Theme 9: Trauma introduction Flashcards
Subtopics: ATLS introduction, General principles of f# Mx, Trauma pt complications, Paeds trauma, Spinal cord injuries
1
Q
SCI
SCI is a devastating injury with high mortality (17%) and often found in the polytrauma scenario.
Comment on the following to highlight the epidemiology
- Sex
- Age
- Which part of the spine mostly
A
- Males: Females
- Bimodal distribution: young in high velocity injuries and older patients (>75) in lower energy falls, with underlying degeneration and spinal stenosis
- Mostly cervical spine affected
2
Q
SCI
List 4 incidences most commoly associated with SCI
A
- MVA
- Falls
- Diving accidents
- Interpersonal violence (GWS, Stabs, Blunt trauma)
3
Q
SCI
Why is there increased risk for cord injury at the cervico-thoracic and thoraco-lumbar junctions?
A
At c1, spinal cord occupies 35% of space.
At lower c-spine and thoracolumbar regions, it occupies 50% (increased neuronal density supplying limbs)
4
Q
SCI:
Conus medullaris syndrome:
- Is the termination of the spinal cord, usually at what level?
- Why is conus medullaris often missed?
- Describe the findings when conus medullaris syndrome is present. Therefore?
- T/F Conus medullaris has a better prognosis for recovery than more proximal cord lesions.
A
- At L1/L2. (thoracolumbar junction)
- Conus medullaris is often missed because the pt is still able to use his lower limbs
- There is typically loss of bladder and sphincter control in conus medullaris. Therefore in any pt with spinal injury at the thoracolumbar junction, evaluate bladder function and sphincter tone and control
- True: good prognosis
5
Q
SCI
Cauda equina syndrome:
- Where is cauda equina found?
- It is less likely to be injured. Why?
- T/F It has a better prognosis post-injury (LMN)`
A
- Distal to conus medullaris.
- Less likely to be injured because there is more space.
- True
6
Q
SCI:
Reflex arc:
- This simple sensory-motor pathway can function without ascending or descending long tract axons. Describe the signs of reflex arc injury during SCI
A
- Lacks modulation: overreaction to stimulus, spasticity, brisk reflexes (UMN signs)
7
Q
SCI
Mechanism of SCI
- SCI occurs as a result of primary or secondary injury. List the 5 primary injuries.
A
- Contusion - most common. potentially reversible.
- Compression
- Traction - tensile distortion
- Laceration - FB penetration, missile fragments etc.
- Ischaemia
8
Q
SCI
Mechanism of SCI
- SCI occurs as a result of primary or secondary injury. Explain briefly the pathophysiology of secondary injury
A
- Secondary injury is a biological response to primary injury»_space; inflammatory mediators»_space; edema, alteration in blood flow and perfusion.
- The adjacent tissues are injured due to decreased perfusion
- There is enzymatic degradation»_space;free radicals and cytokine release»_space; apoptosis.
9
Q
SCI:
- Improved clinical outcomes are seen in pts who are administered methylprednisolone within 8 hours post SCI- why?
- TRUE OR FALSE: These pts are loaded with 30 mg/kg IVI steroids, then 5.4 mg/kg over 24 hours if started within 3 hours or over 48 hours if started within 48 hours.
- What is the concern with these steroids?
- When are steroids contraindicated in SCI?
- List 2 other alternatives to steroids.
A
- Halts secondary injury.
- True
- Gastric bleeds and increased risk of infection.
- C/I: Penetrating SCI, pregnancy, Pt < 13 or > 8 hours after SCI, GSW
- Naloxone, thyrotropin-releasing hormone.
10
Q
SCI
Clinical presentation:
- When taking hx, what 2 main histories do patients present with ?
- The patient will complain of 1 common symptom, namely?
- You are now examining this patient. List 4 possible findings you might find
A
Hx of violent trauma (e.g. MVA»_space; expulsion from a car/ unrestrained passanger) OR low energy trauma in a susceptible pt
- Midline spinal pain
- 1. Palpable step (dislocation)
2. SP splaying (unifacet dislocation)
3. Bony crepitus
4. Hematoma/ swelling/ midline structure disruption.
11
Q
SCI: SPINAL SHOCK
- Define spinal shock
- TRUE OR FALSE: In spinal shock,, neurons are hyperpolarised and unresponsive to stimulus from brain.
- Resolution is recognised by return of function to reflex arcs caudal to the injury. When does spinal shock typically resolve?
