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MSK > Cortex- General Trauma > Flashcards

Cortex- General Trauma Flashcards

1
Q

what fractures are associated with substantial blood loss

A

pelvis and femur

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2
Q

what is primary bone healing

A

occurs when there is a minimal fracture gap and the bone simply bridges the gap with new bone formed from osteoblasts (hairline fractures + fixed fractures)

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3
Q

what is secondary bone healing

A

when there is a gap at fracture site
involves an inflammatory process and the recruitment of pluropotential stem cells which differentiate into different cells during the healing process

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4
Q

what are the stages of secondary bone healing

A

Fracture occurs
Haematoma occurs with inflammation from damaged tissues
Macrophages and osteoclasts remove debris and resorb the bone ends
Granulation tissue forms from fibroblasts and new blood vessels
Chondroblasts form cartilage (soft callus)
Osteoblasts lay down bone matrix (collagen type 1)– Enchondral ossification
Calcium mineralisation produces immature woven bone (hard callus)
Remodelling occurs with organization along lines of stress into lamellar bone

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5
Q

how long do the soft and hard callus take to form

A

soft= 2nd to 3rd week

hard= 6-12 weeks

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6
Q

what does secondary bone healing require

A

blood supply, nutrients, stem cells, a little movement (compression or tension)

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7
Q

what might cause atrophic fracture non union

A

lack of blood supply, no movement, too big a gap (rigid fixation with a fracture gap), soft tissue trapped in gap (interposition)

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8
Q

what might impair fracture healing

A

smoking (vasospasm), vascular disease, chronic ill health, malnutrition, no movement

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9
Q

what causes hypertrophic non unions

A

excessive movement at the fracture sight with abundant hard callous formation

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10
Q

what is and causes a transverse fracture

how can it present

A

occur with pure bending force where the cortex on one side fails in compression and the other in tension

may not shorten (unless completely displaced) but may angulate or result in rotational malalignment

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11
Q

what causes oblique fractures, how can they be fixed, how can they present

A

occur with a shearing force (fall from height, deceleration)
can be fixed with interfragmentary screw

tend to shorten and may angulate

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12
Q

what causes spiral fractures, how can they be fixed, how can they present

A

torsional forces
interfragmentary screws
most unstable to rotational forces, may angulate

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13
Q

what causes comminuted fractures,
what are they,
how can they be fixed,
how can they present

A

high energy/ poor bone quality

fractures with three or more fragments

tend to be stabilised surgically

may be soft tissue swelling and periosteal damage with reduced blood supply to the site (impaired healing). very unstable

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14
Q

what are segmental fractures and how are they fixed

A

when bone is fractured in two different places

very unstable require stabilisation with long rods or plates

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15
Q

how can a fracture of a long bone be described

A

according to site: proximal, middle or epiphyseal

according to type of bone involved: diaphyseal (shaft), metaphyseal or epiphyseal

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16
Q

how can fractures at the end on a lone bone (metaphyseal/ epiphyseal) be described

A

can be intra (extending into the joint)/ extra articular

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17
Q

what do intra articular fractures have a greater risk of

A

stiffness, pain, post traumatic OA,

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18
Q

what does fracture displacement depend on

A

degree of translocation, angulation and rotation

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19
Q

what are the directions of translation of a fracture

A

distal fragment can go anteriorly or posteriorly displaced
or
medially or laterally translated

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20
Q

what words describe displacement in the forearm and hand

A

volar (or palmar) and dorsal

ulnar and radial

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21
Q

what is an off ended fracture

A

one where end is 100% (% of width of bone) displaced

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22
Q

what is angulation

A

the direction which the fragments point towards and the degree of deformity

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23
Q

how can angulation be described- generally and in upper and lower limbs

A

medial or lateral and anterior or posterior

upper limb- radial, ulnar, dorsal, volar

lower limb- varus (distal fragment pointing towards midline) and valgus (distal away from the midline)

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24
Q

how is angulation measured

A

in degrees from the longitudinal axis of the diaphysis of a long bone

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25
Q

what does angulation tell you

A

direction of forces of injury

reversed direction of forces required to reduce a fracture

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26
Q

what can residual displacement/angulation lead to

A

deformity, loss of function, abnormal pressure on joints (post traumatic OA)

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27
Q

why is the rotation of the distal fragment inportant

A

as rotational malalignment is poorly tolerated and needs to be corrected when managing fractures

