Fractures & dislocations - Clinical medicine Flashcards
Define polytrauma/multiple trauma
Severe injury to more than one body system
Describe what the injury severity score and how it is calculated
- Injury Severity Score (ISS) Body split into 6 parts
- Squares of three highest scores are added
- Injury Severity Score > 15 associated with mortality of 10% and classified as major trauma
What does ABCDE represent in the advanced trauma life support system (ATLS) for managment of multiple trauma
A- Airway with cervical spine control
B - Breathing with ventiliation
C - Control of haemorrhage
D - Disability brain protection
E - Exposure
Describe ABCDE in the advanced trauma life support for managment of multiple injuries (ATLS)
A - Airway with Cervical spine control.
- Clear any obstructions in the airway, at the same time safeguarding the neck as in an accident potential for neck injury
B - Breathing with ventilation.
- Ensure they are breathing otherwise assist with breathing (ventilation)
C - Control of haemorrhage
- Stop bleeding, turn off the tap and replace lost blood
D - Disability brain protection.
- Maintain oxygenated blood flow to the brain protecting it
E - Exposure.
- Remove all clothing and inspect the whole body for injury, being careful with children and elderly as they may get cold rapidly
Describe what should be done in pre-hospital care for someone who has undergone multiple trauma
- Basic Life Support with maintenance of airway, breathing, circulation
- All injured patients should be given 100% oxygen to prevent secondary damage to the brain and to the cardiovascular system -best delivery system is a rebreathing bag which delivers 100% Oxygen
- “Scoop and run” in urban setting, most effective
- Crystalloid IV fluids such as normal Saline/Hartmanns are possibly harmful in major trauma
- Lost blood should be replaced by whole blood if available
- Endotracheal intubation-tube placed in the trachea and oxygen given
a) Describe the time and causes of death of the first peak of the trimodal death distribution
b) Decsribe the time and causes of death of the second peak of the trimodal death distribution
c) Describe the time and causes of death of the second peak of the trimondal death distribution
a) Time - first peak within seconds to minutes at accident site
Cause of deah due to lacerations in:
- Brain
- Brainstem
- Aorta
- Cord
- Heart
b) Time - second peak within minutes to hours at hospital
Cause of death due to:
- Brain haemorrage e.g. extradural and subdural
- Pelvic fractures
- Long bone fractures
- Abdomincal injuries
c) Time - days to weeks in hospital intensive care unit
Cause of death due to:
- Sepsis
- Multiple organ dysfunction syndrome (MODS)
- Acute repiratory distress syndrome (ARDS)
- Pneumonia
What is the best thing to do to save life and prevent severe complications occurring during the seocnd peak of the trimodal death distribution?
- “Golden hour” rapid assessment
- Resuscitation using ATLS
Describe the role of trauma teams
- On standby to recieve severly injured
- Team leader normally senior from accident and emergency department
- Representatives from: Anaesthetics, general surgery, ortrhopaedics, urology, neurosurgery, facio-maxillary
a) Describe the body’s physiological response to trauma
b) Draw the systemic response graph
a) After trauma, there is a balance between the systemic inflmammatory response and the counter-regulatory anti-inflammatory response
b)
a) What is recommended not do when a patient is undergoing systemic inflammatory response syndrome? and why?
b) When does this settle?
a) Recommended not to perfrom surgery as there is a high complication rate
b) 4-5 days
Describe the two-hit theory
- First trauma (first hit) can lead to a severe response of multitple organ dysfunction syndrome (MODS) / Acute repiratory distress syndrome (ARDS)
- If they do not go through MODS/ARDS and surgery is performed it is called second hit. They can get better or go through MODS/ARDS
- Timing of surgical procedure is very crutial
Describe what the ‘trauma traid of death’ OR ‘terrible traid’
- Medical term describing the combination of hypothermia, acidosis, and coagulopathy (a condition that affects how your body clots)
- This combination is commonly seen in patients who have sustained severe traumatic injuries
- It should be avoided
What is involved in the ‘trauma triad of death’ or ‘terrible triad’?
- Acidosis
- Hypothermia
- Coagulopathy
What occurs if a patient is not fit for surgery after multiple trauma?
Damage control orthapaedics occurs
What are the principles of managment damage control orthopaedics (DCO)?
- Control of bleeding
- Arterial repair
- Tension pneumothorax (air accumulates between the chest wall and the lung and increases pressure in the chest, reducing the amount of blood returned to the heart)
- Compartment syndrome
- Provisonal fracture stability
Aim is to keep them alive
Where are the four majour sources of bleeding found?
- Chest
- Abdomen
- Pelvis
- Extremities
a) What may you have do when bleeding is found in the chest?
b)
- Chest CT scan
- Put chest drain
- Thoractomy (open chest to stop bleeding)
What may you have to do when bleeding is found in the abdomen?
