CORTEXT: trauma Flashcards
What are signs of airway obstruction?
noisy breathing; gurgling; stridor and agitation from hypoxia and hypercapnia
What is a definitive airway?
cuffed endotracheal tube
What GCS score implies a loss of airway control?
less than 8
What are the signs of a tension pneumothorax?
deviated trachea; repiratory distress; tachycardia; hypotension; sitended neck veins; no air entry on affected side
what is the management for a tension pneumothorax?
needle decomprssion-large bore needle in the 2nd intercostal space, midclavicaular line
chest drain
What are the signs of a haemothorax?
reduced air entry, dull to percussion
What is a flail chest?
segmental fractures of two or more ribs producing discontinuity of a segment of the thoracic cage and paradoxical movemtn of that segment with reduced expansion of the underlying lung
What is pulmonary contusion?
blood filling the alveoli with reduced ventilation
What are the all major trauma patients given IV initially?
2L of IV crystalloid
What is the minimum accepted urine output?
30ml/hr
What is an open book pelvi fracture?
the two hemi-pelvises are sprung apart
What is the treatment for an open book pelvic fracture?
reduced with a pevlic binder or emergency external fixator
What are the signs of intracranial hameorrhage?
pupil fixed, dilated
What is a trauma series of x-rays?
ateral C-spine; chest and pelvis
What clears a c-spine?
is patient is conscious; co-operative, not confused and no signs of injury- tenderness; pain on neck movement and no peripheral neuro deficit
Why are nasogastric tubes usually passed?
to prevent aspiration in the event of gastric dilation which can occur in major trauma
What is the secondary survey of major trauma?
a head-to-toe exam to detect otehr injuries
What is polytrauma?
where more than one major long bone is injured or where a mjor fracture is associated with significant chest or abdo trauma
What is SIRS?
systemic inflammatory response syndrome- an amplifaction of inflam casacades in response to trauma resulting in pyrexia, tachycardia, tachypnoea and leukocytosis
What may cause ARDS?
hypoperfusion, SIRS, aspiration of fat embolism
What happens in ARDS?
there is inflam of the lung parenchyma leading to inflam exudates forming in alveoli and impairment of gas exchange
What is the treatment for ARDS?
positive pressure ventilation
When does primary bone healing occur?
when there is minimal fracture gap- less than 1mm–hairline fractures or when fractures are fixed with compression screws and plates
What happens during primary bone healing?
the bone simplay bridges the gap with new bone from osteoblasts
What are the stage sof secondary bone healing?
fracture–heamatoma occurs with inflam 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 (cillagen type 1)- enchondral ossifiction–clacium mineralisation produces immature woven bone (hard callus)–remodelling occurs with organization along lines of stress into lamellar bone
How long does it take to form the soft callus?
2-3 weeks
How long does the hard callus take to form?
6-12 weeks
What may cause an atrophic non-union?
lack of blood supply, no movement, too big a fracture gap or tissue trapped in the fracture gap
What causes hypertrophic non-unions?
excessive movement at the fracture site
What is seen with hypertrophic non-union?
abundant hard callus formation but too much movement give the fracture no chance to bridge the gap
What are the 5 basic fracture patterns?
transverse; oblique; spiral; comminuted; segmental
What type of force do transverse fractures occur with?
pure bending force
What happens with a transverse fracture?
the cortex on one side fails in compression and the other in tension; tend to angulate or result in rotation malalignment
What type of force causes an oblique fracture?
shearing force eg falling from height or decelration
What management can be given for oblqiue fractures?
interfragmentary screw
Waht is seen with oblique fractures?
tend to shorten and my also angluate
waht type of force causes a spiral fracture?
torsional forces
Which fractures tend to be unstable?
spiral; comminutedl segmental
What is seen with spiral fractures?
rotation and angulation
What is a comminuted fractre?
a fracture with 3 or more fragments
What does comminution indicate?
higher energy injury- or poorer bone quality, tend to have lots of soft tissue swelling and periosteal damage, reducing blood supply to the site
What is a segmental fracture?
where the bone is fractured in two separate places
What are the problems associated with intra-articular fractures?
