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Trauma > Musculoskeletal Trauma > Flashcards

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

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2
Q

What are the 4 principles of fracture management

A
  1. Resuscitate
  2. Reduce
  3. Hold
  4. Rehabilitate
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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

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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

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5
Q

How should open fractures initially be managed

A
  1. IV antibiotics ASAP
  2. Remove obvious contaminants from very contaminated wound in ED
  3. Take bacterial swab
  4. Photograph the wound
  5. Cover with sterile saline-soaked gauze
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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
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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

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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

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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
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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
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11
Q

What pressure is diagnostic of compartment syndrome requiring fasciotomy

A

DBP - intracompartmental pressure <=30mmHg

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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

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13
Q

What classification system is used for open fractures

A

Gustillo-Anderson classification

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14
Q

Describe Gustillo Type 1 fractures

A
  • Wound <1cm
  • Little soft-tissue damage
  • Simple fracture pattern with little comminution
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15
Q

Describe Gustillo Type 2 fractures

A
  • Wound >1cm
  • No extensive soft-tissue damage
  • Moderate contamination and fracture comminution
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16
Q

Describe Gustillo Type 3A fractures

A
  • Extensive soft tissue damage
  • Coverage is adequate
  • Comminution is included
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17
Q

Describe Gustillo Type 3B fractures

A
  • Extensive soft tissue damage
  • Inadequate coverage
  • Requires local of free flap
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18
Q

Describe Gustillo Type 3C fractures

A

Arterial injury that requires repair

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19
Q

What scoring system assesses severity of open fractures indicating need for amputation

A

Mangled Extremity Severity Score

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20
Q

What MESS score indicates amputation

A

> 7

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21
Q

How much blood can be lost from a closed pelvic fracture

A

1-5 litres

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22
Q

How much blood can be lost from a closed femoral fracture

A

1-2.5 litres

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23
Q

How much blood can be lost from a closed tibial fracture

A

0.5-1.5 litres

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24
Q

How much blood can be lost from a closed humeral fracture

A

0.5-1.5 litres

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25
Q

Biochemical results in DIC

A
  • Prolonged clotting times
  • Thrombocytopenia
  • Decreased fibrinogen
  • Increased fibrinogen degradation products
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26
Q

SIRS criteria

A

2 or more of:

  • Pyrexia >38 or <36
  • Tachycardia >90
  • Tachypnoea >20 or PaCO2 <4.26
  • WCC >12
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27
Q

What are the implications of SIRS in surgical planning

A

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

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28
Q

How does Fat embolism syndrome present

A
  • Petechial rash
  • Confusion
  • Hypoxia
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29
Q

Why does fat embolism occur

A

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
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30
Q

What systems can be effected by Fat embolism syndrome

A
  • Pulmonary
  • Cerebral
  • Cardiac
  • Renal
  • Skin
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31
Q

How is fat embolism treated

A
  • Prompt fixation of long bone fractures
  • DVT prophylaxis
  • General supportive care
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32
Q

What structures are at risk in proximal humeral fractures

A
  • Axillary nerve

- Posterior circumflex humeral artery

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33
Q

What structures are at risk in mid-shaft humeral fractures

A

Radial nerve

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34
Q

What structures are at risk in paediatric supracondylar fractures

A
  • Radial nerve (most common)
  • Median/ulnar nerve
  • Brachial artery
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35
Q

What structures are at risk from distal radial fractures

A

Median nerve

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36
Q

What structures are at risk in acetabular fractures/hip dislocation

A

Sciatic nerve

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37
Q

What structures are at risk in knee dislocation

A
  • Popliteal artery

- Common peroneal nerve

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38
Q

Most common cause of cellulitis following fractures

A

Streptococcus pyogenes

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39
Q

Cause of gas gangrene

A

Clostridium perfringens (gram-positive spore forming rods)

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40
Q

Rate of spread of gas gangrene

A

2-3cm/hr

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41
Q

Clinical features of gas gangrene

A
  • Shock, septicaemia
  • Limb initially cool becoming discoloured
  • Crepitus under skin
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42
Q

How is gas gangrene treated

A
  • Surgical debridement
  • High dose penicillin
  • Hyperbaric oxygen (increasing pO2 in tissues inhibits bacteria metabolism and reduces necrosis)
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43
Q

