fractures and dislocations Flashcards
difference between closed and open fracture
higher risk of infection
higher energy of injury
determinants of classification
mechanism and velocity
degree of soft tissue damage
fracture configuration
degree of contamination
open fractures gustilo grading
type 1- low energy, wound<1cm clean, often bone piercing skin from inside
type 11- moderate soft tissue damage, wound<10cm, no soft tissue flap or avulsion
type III-high enegy, extensive soft tissue damage, severe fracture,any gunshot, farm accident, bone loss, severe crush injury
-IIIA soft tissue damage+++ but not grossly containated
IIIB periosteal stripping, extensive muscle damage, heavy contamination
-IIIC assoc neurovascular complication
type IIIB
common,
require flap cover
management
tetanus, antibiotic prophylaxis cover stabilise limb surgery early and thorough wound excision do not close wound-leave skin open review fasciotomies radiographs early definitive skin cover
definitive management
gustilo grades I-IIIA
same for closed fracture
IIB
external fixation to allow plastic surgery
IIIC- external fixator or primary amputation
decision to amputate
duration of ishaemia
nerve damage
surgical debridement and fixation
colour contraction consistency capacity to bleed 4C
MESS scoring system for amputation
skeletal soft tissue injury limb ischaemia shock age scores> 7 predict low limb liability
dislocation
complete joint disruption
subluxation- partial dislocation
common dislocation
shoulder Ant: squared off Post: locked in internal rotation Elbow post- olecrannon prominent post Hip post: leg short flexed, internal rotation knee Anteropost extended ankle Lateral externally rotated subtalar joints lateral displaced os calcis
complex regional pain syndrome type1
aetiology trauma surgery infection repetitive motion dis IHD, MI
incidence
after peripheral nerve injury
after colles fracture
higher in women
CRPS 1
Pain Oedema Reduced ROM Temperature colour changes PORT -extremity -disproportionate to inciting event -aggravated by activity pain-severe swolen +++, skin shiny, discoloured,hot bone osteoporotic +++ joints osteoarthritic+++ muscles wasted reduced NA levels Alpha adrenocepter density increased skin lactate increase
allodynia
painful response to innocuous stimuli
treatment
early active movement +++ regular analgesia and supervised physio encourage normal use of limb determine contribution of sympa nervous system prevention
Pharmacological Therapy
Traditional analgesics Tricyclic antidepressants Gabapentin (other anticonvulsants) Glucocorticoids Transdermal clonidine Intravenous bisphosphonates
Summary
Definition : Complex Regional Pain Syndrome
Recognition : PORT (sensitive but not specific)
Diagnosis : Clinical versus laboratory
Management: Early, medication, diagnostic blocks
functional restoration
Crush syndrome
Crush injury to a large muscle mass (thigh, calf, etc.)
direct muscle injury + muscle ischaemia + cell death with release of myoglobin ATN (acute tubular necrosis of the kidneys) ARF (acute renal failure)
clinical features
dark amber urine(test for Hb and Mb)
acute renal failure(hypovolaemia, metabolic acidoses, hyperkalaemia, hypocalcaemia, DIC)
management
IV fluids +++
early (protect kidney & prevent ARF)
Fluid expansion + osmotic diuresis (to maintain high tubular volume + urine flow – aim
-alkalisation of urine with sodium bicarbonate-> reduce tubular precipitation of myoglobin
acute compartment syndrome
Limb-threatening HIGH INDEX OF SUSPICION! Key pathology = ISCHAEMIA! after trauma also in vascular reperfusion of acutely ischaemic limb burns crush injuries haemorrhage drug injection
definition
A compartment syndrome develops when intramuscular pressure is elevated sufficiently to reduce nutritional blood flow significantly to tissues within the involved compartment.
A compartment syndrome develops when intramuscular pressure is elevated sufficiently to reduce nutritional blood flow significantly to tissues within the involved compartment.
at risk sites
lower leg forearm hand foot thigh
acute compartment syndrome
more common in low energy tibial fractures as fascial compartments more likely to be intact
ACS occurs in open fractures as compartments will often remain intact
acute compartment syndrome 9ps
- PAIN
- Passive dorsiflexion
- Paraesthesiae
- Paresis or Paralysis
- Pallor
- Pulselessness
- Perishing cold
- Pressure
- (Prompt decompression
missed compartment syndrome
If untreated leads to: Muscle ischaemia and necrosis Muscle contractures Delayed fracture healing May nessecitate limb amputation
ACS
if hypotensive, lower BP needed to produce ACSpatient with multiple trauma (incl. limb injuries) + hypovolaemic shock – may be in ITU paralysed and ventilated – therefore lost most important criteria for diagnosis of ACS
fat embolism syndrome
HIGH INDEX OF SUSPICION!
Occurs after trauma – always with a fracture of a long bone – usually 24-72h
Also seen in instrumentation of long bone, e.g. intramedullary nailing
Key pathology = HYPOXIA!
definition
Fat within the systemic circulation that produces embolic phenomena, with or without clinical sequelae
When associated with an identifiable clinical pattern of symptoms and signs, it is known as Fat Embolism Syndrome (FES)
evidence of fat embolism (marrow fat + debris from fracture site) in 90% of patients with traumatic injury
- but only 3-4% of long-bone fractures result in
‘FAT EMBOLISM SYNDROME’
risk factors
long bone fractures conservative management of long bone fractures multiple trauma associated abdominal injuries severe blood loss
pathophysiology
Mechanical Theory
Bone marrow enters venous circulation and lodges in the lungs, smaller particles penetrate pulmonary capillaries and enter arterial circulation
Biochemical Theory
Circulating fatty acids directly affect pneumocytes altering gas exchange
diagnosis
Clinical
- Blood Investigations - Hypoxia on ABGs - Fall in haemoglobin - Thrombocytopaenia - Fat droplets within blood clots - CXR
clinical features
Brain = most sensitive organ to hypoxia Confused/agitated fits drowsy coma dead Tachypnoeic + tachycardic Shock (hypotensive) – late Fever – low grade pyrexia Skin rash
investigations
Chest X-ray - serial Oxygen saturations + blood gases (PaO2) FBC – Hb + platelets (thrombocytopenia <150) (Fat globules in blood clots) (Fat globules in sputum) (Fat globules in urine - “sizzle test”
FAT EMBOLISM SYNDROME
Pulmonary circulation – HYPOXIA
Cerebral circulation – CONFUSION
Cutaneous circulation – PETECHIAE
Paradoxical embolisation through patent Foramen ovale
treatment
There is no current “Treatment” (i.e. cure)
only SUPPORTIVE MANAGEMENT
maintain cerebral and pulmonary perfusion.
OXYGEN!!
may require intensive gas and circulatory monitoring – therefore should be seen by ITU staff
if necessary – mechanical ventilation
– advanced circulatory support
prevention
PREVENTION
- immobilisation/fixation of long bone fractures - possible role for prophylaxis with steroids? - monitoring with pulse oximetry
