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MSK > Mini Symposium - Fractures > Flashcards

Mini Symposium - Fractures Flashcards

1
Q

Define an open fracture?

A

One with direct communication from the fracture to the outside

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2
Q

Describe the Gustilo grading

Based on energy, wound size, soft tissue damage

A

Type 1 - low energy, wound <1cm, clean
Type 2 - moderate soft tissue damage, <10cm, no soft tissue flap or avulsion
Type 3 - high energy, wound >10cm

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3
Q

How do we initially manage a open fracture? [3]

A

ABCDE

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

Also tetanus and Abx prophylaxis

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4
Q

What would indicate you should do emergency (<6hrs) surgery for an open fracture? [4]

A

If:

  • Patient is polytraumatised
  • Occurred in a marine or farmyard environment (infection risk), gross contamination
  • Neurovascular compromsie
  • Compartment syndrome
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5
Q

How do we surgically manage an open fracture? [3]

A
  • Debridement and fixation if viable or
  • Amputate
    + Plasic surgery for skin coverage
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6
Q

How do we determine if muscle is viable for debridement and fixation? [4]

A

Check the 4 Cs:

  • Colour
  • Contraction
  • Consistency
  • Capacity to Bleed
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7
Q

Need for an amputation is scored by what factors? [4]

NB Its a dual consultant decision

A
  • Limb Ischaemia
  • Age
  • Shock
  • Injury mechanism (contamination/energy/complexity)
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8
Q

How do we manage a dislocation? [3]

A

Initial - Reduce and treat associated injuries
Surgery
Followed by physiotherapy for recurrent instability/stiffness

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9
Q

What are the most common shoulder dislocations?

A

Anterior mostly

Posterior is rarer but associated iwth fits and electric shocks

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10
Q

What are the most common elbow dislocations?

How would it appear?

A

Posterior, look for a very prominent olecranon

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11
Q

Whats the most common hip dislocations?

How would it appear?

A

Posterior

Leg short, flexed, internally rotated and adducted

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12
Q

Whats the most common knee dislocation?

How would it appear?

A

Anterior

look for extended knee and loss of normal contour

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13
Q

Whats the most common ankle dislocation?

How would it appear?

A

Lateral

Look for externally rotated ankle and prominent medial malleolus

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14
Q

Whats the most common way for the subtalar joint to dislocate?
How would it appear?

A

Laterally, look for the laterally displaced calcaneus

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15
Q

Describe 3 sub-stages of Type III open fracture according to Gustilo grading

A

IIIA - soft tissue damage but not grossly contaminated
IIIB - periosteal stripping, extensive muscle damage, heavy contamination
IIIC - associated neuromuscular complication

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16
Q

Reasons for fractures [3]

A

High energy transfer
Repetitive stress
Low energy transfer

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17
Q

Delayed union

A

Definition: failure to heal in expected time

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18
Q

Factors that turn off bone healing [4]

A

Infection
Steroids
Immunosuppressed
Smoking

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19
Q

Causes of delayed union [5]

A 
Distraction osteogenesis
Instability
Warfarin
NSAID
Ciprofloxacin
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20
Q

3 ways to deal with delayed unions

A

Different fixation
Dynamisation
Bone grafting

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21
Q

Stress fracture

A

Small linear fractures as a result of repeated stress

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22
Q

Complex fracture

A

multiple types of fractures occurring at one site

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23
Q

Features of non-union (failure to heal) [6]

A 
Pain and tenderness
Failure of calcification of fibrocartilage
Instability
Abundant callus formation
Persistent fracture line
Sclerosis
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24
Q

2 aims in treating fractures

A

Relieving pain

Restoring function

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25
Q

3 phases of bone healing

A

Inflammation
Reparative
Remodelling

26
Q

Modes of treatment of fracture
Conservative pros and cons
Surgery [2]
Risk: conservative vs surgery

A

Conservative management - rapid process, rehabilitation slow
Surgery
- ORIF + compression
- nailing/external fixation

Conservative low risk
Surgery high risk

27
Q

Measurement of fracture healing
Clinical examination
Radiological measurement [2]

A

Radiological measurement:

  • Bridging callus formation
  • Remodeling
28
Q

Early systemic problems [4], complications [2]

A

Problems - hypovolemia, crush syndrome, fat embolism, ARDS

Complications - bed rest complications DVT/PE, tetanus

29
Q

Early local problems [3], 1 complication

A

Early local problems

  • neuromuscular damage
  • skin wound problems
  • compartment syndrome

Complications - infection

30
Q

Late local problems [3], complications [4]

A

Problems-
delayed union
Non-union
avascular necrosis

Complications
malunion
CRPS type 1
implant failure
joint stiffness
31
Q

Malunion

A

Fracture that has healed but not in an anatomically correct position

32
Q

Infected non-union
What is one cause? [3]
Vulnerable group
3 modes of tx

A

Usually introduced at time of operation
Unstable fixation
Metastatic sepsis on foreign body implant

Vulnerable group - immunologically compromised

Tx

  • Suspect
  • Diagnose
  • Debridement
33
Q

Wrist Fractures
Focused history questions [3]
Examination [5] important aspects

A

Hand dominance, occupation, mechanism of injury
Ex: deformity, skin breaks - open fracture, vascular status, neurological status
Examine above and below

34
Q

Wrist fractures

X-ray - how to interpret 5 steps

A
  1. Patient’s details, type of x-ray
  2. Which bones are fractures
    - Distal radius
    - Distal ulna
    - Ulna styloid
  3. Is the fracture intra/extra-articular
  4. Comment on radial length - evidence of shortening
  5. Describe displacement and angulation of distal fragment
35
Q

Eponymous fractures
Colle’s fracture - what deformity is this associated with
Ax

A

Dinner fork

Ax: FOOSH

36
Q

Eponymous fractures
Smiths fractures - what relationship do these have to Colle’s
Ax

A

Reverse Colles fracture

Ax: falling backwards onto the palm of an outstretched hand or falling with wrist flexed

37
Q

Eponymous fractures

Barton fractures - mechanism of injury [2]

A

Shearing force, fall onto extended and pronated wrist

38
Q

Eponymous fractures

Chauffeurs fracture - associated injury?