What are the symptoms of tetanus infection

A
  • Headache
  • Muscle stiffness around the jaw
  • Rigid abdominal muscles
  • Sweating and fever
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44
Q

When do symptoms of tetanus develop after infection

A

3 days to 3 weeks (typically 7-8 days)

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45
Q

What causes tetanus infection

A

Clostridium tetani

  • Gram-positive rods
  • Obligate anaerobes
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46
Q

What two toxins are produced by clostridium tetani

A
  1. Tetanospasmin (carried to CNS)

2. Tetanolysis (haemolytic)

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47
Q

How should tetanus at risk wounds be managed in those who are fully vaccinated

A
  • > 10 years since last dose = repeat full course

- >5 years since last dose = repeat for tetanus prone wounds

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48
Q

How should tetanus at risk wounds be managed in those who are not fully vaccinated

A
  • Give tetanus toxoid

- Give tetanus immunoglobulin for tetanus prone wounds

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49
Q

What causes necrotising fasciitis

A
  • Synergistic infection with anaerobic and aerobic organisms
  • Can occur with Strep pyogenes
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50
Q

What causes Fournier’s gangrene

A

E.coli and bacteroids

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51
Q

List the 4 most common sites of avascular necrosis

A
  • Femoral head
  • Proximal scaphoid
  • Humeral head
  • Body of talus
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52
Q

Describe myositis ossificans

A

Calcification within a muscle

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53
Q

What is complex regional pain syndrome type 1 also known as

A
  • Reflex sympathetic dystrophy
  • Sudeck’s atrophy
  • Algodystrophy
  • Shoulder-hand syndrome
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54
Q

What are the features of complex regional pain syndrome type 1

A
  • Pain (out of proportion of the injury)
  • Swelling
  • Stiffness
  • Colour change (redness)
55
Q

What are the 3 stages of CRPS type 1

A
  1. Pain and tenderness with warm, dry, swollen limb
  2. Cool, sweaty, swollen cyanotic limb
  3. Stiffness, atrophy and osteoporosis
56
Q

What causes CRPS type 1

A
  • Injury alters afferent neurons
  • Altered sympathetic activity
  • Reduced venous drainage
57
Q

How is CRPS type 1 treated

A
  • Usually self-limiting
  • Physio
  • Optimised analgesia
  • Sympathetic blockade
58
Q

Describe CRPS type 2

A

A.K.A. Causalgia - same features as CRPS type 1 but with a demonstrable nerve lesion

59
Q

Which direction of shoulder dislocation is more common

A

Anterior

60
Q

What is the difference between a Bankhart lesion and True Bankhart lesion

A
  • True Bankhart = capsule torn from glenoid anteriorly

- Bankhart = labrum torn

61
Q

Site and cause of Hill-Sachs lesion

A

Impression fracture on the posterolateral head from the glenoid

62
Q

On examining a dislocated shoulder, where should sensation be checked

A

Regimental badge area to assess for axillary nerve damage

63
Q

What x-ray view is required to exclude posterior dislocation of the humerus

A

Axial (tangential) view

64
Q

Outline Kocher’s method for reducing a shoulder dislocation

A
  • Midazolam (max 6mg)
  • Traction and counter-traction holding above flexed elbow
  • External rotation to 75 degs
  • Adduction across chest
  • Internal rotation
65
Q

What should be done following shoulder reduction

A
  • Check x-ray
  • Broad-arm sling
  • Counsel on 50% recurrence rate within 2 years
  • Early mobilisation
66
Q

Describe TUBS dislocation

A
  • Traumatic
  • Unilateral
  • Bankhart lesion
  • Surgery
67
Q

Describe AMBRI dislocation

A
  • Atraumatic (‘born loose)
  • Multidirectional
  • Bilateral
  • Rehabilitation
68
Q

What structures must you be wary of when performing a Bankhart repair

A
  • Cephalic vein between deltoid and pec major

- Musculocutaenous nerve when dividing common tendon of coracobrachialis and short head of biceps

69
Q

Most common site of clavicle fractures

A

Junction between the middle and outer 1/3rds (middle 1/3rd segment)

