regional trauma Flashcards
what is spinal shock
physiologic response to injury woth complete loss of sensatin and motor function and loss of reflexes below the level of the injury
spinal shock usually resolves in ____ hours
24
the return of which reflex signals the end of spinal shock
bulbocavernous reflex
what is neurogenic shock
hypotension and bradycardia secondary to temporary shutdown of sympathetic outflow from T1-L2
neurogenic shock normally resolves in ____ hours
24-48
how is neurogenic shock treated
IV fluid therapy
what is a complete spinal cord injury
no sensory or voluntary motor function below the level of the injury
reflexes should return
what is an incomplete spinal cord injury
some neurologic function (sensory and/or motor) is present distal to the level of injury
sacral sparing indicates which type of spinal cord injury
an incomplete spinal cord injury
neurogenic shock is more common than hypovolaemic shock in spinal cord injuries
true/false
false
treatment of spinal cord injury is aimed at…
preventing further damage
preventing complications of paralysis
loss of intercostal muscle function results from injury to which spinal levels
T1-T12
most common causes of pelvic fracture in young patients
high energy injury
what is the pelvic ring formed by
sacrum
ilium
ischium
pubic bones
supporting ligaments
injury at a single point of the pelvic ring is common
true/false
false
if there is a fracture at one point in the ring, there is likely to be furhter disruption at another point
which vascular structures are prone to injury in a plevic fracture
branches of the internal iliac artery
pre-sacral venous plexus
when would a lateral compression fracture of the pelvis occur
side impact (eg RTC)
a lateral compression fracture results in one half of the pelvis to be displaced laterally/medially
medially
fractures through the pubic rami or ischium are accompanied by
a sacral compression fracture of SI joint disruption
a vertical shear fracture of the pelvis occurs due to
axial force on one hemipelvis (eg fall from height, rapid deceleration)
in a vertical shear fracture, the affected hemipelvis is displaced superiorly/inferiorly
superiorly
in a vertical shear fracture the leg on the affected side will appear
shorter
an anterioposterior compresson injury of the pelvis may result in what sort of injury
the pelvis opening up like a book due to disruption of the pubic symphysis
why is there such a big risk of hypovolaemia with an anteroposterior compression injury
the pelvic volume increases exponentially with the degree of displacement do the pelvis can contain several litres of blood before tamponade and clotting occur
an anteroposterior compression injury is also known as
an open book pelvic fracture
how does presence of blood in a PR exam change the management of a plevic fracture
it would be considered an open fracture
what sort of pelvic fracture is most common in elderly patients
minimally displaced lateral compression injury
what is the acetabulum
intra-articular part of the pelvis and forms the ‘cup’ of the hip joint
posterior wall acetabular fractures may be associated with which further injury
dislocation
which imaging techniques are most useful when assessing an acetabular fracture
CT scans help determine the pattern of the fracture
oblique X-rays may help
most common mechanism of injury for a proximal humeral fracture
FOOSH
the most common pattern of proximal humeral fracture
fracture of the surgical neck with medial displacement of the humeral shaft due to pull of the pectoralis major muscle
treatment of humeral neck fractures
minimally displaced: conservative treatment with a sling
displaced: internal fixation
anterior shoulder dislocation is less common than posterior
true/false
false
anterior is more common
traumatic anterior shoulder dislocation occurs due to…
an excessive external rotation force or fall onto the back of the shoulder
what is a bankart lesion
anterior shoulder dislocation that results in detachment of the naterior glenoid labrum and capsule
how can the axillary nerve be damaged in shoulder dislocation
it can be stretched as it passes through the quadrilateral space
clinical signs of shoulder dislocation
loss of symmetry
loss of roundness of the shoulder
arm held in adducted position supported by patient’s other arm
what is the prinicple sign of axillary nerve injury
loss of sensation on the regimental badge area
which humeral fractures can occur with a shoulder dislocation
surgical neck
greater tuberosity
managment of shoulder dislocation
closed reduction under sedation or anaesthetic
neurovascular assessment before and after reduction
why is it important to do a full neurovascular assessment beofre and after reduction of dislocation
because it is important to identify any nerve injury before reduction so that you can prove that you didnt cause an injury while reducing the dislocation
