6- Trauma Flashcards
What is involved in the primary survey in a trauma case
Quick assessment of vital functions and any appropriate management
ABCDE
What is involved in the secondary survey in a trauma case
Head to toe survey to detect any other injuries
What are the presentations of hypovolemia
Tachycardia
Hypotension
Confusion and lethargy
What score determines level of consciousness
Glasgow Coma score
Define polytrauma
More than one ling bone injured
OR
major fracture and associated chest or abdominal trauma
Describe primary healing of a fracture
Occurs when there is minimal fracture gap
Bone simply bridges gap with new bone from osteoblasts
Describe secondary healing of a fracture
Gap at fracture site is filled temporarily to act as a scaffold for new bone
Involves an inflammatory response
List the steps of secondary bone healing
Haematoma and inflammation occur
Macrophages & osteoclasts remove debris and resorb bone ends
Granulation tissue forms from fibroblasts
Chondroblasts form cartilage (soft callus)
Osteoblasts lay down bone matrix
Calcium minerlisation produces hard callus (woven bone)
Remodelling occurs into lamellar bone
How long does it take the hard callus to form in a fracture
6-12 weeks
Smoking impairs fracture healing - true or false
True
What is a transverse fracture
Occurs with pure bending force
Snaps across bone (horizontal)
What is an oblique fracture
Occurs with shearing force - fall from height
Diagonal fracture
What causes a spiral fracture
Torsional forces
What is a comminuted fracture
Fracture with 3 or more fragments
Very unstable
Usually very high energy
What is a segmental fracture
Bone fractures in 2 separate places
Very unstable
What is the angulation of a fracture
Describes the direction in which the distal fragment points and the degree of deformity
What are the clinical signs of a fracture
Localised bony tenderness
Swelling
Deformity
Crepitus
List some early local complications of fractures
Compartment syndrome
Vascular injury with ischaemia
Nerve compression or injury
Skin necrosis
List some early systemic complications of fractures
Hypovolemia Fat embolism ARDS SIRDS acute renal failure MODS Death
List some late local complications of fractures
stiffness, loss of function, Chronic Regional Pain Syndrome, infection, non‐union, mal‐union, Volkmann’s ischaemic contracture, post traumatic osteoarthritis and deep vein thrombosis.
List late systemic complications of fractures .
Pulmonary embolism
What are the signs of compartment syndrome
Increased pain on stretching
Severe pain out with the clinical context
Swelling
Tender to touch
What causes compartment syndrome
Bleeding and exudate (due to fracture or other injury) compresses the venous system
This results in congestion in the muscle and secondary ischaemia
Which injuries are associated with vascular injury
Knee dislocation
Supracondylar fracture of elbow in kids
Shoulder trauma
Pelvic fractures
What is degloving
Avulsion of skin from underlying blood vessels
Can result in skin ischaemia and necrosis
What are the clinical signs of fracture non-union
ongoing pain
ongoing oedema
movement at fracture site
Bridging callus on imaging
What are the symptoms and signs of a fracture healing
Resolution of pain and function
Absence of point tenderness
No local oedema
Resolution of movement at fracture site
What can lead to non-union of a fracture
Instability Excessive movement at fracture site Lack of blood supply Chronic disease Soft tissue problems Infection
What is complex regional pain syndrome
Heightened chronic pain response that occurs after injury
poorly understood and hard to treat
What is the major complication with an open fracture
Infection
How do you prevent infection with an open fracture
IV broad spectrum antibiotics in A&E
Prompt surgery
What does delayed presentation of dislocation increase risk of
Requirement of open reduction
Recurrent instability
What is the mainstay of treatment for soft tissue injuries
RICE
rest, ice, compression and elevation
How do you grade ligament ruptures
Grade 1 - sprain
Grade 2 - partial tear
Grade 3 - complete tear
How does septic arthritis present
Red, hot, tender, swollen joint
Severe pain
Who is the most prone to septic arthritis
More common in kids than adults
Elderly, IVDU, immunocompromised patients
What is the most common cause of C spine fractures
High energy injury
E.g. RTA or fall from height
What is the most common cause of thoracolumbar fractures
Car accidents
Falls from height
In elderly with osteoporosis - compression or wedge
What is spinal shock
Physiologic response to injury
