Case 24- Pathology 2 Flashcards
Journey of a patient in a major road traffic accident
- Would be brough in by ambulance to a major trauma unit at A&E
- Trauma team is alerted and they go through the primary survey before the fracture is dealt with
- Cervical spine immobilisation
Journey of a patient with a minor accident
- Would self present to a minor injuries unit at A&E
* Assessed by a triage nurse then a nurse practitioner or doctor
Management of open fractures
- Intravenous antibiotics to be administered as soon as possible
- Assessment and documentation of neurovascular status
- Re align and splint the limb, wound debridement (clean the wound) and stabilisation of the fracture
- Tetanus toxoid status should be checked and administered if required
Types of fractures
Comminuted fracture- when the bone splits into lots of different pieces, there are multiple segments
Simple fracture- when the bone splits into two pieces
Segmental fracture- when its fractured at two different places and becomes completely detatched.
Children fracture- the periosteum is very strong so the bone can fracture and the periosteum keeps it in place
Incomplete and complete fracture
A complete fracture is when the two ends of the bone completely break off and an incomplete fracture is when one part off the bone breaks but the other is still intact or the thick periosteum can hold it in. Incomplete fractures are common in children who may get a buckle fracture where the bone buckles but the periosteum is still intact and only part of the bone breaks
Causes of different types of fractures
Spinal and oblique fractures- when the break is at an angle, normally because the arm has been twisted.
Transverse fracture- due to direct trauma, normally a knife wound
Segmental fracture- due to multiple breaks often due to a high impact trauma
Intra-articular fracture and pathological fracture
An intra-articular fracture involves the joint and is more worrying then an extra-articular fracture. If it affects the joint it can lead to arthritis and stiffness.
Pathological fracture- fracture caused without an injury i.e. in osteoarthritis or bone cancer
Structures in the soft tissue
Skin Subcutaneous tissue- fat Muscle Tendon Ligaments Nerve Blood vessels
Anatomy of the soft tissue
Skin- epidermis, dermis
Subcutaneous tissue- fat deep to the skin
Fascia- deep to the fat, overlies the muscles
3 steps of wound healing
1) Inflammation
2) Proliferation
3) Remodelling
Wound healing- Proliferative phase
Epithelialisation
Formation of granulation tissue
Wound contraction
Angiogenesis
Types of soft tissue injuroes
1) Open
2) Penetrating- incised wound, laceration
3) Blunt- Burst laceration, Crush, De-gloving injury, Avulsion, Amputation
Laceration/Incised wound treatment
1) Wound debridement
2) Wound washout
3) Repair damaged structures
4) Wound closure
Skin loss
Burn, Abrasian, De-gloving injury, Skin necrosis
Effects of skin loss
Superficial- Adnexal structures intact, good healing potential
Full-thickness= could heal by secondary intention, may need skin graft or flap
Associated infection/contamination
Complex tissue injury
1) Skin and soft tissue loss
2) Exposed structures- muscle/tendon/nerve
3) Exposed bone/fracture
4) Amputation
Management of tissue loss
1) Reconstructive ladder/elevator
2) Laceration/incised wound- primary closure
3) Skin loss- secondary intention, skin graft
4) Involvement muscle/tendon/bones- skin graft, flap
Skin grafts and flap
Graft- tissue moved from one site to another. Is separated from its blood supply and picks up a new blood supply from the recipient site. Requires a vascularised bed
Fap- tissue moved from one site to another. Brings its blood supply with it. Used to cover non-vascularised tissue i.e. bone, tendon
Skin grafts and flap
Graft- tissue moved from one site to another. Is separated from its blood supply and picks up a new blood supply from the recipient site. Requires a vascularised bed
Fap- tissue moved from one site to another. Brings its blood supply with it. Used to cover non-vascularised tissue i.e. bone, tendon
Split thickness skin graft
Sheet- laid on as sheet tissue
Meshed- lots of small holes in the graft. Allows graft to be stretched to increase area covered. Allows blood to drain from underneath
Full thickness- full thickness skin taken. Need to stitch up donor site
Classifying flaps
Based on:
1) Blood supply- random pattern, axial
2) Constituents- cutaneous, fasciocutaneous, muscle, musculocutenous, osseous, osseocutaneous
3) Method of movement- transposition, advancement, rotation, pedicled, free flap
4) Location to defect- local, regional, distant- free tissue transfer
Compartment syndrome
Increased pressure within a muscle compartment
Causes- fractures, crush injury, reperfusion injury
Bleeding
Swelling
Pain- beyond that expected for injury, on stretching muscles
Pulseless, Pallor, Paraesthesia
Treatment- open up leg
Compartment syndrome
Increased pressure within a muscle compartment
Causes- fractures, crush injury, reperfusion injury
Bleeding
Swelling
Pain- beyond that expected for injury, on stretching muscles
Pulseless, Pallor, Paraesthesia
Treatment- open up leg
Tendon injury
Open- sharp division tendon
Closed- Rupture- tendon snaps mid substance
Closed- Avulsion- tendon avulsed from insertion