- Name the first reflex arc to return and describe this reflex.
- Following resolution of spinal shock, list the signs that may progress over days to weeks (HINT: UMN signs)
- TRUE OR FALSE: Conus and cauda equina injuries may lead to permanent loss of the bulbo-cavernous reflex.
A
Def: Spinal shock is spinal cord dysfunction based on physiological rather than structural disruption: flaccid paralysis/ hypotonia, areflexia/ absent sensation/ priapism/neurogenic shock.
- True
- Spinal shock usually resolves after 48 hours
- 1st- bulbocavernous reflex.
- Spasticity, hyperreflexia, clonus
- TRUE
12
Q
SCI
Neurogenic shock
- Define neurogenic shock and account for it
- Briefly describe the mechanism of neurogenic shock
- Describe the signs that the patient will have
- Describe the treatment of SCI
A
- Hypodybamic sequelae of spinal shock where pt gets hypotensive from loss peripheral vascular resistance. (Sympathetic outflow disruption (T1-L2)»_space; Unopposed vagal parasympathetic tone)
- MOA: Peripheral neurons are temporarily unresponsive to brain stimul»_space; disruption of autonomic pathway»_space; loss of sympathetic tone and decreased systemic vascular resistance.»_space; decreased preload»_space; decreased CO.
- Signs > hypotension, bradycardia, venous pooling and warm skin.
- ## Rx: Swan-Gatz monitoring for careful fluid Mx (do not fluid overload) + vasopressors (adrenaline)
13
Q
SCI:
Associated conditions:
- List injuries which, if present, SCI must be excluded.
A
- Vertebral artery injury
- Closed head lacerations
- Facial/ scalp lacerations
- Spinal fractures
- 1st rib fractures
- Scapular fractures.
14
Q
SCI:
Regarding vertebral artery injuries:
- List 2 risk factors
- What is the best way to make the dx?
-Describe management
A
- Risk: Atlas fractures; facet dislocations
- MRI angiography for dx
- Mx: stenting only if pt is symptomatic from basillar artery insufficiency
15
Q
SCI
SCI injuries can be classified by:
Descriptive (tetraplegia,paraplegia) and complete vs incomplete injury.
Define:
Tetraplegia
A
- Injury to cervical spinal cord leading to impairment of function in the trunk, legs, arms, and pelvis
16
Q
SCI
SCI injuries can be classified by:
Descriptive (tetraplegia,paraplegia) and complete vs incomplete injury.
Define:
Paraplegia
A
- Injury to thoracic, lumbar, and sacral segments leading to impairment of function in the trunk, legs and pelvic organs, depending on level of injury. Arm function preserved.
17
Q
SCI
SCI injuries can be classified by:
Descriptive (tetraplegia, paraplegia) and complete vs incomplete injury.
Define:
Complete injury
A
No spared motor or sensory function below the affected level.
NB! The pt must have recovered from spinal shock before an injury is regarded complete (i.e ASIA A).
18
Q
SCI
SCI injuries can be classified by:
Descriptive (tetraplegia,paraplegia) and complete vs incomplete injury.
Define:
Incomplete injury (give examples)
A
Some reserved motor or sensory functions below the level of injury.
e.g. Anterior/posterior/ central cord syndrome
Brown sequard syndrome
conus medullaris syndrome
cauda equina syndrome
19
Q
SCI
A
TO BE CONTINUED
20
Q
TRAUMA PATIENT COMPLICATIONS
Name 1 early onset complication of trauma injuries
A
Hypovolaemic shock
21
Q
TRAUMA PATIENT COMPLICATIONS
List 3 intermediate onset complications of trauma injury
A
- SIRS/ MOD/ MOF
- Fat embolism
- Complications of prolonged rest
22
Q
TRAUMA PATIENT COMPLICATIONS
List 3 early onset complications associated with fractures
A
- Vascular injury
- Nerve injury
- Compartment syndrome
23
Q
TRAUMA PATIENT COMPLICATIONS
List 4 late-onset complications associated with fractures
A
- AVN
- Posttraumatic OA/ joint stiffening
- Complex regional pain syndrome
- Delayed/ non-unions
24
Q
TRAUMA PATIENT COMPLICATIONS
HYPOVOLAEMIC SHOCK
- Define hypovolaemia/ hypovolaemic shock
- How does hypovolaemia differ from dehydration?