Complete loss of sensation, motor function and reflexes below level of injury
How long does it usually take spinal shock to resolve
24 hours
What reflex is lost in spinal shock
bulbocavernous
When does neurogenic shock occur
Secodnary to temporary shutdown of sympathetic outflow from the spinal chord from T1-L2
Usually due to cervical or thoracic chord injury
How do you treat neurogenic shock
IV fluid therapy
What are the classifications of spinal cord injury
Complete or incomplete
Describe a complete spinal cord injury
There will be no sensory or voluntary motor function below level of injury
Poor prognosis for recovery
Describe an incomplete spinal cord injury
Some neurological function is present distal to injury
Better prognosis for recovery
How do you treat a spinal cord injury
Appropriate immobilisation
Traction - if dislocated or unstable
Surgery - relieve pressure
What is the most common injury mechanism for proximal humerus fractures
low energy injuries in osteoporotic bone due to fall onto outstretched hand or shoulder
What is the most common fracture pattern for proximal humerus
Fracture of the surgical neck
Medial displacement of humeral shaft
How do you treat a proximal humeral fracture
Minimally displaced - sling and gradual mobilisation
Displaced - internal fixation
What is a Bankart lesion
Detachment of the anterior glenoid labrum and capsule
Common in anterior shoulder dislocation
What is the main sign of axillary nerve injury
Loss of sensation in the regimental badge area
How do you manage a dislocated shoulder
Closed reduction under sedation or anaesthetic
If delayed presentation then it may need to be an open reduction
How ACJ injuries occur
Fall onto the point of the shoulder
Common in sport
What type of injury can occur in the ACJ
Sprain
Subluxation - ruptures the acromioclavicular ligaments
Dislocation - disrupts coraclavicular ligaments as well as AC
How do you treat injury to the ACJ
Sling for a few weeks followed by physio
Surgery in those with chronic pain
What can cause a humeral shaft fracture
Direct trauma - gives transverse of comminuted fracture
Fall with or without twist - oblique or spiral
How do you treat humeral shaft fractures
Humeral brace - most cases
Internal fixation
How do olecranon fractures occur
Fall onto the point of elbow
With contraction of the triceps
What is a Nightstick fracture
Fracture to ulnar shaft caused by direct blow
How do you treat a fracture of both arms of the forearm
ORIF with plates and screws
What is ORIF
open reduction with internal fixation
What is a Monteggia fracture dislocation
Fracture of the ulna with dislocation of radial head at elbow
How do you treat a Monteggia fracture dislocation
ORIF of ulnar fracture
reduction of joint
What is a Galeazzi fracture dislocation
fracture of the radius with dislocation of the ulna at the distal radioulnar joint
How do you treat a Galeazzi fracture dislocation
ORIF of radius
should allow radioulnar joint to reduce
What is a Colles fracture
Extra‐articular fracture of the distal radius within an inch of the articular surface and with dorsal displacement or angulation
What causes a Colles fracture
FOOSH with extended wrist
How do you treat a Colles fracture
Minimally displaced - splint
Casts
Percutaneous wires
What is a Smith’s fracture
volarly displaced or angulated extra‐articular fracture of the distal radius
Very unstable
What causes a Smith’s fracture
Falling onto the back of a flexed wrist
How do you treat a Smith’s fracture
ORIF with plates and screws
What usually causes a scaphoid fracture
FOOSH
What are the signs of a scaphoid fracture
Tenderness in anatomical snuffbox
Pain on compression of thumb metacarpal
How do you treat a scaphoid fracture
Plaster cast for 6-12 weeks
List some potential complications of scaphoid fractures
Non-union
AVN
What are the risks of a penetrating injury to the volar aspect of the hand
Damage to the flexor tendons, digital nerves and digital arteries
What are the risks of a penetrating injury to the dorsal aspect of the hand
Damage to extensor tendons
How do you treat an extensor tendon injury
Surgical repair
6 weeks in the splint
What is mallet finger
Avulsion of the extensor tendon from its insertion into the terminal phalanx
What causes mallet finger
Forced flexion of the extended DIPJ, often from a ball at sport
How does mallet finger present
Pain
Drooped DIPJ
Inability to extend at the DIPJ
How do you treat mallet finger
Mallet splint for 4 weeks
What is the most common cause of a 5th metacarpal fracture
Punching injury
also called Boxer’s fracture
What is a fight bite?
