Musculoskeletal Trauma Flashcards
1
Q
What is essential when ordering X-rays for suspected fracture
A
Always view the whole bone with joint above and joint below
2
Q
What are the 4 principles of fracture management
A
- Resuscitate
- Reduce
- Hold
- Rehabilitate
3
Q
What are the benefits of temporary splintage of fractures prior to x-ray
A
- Reduces pain and haemorrhage
- Reduces chance of closed fractures converting to open
4
Q
What should be performed if the viability of overlying skin is in danger due to deformity
A
Gently manipulate under entonox to correct the deformity
5
Q
How should open fractures initially be managed
A
- IV antibiotics ASAP
- Remove obvious contaminants from very contaminated wound in ED
- Take bacterial swab
- Photograph the wound
- Cover with sterile saline-soaked gauze
6
Q
When does a fracture not require reduction
A
- Undisplaced
- Displacement likely to be corrected by remodelling e.g. children
- Patient very old with high anaesthetic risk
7
Q
When are broad-arm slings indicated
A
Support of the distal limb when support of the fracture is needed e.g. clavicle fractures
8
Q
When is a collar-and cuff sling indicated
A
For support of the distal limb where traction is desirable e.g shaft/neck of humerus
9
Q
List the advantages of internal fixation
A
- Anatomical reduction and absolute stability
- Allows primary bone healing
- Allows early mobilisation of joints
- Earlier discharge
10
Q
List the advantages of external fixation
A
- Rapid application
- Useful for multiple injuries
- Stabilises comminuted fractures not amenable to ORIF
- Provides fixation outside the zone of injury and allows access to open wounds
11
Q
What pressure is diagnostic of compartment syndrome requiring fasciotomy
A
DBP - intracompartmental pressure <=30mmHg
12
Q
When should debridement and lavage take place within for open fractures
A
- 6 hours for heavy contamination
- 24 hours for isolated open fractures
13
Q
What classification system is used for open fractures
A
Gustillo-Anderson classification
14
Q
Describe Gustillo Type 1 fractures
A
- Wound <1cm
- Little soft-tissue damage
- Simple fracture pattern with little comminution
15
Q
Describe Gustillo Type 2 fractures
A
- Wound >1cm
- No extensive soft-tissue damage
- Moderate contamination and fracture comminution
16
Q
Describe Gustillo Type 3A fractures
A
- Extensive soft tissue damage
- Coverage is adequate
- Comminution is included
17
Q
Describe Gustillo Type 3B fractures
A
- Extensive soft tissue damage
- Inadequate coverage
- Requires local of free flap
18
Q
Describe Gustillo Type 3C fractures
A
Arterial injury that requires repair
19
Q
What scoring system assesses severity of open fractures indicating need for amputation
A
Mangled Extremity Severity Score
20
Q
What MESS score indicates amputation
A
> 7
21
Q
How much blood can be lost from a closed pelvic fracture
A
1-5 litres
22
Q
How much blood can be lost from a closed femoral fracture
A
1-2.5 litres
23
Q
How much blood can be lost from a closed tibial fracture
A
0.5-1.5 litres
24
Q
How much blood can be lost from a closed humeral fracture
A
0.5-1.5 litres
25
Biochemical results in DIC
- Prolonged clotting times
- Thrombocytopenia
- Decreased fibrinogen
- Increased fibrinogen degradation products
26
SIRS criteria
2 or more of:
- Pyrexia >38 or <36
- Tachycardia >90
- Tachypnoea >20 or PaCO2 <4.26
- WCC >12
27
What are the implications of SIRS in surgical planning
Patients with signs of SIRS should not be exposed to major surgery until their condition improves as the patient may exceed their physiological capacity to autoregulate local organ and systemic circulation
28
How does Fat embolism syndrome present
- Petechial rash
- Confusion
- Hypoxia
29
Why does fat embolism occur
Fracture leads to:
- Release of lipid globules from damaged bone marrow fat cells
- Increased peripheral mobilisation of fatty acids
- Increased synthesis of triglycerides by the liver
30
What systems can be effected by Fat embolism syndrome
- Pulmonary
- Cerebral
- Cardiac
- Renal
- Skin
31
How is fat embolism treated
- Prompt fixation of long bone fractures
- DVT prophylaxis
- General supportive care
32
What structures are at risk in proximal humeral fractures
- Axillary nerve
| - Posterior circumflex humeral artery
33
What structures are at risk in mid-shaft humeral fractures
