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Y3(S) - T & O > Tibial Fractures, Open Fractures And Compartment Syndrome > Flashcards

Tibial Fractures, Open Fractures And Compartment Syndrome Flashcards

1
Q

What nerves need to be assessed in a Neurovascular exam when a patient has a tibial shaft fracture?

A

Superficial fibular
Deep fibular
Tibial
Saphenous
Sural

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2
Q

Where do you assess for sensation for the NV exam following a tibial shaft fracture?

A

Superficial fibular = feel 3rd toe dorsum
Deep fibular = dorsum 1st web space
Tibial nerve = calcaneus
Saphenous nerve = medial malleolus
Sural nerve = lateral malleolus

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3
Q

How do you assess the tibia on x-ray?

A

In 1/3s
Need to see ankle and knee (dislocation?)
Translation?
Type of fracture?
Open or closed?

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4
Q

What imaging should be requested for a potential tibial fracture?

A

AP and lateral plain radiographs of tibia and fibula(X-rays)

CT if can’t visualise fracture properly or if its distal tibial and it may extend into the ankle

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5
Q

What Ix need to be done for a tibial shaft fracture?

A

Urgent bloods
G+S

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6
Q

What is the immediate management of a tibial shaft fracture?

A

Analgesia
Reduce fracture
Immobilise (ABOVE KNEE BACKSLAB)
Re-image following reduction and re assessment of neurovascular status

Elevate leg
NBM
VTE prophylaxis
Non weight bearing

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7
Q

What type of VTE prophylaxis is typically favoured in indivuals that have tibial shaft fractures and why?

A

Mechanical like stockings and flowtrons

Don’t want to give a patient LMWHs when they are likely to be going into surgery

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8
Q

What is the definitive management of a tibial shaft fracture?

A

Surgical

IM nail if not extending into ankle

ORIF with plate and screws if extends into ankle

Temporary external fixation if not stable enough for definitive surgery

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9
Q

What are some IMPORTANT COMPLICATIONS of tibial shaft fractures?

A

COMPARTMENT SYNDROME
Ischaemic limb
OPEN fractures

Post traumatic osteoarthritis

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10
Q

What is compartment syndrome?

A

Critical increase in pressure within a closed fascial compartment leading to local tissue ischaemia

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11
Q

What is the pathophysiology of compartment syndrome?

A

Pressure increases (swelling) veins are the first to be compressed since dont have thick muscular elastic walls

This impairs venous return which further increases the pressure (OUTFLOW issue)

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12
Q

When you first suspect a compartment syndrome in a patient what should your approach be?

And how you assess?

A

Ensure patient has had analgesia and reasses in 10-15mins

Cut open cast to relieve pressure
Look at leg
Passively stretch patients toes (out of proportionate pain?)
Elevate leg

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13
Q

What is the main symptom of compartment syndrome?

A

PAIN (out of proportion)

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14
Q

What are the 6 Ps of compartment syndrome?

A

Pain
Pallor
Pulselessness
Paraesthesia
Paralysis
Perishingly cold

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15
Q

What is the management steps for compartment syndrome?

A

NV assessment
Split cast down the middle
Asses pain on stretching toes
Elevate leg
Analgesia
Ensure BP in normal range
Inform T+O REGISTRAR will need surgery

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16
Q

What is the surgical managemtn of compartment syndrome?

A

Urgent fasciotomy within 1hr of diagnosis

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17
Q

How is an urgent fasciotomy performed?

A

4 compartment decompression

2 incisions on medial and lateral sides

External fixation

18
Q

What complications need to be monitored for when suspecting compartment syndrome is occurring and why?

What substance can be measured?

A

Muscle necrosis

AKI (myoglobin released from rhabdomyolysis)
K+ (arrhythmias from rhabdomyolysis/cell death)

Can measure creatinine kinase

19
Q

What is an open fracture?

A

Fracture of bone when there is a communication between the bone and the environment (bone to skin or bone to rectum or vagina)

20
Q

What is the first approach to assessing a patient with an open fracture?

A

A-E

21
Q

How do you manage a fracture when theres a wound overlying it?

A

Treat like an open fracture (better than not treating it as open and it actually being open)

22
Q

What is the most common long bone fracture that causes open fractures?

A

Tibia

23
Q

What is the most common non long bone causing open fractures?

A

Phalanges

24
Q

What is the classification used to assess open fractures?

A

Gustilo-Anderson classification

25
Q

What are the classes within the Gustilo-Anderson classification system?

A

1
2
3a
3b
3c

26
Q

What is a Class 1 open fracture on the Gustilo-Anderson classification system?

A

Wound <1cm
Clean

27
Q

What is a Class 2 open fracture on the Gustilo-Anderson classification system?

A

1cm< wound <10cm

Clean

Moderate soft tissue damage

28
Q

What type of injuries are class 3a and above in the Gustilo-Anderson classification system for open fractures?

A

High-energy
Highly contaminated
Vascular compromised

29
Q

What is a Class 3a open fracture on the Gustilo-Anderson classification system?

A

High energy injury or highly contaminated wound
Complex fractures

Has adequate soft tissue coverage

30
Q

What is a Class 3b open fracture on the Gustilo-Anderson classification system?

A

Inadequate tissue coverage
High energy injury
Highly contaminated

31
Q

What is a Class 3c open fracture on the Gustilo-Anderson classification system?

A

Any open fracture that has vascular compromise

32
Q

What investigations should be done for a patient with an open fracture?

A

Plain radiograph
CT if more complex

FBCs
U+Es
G+S (+crossmatch)
Coagulation screen

33
Q

How should a patient with an open fracture be managed?

A

Analgesia
URGENT ANTIBIOTICS (CO-AMOXICLAV)
NBM
Fluids
TETANUS VACCINE

NV assessment
Photograph wound
Debridement of gross contamination
Dress wound
Imaging

Call ortho reg

34
Q

What type of wound dressing should be applied to an open fracture?

A

Saline soaked gauze with occlusive dressing

35
Q

What surgical procedure will all open fracture cases require?

A

Surgical washout

36
Q

What is the timeframes by which an open fracture should be taken for surgical washout?

A

Immediately

Within 12hrs

Within 24hrs

37
Q

What types of open fractures are taken immediately to theatre?

A

Highly contaminated
Vascular compromised
Compartment syndrome

38
Q

What types of open fractures are taken to theatre within 12hrs?

A

Solitary high energy open fractures with no contamination or vascular injury

39
Q

What types of open fractures are taken to theatre within 24hrs?

A

Low energy open fractures with low contamination or no vascular injury

40
Q

What must you always do after reducing an open fracture or any Fracture?

A

Re image
Re assess neurovascular status

Y3(S) - T & O (7 decks)

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