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MSK > Cortex- Pelvis and lower limb trauma > Flashcards

Cortex- Pelvis and lower limb trauma Flashcards

1
Q

what forms the pelvic ring

A

sacrum, ilium, ischium, pubic bones

+ supporting ligaments

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2
Q

what do you usually get when the pelvic ring is disrupted in one place

A

fracture or ligamentous injury somewhere else in the ring (polo mint)

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3
Q

what arteries and nerves are at risk in pelvic injuries

A

internal iliac arterial system
pre sacral venous plexus
branches of the lumbo-sacral plexus

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4
Q

what are the three main pattern of pelvic injuries

A

lateral compression fracture
vertical shear fracture
anteroposterior compression fracture

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5
Q

describe a lateral compression fracture of the pelvis

A

occurs with side impact, one half of pelvis (hemipelvis) is displaced medially

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6
Q

what accompanies fractures through the pelvic rami or ischium in lateral compression fractures

A

sacral compression fracture or SO joint disruption

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7
Q

describe a vertical shear fracture of the pelvis

A

occurs due to axial force on one hemi pelvis (fall from height, rapid deceleration)
affected hemi pelvis is displaced superiorly
leg on affected side will appear shorter

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8
Q

what is most at risk in a vertical shear fracture

A

sacral nerve roots
lumbo sacral plexus
(major haemorrhage may occur)

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9
Q

describe an anteropsterior compression injury

A

open book fractures- can cause wide disruption of the pubic symphysis, pelvis opens like the pages of a book

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10
Q

what is the main worry in anteroposterior compression injuries

A

substantial bleeding from torn vessels occurs, as pelvic volume increases with displacement several litres of blood may be lost before tamponade and clotting occurs

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11
Q

what must be done promptly in anteroposterior compression injuries

A

reduction of the disaplcement to minimise the pelvic volume to allow tamponade of the bleeding to occur
fluid resus
Application of a tied sheet or a special pelvic binder around the outside of the pelvis will hold the reduction temporarily and allow clotting of the vessels.
An external fixator will provide more secure initial stabilization.

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12
Q

what might ongoing haemodynamic instability need in pelvic fractures

A

angiongram and embolization or open packing of the pelvis

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13
Q

why is a PR exam mandatory in pelvic injuries

A

assess sacral nerve root function and to look for the presence of blood
blood may indicate a retal tear- open fracture- higher mortality

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14
Q

why should catheterisation be done with caution in pelvic injuries

A

as patient may also have bladder and urethral injuries (blood at the urethral meatus), catheterisation may risk further injury

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15
Q

what do the majority of low energy pubic rami fractures tend to be

A

minimally displaced lateral compression injuries with sacral fracture or SI joint disruption posteriorly
conservative management

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16
Q

what can acetabular posterior wall fractures be associated with

A

hip dislocation

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17
Q

what are the mortality rates for hip fractures

A

10% at one month, 20% at four months and 30% at one year

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18
Q

why do most hip fracture patients undergo surgery despite the risks

A

risks of non‐operative management are just as high. With non‐operative management, prolonged bed rest for several weeks would be required during which time the patient would be very sore for toileting and bathing whilst they would be at very high risk of problems with recumbency (pressure sores, chest infections) and the fracture may not heal, muscular atrophy makes subsequent rehabilitation difficult. Therefore, to maximize the chance of restoration of function and to promote early mobilization almost all hip fractures undergo surgery within the first 24 hours unless time is required for medical optimization.

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19
Q

how many hip fracture patients return to their pre-injury function

A

30%

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20
Q

what is the relevance of intra/extra capsular hip fractures

A

likelihood of disruption of the femoral head blood supply

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21
Q

what is the blood supply to the femoral head

A

ring of anastomosis of the circumflex femoral arteries at the insertion of the hip capsule at the base of the femoral neck

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22
Q

what are the medial and lateral circumflex arteries branches of

A

profunda femoral artery

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23
Q

what is at risk when the blood supply to the femoral head is disrupted

A

AVN and non union of the fracture

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24
Q

how are intracapsular fractures more reliably treated

A

with replacement femoral head (due to possible disruption of blood supply) - hemi arthroplasty/ THR

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25
Q

who should get THR

A

in the higher function hip fracture patient

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26
Q

who should get hemi arthroplasty in intracapsular hip fractures

A

restricted mobility/ cognitively impaired (THR would have increased risk of dislocation)

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27
Q

how are extracapsular fractures fixed

A

hive high union rate so usually internal fixation with compression or dynamic hip screws

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28
Q

what fracture does a fixated extracapsular hip fracture usually heal in

A

a shortened position

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29
Q

when can stress fractures of the femoral shaft occur

A

in osteoporotic bone, metastatic disease, pagets disease, long term bisphosphonate (ironically for osteoporosis)

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30
Q

how much blood loss can occur in displaced femoral shaft fractrues

A

up to 1.5 litres

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31
Q

what can cause the symptoms of confusion, hypoxia and risk of ARDs in a displaced femoral neck fracture

A

fat from the medullary canal entering the damaged venous system- fat embolism

32
Q

what is the management for a femoral shaft fracture

A

after initial resuscitation: femoral nerve block Thomas splint- stabilizes the fracture minimizing further blood loss and fat embolism

closed reduction and stabilization with an intramedullary nail however minimally invasive plate fixation with minimal disruption to the fracture site blood supply can also be used

33
Q

what can cause true knee dislocations

A

high energy injuries, severe hyperextension, rotational forces

34
Q

why is knee dislocation a surgical emergency

A

high risk of vascular injury (intimal tears, vascular occlusion, complete transection), nerve injury, compartment syndrome

