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Ortho ST3 Interview > Trauma > Flashcards

Trauma Flashcards

1
Q

What is a fracture?

A

Soft tissue injury associated with break in the continuity of the bone

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2
Q

How do you manage a peripheral nerve injury 2o to trauma?

A

Follow BOAST guidelines

Key is identifying early
Reducing joint if dislocation
Release compressive bandages
Check for expanding haematoma
Get formal advice (Plastics vs PNI unit) if:

Penetrating injury- within 24 hours
If non operative management of #- within 24 hours
Prior to surgery
Immediately if noticed post op/during surgery

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3
Q

How do you manage arterial injury associated with a fracture?

A

Follow BOAST guidelines
Involve Vascular + Plastics + Ortho

Control Haemorrhage- direct pressure/tourniquet +- MHP
Reduce/realign limb- document NVI pre/post
CT post scan + CTA
Revascularisation within 4 hours of injury

Attempt definitive repair- if fails Use arterial shunts whilst skeletal stabilisation occurs
Then for venous grafting

Aim for definitive repair/interposition grafts over bypass grafting

Consent for amputation

Think prophylactic fasciotomies

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4
Q

From time of arterial injury within what time should you revascularise the limb?

A

4 hours

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5
Q

What is compartment syndrome?

A

Where raised pressure in a closed fascial compartment leads to comprimised microcirculation, ischaemia, hypoxia and soft tissue death- downward spiral

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6
Q

What is the compartment syndrome downward spiral?

A

Injury leads to soft tissue swelling
Increased compartment pressure
Decreased perfusion pressure
Local hypoxia
Cell membrane damage
And so on

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7
Q

What are the symptoms of Compartment syndrome?

A

5Ps- pain, pain, pain, pain, pain
Stretch test
paraesthesia often early
Tight compartments
pH/lactate

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8
Q

Differential Dx for compartment syndrome?

A

DVT
Post op swelling
Peripheral oedema

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9
Q

How do you diagnose compartment syndrome?

A

Clinical diagnosis

Adjuncts for patients in ICU/intubated

compartment pressure monitoring
<30 mm Hg between diastolic and compartment pressure

> 40mm Hg

BOAST guidelines advise continous pressure monitoring better for Dx

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10
Q

How do you treat Compartment syndrome?

A

Normal BP
Elevate limb to level of heart
Take off circumferential dressings
Adequate analgesia
Review in 30 mins

If persistent pain then pre for theatre
NBM
Mark + consent
Alert NOK
Bloods, ECG< 2x G&S
CEPOD, theatre team/anaesthetist

Operation within 1 hour of decision made

Prep and brief for theatre
If fracture not fixed could consider external vs internal fixation
Abx if fracture/metalwork
TXA
No tourniquet
supine
Standard surgical set
Prep to above knee
VAC needed

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11
Q

How do you perform the operation for Lower limb compartment syndrome?

A

2 incision 4 compartment decompressive fasciotomy as per BOA/BAPRAS guidelines

Anterolateral incision to release anterior and lateral compartment
2 cm lateral to tibial crest between the tibial crest and fibula. Extend for 15-20cm. Identify SPN 10cm proximal to lateral malleolus

Posteromedial incision to release posterior compartments- 1-2c medial to posteromedial boarder of tibial and extend distally 15-20cm. Retract saphenous vein and artery out of the way. Be wary of the anterior perforators at 10/15cm from medial malleolus. Ensure you get access to deep posterior compartment- take down soleus origin on posteromedial aspect of tibia. Post tibial NVI run in between the two compartments so be careful.

Debride dead tissue
VAC dressing

Re look in 48 hours +- plastics

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12
Q

Which blade you using for skin incision?

A

10 blade

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13
Q

What is in Pack A and B?

A

In my local unit:

4 units RBC
4 units FFP

Pack B
4 units RBC/FFP
1 unit platelets

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14
Q

What is TXA?

A

Tranexamic acid
Antifibrinolytic
Prevents clot breakdown

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15
Q

How much circulating volume in an adult?

A

5 litres

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16
Q

Grades of haemorrhagic shock?

A

1: 0-15, <750mls lost. Nil
2: 15-30, 750-1500mls. Tachycardia, narrow pulse pressure, decrease UO
3: 30-40, 1500-2000mls. Tachy, BP drop, UO down down
4: >40, >2l, ++ tach/hypotensive, UO nothing

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17
Q

What is the blood supply to bone?

A

Nutrient artery
Periosteal blood supply
Metaphseal-epiphyseal system (at the end of bone)

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18
Q

How to manage an open fracture?

A

BOAST guidelines!!

IV abx within 1 hour(local guidelines, co-amox/clinda)
Tetanus
Photo
Plastics
Reduce
Gross contamination removed
Saline soaked gauze and occlusive dressing

1st stage
2nd stage

19
Q

When do open fractures need to be managed at Major trauma centre?

A

Fracture of long bones/midfoot/hindfoot

Patients with hand, wrist, forefoot or digit injuries may be managed locally following similar principles.