- Abdomen fast scan
- CT scan
- Laportatomy (Surgical procedure involving small incisions through the abdominal wall to gain access into the abdominal cavity)
What may you have to do when there is a pelvis fracture/bleeding
- Pelvis binder –> angiography –> embolization
- If that doesn’t work you do pelvis packing
What are the damages that can occur from a pelvic fracture?
- Organs may be damaged including the muscular pelvic floor
- Severe bleeding occurs from the fractured pelvis, pelvic organs, (the highly vascular), pelvic floor and major vessels
Describe how the pelvi binder is put on and its role
- Pelvic binder over the greater trochanter and binding both legs together
- This stabilises the pelvis to stop the bleeding
What do you do after a pelvic binder fails to stop the bleeding?
Embolisation (Sent to angiography suite and wire inserted by interventional radiologists which embolises and stops the bleeding)
What do you do if pelvic binding and angiology & emobilisation fails to stop the bleeding or patient is in extremis?
Pelvis packing
What is acute compartment syndrome?
Rise of pressure within a closed space resulting in ischaemia of the components
When is compartment sydrome most common?
After lower leg and forearm fractures
What is the main clinical symptom of compartment syndrome
- Severe pain, often unrelieved by opiods and worse on passive stretch
- Parathesia and numbness of limb
Describe compartment syndrome after a tibia fracture
- The tibia fractures and bleeds into compartments
- The fascial covering is unyielding, so the pressure rises in one or more compartments
- Lymphatics are compressed shut down with no clinical signs
- Bleeding continues and the pressure rises further
- Small vessels to muscles are shut off causing severe unremitting ischaemic pain, and painful on passive stretching by moving toes and foot
- Small vessels shut off to nerves leads to paraesthesia, numbness, and paralysis
- Major arteries shut off late stage by which time the whole of the limb is dead
a) What is the treatment of compartment syndrome?
b) What does the treatment aim to do?
c) What is the possible consequence of failing to recognise or treat compartment syndrome?
a) Fasciotomy
b) The treatment is to release the compartment fascia and to correct any underlying cause if possible
c) May result in limb amputation
How is compartment pressure measured?
- Intermittent by a metre
- Continuous with annula in compartment
Describe ‘acute repspiratory distress system (ARDS)’
- Fat globules lodging in small vessels leads to local inflammation
- This leads to impaired gas exchange, hypoxia and can lead to multiple organ failure
What are the advantages of putting an external stabiliser for long bone fractures?
Reduced:
- ARDS
- Pneumonia
- Ventilator days
- ITU days
- Hospital days
- Systemic infections
What are the principles of treatment of open fractures?
- Photograph
- Cover with antiseptic dressing
- Antibiotics, splint
- Theatre within 6 hours
- Debridement
- Stabilisation
What are the advantages of early spinal fracture fixtation?
- Less pulmonary complications
- Shorter length hospital stay
What is a fracture?
A soft tissue envelope in which there happens to be a bone that is broken
a) What fracture pattern does a twisting force produce?
b) What fracture pattern does a bending force produce?
c) What fracture pattern does high energy force produce?
a) Spiral/oblique fracture
b) A transerse fracture & often with a third fragment called a bending wedge
c) A comminuted fracture
Are all pelvic fractures bad?
Yes
What is the healing process of this very severe (ugly) fracture going to be like?
Fracture extends into the joint and thus difficult to manage with a high chance of developing osteoarthritis needing a joint replacement.
a) What is the AO classification?
b) When is it used?
a) A system for classifying bone fractures
b)
- It is for research puporses only
- Occasionaly used in clinical practice e.g. classifying ankle fractures and fractures near or into the joint
What are soft tissues of the body?
- Skin
- Muscles
- Blood vessels
- Nerves
- Tendons and ligaments
- Fascia
What is a closed fracture
The skin is intact
a) What is an open fracture?
b) What is the risk of this?
a) The skin is torn
b) High risk of infection
Describe how you read x-rays of fractures
- You must read the name of the patient
- With the patient and with their wrist band confirm date of birth
- Read Hospital number
- Find out Date of x-ray
- Note part of region, right or left
- Look for whether standing or weight bearing X-rays
What are the types of angulation of limbs?
- Valgus
- Parallel
- Varus
Why is the AO classification applied to the ankle?
- Applied purely for level of fibula fracture
- Easy to remember
- Has practical applications
a) How do you treat a type A (below syndesmosis) ankle fracture?
b) How do you treate a type B (at syndesmosis - connection between tibula and fibula) ankle fracture?
c) How do you treat a type C (above syndesmosis) ankle fracture?
a) non-operation plaster
b) best treated by surgery
c) best treated by surgery
What are the two types of femoral neck or hip fractures
- Intertrochanteric / per trochanteric
- Intracapsular / sub capital
What type of hip fracture is this?