35
Q

how can you revascularise a knee

A

endovascular procedures or bypass

36
Q

what is usually required to treat a knee dilocations

A 
reduction 
nerve and vascular assessment 
revascularisation 
multi ligament repair 
external fixator if knee very unstable
37
Q

what can cause a proximal tibia plateau fracture

A

high energy in young or osteoporosis in old

38
Q

describe tibial plateau fractures

A

intra articular fractures with either a split in the bone, depression of the articular surface or combo of both

39
Q

what is the aim of treatment of most intra articular fractures

A

surgery is usually required with the aim of reduction of the articular surface and rigid fixation with early motion to combat the risk of stiffness and post traumatic OA

40
Q

what type of tibial plateau fracture might a valgus stress injury cause

A

lateral plataeu fracture with failure of the MCL and possibly ACL

41
Q

what might a proximal tibial plateau fracture caused by e.g. a car bumper be associated with

A

injury to the common peroneal nerve with foot drop (loss of power to tibialis anterior)

42
Q

what type of tibial plateau fracture might a varus stress injury cause

A

medial plateau fracture, potential for LCL rupture and stretch to the peroneal nerve

43
Q

what is the treatment for tibial plateau fractures

A

Plates and screws are usually used for fixation. Once a depressed fracture has been elevated, a void in the bone is left requiring bone grafting (usually morsellised packed cancellous autograft from the iliac crest) to provide support.

often need TKR

44
Q

how do tibial shaft fractures usually occur

A

with indirect force + either bending (transverse fracture), rotational energy (spiral fracture), compressive force from deceleration (oblique fracture), or a combination- high energy (comminuted fracture)

45
Q

what is the commonest cause of compartment syndrome post trauma

A

tibial shaft fractures (particularly anterior compartment)

46
Q

when can tibial shaft fractures be treated non operatively

A

up to 50% displacement and 5 degrees of angulation

47
Q

how are tibial shaft fractures non operatively treated

A

above knee cast

48
Q

what way can tibial fractures drift

A

If the fibula is not fractured, the tibia often drifts into varus whilst if the fibula is also fractured valgus alignment is more common

49
Q

how are tibial shaft fractures treated operatively

A

internal fixation

if comminuted or open require surgical stabilisation - usually intramedullary nailing (less disruption to periosteal blood supply)

50
Q

how long do tibial shaft fractures take to heal

A

16 weeks to a year

51
Q

what is a common side effect of intramedullary nailing of a tibial fracture

A

anterior knee pain- nail inserted behind patellar tendon

52
Q

what might non unions require

A

bone grafting or special circular frames

53
Q

what causes most ankle injuries

A

inversion/ rotational force on a planted foot

54
Q

what are the lateral ankle ligaments

A

anterior and posterior talofibular ligaments and calcaneofibular ligament

55
Q

what are the symptoms of a sprain of the lateral ankle ligaments

A

pain, bruising, mild to moderate tenderness

56
Q

what criteria determines the likelihood of a broken ankle and the need for xray

A

ottawa

57
Q

what merits an x ray for a ankle injury

A

severe localised tenderness (bony tenderness) of the distal tibia/ fibula
inability to bear weight for four steps

58
Q

what are stable ankle fractures

A

treatment is walking cast or splint for 6 weeks e.g. insolated distal fibular fracture with no medial fracture/ rupture of the deltoid ligament

59
Q

what is an unstable ankle fracture

A

usually required ORIF e.g. distal fibular fractures with rupture of the deltoid ligament
or
bimalleolar fracture

60
Q

what suggests rupture of the deltoid ligament

A

bruising and tenderness medially

61
Q

what is talar shift

A

asymmetric increased space around the talus within the ankle mortise

62
Q

what is talar tilt

A

when talus and tibial plafond being non parallel

63
Q

what does talar tilt and shift mean

A

the deltoid ligament must have torn (if there is no medial malleolar fracture)

64
Q

what does talar shift/ tilt risk

A

post traumatic OA

65
Q

what treatment is required for talar tilt

A

anatomical reduction and rigid internal fixation

66
Q

what does gross talar shift result in

A

fracture dislocation

67
Q

why may ORIF in ankle fracture be delayed 1-2 weeks

A

as associated with substantial soft tissue swelling and fracture blisters- allowed to settle to reduce the risk of wound healing problems and infection

68
Q

what is a lis franc fracture

A

fracture of the base of the 2nd metatarsal with dislocation of the base of the 2nd metatarsal with/without dislocations of the other metatarsals (at the tarso-metatarsal joints)

69
Q

what happens to the ligaments is a lisfranc fracture

A

The ligament from the medial cuneiform to the base of the 2nd metatarsal no longer holds the metatarsal in joint

70
Q

how does a lisfranc present

A

grossly swollen, bruised foot- be aware of normal x ray - unable to weight bear

71
Q

how do you treat a lisfranc

A

closed/open reduction with fixation using screws

72
Q

what usually causes a fracture of the 5th metatarsal

A

inversion injury - results in an avulsion fracture at the insertion of the peroneus brevis tendon

73
Q

what is the treatment for a metatarsal (2-5) fracture

A

walking cast, supportive bandage or wearing stout boot for 4-6 weeks

if multiple fractures stabilised with K wires

74
Q

why are 1st metatarsal fractures usually fixed

A

as important to foot function

75
Q

when are stress fractures seen on x ray

A

might not be seen until a callus response/ healing has begun

76
Q

how are toe fractures treated

A

protection in a stout boot.

Intra‐articular fractures of the base of the proximal phalanx of the hallux may benefit from reduction and fixation if the fragment(s) are sizeable.

Open fractures require debridement and may be stabilized with a wires

77
Q

how are toe dislocations treated

A

neighbour strapping or wiring

MSK (71 decks)

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