patients less than 20 have an ___% chance of re-dislocation
80%
patients over 30 have a ___% chance of redislocation
20%
recurrent dislocations can be stabilised with a _______ repair
bankart repair
reattachmnet of the torn labrum and capsule by arthroscopic or open means
mainstay of management of recurrent dislocation in a patient eith ligamentous laxity/hypermobility
physiotherapy to strengthen the rotator cuff muscles
posterior shoulder dislocation is caused by
a posterior force on the adducted and internally rotated arm
main xray finding of a posterior shoulder dislocation
‘light bulb’ sign
excessively internally rotated humeral head look symmetrical on AP view
treatment of shoulder dislocation
perior of immobilisation (sling) and physiotherapy
injuries of the acromioclavicular joint usually occur
after a fall onto the point of the shoulder
in an acromioclavicular joint subluxation what happens to the acromioclavicular ligaments
they are ruptured
which ligaments are ruptured in an acromioclavicular dislocation
acromioclavicular ligaments
coracoclavicular ligaments (conoid and trapezoid ligaments)
most acromioclavicular injuries are treated with
conservative management
sling and physiotherapy
reconstruction of the coracoclavicular ligaments is reserved for patients with…
chronic pain
why can a high degree of angulation (30 degrees) be accepted in a humeral shaft fracture
because of the mobility of the shoulder joint and elbow joint
why is the radial nerve susceptible to injury in a humeral shaft fracture
the radial nerve sits in the spiral groove which is a common site of fracture
what are the signs of a radial nerve palsy
wrist drop and loss of sensation in the first dorsal web space
humeral shaft fractures can normally be treated with
a functional humeral brace
olecranon fractures are normally caused by
a fall onto the point of the elbow with contraction of the triceps muscle
what is the fat pad sign
a sign of radial head fracture
a triangle like a sail anterior to the distal humerus
radial head and neck fractures often result in a ______ degree loss of terminal extension
10-15 degree
why might a displaced radial headfracture require surgery
there is a displaced fragment causing a mechanical block to full extension
how to differentiate between loss of elbow movement due to mechanical block and loss of elbow movement due to pain
aspiration of haemarthrosis is present
injection of local steroir to reduce swelling
most elbow dislocations occur in the posterior direction after…
a FOOSH
which fractures are associated with an elbow dislocation
radial head
humeral epicondyle
coronoid process of the ulna
isolated forearm fractures are common
true/false
false
due to the strong ligaments at the proximal and distal radioulnar joints, a fracture of one bone normally results in fracture/dislocation of the other
what is a nightstick fracture
isolated fracture of the ulna
how does an isolated fracture of the ulna occur
a direct blow to the ulna
what is a monteggia fracture dislocation
fracture of the ulna with dislocation of the radial head at the elbow
monteggia fracture management
ORIF (even in children)
why does a montegia fracture require ORIF and not just manipulation
manipulation alone risk re-dislocation due to the unstable nature of the injury
what is a galeazzi fracture
a fracture of the radius with dislocation of the ulna ath te distal radioulnar joint
which xrays should be requested if a galeazzia fracture is suspected
forearm xray
lateral xray of the risk
what types of xray are needed to visualise a monteggia fracture
forearm xray
elbow xray
distal radial fractures are common following a…
FOOSH
what is a colles fracture
an extra-artciular fracture of the distal radius within a inch of the articular surface with dorsal displacement or angulation
treatment of a colles fracture (minimally displaced or angulated)
splintage
treatment of colles fracture (angulated)
manipulation
plaster cast/percutaneous wires/ORIF
which nerve injury is associated with a colles fracture
median nerve compression
(due to stretch of the nerve or a bleed into the carpal tunnel)
a late complication of a colles fracture
rupture of the extensr pollicis longus tendon
what is smiths fracture
a volarly displaced or angulated extra-articular fracture of the distal radius
treatment of smith’s fractures
ORIF using a plate and screws
malunion of a smiths fracture may result in
reduced grip strength and wrist extension
what is barton’s fracture
intra-articular fracture of the distal radius involving the dorsal or volar rim, where the carpal bone of the wrist joint sublux with the displaced rim fragment
treatment of cominuted intra-articular distal radius fractures
external fixation
clinical signs of scaphoid fracture
tenderness in the anatomic snuff box
pain on compressing the thumb metacarpal
