Extremity Trauma

Question 1

Gustilo Classification of Open Fractures:

Answer 1

I- <1cm
II- 1-10cm,
III- >10cm
- A- Adequate bone coverage
- B- Inadequate bone coverage
- C- Arterial injury

Question 2

Vascular injury HARD signs (5):

Answer 2

Expanding or pulsatile haematoma
Severe haemorrhage
Absent pulses
Distal ischaemia
Bruit or thrill

Question 3

List 5 causes of compartment syndrome:

Answer 3

Fracture
Crush
Extravasated fluids
Arterial rupture
Snake bite
Electrocution
Burns
External compression (eg. cast)

Question 4

Clinical features of compartment syndrome:

Answer 4

Typically:
- Lower leg
- Thigh
- Forearm

Symptoms:
- Woody firmness
- Disproportionate pain
- Pain on passive stretch
- Ischaemic signs are late: PPPPP.

Question 5

Normal, and pathological compartment pressures:

Answer 5

Normal = 4-8mmHg

Compartment Sx=
- >30mmHg
or
- Within 30 of diastolic (delta)

Question 6

How long until compartment syndrome causes irreversible ischaemia?

Answer 6

4 - 8 hours

After 8 hours- usually just left alone

Question 7

ED management of suspected compartment syndrome:

Answer 7

• Optimise oxygenation + hydration
• +- Measure compartment pressure
  –> Stryker device
  –> Cannula attached to art line set-up
• Evaluate for rhabdo and renal failure
  –> FBC, UEC, CK, urine myoglobin
• DON’T ELEVATE- neutral.
• Analgesia
• Refer for urgent fasciotomy (ortho/plastics)

Question 8

Clinical features of crush syndrome:

Answer 8

Muscle injury:
- K+
- Acidosis
- Uric acid
- Rhabdo -> CK/ urea/ Ph UP, hypoCa

Danger when limb released and reperfused:
–> Arrhythmia
–> Myocardial depression
–> Renal failure
–> DIC

Question 9

Management of crush syndrome:

Answer 9

PREHOSPITAL:
- Analgesia, presumptive Crystalloid bolus, if hyperK on monitor: CaCarb.
- No tourniquet

IN ED:

URINE OUTPUT
-Give crystalloid until urine output 2-3ml/kg/hr
- Once urine flow ESTABLISHED, add: Mannitol 20% 2mg/kg over 4 hours

URINARY ALKALINISATION
- Give NaBic 1mmol/kg Q5min until urine pH >6.5 then intermittent/ infusion (add to fluids)

…..END POINT: no myoglobin in urine

MANAGE HYPERK
- Usual

LOOK FOR COMPARTMENT SX

————-

• Consider haemodialysis
  –> Anuric
  –> Refractory K
  –> Fluid overload

Question 10

Role of mannitol in crush syndrome:

Answer 10

Urine output to clear metabolites
Reduce urinary myoglobin casts
CANT use frusemide: acidifies urine