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MSK > Fractures Symposium > Flashcards

Fractures Symposium Flashcards

1
Q

Define open fracture

A

Direct communication of the fracture with the outside environment (mostly bones poking through the skin, but also includes pelvic fractures penetrating the rectum)

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2
Q

What kind of injuries are open fractures secondary to?

A

High energy injuries

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3
Q

What investigation must you always do in open fractures?

A

PR

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4
Q

What are open fractures associated with?

A

Significant soft tissue injury, increased risk of complications (poor healing, infection) which leads to increased risk of amputations and long term morbidity

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5
Q

What are the most common open fractures?

A

Tibial shaft and fingers

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6
Q

How many polytraumatised patients have open fractures?

A

1 in 3

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7
Q

What classification is used for open fractures?

A

Gustilo - but it is hardly used now

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8
Q

Describe the gustilo open fracture classification type 1

A

Type 1 - wound <1cm, clean, simple fracture pattern

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9
Q

Describe the gustilo open fracture classification type 2

A

Wound 1-10cm, moderate soft tissue damage, adequate skin covering, simple fracture pattern, no soft tissue flap or avulsion

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10
Q

Describe the gustilo open fracture classification type 3

A

Extensive soft tissue damage due to high energy injury, complex fracture pattern (comminution, displacement), wound >10cm (e.g. any gunshot, farm accident, bone loss, severe crush injury, segmental fracture, marine

3A - adequate periosteal coverage, v. severe soft tissue damage but not grossly contaminated
3B - tissue loss req. soft tissue coverage procedure (e.g. flap/graft), heavy contamination
3C - NV injury req. repair

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11
Q

What are the guidelines for lower limb open fractures?

A

Management of severe open lower limb fractures standards for practice audit

Created by plastics and ortho

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12
Q

What are the key points of the standard to practice audit?

A

MDT (ortho and plastics) w. appropriate experience req. for treatment of all complicated open fractures

Hospitals that lack experience in this must refer to specialist centre immediately

Primary surgical Rx (debridement, excision, stabilisation) should take place at specialist centre where possible

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13
Q

What are the four different types of fracture patterns?

A

Transverse or short oblique tibial fractures q. fibular fractures at a similar level
TIbial fractures with comminution (bone breaks into little bits)/butterfly fragments with fibular fractures at similar level

Segmental tibial fractures

Fractures w. bone loss (from time of extrusion at time of injury/after debridement)

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14
Q

What are the four soft tissue injury patterns?

A

Skin loss such that direct tension-free closure is not possible

Degloving (avulsion in which extensive section of skin is completely torn off underlying tissue severing its BS)

Injury to the muscles which req. excision of devitalised muscle

Injury to 1+ of the major arteries supplying the legs

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15
Q

How do you manage open fractures?

A

Full ATLS
Tetanus and antibiotic prophylaxis
Cefuroxime/augmentin/clindamycin-gent at time of fixation
Repeated NV examination
Wounds only handled to remove gross contamination
Photograph, cover (saline swab) and stabilise limb
No provisional irrigation/exploration
Radiographs - orthogonal views (joints above and below)

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16
Q

Which patients should be offered a full body CT within 30 minutes of their arrival to hospital?

A

Polytraumatised patients

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17
Q

Which patients should be offered emergency surgery (within 6 hours)?

A 
Polytraumatised patients 
Marine/farmyard environment 
Gross contamination 
NV compromise 
Compartment syndrome
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18
Q

All other patients should be offered what in terms of surgery?

A

To have surgery within 24 hours on a scheduled trauma list by a consultant ortho and plastic during normal working times

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19
Q

Why must patients that have had farm or marine exposure have emergency surgery?

A

They are at increased risk of necrotising fasciitis

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20
Q

Who carries out surgical debridement?

A

Experienced consultants

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21
Q

What is involved in surgical debridement?

A 
Observe for the 4 Cs - 
Colour 
Consistency 
Capacity to bleed
Contraction of muscle (is it alive?)
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22
Q

Why is it preferred to not have second debridements?

A

Multiple debridements are associated with poorer outcomes

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23
Q

What are the two types of fixation?

A

Temporary - if unable to do definitively because of soft tissue/technical reasons (can use external fixator)

Definitive

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24
Q

Who does the definitive skin coverage?

A

Plastic surgeon

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25
Q

What kind of skin coverage can be carried out?

