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MSKsara > Soft tissue injuries and compartment syndrome > Flashcards

Soft tissue injuries and compartment syndrome Flashcards

1
Q

what types of injuries can result in visceral organ injuries?

A

rib fracture and pneumothorax
pelvic fractures and bladder and urethra damage
These injuries require emergency treatment before fracture is dealt with.

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2
Q

how can vascular injury occur from trauma?

A

vessels may be torn, compressed or cut by bone fragments.

the vessel may become thrombosed, intima may become detached or may go into spasm

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3
Q

what are the effects of vessel injury?

A

ischaemia, tissue death

peripheral gangrene.

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4
Q

How long does ischaemia have to last for in order to result in limb loss?

A

4-6 hours

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5
Q

what are the clinical features that would suggest vascular damage after trauma?

A

cold, pale/cyanosed limb

weak/absent pulse.

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6
Q

How could you investigate vascular damage after trauma?

A

pulses, capillary refil
pale/cold limb
based on Xray does the injury look like it could damage an artery.
Angiography

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7
Q

how can we treat vascular damage after trauma?

A

temporary shunt across damaged zone to re-establish circulation
vessel repair by vascular surgeon

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8
Q

What artery is at risk of damage from a:

a) first rib fracture
b) supracondylar fracture
c) shoulder dislocation 
d) elbow dislocation
A

a) subclavian artery
b) brachial artery
c) axillary artery
d) brachial artery

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9
Q

What artery is at risk of damage from a:

a) pelvic fracture
b) femoral supracondylar fracture
c) knee dislocation
d) proximal tibial dislocation

A

a) internal iliac
b) femoral artery
c) popliteal artery
d) popliteal artery

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10
Q

what organisms cause gas gangrene?

A

clostridium perfringens
E.coli, pseudomonas aeruginosa, klebsiella pneumonia , proteus

usually causes by multiple bugs at the same time

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11
Q

what is clostridium perfringens?

A

gram positive obligate anaerobe
grows in dirty wound, dead muscle and inadequate debridement (complication of open fracture)

produces alpha toxin (exotoxin) which causes muscle necrosis and vessel thrombosis which can cause haemolysis and shock.

ferments glucose to produce CO2

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12
Q

what are the clinical features of gas gangrene?

A 
intense swelling and pain around the wound
brownish discharge
gas formation 
increased pulse rate
smell
pyrexia (sometimes none at all)
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13
Q

what investigations would you want to do if you suspect gas gangrene?

A

Bloods - raised LDH, WBC, ABG (acidosis) and U&Es
Xray
histology and gram staining

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14
Q

what would you expect to find on xray in someone with gas gangrene?

A

linear streaks of gas in soft tissue

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15
Q

what is a histological hallmark of gas gangrene?

A

absence of neutrophils due to lack of acute inflammatory response

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16
Q

how is gas gangrene treated?

A

non operative:

  • IV fluids
  • IV Abx - first line is penicillin G and clindamycin (alternative = erythromycin and tetracycline)
  • hyperbaric O2 - to limit spread of gangrene

operative:
- decompress wound and remove all dead material (debridement)
- amputation if advanced

17
Q

what are the complications of gas gangrene?

A

shock

renal failure

18
Q

what are the differentials for gas gangrene?

A

necrotising fasciitis

anaerobic cellulitis - superficial gas formation but not as toxic as gas gangrene.

19
Q

what is necrotising fasciitis?

A

rapidly spreading bacterial infection spreading along tissue planes resulting in necrosis of soft tissue.

often caused by a multitude of different organisms

20
Q

what are the risk factors for developing necrotising fasciitis?

A

immune suppression - diabetes, AIDs, cancer
bacterial introduction - IV drug use, insect bites, skin abrasions, abdo surgery
obesity

21
Q

what are the signs and symptoms of necrotising fasciitis ?

