Principles Flashcards
Discussion infection as a complications of fracture
Open fractures are treated as true time dependent orthopaedic emergencies because of the risk of infection.
Gustilo-Anderson classification describes the various types of open fracture
- Grade 1: wound less than 1cm long -punctured from below
- Grade 2 - laceration 5 cm long no contamination or crush, no excessive soft tissue loss or flaps, or avulsion
- Grade 3- large laceration, associated with contamination or crush- frequently includes a segmental fracture
Treat with cephazolin for grade 1 and add gent for grade 2 and 3
Certain open fractures of the finer and toes present a notable exception to the above. There is no evidence that antibiotics reduces infection rate for these fracture which rarely if ever develop osteomyelitis. - Virgorous irrigation and debridement are adequate for preimary treatment of open phalangeal fracutrs in fingers and toes with intact digital arteries.
Discuss nerve injury
Neuropraxia is the contusion or traction injury of an otherwise intact nerve with disurption of the ability to transmite impulses. Paralysis if present is transient and sensory loss is light
Axonotmesis - crush or traction results in more severe injury to axons within an intact epineurium. Becuase the Schwann tubes remain in continuity spontaneous healing is possible but slow
Neuotmesis is the severing of a nerve usually requiring surgical repair.
The following fractures comonly affect the following nerves
1) distal radius –> median
2) elbow injury –> ulnar or median
3) shoudler dislocation –> axillary
4) sacral fracture –> cauda equina
5) acetabulum fracture –> sciatic nerve
6) hip dislocation –> femoral nerve
7) knee dislocation –> tib or peroneal
8) lateral tib platuea fracutre –> peroneal
Discuss compartment syndrome
Serious acute emergency complication that should be considered whenever significant pain and parethesias occur in an extremity after a fracture within an enclosed osseofascial space.
The immediate threat is the viability of the nerve and muscle tissue within the involved compartment. Others complications include
- infection
- gangrene
- myoglobinuria
- renal failure.
Increased pressure in a closed nonexpendable compartment essentially represents a mismatch between the volume of that space and its contents. As such it may arise from 3 circumstances
1) increased compartment contents
2) decreased compartment volume
3) external pressure.
As tissue pressure increases so does venous pressure resulting in compromise of the local circualtion and tissue hypoxia. This results in histamine release to try to vasodilate the veins. THis lead to increase in leak of proteins and fluids into the surrounding tissue and further increase in compartment pressure.
As tissues pressure incrases venous blood flow is impaired as capillary perfusion pressure is exceeded. Finally arteiral capillary blood falls to a point at which the basic metbaolic needs are not met, leading to sichemic necrosis.
Most common in open
What is normal compartment pressure when is microcirculation impaired and when dose tissue perufsion stop
Normal
-0mmhg
Imparied
-30mmhg
Stop of flow
-diastolic pressure
List causes of compartment syndrome
INCREASED COMPARTMENT CONTENT
1) bleeding
- major vascular injury
- coagulation disorder
- anticoagulant therapy
2) Increased capillary filtration
- Reperfusion after ischaemia ( arterial bypass grating, embolectomy, ergotamine ingestion, cardiac cath)
- Trauma (fracture, convulsion)
- Intensive use of muscle (exercise, siezure, eclampsia, tetany)
- Burns
- intra-arterial drug injection
- surgery
- snakebite
3) increased capillary pressures
- intensive use of muscles
- venous obstruction (phlegmasia cerulea dolens, venous ligation, ill fitting brace)
DECREASED COMPARTMENT VOLUME
1) Closure of fascial defects
2) excessive traction on fracturedliumbs
EXRTERNAL PRESSURES
1) tight cast, dressing, air plints
2) lying on limb
MISC
1) infiltrated infusion
2) pressure transfusions
Discuss clinical presentation of compartment syndrome
- Pain that is out of proportion to physical finding .
- Pain is often characterized as deep, burning and unrelenting and is difficult to localise. - need for escalating analgesia
- Pain on passive stretching of the muscle group in the suggestive compartment is an important finding.
- Active flexion of involved muscles produces pain
The 5 ps of reduced arterial flow are late signs and ominous
-pain, pallor, pulselessness, paraesthesia and paralysis
Discuss ix
Clinical Exam
Measurement of compartment pressures. The two most common methods are
1) the Stryker intra-compartmental pressure monitor - hand held digital devise
-zero the device on the plane it will be inserted
-
Doppler ultrasound is not useful for diagnosis
Discuss management of compartment syndrome
Complete fasciotomy is the only treatment that can reliably normalize elevated compartment pressures.
Describe fat embolism syndrome
Serious manifestation of fat embolism occuring most commonly after long bone fractures (usually tibia and femur) in young adults and after hip fractures in older patients.
Symptoms usually appear 1-2 days after an incute injury of after IM nailing.
Respiratory distress and hypoxemia are the earliest most common manifestations. ARDS may occur and is the usual cause of death.
Neurological involvement is an early sign
- restlessness
- confusion
- deteriorating mental status
HAEM
-thrombocytopenia and petechial rahs may be present
Fever, tachycardia, jaundice retinal changes and renal involvement may occur. Fat seen in the urine in 50% of patients within 3 days of injury.
Describe sprains
Ligamentous injuries resulting from an abnormal motion of a joint
A sprain is injury to the fibers of a supporting ligament of a joint.
1) Grade 1
- chracterized by minor tearing of ligamentous fibers, whith resultant mild haemorrhage and swelling. Minimal point tenderness can be elicited.
2) grade 2
- Parital tear
- moderate haemorrhage and sweeling tenderness painful motion, abnormal motion and loss of fucntion.
3) grade 3
- compelte tearing of a ligament. Signs include a further exaggeration of the signs mentoined for 2nd degree. In addition stressing the joint when possible and not limited by pain reveales grossly abnormal joint moevement
Discuss strains
Injury to a musculotendinous unit resulting from violent contraction or excessive forcible stretch.
Similar grades to strains
Lower limb neuropraxia
1) Sciatic nerve L4 -S3
- leg weakness effecting most lower leg muscles
- sensory loss in peroneal tibial and sural territories; may spare medial calf and arch of foot
- normal knee jerk, absent ankle jerk
2) femoral - L2, L3, L4
- quadriceps weakness and sensory loss
- quad weakness, sensory loss over anterior and medial thigh extending down medial shin to arch of foot
- reduced or unobtainable knee jerk
3) Common peroneal L4-s2
- injured with neck of fibula injury
- foot drop paraehtesias and or sensory loss over dorsum of the foot and lateral shin
- weakness on foot dorsiflexion and eversion, sensory loss on dorsum of foot normal reflees
4) Deep peroneal
- minimal weakness and sensory loss over web space between digits 1 and 2
- minimal signs
5) posterior tibial L4-s3
- aching burning numbness over sole of foot
- positive tinel’s sign over nerve posterior to medial mal
- -sensory loss of foot
- atrophy to foot muscles if severe
Describe nerve block to the foot and areas supplied by each of the five nerves
1) tibial nerve
- provides innervation to the heel and sole of the foot
- posterior to the posterior tib artery behind the medial mal
2) Deep peroneal -
- web space between the first and second toes
3) superifical peroneal nerve
- Dorsum of the foot
- emerges to lie superficail to the fascia 10-20cm above the anle joint on the anterolateral surface
4) Sural nerve -innervates the lateral margin of the foot and ankle
- superficial to the achilles tendon and gastrocnemius
5) saphenous
- innervates the medial malleolus and a variable portion of medial aspect of the leg below the knee
