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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
what does angulation tell you
direction of forces of injury | reversed direction of forces required to reduce a fracture
26
what can residual displacement/angulation lead to
deformity, loss of function, abnormal pressure on joints (post traumatic OA)
27
why is the rotation of the distal fragment inportant
as rotational malalignment is poorly tolerated and needs to be corrected when managing fractures
28
what are the clinical signs of a fracture
localised bony tenderness- not diffuse mild tenderness swelling deformity crepitus (bone ends grating)
29
what is a useful rule to determine if a patient needs an x ray to exclude a fracture
if they can weight bear
30
what should the assessment of an injured limb include
open or closed? distal neurovascular status (pulses, cap refill, temp, colour, sensation, motor power) compartment syndrome? status of the skin and soft tissue envelope
31
what usually views are done in x rays for fractures
AP and lateral (two views always required)
32
when are oblique views helpful
complex views: scaphoid, acetabulum, tibial plateau
33
what is a tomogram
moving x ray to take images of complex bones- mandibular fractures
34
when is CT used in fractures
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)
35
when is an MRI used for fractures
to detect occult (hidden) fractures when suspected but not on x ray (hip scaphoid)
36
when are technetium, bone scans used in fractures
to detect stress fractures (hip, femur, tibia, fibula, 2nd metatarsal) as these may fail to show up until hard callus begins to appear
37
what is the initial management for a long bone fracture
clinical assessment, analgesia (usually IV morphine), splintage/ immobilisation, investigation (usually X rays)
38
what might splintage or immobilisation involve
the application of a temporary plaster slab (backslab), sling, orthosis, thomas splint (femoral shaft fractures
39
when should reduction of a fracture be done before x rays
if there is obvious fracture dislocation or if there is risk of skin damage from excessive pressure
40
how are undisplaced, minimally displaced and minimally angulated fractures which are considered stable treated
non operatively with a period of splintage or immobilisation and then rehab
41
what do displaced or angulated fractures need
reduction under anaesthetic | closed reduction and cast application may be performed with serial x rays to ensure no loss of position
42
how are unstable injuries be treated
with surgical stabilisation
43
how are unstable extra articular diaphyseal fractures treated
open reduction and internal rotation (ORIF) | or external fixation (but pin site infection and loosening)
44
when should ORIF be avoided
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
45
what do displaced intra articular fractures need
anatomical reduction and rigid fixation by way of ORIF | if involving joint mat need joint replacement or arthrodesis
46
eldery patients with co morbidities, osteoporosis and dementia are at higher risk of what?
complications of surgery, failure of fixation, failure to rehabilitate
47
why are older patients more likely to be treated non surgically
as lower functional demand usually
48
what are the early local complications of fractures
compartment syndrome, vascular injury with ischaemia, nerve compression/ injury, skin necrosis
49
what are the early systemic complications of fractures
hypovolaemia, fat embolism, shock, acute respiratory distress syndrome, acute renal failure, systemic inflammatory response syndrome (SIRS), multi organ dysfunction syndrome, death
50
what are the late local complications of fractures
stiffness, loss of function, chronic regional pain syndrome, infection, non union, mal union, volkmann's ischaemic contracture, post traumatic osteoarthritis, DVT
51
what are the main late systemic complications of a fracture
PE- several days to weeks after fraction
52
what causes the pressure to rise in compartment syndrome
bleeding and inflammatory exudate from fracture and injury
53
what does the rise in pressure in compartment syndrome cause
can compress the venous system causing congestion within the muscle and secondary ischaemia as arterial blood cannot supply the congested muscle
54
how does muscle ischaemia manifest
severe pain | compression of nerves can cause paraesthesiae and sensory loss
55
what are the cardinal clinical signs of compartment syndrome
increase pain on passive stretching of the involved muscle | severe pain outwith the anticipated severity in the clinical contex
56
what are the physical signs of compartment syndrome
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
what must be done when a diagnosis of compartment syndrome has been made
removal of any tight bandages emergency fasciotomies (open wound left for a few days) secondary closure
58
what happens if compartment syndrome is left untreated
ischaemic muscle will necrose= fibrotic contracture a.k.a. volkmann's ischaemic contracture and poor function
59
name the nerve injury commonly affected by a colles fracture
acute median nerve compression/ carpal tunnel syndrome
60
name the nerve injury commonly affected by an anterior shoulder dislocation
axillary nerve palsy
61
name the nerve injury commonly affected by a humeral shaft fracture
radial nerve palsy (in spiral groove)
62
name the nerve injury commonly affected by a supracondylar fracture of the elbow
median nerve injury
63
name the nerve injury commonly affected by a posterior dislocation of the hip
sciatic nerve injury
64
name the nerve injury commonly affected by a 'bumper' injury to lateral knee
common peroneal nerve palsy
65
how can vessels be damaged
stretches, compressed, torn or transected
66
when can vascular damage cause arterial occulusion
partial tears affected the arterial intima can thrombose
67
what injuries have a higher risk of vascular injuries
``` penetrating injuries knee dislocation (popliteal artery) paediatric supracondylar fracture of the elbow (brachial artery) shoulder trauma (axillary artery) pelvic fractures ```
68
what are signs of reduced distal circulation
reduced/ absent pulses, pallor, delayed cap refill, cold to touch
69
what what can help distinguish location of a arterial occulsion
urgent angiography in theatre
70