how many xray views are needed if a scaphoid fracture is suspected
4 views
AP, lateral and 2 oblique
what is a ‘clinical scaphoid fracture’
scaphoid fracture is suspected but there is no xray evidence
managment of clinical scaphoid fracture
splintage of wrist
clinical assessment +/- further xray 2 weeks later
treatment of definite scaphoid fracture
plaster cast for 6-12 weeks
scaphoid fracture complications
non-union (synovial fluid inhibits fracture healing)
AVN of the proximal pole
risk of penetrating injuries to the volar aspect of the hand
damage to flexor tendons, digital nerves and digital arteries
risk of dorsal penetrating injury to hand
damage to extensor tendons
digital nerve injuries proximal to the DIPJ require surgical repair
true/false
true
what is mallet finger
avulsion of the extensor tendon from its insertion into the terminal phalanx
what causes mallet finger
forced flexion of the extended DIPJ
mallet finger presentation
pain
drooped DIPJ
inability to extend at the DIPJ
treatment of mallet finger
mallet splint holding the DIPJ extended worn continuously for at least 4 weeks
fractures ofthe 3rd, 4th and 5th metacarpals are usually treated conservatively
true/false
true
fractures of the 5th metacarpal often occur with what type of injury
punching injury
treatment of metacarpal fractures
neighbour strapping of the affected digit to the adjacent finger
early motion to regain function
complications of ‘fight bite’ injury in the hand
damage to MCP joint
disruption of the extensor tendon
intra-oral organsims may cause infection and septic arthritis
what is a ring block
a digital nerve block
why is mortality so high for hip fractures in the elderly
comorbidities (cardiorespiratory disease, renal failure etc)
reduced physiological reserves
management of hip fracture in elderly
surgery within 24 hours
complications of non-surgical treatment of hip fracture in elderly patients
prolonged bed rest is required and can result in;
pain while toileting/bathing
pressure sores
chest infections
potential non-/mal-union
muscular atrophy making rehabilitation more difficult
what is the relevance of the intra-/extra-capsular classification
determines the likelihood of disruption to the femoral head blood supply
arterial supply to the femoral head arises from which arteries
circumflex femoral arteries
(medial and lateral circumflex arteries are branches of profunda femoris)
intracapsular hip fractures are less likely to disrupt blood supply to the femoral head
true/false
false
they are more likely than extra-capsular fractures
management of intracapsular hip fracture
replacement of the femoral head (total or hemi-arthroplasty)
THR vs hemi-arthroplasty in intra-capsular hip fractures
THR has higher rates of dislocation but better function
hemi-arthroplasty more secure but poorer functional outcome
AVN is a complication of extracapsular hip fractures
true/false
false
extacapsular hip fractures should not cause AVN as it shouldn’t disrupt the blood supply to the femoral head
management of extracapsular hip fractures
internal fixation
subtrachanteric proximal femoral fractures heal well
true/false
false
the blood supply is quite poor and the area is under considerable bending stress
high energy fractures have a higher risk of concomitant fracture elsewhere
true/false
true
femoral shaft fractures are associated with substantial blood loss
true/false
true
how does a femoral shaft fracture result in fat embolism
fat from the medullary canal can enter the damaged venous system
initial management of femoral shaft fracture
ABCDE
optimising analgesia (femoral nerve block)
thomas splint
definitive management of femoral shaft fracture
close reduction and stabilsation with an IM nail
distal femoral fracture management
fixed with plate and screws
management of knee dislocation
reduction of obvious dislocations
neurovascular assessment (doppler, duplex scan, angiogram)
revascularisation
external fixator
multi-ligament reconstruction normally required
virtually all patellar dislocations are medial
true/false
false
they are mostly lateral
risk factors for patellar dislocation
generalised ligamentous laxity
valgus alignment of the knee
rotational malalignement (eg femoral neck anteversion)
shallow trochlear groove
are tibial plateau fractures extra-articular or intra-articular
intra-articular
management of tibial plateau fracture
reduction of articular surface and rigid fixation
foot drop is a sign of damage to which nerve
common peroneal
a valgus stress injury to the knee may cause what sort of fracture and injury to which ligaments
lateral plateau fracture
injury to MCL and possibly ACL
a varus stress injury to the knee may result in what type of fracture and injury to which structures
medial plateau fracture
LCL injury
stretch injury to common peroneal nerve
management of proximal tibia (plateau) fracture
