Mini Symposium - Fractures

Question 1

Define an open fracture?

Answer 1

One with direct communication from the fracture to the outside, usually via skin but sometimes elsewhere e.g. pelvic fragments pierce rectum

Question 2

Where do most open fractures occur?

Answer 2

> 50% are in the fingers or shaft of tibia

Question 3

How do we classify open fractures?

Answer 3

Using the Gustilo Classification
Types 1-3 based on:
- Wound size
- Soft tissue damage
- Periosteal of neurovascular damage
- Complexity of fracture

Question 4

,What guidelines do we follow for management of open fractures?

Answer 4

The national guidelines for orthopaedic & Plastic teams.
Made by BAPRAS which is the British Association of Plastic, reconstructive & Aesthestic surgeons

Question 5

How do we initially manage a open fracture?

Answer 5

ATLS assessment
Remove gross contaminents, photograph, cover with saline swabs and stabilize the limb

Also tetanus and Abx prophylaxis

Question 6

What drugs do we give for tetanus and Abx prophylaxis of an open fracture?

Answer 6

E.g. Cefuroxime/ augmentin/ clindamycin/ Gentamicin

For Tetanus:
- Booster Vaccine
- Tetanus Immunoglobulin

Question 7

What investigation is standard for any open fracture?

Answer 7

A bare-bones, basic-bitch, X-ray

Question 8

What would indicate you should do emergency (<6hrs) surgery for an open fracture?

Answer 8

If:
- Patient is polytraumatised
- Occurred in a marine or farmyard environment (infection risk)
- Gross contamination
- Neurovascular compromsie
- Compartment syndrome

Question 9

How do we surgically manage an open fracture?

Answer 9

Either Debridement and fixation if viable or an amputation

+ Plasic surgery for skin coverage

Question 10

How do we determine if muscle is viable for debridement and fixation?

Answer 10

Check the 4 Cs:
- Colour
- Contraction
- Consistency
- Capacity to Bleed

Question 11

Need for an amputation is scored by what factors?

Answer 11

• Limb ISchaemia
• Age
• Shock
• Injury mechanism (contamination/energy/complexity)

It’s a dual consultant decision

Question 12

Define dislocation vs subluxation?

Answer 12

Dislocation - Complete joint dislocation
Subluxation - Partial dislocation

Question 13

How do we manage a dislocation?

Answer 13

Emergency - Reduce and treat associated injuries
Surgery

Followed by physiotherapy for recurrent instability/stiffness

Question 14

What are the most common shoulder dislocations?

Answer 14

Anterior mostly
Posterior is rarer but associated iwth fits and electric shocks

Question 15

What are the most common elbow dislocations?

Answer 15

Posterior, look for a very prominent olecranon

Question 16

Whats the most common hip dislocations?

Answer 16

Posterior
Leg short, flexed, internally rotated and adducted

Question 17

Whats the most common knee dislocation?

Answer 17

Anterior then posterior
look for extended knee and loss of normal contour

Question 18

Whats the most common ankle dislocation?

Answer 18

Lateral
Look for externally rotated ankle and prominent medial malleolus

Question 19

Whats the most common way for the subtalar joint to dislocate?

Answer 19

Laterally, look for the laterally displaced calcaneus

Question 20

Summary of how to immediately manage an open fracture:

Answer 20

• ATLS assessment
• Tetanus/Abx prophylaxis
• Repeated exam of NV status
• Remove gross contaminants
• Photogrpah, cover & Stabilize
• Radiographs