have a greater risk of stiffness, pain and post-traumatic OA esp, is there is any residual displacement resulting in an unevene articualr surface
What does displacement describe?
the direction of translation of the distal fragment
What is an off-ended fracture?
fracture with 100% displacement
What does angluation describe?
the direction in which the distla fragment points towards and the degree of this deformity
What can residual displacement or angulation result in?
defomrity, loss of function and abdnormal pressure on joints leading to post0traumatic OA
What are the clinical signs of a fracture?
oaclised bony tenderness; swelling; deformity; crepitus
What is a useful rule in terms of ordering x-rays for MSK injuries?
if patient cannot weight bear on an injured lower limb- x-ray
What should assessment of an injured limb incluse?
if injury is open/closed; distal neurovascular status; compartment syndrome; status of the skin and soft tissue envelope
What should you look for in a neurovascular assessment?
pulses; CRT; temp; colour; sensation; motor power
What bones are oblique views useful for?
complex shaped bones eg scaphoid; acetabulum; tibial plateau
What type of x-ray is used to diagnose mandibular fractures?
tomogram
What are technetium bone scans useful in detecting?
stress fractures
What type of splint is used for femoral shaft fractures?
Thomas splint
How are stable undisplaced, minimally displaced and minimally angulated fractures treated?
period of splintage or immobilization
When should ORIF e avoided?
is the soft tissues are too swollen; where the blood supply to the fracture sit is tenusou (high energy); where it may cause extensive blood loss- femoral shaft or plate fixation may be prominent (tibia)
what are the options aside from ORIF?
closed reduction and indirect internal fixation- IM nail with dissection distant to the fracure; external fixation
What are the early local complications of frractures?
compartment syndrome; vascaulr injury with ischaemia; nerve compression or injury; skin necrosis
What are the early systemic omplications of a frcatures?
hypovolaemia; fat emblism; shock; ARDS; acute renal failure; SIRS; MODS and death
Waht are the late local complications of a fracrure?
stiffness; LOF; chornic regional pain syndrome; infection; non-union; malnuion; Volkmann’s ischamic contracture; post-traumatic OA and DVT
What are the late systemic complications of fracture?
PE
What are the cardinal clinical signs of compartment syndrome?
increased pain on passive stretching of the ivolved muscle and sever pain outwit the anticipated severity in the clinical context
What are the other signs of compartment syndrome?
tensely swollen limb, tender muscles, loss of pulses (late sign)
What is Volkamann’s ischaemic contracture?
when there is acute ischaemia and necrosis of the muscle fibres of the flexor forearm mucles causing them to become fibrotic and shortened resulting in premanaent flexion contracture at the wrist
What is neurapraxia?
when the nerve has atemprorary conduction defect from compression or stretch and resolves over time
How long can it take neuropraxia to resolve?
28 days
What does axonotmesis result from?
a sustained compression or stretch or from higher degree of force
What are the features of axonotmesis?
the nerve remains in continuity and the internal structure (endoneurial tubes) remain intact, the long nerve cell axoons distal the point of injury die
What is the name for the death of the nerve cell axons in axonotmesis?
Wallerian degenration
How fast does regenration of nerves occur?
1mm per day
What is neurotmesis?
completel transection of a nerve- needs surgical repair
What nerve is damaged with a Colles fracture?
median nerve
What nerve is damaged in anterior shoulder discolation?
axiallry nerve
What nerve is damaged in a humeral shaft fracture?
radial nerve
What nerve is damaged in supracondylar fractures of the elbow?
median nerve
What nerve is damaged in posterior dislocation of the hip?
sciatic nerve
What nerve is damaged in a “bumper” injury to lateral knee?
common fibular nerve
What can happen with aprtial tears of the arterial intima of vessels?
can thrombose
What vessel is at risk with a knee dislocation?
popliteal artery
What vessel is at risk with supracondylar fractures?
brachial artery
What vessel is at risk with shoulder trauma?
axiallry artery
What are the signs that the fracture is causing excessive pressure on skin?
tenting of the skin and “blanching”
What should be done is the fracture is causing excessive pressure on skin? Why?