A 
severe pain
tender
slight erythema and swelling 
pyrexia 
discolouration 
bruising 
haemorrhagic blisters
necrosis of skin

toxic shock may develop

22
Q

how do you test for necrotising fasciitis?

A

sweep test: make an incision and if fascia comes away = positive test

bloods: high WCC, CRP, disturbed U&Es, acidosis and hypoxaemic.

need to get blood and tissue cultures.

oedema extending along fascial planes on CT/MRI/Xray

23
Q

how is necrotising fasciitis treated?

A

radical debridement with broad spec Abx
haemodynamic monitoring and resus - sepsis 6
operative when life threatening - often amputation required.

24
Q

how do you distinguish gas gangrene from aerobic cellulitis?

A

Muscle swelling and severe pain are prominent features of gas gangrene. The pain is often out of proportion to physical findings

25
Q

what is the pathophysiology of compartment syndrome?

A

injured tissue can expand due to oedema, infection or haemorrhage. This results in increased pressure within a fascia compartment because fascia does not expand. this pressure builds and presses nerves, capillaries and muscle.
when pressure > than blood pressure, blood flow caeses leading to ischaemia of tissues and necrosis. This can result in permanent muscle fibrosis (volkmans ischaemic contractures)

26
Q

at what pressure does compartment syndrome cause ischaemia?

A

40mmHg or more - surgery is urgently indicated at this point.

27
Q

what compartments are present in the arm and forearm?

A

arm: posterior and anterior
forearm: dorsal, palmar and radial

28
Q

how many compartments are present in the hand?

A

10

- hypothenar, thenar, 4 dorsal interossei, 3 palmar interossei, adductor pollicis

29
Q

what compartments are present in the leg and thigh?

A

thigh: anterior, medial and posterior
leg: anterior, lateral, superficial posterior and deep posterior

30
Q

which fascial compartment does compartment syndrome most commonly affect?

A

anterior compartment of lower leg.

31
Q

what are the causes of compartment syndrome?

A

trauma:

  • fracture - open or closed - mainly tibial or supracondylar humeral.
  • bruised muscle
  • crush injuries
  • burns

iatrogenic:
- anabolic steroids
constricting bandages
haemorrhage (anticoagulants)

ischaemic repurfusion injury
infections

32
Q

how can we diagnose compartment syndrome?

A

based on symptoms
pressure monitoring using slit catheter/manometer
= if difference in pressure and diastolic pressure is less than 30 it is diagnostic.
or just compartment pressure >30mmhg

33
Q

what are the early signs of compartment syndrome?

A

pain out of proportion - main symptom
swollen tense compartment
passive stretching causes pain
paraesthesia - tingling, numbness and burning

34
Q

what are the late signs of compartment syndrome?

A

paralysis
pallor
pulselessness - very late sign, should be treated before this.

35
Q

what are symptoms of compartment syndrome?

A

5 P:

  • pain
  • paraesthesia
  • pallor
  • paralysis
  • pulseless
36
Q

how do we treat compartment syndrome?

A

medical emergency - treat within 1 hour

remove all dressing /casts to allow swelling
limb elevated to heart level
take measures to maintain BP
re-evaluate in 30 mins
urgen surgical decompression - fasciotomy and excision of necrotic tissue

for lower limb 2 incisions in lower leg - medial and anterolateral

leave wound open to allow low pressure to be maintained. loose absorbant dressing
gentle elevation.
pain relief and fluids
reinspect +/- debridement +/- closure

37
Q

what are the complications of compartment syndrome?

A 
muscle necrosis - weakness and contractures. 
joint stiffness
nerve fibrosis 
delayed fracture union 
may need amputation.
38
Q

what is chronic exertional compartment syndrome?

A

seen in athletes after exertion
not an emergency
numbness, difficulty moving, obvious muscle bulge.
treat with physio, NSAIDs, and may require surgery to make more room within fascia compartment

MSKsara (9 decks)

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