70
Q

When does floating shoulder complicate clavicular fractures

A

Clavicle fractures associated with proximal humeral fractures

71
Q

How are greenstick and undisplaced clavicular fractures managed

A
  • Broad-arm sling
  • Mobilise at 2-4 weeks
  • Strengthen at 6-10 weeks
72
Q

How can anterior drift of the scapula be corrected in clavicle fractures with marked displacement

A
  • Ring or Quoit method

- Figure-of-eight bandage

73
Q

What x-ray views are recommended to assess clavicle fractures

A
  • AP

- 15 degrees cephalic tilt to asses superior/inferior displacement

74
Q

What are the absolute indications for ORIF in mid clavicular fractures

A
  • Open fractures
  • Displaced with skin tenting
  • Subclavian artery/vein injury
  • Floating shoulder
  • Symptomatic non-union/malunion
75
Q

What are the relative indications for ORIF in mid clavicular fractures

A
  • Displaced with >2cm shortening
  • Bilateral displaced fractures
  • Brachial plexus injury
  • Closed head injury
  • Seizure disorder
  • Polytrauma patient
76
Q

Describe the pathoanatomy of ACJ dislocation

A

Clavicle loses all contact with scapula - conoid and trapezoid ligaments tear away from inferior border of clavicle

77
Q

Outline the management of ACJ dislocation

A
  • No gross instability = broad-arm sling for 4-6 weeks

- Reliant on overhead work = fixation with lag screw

78
Q

Important nerve relations in surgical neck of humerus fractures

A
  • Axillary nerve

- Circumflex humeral vessels

79
Q

Important nerve relations in the spiral groove of the humerus

A
  • Radial nerve

- Profundal brachii vessels

80
Q

Important nerve relations of the posterior aspect of the medial epicondyle

A

Ulnar nerve

81
Q

Classification system for humeral fractures

A

Neer classification

82
Q

What distinguishes a ‘part’ of a proximal humeral fracture

A

Significant size and have either:

  • 1 cm of displacement
  • 45 degrees of angulation
83
Q

What is the most common proximal humeral fracture in children

A

Greenstick fracture of the surgical neck - Neer 1

84
Q

How should basic proximal humeral fractures be managed

A
  • Conservative with collar and cuff
  • Hand and elbow mobilisation from day 1
  • Shoulder mobilisation at 3 weeks
85
Q

What type of plate is used in multiple-part proximal humeral fractures

A

Philos plate

86
Q

How are fracture-dislocations of the humerus managed and why

A

Hemiarthroplasty due to risk of AVN

87
Q

In which direction does the proximal fragment tend to migrate in A) upper-shaft, B) mid-shaft humeral fractures and why

A

A) Adducted by pull of pec major

B) Abducted by deltoid

88
Q

What is the management of simple humeral shaft fractures

A
  • Long-arm plaster with collar and cuff

- U-slab

89
Q

When should internal fixation or IM nailing be considered in humeral shaft fractures

A
  • 2 fractures in the same limb
  • Multiple injuries
  • Fractures in both arms
  • Significant head injury
  • Pathological fracture
  • Radial nerve palsy
90
Q

Management of undisplaced adult supracondylar fracture

A

Casting

91
Q

Management of displaced adult supracondylar fracture

A

ORIF using medial and lateral plates

92
Q

Outline the management of intercondylar humeral fractures

A
  • 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
Q

Outline the management of olecranon fractures

A
  • Undisplaced = elbow in flexion in long-arm cast for 6-8 weeks
  • Displaced = screw fixation or tension-band wiring
  • Comminuted = plate fixation
94
Q

What is fracture is commonly associated with posterior dislocation of the elbow

A

Coronoid fracture

95
Q

Outline the management of coronoid fractures

A
  • Conservative unless more than half of the coronoid is involved
  • Internal fixation may be used to prevent dislocation
96
Q

Outline the management of radial head fractures

A
  • Undisplaced = simple immobilisation for 2 weeks
  • Displaced = ORIF
  • Excision and replacement if severely comminuted
97
Q

Define a Essex-Lopresti fracture

A

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
Q

What are the complications of radial head surgery

A

Posterior interosseous nerve damage

99
Q

Outline the management of radial neck fractures

A

Depends on angulation:

  • <30 = simple immobilisation
  • > 30 = MUA
  • > 45 or dislocated = ORIF in adults (open reduction only in children)
100
Q