reduced- to avoid subsequent necrosis
What is de-gloving?
when a shearing force on the skin can result in avulsion of the skin from its underlying blood vessels
What can de-gloving result in?
skin ischaemia and necrosis
What do fracture blisters happen as a result of?
inflammatory exudates causeing lifting of the epidermis of the skin
Why is a surgical wound through swollen and contused skin and soft tissues not advisable?
the wound may not be able to be closed- infection, or excessive tension on the wound may cause necrosis and wound breakdown
What are clinical signs of non-union?
ongoing pain; oedema; movement at the fracture site
What is a delayed union fracture?
a fracture that has not healed within the expected time
What can cause delayed union?
infection
What fractures are particularly at risk to poor healing due to a lack of blood supply?
scaphoid; distal clavicle; subtrochanteric fractures; Jones fracture of the fifth metatarsal
What is the treatment for hypertrophic non-union?
application of a plate
What is the managemtn fro atrophic non-union?
removal of fibrous tissue; restoration of bleeding; restoration of medullary canal continuity; bone grafting to stimulate bone formation and to act as a scaffold for new bone to grow into and internal/external fixation with compression across the fracture
What should be done is a DVT is suspected?
duplex scanning and anti-coag
What is fracture disease?
a term used to describe stiffness and weakness due to teh fracture and subsequent splintage in case
Waht is the prognosis for fracture disease?
most cases resolve with time and may b aided with PT
What fractures are prone to developing AVN?
femoral neck, scaphoid, talus
What are the characteristics of complex regional pain syndrome?
constant burning/throbbing; sensitivity to stimuli no normally painful (allodynia); chronic swelling, stiffness, painful movemetn and skin colour changes
What is the difference between type 1 and 2 complex regional pain syndrome?
type 2 have a perioheral nerve injury whereas type 1 dont
What is the managemnt for chronic regional pain syndrome?
analgesia, anti-depressants, anticonvulsants, steoirds
What are the 2 mechanisms for open fractures?
inside out (bone from within puncturing the skin) and outside-in (laceration of the skin from tearing or penetrating injury
What are the antibiotics given for open fractures?
IV broad spectrum- fluclox (gram postiivtes); gent (gram negs); metronidazole (anaerobes)
Why are open fractures difficult to treat in plaster case?
frequen wound inspections are requied
How are opne fractures usually stabilised?
internal or external fixation after early and thorough debridement
Which tissues will readily accept a skin graft?
muscle, fascia, granulation tissue
What will not take skin grafting?
bare tendon, bone or exposed metalwork, fat
How are most dislocations reduced?
close manipulation under sedation and analgesia
What are the common associated injuries with dislocations?
tendon tears, nerve injurym vascular injury and compartment syndrome
What is a sprain?
intra-substance tearing of some gibres
What are the three grades of ligament rupture?
grade 1-sprain; grade 2- partial tear; grade 3- completel tear
What is the mainstay of treatment for soft tissue injuries?
rest; ice; compression; elevation and then early movemetn to reduce stiffness
What tendons require surgical repair after a tear?
quadriceps and patellar tendons
What are the presenting features of a septic arthritis?
acute onset of a severely painful red, hot, swollen and tender joint with severe pain on any movement
How does septic arthritis arise?
pathogen spreads to the joint via blood or from an infection of adjacent tissues
Why is septic arthritis considered an emergency?
can irreversibly damage hylain cartilage within days
What patientes are most prone to septic arthritis?
young, elderly, IVDUs, immunocompromised
Why shoul endocarditis be looked for if suspected- if more than one joint or bone is involved?
due to septic emboli
What are the 2 most common bacteria that cause septic arthritis?
s.aureus; streptococci
What was the most common causative bacteria in children before the vaccination?
haemophilus influenzae
What organism causes septic arthritis in young adults?
neisseria gonorrhea
What organism causes septic arthritis in the elderly, IVDUs and very ill??
E.coli
How is septic arthritis diagnosed?
aspiration-frank pus
What is the treatment for septic arthritis?
surgical washout via open surgery or using arthroscopic techniques
