ortho basics Flashcards
rule of 2s when assessing patient
two joints
two views (AP lateral)
two times ( pre post reduction)
two limbs ( for comparison)
two injuries ( calcaneal + spine)
cause of spiral fx
torsional force
define translation on xrays
displacement of distal segment compared to proximal segment (medial, lateral, anterior, posterior)
define angulation on xrays
draw arrow going down, if bone going towards midline = varus if going away from midline = valgus
define length on xrays
shortening vs distraction
define rotation on xrays
IR vs ER
how to comment on xrays
patient details
location (right or left)
bone
part of bone: proximal, middle, distal
type of fx
TALR:
- translation
- angulation
- length
- rotation
early fx complications (local)
open fx
compartment syndrome
neurovascular injury
infection
implant failure
soft tissue complications (blisters)
early fx complications (systemic)
sepsis
DVT/PE
ARDS
Fat mebolism
haemorhagic shock
late fx complications
malunion/nonunion
AVN
osteomyelitis
HO
post traumatic arthritis
CRPS
Gustillo Anderson type 1
<1cm, 1st generation cephalosporin for 72 hrs
Gustillo Anderson type 2
1-10cm, 1st generation cephalosporin for 72 hrs
Gustillo Anderson type 3A
> 10cm, soft tissue converage, 1st generation cephalosporin (pos&neg) + gentamicin (aminoglycoside for neg)
Gustillo Anderson type 3B
<10cm, no soft tissue converage, enough soft tissue coverage to close primarily, 1st generation cephalosporin (pos&neg) + gentamicin (aminoglycoside for neg)
Gustillo Anderson type 3C
> 10cm,high energy, no soft tissue converage, 1st generation cephalosporin (pos&neg) + gentamicin (aminoglycoside for neg), MAJOR VASCULAR INJURY PRESENT
exceptions to Gustillo-Anderson thatll make a fx 3 immediately
farmland/dirty soil/water contamination, exposure to oral flora, shotgun, fx duration > 8hrs
abx role in open fx
to prevent osteomyelitis by staph aureus
farmland/soil injury open fx extra treatment?
penicillin (anaerobic) to cover clostridium infection
management of open fx (emergency room)
- ATLS to rule out other life ending injuries
- stop haemorhage: direct pressure preferred over tourniquet
- give analgesia and tetanus if needed
- IV abx <1hr and to continue for 72 hrs
- photo
- NV assessment, realign limb (splint etc), repeat NV, document
- Remove gross contamination and place sterile saline-soaked dressing on wound
- imaging if pt stable
- prepare pt for OT: NPO, labs, consent
management of open fx (OT)
- irrigation with NS
- debridement within 24 hours
- stabilise with ex fix
- delayed closure preferred in 72 hours
criteria of fracture related infections (4)
- fistula/sinus/wound
- purulent drainage
- two cultures positive
- high wbc
chance of infection in GA classification
closed and type 1: 1-4%
type 2 & 3A: 3-8%
type 3B & C: 10-30%
fracture related infection bacteria (early <10 weeks vs late >10 weeks)
early: staph aureus, E.coli
late: staph epidermidis
fresh water vs salt water open fx abx
fresh cipro salty doxy (FC SD)
tetanus situation in open fx?
if unknown or no booster in 5 years then give tetanus toxoid
if clostridium infection/immunocompromised/no booster in 10 years then tetanus IG
how many L to irrigate open fx?
3,6,9L for for Gustillo type 1,2,3
why stabilise fx? (3 reasons)
prevent further soft tissue injury
maintain alignment
reduce pain
what is closed reduction?
no direct exposure to bone, traction along axis of bone and reverse MOI under analgesia
indications for open reduction over closed
NO CASP:
nonunion
open fx
compromised neurovascular
articular fx displaced
Salter Harris 3,4,5
Polytrauma
non-operative fx management options
brace
splint
cast
slab
traction
Ex Fix indications (6)
severe open fx (3b+)
contaminated fx
infected non-unions
initial stabilisation (damage control) in polytrauma
pelvic fx
unstable elbow, elbow, knee dislocations
components of ex fix (3)
pin (in bone)
rod
clamp
contraindications to ORIF (5)
active infection/osteomyelitis
severe osteoperosis
severe communition
severe soft tissue injury
non-displaced fx
ORIF options? (4)
screws: cortical, cancellous, locking
nails
k wire
plates
why use splint in fx management? 5
reduce pain
facilitate transport of pt
allow soft tissue swelling which reduces risk of compartment
reduces risk of closed fx becoming open
reduces risk of soft tissue and NV damage
why use traction in fx?
maintain length, alignemnt, rotation of limb
reduces muscle spasms
extra note: skeletal traction is done distal to fx
pathophysiology of compartment syndrome
increased TISSUE PRESSURE within a FIBROSSEOUS compartment, which exceeds VENOUS and CAPILLARY PERFUSION pressure > muscle ISCHAEMIA and NECROSIS > accumulation of WASTE > LACTIC ACIDOSIS > PAIN and loss of SENSATION due to NERVE IRRITATION
intra-compartmental causes of compartment syndrome 5
trauma
fx (tibia, supracondylar)
Revascularisation injury
crush injury
haemophilia, venom, tumours, anaphylaxis, DVT
extra-compartmental causes of compartment syndrome 3
tight dressing/cast
circumfrential burns
lithotomy position (well leg compartment syndrome): Prolonged surgical procedures in the lithotomy or the hemilithomy position along with perioperative hypoperfusion lead to ischaemia and increased capillary permeability, followed by a reperfusion injury once the leg is released from the compromising position.
most important clinical sign in compartment syndrome + 3 descriptive words
pain
1. out of proportion to injury
2. not relieved by strong analgesics
3. increased by passive extension of compartment
how will the limb feel in compartment syndrome
firm and wooden on deep palpation
5Ps of acute ischaemia compartment syndrome (late signs)
pain
pallor
parasthesia
pulsenessness
paralysis
perishingly cold
most common early finding of compartment syndrome
loss of 2 point discrimination (not loss of cap refill or pulses)
compartment syndrome diagnosis
clinical
when to use stryker needle in compartment syndrome
atypical presentation, unconscious pt
how to measure intracompartmental pressure (2 ways)
delta P: diff bw diastolic and intra-comparmtental pressure <30 then fasciotomy
absolute P >30 then fasciotomy
(delta P is better than absolute P)
(absolute P is direct intra-comparmtental pressure)
compartment syndrome complication
rhabdo, check for CK, RFTs, urinalysis, urine myoglobin
compartment syndrome management
remove cast
limb placed at level of heart to not decrease arterial flow even more
observe one hour, if no improvement then fasciotomy
delayed closure with shoelace technique/skin graft/vacuum assisted closure over 72 hrs
compartment syndrome untreated comlpication
Volkmann contracture: muscle necrosis and fibrosis
compartment syndrome fasciotomy leg thigh forearm ?
leg: double incision laterally and medially to open all 4 comps
thigh: lateral incision to open ant and post, adductor rarely requires
forearm: volar and dorsal
4 Cs to assess muscle for fasciotomy
colour
consistency
contractility
capillary bleeding
