Emergency MSK Flashcards
What is an open fracture?
Fracture with communication with the outside world
What system is used to classify open fractures?
Gustilo classification
What is a type I Gustilo fracture?
Wound <1cm, low energy, no contamination, simple fracture
What is a type II Gustilo fracture?
wound is 1-10cm, moderate energy, mild contamination, mild comminution
What is a type IIIa Gustilo fracture?
Wound >10cm, high energy, enough tissue for coverage, contamination
PLUS any wounds with comminuted fractures and ALL farm injuries
What is a type IIIb Gustilo fracture?
Extensive peritoneal stripping and requires a free tissue transfer
What is a type IIIc Gustilo fracture?
Vascular injury requiring vascular repair
What antibiotics are recommended for a Gustilo I or II open fracture?
Cephalosporin (eg. Cefazolin)
What antibiotics are recommended for a Gustilo III open fracture?
Cephalosporin and an Aminoglycoside
What antibiotics are given additionally in an open wound contaminated with bowel contents or occuring on a farm?
Penicillin (for C.diff coverage)
In tetanus prophylaxis, what toxoid dose should be given in open fractures regardless of age?
0.5mL
How is an open fracture managed in A&E?
Antibiotics
Tetanus prophylaxis
Control bleeding
Assess soft tissue damage and neurovascular supply
Remove debris from wound
Splint the fracture to decrease pain and reduce risk of further damage
How are open fractures managed surgically?
Debridement and irrigation with saline
Fracture stabilisation
Early soft tissue coverage or wound closure
Bone gap reconstruction
How much saline is needed to debride a:
a. Type I Gustilo open fracture
b. Type II Gustilo open fracture
c. Type III Gustilo open fracture
a. 3L
b. 6L
c. 9L
What is compartment syndrome?
A condition where an osteofascial compartment pressure rises to a level that restricts blood flow to the distal limb.
Give 5 causes of compartment syndrome
BEST BAE Burns Extravasation of IV infusion Swelling (post-ischaemia) Trauma- fractures/crush injury/gunshot wound/contusions Bleeding disorders Arterial injury External casts/dressings/wrappings
What are the symptoms of compartment syndrome?
5Ps: pulselessness, pain, pallor, paresthesia, paralysis
Pain will be out of proportion to injury, pain will occur on passive stretching, the leg will swell
How is compartment syndrome treated?
Observation
Remove/loosen cast or dressing
Hyperbaric oxygen therapy
Emergency fasciotomy
What is the major complication of compartment syndrome?
Permanent injury to muscle and nerves due to ischaemia
What is cauda equina syndrome?
Terminal spinal nerve root compression in the lumbosacral region. It is a medical emergency.
Give 4 symptoms of cauda equina syndrome
Bilateral leg pain Urinary retention Urinary overflow incontinence Saddle anaesthesia Sensorimotor changes Impotence Bowel dysfunction Decreased rectal tone
Give 3 potential causes of cauda equina
Disc herniation Spinal stenosis Tumour Trauma Spinal epidural haematoma Epidural abscess
How is cauda equina treated?
Urgent surgical decompression within 48hrs
Discectomy or laminectomy
Give 3 potential complications of cauda equina
Sexual dysfunction
Urinary dysfunction
Chronic pain
Persistent leg weakness
What is septic arthritis?
Infection of the joint space which can lead to profound, extensive cartilage damage within hours
Where is the most common place affected by septic arthritis?
Knee (50% of cases)
Give 4 risk factors of septic arthritis
>80 years old Diabetes RA Cirrhosis HIV Endocarditis IV drug user Recent joint surgery
Give the 3 potential ways a joint can become infected
Bacteraemia –> spread of infection through the blood
Direct inoculation –> from trauma or surgery
Contiguous spread –> from adjacent osteomyelitis
What is the most common bacteria responsible for septic arthritis?
Staphylococcus aureus
Give 2 symptoms of septic arthritis
Pain in joint Fever Erythematous joint Swollen joint Warm and tender to touch Inability to bear weight on joint
What can be seen on an x-ray of septic arthritis?
Joint space widening
Effusion
Periarticular osteopenia
What is the gold standard diagnostic test for septic arthritis?
Joint fluid aspirate analysis
How is septic arthritis managed?
IV antibiotics
Drainage of the joint
What is necrotising fasciitis?
Life-threatening infection which spreads along soft tissue planes
Give 4 risk factors for necrotising fasciitis
Diabetes AIDS Cancer IV drug use Skin abrasions Obesity Abdominal surgery
What is Type I necrotising fasciitis?
Most common (80-90%)
Polymicrobial cause
Seen in immunosuppressed and post-op patients
What is Type II necrotising fasciitis?
Monomicrobial- usually group A beta-haemolytic streptococci
What is Type IV necrotising fasciitis?
Caused by MRSA
What are the early signs of necrotising fasciitis?
Localised abscess Rapid progression Mild swelling No trauma No discolouration
What are the late signs of necrotising fasciitis?
Severe pain High fever Chills Rigor Tachycardia
What is found on examination of necrotising fasciitis?
Skin bullae, cutaneous gangrene, ischaemic patches, swelling, oedema, erythema, subcutaneous emphysema
What score can be used to assess diagnosis of necrotising fasciitis?
LRINEC score
Looks at CRP, leukocytes, haemoglobin, sodium, creatinine and glucose
How is necrotising fasciitis treated?
Emergency radical debridement
Broad spectrum IV antibiotics
During the operation to fix necrotising fasciitis, what may be found?
Liquified subcutaneous fat
Dishwater pus
Muscle necrosis
Venous thrombosis
Which empirical antibiotics are given in necrotising fasciitis?
Penicillin
Clindamycin
Metronidazole
Aminoglycoside
If MRSA is confirmed in necrotising fasciitis, what antibiotics should be given?
Vancomycin
What is osteomyelitis?
Infection of the bone characterised by progressive inflammatory destruction and apposition of new bone
Give 4 risk factors for osteomyelitis
Recent trauma Recent surgery Immunocompromised IV drug use Poor vascular supply Diabetes Sickle cell disease Peripheral neuropathy
Why are antibiotics less efficient at treating osteomyelitis
Bacteria produce a biofilm layer which covers necrotic bone and stops antibiotics from penetrating the bone
What is the most common infecting organism in adults with osteomyelitis?
Staphylococcus aureus
What can be seen on an x-ray of osteomyelitis?
Lytic region surrounded by sclerosis
May look like neoplastic changes
Sequestrum
New bone around bone necrosis
How is osteomyelitis treated?
IV antibiotics Hyperbaric oxygen therapy Surgical irrigation and debridement Vascularised bone grafts Stabilisation of bone
What is gas gangrene?
Rapidly spreading gangrene which affects injured tissue infected by clostridium bacteria.
What are the pathological effects of gas gangrene?
Muscle necrosis Vessel thrombosis Haemolysis Shock Foul-smelling odour (glucose breakdown)
Give 4 risk factors for gas gangrene
Car accidents Crush injuries Gunshot wounds Burns Frostbite IV drug abuse Bowel resection Biliary surgery Colon cancer Neutropenia
Give 2 symptoms which precede evidence of gas gangrene
Feeling of impending doom
Sudden progressive pain out of proportion of what is expected
Tachycardia
How is gas gangrene managed?
IV antibiotics
Hyperbaric oxygen therapy
Radical surgical debridement with fasciotomy
