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MSK physiology > Fractures > Flashcards

Fractures Flashcards

1
Q

What is an open fracture?

A

• Direct communication between the outside world and the fracture
• Usually through a break in the skin (not always)
○ e.g. fragments of bone from a fractured pelvis penetrating the rectum
• Can be big or small
• Gustilo classification of open fractures (1 is less bad 3)

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2
Q

What is the epidemiolgy of open fractures?

A

○ 23 per 100,000 population per year
○ fingers + tibial shaft account for >50%
○ Probably about 3,500 open tibial shaft fractures in UK per year
○ 1/3 of polytraumatised patients have open fractures- distracting injuries

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3
Q

Why are open fractures important?

A

○ Higher energy injury
○ Increased infection rate
○ Soft tissue Complications
○ Long term morbidity….

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4
Q

What is a type 1 fracture acording to gustilo classification of open fractures?

A
  • Low energy
  • Wound <1cm
  • Clean
  • Simple fracture pattern
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5
Q

What is a type 2 fracture acording to gustilo classification of open fractures?

A
  • Wound >1cm, <10cm
  • Moderate soft tissue dmage
  • Adequate skin coverage
  • Simple fracture pattern
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6
Q

What is a type 3A fracture acording to gustilo classification of open fractures?

A
  • High energy
  • Extensive soft tissue damage
  • Complex fracture pattern
  • Wound >10cm
  • Any gunshot, farm accident, segmental fracture, bone loss, severe crush, marine
  • Adequate periostal coverage
  • Soft tissue damage +++ but not grossly contaminated
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7
Q

What is a type 3B fracture acording to gustilo classification of open fractures?

A
  • High energy
  • Extensive soft tissue damage
  • Complex fracture pattern
  • Wound >10cm
  • Any gunshot, farm accident, segmental fracture, bone loss, severe crush, marine
  • Tissue loss requiing soft tissue coverage procedure (such as a flap or graft)
  • Periostal stripping
  • Extensive muscle damage
  • Heavy contamination
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8
Q

What is a type 3C fracture acording to gustilo classification of open fractures?

A
  • High energy
  • Extensive soft tissue damage
  • Complex fracture pattern
  • Wound >10cm
  • Any gunshot, farm accident, segmental fracture, bone loss, severe crush, marine
  • Vascular injury requiring repair
  • Associated with neurovascular complicatiuons
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9
Q

What guidlines are used for the treatment of open fractures?

A

BOAST guidlines

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10
Q

Explain multi-disiplinary team that manages open fractures

A
  • Needs orthopaedic and plastic surgeons with appropriate experience
  • Hospitals lacking this should immediately refer to the closest specialist centre
  • The primary surgery treatment (wound debridement/ excision and skeletal stabilisation) of these complex injuries takes place at the specialist centres whenever possible
  • Specialist centres for the management of severe open fractures are organized on a regional basis as part of a regional trauma system. Usually these centres also provide regional service for major trauma
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11
Q

How are open fractures managed?

A
  • Full ATLS assessment and treatment
  • tetanus and antibiotic prophylaxis
  • Cefuroxime / Augmentin / Clindamycin- Gent at time of fixation
  • Repeated examination neurological/ vascular status
  • Wounds only handled to remove gross contamination,
  • photograph, cover (saline swabs) and stabilise limb
  • No provisional irrigation / exploration
  • Radiographs- orthogonal views including joint above and below
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12
Q

When should surgery for open fractures be preformed?

A
  • Perform surgery within 24 hours of the sustained injury
  • Cases where you need to perform surgery within 6 hours
    □ Polytraumatised patient
    □ Marine or Farmyard environment
    □ Gross contamination
    □ Neurovascular compromise
    □ Compartment syndrome
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13
Q

What do surgeons look for when debriding and fixing open fractures?

A
  • Colour
  • Contraction
  • Constancy
  • Capacity to bleed
  • Second looks may be necessary but multiple debridement can be associated with poorer outcomes
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14
Q

What happens in definitive skin coverage?

A
  • Plastic surgeons
  • Split Skin Graft (SSG)/ Myofasciocutaneous/ fasciocutaneous/ rotation/ free flaps
  • Rob Peter to pay Paul
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15
Q

What are the different fracture pattens of tibial fractures?

A

○ Transverse or short oblique tibial fractures at a similar level
○ Tibial fractures with comminution/ butterfly fragments with fibular fractures at a similar level
○ Segmental tibial fractures
○ Fractures with bone loss, either from extrusion at the time of injury or after debridement

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16
Q

What are the different soft tissue injury patterns in open fractures?

A

○ Skin loss such that direct tension-free closure is not possible following wound excision
○ Degloving
○ Injury to the muscles which requires excision of devitalised muscle via wound extensions
○ Injury to one or more of the major arteries in the leg

17
Q

What is the scoring system for amputation in open fractures?

A

□ Limb ischaemia
□ Patient age range
□ Shock
□ Injury mechanism

18
Q

Explain amputation in open fractures

A
  • Dual consultant decision
  • Insensate limb / foot
  • Irretrievable soft tissue or bony damage
  • Other life threatening injuries
  • “Guillotine” type and refashion at a later stage
19
Q

Why are some rib fractures fixated?

A
  • Less time in ITU
  • Decrease instances of tracheostomy
  • Makes people feel better
  • Makes a massive difference to poly traumatised patients
20
Q

How are patients selected for rib fracture fixation?

A 
○ Large flail section
○ Paradoxical breathing
○ Multiple rib fractures 
○ Significant displacement
○ Intrathoracic pathology e.g. herniation
○ Chest wall deformity
○ Inability to control pain
21
Q

What is a dislocation?

A

Complete joint disruption

22
Q

What is a subluxation?

A

Partial disruption- not fully out of the joint

23
Q

How are dislocations diagnosed?

A

○ Clinical and Radiological diagnosis
○ Associated injuries, soft tissue, musculoskeletal, multi-system
- Make sure you assess them
○ Associated injuries - #’s, neurovascular damage- assessment pre post
○ Emergency treatment
○ Surgery
○ Sequelae
○ Recurrent instability (e.g. shoulder) or stiffness

24
Q

What are the top 2 most common shoulder dislocations and what would they look like on examination?

A
  • Anterior (90%): squared off

- Posterior (9%): locked in internal rotation (lightbulb appearance)

25
Q

What is the most common elbow dislocation and what would it look like on examination?

A

Posterior: olecranon prominant posterior

26
Q

What is the most common hip dislocation and what would it look like on examination?

A

Posterior: leg short, flexed, internal rotation, adducted

27
Q

What is the most common knee dislocation and what would it look like on examination?

A

Anteroposterior: loss of normal contour, extended

28
Q

What is the most common ankle dislocation and what would it look like on examination?

A

Lateral: Externally rotated, prominant medial malleolus

29
Q

What is the most common subtalar joint dislocation and what would it look like on examination?

A

Lateral: lateraly displaced os calcis

MSK physiology (5 decks)

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