Radial nerve
34
What structures are at risk in paediatric supracondylar fractures
- Radial nerve (most common)
- Median/ulnar nerve
- Brachial artery
35
What structures are at risk from distal radial fractures
Median nerve
36
What structures are at risk in acetabular fractures/hip dislocation
Sciatic nerve
37
What structures are at risk in knee dislocation
- Popliteal artery
| - Common peroneal nerve
38
Most common cause of cellulitis following fractures
Streptococcus pyogenes
39
Cause of gas gangrene
Clostridium perfringens (gram-positive spore forming rods)
40
Rate of spread of gas gangrene
2-3cm/hr
41
Clinical features of gas gangrene
- Shock, septicaemia
- Limb initially cool becoming discoloured
- Crepitus under skin
42
How is gas gangrene treated
- Surgical debridement
- High dose penicillin
- Hyperbaric oxygen (increasing pO2 in tissues inhibits bacteria metabolism and reduces necrosis)
43
What are the symptoms of tetanus infection
- Headache
- Muscle stiffness around the jaw
- Rigid abdominal muscles
- Sweating and fever
44
When do symptoms of tetanus develop after infection
3 days to 3 weeks (typically 7-8 days)
45
What causes tetanus infection
Clostridium tetani
- Gram-positive rods
- Obligate anaerobes
46
What two toxins are produced by clostridium tetani
1. Tetanospasmin (carried to CNS)
| 2. Tetanolysis (haemolytic)
47
How should tetanus at risk wounds be managed in those who are fully vaccinated
- >10 years since last dose = repeat full course
| - >5 years since last dose = repeat for tetanus prone wounds
48
How should tetanus at risk wounds be managed in those who are not fully vaccinated
- Give tetanus toxoid
| - Give tetanus immunoglobulin for tetanus prone wounds
49
What causes necrotising fasciitis
- Synergistic infection with anaerobic and aerobic organisms
- Can occur with Strep pyogenes
50
What causes Fournier's gangrene
E.coli and bacteroids
51
List the 4 most common sites of avascular necrosis
- Femoral head
- Proximal scaphoid
- Humeral head
- Body of talus
52
Describe myositis ossificans
Calcification within a muscle
53
What is complex regional pain syndrome type 1 also known as
- Reflex sympathetic dystrophy
- Sudeck's atrophy
- Algodystrophy
- Shoulder-hand syndrome
54
What are the features of complex regional pain syndrome type 1
- Pain (out of proportion of the injury)
- Swelling
- Stiffness
- Colour change (redness)
55
What are the 3 stages of CRPS type 1
1. Pain and tenderness with warm, dry, swollen limb
2. Cool, sweaty, swollen cyanotic limb
3. Stiffness, atrophy and osteoporosis
56
What causes CRPS type 1
- Injury alters afferent neurons
- Altered sympathetic activity
- Reduced venous drainage
57
How is CRPS type 1 treated
- Usually self-limiting
- Physio
- Optimised analgesia
- Sympathetic blockade
58
Describe CRPS type 2
A.K.A. Causalgia - same features as CRPS type 1 but with a demonstrable nerve lesion
59
Which direction of shoulder dislocation is more common
Anterior
60
What is the difference between a Bankhart lesion and True Bankhart lesion
- True Bankhart = capsule torn from glenoid anteriorly
| - Bankhart = labrum torn
61
Site and cause of Hill-Sachs lesion
Impression fracture on the posterolateral head from the glenoid
62
On examining a dislocated shoulder, where should sensation be checked
Regimental badge area to assess for axillary nerve damage
63
What x-ray view is required to exclude posterior dislocation of the humerus
Axial (tangential) view
64
Outline Kocher's method for reducing a shoulder dislocation
- Midazolam (max 6mg)
- Traction and counter-traction holding above flexed elbow
- External rotation to 75 degs
- Adduction across chest
- Internal rotation
65
What should be done following shoulder reduction
- Check x-ray
- Broad-arm sling
- Counsel on 50% recurrence rate within 2 years
- Early mobilisation
66
Describe TUBS dislocation
- Traumatic
- Unilateral
- Bankhart lesion
- Surgery
67
Describe AMBRI dislocation
- Atraumatic ('born loose)
- Multidirectional
- Bilateral
- Rehabilitation
68
What structures must you be wary of when performing a Bankhart repair
- Cephalic vein between deltoid and pec major
| - Musculocutaenous nerve when dividing common tendon of coracobrachialis and short head of biceps
69
Most common site of clavicle fractures
Junction between the middle and outer 1/3rds (middle 1/3rd segment)
