Musculo-skeletal trauma and Emergency orthopaedics

Question 1

What are two core principles of treating severe trauma? [2]

Answer 1

Treat life threatening injuries 1st
* e.g. apply pressure to haemorrhage from an open wound / reduce a pelvic fracture if haemodynamically unstable, etc

Prevent long term complications:
* systematic examination of everything and planned treatment of non-life threatening injuries when patient stable

Question 2

How do you assess level of consciousness in a trauma incident? [4]
Which state is only normal state? [1]

Answer 2

Level of consciousness AVPU = Alert, verbal stimuli, painful stimuli, unresponsive
Alert = normal

Question 3

Where should you assess when investigating an impacted joint?

Answer 3

Investigate the joint above and the joint below the area impacted

Question 4

What is a polytrauma?

Answer 4

polytrauma= trauma to several body areas or organ systems. One or more of these may be life threatening

Question 5

State out of lower and upper limb which is more life threatening [1] and more disabling [1]

Answer 5

Upper limb:
* More disabling
* Less life threatening

Lower limb:
* Less disabling
* Can be lifethreatening

Question 6

How much blood loss is possible from the first 2hrs from

Tibia / fibula region [1]
Femur region [1]
Pelvic region [1]

Answer 6

Possible blood loss within the first 2 hours

tibia/fibia= 500ml
femur= 500ml
pelvic= 2000ml

Question 7

Which type of fracture is called ‘the killing fracture’ [1]

Answer 7

Open pelvic fractures

Question 8

Explain why open pelvic fractures are so problematic? [1]

Answer 8

• Due to the number of blood vessels: both internal and external iliac arteries and veins.
• pelvis is usually the protective structure for these vessels
• fractured and fracture dislocations involving the sacroiliac joint can rupture any of these vessels.

Question 9

Open pelvic fracture bleeds are commonly caused by damage to which structures? [3]

Answer 9

• Posterior pelvic venous plexus (85%)
• Bleeding from trabecular bone
• < 10 % is arterial source

Question 10

Explain specifically why the venous plexus undergoes such bad haemorrhage in an open pelvic fracture [2]

Answer 10

Pre-sacral venous plexus overlies sacro-iliac joint, fracture disrupts SI joint and tears veins causing bleeding

Question 11

What is the mortality of open pelvice fracture? [1]

Answer 11

10-20%

Question 12

Describe methods used to stabilise a pelvic fracture

Answer 12

External fixation = left for 8 weeks if possible

Question 13

Define the damage the occurs in each of the following:

neuropraxia
axonotemsis
Neurotmesis

Answer 13

• Neurapraxia: no axonal discontinuity
• Axonotmesis: axoplasmic disruption endoneural sheath intact
• Neurotmesis: axon disrupted loss of tubules, support cells destroyed

Question 14

Define what is meant by a degloving injury [1]

Answer 14

avulsions or detachment of the skin and subcutaneous tissue from the underlying muscle and fascia secondary to a sudden shearing force applied to the skin surface

Question 15

Define crush injury [1] and crush syndrome [1]

Answer 15

Crush injury:
* Injury caused as a result of direct physical crushing of the muscles due to something heavy.

Crush syndrome:
* Also termed rhabdomyolysis, involves a series of metabolic changes produced due to an injury of the skeletal muscles of such a severity as to cause a disruption of cellular integrity and release of its contents into the circulation.

Question 16

Describe overview of treating severe soft tissue injuries [2]

Answer 16

All severe soft tissue injuries require urgent treatment because of potential complications

After treatment of the soft tissue injury the fracture requires fixation

A severe soft-tissue injury will delay fracture healing

PRICE:
* Protect
* Rest
* Ice
* Compression
* Elevate

Question 17

Which organ may speficcally be damaged in soft tissue injury [1]

Answer 17

Kidney damage

Question 18

How can you treat a non-displaced fracture? [1]

Answer 18

Simple splintage

Question 19

What type of reduction would you use for a Colles fracture? [1]

Answer 19

Closed reduction (alignment without angulation) with a splint

Question 20

What is an open reduction internal fixation (ORIF) used? [1]

Why is an ORIF useful? [1]
Name a risk of an ORIF [1]

Answer 20

ORIF:
* Used when internal fixation needed
* Allows v accurate reduction
* RIsk of an infection

Question 21

Name two methods of holding fracture reduction? [2]

Answer 21

Semi rigid (plaster)
Rigid (internal fixation)

Question 22

When creating a a fracture treatment plan, what do you need to think about? [4]

Answer 22

When can the patient load the injured limb?

