complications of fractures and life threatening ortho emergencies Flashcards
1
Q
5 early types of complications from fractures
A
vascular nerve compartment syndrome infection fracture blisters
2
Q
6 late complications from fractures
A
- delayed/non-union
- malunion
- avascular necrosis
- growth disturbance
- stiffness, post-trauma OA
- complex regional pain syndrome
3
Q
general complications of fractures
A
- fat embolism syndrome
- DVT and PE
- complications of immobility
4
Q
pre-op fracture considerations
A
- thrombophylaxis-DVT common so give LMWH
- fat emoblism syndrome
- hetertopic ossification
- infection
5
Q
fat embolism syndrome
- symptoms
- fracture
- treatment
- who most commonly
A
symptoms: hypoxia, confusion, petechiae, tachycardia
fracture: 24-72 hrs after a pelvic or femur fracture
treatment: given oxygen and early IM stabilisation
who: young men
6
Q
heterotopic ossification
- injury
- treatment
- onset
A
- head injury, acetabular fractures, elbow surgery
- give low dose indomethacin 25mg daily for 6 weeks or local radiation
- develops 3-6 months after
7
Q
what is heterotopic ossification
A
bone growing in soft tissue
8
Q
main prophylactix antibiotic for surgery
A
cephalosporin
9
Q
5 fractures that are watershed areas with risk of non-union
A
- scaphoid
- NOF femur
- Jones of 5th metatarsal
- head of humerus
- talus
10
Q
5 main orthopaedic life threatening complications
A
open fractures dysvascular limb compartment syndrome nerve injury ortho infections
11
Q
3 main ortho infections
A
septic arthritis
cellulitis
necrotising fasciitis
12
Q
what is an open fracture definition
A
a direct communication between external environment and fracture with bone penetrating the skin
13
Q
history for an open fracture
A
- type of injury
- force
- environment
- farmyard waste or immersion in water(contamination)
- after injury
14
Q
what classification is used for open fractures
A
gustilo classification
15
Q
type 1 gustilo
A
low energy <1cm simple fracture minimal soft tissue minimal contamination no NV injury
16
Q
type 2 gustilo
A
moderate energy 1-10cm moderate communition moderate soft tissue moderate contamination no NV injury
17
Q
Type 3a gustilo
A
energy: high >10cm highly comminuted/seg soft tissue requires local flap extensive contamination NO NV injury
18
Q
Type 3b gustilo
A
energy high >10cm highly comminuted soft tissue requires free flap extensive contamination NO NV injury
19
Q
type 3c gustilo
A
energy high >10cm highly comminuted often requires free flap contamination extensive NV injury requires arterial repair
20
Q
4 R’s for managing fracture
A
resuscitate
reduce
restrict
rehabilitate
21
Q
what antibiotics should be given for open#
A
cefuroxime
clindamycin
gentamicin if heavy contamination
22
Q
other consideration of infection risk for open#
A
tetany and anti-tetanus booster
23
Q
what can be used to make a sterile saline dressing
A
poviclone iodine
24
Q
surgical management of open#
A
-sequential operations
1. debridement and external fixation/ IM nailing
2.debridement and internal fixation if not done
depends on whether debriding can be done in 1st
25
what are dysvascular lumbs assoc too
high energy fracture after open#
sometimes
closed injuries eg knee dislocation and supracondylar # of humerus in children
26
what is the minimum systolic pressure needed to feel a peripheral pulse
80-90
27
management of dysvascular limb
- resuscitate
- realign with splint
- reduce
- restrict
- closed reduction to improve circulation
- vascular injury so use angiogram and temporary vascular shunt to perfuse limb
28
6p's of critical ischaemia
```
symptoms
-pain
-paraesthesia
-paralysis
signs
-pale
-pulseless
-perishingly cold
```
29
causes of critical ishceamia
-kink of major vessel in #
-disruption of vessel structure: lacerations/ transection/ dissection
-arterial spasm
-loss of blood
-thrombosis:blood in wall of artery
can be acute or delayed
30
3 types of nerve injuries
neuropraxia
axonotemesis
neurotemesis
31
what is neuropraxia
temporary
structure intact
need to remove pressure to relieve numbness
full recovery
32
axonotemesis is and recovery
axon damaged but myelin sheath preserved
- so distal axon needs to repair
- scarred myelin sheath may prevent full recovery
33
neurotemesis and recovery
complete nerve division
no myelin sheath to guide regeneration
irreversible without surgical repair
-no motor or sensory
34
