MSK tibial and open # teaching

Question 1

describe how high energy and low energy traumas can cause different patterns of tibial/fibular fractures

Answer 1

high energy mechanisms often result in a fibula fracture at the same level as the tibia, whilst low energy fractures often result in a fibula fracture at a different level

Question 2

initial investigations for a tibial fracture

Answer 2

neurovascular examination
Urgent bloods, including a coagulation and Group and Save
AP and lateral XR of tibia and fibula should be requested, need to include the knee and ankle
for suspected more complicated fractures CT may be indicated

Question 3

what is the initial management for a tibial fracture

Answer 3

ABCDE
re-aligned asap
repeat neurovascular exam and XR after
most are managed with IM nails

Question 4

what complications are common post tibial fracture

Answer 4

DVT - needs 28 days of LMWH
compartment syndrome (within 48 hours)

Question 5

how long should it take for union of tibial fractures

Answer 5

20-25 wks

Question 6

what are the risks associated with IM nails as the management for tibial #

Answer 6

higher risk of compartment syndrome
risk of chronic anterior knee pain

Question 7

what causes tibial plateau fractures

Answer 7

high-energy trauma, with axial loading, from the impaction of the femoral condyle onto the tibial plateau

Question 8

management of tibial plateau fractures

Answer 8

uncomplicated: hinged knee brace and analgesia for 8-12 weeks + physio

Most commonly ORIF to restore the joint surface congruence and ensure joint stability. hinged knee brace is fitted with an early passive range of movement
non-weight bearing for around 8-12 weeks months is typically required.

Question 9

when generally for fractures is external fixation considered

Answer 9

significant soft tissue injury (e.g. not enough skin coverage for the open wound), polytrauma and highly comminuted fractures where an immediate ORIF may not be suitable.
or not clinically stable enough for ORIF

Question 10

define compartment syndrome

Answer 10

critical pressure increase within a confined compartmental space

Question 11

what is the normal range for fascial compartment pressure

Answer 11

0mmHg to 8mmHg

Question 12

pathophysiology of compartment syndrome

Answer 12

veins become compressed by increasing pressure.
This increases the hydrostatic pressure within them, so fluid to moves out of the veins into the compartment
Nerves can also be compressed causing a sensory +/- motor deficit in the distal distribution (Paraesthesia).
As the intra-compartmental pressure reaches the diastolic blood pressure, the arterial inflow will be compromised, and the leg will become ischaemic (may see the 6Ps at this point).

Question 13

presentation of compartment syndrome

Answer 13

pain out of proportion
pain on passive movement
pain despite strong analgesia

Question 14

are there any investigations for compartment syndrome

Answer 14

clinical diagnosis

intra-compartmental pressure monitoring
in patients where there is suspicion but they are unconscious/ intubated or have an atypical presentation

Question 15

management of compartment syndrome before emergency fasciectomy

Answer 15

Keep the limb at a neutral level
high flow oxygen
intravenous crystalloid fluids to transiently improves perfusion of the affected limb
Remove all dressings / splints / casts, down to the skin
Treat symptomatically with opioid analgesia (usually intravenous)

Question 16

when do patients require review post emergency fasciectomy

Answer 16

24-48 hours to assess for any dead tissue that needs to be debrided. If the remaining tissues are healthy, the wounds can then be closed.

Question 17

apart from ischaemia what is a complication that can arise from compartment syndrome

Answer 17

AKI
Monitor renal function closely, due to the potential effects of rhabdomyolysis or reperfusion injury

Question 18

define open fractures

Answer 18

surrounding haematoma has communication with the external epithelial surface.

Question 19

what are the three main sources of contamination you need to rule out in open fractures

Answer 19

marine
sewage
agricultural

Question 20

what is an ample history

Answer 20

Allergies
Medications
PMHx
Last E&D
Events surrounding the injury (where, when, high impact, any other injuries)

Question 21

what is the time frame that open fractures need to be managed within

Answer 21

Higher impact injury should be managed within 12 hours. Lower energy injuries should be managed within 24 hours.

Question 22

inital management of open fractures

Answer 22

ABCDE
Photograph the wound and remove any gross debris
if any need for surgical washout (contamination) cover with sterile saline soaked gauze
urgent realignment and splinting of the limb is warranted.
re-assess and document the neurovascular

Question 23

what medication can be given for open fractures as part of the management

Answer 23

Broad-spectrum antibiotic
tetanus vaccination is required if the patient is not fully up-to-date with their vaccination

Question 24

what classification is used for open fractures

Answer 24

The Gustilo Anderson Classification
3A can be managed by orthopaedics alone, 3B requires plastics input, and 3C requires vascular input.

Question 25

how long do you have to convert external fixation to internal fixation

Answer 25

3 days