A
- Decreased blood volume. More specifically: decreased volume of blood plasma.
- In dehydration, there is excessive loss of water (leading to hypernatraemia) whereas in hypovolemia, there is salt (sodium) depletion as well.
25
TRAUMA PATIENT COMPLICATIONS
HYPOVOLAEMIC SHOCK
- What is the most common cause of hypovolaemic shock in trauma patients?
- List and give examples of 4 ways in which hypovolaemic hemorrhage could occur.
1. Bloos loss (external or internal bleed)
2. Loss of plasma (burns, third space loss)
3. loss of body sodium (vomiting, diarrhoea)
4. Vasodilation (widening of vessels >> neurogenic shock)
26
TRAUMA PATIENT COMPLICATIONS
HYPOVOLAEMIC SHOCK
- Clinical symptoms of hypovolaemic shock may not be present until about 10- 20% to total whole blood volume is lost. List 4 main signs that you need to look for in a pt with hypovolaemic shock (Vital!)
- What needs to be borne in mind when dealing with children?
1. Tachycardia, low blood pressure, Decreased CRT (palor), Low GCS (dizzy/ faint/ nauseated)
- Children take a long time to compensate (i.e they will have an artificially high BP) until they decompensate. When they compensate, they decompensate rapidly and severely.
27
Explain the management of hypovolaemic shock in the following setting :
First aid
- Apply pressure on external bleeding
- If the above fails, use a tourniquet
- Other techniques: elevation,
28
Explain the management of hypovolaemic shock in the following setting :
Ambulance care
- Emergency O2 (to increase the efficiency of the pt's remaining blood supply)
= IV fluids to compensate for blood loss. (However, colloid/ crystalloid infusion may dilute the clotting factors remaining >> increasing risk of bleeding)
29
Explain the management of hypovolaemic shock in the following setting :
Hospital treatment
- Fluid management
-Blood transfusions as needed + definitive surgical repair of the bleed
30
In the pt that develops hypovolaemic shock in the hospital:
- List 4 blood investigations to do
- List 5 monitoring interventions you will mobilize for this patient
- Then, you will need to intervene. Describe your management
BLOODS:
- FBC
- X-match
- U+E
- Blood glucose
MONITORING:
- Central venous line >> indirect blood volume measurement
- Arterial line >> direct blood pressure measurement and access ABGs
- Input and output monitoring: catheter
- Bp cuff serially
- SpO2
INTERVENTIONS
- IV access >> FFPs
- O2 as required
- Inotrope therapy - dopamine, noradrenaline
- Surgery >> repair hemorrhage site.
31
TRUE OR FALSE:
Shock must be initially assumed to be hypovolaemic, even though other forms of shock do occur regularly
TRUE
32
SIRS/MOD/MOF
Traumatic injury leads to SIRS (increased TNF-a, IL-1, IL-6). This is followed by?
Followed by recovery period -CARS >> Counter regulatory Anti-inflammatory Response (lowers IL4, -10 and 11)
33
SIRS/MOD/MOF
- Define SIRS
- TRUE OR FALSE: Pts that develop SIRS are most likely genetically predisposed.
- SIRS most often complicated into ___
- 3 systems are typically involved in SIRS. List and explain how
- List 4 signs indicative of SIRS
- SIRS is a generalised response to trauma characterised by an increase in: cytokines, complement and hormones.
- True: there is a genetic predisposition.
- Mostly complicated into MOD - multi-organ dysfunction
3 SYSTEMIC IMPLICATED IN SIRS:
1. Haematopoiec system >> DIC
2. Resp system >> ARDS
3. Renal system >> renal failure
VITALS
1. HR > 90
2. RR >20 or pCO2 < 32mm
3. Temp < 36 or > 38
4. WCC < 4000 or > 12 000 cells
34
FAT EMBOLISM
- Define fat embolism
- Briefly explain the pathophysiology of fat embolism
- A syndrome caused by an inflammatory response to globules of fat characterised by: hypoxia, pulmonary edema, CNS depression and petechial rash
- Fat and marrow elements are embolised into the bloodstream during acute long bone fractures >> metabolic OR mechanical sequelae :
mechanical theory
embolism is caused by droplets of bone marrow fat released into the venous system
biochemical theory
lipoprotein lipase induces free fatty acid production with a resultant hyperinflammatory response similar to ARDS
35
FAT EMBOLISM
- List the major criteria of fat embolism
- List 6 parameters that fall under the minor criteria
- TRUE OR FALSE:
- Other considered signs include: anxiety, PaCO2 > 55, pH < 7.3, RR > 35, Dyspnoea
MAJOR CRITERIA
- Hypoxia
- CNS depression
- Pulmonary edema
- Petechiae
MINOR CRITERIA
- Retinal emboli
- Tachycardia
- Fever
- Fat in urine/ sputum
- Thrombocytopaenia
- Decreased serum glucose
Other> true
36
FAT EMBOLISM
- Symptoms may present within ___ of the inciting event unto ____
- Describe the main symptoms of the patient with fat embolism
- On examination, what will you find?
