Cortex - general trauma 3 (this is the more important stuff from this section)

Question 1

What are the clinical signs of a fracture ?

Answer 1

• Localised bony (marked) tenderness – not diffuse mild tenderness
• Swelling
• Deformity
• Crepitus (a grating sound or sensation) – from bone ends grating with an unstable fracture

Question 2

What is a useful rule for knowing when you need to X-ray an injured lower limb ?

Answer 2

If they cannot weight bear then you should X-ray the painful area

Question 3

What should the assessment of an injured lower limb include ?

Answer 3

• Wether injury is open or closed
• Assessment of the distal neurovascular status (pulses, capillary refill, temperature, colour, sensation, motor power)
• Whether there is a compartment syndrome
• Assessment of the status of the skin and soft tissue envelope.

Question 4

What are the different investigations used in the investigation of fractures ?

Answer 4

• X-rays
• Tomogram - a moving x-ray for complex bones
• CT - for complex bones e.g. vertebrae, pelvis, calcaneus, scapular glenoid
• MRI
• Technetium bone scans

Question 5

What are x-rays used for in fractures ?

Answer 5

• They are used for the majority of fractures
• Usually a AP and lateral one, as always need to take it from two views

Question 6

What type of fracture would a tomogram be used for ?

Answer 6

Mandibular fracture

Question 7

What are CT’s used for in terms of fractures ?

Answer 7

Assess fractures of complex bones e.g. vertebrae, pelvis, calcaneus, scapular glenoid

Question 8

What are MRI’s used for in terms of fractures ?

Answer 8

For occult fractures (clinical signs but no radiological signs)

Question 9

What are Technetium bone scans used for in terms of fractures ?

Answer 9

Useful to detect stress fractures (eg hip, femur, tibia, fibula, 2nd metatarsal) as these may fail to show up on xray until hard callus begins to appear.

Question 10

What is the initial management of fractures ?

Answer 10

• Clinical assessment
• Analgesia
• Splintage/immoblisation
• Investigation - usually X-ray

Question 11

What is the definite management of undisplaced, minimally displaced and minimally angulated fractures which are considered to be stable?

Answer 11

Treated non‐operatively with a period of splintage or immobilization and then rehabilitation.

Question 12

What is the treatment of Displaced or angulated fractures where the position is deemed unacceptable ?

Answer 12

• Closed reduction and cast application may be performed with serial x‐rays to ensure no loss of position
• Unstable injuries may be treated with surgical stabilisation

Question 13

Unstable extra‐articular diaphyseal fractures can be fixed with what?

Answer 13

Open reduction and Internal Fixation (ORIF)

Question 14

What is the treatment of Displaced intra‐articular fractures?

Answer 14

Anatomic reduction and rigid fixation by way of ORIF

Question 15

What are the main complications which can occur following a fracture ?

Answer 15

• Early local complications of fractures - compartment syndrome, vascular injury with ischaemia, nerve compression or injury, and skin necrosis.
• Early systemic complications - hypovolaemia, fat embolism, shock, ARDS, acute renal failure, Systemic Inflammatory Response Syndrome, Multi‐Organ Dysfunction Syndrome and death.
• Late local complications - stiffness, loss of function, Chronic Regional Pain Syndrome, infection, non‐union, mal‐union, Volkmann’s ischaemic contracture, post traumatic osteoarthritis and DVT.
• The main late systemic complication of fractures is PE - tends to occur a few days after

Question 16

Compartment syndrome is a serious potential complication of fractures - how does this occur ?

Answer 16

Can occur due to bleeding and inflammatory exudate from fracture and injury, pressure begins to rise.

Question 17

What is the cardinal clinical signs of compartment syndrome ?

Answer 17

1. Increased pain on passive stretching of the involved muscle
2. Severe pain outwith the anticipated severity in the clinical context

Question 18

Match the following different types of nerve injuries to there definition:

1. Occurs when the nerve has a temporary conduction defect from compression or stretch and resolve over time with full recovery (can take up to 28 days).
2. Occurs from either a sustained compression or stretch or from a higher degree of force. The long nerve cell axons distal to the point of injury die axons then regenerate along the endoneurial tubes at a rate of 1mm per day.
3. A complete transection of a nerve and is rare in closed injuries but can occur in penetrating injuries. No recovery uness surgical

Neuropraxia, Aonotmesis, Neurotmesis

Answer 18

1. Neuropraxia
2. Aonotmesis
3. Neurotmesis

Question 19

Appreciate some of the injuries characteristically associated with nerve injuries

Answer 19

• Colles fracture and acute median nerve compression / carpal tunnel syndrome
• Anterior dislocation of the shoulder and axillary nerve palsy
• Humeral shaft fracture and radial nerve palsy (in spiral groove)
• Supracondylar fracture of the elbow and median nerve injury (usually anterior interosseous branch)
• Posterior dislocation of the hip and sciatic nerve injury
• “Bumper” injury to lateral knee and common peroneal nerve palsy

Question 20

Vascular injury is uncommon in trauma but can occur - what are the signs of vascular injury?

Answer 20

• Reduced or absent pulses,
• Pallor
• Delayed capillary refill
• Cold to touch

Question 21

How can an arterial occlusion be localised ?

Answer 21

Angiography

Question 22

When vascular injury occurs what can be done to temporarily restore circulation ?

Answer 22

• Use of a vascular shunt or vascular repair
• With either a bypass graft or endoluminal stent

Question 23

Ongoing haemorrhage from arterial injury can be controlled how ?

Answer 23

Angiographic embolization performed by interventional radiologists.