Leg trauma Flashcards
What do before the assessment?
- put out 2222 trauma call
- move pt to resus
A+B
A: Triple immobilize the cervical spine
Ensure airway patency (using adjuncts if necessary)
Breathing:
- Administer high flow O2(15L via non-rebreather mask)
- Gain observations: oxygen saturations, respiratory rate.
- Inspect/ palpate thorax for equal chest movements and signs of trauma
- Auscultate and percuss chest
- CXR
- ABG
C + D
BP 95/73, HR 120
Circulation and Control of haemorrhage:
- Establish IV access with 2 wide bore cannulae
- Send off bloods including FBC, U&E, LFT, clotting, G&S and cross match 4 units
- Commence warmed IV fluids and consider O -ve blood depending on availability of cross-matched blood
- Assess peripheral circulation and assess for major sources of bleeding.
- From the information given I would be most concerned about bleeding from long bone fracturesbut would also consider bleeding into the thorax, abdomen, pelvis, and peripherally (“blood on the floor and 4 more”).
- Ordering x-rays and FAST scan as required.
- Considering immediate management such as in line traction splinting.
Disability:
- Assess conscious level (GCS or AVPU)
- Assess for lateralizing sign
- Temperature
- BM/ blood glucose
E + everything else
Exposure:Completely expose patient to assess for any missed injuries whilst avoiding hypothermia.
- Discuss concerning findings with a senior
- Patient comfort: analgesia as in severe pain
- take an AMPLE history and secondary survey including a full head to toe examination to diagnose lesions that were missed on the primary survey.
In a secondary survey describe how you would examine the left lower limb in this case, and the key signs to assess for?
Establish:
- location and nature of any fractures
- identify features of peripheral neurovascular compromise
Ask: pt about location and severity of pain + distal parasthesia
Inspect both limbs for:
- deformity - angulation, shortening
- swelling
- wounds - superficial or open fracture
- discolouration/bruising
- colour/pallor
- perfusion status
Palpate:
- tenderness
- pressure - ?haematoma ?compartment syndrome
- pulses - femoral, popliteal, dorsalis pedis, post tibialis
- CRT, temp
- assess sensation
Move:
- joints esp hip for #NOF
- peripheral motor function
Neurovascular
Secondary survey assessment indicates an isolated left lower limb injury. What investigations would you order?
Haematological: Basic bloods (FBC, U&Es, LFT, clotting, X-match)
Radiological: AP and lateral radiographs of the left hip, knee femur (long view). CT scans may be helpful to assess for fractures if plain film radiographs are inconclusive.
How would you describe a fracture type on X-ray?
Complete:
- transverse
- oblique
- spiral
- comminuted
Incomplete:
- bowing
- buckle
- greenstick
Salter-Harris (involves growth plate)
How would you describe fracture location on X-ray?
- diaphysis
- metaphysis
- epiphysis
How would you describe fracture displacement on X-ray?
- angulation
- translation
- rotation
- distraction or impaction
How would you manage a patient with displaced fracture?
Prepare patient for surgery:
- Contact senior orthopaedics/ registrar,
- Reassess ABCDE and continue to resuscitate
- Traction and splinting to reduce pain and neurovascular/ soft tissue injury
- Chase bloods and ensure blood x-matched blood products available
- Peripheral neurovascular monitoring
- Analgesia
- Ensure patient consented + marked (only if you are competent to do so)
- Book the case/ notify the theatre team
- Contact anaesthetics for preoperative review
On further assessment, the patient is noted to have a peripherally a pale and cold leg and absent pulses. What are the main differential diagnoses in this case?
Compartment syndrome
traumatic arterial injury
devascularised limb
What are the key features of a devascularised limb?
**Hard signs
**
- Absent pulses
- Bruit or thrill
- Active or pulsatile haemorrhage
- Signs of limb ischemia/ compartment syndrome (the 6 Ps)
- Pulsatile or expanding hematoma
**Soft signs
**
- Proximity of injury to vascular structures
- Major single nerve deficit (e.g. sciatic, femoral)
- Non-expanding haematoma
- Reduced pulses (not absent)
- Posterior knee or anterior elbow dislocation
- Hypotension or moderate blood loss at the scene
What are other differentials of #NOF?
Anterior dislocation, but only 10% of dislocations are anterior.
Posterior dislocations are more common but limb is shortened and INTERNALLY rotated
What are the guidelines on VTE prophylaxis before surgery?
According to NICE:
Offer VTE prophylaxis for a month to people with fragility fractures of the pelvis, hip or proximal femur if the risk of VTE outweighs the risk of bleeding. Choose either:
- LMWH, starting 6 to12 hours after surgery or
- fondaparinux sodium, starting 6 hours after surgery, providing there is low risk of bleeding. [2018]
Consider pre‑operative VTE prophylaxis for people with fragility fractures of the pelvis, hip or proximal femur if surgery is delayed beyond the day after admission. Give the last dose no less than 12 hours before surgery for LMWH or 24 hours before surgery for fondaparinux sodium. [2018]
Consider intermittent pneumatic compression for people with fragility fractures of the pelvis, hip or proximal femur at the time of admission** if pharmacological prophylaxis is contraindicated.** Continue until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility
What are some complications of intracapsular #NOF?
- Avascular necrosis due to retrograde blood supply to femoral head
- Malunion
How is #NOF classified?
Garden’s classification
- type 1: stbale fracture with valgus impaction
- type 2: non-displaced, complete fracture
- type 3: displaced # with maintainence of ‘end to end’ contact
- type 4: completely displaced with no contact
type 3 and 4 inc risk of AVN
