Tibial Fractures, Open Fractures And Compartment Syndrome Flashcards
What nerves need to be assessed in a Neurovascular exam when a patient has a tibial shaft fracture?
Superficial fibular
Deep fibular
Tibial
Saphenous
Sural
Where do you assess for sensation for the NV exam following a tibial shaft fracture?
Superficial fibular = feel 3rd toe dorsum
Deep fibular = dorsum 1st web space
Tibial nerve = calcaneus
Saphenous nerve = medial malleolus
Sural nerve = lateral malleolus
How do you assess the tibia on x-ray?
In 1/3s
Need to see ankle and knee (dislocation?)
Translation?
Type of fracture?
Open or closed?
What imaging should be requested for a potential tibial fracture?
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
What Ix need to be done for a tibial shaft fracture?
Urgent bloods
G+S
What is the immediate management of a tibial shaft fracture?
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
What type of VTE prophylaxis is typically favoured in indivuals that have tibial shaft fractures and why?
Mechanical like stockings and flowtrons
Don’t want to give a patient LMWHs when they are likely to be going into surgery
What is the definitive management of a tibial shaft fracture?
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
What are some IMPORTANT COMPLICATIONS of tibial shaft fractures?
COMPARTMENT SYNDROME
Ischaemic limb
OPEN fractures
Post traumatic osteoarthritis
What is compartment syndrome?
Critical increase in pressure within a closed fascial compartment leading to local tissue ischaemia
What is the pathophysiology of compartment syndrome?
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)
When you first suspect a compartment syndrome in a patient what should your approach be?
And how you assess?
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
What is the main symptom of compartment syndrome?
PAIN (out of proportion)
What are the 6 Ps of compartment syndrome?
Pain
Pallor
Pulselessness
Paraesthesia
Paralysis
Perishingly cold
What is the management steps for compartment syndrome?
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
What is the surgical managemtn of compartment syndrome?
Urgent fasciotomy within 1hr of diagnosis
How is an urgent fasciotomy performed?
4 compartment decompression
2 incisions on medial and lateral sides
External fixation
What complications need to be monitored for when suspecting compartment syndrome is occurring and why?
What substance can be measured?
Muscle necrosis
AKI (myoglobin released from rhabdomyolysis)
K+ (arrhythmias from rhabdomyolysis/cell death)
Can measure creatinine kinase
What is an open fracture?
Fracture of bone when there is a communication between the bone and the environment (bone to skin or bone to rectum or vagina)
What is the first approach to assessing a patient with an open fracture?
A-E
How do you manage a fracture when theres a wound overlying it?
Treat like an open fracture (better than not treating it as open and it actually being open)
What is the most common long bone fracture that causes open fractures?
Tibia
What is the most common non long bone causing open fractures?
Phalanges
What is the classification used to assess open fractures?
Gustilo-Anderson classification
What are the classes within the Gustilo-Anderson classification system?
1
2
3a
3b
3c
What is a Class 1 open fracture on the Gustilo-Anderson classification system?
Wound <1cm
Clean
What is a Class 2 open fracture on the Gustilo-Anderson classification system?
1cm< wound <10cm
Clean
Moderate soft tissue damage
What type of injuries are class 3a and above in the Gustilo-Anderson classification system for open fractures?
High-energy
Highly contaminated
Vascular compromised
What is a Class 3a open fracture on the Gustilo-Anderson classification system?
High energy injury or highly contaminated wound
Complex fractures
Has adequate soft tissue coverage
What is a Class 3b open fracture on the Gustilo-Anderson classification system?
Inadequate tissue coverage
High energy injury
Highly contaminated
What is a Class 3c open fracture on the Gustilo-Anderson classification system?
Any open fracture that has vascular compromise
What investigations should be done for a patient with an open fracture?
Plain radiograph
CT if more complex
FBCs
U+Es
G+S (+crossmatch)
Coagulation screen
How should a patient with an open fracture be managed?
Analgesia
URGENT ANTIBIOTICS (CO-AMOXICLAV)
NBM
Fluids
TETANUS VACCINE
NV assessment
Photograph wound
Debridement of gross contamination
Dress wound
Imaging
Call ortho reg
What type of wound dressing should be applied to an open fracture?
Saline soaked gauze with occlusive dressing
What surgical procedure will all open fracture cases require?
Surgical washout
What is the timeframes by which an open fracture should be taken for surgical washout?
Immediately
Within 12hrs
Within 24hrs
What types of open fractures are taken immediately to theatre?
Highly contaminated
Vascular compromised
Compartment syndrome
What types of open fractures are taken to theatre within 12hrs?
Solitary high energy open fractures with no contamination or vascular injury
What types of open fractures are taken to theatre within 24hrs?
Low energy open fractures with low contamination or no vascular injury
What must you always do after reducing an open fracture or any Fracture?
Re image
Re assess neurovascular status
