Trauma Flashcards
What are the 2 types of femoral fractures?
Shaft and distal (supracondylar)
How are femoral shaft fractures caused?
What are the types of femoral shaft fractures?
-Femoral shaft fractures are caused by HIGH-ENERGY injury e.g. Falls, crushing injury or high speed RTC
Types:
- transverse (horizontal)
- linear (vertical)
- oblique (diagonal)
- spiral (due to twisting force)
- comminuted (>2 bone pieces)
- greenstick (bends and cracks)
- compound or open (penetrates through skin)
Clinical presentation of femoral shaft fracture?
Clinical presentation of femoral shaft fracture
- Severe pain
- Unable to WB
- tense and swollen upper thigh
- Hip EXTERNALLY ROTATED and SHORTENED (but abducted unlike NOFF)
- Often very clear deformity
Investigations of femoral shaft fracture?
Investigations of femoral shaft fracture Bedside -Examination -(look feel move) of hip and knee joint -assess sensation and pulses -Thomas splint – prevent deformity and ↓haemarthrosis
Bloods
-FBC and crossmatch
Xray of femur (AP and lateral views of)
- femur (determine type and severity)
- knee and hip to exclue NOFF
Management of femoral shaft fracture?
Management of femoral shaft fracture
- Femoral-nerve block (Analgesia) – useful
- Open (surgery) or Closed reduction to put back in place
- Fixation –internal (most common is intramedullary nail) or external (big metal cage outside skin)
- Immobilise – Plaster (back slab) or Thomas splint
- X-Ray femur – verify alignment of femur + monitor healing
How long does a femoral shaft fracture take to heal?
femoral shaft fracture takes 4-6 months completely healed – open fracture takes longer
Complications of femoral shaft fracture? (8)
Complications of femoral shaft fracture
- Neurovascular damage – from sharp bone ends
- Acute compartment syndrome – high risk
- Large haematoma (subtle in closed fractures, as it involves large volumes of blood loss before swelling is obvious)
- Infection –high risk in open fractures
- Delayed union (keep cast on for longer)
- Non union (surgery)
- Fat embolism, DVT (PE)
- Shortening, angular, misalignment
Differentials for femoral shaft fracture?
Differentials for femoral shaft fracture
- Hip fracture (NOFF)
- Supracondylar fracture
What is a supracondylar fracture?
What TYPE of fracture are common with supracondylar fracture?
-supracondyl fracture is fracture to the distal 1/3 of femur
(typically weaker metaphyseal bone)
-Commonly COMMINUTED and intra-articular → damage to knee joint
How do supracondylar fractures most commonly occur?
What can supracondyl fractures cause damage to?
Supracondylar fractures common causes:
- Direct violent trauma in adolescent and young adults
- Osteoporosis with low energy trauma in elderly
-Supracondyl fractures can cause damage to the popliteal artery (because the distal fragment of femur pulls backward)
How do supracondylar fractures present?
Supracondylar fractures
- Pain
- Deformity
- Weakness
- History of falls (elderly)
- High impact injury (young adults)
Investigations for supracondylar fracture?
Bedside
- Examination
- (look feel move) of hip and knee joint
- assess sensation and pulses
- Thomas splint – prevent deformity and ↓haemarthrosis
Bloods
-FBC and crossmatch
Xray of femur (AP and lateral views of)
- femur (Categorise as extra-articular, partial articular or complete articular)
- knee Xray is essential
What is Flexor Tenosynovitis? What is the most common cause?
What are the four signs of flexor tenosynovitis?
Flexor Tenosynovitis is an infection of finger flexor tendon sheath (surrounds tendon) following PENETRATING INJURY (common)
Kanaval’s 4 signs
- Fixed flexion of digit – “trigger finger”
- Symmetrical fusiform swelling of digit (sausage finger)
- Excruciating tenderness over flexor sheath
- EXTREME pain on passive extension
What is the treatment of flexor tenosynovitis?
What is a complication of flexor tenosynovitis?
