LIMB INJURY Flashcards
1
Q
What is a fracture?
A
A discontinuity in the mechanical integrity of the cortex of a bone
2
Q
What is a compound fracture?
A
When skin is broken and broken bone is exposed to the air
3
Q
What is a stable fracture?
A
When sections of the bone remain in alignment with the fracture
4
Q
What is a pathological fracture?
A
When bones break due to abnormalities within the bone e.g. tumour, osteoporosis, Paget’s disease
5
Q
Which cancers metastasise to the bones?
A
Prostate
Kidney
Thyroid
Breast
Lung
6
Q
What are fragility fractures?
A
Fractures that occur due to weakness in the bone usually due to osteoporosis
They often occur without appropriate trauma usually required to break a bone
7
Q
How can you predict the risk of a fracture over the next 10 years?
A
Using the FRAX tool
8
Q
How do we measure bone mineral density?
A
DEXA scan to measure the T score at the hip
9
Q
What T score is osteopenia and osteoporosis?
A
Normal more than -1
-1 to -2.5 is osteopenia
<-2.5 is osteoporosis
10
Q
What imaging should all fractures get?
A
2 XR views
11
Q
ABCs approach to looking for fractures on an XR?
A
Adequacy and Alignment
Bone - fractures
Cartilage - joint space widened or distorted?
Soft tissues - effusions or swellings
12
Q
What are the types of complete fractures?
A
Transverse
Spinal
Oblique
Comminuted
Segmental
13
Q
What are the types of incomplete fractures?
A
Bowing
Buckle
Greenstick
14
Q
What is a transverse fracture and what mechanism causes it?
A
A fracture perpendicular to the long axis of the bone
Occurs due to tension of the bone
15
Q
What is a spiral fracture and what mechanism causes it?
A
A severe oblique fracture with rotation along the long axis of the bone
Occurs due to torsion forces
16
Q
What is an oblique fracture and what mechanism causes it?
A
Fractures that like obliquely to the long axis of the bone
From compressive forces
17
Q
What is a segmental fracture?
A
When there is more than 1 fracture along a bone
18
Q
What is a comminuted fracture and what mechanism causes it?
A
This is similar to a segmental fracture where the bone has been broken in two or more places, but the break is more of a shatter, resulting in several different bone fragments.
Occurs due to high energy force
19
Q
What is an avulsion fracture?
A
This occurs when a small piece of bone that is attached to a ligament or tendon gets drawn away from the main part of the bone. This is common in joints such as the ankles, elbows, and hips.
20
Q
How can you categorise fractures?
A
Displaced Fracture vs Non-Displaced Fracture
Closed Fracture vs open fracture
21
Q
What is a bowing fracture
A
Bowing fractures are incomplete fractures of tubular long bones in paediatric patients as they have some elasticity to their bones (especially the radius and ulna)
22
Q
What is a buckle fracture?
A
A buckle fracture occurs when one side of the bone bends or is compressed but the other side remains intact.
Seen in paediatrics
23
Q
What is a greenstick fracture?
A
when a bone bends and breaks, but doesn’t break into two separate pieces
Usually seen in paediatrics
24
Q
What is a Salter-Harris fracture?
A
A fracture involving the growth plate in paediatric patients
25
What classification system can be used for open fractures?
Gustilo and Anderson classification system
26
Outline the Gustilo and Anderson classification system?
Type 1: <1cm wound and clean
Type 2: 1-10cm wound and clean
Type 3A: >10cm wound and high-energy, but with adequate soft tissue coverage
Type 3B: >10cm wound and high-energy, but with inadequate soft tissue coverage
Type 3C: All injuries with vascular injury
27
What are the 3 stages to managing a fracture?
Reduction
Hold
Rehabilitation
28
What is fracture reduction?
Restoring the anatomical alignment of a fracture q
29
What are the 4 reasons for reducing a fracture?
Tamponade of bleeding at fracture site
Reduction in traction on the surrounding soft tissues which will reduce the swelling
Reduction in traction along traversing nerves reducing the risk of neuropraxia
Reduction of pressures on transversing blood vessels
30
What are the 2 ways a fracture can be reduced?
