Mini Symposium - Fractures Flashcards
Define an open fracture?
One with direct communication from the fracture to the outside
Describe the Gustilo grading
Based on energy, wound size, soft tissue damage
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
How do we initially manage a open fracture? [3]
ABCDE
Remove gross contaminents, photograph, cover with saline swabs and stabilize the limb
Also tetanus and Abx prophylaxis
What would indicate you should do emergency (<6hrs) surgery for an open fracture? [4]
If:
- Patient is polytraumatised
- Occurred in a marine or farmyard environment (infection risk), gross contamination
- Neurovascular compromsie
- Compartment syndrome
How do we surgically manage an open fracture? [3]
- Debridement and fixation if viable or
- Amputate
+ Plasic surgery for skin coverage
How do we determine if muscle is viable for debridement and fixation? [4]
Check the 4 Cs:
- Colour
- Contraction
- Consistency
- Capacity to Bleed
Need for an amputation is scored by what factors? [4]
NB Its a dual consultant decision
- Limb Ischaemia
- Age
- Shock
- Injury mechanism (contamination/energy/complexity)
How do we manage a dislocation? [3]
Initial - Reduce and treat associated injuries
Surgery
Followed by physiotherapy for recurrent instability/stiffness
What are the most common shoulder dislocations?
Anterior mostly
Posterior is rarer but associated iwth fits and electric shocks
What are the most common elbow dislocations?
How would it appear?
Posterior, look for a very prominent olecranon
Whats the most common hip dislocations?
How would it appear?
Posterior
Leg short, flexed, internally rotated and adducted
Whats the most common knee dislocation?
How would it appear?
Anterior
look for extended knee and loss of normal contour
Whats the most common ankle dislocation?
How would it appear?
Lateral
Look for externally rotated ankle and prominent medial malleolus
Whats the most common way for the subtalar joint to dislocate?
How would it appear?
Laterally, look for the laterally displaced calcaneus
Describe 3 sub-stages of Type III open fracture according to Gustilo grading
IIIA - soft tissue damage but not grossly contaminated
IIIB - periosteal stripping, extensive muscle damage, heavy contamination
IIIC - associated neuromuscular complication
Reasons for fractures [3]
High energy transfer
Repetitive stress
Low energy transfer
Delayed union
Definition: failure to heal in expected time
Factors that turn off bone healing [4]
Infection
Steroids
Immunosuppressed
Smoking
Causes of delayed union [5]
Distraction osteogenesis Instability Warfarin NSAID Ciprofloxacin
3 ways to deal with delayed unions
Different fixation
Dynamisation
Bone grafting
Stress fracture
Small linear fractures as a result of repeated stress
Complex fracture
multiple types of fractures occurring at one site
Features of non-union (failure to heal) [6]
Pain and tenderness Failure of calcification of fibrocartilage Instability Abundant callus formation Persistent fracture line Sclerosis
2 aims in treating fractures
Relieving pain
Restoring function
3 phases of bone healing
Inflammation
Reparative
Remodelling
Modes of treatment of fracture
Conservative pros and cons
Surgery [2]
Risk: conservative vs surgery
Conservative management - rapid process, rehabilitation slow
Surgery
- ORIF + compression
- nailing/external fixation
Conservative low risk
Surgery high risk
Measurement of fracture healing
Clinical examination
Radiological measurement [2]
Radiological measurement:
- Bridging callus formation
- Remodeling
Early systemic problems [4], complications [2]
Problems - hypovolemia, crush syndrome, fat embolism, ARDS
Complications - bed rest complications DVT/PE, tetanus
Early local problems [3], 1 complication
Early local problems
- neuromuscular damage
- skin wound problems
- compartment syndrome
Complications - infection
Late local problems [3], complications [4]
Problems-
delayed union
Non-union
avascular necrosis
Complications malunion CRPS type 1 implant failure joint stiffness
Malunion
Fracture that has healed but not in an anatomically correct position
Infected non-union
What is one cause? [3]
Vulnerable group
3 modes of tx
Usually introduced at time of operation
Unstable fixation
Metastatic sepsis on foreign body implant
Vulnerable group - immunologically compromised
Tx
- Suspect
- Diagnose
- Debridement
Wrist Fractures
Focused history questions [3]
Examination [5] important aspects
Hand dominance, occupation, mechanism of injury
Ex: deformity, skin breaks - open fracture, vascular status, neurological status
Examine above and below
Wrist fractures
X-ray - how to interpret 5 steps
- Patient’s details, type of x-ray
- Which bones are fractures
- Distal radius
- Distal ulna
- Ulna styloid - Is the fracture intra/extra-articular
- Comment on radial length - evidence of shortening
- Describe displacement and angulation of distal fragment
Eponymous fractures
Colle’s fracture - what deformity is this associated with
Ax
Dinner fork
Ax: FOOSH
Eponymous fractures
Smiths fractures - what relationship do these have to Colle’s
Ax
Reverse Colles fracture
Ax: falling backwards onto the palm of an outstretched hand or falling with wrist flexed
Eponymous fractures
Barton fractures - mechanism of injury [2]
Shearing force, fall onto extended and pronated wrist
Eponymous fractures
Chauffeurs fracture - associated injury?