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28
Q

what are the clinical signs of a fracture

A

localised bony tenderness- not diffuse mild tenderness
swelling
deformity
crepitus (bone ends grating)

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29
Q

what is a useful rule to determine if a patient needs an x ray to exclude a fracture

A

if they can weight bear

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30
Q

what should the assessment of an injured limb include

A

open or closed?
distal neurovascular status (pulses, cap refill, temp, colour, sensation, motor power)
compartment syndrome?
status of the skin and soft tissue envelope

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31
Q

what usually views are done in x rays for fractures

A

AP and lateral (two views always required)

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32
Q

when are oblique views helpful

A

complex views: scaphoid, acetabulum, tibial plateau

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33
Q

what is a tomogram

A

moving x ray to take images of complex bones- mandibular fractures

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34
Q

when is CT used in fractures

A

asses fractures of complex bones (vertebrae, pelvis, calcaneus, scapular glenoid)
can help to determine the degree of articular damage and help surgical planning for complex intra-articular fractures (tibial plateau, distal tibia)

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35
Q

when is an MRI used for fractures

A

to detect occult (hidden) fractures when suspected but not on x ray (hip scaphoid)

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36
Q

when are technetium, bone scans used in fractures

A

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

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37
Q

what is the initial management for a long bone fracture

A

clinical assessment, analgesia (usually IV morphine), splintage/ immobilisation, investigation (usually X rays)

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38
Q

what might splintage or immobilisation involve

A

the application of a temporary plaster slab (backslab), sling, orthosis, thomas splint (femoral shaft fractures

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39
Q

when should reduction of a fracture be done before x rays

A

if there is obvious fracture dislocation or if there is risk of skin damage from excessive pressure

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40
Q

how are undisplaced, minimally displaced and minimally angulated fractures which are considered stable treated

A

non operatively with a period of splintage or immobilisation and then rehab

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41
Q

what do displaced or angulated fractures need

A

reduction under anaesthetic

closed reduction and cast application may be performed with serial x rays to ensure no loss of position

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42
Q

how are unstable injuries be treated

A

with surgical stabilisation

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43
Q

how are unstable extra articular diaphyseal fractures treated

A

open reduction and internal rotation (ORIF)

or external fixation (but pin site infection and loosening)

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44
Q

when should ORIF be avoided

A

where the soft tissues are too swollen or blood supply is tenuous, where ORIF might cause extensive blood loss or is plate fixation may be prominent

in this case- closed reduction and indirect internal fixation with intramedullary nail

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45
Q

what do displaced intra articular fractures need

A

anatomical reduction and rigid fixation by way of ORIF

if involving joint mat need joint replacement or arthrodesis

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46
Q

eldery patients with co morbidities, osteoporosis and dementia are at higher risk of what?

A

complications of surgery, failure of fixation, failure to rehabilitate

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47
Q

why are older patients more likely to be treated non surgically

A

as lower functional demand usually

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48
Q

what are the early local complications of fractures

A

compartment syndrome, vascular injury with ischaemia, nerve compression/ injury, skin necrosis

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49
Q

what are the early systemic complications of fractures

A

hypovolaemia, fat embolism, shock, acute respiratory distress syndrome, acute renal failure, systemic inflammatory response syndrome (SIRS), multi organ dysfunction syndrome, death

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50
Q

what are the late local complications of fractures

A

stiffness, loss of function, chronic regional pain syndrome, infection, non union, mal union, volkmann’s ischaemic contracture, post traumatic osteoarthritis, DVT

51
Q

what are the main late systemic complications of a fracture

A

PE- several days to weeks after fraction

52
Q

what causes the pressure to rise in compartment syndrome

A

bleeding and inflammatory exudate from fracture and injury

53
Q

what does the rise in pressure in compartment syndrome cause

A

can compress the venous system causing congestion within the muscle and secondary ischaemia as arterial blood cannot supply the congested muscle

54
Q

how does muscle ischaemia manifest

A

severe pain

compression of nerves can cause paraesthesiae and sensory loss

55
Q

what are the cardinal clinical signs of compartment syndrome

A

increase pain on passive stretching of the involved muscle

severe pain outwith the anticipated severity in the clinical contex

56
Q

what are the physical signs of compartment syndrome

A

limb will be tensely swollen and the muscle is tender to touch
loss of pulses- end stage ischaemia (diagnosis has been made too late)

