Orthopaedic emergencies

Question 1

define open fractures

Answer 1

disruption of the bony cortex associated with a breach in overlying skin

Question 2

what should always be suspected a s an open fracture

Answer 2

any wound present in the same limb as a fracture

Question 3

what can be damaged in an open fracture 3

Answer 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

Question 4

what classification system is used for open fractures

Answer 4

Gustilo classification

Question 5

regarding the gustilo classification for open fractures:
define grade 1

Answer 5

low energy wound <1cm

Question 6

regarding the gustilo classification for open fractures:
define grade II

Answer 6

low energy wound ≥1cm with moderate soft tissue damage

Question 7

regarding the gustilo classification for open fractures:
define grade IIIA

Answer 7

All high-energy injuries irrespective of wound size

IIIA- fractures have adequate soft tissue damage

Question 8

regarding the gustilo classification for open fractures:
define grade IIIB

Answer 8

All high-energy injuries irrespective of wound size

IIIB- fractures have inadequate soft tissue coverage

Question 9

regarding the gustilo classification for open fractures:
define grade IIIC

Answer 9

all high-energy injuries irrespective of wound size

IIIC- fractures have arteiral injury needing repair

Question 10

what can be used to predict the need for amputation in an open fracture

Answer 10

MESS [52]
-mangled
-extermity
-scoring
-system

Question 11

Initial management of open fractures 3

Answer 11

careful patient examination to check for associated injuries, control of haemorrhage & extent of injuries

Give IV Abx ASAP

assess neurovascular status

Question 12

ABx regime for open fractures 3

Answer 12

given within 3hrs of injury

co-amox 8hrly
-continue for 72hrs or definitive wound closure

consider tetanus status

Question 13

when would surgery be considered for open fractures 3

Answer 13

immediate surgery if vascular impairment
or
compartment syndrome
or
wound is heavily contaminated (sewage)

Question 14

how should the wound in. an open fracture be managed 4

Answer 14

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

Question 15

define neuropraxia

Answer 15

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

Question 16

define axonotmexisi

Answer 16

means damage to the nerve fibre
-but the epineural tube is intact

provides guidance to the regrowing nerve
-1-3mm/day

Question 17

define neurotmesis

Answer 17

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

Question 18

what can cause compartment syndrome 2

Answer 18

following fractures
or
ischaemic repurfusion injury

Question 19

important point about comparment syndroem 1

Answer 19

is life and limb threatening

Question 20

basic pathophys of compartment syndrome 3

Answer 20

raised pressure within a closed anatomical space

-raised pressure will eventually compromise tissue perfusion resulting in necrosis
-subsequent rhabdomyolysis can cause renal failure

Question 21

2 main fractures causing compartment syndrome 2

Answer 21

supracondylar fracture

tibial shaft fracture

Question 22

features of compartment syndrome 4

Answer 22

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

Question 23

diagnosis of compartment syndrome 1

Answer 23

measure intracompartmental pressure measurements
>20mmHg= abnormal
>40mmHg= diagnostic

typically NO pathology on XR

Question 24

management of compartment syndrome 4

Answer 24

prompt and extensive fasciotomies

correct hypovolaemic vigorously

debride and amputate any frankly necrotic muscle

keep an eye out for hyperkalemia

Question 25

define cauda equina syndrome

Answer 25

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

Question 26

causes of cauda equina syndrome 4

Answer 26

most common- large prolapses/ hernitation of lumbar discs extrinsic tumours primary cord tumours spondylosis, spinal stenosis

Question 27

features of cauda equina syndrome 5

Answer 27

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

Question 28

management of cauda equina syndrome 2

Answer 28

URGENT MRI REFER TO NEUROSURGERY - surgical decompression

Question 29

define major trauma

Answer 29

any injury that has potential to cause prolonged disability/ death

Question 30

define polytrauma

Answer 30

syndrome of multiple injuries exceeding a defined severity with sequential systemic reactions that may lead to dysfunction/ failure of remote organs and vital systems

Question 31

how can a major trauma be calculated using a scoring system

Answer 31

an injury severity score >15 [53]

Question 32

aim of a primary survey in a major trauma

Answer 32

inital assessment detect and treat actual or imminent life threats -prevent complications systemic process

Question 33

asepcts of airway in a-e 3

Answer 33

if ptx can talk airway patent adjuncts for airway protection -chin lift & jaw thrust if not able to maintain airway- definitive airway -call anaethetics

Question 34

indications for intubation 5

Answer 34

GCS<9 (8=intubate) sustained seziure activity facial or airway trauma high aspiration risk flail segments or respiratory failure

Question 35

overveiw of c-spine stabilisation 3

Answer 35

ALL major trauma patients MUST be managed as potentially unstable manual inline stabilisation triple immonilisation (hard collar, tape, blocks)

Question 36

aspects of breathing in a-e 4

Answer 36

look at neck and chest -trachea position -accessory muscles -asymmetry palpate for rib fractures or surgical emphysema percuss & ausculate O2 saturations

Question 37

aspects of circulation in a-e 5

Answer 37

central and peripheral perfusion- CRT HR BP urine output any source of bleeding -head,chest, abdo, PELVIS, long bones

Question 38

aspects of disability in a-e 2

Answer 38

assess GCS Glucose

Question 39

asepcts of exposure in a-e 2

Answer 39

full exposure , maintain dignity and reduce heat loss blogroll to examine patients back

Question 40

define shock

Answer 40

life threatening condition of circulatory failure resulting in cellular injury and inadequate tissue function -usually secondary to haemorrhage in trauma

Question 41

classifications of shock

Answer 41

[54]

Question 42

sources of blood loss 5

Answer 42

on the floor and 4 more Obvious on the ground Long bones Pelvis # abdomen chest

Question 43

aspects of secondary survey in major trauma

Answer 43

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

Question 44

pelvic injury overview

Answer 44

single fracture often stbale ≥2 fractures in pelvis renders the ring unstable (serious injury) >25% have internal injuries Tile classification of pelvic fracture

Question 45

associated complications of major trauma patients

Answer 45

sepsis, adult respiratory distress syndrome, acute renal failure, or multiple systems organ failure. compartment syndrome fat emoblism syndrome

Question 46

life threatning complciations of major trauma patients

Answer 46

acute respiraorty distress syndrome (ARDS) systemic inflammatory response syndrome (SIRS)

Question 47

cause of fat embolism syndrome 1

Answer 47

pelvis/long bone fracture or significant soft tissue injury

Question 48

syx of fat emoblism syndrome 4

Answer 48

respiraory-SOB, hypoxia neurological- confusion, delirium dermatological- petechial rach haematomological -anaemia -low platelets

Question 49

cause of septic arthritis

Answer 49

most common is staph A -in sexually active N. gonorrhoea is the most common organism

Question 50

how does septic arhitis spread to joint

Answer 50

most common is hematogenous spread -from distant bacterial infections eg abscessess

Question 51

most common location of septic arthitis in adults

Answer 51

knee

Question 52

features of septic arthitis 2

Answer 52

acute, swollen joint -restricted movemvent in 80% of patients -examination findings - warm to touch/fluctuant fever- present in majority of patients

Question 53

Ix for septic arthtis 3

Answer 53

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

Question 54

Mx of septic arthritis 3

Answer 54

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

Question 55

describe the Koche criteria for diagnosis of septic arthritis 4

Answer 55

fever >38.5 degrees non-weight bearing raised ESR raised WCC

Question 56

complications of septic arthitis 7

Answer 56

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

Question 57

complications of cauda equina syndrome

Answer 57

permanent paralysis permanent incontience