Closed - manual manipulation of bones
Open - surgical. Usually followed by internal fixation
31
How are fractures immobilised?
Splints
Casts = plaster of Paris or loghtweaight cast
Internal - Nails and screws and plates
Collar, cuff sling
32
When might a fracture need a traction splint?
When there is strong muscular pull across the fracture site which makes the fracture unstable e.g. subtrocganteric NOF or pelvic fractures
33
What is an ‘above knee’ plaster?
This is when the plaster crosses over both above and below the damaged joint
Used when there is risk of axial instability as it prevents the limb rotating on its long axis
34
What is the main complications of internal fixation?
Osteomyelitis
35
How should you manage an open fracture?
Urgent realignment and splinting of Assess and document the neurovascular status following any realignment or reduction.
Broad-spectrum antibiotic cover should be administered and a tetanus vaccination is required if the patient is not fully up-to-date with their vaccination.
Photograph the wound and remove any gross debris. Dress the wound with a saline-soaked gauze. - this should be done within 6 hours of injury
Ensure definitive skeletal stabilisation; if soft tissue coverage is required, this should happen within 72 hours, or as guided by plastic surgeon advice.
If there is vascular compromise, this needs immediate surgical exploration by vascular surgery.
36
What is the rehabilitation stage of managing a fracture?
Intensive PT following fracture management to prevent muscle wasting and reduce joint stiffness
It starts immediately after the fracture!
37
Local complications of fractures?
Non-union
Mal-union
Ulcers
Muscle wasting
Joint stiffness
Reflex sympathetic dystrophy
Painful scar
Infection
Nerve injury
Compartment syndrome
Contractures
Arthritis
38
Systemic complications of fractures?
Bedsores
Pneumonia and hospital acquired infections
DVT and PE
Systemic inflamamtory response/fat embolism
Haemorrhage leading to shock and potentially death
Chronic pain
Complex regional pain sundrome
39
What are operative treatment options for fixation of a fracture?
Internal fixation:
Intramedullary - kirshner wires, nails
Extramedullary - plate, screws, cerclage wires
External fixation:
E.g. Circular frames, hybrid frames
40
What is “bag of bones” treatment?
A conservative treatment method where you accept the displacement of the bony fragments. There is a brief stage of immobilisation following by early mobilisation
Used when bone quality or fracture pattern was not sufficient to gain stable fixation e.g. in the elderly
41
What is the most common fracture in the elderly?
NOF
42
Aetiology of NOF #?
In the elderly it’s usually low energy e.g. falls
In younger pt its high energy such as RTAs
43
Outline the blood supply to the neck of femur?
Retrograde blood supply from the medial femoral circumflex artery which lies on the neck of femur
44
30 day mortality of NOF #?
12 month mortality?
10%
Up to 30% at 12 months
45
How soon should surgery be performed on NOF #?
Within 48 hours
46
What are the 2 broad categories of NOF #?
Intra-capsular
Extra-capsular - can be trochanteric or subtrochanteric
47
What is the Garden classification?
A classification system for intra-capsular fractures
48
Outline the Garden classification?
1 - non-displaced and incomplete
2 - non-displaced but complete
3 - partially displaced but still with bony contact, but complete
4 - fully displaced and complete
49
In which levels of Garden classification is blood supply disruption most common for intracapsular NOF #?
Gardner type 3 and 4 as these are displaced
50
Examination findings for NOF #?
Shortened, abducted, externally rotated leg
Unable to straight leg raise
Pain on internal and external rotation
(Remember to check neurovascular status of the whole lower limb)
51
How are undisplaced intracapsular fractures managed?
Internal fixation
52
How are displaced intracapsular NOF # managed?
hemiarthroplasty
or total hip replacement if good baseline i..e can walk independantly outside with no more than a stick, not cognitively impaired and medically fit for procedure
53
Why are extracapsular NOF # managed differently to intracapsular NOF #?
These leave the blood supply to the head of the femur intact so the head of femur does not need to be replaced
54
How are intertrochanteric NOF # managed?
Dynamic hip screw
55
How are subtrochanteric NOF # managed?