57
Q

what must be done when a diagnosis of compartment syndrome has been made

A

removal of any tight bandages
emergency fasciotomies
(open wound left for a few days)
secondary closure

58
Q

what happens if compartment syndrome is left untreated

A

ischaemic muscle will necrose= fibrotic contracture a.k.a. volkmann’s ischaemic contracture and poor function

59
Q

name the nerve injury commonly affected by a colles fracture

A

acute median nerve compression/ carpal tunnel syndrome

60
Q

name the nerve injury commonly affected by an anterior shoulder dislocation

A

axillary nerve palsy

61
Q

name the nerve injury commonly affected by a humeral shaft fracture

A

radial nerve palsy (in spiral groove)

62
Q

name the nerve injury commonly affected by a supracondylar fracture of the elbow

A

median nerve injury

63
Q

name the nerve injury commonly affected by a posterior dislocation of the hip

A

sciatic nerve injury

64
Q

name the nerve injury commonly affected by a ‘bumper’ injury to lateral knee

A

common peroneal nerve palsy

65
Q

how can vessels be damaged

A

stretches, compressed, torn or transected

66
Q

when can vascular damage cause arterial occulusion

A

partial tears affected the arterial intima can thrombose

67
Q

what injuries have a higher risk of vascular injuries

A 
penetrating injuries 
knee dislocation (popliteal artery) 
paediatric supracondylar fracture of the elbow (brachial artery)
shoulder trauma (axillary artery) 
pelvic fractures
68
Q

what are signs of reduced distal circulation

A

reduced/ absent pulses, pallor, delayed cap refill, cold to touch

69
Q

what what can help distinguish location of a arterial occulsion

A

urgent angiography in theatre

70
Q

how can temporary restoration of circulation be achieved

A

shunt or vascular repair with bypass graft or endoluminal stent

71
Q

how can haemorrhage from arterial injury in the pelvis be controlled

A

angiographic embolisation performed by interventional radiologists

72
Q

why might skin breakdown after a fracture

A

if there is a protruding spike/ tension on the skin it can cause devitalisation and necrosis

73
Q

what needs to be done when there is tenting of the skin seen with ‘blanching’ - why

A

fracture should be reduced as an emergency (under analgesia +/- sedation)
to avoid subsequent necrosis

74
Q

what is de gloving and what can it cause

A

when a shearing force caused avulsion of the skin from the underlying blood vessels
can result in skin ishaemia and necrosis
underlying haematoma may also increase pressure on the skin occluding the capillaries

75
Q

what are the signs of de gloving

A

will not blanch on pressure and may be insensate

76
Q

what is a fracture blister

A

when inflammatory exudates cause lifting of the epidermis of the skin

77
Q

what are the signs of fracture healing

A

resolution of pain and function
absence of point tenderness
no local oedema
resolution of movement at fracture site

78
Q

what are the signs of non union

A

ongoing pain
ongoing oedema
movement at fracture site
bridging callus may be seen on x ray

79
Q

which bones heal slowly

A

tibia (16 weeks- over a year)
femoral shaft (3-4 months)
cortical fractures heal slower than metaphyseal fractures

80
Q

what is delayed union

A

when a fracture has not heal in the expected time

81
Q

how can infection influence delayed union

A

infection can cause delayed union
if diagnosed can be suppressed with antibiotics and healing can occur
if not treated can cause infected non union

82
Q

what type of non union can infection cause

A

infected, atrophic, hypertrophic

83
Q

what fractures are prone to poor healing due to poor blood supply

A

scaphoid, distal clavicle, subtrochanteric of the femur, jones fracture of the fifth metatarsal

84
Q

why might intraarticular fractures not heal (hip, scaphoid)

A

synovial fluid inhibits healing of fracture gap

85
Q

when do DVTs occur after fractures

A

pelvic or lower limb fractures with a period of instability

86
Q

what prophylaxis should be given for DVTs

A

LMWH

is suspected do duplex scanning and anticoagulation

87
Q

what is fracture disease

A

stiffness and weakness due to the fracture and subsequent splintage in cast

88
Q

how is fracture disease treated

A

most resolve, may be helped with physio

89
Q

what fractures are prone to developing AVN

A

femoral neck, scaphoid, talus

90
Q

what is the treatment of symptomatic cases of AVN

A

surgical management- THR, arthrodesis

91
Q

what can cause post traumatic OA

A

intraarticular fracture, ligamentous instability, fracture malunion

92
Q

what is complex regional pain and syndrome

A

chronic pain response to injury- constant burning or throbbing, sensitivity to stimuli (allodynia), chronic swelling, stiffness, painful movement, skin colour changes