Occurs in association with Boxer’s fracture
Laceration on puncher’s hand from victims teeth
Can get infected
How do you treat metacarpal fractures
Strapping to neighbouring digit
How do you treat a phalangeal fracture
Neighbour strapping or splintage
May need wires or fixing if unstable
Children’s fractures heal faster than adults fractures - true or false
True
Why do children’s fractures heal faster
Thicker periosteum which has a rich source of osteoblasts
Much better at remodelling
What are the benefits of the remodelling potential in children
Need surgical stabilisation less
Greater degrees of displacement and angulation can heal
What is the major risk with fractures around the physis
Potential to disturb growth
Can lead to a shortened limb or angular deformity
How do you treat buckle fractures
3-4 weeks of splintage
How do you treat greenstick fracture
May need manipulation and casting
Why are supracondylar fractures common in kids
Weak point in the growing upper limb
Occurs on FOOSH or less commonly fall onto flexed elbow
How do you treat an undisplaced supracondylar fracture
Stable so treated with a splint
How do you treat an displaced or angulated supracondylar fracture
Closed reduction and pinning with wires to stop deformity
How do femoral shaft fractures in children occur
Fall onto flexed knee
Indirect bending Rotational forces
How do you treat a femoral shaft fracture in kids
By age <2 - gallows traction and hip cast 2-6 - Thomas splint or cast 6-12 flexible intermedullary nails 12> - adult type intermedullary nail
What must you consider with femoral shaft fractures in the under 2’s
non-accidental injury
How do you treat a tibial fracture in kids
Casting for a short time
Nails etc if very unstable
How do hip fractures usually occur
Young - high energy injury (RTA)
Elderly - low energy falls if osteoporotic
What is a lateral compression fracture
Occurs with side impact
One half of pelvis is displaced medially
Often accompanied by sacral compression fracture or SI joint issues
What is a vertical shear fracture
Occurs due to axial force on one hemipelvis
Affected hemipelvis is displaced superiorly
High risk of injury to sacral nerve roots or lumbosacral plexus
What is a anteroposterior compression injury
Results in wide disruption of pubic symphysis
Pelvis opens like book
Leads to substantial bleeding
What is the acetabulum
The intra-articular section of the pelvis
Forms the ‘cup’ in the hip joint
How do acetabular injuries usually occur
High energy injury in young or low energy in elderly
Associated with hip dislocation as femoral head breaks it when it pops out
How do you treat acetabular fractures
Undisplaced - conservatively
May need reduction and fixation
THR in elderly
What is the most common cause of hip fractures
Osteoporosis in the elderly
What sex is more prone to hip fractures
Females
Is management of hip fractures surgical or conservative
Almost always surgical - within 24 hrs
How do you classify hip fractures
Intracapsular or extracapsular
What normally causes femoral shaft fractures
High energy injury
Stress fracture in those with underlying bone disease
What is the major risk with displaced femoral shaft fractures
Significant blood loss
How do you manage a femoral shaft fracture
Analgesia
Thomas splint
Closed reduction and stabilisation with intramedullary nail
How do you treat a true knee dislocation
It is a surgical emergency due to vascular risk
Urgent reduction
If unstable then use fixation
what predisposes you to a patellar fracture
Generalised ligamentous laxity
Valgus alignment of the knee
Rotational malalignment (including femoral neck anteversion), Shallow trochlear groove.
Describe a tibial plateau fracture
Intra‐articular fractures with either a split in the bone, a depression of the articular surface or a combination of both
How do you treat a tibial plateau
Surgery to reduce the articular surface and fix it for stabilisation
What are some of the other risks with tibial plateau fractures
Neurovascular injury
Compartment syndrome
What usually causes a tibial shaft fracture
Indirect force Bending (transverse fracture) or rotational energy (spiral fracture), compressive force from deceleration (oblique fracture) or a combination
What is the commonest cause of compartment syndrome after trauma
Tibial shaft fracture
Describe the non-operative treatment of tibial shaft fracture
Repositioning Above knee cast
Describe the operative treatment of tibial shaft fracture
Internal fixation
Surgical stabilisation - ORIF
Intermedullary nails
What are Pilon fractures
Intra-articular fractures of the distal tibia
What movement most commonly causes ankle injury
inversion injury and/or rotational force on a planted foot.
What is the key symptom of ankle sprain
Pain, bruising and mild to moderate tenderness over the involved ligaments
What is the treatment for a stable ankle fracture
Walking cast or splint for around 6 weeks
What is the treatment for an unstable ankle fracture
ORIF - plates and screws
anatomical reduction
How does a midfoot dislocation/fracture present
Grossly swollen and bruised foot
Unable to weight bear
X-ray may appear normal
How do you treat a midfoot dislocation/fracture
Closed or open reduction with fixation (screws)
Describe common metatarsal fractures
base of 5th common - inversion injury
2nd is common place for stress fracture
Lesser ones common to fracture but 1st is uncommon as so strong
How do you treat metatarsal fractures
Walking cast or boot - 4-6 weeks
Stabilized with K wires
How do you treat a toe fracture
Protection in stout boot
Open fractures need debridement and stabilisation with wires