Intramedulalry device
56
How are hemiarthroplasty and total hip replacement different?
Hemiarthroplasty = replacing the head of the femur but leaving the acetabulum in place. Cement is used to hold the stem of the prosthesis in the shaft of the femur.
Total hip replacement = replacing the head of the femur and the socket. Better for pt who can walk independantly and are fit for surgery.
57
What is a pelvic ring fracture and what causes it?
When 1 part of the pelvis fractures another part will also fracture as it is in a ring
Most commonly occur from high energy blunt trauma e.g. RTA
58
Why are pelvic fractures managed as trauma?
As they often lead to significant intra-abdominal bleeding which can lead to shock and death
They can also lead to neurological deficit, urogenital trauma dn bowe injury
59
What is a sesamoid bone?
a small bone found embedded within a muscle or tendon near joint surfaces
E.g. patella embedded in quadriceps tendon
60
How can patella fracture occur?
Directly injured e.g. blow to knee
Indirectly e.g. quadriceps forcefully contract against a block to knee extension
61
How does a patella fracture present?
Swelling
Bruising
Pain around knee
Palpable gap in knee
May be diffiuclty to do straight leg raise
62
What is a stress fracture?
A fracture that occurs due to repeated mechanical stress
63
Where is the most common site of a metatarsal stress fracture?
The 2nd metatarsal shaft
64
Whats the most common site for a fracture in the foot?
5th proximal metatarsal
65
What is a pseudojones fracture? what are jones fractures?
Pseudojones: A proximal avulsion fracture of the 5th metatarsal. More common
Jones: a transverse fracture at the metaphyseal-diaphyseal junction - much less common
66
Whats the least commonly fractured metatarsal?
The 1st metatarsal
67
Whats the likely mechanism of injury for a pseudo-jones fracture?
Inversion injury of the ankle
68
Presentation of metatarsal fractures?
Pain and bony tenderness
Swelling
Antalgic gait
69
investigations for ?metatarsal fracture?
X-rays: distinguishes between displaced and non-displaced fractures which guides management. Although stress fractures may appear normal on X-ray, sometimes there is a periosteal reaction seen on 2-3 weeks later.
Isotope scan or MRI: in the case of stress fractures, X-rays are often normal and may remain normal in up to half of all cases.
70
What is a lisfranc injury?
A midfoot injury - a tarsometatarsal joint fracture between the medial cuneiform and the base of the 2nd metatarsal
They can be solely ligamentous or fracture-dislocations
71
What can cause a lisfranc injury?
Severe torsional or translational forces applied through a plantar flexed foot e.g. athletic injuries or RTA
72
Presentation of a lisfranc injury?
Severe pain in midfoot
Difficult weight bearing
Swelling and tenderness over midfoot
Plantar bvurising
Piano key sign is prominence of the metatarsal bones which reduce back down with pressure
73
Radiological features of a lisfranc injury?
Widening of the interval between the base of the first and second metatarsals
Bony fragment visible in the space between the 1st and 2nd metatarsal (avulsion of lisfranc ligament from base of 2nd metatarsal)
Disruption of line drawn from medial base of 2nd metatarsal to medial side of middle cuneiform
Malalignment of the medial border of the lateral cuneiform and the medial edge of the 3rd metatarsal or the medial border of the cuboid and medial edge of the 4th metatarsal
Dorsal displacement of the proximal bases of the 1st or 2nd metatarsals
74
What classification is used for Lisfranc injuries?
Hardcastle and myerson classification
75
How common are clavicle fractures?
3% of all fractures!
76
What classification system is used for clavicle fractures?
Allman classification system
77
Outline the Allman classification system?
Type 1 - fracture of the middle 1/3rd of the clavicle. Stable but significant deformity is present. - 75%
Type 2 - fracture of the lateral 1/3rd of the clavicle. When displaced they are often unstable - 20%
Type 3 - fracture of the medial third of the clavicle. Commonly associated with multisystem poly trauma. Can be associated with neurovascular compromise, pneumothorax or haemothorax. Only 5%
78
What mechanism causes clavicle fractures?
