Orthopaedic emergencies Flashcards
define open fractures
disruption of the bony cortex associated with a breach in overlying skin
what should always be suspected a s an open fracture
any wound present in the same limb as a fracture
what can be damaged in an open fracture 3
skin (is relatively resistant to trauma)
underlying muscle can be damaged or devitalised
nerves, blood vessels and periosteum may be disrupted
-degree correlates with the severity of the injury and outcome
what classification system is used for open fractures
Gustilo classification
regarding the gustilo classification for open fractures:
define grade 1
low energy wound <1cm
regarding the gustilo classification for open fractures:
define grade II
low energy wound ≥1cm with moderate soft tissue damage
regarding the gustilo classification for open fractures:
define grade IIIA
All high-energy injuries irrespective of wound size
IIIA- fractures have adequate soft tissue damage
regarding the gustilo classification for open fractures:
define grade IIIB
All high-energy injuries irrespective of wound size
IIIB- fractures have inadequate soft tissue coverage
regarding the gustilo classification for open fractures:
define grade IIIC
all high-energy injuries irrespective of wound size
IIIC- fractures have arteiral injury needing repair
what can be used to predict the need for amputation in an open fracture
MESS [52]
-mangled
-extermity
-scoring
-system
Initial management of open fractures 3
careful patient examination to check for associated injuries, control of haemorrhage & extent of injuries
Give IV Abx ASAP
assess neurovascular status
ABx regime for open fractures 3
given within 3hrs of injury
co-amox 8hrly
-continue for 72hrs or definitive wound closure
consider tetanus status
when would surgery be considered for open fractures 3
immediate surgery if vascular impairment
or
compartment syndrome
or
wound is heavily contaminated (sewage)
how should the wound in. an open fracture be managed 4
debridement by plastics & orthosurgeroens within 24hrs of injury
cover wound in saline-soaked gauze to prevent desiccation
-only handle to remove gross contamination and allow photography
splint the limb
definitive skeletal stabilisation & wound cover achieved withn72hrs
define neuropraxia
implies temporary loss of nerve conduction often via iscahemia following pressure
-eg common peroneal nerve as it crosses the neck of the fibula (foot drop)
in mixed nerves, motor component is the more vulnerable compoenetnet
-saturday night palsy
define axonotmexisi
means damage to the nerve fibre
-but the epineural tube is intact
provides guidance to the regrowing nerve
-1-3mm/day
define neurotmesis
means divison of the whole nerve
no guidance from endonerual tube
-regrowing fibrils cause a traumatic neuroma if they are unable to bridge the gap
current surgical repair is epineural repair with nylon sutures
what can cause compartment syndrome 2
following fractures
or
ischaemic repurfusion injury
important point about comparment syndroem 1
is life and limb threatening
basic pathophys of compartment syndrome 3
raised pressure within a closed anatomical space
-raised pressure will eventually compromise tissue perfusion resulting in necrosis
-subsequent rhabdomyolysis can cause renal failure
2 main fractures causing compartment syndrome 2
supracondylar fracture
tibial shaft fracture
features of compartment syndrome 4
pain- especially on movement
-disproportionate to injury
paraesthesia, swelling, redness, mottling
-pallor may be present
arterial pulsation may still be felt
paralysis of muscle group
diagnosis of compartment syndrome 1
measure intracompartmental pressure measurements
>20mmHg= abnormal
>40mmHg= diagnostic
typically NO pathology on XR
management of compartment syndrome 4
prompt and extensive fasciotomies
correct hypovolaemic vigorously
debride and amputate any frankly necrotic muscle
keep an eye out for hyperkalemia
define cauda equina syndrome
lumbar and sacral nerve roots arise from the cauda equina
-arises from the conus medullaris at L1 in adults
compression of cauda ewuina causes the syndrome
causes of cauda equina syndrome 4
most common- large prolapses/ hernitation of lumbar discs
extrinsic tumours
primary cord tumours
spondylosis, spinal stenosis
features of cauda equina syndrome 5
clinically produces a LMN lesion:
-poor anal tone (perform PR)
-saddle anaesthia
-lower severe back pain