Tendon injury- Division
1) Open injury
2) Sharp object
3) Most commonly knife or glass
4) Most commonly see in the forearm and hand- Falls, DIY, Cooking, Deliberate self harm
Terminology- Upper limb
Radial= thumb side (lateral) Ulnar= little finger side (medial) Palm= Palmar= Volar= Flexor Dorsal= extensor Active movement- movement achieved by the muscle action of the patient Passive movement- movement achieved
Different types of tendons
Extensor tendon- dorsal aspect of forearm and hand
Flexor tendons- volar aspect forearm and hand
Assessment of tendon injury
Posture of hand Cascade- normal resting position fingers Active movement Pain on movement Posture of hand Extensor lag- no active movement, can passively extend
Tendon rapair
1) Skin marketing
2) Protect other structures
3) Sound repair
4) Post-operative rehabilitation
5) Modified Kessler
6) Adelaide repair
7) Tendon repair- epitendinous suture
Post-operative rehabilitation Tendon injury
1) Splint
2) Physiotherapy
3) Controlled mobilisation
Tendon injury- rupture
1) Closed injury
2) Tendon ruptures mid substance
3) Associated with fractures
4) Associated with arthritis
EPL rupture
1) Extensor pollicis longus
2) 3rd dorsal compartment
3) Distal radius fracture
Tendoachilles
1) Plantarflexes ankle
2) Sports injury- sudden dorsiflexion of foot when the calf muscles are tensed, direct impact
3) Elderly
4) Treatment- Quinolone antibiotics, steroid injections
5) Sudden pain, difficulty walking, snapping sound
6) Loss of plantarfexion, unable to stand on toes
Management of tendoachilles
Non-operative management- cast
Surgery- tendon repair, better outcomes. Increased risk of complications
Tendon injury- avulsion
1) Tendon pulled away from bone due to sudden force
2) Most commonly seen sports injury
3) Commonly seen in the hand at lower limbs
Soft- tissue mallet
1) Extensor tendon avulsed base distal phalanx
2) Extensor lag- unable to extend DIP joint
3) May be associated with fracture- bony mallet
4) Management- splintage
FDP avulsion
1) Jersey finger- rugby injury
2) Unable flex DIP joint
3) May be associated with fracture
4) Management- surgical repair
Nerve injury
Open- incised wound/laceration. Nerve division
Closed- traction, compression
Nerve injury- division
1) Open injury
2) Incised or penetrating wound
3) Most commonly in the hand and forearm
4) Primary repair
Nerve injury- division
1) Open injury
2) Incised or penetrating wound
3) Most commonly in the hand and forearm
4) Primary repair
Nerve anatomy of the hand
Normal anatomy- median nerve, ulnar nerve, radial nerve Danger sites (superficial nerves)- Superficial radial nerve, digital nerve (radial and ulnar)
Assessment of nerve injury
Sensation- radial (extensor pollicis longus), median (abductor pollicis brevis), ulnar (abductor digiti minimi)
Compare with normal- out of 10
Biro= 2-point discrimination
Nerve injury- traction injury
Nerve stretched- sudden high velocity force. High speed road traffic accidents, associated with fractures or dislocation
Rupture- axons, fascicles, nerve
Nerve avulsed spinal cord
Classification of nerve injuries
Seddon
Neuropraxia- concussion
Axonotmesis- sheath intact, axons cut
Neurotmesis- sheath and axons cut
Nerve injury- compression
Soft tissue swelling- compartment syndrome
Fractures or dislocations
Long-lie= Saturday night palsy
Usually neurapraxia
Longer duration or greater compression recovery depends on the extent of nerve damage
Management of nerve compression
Watch and wait Repeated clinical examination Neurophysiology Nerve grafts Nerve transfers
Nerve injury and compression= acute/ chronic
Acute- Laceration, Penetrating wounds, fracture, haematoma
Chronic- Meralgia paraesthesia, Tarsal tunnel syndrome
Injury to the Femoral nerve
1) Posterior dislocation hip
2) Hip surgery
3) Laceration- stab wound, penetrating injury
Femoral nerve sensation
1) Anterior thigh
2) Medial leg via saphenous nerve
3) Motor- knee extension
Sciatic nerve injury
1) Posterior dislocation hip
2) Hip surgery
3) Laceration- stab wound, penetrating injury
Sciatic nerve sensation
Sensation- no sensory branches in the thigh
Hip extension/knee flexion (motor)- Semimembranosus, Semitendinosus, Biceps femoralis (long head), Branch to adductor magnus
Tibial nerve injury
Fractures Dislocation knee Dislocation ankle Compression Baker's cyst Tarsal tunnel
Tibial nerve sensation
Motor
Ankle plantar flexion
Toe flexion
Sensory- sole of the foot
Injury to the common peroneal nerve
Fracture of the fibula head
Lacerations
Compression- Casts/braces. Habitual knee flexion ‘Strawberry pickers’ palsy’
Divides into a deep and superficial nerve
Superficial peroneal nerve sensory
Sensation- two thirds lateral leg, dorsum foot except 1st webspace
Motor- Ankle eversion (Peroneus longus, Peroneus brevis, Peroneus tertius)
Deep peroneal nerve sensory
Sensation- dorsum foot 1st webspace
Motor- Ankle dorsiflexion (anterior tibialis), Toe extension (Extensor hallucis longus, Extensor digitorum brevis)
Results- stub toe, Footdrop
Nerve compression syndromes
1) Meralgia parasthesia
2) Tarsal tunnel syndrome
Lateral cutaneous nerve thigh
Meralgia paraesthesia
Compression- Idiopathic, External i.e. seat belt/tool belt, Pregnancy, Obesity
Injury- Iatrogenic (Hip surgery, Inguinal hernia repair)
Sensation= Anterior-lateral thigh
