Fracture - Early Local complications

Question 1

What is compartment syndrome?

Answer 1

A condition where increased pressure in a muscle compartment compresses muscles, nerves, and blood vessels, impairing their function.

Question 2

What are the risk factors for CS?

Answer 2

(1) Tibial fractures (males, 10-35 years)

(2) Open fractures
(3) High-energy fractures
(4) Forearm fractures
(5) IV drug abuse (comatose)
(6) Anticoagulation
(7) Burns (no fractures)

Question 3

What are the symptoms of CS?

Answer 3

(1) 4 P’s
= Pain, Paresthesia, Pallor, Pulselessness (late) - severe pain that is typically out of proportion to the initial injury

(2) Tense, swollen limb

(3) Pain on passive muscle stretch

(4) Paralysis (sometimes)

Question 4

What happens when pressure increases in a compartment syndrome?

Answer 4

Increased pressure reduces venous return, leading to muscle ischemia

Question 5

What pressure causes muscle damage in compartment syndrome?

Answer 5

Pressures greater than 30-40 mmHg or within 10-30 mmHg of diastolic blood pressure can cause muscle damage

Question 6

What happens if compartment syndrome is left untreated?

Answer 6

Muscle necrosis

= resulting in Volkmann’s ischemic contracture and permanent functional impairment

Question 7

How is CS managed?

Answer 7

1. Immediate
   = Release dressings, do not elevate the limb
2. Surgical
   = Emergency fasciotomy
3. Post-surgery
   = Leave the wound open; may require skin grafting

Question 8

What is the correct position for the limb?

Answer 8

Lower limb to the level of the heart

DO NOT ELEVATE

Question 9

What is the management for compartment syndrome?

Answer 9

(1) Lower the limb to the level of the heart
(2) Do not administer fluids, as the patient should be fasted

Question 10

What risks are associated with distal limb ischemia?

Answer 10

Subsequent amputation

Question 11

What can haemorrhage from arterial or venous injury lead to?

Answer 11

hypovolemic shock

Question 12

What types of injuries can cause vessel transection?

Answer 12

Penetrating injuries

Question 13

How does a knee dislocation affect vasculature?

Answer 13

Popliteal artery injury

Question 14

How does a Paediatric supracondylar fracture of the elbow affect vasculature?

Answer 14

Brachial artery injury

Question 15

How does shoulder trauma affect vasculature?

Answer 15

Axillary artery injury

Question 16

What should be done if there are signs of reduced distal circulation?

Answer 16

Urgent vascular surgery review and emergency surgical management are required

Question 17

How can the site of arterial occlusion be localised?

Answer 17

Urgent angiography in theatre

Question 18

What is 1st-degree neuropraxia?

Answer 18

Temporary nerve conduction defect from compression or stretch, with full recovery in up to 28 days

Question 19

What is 2nd-degree axonotmesis?

Answer 19

Nerve axons die
(Wallerian degeneration) but the nerve remains intact.

Recovery is slow and incomplete

Question 20

What is 3rd-degree neurotmesis?

Answer 20

Complete nerve transection, requiring surgery for recovery

Question 21

What are treatments for nerve injuries?

Answer 21

1. Nerve grafting
2. Tendon transfers

Question 22

What can cause skin breakdown in fractures?

Answer 22

A protruding bone or tension from deformity can lead to skin devitalisation and necrosis

Question 23

How should a fracture causing pressure on the skin be managed?

Answer 23

Reduced urgently under analgesia or sedation to avoid skin necrosis

Question 24

What is de-gloving?

Answer 24

Avulsion of skin from its blood supply due to shearing forces, leading to ischemia and necrosis

Question 25

How does de-gloving affect the skin?

Answer 25

The skin won't blanch with pressure and may be insensate. Haematoma can also increase pressure, occluding capillaries

Question 26

What is the management for de-gloving injuries?

Answer 26

Skin grafting or flap coverage

Question 27

What causes meniscal tears in younger vs older patients?

Answer 27

Younger patients often tear menisci in sports or squatting; older patients may experience spontaneous degenerative tears

Question 28

How are meniscal tears investigated?

Answer 28

MRI is used to investigate suspected meniscal tears

Question 29

What is the most sensitive examination test for an ACL rupture?

Answer 29

Lachman's test

Question 30

A 27-year-old man presents to A&E two days after a right tibial fracture repair with intramedullary nailing following a ski injury. Since the operation, he reports worsening pain and a feeling of tightness in his right leg. On examination, the right leg is in a cylinder cast. There is paraesthesia of the right toe and pain in passive movement of the knee joint and ankle joint. The dorsalis pedis and posterior tibial pulses are palpable bilaterally. Observations are stable and he is afebrile. Compartment syndrome is suspected. What is the next best step in managing this patient?

Answer 30

(1) Remove cast and wrappings (2) Fasciotomy

Question 31

When is Fasciotomy the option for compartment syndrome?

Answer 31

if removal of the cast and wrapping does not relieve the symptoms, and compartment syndrome is confirmed by compartment pressure measurements

Question 32

What is the gold-standard diagnostic test for confirming compartment syndrome?

Answer 32

Measurement of compartment pressures - to confirm raised compartment pressures

Question 33

A 46-year-old man who is awaiting surgery for a fractured left tibia and fibula following a motorcycle accident is reviewed in the orthopaedic ward. He has severe pain in his left leg despite receiving regular and PRN morphine. On examination, he is alert and orientated but visibly distressed. Respiratory and cardiovascular examinations are unremarkable. There is an above-knee back slab on his left leg. On removal of the bandaging, the left lower leg is tense, swollen, and tender. Passive ankle plantarflexion causes severe pain, and sensation is decreased in the left foot. Distal pulses are intact bilaterally. What is the definitive management?

Answer 33

Fasciotomy of the left lower leg

Question 34

When is measuring compartment pressures the next step in management?

Answer 34

Measuring compartment pressures is usually done when there is uncertainty regarding the diagnosis of compartment syndrome and the presentation is not as severe

Question 35

A 27-year-old woman is admitted to the ward following the external fixation of a tibial fracture. Six hours later, she complains of pain in the leg and she is prescribed oral morphine. Twelve hours after the operation, she is still in pain despite removing the dressing, elevating the leg and taking 40 mg of oral morphine. She now complains of tingling and numbness in the toes. Which is the best next step in the management of this patient?

Answer 35

Take patient to theatre immediately for fasciotomy

Question 36

Which three anatomical areas are most at risk of developing a compartment syndrome, and how many compartments does each have?

Answer 36

(1) Lower leg (5 compartments) (2) Hand (10 compartments) (3) Forearm (4 compartments)