- Name an important side room investigation to do in these patients
- Symptoms: within 24 hrs and up to 72 hrs post inciting event
- Main symptoms: SOB and confusion
- O/e: tachycardia, tachypnoea, petechiae (axilla, conjunctiva, oral mucosa)
- Sideroom: ABG
37
FAT EMBOLISM
- Explain the management of fat embolism
- How can fat embolism be prevented?
- Management: Essentially supportive >> mostly mechanical ventilation with high levels of PEEP >> this is indicated in acute fat emboli syndrome
- Prevention >> early fracture stabilization
38
COMPLICATIONS OF PROLONGED BED REST
List 4 main complications seen as a result of being bed-ridden
List 4 most common conditions necessitating prolonged bedriddenness
1. Thromboembolism >> DVT >> PE
2. Pressure sores (perfusion pressure greater than capillary pressure 30 mmHg for a prolonged period)
3. Constipation
4. Bladder distension
Conditions:
1. SCI
2. Multiple injury/ polytrauma/ Orthopaedic injury
3. Stroke
4. Prolonged hospitalization
39
VASCULAR INJURIES
- Vascular injury is suspected in 5 main scenarios: list these.
- Once you have suspected a vascular injury, you do an ABI. Based on the ABI, what will your next step be?
SUSPECT IF:
1. injury proximal to major vessel
2. Diminised pulse
3. diminished doppler
4. Cool/ mottled extremity
5. MOI: knee dislocation, elbow dislocation
You do n ABI.
iF > 0.9 : do serial exams
IF < 0.9 : do a CTA and/or explorative surgery
40
VASCULAR INJURY
- Explain how an ABI is done
An ABI (Ankle Brachial Index) test is performed by measuring the blood pressure in both arms and both ankles while the patient lies down, using an inflatable cuff and a handheld ultrasound device to locate the pulse in the arteries, and then calculating a ratio between the ankle pressure and the arm pressure to assess for potential blockages in the leg arteries
41
VASCULAR INJURY
- Aetiology of vascular injury is from penetrating and blunt force injuries: give examples to elaborate.
Penetrating: stab/ GWS/ Industrial accidents/ Iatrogenic
Blunt: fractured long bones/ dislocated joints/ direct contusion
42
VASCULAR INJURY
- List 5 hard signs of vascular injury
- List 4 soft signs of vascular injury
- You are now examining this patient, what will you find on examination ?
Hard signs
- Observed pulsatile bleeding
- Heard a bruit over an artery
- See an arterial thrill (vibration) by manual palpation
- Signs of distal ischemia
- Visible expanding hematoma
Soft signs
- Hx from pt of lots of bleeding
- Decreased pulse compared to contralateral extremity
- Bony injury/ proximity penetrating wound
- Neutologic abnormality
O/e
- BP low
- Cool, cold extremities
- Pulse abnormalities
- Neurological deficit
- delayed CRT
- Bony abnormalities e.g. fractures of long bones, joint dislocation
43
VASCULAR INJURY
1. Name 2 Ix to do in a pt with a suspected vascular injury
2. Explain the management of vascular injury in trauma patients
Ix: Doppler U/S AND arteriogram
Mx:
- Emergency arteriogram
- Temporary vascular control >> prressure on vessel or tourniquet
- Emergency surgical exploration
44
VASCULAR INJURY
- List 2 indications of primary amputation in pts with vascular injury
1. Severe injury with severe risk of reperfusion injury (> 6 hours)
2. The limb is likely painful and useless.
45
NERVE INJURY
Define the following terms commonly used for nerve injuries:
Neuropraxia
NEUROPRAXIA
1st degree nerve injury:
- Histopath >>focal demyelination of the axon sheath (all structures remain intact)
- Potential good recovery
46
NERVE INJURY
Define the following terms commonly used for nerve injuries:
Axonotmesis
AXONOTMESIS
2nd-degree nerve injury
- endometrium intact
- recovery, but usually incomplete
47
NERVE INJURY
Define the following terms commonly used for nerve injuries:
Neurotmesis
NEUROTMESIS
- Complete nerve division with disruption of the endometrium.