Treatment of flexor tenosynovitis
1. Urgent incision, drainage and irrigation of flexor tendon sheath
2. Tendon sheath release
3. URGENT broad IV Abx (commonly staph infection) –
Co-amox (animal bite), narrow Abx following cultures
Complication: significant sheath scaring → compromise finger function
What is a felon? What is the most common cause?
- Felon is a subcutaneous abscess over the pulp of distal phalanx or thumb
- Due to penetrating injury
What is the treatment of felon?
Treatment of felon
- Urgent incision, drainage and irrigation of absess
- Warm antiseptic soaks
- Oral Abx (IV if septic)
What is Paronychia?
What 2 pathogens can cause this and whats the difference in presentations between them?
Paronychia
-Infection of nail fold adjacent to nail
Pathogens
- Bacteria (S aureas most common): sudden onset and painful
- Candida: slow and chronic
Treatment of paronychia?
Treatment of paronychia with absess?
Treatment of paronychia
- Flucoxacillin if cellulitis (curative in early stages)
- Fungal/chronic: topical antifungals
-If abscess/pus develops> urgent incision, drainage and irrigation under LA digital block with oral AB
What are the 3 types of humerus fractures?
Where does the radial nerve run?
Humeral fractures: proximal (5%), shaft, distal
Radial nerve runs posterior at middle 1/3rd of shaft in spiral groove
What features may indicated PATHOLOGICAL FRACTURE?
PATHOLOGICAL FRACTURE
- Bone pain preceeding fracture
- Limb swelling preceeding fracture or large post fracture swelling
- Cystic abnormality on Xray
- History of malignancy
- Pagets disease of the bone
What is the most common site of proximal humorous fracture?
Surgical neck (below tuberosities) is most common place for proximal humorous fracture
What is a common mechanism of injury for proximal humerus fracture? (what other signs may they have)
- Proximal humorous fracture often caused by FOOSH
- May also have posterior shoulder dislocation
Presentation of proximal humorous fracture?
Presentation of proximal humorous fracture
- Tenderness or swelling of proximal humerus
- ↓RoM at shoulder (due to pain)
Investigations for proximal humeral fracture?
BEDSIDE
MSK and neuro exam
-shoulder and elbow
Axillary nerve – sensation of regimental badge over deltoid + assess UL power
Brachial plexus – distal PNS exam of UL
Peripheral pulses
IMAGING
-AP and lateral of scapular and axillary
Special tests (NEER CLASSIFICATION) -based on 4 usual cleavage lines (head, LT, GT, surgical neck/shaft), therefore either 2, 3 or 4-part fractures
Management of proximal humeral fracture?
- Immobilise joint + Analgesia
- Collar and Cuff support – 85% treated non-operatively
If more complex or if displaced
- Surgery
- closed reduction and percutaneous fixation
- open reduction and internal fixation
- proximal head replacement - Physiotherapy
- Follow- up
Complications of proximal humeral fractures?
Complications of proximal humeral fractures
- AXILARY NERVE DAMAGE
- loss of sensation to regimental badge (appears flat)
- suprascapular nerve and radial artery can also happen - AVASCULAR NECROSIS
-common in complex fractures with multiple fragments
Neurovascular injury (1/3rd )
What are the common mechanisms for shaft of humerus fracture?
Shaft of humerus fracture
- direct blunt trauma>transverse
- torsion injury> spiral fracture
- FOOSH when abducted
Management of humeral shaft fracture?
A) Non-operatively
- Hanging arm cast or Coaptation splint (extends from axilla → nape of neck w/ stirrup around elbow)
- Then Functional arm brace (looks like a robot arm)
- Physiotherapy
B) Operatively
- Closed reduction + long arm splint – if mildly displaced (repeat X-ray post-reduction)
- Open reduction + surgical fixation – if comminuted or vascular compromise
What is a complication of a humeral shaft fracture?
What is the prognosis?
How could you tell?
Complication of a humeral shaft fracture?