70
When does floating shoulder complicate clavicular fractures
Clavicle fractures associated with proximal humeral fractures
71
How are greenstick and undisplaced clavicular fractures managed
- Broad-arm sling
- Mobilise at 2-4 weeks
- Strengthen at 6-10 weeks
72
How can anterior drift of the scapula be corrected in clavicle fractures with marked displacement
- Ring or Quoit method
| - Figure-of-eight bandage
73
What x-ray views are recommended to assess clavicle fractures
- AP
| - 15 degrees cephalic tilt to asses superior/inferior displacement
74
What are the absolute indications for ORIF in mid clavicular fractures
- Open fractures
- Displaced with skin tenting
- Subclavian artery/vein injury
- Floating shoulder
- Symptomatic non-union/malunion
75
What are the relative indications for ORIF in mid clavicular fractures
- Displaced with >2cm shortening
- Bilateral displaced fractures
- Brachial plexus injury
- Closed head injury
- Seizure disorder
- Polytrauma patient
76
Describe the pathoanatomy of ACJ dislocation
Clavicle loses all contact with scapula - conoid and trapezoid ligaments tear away from inferior border of clavicle
77
Outline the management of ACJ dislocation
- No gross instability = broad-arm sling for 4-6 weeks
| - Reliant on overhead work = fixation with lag screw
78
Important nerve relations in surgical neck of humerus fractures
- Axillary nerve
| - Circumflex humeral vessels
79
Important nerve relations in the spiral groove of the humerus
- Radial nerve
| - Profundal brachii vessels
80
Important nerve relations of the posterior aspect of the medial epicondyle
Ulnar nerve
81
Classification system for humeral fractures
Neer classification
82
What distinguishes a 'part' of a proximal humeral fracture
Significant size and have either:
- 1 cm of displacement
- 45 degrees of angulation
83
What is the most common proximal humeral fracture in children
Greenstick fracture of the surgical neck - Neer 1
84
How should basic proximal humeral fractures be managed
- Conservative with collar and cuff
- Hand and elbow mobilisation from day 1
- Shoulder mobilisation at 3 weeks
85
What type of plate is used in multiple-part proximal humeral fractures
Philos plate
86
How are fracture-dislocations of the humerus managed and why
Hemiarthroplasty due to risk of AVN
87
In which direction does the proximal fragment tend to migrate in A) upper-shaft, B) mid-shaft humeral fractures and why
A) Adducted by pull of pec major
| B) Abducted by deltoid
88
What is the management of simple humeral shaft fractures
- Long-arm plaster with collar and cuff
| - U-slab
89
When should internal fixation or IM nailing be considered in humeral shaft fractures
- 2 fractures in the same limb
- Multiple injuries
- Fractures in both arms
- Significant head injury
- Pathological fracture
- Radial nerve palsy
90
Management of undisplaced adult supracondylar fracture
Casting
91
Management of displaced adult supracondylar fracture
ORIF using medial and lateral plates
92
Outline the management of intercondylar humeral fractures
- Undisplaced = long-arm cast w/ collar and cuff
- Displaced = double-plate fixation with intrafragmentary screws to reconstruct articular surface
- Elderly and very displaced = elbow replacement
93
Outline the management of olecranon fractures
- Undisplaced = elbow in flexion in long-arm cast for 6-8 weeks
- Displaced = screw fixation or tension-band wiring
- Comminuted = plate fixation
94
What is fracture is commonly associated with posterior dislocation of the elbow
Coronoid fracture
95
Outline the management of coronoid fractures
- Conservative unless more than half of the coronoid is involved
- Internal fixation may be used to prevent dislocation
96
Outline the management of radial head fractures
- Undisplaced = simple immobilisation for 2 weeks
- Displaced = ORIF
- Excision and replacement if severely comminuted
97
Define a Essex-Lopresti fracture
Serious force causing tearing of the interosseous membrane and severe comminution of the radial head, associated with subluxation of the distal end of the ulna
98
What are the complications of radial head surgery
Posterior interosseous nerve damage
99
Outline the management of radial neck fractures
Depends on angulation:
- <30 = simple immobilisation
- >30 = MUA
- >45 or dislocated = ORIF in adults (open reduction only in children)