Define a Monteggia fracture

A

Fracture of the proximal ulna with dislocation of the radial head (Monty loses his head)

101
Q

Define a Galeazzi fracture

A

Fracture of the shaft of the radius is accompanied by dislocation of the distal ulna

102
Q

Outline the management of Monteggia and Galeazzi fractures

A

ORIF

103
Q

How do you identify axial rotation of the ulna in fractures

A

In the lateral projection the olecranon, coronoid, and styloid process should all be clearly visible - this is lost in axial rotation

104
Q

How do you identify axial rotation of the radius in fractures

A
  • 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
Q

What muscle pronates the distal fragment in radial shaft fractures

A

Pronator teres

106
Q

Outline the management of forearm shaft fractures in children

A
  • Undisplaced angulated greenstick = correct angulation under GA
  • Displaced = MUA and plaster for 3-4 weeks
    (ORIF if stable reduction cannot be maintained)
107
Q

Define a Colles’ fracture

A

Dorsally/radially displaced fracture of the radius within 2.5cm of the wrist

108
Q

What fracture is associated with Colles’ fracture

A

Avulsion fracture of the ulna styloid

109
Q

What degree of displacement required reduction in Colles’ fracture

A

> =10 degrees of dorsal tilt

110
Q

How should a Colles’ fracture be held in reduction

A
  • Volar displacement
  • Ulnar deviation
  • Slight flexion
111
Q

What tendon may suffer delayed rupture in Colles’ fracture

A

Extensor pollicis longus

112
Q

Define a Smiths’ fracture

A
  • Reverse Colles’

- Extra-articular distal radius fracture with volar displacement

113
Q

Define a Barton’s fracture

A

Intra-articular fracture of the distal radius

114
Q

What provides the main blood supply to the scaphoid

A

Dorsal carpal branch of the radial artery

115
Q

What part of the scaphoid is most at risk of AVN in fracture

A

Proximal pole

116
Q

What should you do if you suspect scaphoid fracture but it is not visible on x-ray

A
  • Futura splint
  • MRI in 10 days
  • Fracture clinic review
117
Q

How should un-displaced scaphoid fractures be managed

A
  • Scaphoid plaster

- Wrist is pronated, radially deviated and moderately dorsiflexed

118
Q

How should displaced scaphoid fractures be managed

A

Fixation with dual-pinch Herbert screw

119
Q

Describe the Garden classification for intracapsular hip fractures

A
  • 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
Q

Management of stable trochanteric fracture

A

DHS

121
Q

Management of subtrochanteric fracture

A

Gamma nail

122
Q

Approximate blood loss from femoral shaft fracture

A

1-1.5L

123
Q

Describe orthograde IM nailing of the femur

A

Nail inserted via tip of the GT

124
Q

X-rays required in suspected patella fracture

A
  • AP

- Skyline (Tangential)

125
Q

Outline the management of patella fractures

A
  • Vertical = conservative with cylinder cast

- Displaced horizontal = tension band wiring if the articular surface can be restored

126
Q

What system is used to classify tibial plateau fractures

A

Schatzker classification

127
Q

Outline the management of tibial plateau fractures

A
  • Table depression <5mm with no ligament damage = hinged knee brace for 6 weeks
  • Displacement >10mm = ORIF
128
Q

Describe Volkmann’s ischaemia

A

Popliteal artery damage in proximal tibial fractures causing calf ischaemia

129
Q

Tibial fracture uniting time

A

16 weeks

130
Q

Outline the management of tibial fractures

A
  • Transverse minimally displaced = long-leg cast
  • Diaphyseal = nail
  • Metaphyseal = plate
131
Q

Outline the Weber ankle fracture classification

A
  • 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
Q

List the indications for fixation in ankle fractures

A
  • Talar shift
  • Potential talar shift
  • Fibular fracture above inferior tibiofibular joint
  • Displaced medial malleolus
  • Fibula shortening
  • Significantly displaced articular fragments
133
Q

Describe the immediate management of unstable ankle fractures

A

Reduction in backslab prior to ORIF

134
Q

Describe a Holstein-Lewis fracture

A

Fracture of distal 1/3rd humerus with radial nerve entrapment

Trauma (3 decks)

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