Interochanteric / per trochanteric fracture of the femoral neck
What type of hip fracture is this?
Intracapsular / Sub capital fracture of the femoral neck
What is the treatment for an intertrochanteric fracture in all ages?
Reduce and fix with a dynamic hip screw
What is the garden classification?
Classifies sub capital/intracapsular neck fractures
Describe grade I, II, III, IV sub capital fractures of the garden classification using the image
- Grade I - Incomplete, not displaced
- Garde II - complete, not displaced
- Grade III - Comple, minimally displaced
- Grade IIII - Complete, completely displaced
Describe the treatment process for a young person has a sub captical/intracapsular fracture?
It’s an emergency in all 4 grades of the garden classification
- Take to operating theatre within 6 hours
- Closed/open reduction and then internal fixation
a) What is the treatment for an elderly patient with a grade I or II sub capital/intracapsular fracture?
b) Why this treatment?
a) Minimally displaced fix in situ using a dynamic hip screw
b) Although blood supply is interrupted, it is not badly interrupted and will heal
a) What is the treatment in an elderly patient with a grade III and IV sub capital/intracapsular fracture to the femoral neck?
b) Why this treatment?
a) Total hip replacement (socket and ball)/hemiarthroplasty (ball only)
b) No blood supply to femoral head and avascular necrosis will eventually occur
Why do children, unlike adults do not usually have a hip replacement when they suffer a sub capital/intra capsular of grade III and grade IV fracture?
- They have an artery in the ligamentus teres called the foveal artery that provides blood supply to the neck of femur (as well as blood vessels from the capsule)
- The foveal artery is insignificant in adults.
In what type of adult patients, who have suffered a sub capital/intracapsular fracture be given a total hip replacement surgery?
Fit and healthy patients
What does the managment of femoral neck fractures depend on?
The blood supply to the femoral neck
What is the salter-harris classification?
A classfication system that grades growth plate fractures in children
What is the salter-harris mneumonic for the different types of growth plate fractures?
Normal
Type I - Straight (across growth plate)
Type II - Above (growth plate + metaphysis)
Type III - beLow (growth plate + epiphysis)
Type IV - Through (growth plate + epiphysis + metaphysis) and ephysis)
Type IV - cRushed (compression of growth plate)
Describe each type of ephyiseal plate fracture
Normal
Type I - Straight (across growth plate)
Type II - Above (growth plate + metaphysis)
Type III - beLow (growth plate + epiphysis)
Type IV - Through (growth plate + epiphysis + metaphysis) and ephysis)
Type IV - cRushed (compression of growth plate)
According to the salter-harris classification, what type growth plate fracture is this?
Salter type II
According to the salter-harris classification, what type growth plate fracture is this?
Salter type IV
Describe the approach to manage a fractures or dislocated joint
- Ample -Allergies, medications, past medical hisotry, last meal, events
- Look - compare left and right side
- Feel - assess for nerves and their vascular supply
- Move
What does AMPLE stand for
Allergies, medications, past medical histort, last meal, events
a) What investigation is normally taken after a fracture or dislocation
b) What investigation would be taken if there is uncertainty of the causes of the underlying problem?
a) X-ray
b) CT scan
What should be assessed after a reduction?
Neurovascular state
Describe the management of a patient who comes in with a radial fracture
- ample (allergies, medications, past medical history, last meal, events)
- Assess neurlogoical state for both the medial, radial and ulnar nerves of the hand
- Assess vascular state by doing the capillary refill. Should be less than 2 seconds
- Undergo reduction
- Inject a local anaesthetic around the fracture and provide analgesia for manouvre
- Put a needle into haemaoma where the blood clot is around the fracture
- Reduction to pull radius to realign back - Reassess neurovascular state of nerve
- Plaster is applied
Describe the management of a patient who comes in with a humeral fracture
- AMPLE (allergies, mediations, PMH, last meal, events)
- Provide analgesia
- Assess neurological status
- Translate and angulate frature that was displaced
- Kirschner wires (K-wires) holds displacement
- Full assessment of motor and sensory function of the nerves and the vascular supply
Describe the managment of a patient who comes in with an ankle fracture?
- AMPLE (allergies, medications, PMH, last meal, events)
- Provide analgesia
- Assesment of neurovascular status
- Reduce fracture by raising big toes
- Plaster cast
- Any signs of instability are recommened surgery e.g., screws holding fracture
Describe the management of a patient who comes in with an intracapsular hip fracture
- Ample (allergies, medications, past medical history, last meal, events)
- Provide appropriate analgesia
- Reduce femoral head into acetabulum
- Downward pressure on pelvis
- External and internal rotation and upward pull-on femur
- Reduction - Hemiarthorplast or compete hip replacement
Describe the management of a patient with an intertrochanteric fracture?
