Open Fractures

Question 1

Describe the fracture seen below

List 4 additional things you would like to know about the foot

Answer 1

Open fracture, ~ 8cm transverse wound, Tibia visible

Examination of the foot: DP+PT Pulses, Sensation, Capillary Refill Time

Also check for any other injuries

Question 2

First line management of an open fracture in ED (incl all actions that need to be completed)

Answer 2

1. ATLS review to ensure no other (life threatening) injuries.
2. Photograph wound then cover with sterile saline soaked dressing
3. Tetanus toxoid if indicated
4. Broad spectrum antibiotics IV (Eg Co-Amoxyclav) if no allergy
5. Immobilise leg with above knee Back-Slab.
6. Analgesia + Nil By Mouth
7. Urgent referral to Trauma team.
8. X-ray

Question 3

What is the classification system for Open Fractures?

Answer 3

Gustillo-Anderson

Question 4

What type, according to GA classificaton, is an 8cm laceration on the distil tibia?

If there was any NV damage, skin loss or wound was > 10cm, what type would this be?

Answer 4

Type 2

Type 3

Question 5

What is the definitive management of a type 2 open fracture, once everything else has been done?

Answer 5

Referred to local Major Trauma Unit (level 1 trauma centre) for a ortho-plastic procedure - ‘fix and flap’.

Question 6

2 hours after surgery for an open fracture:

• Pain levels rise
• Leg is increasingly swollen and very tender
• Pain on passive toe dorsiflexion.
• Morphine does not seem to be helping

What is your clinical diagnosis?

What is the urgent management?

Answer 6

Compartment Syndrome - urgent management is a fasciotomy

Question 7

If a diagnosis of compartment syndrome is missed what may be a serious consequence?

Answer 7

Volkman’s Ischaemic Contracture

Death of muscles in the affected compartment(s), and contraction of their fibres resulting in foot deformity and stiffness

Question 8

These medications come up commonly in the PSA

• Prednisolone
• Azathioprine
• Metformin
• Gliclazide
• Oxybutynin

Revise these

Question 9

For what conditions is azathioprine prescribed?

Answer 9

Maintenance of remissionin IBD

Disease modifying in rheumatoid arthritis and other autoimmune conditions

Transplant rejection

Question 10

How does azathioprine work?

Answer 10

Pro-drug metabolized to 6-mercaptopurine → Inhibits purine synthesis → inhibits RNA replication

Question 11

Most impt side effects of azathioprine

Answer 11

Bone marrow suppression – increased risk of infection

Question 12

Why should thiopurine methyltransferase activity be measured prior to starting azathioprine?

Answer 12

The enzyme thiopurinemethyltransferase is required for the metabolism and excretion of azathioprine.

This enzyme may be reduced or absent in some people and it should not be prescribed in them.

Question 13

Why should allopurinol not be prescribed in a patient taking azathioprine?

Answer 13

Allopurinol is an xanthine oxidase inhibitor

Xanthine oxidase is an enzyme in the metabolism and elimination of azathioprine

Thus if inhibited may lead to toxicity.

Question 14

What may happen if trimethoprim is prescribed in a patient taking azathioprine?

Answer 14

Increased risk of leucopenia – trimethoprim also effects purine synthesis

Question 15

How may gliclazide lead to a fall in the elderly?

Answer 15

Gliclazide is a sulphonylurea which works by stimulating pancreatic insulin secretion.

In the elderly there is an increased risk of hypoglycaemia – dizzy, sweating and confusion.

Question 16

How may Oxybutynin lead to a fall in the elderly?

Answer 16

Oxybutynin is a competitive inhibitor of ACh and used to treat an overactive bladder

Common side effects in the elderly are drowsiness and confusion – both likely to cause falls.