plates and screws for fixation
may require bone graft to provide support
tibial fractures are the most common cause of compartment syndrome
true/false
true
particularly the anterior compartment of the leg
why are open fractures common in tibial fractures
the tibial shaft is subcutaneous
average time for a tibial shaft to heal
16 weeks
what is commonest surgical method of stabilisation of tibial shaft fracture
IM nail
benefits of IM nail in tibial shaft fracture
promotes secondary bone healing
less disruption of the periosteal blood supply
what are the most common causes of ankle injury
inversion and rotational force on a planted foot
which ankle ligaments are most commonly sprained
anterior and posteior talofibular ligaments
calcaneofibular ligament
signs of ankle sprain
pain, bruising and mild to moderate tenderness over the involved ligaments
what criteria is used to indentify suspected ankle fractures
ottawa criteria
indication for xray in investigation of ankle fracture
severe localised bony tenderness of distal tibia or fibula
inability to weight bear for four steps
treatment of stable ankle fracture
walking cast or splint
isolated distal fibular fractures with no medial fracture or rupture of delotoid ligament
stable/unstable
stable
distal fibular fractures with rupture of the deltoid ligament
stable/unstable
unstable
treatment of unstable ankle fracture
ORIF
(plates and screws)
xray signs of deltoid ligament rupture (ankle)
talar shift
talar tilt
talar shift increases the risk of post-traumatic OA
true/false
true
ankle joint contact pressures increase greatly which increases the risk of OA
bimalleolar fractures are stable/unstable
unstable
why might ORIF be delayed when treated an ankle fracture
ankle fractures can be associated with substantial soft tissue swelling and fracture blisters
1-2 weeks may be necessary to allow swelling to reduce and lower the risk of wound healing problems and infection
what are the tarsal bones
talus
calcaneus
cuboid
medial, lateral and middle cuneiforms
navicular
why do calcaneal fractures occur
fall from height
which joint may be involved in a calcaneal fracture
subtalar joint
what facotrs increase the risk of wound healing problems and infection
heavy smoking
vascular disease
diabetes
poor surgical technique
increasing age
with displacement of the fracture or subluxation/dislocation of the talus, there is a high risk of ____
AVN affecting the talar body
what is a midfoot fracture/dislocation
fracture of the base of the 2nd metatarsal is associated with dislocation of the base of the 2nd metatarsal with or without dislocation of the other metatarsals at the tarso-metatarsal joints
presentation of midfoot fracture
grossly swollen, bruised foot
unable to weight bear
poosibly a normaly xray
treatment of midfoot fracture
open or closed reduction
fixation using screws
what is a midfoot fracture/dislocation also known as
lisfranc fracture/dislocation
treatment of 5th metatarsal fractures
walking cast/supportive bandage/stout boot for 4-6 weeks
fractures of the first metatarsal are normally treated with
fixation
why can it take several weeks for a stress fracture to the 2nd metatarsal to appear on xray
it may not be visible until healing (callus response)
what does a ‘greenstick’ fracture refer to
paediatric fracture where the bone hasn’t completely fractured, with some continuity of ‘fibres’ within the bone
(like breaking a green stick from a tree)
children’s bones are more elastic and pliable than adult bones
what role does the periosteum play in the healing of paediatric fractures
can help stabilty and assist reduction as it is thicker than in adults
it also helps fractures heal faster as the periosteum is a rich source of osteoblasts
how does the periosteum differ between children and adults
children have thicker periosteum which serve to increase the circumference of growing long bones
why do children’s fractures heal faster than adults
the thicker periosteum is a rish source of osteoblasts
how does the management of paediatric fractures differ from adult fractures
paediatric fractures are less commonly surgically stabilised and a greater degree of angulation can be accepted
at what point do children’s fractures tend to be treated as adult’s fractures and why
at puberty (12-14)
because they have a lesser potential for remodelling
complications of fractures to the physis (in children)
potential to disturb growth
may result in shortened limb or an angular deformity if only one side if physis is affected
what is the salter-harris classification
classification of physeal fractures in children
what is a salter-harris I fracture and what is its prognosis
pure physeal separation
best prognosis, least likely to affect growth
what is a salter-harris II fracture and its prognosis
separation of the physis, but with a small metaphyseal fragment attached to the physis and epiphysis