Direct - trauma to clavicle
Indirect - fall onto shoulder
The medial fragment will often displace superiorly due to the pull of the sternocleidomastoid muscle and the lateral fragment will displace inferiorly from the weight of the arm
79
Presentation of clavicle fractures?
Sudden onset localised severe pain that nearly always follows trauma
Limited mobility
Deformity
Open injuries or threatened skin are common as clavicle is very superficial
80
Management of clavicle fractures?
Conservatively with single most commonly. Early movement is important to prevent frozen shoulder!
If open it ill require surgical fixation
81
Prognosis of clavicle fractures?
Non-union is a major complication and is most associated with a distal 1/3rd clavicle fracture
Healing time for most fractures is 4-6 weeks
82
Who do olecranon fractures affect and what is the mechanism?
Bimodal:
Young - high energy trauma
Old - low energy trauma e.g. pt falling on outstretched arm resulting in the sudden pull of the triceps muscle whose site of insertion is in the olecranon
83
Presentation of olecranon head fractures?
Elbow pain
Swelling
Lack of mobility
Tenderness palpating over posterior aspect of elbow with a potentially palpable defect
Inability to extend elbow against gravity due to disruption of triceps mechanism
84
What is the most common fracture of the elbow?
The radial head fracture
85
What mechanism usually causes radial head fracture?
Indirect trauma with axial loading of the forearm causing the radial head to be pushed against the capitulation of the humerus
Most commonly occcurs with the arm in extension and pronation e.g. FOOSH
86
Clinical features of a radial head fracture?
history of FOOSH -> elbow pain, swelling, tenders over lateral aspect of elbow and radial head
Pain worse with supination and pronation
87
How are radial head fractures classified?
Using the Mason classification
88
Why are humeral shaft fractures at a reasonably high risk of neurovascular injury?
As the radial nerve travels posteriorly on the humeral shaft so its at high risk of injury
89
What usually causes a humeral shaft fracture?
FOOSH
Falling lateral onto an adducted limb
90
Clinical features of a humeral shaft fracture?
Pain and deformity following trauma
If the radial nerve is involved there may be reduced sensation over the dorsal 1st webspace and weakness in wrist extension
91
What is a Holstein-Lewis fracture?
a fracture of the distal 1/3rd of the humerus resulting in entrapment of the radial nerve. This causes loss of sensation in radial distribution and a wrist drop. This requires urgent surgical management
92
Prognosis of humeral shaft fractures?
Good in most cases
90% of radial nerve injuries will improve within 3 months
93
What is a toddlers fracture?
An oblique fracture of the distal tibia
Occurs in children aged 9 months-3 years
94
Outline the Salter-Harris classification system?
SALTR
1 - fracture through physis only (Straight)
2 - fracture through physis and metaphysis (Above growth plate)
3 - fracture through physis and epiphysis (Low to growth plate)
4 - fracture involving the physis, epiphysis and metaphysis (Through)
5 - crush injury involving the physis (cRush)
95
Whats the most common Salter Harris fracture?
Type 2!
96
Prognosis of salter Harris fractures?
Type 1 and 2 usually have goof outcomes with conservative management
Types 3 and 4 usually require surgery as they are associated with greater displacement and instability. Usually ORIF is done.
If a fracture is missed or mismanaged it can result in disruption or early closure of the growth oplate resulting in impaired function, growth arrest or limb deformity
97
Outline the structure of the growth plate?
Epiphysis, physis and metaphysis
The physis is the hyaline cartilage plate found at each end of the long bones in children and is the site of endochondral ossification where chondrocytes replace cartilage with bone resulting in growth
98
When do growth plates usually close?
Females 13-15
Males 15-17
99
What mechanism usually causes growth plate fractures?
Falls or twists
Les commonly caused by repetitive activities e.g. gymnastics or running
100
Clinical features of growth plate fractures?
Pain at affected site
Unable to weight bear
Bruising and swelling
Visible deofmirty in severe cases
101
Investigations for growth plate fractures?
At least 2 views of XR. Image the joints above and below too
May require CT or MRI to inform operative planning or to assess surrounding soft tissues
102
Signs with fractures that suggest NAI?
