Burns, wound healing and orthopaedics Flashcards
Describe possible reasons for low gcs in burns patient
-Hypoxia
-Inhalation injury
-Head injury
Possible:
–> drug/alcohol overdose
–> hypoglycaemia
When would you expect inhalation injury from history?
-Burns occuring in enclosed space
-Smoke during incident
-Injury from blast
-Pt brought in unconcious/decreased GCS
What are the signs of smoke inhalation injury?
-Facial +/- neck burns
-Singed hairs (eyebrows, nose hairs)
-Soot in airway
-Hoarseness/stridor
-Carbonaceous sputum
-Hypoxia
-Low GCS
How would you initially manage burns pt?
-Manage according to ATLS guidelines
-A-E
-Analgesia, tetanus, investigations, fluid resuscitation
What investigations would you request in burns pt?
-FBC, U + E, coag, G + S
-ABG, COHb levels
-CT head
-CT trauma if evidence of trauma
What is half life of carbon monoxide?
-Room air: 250 mins
-100% O2: 40 mins
How would you clinically assess depth of a burn?
-Colour
-Cap refill
-Presence/abscence of blisters
-Sensation
How would you estimate the extent of the burn as mesaured by TBSA?
-Hand surface area = 1% (patient’s hand)
-Rule of 9’s
-Lund and browder chart
Describe rule of 9s
Head = 9%
Arm = 9%
chest = 9%
abdomen = 9%
Back: 18%
Leg = 18%
Genitals = 1%
What are the indications for fluid resuscitation in burns?
->10% deep partial/full thickness in children
->15% deep partial/full thickness in adults ?? 20% according to new atls guidelines
What fluid resuscitation is given? When is it indicated?
New ATLS guidelines:
-2ml x body weight Kg x % TBSA
-Half over 8 hrs, subsequent over 16
-Indicated if over 20% deep partial thickness or full thickness burn
What would you expect in a deep dermal burn?
-Dry, blotchy red cherry skin
-Absence of a capillary refill
-Loss of sensation
What emergency treatment is required for circumferential burns?
Escharotomy
What are the indications/criteria for referring to the burns unit?
-5% TBSA full thickness burn in adults
-5% TBSA in children (any depth)
-10% TBSA in adults (any depth)
-Burns + inhalation
-Burns + trauma
-Electrical and chemical burns
-Burns in certain anatomical areas e.g. face, hands, feet, perineum and genitals
-Circumferential full thickness burns
Healing by primary intention
-Wound edges are approximated by sutures, glue, staples or steristrips
-Healing occurs in an orderly manner
-Good cosmetic outcome
Healing by delayed primary intention
-Used in bites (human/animal) or contaminated wounds
-Following thorough debridement, the wound is left open for 24-48 hrs and then primary closure is performed
Healing by secondary intention
-The wound edges cannot be approximated (tissue loss)
-Wound heals by contraction
-Poorer cosmetic outcome compared to healing by primary intention
-Myofibroblasts are the predominant cell type in this type of healing
Healing by re-epithelialisation
-Only epiderms and superficial part of the dermis are injured
-Adnexal structures are intact and the wound heals by re-epithelialisation
-Seen in abrasions and split-skin donor sites
What are the stages of wound healing?
- Haemostasis
- Inflammation
- Proliferation
- Re-modelling
Haemostasis
-Vasoconstriction
-Platelet aggregation and activation
-Fibrin clot formation
Describe inflammation stage of wound healing
-Early phase (first 24 hrs) - neutrophils are the predominant cell type
-Late phase (>24 hrs) - lymphocytes and macrophages are seen
Proliferation
-Extracellular matrix formation
-Collagen deposition
-Fibroblast proliferation
-Angiogenesis
-Epithelialisation
Re-modelling
-Decresased fibroblast formation. Collagen is rearranged along tension lines
-Gradual increase in tensile strength of wound
What is the fundamental difference between a ‘graft’ and a ‘flap’?
-A graft relies on recepient wound bed for vascularity and nutrition
-A flap brings its own blood supply
How would you classify skin grafts?
-SSG
-Full thickness
Describe split thickness graft
-Used for large surface area e.g. extensive burns
-Epidermis and part of dermis taken, donor site left to heal by re-epithelialisation
-Common donor sites: lateral aspects of thigh, buttocks, back
Describe full thikness grafts
-Used in areas e.g. digits of hand or over joints to minimise contractures
-FT skin grafts have better colour match and are therefore preferred in exposed areas e.g. face
-Common donor sites for FT graft: pre and post-auricular region, supraclavicular region, medial surface of forearm/arm
How would you classify ‘flaps’?
-Random patterns (does not have named blood vessel)
-Pedicled (has named blood vessel)
-Free (blood supply is disconnected from one part of body and connected to a vessel at recipient site)
What types of flaps are used in which locations?
