Trauma Flashcards
Classification of soft tissue injury in fracture surgery
Tscherne classification
Grade 0 - Closed fx, no soft tissue injury
Grade 1 - indirect fx, superficial laceration
Grade 2 - direct injury with sig bleeding and oedema, impending compartment syndrome
Grade 3 - extensive crushing and muscle damage. Vascular injury or compartment syndrome
Skim grafts
Split skin grafting
Full thickness skin grafting
Both require an underlying vascular bed (eg covered by muscle)
Avoid use of split skin grafting over joints
Isolated ulna fracture
Greater than 10° angulation or 50% displacement can result in loss of rotation of the forearm if treated non-operatively
For minimally displaced fractures, Non-operative treatment results in union and good function
Criteria for direct bone healing
Anatomic reduction of the fracture
Absolute rigidity and interfragmentary compression
Sufficient blood supply to provide for direct healing of the fracture –> stripping of vast amounts of periosteum may not lead to direct bone healing
Why often re-fracture after, say, direct healing by plating?
Partly due to the
stress risers of screw holes,
Plate-related osteopenia,
Absence of the strong natural callus
Internal fixation per se will not make fractures heal; it only helps with alignment and with the stability and restoration of nearby joints
Delayed-union and Non-union
Controversial
If a fracture is not healed after 4 and 6 months respectively
Causes of non-union
Biological causes eg impaired vascularity
Mechanical causes eg instability and gaps, over-distraction
Infection
General (miscellaneous) causes
Fracture communication, malnutrition, drinking, smoking, DM, peripheral vascular disease, poly-trauma, drugs like cytotoxics/steroids, pathology in bone itself (metastases, metabolic bone disease)
Classification and treatment of non-union
Hypertrophic non-union
Instability of fracture but osteogenic response is intact
To restore stability plus/minus avoid heavy external loading, may need revision of a previous osteosynthesis
Atrophic non-union
Insufficient osteogenic activity at fracture site, in advanced cases, bone ends resorption occurs and produces a pencil-like appearance, mostly due to impaired vascularity
To restore the osteogenic potential of the fracture, resection of fibrous tissue within the non-union gap sometimes needed, and bone grafting (usually autograft).
In both categories, one important key is to avoid nearby joint stiffness, especially in peri-articular non-unions
Why tackle malunions?
Danger of loss of malfunction
Altered biomechanics/early arthrosis of joints
Decreased motion
Soft-tissue imbalance
Cosmesis
Principle ways to tackle malunions
Define the deformity
- Assess angulation im sagittal plane
- Assess angulation in coronal plane
- Assess rotational malalignment
- Assess mechanical axis
- Assess degree of shortening
- Assess any translational deformity
- Assess articular surface
Check status of nearby joint, which, if stiff, puts a lot of stress on the non-union site and can cause persistent non-union
Check status of soft tissues
Check the status of the bone - normal bone stock or pathologic bone
The weakest zone where injuries to the growth plate tend to occur
Through hypertrophic zone
During skeletal maturation the growth plate is weaker than the supporting ligaments
Complications of tibial tuberosity fractures
Laceration of the anterior tibial artery (check prior to the OT)
depending on the amount of growth remaining, the patient may be at risk of subsequent recurvatum deformity
Prominent hardware –> pain and irritation
What accounts for 90% of the hemorrhage with pelvic ring injuries
Venous plexus in posterior pelvis
Classification pelvic ring fractures
Tile fracture
A stable
B rotationally unstable, vertically stable
C rotationally and vertically unstable
Young-Burgess classification
Anterior posterior compression
lateral compression
Vertical shear
Physical exam pelvic injury
Inspection
Test stability by placing gentle rotational force on each crest
Look for abnormal lower exremity position
Skin Scrotal, labial or perineal hematoma, swelling or ecchymosis Flank hematoma Lacerations of perineum Degloving injury
Neurologic exam
Rule out lumbosacral plexus injuries (L5+S1 most common)
Rectal exam to evaluate sphincter tone and perirectal sensation
Urogenital exam
Most common finding : gross haematuria (m>f)
Vaginal and rectal examinations mandatory to rule out occult open fracture
Radiographic signs of instability in pelvic ring injuries
> 5mm displacement of posterior sacroiliac complex
Presence of posterior sacral fracture gap
Avulsion fractures (ischial spine, ischial tuberosity, sacrum, transverse process of 5th lumbar vertebrae)
Contraindications for external fixation of pelvis
Ilium fracture that precludes safe application
Acetabular fracture
Type of pelvic injuries that has highest rate of head injury?
Lateral compression injuries, especially type III
Type of pelvic injury that has highest rate of morality, blood loss, and need for transfusion
APC (anterior posterior compression) type III
Most common urological injury with pelvic ring injury
Posterior urethral tear, followed by bladder rupture
Risk of infection
Nerve at risk when applying external fixation with supraacetabular pins through the AIIS to stabilise a pelvic fracture
Lateral femoral cutaneous nerve
Structure at risk with retractor placement on the anterior aspect of the sacrum
L4 and L5 nerve roots
Ipsilateral pelvic ring and acetabular fracture
What should be reduced and stabilised first?
Pelvic ring fracture (SI joint)