what takes place in axonotemesis and neurotemesis
Wallerian degeneration
35
signs of nerve injury
paraesthesia
dyaesthesia
pain: still kink
36
dermatome for
- nipple
- umbilicus
- groin crease
- radial side of hand
- middle finger
- ulna side of hand
- foot dorsum
- plant foot
- back of knee and buttocks
```
t4
t10
l1
c6
c7
c8
l5
s1
s3
```
37
symptoms of a radial nerve palsy and what is it assoc too and what causes it
wrist drop
assoc. to numbness over the 1st web space
caused by humeral shaft#
38
what area is affected in axillary nerve injury and what causes axillary nerve injury
regimental badge
| shoulder dislocation
39
anterior interosseous nerve median nerve injury symptoms and what cant they do
cant do an ok sign
| -weakness of FPL and FDL
40
what is at risk in a distal radius #
median nerve
41
what is at risk in a posterior hip dislocation
sciatic nerve
42
what is at risk in a knee dislocation
common peroneal nerve
43
what is at risk in a# at the elbow
ulnar entrapment-cubital tunnel syndrome=
44
what is the other type of ulnar injury
guyon's canal nerve entrapment ulnar = motor and sensory
45
what can cause upper limb nerve entrapment
```
#
dm
alcohol
synovitis
pregnancy
myxoedema
```
46
features of upper limb entrapment
```
pain
paraesthesia
numbness
weakness
swelling, soft tissue wasting
```
47
what is compartment syndrome
- increased pressure inside a fixed fascial compartment
- result in reduced tissue perfusion
- severe muscle pain from pressure and ischaemia
- tissue becomes necrotic
48
who is most likely to get compartment syndrome
young men with tibia fractures
| or on a blood thinner get haematoma
49
how does compartment syndrome happen
-injury
-tissue swelling
-increased compartment pressure
-decreased perfusion pressure
-local hypoxia
-cell membrane damage
-tissue swelling increased
=cycl
50
what # is compartment syndrome usually seen with
-lower leg
forearm
crush injuries
51
clinical signs of compartment syndrome
- pain disproportionate to the injury and unresponsive to strong analgesia and resists movement
- tightly swollen
- paraesthesia
52
important thing not to mix up in compartment syndrome
DISTAL PULSE DOES NOT MEAN NO COMPARTMENT SYNDROME- by this point things are v.bad and irreversible damage
53
at what point do long term changes occur in compartment syndrome and when does it become irreversible
4-6
| then 12 hours
54
management of compartment syndrome
-split cast down to skin
-limb to heart level
-compartment monitors
-decompressive fasciotomy full length
then left open
55
what pressure is indicative for fasciotomy incision
30-40mmHg
56
4 main types of bone infections
cellulitis: infection of skin and subcutaneous fat
abscess: pus
septic arthritis: in joint
prosthetic: related to joint
57
risk factors for cellulitis
immunodeficient
| chronic venous insufficiency
58
differentials for septic arthritis
```
GRASP
gout
reactive
autoimmune
septic
pseudo-gout
```
59
mortality % for septic arthritis
10%
60
what is the most common spread pattern for septic arthritis
haematogenous spread
61
clinical features of septic arthritis
- acute monoarthritis and fever
- swollen, hot and red joint
- pain at rest/moving
- throbbing, aching
- usually lower limbs knee and hip
62
most likely cause of septic arthritis
s.aureus
63
other cause of septic arthritis
- disseminated gonococcal infection from untreated gonorrhoea in young 10%
- elderly and IV gram negative bacilli or group bc and g strep
- haem influenzae in babies
- pseudomonas aeruginosa in iv drug user
- fungal in immunocompromised
64
risk factors for septic arthritis
dm
immunosuppression
prosthetic joint
65
medication for septic arthritis
diuretics
aspirin or anticoagulants
immunosuppressants
66
SIRS stands for and 4 def
```
systemic inflammatory response syndrome
temp>38
HR>90
resp>20
wbcc>12
```
67
empirical iv antibiotic for septic arthritis
flucoxacillin
68
what must be done before giving antibiotics for septic arthritis
joint aspiration
69
what is necrotising fasciitis
- cellulitis and severe systemic infection and inflammatory response
- soft tissue destruction
70
pathogens of nf
- strep
- staph
- clostridia gas gangrene
- e.coli
71
3 measurements for nf
>150 crp
wbc >15
creatinine and lactate rise
72
management of nf
```
sepsis 6
-give o2
-take blood culture
-iv antibiotics
-fluid challenge
-measure lactate
-measure urine output
=radical surgical debridement strip off the skin
```