-Face: mostly random pattern flaps
-Breast recon: pedicled flaps (LD) and free flaps (DIEP) is used
-Pedicled and free flaps also used in variety of recons following trauma (e.g. gracillis musculocutaneous free flap to cover defect over dorsum of foot)
Name some types of dysfunctional wound healing
Non-Healing wounds
Healing with hypertrophic scar
Healing with formation of keloid
What are the differences between hypertophic and keloid scar?
Borders
–> confined to original wound
–> outgrows wound area
Incidence
–> usually develops in weeks following surgery/injury
–> can develop months or years from original injury
Site
–> usually in flexor surfaces
–> predilection for sternum, shoulder and ear lobes
Aetiology
–> Usually related to wound factors (e.g. infection/haematoma/dehiscence) and those crossing tension lines
–> unknown
Racial predisposition
–> Not race related
–> non whites >whites
How would you manage hypertrophic scars?
-Subside with time and respond to conservative measures e.g. pressure treatment/silicone gel/plasters
How would you manage keloid scars?
-No effective treatment
-Conservative: steroid injections, pressure treatment, silicone gel
-Surgery rarely advocated, only if severe/for cosmetic purposes
-Rarely subside, do not have established treatment option
-No treatment is proven to be effective, recurrence is common following excision
-Commonly used symptom control measures include pressure treatment, intra-lesional steroid + silicone gel/plasters
-Surgery rarely advocated and is performed if symptoms severe/for cosmetic purposes
-Surgery includes debulking keloid by ensuring incision is kept within margin of keloid and does not overrun into normal skin
What is the aetiology of septic arthritis?
-Micro-organisms invade joint by direct penetration into joint, spread from adjacent soft tissue infection or via blood stream
What micro-organisms are known to cause septic arthritis?
Bacterial
-Staph
-Haemophilus
-E.coli
Viruses
-Heptatitis A, B, C
-Herpes viruses
Fungi
-Histoplasma
What are risk factors for developing septic arthritis?
-previous joint disease/injury/surgery
-IV drug abse
-Immune deficiency/immunosuppression
Underlying medical illness:
-Diabetes
-Alcoholism
-Rheumatic diseases
Which investigations would you perform in septic arthritis?
-Bloods: FBC, CRP, Urate
-X-ray
-joint aspiration for M, C and S
How would you manage a pt with septic arthritis?
-Bloods including urate, CRP, FBC
-Analgesia, immobilisation
-Aspirate joint
-IV abx
-Washout of joint
-Surgery to remove prosthesis (if present)
-IV abx
-Analgesia
-Immobilisation
-Washout/aspiration of joint
-Surgery to remove prosthesis (if present)
What are the complications of septic arthritis?
-Soft tissue injury
-Degenerative joint disease
-Osteomyelitis
-Sepsis
Can you differentiate between septic arthritis and other inflammatory joint diseases e.g. gout or reactive arthritis?
-Septic arthritis is mono-articular, inflammatory arthropathies can be mono or poly-articular
What is the difference between gout and pseudogout
Joints
–> affects smaller joints
–> affects larger joints
Investigations
–> Associated with high serum urate levels
–> not associated with high serum urate levels
Crystals
–> monosodium urate crystals, needle shaped crystals, negatively birefringent on polarised light microscopy with rhomboid shaped crystals
–> Positively birefringent on polarised light microscopy
How would you treat gout?
During acute flare up: Colchicine, NSAIDs or corticosteroids (intra-articular or systemic)
To induce remission: allopurinol, dietary advise (reduce alcohol intake, reduce red meat consumption, good hydration)
Define compartment syndrome
-Increase in interstitial fluid pressure within osseo-fascial compartment with sufficient magnitude to cause compromise of microcirculation leading to myoneural necrosis
What are the signs and symptoms of compartment syndrome?
-Pain on passive stretch of affected compartment
-Paraesthesia
-Paralysis
-Pallor
-Pulslessness
-Perishingly cold leg
What is the normal compartment pressure in the lower leg?
Normal resting pressure 0-6mmhg
What happens to this pressure in compartment syndrome?
-Pressure is >30mmhg or difference in diastolic pressure and compartment pressure is <30mmhg
Name the compartments in the lower leg
-Anterior
-Lateral
-Superficial posterior
-Deep posterior
Name structures present in deep posterior compartment of lower leg
-Tibialis posterior
-Flexor hallucis longus
-Flexor digitorum longus
-Popliteus
Nerve
-Tibial nerve
Artery
-Posterior tibial artery
-Peroneal artery
How would you treat compartment syndrome in this pt?
-Immediate fasciotomies
-Address underlying cause
Describe incisions for fasciotomies
Two longitudinal incisions on medial and lateral sides of leg
–> medial longitudinal incision 1-2cm posterior to medial border of tibial to release superficial and deep posterior compartments
–> Lateral longitudinal incision 2cm lateral to anterior border of tibia releases anterior and lateral compartments
