Infection can result in non-union, and is difficult to get rid off Bone infection of open fracture of a long bone often needs extensive removal of bone with shortening which may require complex surgery to lengthen the bone Some infected non-unions lead to amputation (presence of vascular injuries increases the risk of amputation)

Question 95

how is infection of an open fracture prevented initially?

Answer 95

IV broad spectrum antibiotics in A&E flucloxacillin for gram +ve organisms gentamicin for gram -ves metronidazole for anaerobes (if soil contamination) Sterile/antiseptic soaked dressing before fracture is splinted Open fractures usually require prompt surgery, involves debridement Unstable fracture may produce haematoma which acts as a culture medium for bacteria, may cause more necrosis Open fractures are often high energy and delayed union is more common

Question 96

how is an open fracture managed ongoingly?

Answer 96

Need frequent wound inspections (so difficult to treat with plaster cast) Open fractures are usually stabilised with internal/external fixation Wounds may require skin graft Skin graft will NOT take on bare tendon, bone or any exposed metalwork, also might not take fat (due to poor vascularisation) Muscle, fascia, granulation tissue, paratenon and periosteum can accept a skin graft If there is doubt over viability of soft tissues/if the wound is heavily contaminated then leave the wound open to allow ongoing infection to drain out and then return to theatre for further debridement in 48 hrs (necrotic tissue will have declared itself by this time)

Question 97

what is a mangled extremity?

Answer 97

limb with injury to 3/4 systems in the extremity many damaging outcomes may need early amputation

Question 98

how should dislocations be managed?

Answer 98

Any dislocation should be REDUCED as soon as possible. Most are done by closed manipulation under sedation and analgesia/sometimes general/local anaesthetics. Delayed presentations (e.g. in alcoholics) increases the risk of needing an open reduction and recurrent instability.

Question 99

who gets dislocations?

Answer 99

May occur after significant trauma but people with hyper mobility (inc. Ehlers Danlos and Marfan’s) might get a dislocation with an innocuous injury, some can voluntarily dislocate joints (e.g. shoulder). Dislocations can occur with associated injuries: tendon tears, nerve injury, vascular injury, compartment syndrome.

Question 100

management of recurrent dislocation?

Answer 100

soft tissue repair/reconstruction or bony surgical procedures

Question 101

how to manage fracture-dislocations?

Answer 101

may reduce with closed reduction ORIF may be needed if reduction cannot be achieved due to a bony fragment preventing congruent reduction or joint instability

Question 102

grading ligament ruptures

Answer 102

grade 1 - sprain grade 2 - partial tear grade 3 complete tear

Question 103

how to treat soft tissue injuries

Answer 103

``` RICE rest Ice compression elevation followed by early movement to prevent stiffness ```

Question 104

tendon tears able to be conservatively treated?

Answer 104

Achilles tendon, rotator cuff, long | head of biceps brachia, distal biceps) though may need repair to restore function

Question 105

complete tears of... need surgical repair

Answer 105

tendons fundamentally for function quadriceps tendon patellar tendon tendon injuries in the hand - need surgical repair

Question 106

what is septic arthritis?

Answer 106

an emergency | Bacterial infections can irreversibly damage hyaline cartilage within days

Question 107

who gets septic arthritis?

Answer 107

Uncommon in adults but important so should be excluded with any unexplained acute mono arthritis Young, elderly, IVDUs and immunocompromised patients are most prone to infection can evolve from metphyseal osteomyelitis in some joints - neonates and infants

Question 108

What is the pathology of septic arthritis?

Answer 108

pathogens usually spread to the joint via the blood/from infection of adjacent tissues Suspect endocarditis esp. if more than one joint/bone is involved (due to septic emboli)

Question 109

how does septic arthritis present?

Answer 109

``` acute onset severe painful red hot swollen and tender joint severe pain on any movement sometimes history of direct penetration with a sharp object, can also occur following intra-articular surgery ```

Question 110

pathogens causing septic arthritis

Answer 110

Staph aureus = most common cause in adults Streptococci = second most common cause Haemophilus influenzae = most common in children though now there’s a vaccine Nesseria gonorrhoea = in young adults, rare Escherichia coli - in the elderly, IVDUs, very ill patients

Question 111

how is septic arthritis diagnosed?

Answer 111

aspirate under aseptic technique before giving antibiotics to confirm it and to identify causative organism (single dose of antibiotics can lead to a falsely negative gram stain and culture), frank pus aspirated and positive gram stain are indicators of septic arthritis

Question 112

how is septic arthritis treated?

Answer 112

surgical washout either via open surgery or arthroscopically, can do repeat aspirations esp. in children, response to treatment is based on clinical findings and serial CRP