Fractures

Question 1

Open # Definition

Answer 1

DIRECT COMMUNICATION bwtn EXTERNAL ENVIRONMENT & FRACTURE - pelvic # going into GIT also count

Question 2

Open # Classification

Answer 2

Gustilo

Type 1:
• LOW ENERGY
• WOUND < 1cm
• CLEAN, SIMPLE FRACTURE PATTERN
• OFTEN BONE PIERCING SKIN from INSIDE

Type 2:
• MODERATE SOFT TISSUE DAMAGE
• WOUND > 1cm &amp; < 10cm
• NO SOFT TISSUE FLAP/AVULSION as MODERATE SOFT TISSUE INJURY + ADEQUATE SKIN COVERAGE
• SIMPLE FRACTURE PATTERN

Type 3:
• HIGH ENERGY, EXTENSIVE SOFT TISSUE DAMAGE
• SEVERE FRACTURE (COMMINUTION, DISPLACEMENT), COMPLEX FRACTURE PATTERN
• WOUND > 10cm

• ANY GUNSHOT, FARM ACCIDENT, SEGMENTAL FRACTURE, BONE LOSS, SEVERE CRUSH INJURY, MARINE
  
  • 3A = SOFT TISSUE DAMAGE +++ but NOT GROSSLY CONTAMINATED, ADEQUATE PERIOSTEAL COVERAGE
  • 3B = PERIOSTEAL STRIPPING, EXTENSIVE MUSCLE DAMAGE, HEAVY CONTAMINATION - TISSUE LOSS req. SOFT TISSUE COVERAGE PROCEDURE
    
    • 3C = ASS. NEUROVASCULAR COMPLICATION - VASCULAR INJURY req. REPAIR

Question 3

Timing for open # surgery

Answer 3

Emergency urgent surgery w/I 6hrs = POLYTRAUMATISED PT., MARINE/FARMYARD ENVIRONMENT, GROSS CONTAMINATION, N/V COMPROMISE, COMPARTMENT SYNDROME

Scheduled trauma operating lists w/I normal working hours & w.i 24hrs of injury = everyone else

Question 4

Initial open # management

Answer 4

MDT approach w/ senior surgeons + BOAST guidelines

• FULL ATLS ASSESSMENT & TREATMENT
• TETANUS & ANTIBIOTICS PROPHYLAXIS
• CEFUROXIME/AUGMENTIN/CLINDAMYCIN - GENTAMICIN at TIME of FIXATION○ Gentamicin - any metalwork put in etc.
• REPEATED NEUROVASCULAR STATUS EXAMINATION - BEFORE & AFTER INTERVENTION
• WOUNDS ONLY HANDLED to REMOVE GROSS CONTAMINATION○ NO PROVISIONAL IRRIGATION/EXPLORATION
  ○ PHOTOGRAPH, COVER (w/ saline swabs) & STABILISE LIMB

• RADIOGRAPHS = ORTHOGONAL VIEWS incl. JOINT ABOVE & BELOW

Question 5

Other open # management

Answer 5

Surgical debridement = colour, contraction, capacity to bleed, consistency

Internal/external fixation

Definitive skin coverage - plastic surgeons (may involve - skin loss so that tension-free closure not poss., degloving, injury to muscles, injury to 1/more major arteries)

Amputation = dual consultant decision, insensate limb, irretrievable soft tissue/bony damage, other life-threatening injuries

Question 6

Dislocation + Subluxation definitions

Answer 6

Dislocation = complete joint dislocation

Subluxation = partial joint dislocation

Question 7

Dislocation Diagnosis

Answer 7

• CLINICAL & RADIOLOGICAL DIAGNOSIS e.g. X-RAYS (also look for LIGAMENT & CAPSULE DAMAGE)
  
  • ASS. INJURIES: #’s, N/V DAMAGE = ASSESSMENT PRE & POST INTERVENTION
  • EMERGENCY TREATMENT = FIXATION, usually under PROPOFOL, MIDOZOLAM; 2 DOCTORS REQ. - 1 for REDUCTION TECHNIQUE, 1 for SEDATION
  • SURGERY
  • SEQUELAE
  • RECURRENT INSTABILITY e.g. shoulder or STIFFNESS

Question 8

Common Dislocations

Answer 8

Anterior shoulder = squared off

Posterior shoulder = locked in internal rotation

Posterior elbow = prominent olecranon posteriorly

Posterior hip = leg short, flexed, internal rotation, adducted

Anteroposterior knee = loss of normal contour, extended

Lateral ankle = externally rotated, prominent medial malleolus

Lateral subtalar joint - laterally displaced os calcis