When can the patient be allowed to move the joints?

How long will we have to immobilise the fracture for?

If internal fixation used should be leave it there or remove it?

Question 23

What type of internal fixation is this? [1]

Answer 23

K wires

Question 24

What type of internal fixation is this?

Answer 24

Intramedullary nail

Question 25

State some different types of external stabilisations

Answer 25

All protect bone fracture when healing

Question 26

What are absoulte indications for operative treatment? [5]

Answer 26

* Displaced intra-articular fractures * Open fractures * Fractures with vascular injury or compartment syndrome * Pathological fractures * Non-unions

Question 27

What are current relative indications for operative treatment? [4]

Answer 27

* Loss of position with closed method * Poor functional result with non-anatomical reduction * Displaced fractures with poor blood supply * Economic and medical indications

Question 28

Which populations have quicker healing time? Which bones have a quicker healing time? [1]

Answer 28

**Children and upper limbs** heal quicker than adults and lower limbs respectively

Question 29

# Healing time Define what clinical union is [1] Define what radiological union [1]

Answer 29

**Clinical union**: * the bones move as one and can be tender when stressed **Radiological union:** * Bridging callus formation * Fracture line is often still present * Remodelling

Question 30

State the healing time for

Answer 30

:)

Question 31

What is a fat embolism? [1]

Answer 31

Fat embolism syndrome occurs when embolic fat macroglobules pass into the small vessels of the lung and other sites, roducing endothelial damage and **resulting respiratory** fapilure (acute respiratory distress syndrome (ARDS-like) picture), **cerebral dysfunction**

Question 32

What is an early [1] and late [3] complication to bone from trauma?

Answer 32

Early: * **infection: osteomyelitis** Late: * **Non-union** * **Mal-union** * **AVN**

Question 33

What is are early [4] and late [3] complication to soft tissue from trauma?

Answer 33

**Early**: * Plaster sores * Infection * Neurovascular injury * Compartment syndrome **Late**: * Tendon rupture * Nerve compression * Volkmann contracture

Question 34

Define volkman contracture [1]

Answer 34

Volkmann contracture is a **deformity of the hand, fingers, and wrist caused by injury to the muscles of the forearm**. The condition is also called Volkmann ischemic contracture.

Question 35

What triad of things are you looking for with a fat embolism? [3]

Answer 35

**Lung involement**: causes hypoxaemia **Brain involvement**: fat droplets get lodged in white matter in brain **Petachie**: droplets get stuck in vessels and cause haemorrhage

Question 36

Tx for fat embolism? [3]

Answer 36

Fluids O2 Albumin

Question 37

What are the 6Ps of compartment syndrome? [6] Which one is early? [1] and which is late? [1]

Answer 37

Pale Pulseless Parenthesis: first stage Pain Paralysis: late stage Polar

Question 38

What pressures are normal in compartment? [1] What are elevated [1] and emergency [1] pressures in a compartment? Why are these clinically significant? [2]

Answer 38

Normal 0-10mmHg **Elevated 20-30mmHg**: venous flow compromised **Emergency 30+ mmHg**: arterial flow compromised

Question 39

What pressures are normal in compartment? [1] What are elevated [1] and emergency [1] pressures in a compartment? Why are these clinically significant? [2]

Answer 39

Normal 0-10mmHg Elevated 20-30mmHg Emergency 30+ mmHg

Question 40

Name for the procedure to treat compartment syndrome? [1] How long should this be left open for to allow pressure to subside? [1]

Answer 40

**Fasciotomy**: open for five days or so to allow the pressure to go down.

Question 41

What is delta pressure? [1] How do you calculate delta pressure? [1]

Answer 41

**Delta pressure**: * perfusion pressure of a compartment * Delta pressure = **diastolic blood pressure - intracompartment pressure**

Question 42

What delta pressures would be a definite indication [1] and relative indication for a fasciotomy? [2]

Answer 42

**< 20mmHg** = definite indication for a fasciotomy **< 30mmHg** = relative indication for a fasciotomy

Question 43

Apart from increases in delta pressures, name two indications for a fasciotomy [2]

Answer 43

* Interruption of arterial perfusion for 4 or more hours * Clinical signs of acute compartment syndrome