• Delayed presentation
• Delay in attaining milestones
• Lack of concordance between proposed and actual mechanism of injury
• Multiple injuries
• Injuries at sites not commonly exposed to trauma
• Children on the at risk register
• Fractures of different ages
• Metaphyseal corner fractures
• Evidence of occult rib fractures - common if child has been grabbed by the chest and shaken
• Spiral fractures cannot be cased by simple falling because they are as result of twisting forces
103
What are the 3 most common fractures associated with NAI?
Radial
Humeral
Femoral
104
What is compartment syndrome?
Characterised by raised pressure within a closed anatomical space which will eventually compromise tissue perfusion and result in necrosis
Occurs following fractures or ischaemia reperfusion injury in vascular patients
Rarely can occur from tight plaster casts or compression bandages
105
What are the 2 fractures most associated with compartment syndrome?
Supracondylar fractures
Tibial shaft fractures
106
Presentation of compartment syndrome?
pain on passive and active movement that is out of proportion to injury
paraesthesia, pallor, may be paralysis. Likely still have pulses - late presentations
Affected compartment may feel tense but will not be swollen
If disease progresses then the 5 Ps of acute limb ischaemia may present
107
Pathophysiology of compartment syndrome?
Fascial compartments are closed and cannot be distended so any fluid deposited there will increase the intra-compartmental pressure
As pressure increases the veins will be compressed which increases the hydrostatic pressure within them causing fluid to move down its gradient and out of the veins into the compartment, further increasing the pressure
Next the traversing nerves are compressed which can cause a sensory or motor deficit
As the intra-compartmental pressure reaches the diastolic bp the arterial inflow will be compromised and the leg will become ischaemic
108
How is compartment syndrome diagnosed?
Clinical diagnosis
Most reliable diagnostic test is an intra-compartmental pressure monitor
CK may be raised
109
Management of compartment syndrome?
Fasciotomy
(Monitor renal function closely due to potential effects of rhabdomyolysis or reperfusion injury
110
What is volkmanns contracture?
A fixed flexion contracture of the hanf and wrist resulting in a claw-like deformity of the hand and fingers
This can occur when compartment syndrome is left untreated as it causes necrosis of the muscles of the flexor compartment in the forearm
111
What are the long term physical, psychological and socioeconomic consequences of trauma?
• Physical
◦ Chronic pain
◦ Mobility limitations
◦ Permenant disabilities or functional impairments
• Psychological
◦ PTSD
◦ Depression and anxiety
• socioeconomic
◦ Financial strain e.g. time off work
◦ Social isolation
◦ Occupational challenges
112
What are the stages of bone healing?
Reactive phase - Haematoma forms
Reparative phase - cellular tissue grows out to form a callus and then this is gradually replaced with lamellar bone
Remodelling - osteoclasts strengthen the new bones along the lines of stress when pt returns to normal function
113
What factors can influence the healing rate of a fracture?
Infection
Poor alignment
Disrupted vascular supply
Age
Smoking
Poor nutrition/deficiencies
Systemic disease
Meds e.g. steroids
114
What heals faster cancellous or cortical bone?
Cancellous
115
What heals faster an upper or a lower limb?
Upper limb is half the time of a lower limb
116
What most commonly causes a colles fracture?
FOOSH
117
What is a classic colles fracture?
A fracture with 3 of the following features:
Transverse fracture of the radius 1 inch proximal to the radiocarpal joint
Dorsal displacement
Angulation
118
What is a dinner fork type deformity?
Seen in colles
A distal radius fracture with dorsal displacement of the fragments
119
What are the common complications of colles fractures?
Early - median nerve injury, compartment syndrome, vascular compromise, malunion, rupture of extensor pollicis longus tendon
Late - OA, complex regional pain syndrome
120
What is a smiths fracture?
A reverse colles fracture
Volar angulation of the distal radius fragment (called a garden spade deformity)
121
What causes a smiths fracture?
Falling backwards into the plan of an outstretch hand or falling with the wrists flexed
122
What is a Bennett’s fracture?