93
Q

what can cause CRPS

A

idiopathic (type 1)

peripheral nerve injury (type 2)

94
Q

what is the management for CRPS

A

analgesics, anti depressants (amitriptyline), anticonvulsants (gabapentin), steroids might help
tens machine, physio, lidocaine patches, nerve blocking injections

95
Q

can fractures will an infection lasting more than 2-3 weeks still heal

A

yes if suppressed by metal work will need to be removed

96
Q

what are the two causes open fractures

A

inside out- bone punctures skin

outside in- laceration of the skin from tearing or penetrating injury

97
Q

what is the main priority in treating open fractures

A

avoiding infection

98
Q

what do infection of long bone after open fractures often require

A

extensive removal of bone with shortening- surgery to lengthen
sometimes amputation

99
Q

what does gustiol classification do

A

describes the degree of contamination, the size of the wound- whether it can be closed or requires plastic surgery cover, and the presence of an associated vascular injury

100
Q

what does initial management of an open fracture include

A

IV broad spectrum antibiotics (flucloxacillin- gram pos, gentamicin- gram neg, metronidazole- anaerobes if soil contamination)

application of sterile/ antiseptic soaked dressing

fairly prompt surgery

101
Q

what does surgical management of an open fracture involve

A

removal of all contaminated or non viable soft tissue (debridement)

internal or external fixation

102
Q

how can haematoma spread infection

A

acts as culture medium

103
Q

what can wound tension result in

A

skin necrosis and wound breakdown

104
Q

how can wounds that cannot be primarily closed be treated

A

skin graft, local flap coverage

105
Q

what tissues readily accept a skin graft

A

muscle, fascia, granulation tissue, paratendon, periosteum

106
Q

what does a delayed reduction increase the risk of

A

requiring an open reduction

recurrent instability

107
Q

what conditions can cause hypermobility

A

ehlers danlos and marfans

108
Q

what injuries can be associated with dislocations

A

tendon tears
nerve injuries
vascular injuries
compartment syndrome

109
Q

what might recurrent dislocations require

A

soft tissue repair
reconstruction
occasionally bony surgical procedures

110
Q

what is fracture dislocation

A

when fractures occur with dislocation

111
Q

what are the types of ligament ruptures

A

1- sprain
2- partial tear
3- complete tear

112
Q

what is the mainstay of treatment for soft tissue injuries

A

RICE- rest, ice, compression, elevation

113
Q

why do you elevate a soft tissue injury

A

to reduce initial swelling

114
Q

why should you have early movement in a ligament injury

A

to prevent stiffness

115
Q

what do some complete ligament ruptures need

A

repair, tightening, graft reconstruction

116
Q

what tendons when completely torn require surgical repair

A

ones fundamental for function- quads tendon, patellar tendon

117
Q

what complete tendon tears can be treated conservatively

A

achilles, rotator cuff, long head of biceps brachii, distal biceps

118
Q

what tendons can commonly divided with penetrating incised wounds

A

flexor and extensor tendon injuries in the hand and wrist- require surgical repair

119
Q

what are the presenting features of septic arthritis

A

acute onset of a severely painful, hot, swollen and tender joint with severe pain on any movement

120
Q

how does an infection get into a joint

A

spread by blood, adjacent tissue, direct penetration, intra articular surgery

121
Q

why is early diagnosis of septic arthritis important

A

as bacterial infections can irreversible damage hyaline articular cartilage within days

122
Q

what should be looked for if more than one joint is affected by septic arthritis

A

endocarditis (septic emboli)

123
Q

list the bacteria known to commonly cause septic arthritis

A 
S aureus - adults 
streptococci- 2nd most common 
haem influenza- children 
neisseria gonorrhoea- in YA
e coli- elderly, IVDU, seriously ill
124
Q

what is the treatment for septic arthritis

A

aspiration before antibiotics given (if frank pus aspirated then defos SA) to confirm diagnose, choose best antibiotic

surgical wash out (open/ arthroscopic)

antibiotics

response measured by clinical findings and CRP

MSK (71 decks)

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