No recovery
48
NERVE INJURY: Treatment
It is critical to properly align nerve ends during repair to maximize potential recovery. A gap of > ________ needs to be repaired with nerve grafting
> 2.5 cm must be repaired.
49
NERVE INJURY
List 4 factors that affect the success of recovery following repair of a nerve
1. Age (single most NB factor)
2. Type of injury (sharp transection better than crush injury)
3. Level of injury (the more distal the better)
3. Repair delay >> worsen prognosis (time limit for repair is 18 months)
50
COMPARTMENT SYNDROME
- Define compartment syndrome
- Why is it an emergency?
- Compartment syndrome may occur anywhere that skeletal muscle is surrounded by fascia. List 8 places that is most commonly occur at
- When osseofascial compartment pressures exceed that of perfusion pressure.
- Cna lead to irreversible muscle and nerve damage.
- Lower limb: foot, leg, thigh, buttock
- Upper limb: shoulder, forearm, hand
Trunk: paraspinous muscles
51
COMPARTMENT SYNDROME
- Aetiology: Compartment syndrome comes about when the compartment size is decreased or when the content within the compartment is increased. List 7 main causes
- Patho-anatomy:
TRUE OR FALSE: The cascade of events includes: local trauma and soft tissue destruction >> bleeding and edema >> increased interstitial pressure >> vascular occlusion >> myoneural ischemia
1. Trauma (fractures, crush injuries, contusions. GSW)
2. Tigh casts/ bandages/ external wrappings
3. Extravasation of IV fluid
4. Burns
5. Post-ischaemic swelling
6. Bleeding disorders
7. Arterial injury
True
52
COMPARTMENT SYNDROME
- Describe the symptoms indicative of compartment syndrome
- What are the limitations of using pain as the main symptom of compartment syndrome
- You are now examining this pt. List and explain
- SYmtoms: pain way out of proportion to the clinical situation and in a crescendo pattern
Limitations: pain is difficult to assess in children, may be absent in SCI, the polytrauma pt may be sedated.
Signs
1. Pain of passive stretching - most sensitive prior to the onset of ischemia
2. Paraesthesia/hypoesthesia - d/t nerve ischemia
3. Paralysis - late sign.
4. Palpable, woody swelling
5. Peripheral pulses absent - late sign. Amputation inevitable here.
53
COMPARTMENT SYNDROME
- List the 2 late findings of compartment syndrome
- What imaging and special tests will you do for these patients? What are the 3 indications of the special test you will do?
LATE FINDINGS: paraesthesia, pulselessness
- Imaging: xray to exclude a f#. Speciall test: establish compartment pressures in 1. polytrauma pt, 2. pt not alert unreliable 3. inconclusive physical exam
54
AVASCULAR NECROSIS
- Also known as?
- AVN is associated with trauma - explain how
- AVN can be caused by intra-capsular or extra-capsular fractures. List 4 intracapsular causes from the most common down.
- List 3 causes of AVN in the shoulder in the order from the most common down
- Talar neck fractures are the most common type of fracture in the talus. What is a predictor for AVN in these fractures?
- osteonecrosis
- Trauma >> injury to femoral head blood supply >> medial circumflex
- INtra-caps: fead of femur, basicervical f#, cervico-trochanteric f#, hip dislocation
- Shoulder: post-traumatic, 4-part fracture-dislocation, 3-part fracture
- If talar neck is dislocated.
54
COMPARTMENT SYNDROME
- Explain the management of compartment syndrome (non-op and op)
- Regarding your management, special considerations need to be borne in mind for paediatrics and haemophiliacs - explain
Non-op:
- Observe: IF it is very early in the disease/ presentation not consistent with compartment syndrome
- Bivalving the cast/ loosen circumferential dressings: IF initial swelling/ pain that is NOT compartment syndrome
Operative:
- Emergency fasciotomy in all 4 compartments > clinical presentation consistent (anterior, lateral, posterior deep, posterior superficial)
In Paeds >>Difficult to assess pain. If suspicion, obtain compartment pressures under sedation.