how can temporary restoration of circulation be achieved
shunt or vascular repair with bypass graft or endoluminal stent
71
how can haemorrhage from arterial injury in the pelvis be controlled
angiographic embolisation performed by interventional radiologists
72
why might skin breakdown after a fracture
if there is a protruding spike/ tension on the skin it can cause devitalisation and necrosis
73
what needs to be done when there is tenting of the skin seen with 'blanching' - why
fracture should be reduced as an emergency (under analgesia +/- sedation) to avoid subsequent necrosis
74
what is de gloving and what can it cause
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
what are the signs of de gloving
will not blanch on pressure and may be insensate
76
what is a fracture blister
when inflammatory exudates cause lifting of the epidermis of the skin
77
what are the signs of fracture healing
resolution of pain and function absence of point tenderness no local oedema resolution of movement at fracture site
78
what are the signs of non union
ongoing pain ongoing oedema movement at fracture site bridging callus may be seen on x ray
79
which bones heal slowly
tibia (16 weeks- over a year) femoral shaft (3-4 months) cortical fractures heal slower than metaphyseal fractures
80
what is delayed union
when a fracture has not heal in the expected time
81
how can infection influence delayed union
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
what type of non union can infection cause
infected, atrophic, hypertrophic
83
what fractures are prone to poor healing due to poor blood supply
scaphoid, distal clavicle, subtrochanteric of the femur, jones fracture of the fifth metatarsal
84
why might intraarticular fractures not heal (hip, scaphoid)
synovial fluid inhibits healing of fracture gap
85
when do DVTs occur after fractures
pelvic or lower limb fractures with a period of instability
86
what prophylaxis should be given for DVTs
LMWH | is suspected do duplex scanning and anticoagulation
87
what is fracture disease
stiffness and weakness due to the fracture and subsequent splintage in cast
88
how is fracture disease treated
most resolve, may be helped with physio
89
what fractures are prone to developing AVN
femoral neck, scaphoid, talus
90
what is the treatment of symptomatic cases of AVN
surgical management- THR, arthrodesis
91
what can cause post traumatic OA
intraarticular fracture, ligamentous instability, fracture malunion
92
what is complex regional pain and syndrome
chronic pain response to injury- constant burning or throbbing, sensitivity to stimuli (allodynia), chronic swelling, stiffness, painful movement, skin colour changes
93
what can cause CRPS
idiopathic (type 1) | peripheral nerve injury (type 2)
94
what is the management for CRPS
analgesics, anti depressants (amitriptyline), anticonvulsants (gabapentin), steroids might help tens machine, physio, lidocaine patches, nerve blocking injections
95
can fractures will an infection lasting more than 2-3 weeks still heal
yes if suppressed by metal work will need to be removed
96
what are the two causes open fractures
inside out- bone punctures skin | outside in- laceration of the skin from tearing or penetrating injury
97
what is the main priority in treating open fractures
avoiding infection
98
what do infection of long bone after open fractures often require
extensive removal of bone with shortening- surgery to lengthen sometimes amputation
99
what does gustiol classification do
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
what does initial management of an open fracture include
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
what does surgical management of an open fracture involve
removal of all contaminated or non viable soft tissue (debridement) internal or external fixation
102
how can haematoma spread infection
acts as culture medium
103
what can wound tension result in
skin necrosis and wound breakdown
104
how can wounds that cannot be primarily closed be treated
skin graft, local flap coverage
105
what tissues readily accept a skin graft
muscle, fascia, granulation tissue, paratendon, periosteum
106
what does a delayed reduction increase the risk of
requiring an open reduction | recurrent instability
107
what conditions can cause hypermobility
ehlers danlos and marfans
108
what injuries can be associated with dislocations
tendon tears nerve injuries vascular injuries compartment syndrome
109
what might recurrent dislocations require
soft tissue repair reconstruction occasionally bony surgical procedures
110
what is fracture dislocation
when fractures occur with dislocation
111
what are the types of ligament ruptures
1- sprain 2- partial tear 3- complete tear
112
what is the mainstay of treatment for soft tissue injuries
RICE- rest, ice, compression, elevation
113
why do you elevate a soft tissue injury
to reduce initial swelling
114
why should you have early movement in a ligament injury
to prevent stiffness
115
what do some complete ligament ruptures need
repair, tightening, graft reconstruction
116
what tendons when completely torn require surgical repair
ones fundamental for function- quads tendon, patellar tendon
117
what complete tendon tears can be treated conservatively
achilles, rotator cuff, long head of biceps brachii, distal biceps
118
what tendons can commonly divided with penetrating incised wounds
flexor and extensor tendon injuries in the hand and wrist- require surgical repair
119
what are the presenting features of septic arthritis
acute onset of a severely painful, hot, swollen and tender joint with severe pain on any movement
120
how does an infection get into a joint
spread by blood, adjacent tissue, direct penetration, intra articular surgery
121
why is early diagnosis of septic arthritis important
as bacterial infections can irreversible damage hyaline articular cartilage within days
122
what should be looked for if more than one joint is affected by septic arthritis
endocarditis (septic emboli)
123
list the bacteria known to commonly cause septic arthritis
``` S aureus - adults streptococci- 2nd most common haem influenza- children neisseria gonorrhoea- in YA e coli- elderly, IVDU, seriously ill ```
124
what is the treatment for septic arthritis
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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