Musculo-skeletal trauma and Emergency orthopaedics Flashcards
What are two core principles of treating severe trauma? [2]
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
How do you assess level of consciousness in a trauma incident? [4]
Which state is only normal state? [1]
Level of consciousness AVPU = Alert, verbal stimuli, painful stimuli, unresponsive
Alert = normal
Where should you assess when investigating an impacted joint?
Investigate the joint above and the joint below the area impacted
What is a polytrauma?
polytrauma= trauma to several body areas or organ systems. One or more of these may be life threatening
State out of lower and upper limb which is more life threatening [1] and more disabling [1]
Upper limb:
* More disabling
* Less life threatening
Lower limb:
* Less disabling
* Can be lifethreatening
How much blood loss is possible from the first 2hrs from
Tibia / fibula region [1]
Femur region [1]
Pelvic region [1]
Possible blood loss within the first 2 hours
tibia/fibia= 500ml
femur= 500ml
pelvic= 2000ml
Which type of fracture is called ‘the killing fracture’ [1]
Open pelvic fractures
Explain why open pelvic fractures are so problematic? [1]
- 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.
Open pelvic fracture bleeds are commonly caused by damage to which structures? [3]
- Posterior pelvic venous plexus (85%)
- Bleeding from trabecular bone
- < 10 % is arterial source
Explain specifically why the venous plexus undergoes such bad haemorrhage in an open pelvic fracture [2]
Pre-sacral venous plexus overlies sacro-iliac joint, fracture disrupts SI joint and tears veins causing bleeding
What is the mortality of open pelvice fracture? [1]
10-20%
Describe methods used to stabilise a pelvic fracture
External fixation = left for 8 weeks if possible
Define the damage the occurs in each of the following:
neuropraxia
axonotemsis
Neurotmesis
- Neurapraxia: no axonal discontinuity
- Axonotmesis: axoplasmic disruption endoneural sheath intact
- Neurotmesis: axon disrupted loss of tubules, support cells destroyed
Define what is meant by a degloving injury [1]
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
Define crush injury [1] and crush syndrome [1]
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.
Describe overview of treating severe soft tissue injuries [2]
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
Which organ may speficcally be damaged in soft tissue injury [1]
Kidney damage
How can you treat a non-displaced fracture? [1]
Simple splintage
What type of reduction would you use for a Colles fracture? [1]
Closed reduction (alignment without angulation) with a splint
What is an open reduction internal fixation (ORIF) used? [1]
Why is an ORIF useful? [1]
Name a risk of an ORIF [1]
ORIF:
* Used when internal fixation needed
* Allows v accurate reduction
* RIsk of an infection
Name two methods of holding fracture reduction? [2]
Semi rigid (plaster)
Rigid (internal fixation)
When creating a a fracture treatment plan, what do you need to think about? [4]
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?
What type of internal fixation is this? [1]
K wires
What type of internal fixation is this?
Intramedullary nail
State some different types of external stabilisations
All protect bone fracture when healing
What are absoulte indications for operative treatment? [5]
- Displaced intra-articular fractures
- Open fractures
- Fractures with vascular injury or compartment syndrome
- Pathological fractures
- Non-unions
What are current relative indications for operative treatment? [4]
- Loss of position with closed method
- Poor functional result with non-anatomical reduction
- Displaced fractures with poor blood supply
- Economic and medical indications
Which populations have quicker healing time?
Which bones have a quicker healing time? [1]
Children and upper limbs heal quicker than adults and lower limbs respectively
Healing time
Define what clinical union is [1]
Define what radiological union [1]
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
State the healing time for
:)
What is a fat embolism? [1]
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
What is an early [1] and late [3] complication to bone from trauma?
Early:
* infection: osteomyelitis
Late:
* Non-union
* Mal-union
* AVN
What is are early [4] and late [3] complication to soft tissue from trauma?
Early:
* Plaster sores
* Infection
* Neurovascular injury
* Compartment syndrome
Late:
* Tendon rupture
* Nerve compression
* Volkmann contracture
Define volkman contracture [1]
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.
What triad of things are you looking for with a fat embolism? [3]
Lung involement: causes hypoxaemia
Brain involvement: fat droplets get lodged in white matter in brain
Petachie: droplets get stuck in vessels and cause haemorrhage
Tx for fat embolism? [3]
Fluids
O2
Albumin
What are the 6Ps of compartment syndrome? [6]
Which one is early? [1] and which is late? [1]
Pale
Pulseless
Parenthesis: first stage
Pain
Paralysis: late stage
Polar
What pressures are normal in compartment? [1]
What are elevated [1] and emergency [1] pressures in a compartment?
Why are these clinically significant? [2]
Normal 0-10mmHg
Elevated 20-30mmHg: venous flow compromised
Emergency 30+ mmHg: arterial flow compromised
What pressures are normal in compartment? [1]
What are elevated [1] and emergency [1] pressures in a compartment?
Why are these clinically significant? [2]
Normal 0-10mmHg
Elevated 20-30mmHg
Emergency 30+ mmHg
Name for the procedure to treat compartment syndrome? [1]
How long should this be left open for to allow pressure to subside? [1]
Fasciotomy: open for five days or so to allow the pressure to go down.
What is delta pressure? [1]
How do you calculate delta pressure? [1]
Delta pressure:
* perfusion pressure of a compartment
* Delta pressure = diastolic blood pressure - intracompartment pressure
What delta pressures would be a definite indication [1] and relative indication for a fasciotomy? [2]
< 20mmHg = definite indication for a fasciotomy
< 30mmHg = relative indication for a fasciotomy
Apart from increases in delta pressures, name two indications for a fasciotomy [2]
- Interruption of arterial perfusion for 4 or more hours
- Clinical signs of acute compartment syndrome
