MSK tibial and open # teaching Flashcards
describe how high energy and low energy traumas can cause different patterns of tibial/fibular fractures
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
initial investigations for a tibial fracture
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
what is the initial management for a tibial fracture
ABCDE
re-aligned asap
repeat neurovascular exam and XR after
most are managed with IM nails
what complications are common post tibial fracture
DVT - needs 28 days of LMWH
compartment syndrome (within 48 hours)
how long should it take for union of tibial fractures
20-25 wks
what are the risks associated with IM nails as the management for tibial #
higher risk of compartment syndrome
risk of chronic anterior knee pain
what causes tibial plateau fractures
high-energy trauma, with axial loading, from the impaction of the femoral condyle onto the tibial plateau
management of tibial plateau fractures
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.
when generally for fractures is external fixation considered
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
define compartment syndrome
critical pressure increase within a confined compartmental space
what is the normal range for fascial compartment pressure
0mmHg to 8mmHg
pathophysiology of compartment syndrome
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).
presentation of compartment syndrome
pain out of proportion
pain on passive movement
pain despite strong analgesia
are there any investigations for compartment syndrome
clinical diagnosis
intra-compartmental pressure monitoring
in patients where there is suspicion but they are unconscious/ intubated or have an atypical presentation
management of compartment syndrome before emergency fasciectomy
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)
when do patients require review post emergency fasciectomy
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.
apart from ischaemia what is a complication that can arise from compartment syndrome
AKI
Monitor renal function closely, due to the potential effects of rhabdomyolysis or reperfusion injury
define open fractures
surrounding haematoma has communication with the external epithelial surface.
what are the three main sources of contamination you need to rule out in open fractures
marine
sewage
agricultural
what is an ample history
Allergies
Medications
PMHx
Last E&D
Events surrounding the injury (where, when, high impact, any other injuries)
what is the time frame that open fractures need to be managed within
Higher impact injury should be managed within 12 hours. Lower energy injuries should be managed within 24 hours.
inital management of open fractures
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
what medication can be given for open fractures as part of the management
Broad-spectrum antibiotic
tetanus vaccination is required if the patient is not fully up-to-date with their vaccination
what classification is used for open fractures
The Gustilo Anderson Classification
3A can be managed by orthopaedics alone, 3B requires plastics input, and 3C requires vascular input.
how long do you have to convert external fixation to internal fixation
3 days