In hemophiliacs>> administer factor VIII before measuring compartment pressures
55
POSTTRAUMATIC OA / JOINT STIFFNESS
- All intra-articular fractures can predispose to post-traumatic OA. Prevention is better than cure. Explain how to prevent posttraumatic arthritis
- Accurate fracture reduction and stable immobilization - allow early movement.
56
COMPLEX REGIONAL PAIN SYNDROME
57
COMPLEX REGIONAL PAIN SYNDROME
58
DELAYED/ NON-UNIONS
59
GENERAL PRINCIPLES F# MX
Define the following terms:
- Fracture
- Dislocation
- Subluxation
Fracture: break in the continuity of the bone
Dislocation: Total loss of congruity between articular surfaces
Subluxation: A partial loss of congruity between articular surfaces
60
GENERAL PRINCIPLES F# MX
TRUE OR FALSE:
Fracture heals by restoration of bone continuity. The rate of healing varies (higher in children). Cancellous bone heals faster than cortical bone. Some movement is needed for bone to heal. Bone healing also required adequate blood supply
TRUE
61
GENERAL PRINCIPLES F# MX
- There are 5 stages of fracture healing: Name and explain these briefly
1= Haematoma ,(bone end bleeding, periosteal strippping)
2= Acute inflammation (cell divisoin, cell proliferation in periosteum)
3= Callus formation (dead bone resorbed. Immature woven bone forms)
4= Lamellar bone (fracture union)
5= remodelling (medullary cavity restored, normal shape of bone)
62
GENERAL PRINCIPLES F# MX
- Compare the forces needed to shatter vs to crack the bone.
Crack: the bone's breaking point has been exceeded only slightly. Shatter: the force is extreme.
63
GENERAL PRINCIPLES F# MX
Define the following common types of fractures:
Stable fracture
The broken ends of the bone line up and are barely out of place.
64
GENERAL PRINCIPLES F# MX
Define the following common types of fractures:
Open, compound fracture
the skin may be pierced by the bone or by a blow that breaks the skin at the time of the f#. The bone may or may not be visible through the wound.
65
GENERAL PRINCIPLES F# MX
Define the following common types of fractures:
Transverse fracture
horizontal line fracture
66
GENERAL PRINCIPLES F# MX
Define the following common types of fractures:
Oblique fracture
angled pattern
67
GENERAL PRINCIPLES F# MX
Define the following common types of fractures:
Comminuted fracture
bone shatters into 3 or more fragments
68
Which type of fracture does the following description refer to?
69
Which type of fracture does the following description refer to?
-Compression forces. Treatment depends on treatment
Compression fracture
70
Which type of fracture does the following description refer to?
Caused by muscle contraction pulling off a portion of the bone. Muscle pull displaces the fracture
Avulsion fracture
71
Which type of fracture does the following description refer to?
Direct blow.
Reduced risk of shortening following reduction
Length stable
Small surface area >> longer time to union
Transverse fracture
72
Which type of fracture does the following description refer to?
Usually cancellous bone and union is rapid
Treatment depends on the displacement
Impacted
73
Which type of fracture does the following description refer to?
Muscle contraction and early weight bearing can cause shortening
Time to union shorter because of of larger area of bone contact
Oblique F#
74
Which type of fracture does the following description refer to?
Fracture caused by rotational force.
Large surface area >> early healing
Spiral F#
75
Which type of fracture does the following description refer to?
High energy injury
often associated with soft tissue injuries
Poor prognosis
Comminuted
76
List 4 most common causes of fractures
- How do you take hx in a pt with a possible F#?
- Explain the most common symptoms
- The most common and accessible way to examine the bone is through?
1. Trauma
2. Osteoporosis
3. Overuse (stress f# more common in athletes)
4. Fractures in children
Hx: AMPLE hx, MOI, Symptoms
Symptoms:Pain, decreased ROM, swelling, deformity, skin changes (erythema, bruising)
Xray
77
Radiological principles
- What is the rule of 2s
2 views, 2 occasions, 2 joints, 2 limbs
78
- Define the following terms often used in X-ray interpretation
Displacement
described the movement of the distal segment
79
- Define the following terms often used in X-ray interpretation
Apposition
How much contact do the bone pieces have with each other
80
- Define the following terms often used in X-ray interpretation
Angulation
The direction of the apex of the deformity
81
- Define the following terms often used in X-ray interpretation
Shortening
Perpendicular measurement of a chosen point on the proximal and distal fragment.