An intra-articular fracture at the base of the thumb metacarpal
123
What causes a Bennett’s fracture?
Impact on a flexed metacarpal e.g. fist fight
124
What is a monteggias fracture?
Dislocation of the proximal radioulnar joint in associated with an ulnar fracture
125
What causes a monteggias fracture?
FOOSH with forced pronation
126
What is a galeazzi fracture?
A radial shaft fracture with associated dislocation of the distal radioulnar joint
127
What causes a galeazzi fracture?
FOOSh with a rotational force superimposed
128
What is a Barton’s fracture?
A distal radius fracture (colles or smiths) with associated radiocarpal dislocation so that the hand and carpal bones are displaced along with the fragment segment
129
What causes a Barton’s fracture?
Fall onto an extended and pronated wrist
130
What is the most common carpal fracture?
A scaphoid fracture
131
Whats the issue with scaphoid fracture imaging?
They are not visible on initial imaging in 16% of cases so often need to be re-imaged 10-14 days later
132
Whats the big complication with scaphoid fractures and why?
Avascular necrosis
The surface of the scaphoid is covered by articular cartilage with a small area available for blood vessels. 80% of the blood supply is derived from the dorsal carpal branch of the radial artery in a retrograde manner so risk of interruption
133
What usually causes scaphoid fractures?
FOOSH
Contact sports
(Axial compression of the scaphoid with wrists hyperextended and radially deviated)
134
How do scaphoid fractures present?
Swelling and tenderness in the anatomical snuffbox
Pain along the radial aspect of the wrist, at base of thumb, on wrist movement and on longitudinal compression of the thumb and on ulnar deviation of the wrist.
May be loss of grip and pinch strength
135
What test can be done to help diagnosed scaphoid fracture?
Positive scaphoid compression test - exert longitudinal pressure down the thumb to compress the scaphoid - this causes pain in the wrist
136
Investigations for scaphoid fracture?
Plain film radiographs should be requested of the wrist in the AP, and lateral view, 'Scaphoid views': posterioranterior (PA), lateral, oblique (with wrist pronated at 45º) and Ziter view (PA view with the wrist in ulnar deviation and beam angulated at 20º)
A CT scan is superior to plain film radiographs, and may be requested in the context of ongoing clinical suspicion, planning operative management, or to determine the extent of fracture union during follow-up.
MRI is considered the definite investigation to confirm or exclude a diagnosis, NICE guidance from 2016 suggested the MRI should be considered the first-line imaging following clinical examination. However, this is still not common practice in the UK
however, MRI is much more commonly used second-line when radiographs are inconclusive
137
Management of scaphoid fractures?
cast for 6-8 weeks is effective in >95%. Professional sports people may benefit from early surgical intervention. If displaced or proximal scaphoid pole fractures then it requires surgical fixation.
138
Function of the flexor digitorum profundus?
Flexes MCP, PIP and DIP joints
Cannot flex fingers individually!
139
Presentation of flexor digitorum profundus injury?
Loss of flexion of DIP joints only
(Doesn’t affect MCP and PIP as these can still be flexed by the flexor digitorum superficialis)
T
To test this hold their finger straight and see if they can bend the tip of the finger
140
Function of flexor digitorum superficialis?
To flex the MCP and PIP joints - the action is independent of the adjacent fingers
141
Presentation of flexor digitorum superficialis injury?
As long as FDP is still intact then a finger will not be able to flex whilst the adjacent fingers are held in the extended position
By holding the other fingers in extension you keep the FDP tendon extended so any flexion in PIP joints must be from the FDS
142
What is the fallout sign?
When the flexor digitorum superficialis and profundus are both severed
the patient will be unable to flex the distal phalanges of the fingers (bend them downwards) and will exhibit a characteristic posture where the fingers remain extended at the DIP, but are flexed at the PIP and MCP
143
What is a boutonnière deformity? What causes it?
the finger is flexed at the PIP, and there is hyperextension at the DIP
Due to division of the extensor tendon over the PIP joint
144
What is mallet finger deformity?
What causes it?
Drooping of the tip of the finger
Due to division of the extensor tendon distal to the PIP joint
145
Risk factors for NOF #?