100
Define a Monteggia fracture
Fracture of the proximal ulna with dislocation of the radial head (Monty loses his head)
101
Define a Galeazzi fracture
Fracture of the shaft of the radius is accompanied by dislocation of the distal ulna
102
Outline the management of Monteggia and Galeazzi fractures
ORIF
103
How do you identify axial rotation of the ulna in fractures
In the lateral projection the olecranon, coronoid, and styloid process should all be clearly visible - this is lost in axial rotation
104
How do you identify axial rotation of the radius in fractures
- Discrepancy in the widths of the fragments at fracture level
- Relationship between radial tubercle and styloid (tubercle is medial in supination and lateral in pronation)
105
What muscle pronates the distal fragment in radial shaft fractures
Pronator teres
106
Outline the management of forearm shaft fractures in children
- Undisplaced angulated greenstick = correct angulation under GA
- Displaced = MUA and plaster for 3-4 weeks
(ORIF if stable reduction cannot be maintained)
107
Define a Colles' fracture
Dorsally/radially displaced fracture of the radius within 2.5cm of the wrist
108
What fracture is associated with Colles' fracture
Avulsion fracture of the ulna styloid
109
What degree of displacement required reduction in Colles' fracture
>=10 degrees of dorsal tilt
110
How should a Colles' fracture be held in reduction
- Volar displacement
- Ulnar deviation
- Slight flexion
111
What tendon may suffer delayed rupture in Colles' fracture
Extensor pollicis longus
112
Define a Smiths' fracture
- Reverse Colles'
| - Extra-articular distal radius fracture with volar displacement
113
Define a Barton's fracture
Intra-articular fracture of the distal radius
114
What provides the main blood supply to the scaphoid
Dorsal carpal branch of the radial artery
115
What part of the scaphoid is most at risk of AVN in fracture
Proximal pole
116
What should you do if you suspect scaphoid fracture but it is not visible on x-ray
- Futura splint
- MRI in 10 days
- Fracture clinic review
117
How should un-displaced scaphoid fractures be managed
- Scaphoid plaster
| - Wrist is pronated, radially deviated and moderately dorsiflexed
118
How should displaced scaphoid fractures be managed
Fixation with dual-pinch Herbert screw
119
Describe the Garden classification for intracapsular hip fractures
- Garden 1 = impacted fracture, inferior cortex not completely broken
- Garden 2 = complete but undisplaced fracture
- Garden 3 = complete, partially displaced fracture
- Garden 4 = completely displaced fracture
120
Management of stable trochanteric fracture
DHS
121
Management of subtrochanteric fracture
Gamma nail
122
Approximate blood loss from femoral shaft fracture
1-1.5L
123
Describe orthograde IM nailing of the femur
Nail inserted via tip of the GT
124
X-rays required in suspected patella fracture
- AP
| - Skyline (Tangential)
125
Outline the management of patella fractures
- Vertical = conservative with cylinder cast
| - Displaced horizontal = tension band wiring if the articular surface can be restored
126
What system is used to classify tibial plateau fractures
Schatzker classification
127
Outline the management of tibial plateau fractures
- Table depression <5mm with no ligament damage = hinged knee brace for 6 weeks
- Displacement >10mm = ORIF
128
Describe Volkmann's ischaemia
Popliteal artery damage in proximal tibial fractures causing calf ischaemia
129
Tibial fracture uniting time
16 weeks
130
Outline the management of tibial fractures
- Transverse minimally displaced = long-leg cast
- Diaphyseal = nail
- Metaphyseal = plate
131
Outline the Weber ankle fracture classification
- Type A = fibula fracture below the syndesmosis
- Type B = starts at level of syndesmosis
- Type C = initiated above the syndesmosis and associated with syndesmotic injury
132
List the indications for fixation in ankle fractures
- Talar shift
- Potential talar shift
- Fibular fracture above inferior tibiofibular joint
- Displaced medial malleolus
- Fibula shortening
- Significantly displaced articular fragments
133
Describe the immediate management of unstable ankle fractures
Reduction in backslab prior to ORIF
134
Describe a Holstein-Lewis fracture
Fracture of distal 1/3rd humerus with radial nerve entrapment