Scapholunate ligament # of radial styloid
Wrist fracture Mx
Options for anaesthesia [6]
Indicate which are typically used * [2]
Reduction without anaesthesia Oral/IV analgesia* Hematoma block* Bier block Conscious sedation GA
Wrist fracture Mx for non-operative distal radius fractures [2]
Closed reduction
Casting in ED
Wrist fracture Mx
Surgical interventions [2]
ORIF with volar or dorsal plate
External fixation
Compartment syndrome definition [2]
Raised pressure within a closed compartment [1] resulting in tissue ischemia [1]
Compartment syndrome - sequelae [3]
If untreated, necrosis > fibrosis > muscle contracture
Compartment syndrome
Epidemiology [3]
M>F
<35yo
Leg then forearm - common sites
Compartment syndrome
Causes - 2 mechanisms
Decreases in compartment size
Increase in compartment content
Compartment syndrome
Causes by decrease in compartment size [4]
Closure of fascial defects
Tight plaster casts/bandages
Localised external pressure eg lying on limb
Pneumatic antishock garments
Compartment syndrome
Causes by increase in compartment content [3]
Hemorrhage following soft tissue injury #
Post-op swelling and edema
Post-ischemic swelling eg after tourniquet use intra-operatively
Compartment syndrome
Symptoms [3] + 6 P’s
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
Compartment syndrome
Examination - what would you see that would point to this diagnosis and why? [3]
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]
Compartment syndrome
Diagnosis in a suspected patient who is sedated or unconscious - what investigation [1]
Pressure monitor inserted into compartments of affected limb
What is the delta pressure [2]
A difference between the patients
compartment pressure and their diastolic
blood pressure [1] of less than 30mmHg [1] is suggestive of compartment syndrome
Compartment syndrome
Initial management [2]
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
Compartment syndrome
Gold standard management
Urgent fasciotomy - release of restrictive fascial compartment
Fat embolism
Clinical features split into 3 groups
Respiratory
Dermatological
CNS
Fat embolism: clinical features
Respiratory [3]
Dermatological [2]
CNS [2]
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
Fat embolism: imaging
CTPA
- Tend to lodge distally so may not show any vascular occlusion
- Ground glass appearance at periphery
Fat embolism: treatment [3]
Prompt fixation of long bone fractures
DVT prophylaxis
General supportive care
Complex regional pain syndrome (CRPS)
Ep [3]
Clinical features
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
CRPS
Describe the characteristic of pain [3]
What is sudomotor?
Mx
Continuous pain (hyperalgesia)
Allodynia
Aggravated by activity
Sudomotor: stimulation of sweat glands
Mx: early physiotherapy, neuropathic analgesia, refer to pain clinic
What is CRPS?
Describe the 2 types of CRPS
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
Crush syndrome definition [2]
Pathophys [2]
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
Crush syndrome Clinical features [2]
Management
Dark amber urine positive for Hb
Acute renal failure signs (hypovolemia, metabolic acidosis, hyperkalemia, hypocalcemia, DIC)
Mx: IV fluids