82
- Define the following terms often used in X-ray interpretation
Rotation
Mostly a clinical measurement. Radiologically, we check the joint below and above, as well as the width of the bone.
83
List and briefly explain the 4 non-operative treatment options for fractures
1. Cast immobilisation >> most commonly used.
2. Functional cast or brace >> here the limb can move in a controlled/ restricted movement. Common in humeral fractures.
3. Traction >>align bone by gentle pulling action. Mostly in Paeds (short time to union). Compl> pressure sores, etc,
4. External fixation >> metal pins and screws placed into the broken bone above and below the fracture site.
84
List 6 indications of external fixation
1. Acute trauma with excessive swelling
2. Limb lengthening
3. Non-union fractures
4. Arthrodesis
5. Correction of a joint contracture
6. Filling of segmental bone defects e.g. tumor, infection, osteomyelitis
85
List 3 complications of external fixation
1. Pin-tract sepsis
2. Overdistraction
3. Malunion if poorly indicated/ applied.
86
TRUE OR FALSE:
This is how a pt is generally evaluated pre-op in Ortho:
Hx: smoking, diabetes/ other systemic conditions, drugs- immunosuppressive
Special Ix: HIV, Albumin, lymphocyte count
Type of host: A/B (>60 yo, comorbidities)/C
True
87
List 3 indications of emergency surgeries in orthopedics
1. Compartment syndrome
2. Open fractures
3. Irreducible dislocation
88
ORIF
During this op, the bone fragments are first repositioned (reduced) in their normal alignment, then held in place with screws or by attaching metal plates to the outer surface of the bone. OR intramedullary.
List 8 indications of ORIF
1. Intra-articular fractures
2. Polytrauma/ multiple injuries
3. Repair of blood vessels (neurovasc injury)
4. Pathological fractures
5. Head injury
6. Elderly pts >> to allow for early mobilisation
7. Failure of conservative Mx
8. Unstable fractures >> cannot get or keep reduction
89
ORIF
List 4 complications of ORIF
1. Infection
2. Non-union
3. Implant failure
4. Refracture at edge of the implant
90
List 5 ways in which you can clinically /radiologically assess for fracture healing
1. Nontenrder at the fracture site
2. Palpable callus
3. Xray - bridging callus
4. Stable bone at the fracture site
5. Trabeculae crossing fracture site.
91
Explain perkin's time table when it comes to:
- Lower limb vs upper limb fractures in adult vs children
- Other fractures vs transverse fractures
Child upper limb = 3 weeks
Adult = 2X child to heal
Transverse = 2X the time for a normal f#
Lower limb= 2X the time of upper limb
Therefore:
Upper limb:
- Child = 3/53
- Adult + transverse = 6/52
Lower limb
= Child - 6/52
= Adult + transverse = 12/ 52
92
TRUE OR FALSE: (Regarding Closed f# management)
- We need to consider reduction of the fracture (correcting any varus/valgus/shortening/angulation), maintaining that reduction, immobilizing the fracture, and then offering the pt rehabilitation
93
Fracture immobilization is done either via external methods (3) or internal methods (3). List all of these.
External methods:
- Casts
- Ex fix
- Traction
Internal methods
- K-wires
- Plates
- Screws
94
Explain how you go about performing closed reduction
1. Administer analgesia and muscle relaxant
2. Disimpact the fracture (reverse the MOI - longitudinal traction)
3. Assistant applies POP
4. Mould cast using the 3-point fixation/ pressure
5. Repeat circulation and nerve check 24 hrs post cast
95
Guidelines for POP
- What is the most important thing to check before POP application
- Why is it important to elevate the limb in a cast?
- How many layers of POP should you use?
- If the water is too hot, it can __
- Check the neurovascular system and record it!
- Elevation >> allow drainage from extremity >> decrease swelling
- 3 POP layers
- It can burn the pt
96
List 6 complications possible with POP
1. Can burn the pt
2. Compartment syndrome if too tight
3. Ischaemic injury
4. Nerve injury
5. Pressure necrosis
6. Stiff, contracted joints.
97
Why does the pt need rehabilitation post cast?
- Because during the cast, the pt loses muscle bulk and joint mobility. This needs to be restored when the cast is out
98
List 3 ways to prevent fractures in the elderly
1. Diet rich in Ca+ and Vit D
2. Strength training/ weight bearing exercise
3. Early referral to endocrinology for osteoporosis
