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

Untreated compartment syndrome leads to muscle necrosis, resulting in Volkmann’s ischemic contracture and permanent functional impairment

Question 7

How is CS managed?

Answer 7

Immediate: Release dressings, do not elevate the limb.

Surgical: Emergency fasciotomy.

Post-surgery: Leave 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 happens if CS is untreated?

Answer 9

Muscle necrosis, leading to Volkmann’s ischemic contracture and permanent functional impairment

Question 10

What is the management for compartment syndrome?

Answer 10

Lower the limb to the level of the heart and do not administer fluids, as the patient should be fasted

Question 11

What risks are associated with distal limb ischemia?

Answer 11

Subsequent amputation

Question 12

What can haemorrhage from arterial or venous injury lead to?

Answer 12

hypovolemic shock

Question 13

What types of injuries can cause vessel transection?

Answer 13

Penetrating injuries

Question 14

How does a knee dislocation affect vasculature?

Answer 14

Popliteal artery injury

Question 15

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

Answer 15

Brachial artery injury

Question 16

How does shoulder trauma affect vasculature?

Answer 16

Axillary artery injury

Question 17

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

Answer 17

Urgent vascular surgery review and emergency surgical management are required

Question 18

How can the site of arterial occlusion be localised?

Answer 18

Urgent angiography in theatre

Question 19

What is 1st-degree neuropraxia?

Answer 19

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

Question 20

What is 2nd-degree axonotmesis?

Answer 20

Nerve axons die (Wallerian degeneration) but the nerve remains intact. Recovery is slow and incomplete

Question 21

What is 3rd-degree neurotmesis?

Answer 21

Complete nerve transection, requiring surgery for recovery

Question 22

When should nerve exploration be done?

Answer 22

Open fracture
Penetrating injury
Neuralgic pain
Nerve conduction studies

Question 23

What are treatments for nerve injuries?

Answer 23

Nerve grafting
Tendon transfers

Question 24

What can cause skin breakdown in fractures?

Answer 24

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

Question 25

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

Answer 25

Reduced urgently under analgesia or sedation to avoid skin necrosis

Question 26

What is de-gloving?

Answer 26

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

Question 27

How does de-gloving affect the skin?

Answer 27

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

Question 28

What is the management for de-gloving injuries?

Answer 28

Skin grafting or flap coverage

Question 29

What causes meniscal tears in younger vs older patients?

Answer 29

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

Question 30

How are meniscal tears investigated?

Answer 30

MRI is used to investigate suspected meniscal tears

Question 31

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

Answer 31

Lachman’s test

Question 32

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 32

(1) Remove cast and wrappings

(2) Fasciotomy

Question 33

When is Fasciotomy the option for compartment syndrome?

Answer 33

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

Question 34

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

Answer 34

Measurement of compartment pressures - to confirm raised compartment pressures

Question 35

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 35

Fasciotomy of the left lower leg

Question 36

When is measuring compartment pressures the next step in management?

Answer 36

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

Question 37

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 37

Take patient to theatre immediately for fasciotomy

Question 38

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

Answer 38

(1) Lower leg (5 compartments)

(2) Hand (10 compartments)

(3) Forearm (4 compartments)