Increasing age
Osteoporosis
Osteomalacia
Falls
Instability
Lack of core strength
Gait disturbance
Sensory impairment
146
What are examples of acute knee injuries?
Acute patellar dislocation
Collateral ligament rupture
Contusion
Meniscus injury
ACL injury
147
Whats the most common long bone fracture?
Tibia
148
What classification is used for ankle fractures?
The Weber classifxtion - note this is for farctyres of the lateral malleolus
149
Outline the Danis-Weber classification for ankle fractures?
This classification is based on the level of the fibular fracture relative to the syndesmosis
A - fracture below the tibiotalar joint
B - fracture at the level of the tibiotalar joint - may or may not partially tear the syndesmosis
C - fractures above the tibiotalar joint - will disrupt the syndesmosis
150
Management of ankle fracture?
Weber classification:
A - conservative.
B - cnervstive if stable and no talar shift otherwise reduction and immobilisation
C - reduction and immobilisation
151
What is the sensitivity of Ottawa ankle rules?
Nearly 100%
152
Whats the aim of Ottawa ankle rules?
To try to minimise unnecessary use of XR
153
What are the Ottawa ankle rules?
An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings:
• bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular)
• bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia)
• inability to walk four weight bearing steps immediately after the injury and in A&E
154
What usually causes ankle fractures?
Indirect injury .g. Inversion injury of ankle
So are commonly associated with dislocations and ligament injuries
155
What mechanism usually causes talus fractures?
Forced dorsiflexion e.g. RTA, fall from height
156
What mechanism usually causes calcaneum fractures?
Falling onto the hell e.g. falling from a height
So commonly associated with spine, pelvis, tibial plateau fractures
And also commonly bilateral
157
What are pilon fractures?
A type of fracture that occurs when the lower end of the tibia is severely damaged by a high energy force
These are bad!
158
Common mechanism for pilon fractures?
high energy axial load (most common)
talus is driven into the plafond resulting in articular impaction of the distal tibia
E.g. falls from height and motor vehicle accidents
159
What are the Ottawa rules for a foot XR?
A foot x-ray is required if there is any pain in the midfoot zone and any of these findings:
• Bone tenderness at Navicular bone
• Bone tenderness at base of the 5th metatarsal
• Inability to weight bear both immediately and in the emergency department
160
What are Ottawa rules for a knee XR?
An xray is indicated in patients with knee injuries with any of the following:
• Age >=55
• Tenderness at the head of the fibula
• Isolated tenderness of the patella (i.e. no other bony tenderness)
• Inability to flex knee to 90 degrees
• Inability to walk 4 weight bearing steps immediately after the injury and in the emergency department (4 steps limping is ok)
161
Most common open fracture/
Tibia
162
Which group of pts are prone to compartment syndrome but may present atypically?
IVDUs
163
Necrotising fasciitis: causative organism?
Group A strep - strep pyogenes most common
164
Necrotising fasciitis: typical pt?
Elderly frail comorbid pt
Diabetes, alcohol excess, immunosuppression, IVDU
165
Necrotising fasciitis: where is the infection?
In the subcutaneous tissue and it destroys the fascia
166
Necrotising fasciitis: signs
Tenderness
Oedema
Crepitus
Skin blistering
Greyish draining - dishwater pus
Pink/orange skin staining
Skin gangrene - late sign
Shock, coagulopathy and multi organ failure
Fever - often absent
167
Necrotising fasciitis: management?
Analgesia
Call microbiology for Abx choice
Call orthopaedics/plastic surgeons
168
Necrotising fasciitis: scoring syste,
Laboratory Risk Indicaor for Nectrosing Fascitis
A score based off these:
CRP
WBC
Hb
Na+
Cr
Glucose
169
Septic arthritis: investigations
Bloods: FBC, CRP, blood cultures, Coag studies, uric acid
XR (rule out osteomyelitis and chondrocalcinosis)
Synovial fluid aspirate with urgent gram stain and crystals - gold standard
170
Septic arthritis: causative organisms
Most common overall - staph aureus
Young adults sexually actively: neisseria gonorrhoea
