Musculoskeletal Trauma

Question 1

Do injuries to the musculoskeletal system present in blunt trauma or penetrating trauma?

Answer 1

Blunt trauma

Question 2

What are you assessing when assessing the limb that has a musculoskeletal trauma?

Answer 2

Colour and perfusion
Wound
Deformity
Swelling
Discolouration
Bruising

Question 3

What does swelling over the region of a major muscle group suggest?

Answer 3

Crush injury with impending compartment syndrome

Question 4

What does a pale or white distal extremity suggest?

Answer 4

A lack of arterial inflow

Question 5

What does swelling or ecchymosis in or around a joint and/or over the subcutaneous surface of a bone suggest?

Answer 5

Musculoskeletal injury

Question 6

What do wound over a bony prominence suggest?

Answer 6

Open fracture

Question 7

Why is palpation of the extremity important when assessing limbs?

Answer 7

It helps determine sensation and to identify areas of tenderness

Question 8

What does a loss of sensation to touch or pain to a limb indicate?

Answer 8

A spinal or peripheral nerve injury

Question 9

What does pain, swelling and deformity over a boney prominence indicate?

Answer 9

A possible underlying fracture

Question 10

What is indicative of a ligamentous rupture?

Answer 10

Abnormal motion of the joint

Question 11

What is extremely important following musculoskeletal trauma?

Answer 11

Palpation of distal pulses and assessment of capillary refil

Question 12

What can be used if hypotension limits the assessment of distal pulses?

Answer 12

A Doppler

Question 13

What might penetrating extremity trauma result in?

Answer 13

Arterial vascular injury

Question 14

Apart from penetrating extremity injury, what else could disrupt arterial blood flow?

Answer 14

Blunt trauma resulting in an extremity fracture or joint dislocation in close proximity to arterial vasculature

Question 15

What is the best way to manage a haemorrhage to a limb?

Answer 15

Direct pressure and the use of a tourniquet

Question 16

If a fracture is associated with arterial bleeding, what is advisable?

Answer 16

Realignment of the boney structure with concurrent application of pressure - where possible joint dislocation should be relocated

Question 17

What does crush syndrome refer to?

Answer 17

The clinical sequela of injured muscle

Question 18

What happens if crush injuries are left untreated?

Answer 18

Lead to acute renal failure

Question 19

What is the muscular injury seen in crush injury a combination of?

Answer 19

Direct muscle injury, muscle ischaemia and cell death

Question 20

What is muscular trauma often associated with?

Answer 20

Rhabdomyolysis - which can range from an asymptomatic illness with elevated creatinine kinase to life threatening associated with acute renal failure and disseminated intravascular coagulation (DIC)

Question 21

What is the initial management and goal for crush syndrome?

Answer 21

Aggressive fluid resuscitation in order to protect the kidneys and avoid acute renal failure

Question 22

What helps to prevent myoglobin-induced renal failure?

Answer 22

Intravascular expansion and osmotic diuresis to maintain a high tubular volume and urine flow

Question 23

Why do open fractures require timely multidisciplinary management?

Answer 23

The consequence of infection following open fractures can be significant and lead to life long disability

Question 24

What are the BOAST-4 guidelines?

Answer 24

Guidelines that focus specifically on the management of open fractures

Question 25

Where should patients be taken if they have an open fracture to the long bones, hind or mid foot?

Answer 25

Taken directly or transferred to a specialist centre that has the ability to provide orthoplastic care

Question 26

When should antibiotics be given for an open fracture?

Answer 26

Within 1 hour of injury

Question 27

For an open fracture that should the documentation of the examined limb contain?

Answer 27

Assessment of neurological and vascular status

Question 28

Should an open fracture limb be realigned and splinted?

Answer 28

Yes

Question 29

Prior to formal debridement of an open fracture, how should the wound be handled?

Answer 29

Only to remove gross contamination and allow for photographs to be taken. The wound should be dressed in saline soaked gauze and occlusive dressing

Question 30

When should debridement be undertaken using fasciotomy tones for wound extension?

Answer 30

- immediately for heavily contaminated wounds (agricultural, aquatic or sewage) or associated vascular compromise - within 12 hours of injury for other solitary high energy open fractures - within 24 hours for all other low energy open fractures

Question 31

What is acute compartment syndrome of a limb caused by?

Answer 31

Raises pressure within a closed fascial compartment causing local tissue ischemia and hypoxia

Question 32

In clinical practice when is acute compartment syndrome of a limb commonly seen?

Answer 32

After tibial and forearm fractures High energy wrist fractures Crush injuries Restrictive dressings or casts Prolonged immobilisation Reperfusion of ischemic limb

Question 33

What should be part of routine evaluation of patients presenting with significant limb injuries?

Answer 33

Assessment for compartment syndrome

Question 34

What should you be documenting for a patient with suspected compartment syndrome?

Answer 34

Time and mechanism of injury Time of evaluations Level of pain Level of consciousness Response to analgesia Whether regional anaesthesia has been given

Question 35

What are the clinical key finding for a patient with compartment syndrome?

Answer 35

Pain out of proportion to the associated injury Pain on passive movement of the muscle of the involved compartments

Question 36

What should patients who are at risk of compartment syndrome have?

Answer 36

Hourly documented nursing assessment of the injured limb

Question 37

Patient with symptoms or clinical signs of compartment syndrome and are wearing a dressing should have what done to them?

Answer 37

All circumferential dressing to the skin releases and the limb elevated to heart level

Question 38

What should all hospital that treat patients with significant limb injuries have?

Answer 38

The ability to measure inter compartmental pressures

Question 39

Is compartment syndrome a surgical emergency?

Answer 39

Yes, surgery should occur within 1 hour of the decision to operate

Question 40

For patient shaving compartment pressures measured, what else should be monitors and what would be the sign that the patient has an increased risk of compartment syndrome?

Answer 40

Diastolic blood pressure should be monitored. A difference between the diastolic pressure and the compartment pressure of 30mmHg suggests risk of compartment syndrome

Question 41

If absolute compartment pressure is greater than 40 mmHg and the patient has clinical symptoms of compartment syndrome, what should be done?

Answer 41

Urgent decompression should be considered - immediate open fascial decompression of all involved compartments