A 
Scapholunate ligament
# of radial styloid
39
Q

Wrist fracture Mx
Options for anaesthesia [6]
Indicate which are typically used * [2]

A 
Reduction without anaesthesia
Oral/IV analgesia*
Hematoma block*
Bier block
Conscious sedation
GA
40
Q

Wrist fracture Mx for non-operative distal radius fractures [2]

A

Closed reduction

Casting in ED

41
Q

Wrist fracture Mx

Surgical interventions [2]

A

ORIF with volar or dorsal plate

External fixation

42
Q

Compartment syndrome definition [2]

A

Raised pressure within a closed compartment [1] resulting in tissue ischemia [1]

43
Q

Compartment syndrome - sequelae [3]

A

If untreated, necrosis > fibrosis > muscle contracture

44
Q

Compartment syndrome

Epidemiology [3]

A

M>F
<35yo
Leg then forearm - common sites

45
Q

Compartment syndrome

Causes - 2 mechanisms

A

Decreases in compartment size

Increase in compartment content

46
Q

Compartment syndrome

Causes by decrease in compartment size [4]

A

Closure of fascial defects
Tight plaster casts/bandages
Localised external pressure eg lying on limb
Pneumatic antishock garments

47
Q

Compartment syndrome

Causes by increase in compartment content [3]

A

Hemorrhage following soft tissue injury #
Post-op swelling and edema
Post-ischemic swelling eg after tourniquet use intra-operatively

48
Q

Compartment syndrome

Symptoms [3] + 6 P’s

A

Pain out of proportion [1] to the injury not improving with suitable opioids [1]
IN AN ALERT PATIENT [1]

Pain, pallor, pressure, paresthesia, paralysis, pulselessness

49
Q

Compartment syndrome

Examination - what would you see that would point to this diagnosis and why? [3]

A

Severe pain on passive stretching [1] of involved limbs digits ie fingers or toes [1] as this stretches the muscles within the affected compartment [1]

50
Q

Compartment syndrome

Diagnosis in a suspected patient who is sedated or unconscious - what investigation [1]

A

Pressure monitor inserted into compartments of affected limb

51
Q

What is the delta pressure [2]

A

A difference between the patients
compartment pressure and their diastolic
blood pressure [1] of less than 30mmHg [1] is suggestive of compartment syndrome

52
Q

Compartment syndrome

Initial management [2]

A

TIME IS MUSCLE
Remove any constrictive dressings or split them down to the skin
Hold limb at level of heart not above to promote arterial inflow

53
Q

Compartment syndrome

Gold standard management

A

Urgent fasciotomy - release of restrictive fascial compartment

54
Q

Fat embolism

Clinical features split into 3 groups

A

Respiratory
Dermatological
CNS

55
Q

Fat embolism: clinical features
Respiratory [3]
Dermatological [2]
CNS [2]

A

Respiratory

  • Early persistent tachycardia
  • Tachypnoea, dyspnoea, hypoxia usually 72 hours following injury
  • Pyrexia

Dermatological

  • Red/ brown impalpable petechial rash (usually only in 25-50%)
  • Subconjunctival and oral haemorrhage/ petechiae

CNS

  • Confusion and agitation
  • Retinal haemorrhages and intra-arterial fat globules on fundoscopy
56
Q

Fat embolism: imaging

A

CTPA

  • Tend to lodge distally so may not show any vascular occlusion
  • Ground glass appearance at periphery
57
Q

Fat embolism: treatment [3]

A

Prompt fixation of long bone fractures
DVT prophylaxis
General supportive care

58
Q

Complex regional pain syndrome (CRPS)
Ep [3]
Clinical features

A

1-5% after peripheral nerve injury
15-30% after Colles’ fracture
Higher incidence in women

PORT

  • Pain disproportionate to inciting event
  • Oedema + sudomotor
  • Reduced ROM but passive normal
  • Temperature + cooler changes
59
Q

CRPS
Describe the characteristic of pain [3]
What is sudomotor?
Mx

A

Continuous pain (hyperalgesia)
Allodynia
Aggravated by activity

Sudomotor: stimulation of sweat glands

Mx: early physiotherapy, neuropathic analgesia, refer to pain clinic

60
Q

What is CRPS?

Describe the 2 types of CRPS

A

Umbrella term for a number of conditions such as reflex sympathetic dystrophy and causalgia
It describes a number of neurological and related symptoms which typically occur following surgery or a minor injury.

Type 1* no demonstrable lesion to major nerve
Type 2: lesion present to major nerve

61
Q

Crush syndrome definition [2]

Pathophys [2]

A

Crush injury to large muscle mass like thigh or calf
Traumatic rhabdomyolysis

Pathophys:
Muscle ischemia > cell death with release of myoglobin
> acute tubular necrosis > acute renal failure

62
Q

Crush syndrome Clinical features [2]

Management

A

Dark amber urine positive for Hb
Acute renal failure signs (hypovolemia, metabolic acidosis, hyperkalemia, hypocalcemia, DIC)

Mx: IV fluids

MSK (28 decks)

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