20
Q

When do you go to theatre for an open fracture

A

Immediately if vascular compromise (compartment syndrome or vascular injury leading to ischaemia)
Or high contamination- agricultural, sewage or aquatic

Within 12 hours- high energy injuries

Within 24 hours- low energy injuries

21
Q

How to do your 1st stage for an open fracture

A

Following BOAST/BAPRAS guidelines- Plastics/Ortho consultant present

Adhere to fasciotomy lines- avoid perforators for potential further soft tissue coverage.

Excise degloved/dead tissue back to bleeding tissue
Shotgun leg
Remove dirt/contaminant- 5L of wash
Remove dead bone? Tug test
Careful of nerves/vessels- great saphenous often cut

In fix vs ex fix

VAC

22
Q

When and how to do second stage

A

Within 72 hours
Orthoplastic list
Fix as per ortho

Soft tissue coverage as per plastics
Free flap over #- lower infection rates

23
Q

How and when do you classify open fractures?

A

Gustillo anderson classification
At 1st stage post debridement
1-<1cm and clean
2->1cm no extensive damage
3a- extensive soft tissue damage + high energy trauma
3b- periosteal stripping + bone exposure + contamination
3c- arterial injury or repair required

24
Q

When do you primarily close open fractures?

A

Small defect
Low energy
No contamination
Low demand/comorbid patient

25
Q

What is the relationship between stiffness and stability for IM Nailing?

A

Stability is proportional to working length

Stiffness inversley proportional to working length

26
Q

What is the aetiology in terms of spread and bacterial for septic arthritis?

A

Spread- direct, local or haematogenous

Bacterial:

Commonest is staph a >50%
Neisseria gonorrhoea- 20%
Gram - bacilli- 10%
Psedumonas0 IVDU- Sternoclavicluar joint SA

27
Q

Differential for red hot swollen joint?

A

Septic
Crystal
Reactive/rehumatological
Osteoarthritis
Trauma

28
Q

Risk factors for septic arthritis?

A

> 80years old
Comorbid
IVDU
Immunocompromised
Recent joint surgery
bacteraemia

29
Q

Management of septic arthritis?

A

Aspirate then Abx then Washout

If septic shock then Abx straight away

If able to aspirate send for MCS, crystals and gram stain
For urgent washout if organisms on gram stain

CEPOD list- deep tissue culture, washout and debridement

FWB
Monitor CRP
MOnitor clinical signs/temp
For re washout if needed
Micro input

30
Q

Important points in the history of a ?PJI patient

A

Which surgeon
When
OPeration notes- prostheses used
Assess for endocarditis
Any complication from operation

31
Q

How do you manage a patient with an acute suspected PJI?

A

As per PJI BOAST

Acutely:
If in septic shock treat with sepsis 6
Otherwise aspirate in sterile environment- anaesthetic room/theatre

In an acutely unwell patient DAIR within 6 hours of diagnosis as per BOAST

During DAIR take 5 samples for for MCS and 2 for histopathology using different and new sterile equipment

If patient is not septic no Abx until deep tissue samples taken

Check for endocarditis

32
Q

Overall PJI Management?

A

Micro + MDT

Is it acute or chronic?Acute = DAIR

Chronic = revision vs suppresion vs amputation

33
Q

What are the risk factors for PJI?

A

Patient vs operative

Patient:
Diabetes, smoking, IVDU, alcohol, steroids, immunocompromised, MRSA

Operative:
Abx at induction, laminar flow, minimise traffic, good wound closure + occlusive dressing, short anaesthetic and tourniquet time, cold site operating

34
Q

Which injuries are at high risk of compartment syndrome?

A

Tib/fib #
radius/ulna #
high energy wrist #
crush injury
circumferential burns

35
Q

Landmarks and process of FIB?

A

Mark on ASIS and PT
Lateral 1/3 of line between 2

Down through fascia lata and fascia iliaca
No resistance

36
Q

What paper is critical in DHS operation?

A

Baumgartner’s
1995
Tip apex distance should be less than 25mm in AP and lateral view to avoid cut out of DHS screw

37
Q

What does the nottigham hip fracture score predict?

A

30 day mortality

38
Q

What is gold standard for diagnosising a ?NOF# and what is used in reality?

A

MRI

But CT used in ED

39
Q

In pelvic fractures when should pelvic reconstruction occur?

A

Within 72 hours of haemodynamic stabilisation

40
Q

Why is packing generally better than angiography for stabilising haemodynamically unstable pelvic fractures?

A

90% of bleeding from sacral plexus
Therefore no angio target

41
Q

Why do you get D5 dopplers in pelvic operation patients?

A

High risk of clots
60% have them
Concerns about proximal femoral clots- consider anticoagulation vs vena cava filter

42
Q

What is damage control orthopaedic surgery?

A

Contain and stabilise orthopaedic injuries to minimise the second hit on physiology associated with orthopaedic surgery.

Aim to optimise patient prior to definitive fixation

Early appropriate care- lactate/UO/pH guided

43
Q

What must you consent for when taking a patient to theatre with an arterial injury?

A

Fasciotomies and amputation

44
Q

NICE guidelines for NOFs?

A

Expected to carry out ADLs for next 2 years
No significant medical comorbidities
Can walk with 1 stick of less outside

Proven femoral stem
Cemented arthroplasty
Anterolateral approach

FWB
DHS for EC NOFs apart from Subtroch/reverse oblique
IM Nail for subtroch

Ortho ST3 Interview (12 decks)

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