low risk of growth disturbance
what is a salter-harris III fracture and its prognosis
intra-articular fracture where only part of the physis separates from the diaphysis
increased risk of grwoth disturbance
what is a slater-harris IV fracture and its prognosis
intra-articular fracture where only part of the physis separates, but part of the diaphysis is attached
increased risk of growth disturbance
what is salter-harris V fracture and its prognosis
compression injury to the physis
definite growth arrest
multiple fractures of varying ages (varying amounts of callus or helaing) or multiple trips to A&E with different injuries raises the suspicion of
NAI/child abuse
which type of salter-harris fracture often occurs in the distal radial physis of older children
salter-harris II
dorsal angulation is more common than volar in distal radial fractures
true/false
true
management of paediatric monteggia and galeazzi fracture/dislocations
reduction and rigid fixation with plates and screws
(reduces rate of redislocation)
what are the two types of supracondylar fractures and how are they caused
extension type - heavy FOOSH
flexion type - fall onto point of flexed elbow
treatment of supracondylar fractures
undisplaced - splint
angulated/rotated/displaced - closed reduction and pinning with wires
which neurovascular structures may be damaged in an off-ended extension type supracondylar fracture
what is a sign of damage to the nerve
brachial artery and median nerve
patient is unable to make OK sign
femoral shaft fractures occur in children due to
fall onto flexed knee
indirect bending
rotational forces
why can a small degree of shortening be accepted in a paediatric femoral shaft fracture
because there tends to be a degree of overgrowth after fracture healing
main cause of femoral shaft fracture in under 2 years olds
NAI/child abuse
treatment of femoral shaft fractue in child less than 2
gallows traction and early hip spica cast
treatment of femoral fracture in child 2-6
thomas splint or hip spica cast
treatment of femoral shaft fracture in child 6-12
flexible IM nail
treatment of femoral shaft fracture in child 12 or over
adult type IM nail
what type of tibial fracture is common in toddlers
undisplaced spiral fracture of tibial shaft
‘toddler’s fracture’
how are intra-capsular hip fractures often treated
hemiarthroplasty or THR
what nerve is most at risk secondary to a displaced Colles fracture
median
A - lateral femoral condyle
B - medial tibial plateau
C - fibula head
D - medial femoral condyle
E - lateral tibial plateau
what is the most common type of shoulder dislocation
anterior
it is common for srugery for hip fractures to be avoided due to the significant comorbidities often present in this population
true/false
false
non-operative risks are just as high
the most common anatomical site for proxima lhumeral fracture is the…
surgical neck of the humerus
a colles fracture describes a dorsally angulated or displaced fracture at what site
distal radius
A - greater tuberosity
B - lesser tuberosity
C - pubic symphysis
D - superior pubic rami
E - left sacro-iliac joint
what is the most common management of a minimally displaced, 2 part proximal humeral fracture
operatively with an IM nail
operatively with external fixation
non-operatively in collar and cuff
non-operatively in collar and cuff
what type of splint may be used for the temporary splintage of femoral shaft fractures
thomas splint
finger flexor tendon injuries may occur secondary to a penetrating wound to the volar aspect of the forearm
true/false
true
lateral circumflex artery
profunda femoris
obturator artery
A - obturator artery
B - lateral circumflex artery
which 3 are true in relation to scaphoid fractures
scaphoid fractures may cause AVN of the distal pole
may not be visible on xrays immediately post injury
undisplaced fractures are usually treated in a cast for 6-12 weeks
scaphoid xrays involve obtaining 4 different views of the bone
patient with signs/symptoms of scaphoid but no xray evidence are reviewed again at 6 weeks
may not be visible on xrays immediately post injury
undisplaced fractures are usually treated in a cast for 6-12 weeks
scaphoid xrays involve obtaining 4 different views of the bone
which nerve is particularly at risk of injury in humeral shaft fracture
radial nerve
(radial groove)
radiographic sign associated with posterior dislocation of the humeral head
lightbulb sign
A - medial malleolus
B - talus
C - calcaneus
D - cuboid
E - tibia
F - navicular
G - lateral malleolus
what is the approximate mortality rate post hip fracture at 1 year
30%
which nerve is most at risk of injury during traumatic anterior shoulder dislocation
axillary nerve
the risk of recurrent shoulder dislocation is inversely proportional to the age of first time dislocation
true/false
true