-incontinence/ retention of faeces or urine
-paralysis ± sensory loss
management of cauda equina syndrome 2
URGENT MRI
REFER TO NEUROSURGERY - surgical decompression
define major trauma
any injury that has potential to cause prolonged disability/ death
define polytrauma
syndrome of multiple injuries exceeding a defined severity with sequential systemic reactions that may lead to dysfunction/ failure of remote organs and vital systems
how can a major trauma be calculated using a scoring system
an injury severity score >15 [53]
aim of a primary survey in a major trauma
inital assessment
detect and treat actual or imminent life threats
-prevent complications
systemic process
asepcts of airway in a-e 3
if ptx can talk airway patent
adjuncts for airway protection
-chin lift & jaw thrust
if not able to maintain airway- definitive airway
-call anaethetics
indications for intubation 5
GCS<9 (8=intubate)
sustained seziure activity
facial or airway trauma
high aspiration risk
flail segments or respiratory failure
overveiw of c-spine stabilisation 3
ALL major trauma patients MUST be managed as potentially unstable
manual inline stabilisation
triple immonilisation (hard collar, tape, blocks)
aspects of breathing in a-e 4
look at neck and chest
-trachea position
-accessory muscles
-asymmetry
palpate for rib fractures or surgical emphysema
percuss & ausculate
O2 saturations
aspects of circulation in a-e 5
central and peripheral perfusion- CRT
HR
BP
urine output
any source of bleeding
-head,chest, abdo, PELVIS, long bones
aspects of disability in a-e 2
assess GCS
Glucose
asepcts of exposure in a-e 2
full exposure , maintain dignity and reduce heat loss
blogroll to examine patients back
define shock
life threatening condition of circulatory failure resulting in cellular injury and inadequate tissue function
-usually secondary to haemorrhage in trauma
classifications of shock
[54]
sources of blood loss 5
on the floor and 4 more
Obvious on the ground
Long bones
Pelvis #
abdomen
chest
aspects of secondary survey in major trauma
once ABCD / vitals stable
thourough head to toe
-check for minor injuries
careful documentation of secondary survey injuries
further imaging as warranted by examination
-US, angiography, peripheral XR
focused history
pelvic injury overview
single fracture often stbale
≥2 fractures in pelvis renders the ring unstable (serious injury)
>25% have internal injuries
Tile classification of pelvic fracture
associated complications of major trauma patients
sepsis, adult respiratory distress syndrome, acute renal failure, or multiple systems organ failure.
compartment syndrome
fat emoblism syndrome
life threatning complciations of major trauma patients
acute respiraorty distress syndrome (ARDS)
systemic inflammatory response syndrome (SIRS)
cause of fat embolism syndrome 1
pelvis/long bone fracture or significant soft tissue injury
syx of fat emoblism syndrome 4
respiraory-SOB, hypoxia
neurological- confusion, delirium
dermatological- petechial rach
haematomological
-anaemia
-low platelets
cause of septic arthritis
most common is staph A
-in sexually active N. gonorrhoea is the most common organism
how does septic arhitis spread to joint
most common is hematogenous spread
-from distant bacterial infections eg abscessess
most common location of septic arthitis in adults
knee
features of septic arthitis 2
acute, swollen joint
-restricted movemvent in 80% of patients
-examination findings - warm to touch/fluctuant
fever- present in majority of patients
Ix for septic arthtis 3
synovical fluid sampling obligatory
-should be done prior to administration of ABx if necessary
-may need to be done under radiographic guidance
blood cultures
-remember most common cause is hematogenous spread
joint imaging
Mx of septic arthritis 3
IV ABx cover gram +ve occic
-usually fluclox or clindamycin if penicillin allergic
-given for 4-6wks
-switched to oral after 2wks
needle aspiration to decompress joint
arthorosopic lavavge may be required
describe the Koche criteria for diagnosis of septic arthritis 4
fever >38.5 degrees
non-weight bearing
raised ESR
raised WCC
complications of septic arthitis 7
Chronic pain.
Osteomyelitis (inflammation or swelling in the bone).
Osteonecrosis (bone tissue dies due to lack of blood flow).
A difference in leg length.
Sepsis (widespread inflammation in the body).
Death.
osteoarthritis
complications of cauda equina syndrome
permanent paralysis
permanent incontience