A

SSG/myofasciocutaneous/fasciocutaneous/rotation/free flaps

idea is robbing peter to pay paul

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26
Q

What is MESS?

A

Mangled extremity severity score - estimates viability of limb after trauma

It is used to help make the decision between saving a limb or carrying out an empiric amputation

Score of 7 or more indicates amputation is likely to be req.

27
Q

What is involved in MESS?

A

Limb ischaemia
Patient age
Shock
Injury type (energy)

28
Q

What does amputation req?

A

Dual consultant decision

29
Q

Why might we amputate after an open fracture?

A

Insensate foot/limb
Irretrievable soft tissue or bony damage
Other life-threatening injuries

30
Q

What kind of amputation is done?

A

Gulliotine type and refashioned later

31
Q

Define dislocation

A

100% lack of contact between bone surfaces

Complete joint disruption

32
Q

Define subluxation

A

Partial dislocation

33
Q

How do you investigate a suspected dislocation?

A

Xray always - confirm diagnosis and rule out fractures (can also see capsule and ligament damage)

34
Q

What kind of views do you req. for Xraying a dislocation?

A

Orthogonal

35
Q

What must you document in dislocations?

A

Associated injuries (e.g. axillary nerve palsy, subclavian artery rupture)

36
Q

What is the most common dislocation?

A

Shoulder

37
Q

What is the most common type of shoulder dislocation?

A

Anterior/anterio-inferior

38
Q

What most commonly causes shoulder dislocation?

A

Anterior - falling on outstretched hand

Posterior - tends to be from uncoordinated muscle contractions (e.g. seizure/electric shock)

39
Q

What symptoms are associated with shoulder dislocation?

A

Pain, restricted RoM

40
Q

What signs are associated with shoulder dislocation?

A

Palpable dent (empty glenoid fossa), arm internally rotated, shoulder squared off

41
Q

How do you manage shoulder dislocation?

A

Analgesics, muscle relaxants to allow you to put the humerus head back in the glenoid fossa

42
Q

What complications are associated with shoulder dislocation?

A

Axillary nerve palsy

Rotator cuff injury

43
Q

What is the most common cause of elbow dislocation?

A

Fall on outstretched arm

44
Q

What direct of dislocation is most common in elbow dislocation?

A

Posterior

45
Q

What are the signs and symptoms of elbow dislocation?

A

Symptoms: pain, inability to flex or extend elbow, swelling

Signs: olecranon prominent posteriorly

46
Q

What are complications of elbow dislocation?

A

Median/radial/ulnar nerve palsy, rarely brachial artery injury

47
Q

How do you manage elbow dislocations?

A

Analgesia, closed reduction

48
Q

What is closed reduction?

A

Physical manipulation back into place followed by casting/splinting

49
Q

What is the most common direct for the hip to dislocate?

A

Posterior

50
Q

What are the signs of hip dislocation?

A

Short leg, internally rotated, adducted, flexed

51
Q

What causes hip dislocation?

A

Usually high energy injuries

52
Q

What is the most common direction for the knee to dislocated?

A

Anterioposteriorly

53
Q

What are the signs and symptoms of knee dislocation?

A

Loss of normal contour of the knee, extended

Inability to straighten leg, pop, immediate swelling and pain, unable to walk

54
Q

What usually causes a knee dislocation?

A

Caused by blow/sudden change in direction by planted knee

55
Q

In which direction most commonly does ankle dislocate?

A

Laterally

56
Q

What are signs of a dislocated ankle?

A

Externally rotated, prominent medial malleolus

57
Q

What causes ankle dislocation?

A

Severe injury that causes 1+ of the ankle ligaments to tear

58
Q

What are the symptoms of ankle dislocation?

A

Immediate, severe pain, swelling and bruising, inability to wt bear, restricted RoM

59
Q

How do you manage ankle dislocation?

A

Analgesia, closed reduction

60
Q

In which direct is subtalar dislocation most common?

A

Lateral

61
Q

What is a sign of subtalar dislocation?

A

Laterally displaced os calcis

62
Q

What causes subtalar dislocation?

A

High energy injury, tends to be assoc. with fractures!!

63
Q

How do you manage a subtalar dislocation?

A

Closed reduction and non-wt bearing cast (sometimes requires open reduction!)

MSK (27 decks)

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