- Ample (allergies, medications, PMH, last meal, events)
- Provide appropriate analgesia
- Repaired with a dynamic hip screw
List the psychological effects of trauma on patients
- Exhaustion
- Confusion
- Sadness
- Anxiety
- Agitation
- Numbness
- Dissociation
- Confusion
- Physical arousal
- Depression
- Low self esteem
List the Ottowa ankle rules that mean a fracture is more likely and an ankle x-ray needed
- If pain in the malleolar zone AND
- Bony tenderness tip of medial malleolus distal 6cm tibia
- OR bony tenderness at lateral malleolus or distal 6cm fibula
- OR immediately non-weight bearing and continues in A&E
List the risk factors of having a fall
- 2 or more falls in 6 months
- Fear of falling/giddiness/reduced confidnce
- Complex medical problems
- 4 or more medicationsor 2 medications on list over
- Change of medications in last 2 weeks
- Postural BP (a condition in which a person’s blood pressure drops abnormally when they stand up after sitting or lying down)
- Risk factors for hip fracts or equal or greater
- Risk factors for osteporosis
- Excess alcohol problem
- Hearing difficulties
- Depression/low mood
- Abbreviated mental test (AMTS) less than 8/10
- Concerns about home environment/or hazards at home
- Struggles in “get up and go test”
- Poor vision
- Poor footwear/foot care
List the medical conditions specifically implicated in falls
- Stroke
- Depression
- Cardiac disease
- Parkinson’s disease
- Neurological conditions
- Diabates
- Bone disorders/deformities
List the medications implicated in falls
- Antidepressants
- Steroids
- Benzodiazepines
- Hypoglycaemics
- Hypnotic/major tranquillisers
- Anticholinergics
- Analgesics/NSAIDs
- Diuretics
- Cardiac drugs
a) List the major risk factors for osteoporosis
b) List the minor risk factors for osteoporosis
a)
- Fragility fracture
- Steroid use
- Radiological osteopaenia
- Medical conditions associated with oteopororsis
- Hypogonadism
b)
- Family
- Low body weight
- Smoking
- Height loss
a) What is a colle’s fracture?
b) Describe the epidemiology
c) Describe the clinical presentation
d) Describe the treatment
e) What are the complications?
a) Fracture of distal radius after falling on out stretched hand
b) Common in patients with osteoporosis, so seen in elderly women. Younger patients would usually be involved in high impact trauma
c) Pain, tenderness and swelling in forearm, dinner fork deformity (due to lateral angulation)
d) Cast immbolisation, open reduction and internal fixation (ORIF) if fracture is unstable
e) Mal/non-union, median nerve injury, udek’s atrophy/complex regional pain syndrome, extensor pollicis longus rupture, carpal tunnel syndrome, frozen shoulder
a) How does a hamate fracture occur?
b) Describe the clinical presentation
c) Describe the treatment
a) Direct trauma to base of thumb
b) Pain, tenderness and swelling over the hypothenar eminence
c) Conservative with immobilisation or surgical treatment in severe cases
Describe the clinical presentation of an anterior shoulder dislocation
- Pain
- Elbow flexed
- Arm in slight abduction
- Shoulder flattened
- Humeral head prominent
- Acromion process prominent
a) When do posterior shoulder dislocations occur?
b) What are the most commonest cause of posteriou
c) Describe what you would see on x-ray?
a) After a strong, sustained muscle contraction or direct trauma, commonly epilepsy, electrocution and trauma
b) lightbulb sign - head of humerus is in the shame axis as the shaft
c) Orthopaedic input for closed reduction
a) How does an axillary nerve injury usually occur?
b) How can you test the sensation of this?
a) Typically occurs as a result of a shoulder injury, particularly anterior dislocation and proximal humeral fractures
b) Test the sensation over the lower half of the deltoid
Describe the following fractures in childen
a) Green stick
b) Torus/buckle
a) Ocurs due to a bending force. Leads to an incomplete fracture, where the bone is bent and cracked (looks like a wedge)
b) Incomplete fractures of the shaft of a long bone (usually occurs in the distal radius or tibia). Usually result from trabecular compression due to an axial loading force along the long axis of the bone (difficult to see on x-rays)
What is the difference between a Colles fractures and a Smith’s fracture?
Colles fracture = distal radius fracture with dorsal angulation of the distal fragment
Smith fracture = distal radius fracture with volar angulation of the distal fragment
Describe the treatment between non-displaced vs displaced radial/ulnar fractures
- Non-displaced closed fractures are treated with immobilisation for 3-4 weeks.
- Displaced fractures require reduction (and internal fixation) and immobilisation