RADIAL NERVE INJURY (12%)
-more common with transverse/spiral fractures
-should recover (70%) with conservative treatment
Signs of radial nerve injury
- wrist drop (when elbow flexed and pronated)
- sensory loss (dorsal 3 ½ fingers webspace) (plantar lateral 1/2 thumb)
- moto loss: cant thumbs up
List the nerves that can be affected in humeral fractures (proximal, shaft and distal)
What are the signs?
Proximal fracture: AXILLARY
-loss sensation to regimental badge, appears flat
Shaft fracture:RADIAL
- wrist drop
- LOS dorsal 3 & 1/2 fingers
- LOS plantar lateral 1/2 thumb
Distal fracture: RADIAL (18%), MEDIAL, ULNAR RADIAL -wrist drop -LOS dorsal 3 & 1/2 fingers -LOS plantar lateral 1/2 thumb
MEDIAL
- inability to flex index finger and thumb
- LOS medial 1/2 thenar eminence
ULNAR
- Froments paper sign shows flexing of thumb
- inability to cross fingers ‘good luck sign’
- claw hand
How do distal humerus (elbow) fractures present?
Distal humerus (elbow) fractures presentation
-S shaped fracture
-significant rapid swelling
-nerve damage:
> radial nerve (18%)
>median nerve (inability to flex index finger and thumb with LOS medial 1/2 thenar eminence
>ulnar nerve (Froments paper sign shows flexing of thumb, inability to cross fingers ‘good luck sign’
Management of distal humerus fracture?
Distal humerus fracture
-Immobilise elbow (posterior long arm splint, elbow at 90o to forearm in neutral position)
Surgical repair – for displaced or open fractures (most common is open reduction and internal fixation)
What is a hip fracture and what are the 3 types?
Hip fracture is a fracture of the PROXIMAL femur (proximal to 5cm below lesser trochanter)
3 types:
- Intracapsular NOFF
- Extracapsular inter-trochanteric
- Extracapsular sub-trochanteric
Define intra capsular NOFF
How does it normal happen?
Intracapsular NOFF
-between edge of femoral head and intertrochanteric line
-typically follows a fall onto hip or bum
What is the clinical presentation of intracapsular NOFF
Intracapsular NOFF
- leg appears SHORTENED + EXTERNALLY rotated (and adducted)
- TENDERNESS over hip ± greater trochanter particularly on rotation
- may have referred knee pain
- inability to weight-bear (although some may be able to)
Investigations for intracapsular NOFF?
Investigations for intracapsular NOFF
1. X ray -Shenton’s line disrupted (medial edge of femoral head and inferior edge of superior pubic ramus)
- Garden classification – used for Intracapsular NOFF
I - INCOMPLETE undisplaced fracture with the inferior cortex intact
II - COMPLETE undisplaced fracture through the neck
III - Complete neck fracture with PARTIAL displacement
IV - Complete neck fracture thats FULLY displaced
Initial managment of NOFF?
Managment of NOFF
ABCD(hypothermia) E assessment
IV access
- Bloods - FBC, U+Es (AKI), CK (could be lying for ages), glucose, crossmatch to prepare for surgery
- IV fluids if hypotension/dehydrated
- IV morphine (titrate up) + antiemetic
- ECG (look for arrhythmias/MI, may explain fall)
Additional
- Femoral nerve block (women in AndE)
- Lateral hip X-ray (repeats/MRI may be needed if cant see)
- Refer to orthopaedic surgery
- May need to realign or apply splint in the mean time
Treatment on INTRAcapsular NOF?
Intracapsular NOFF
-General rule is that intracapsular gets replaced and extracapsular gets fixed
However, UNdisplaced (garden 1 and 2)
- open reduction and internal fixation (ORIF) with cannulated hip screws
- comorbid and old=hemi
DISplaced (garden 3 and 4)
<55 ORIF with cannulated hip screws (unless AVN>arthroplasty)
In between: Total hip replacement (active or arthritis)
>75 Hemiarthroplasty
What is a complication of intracapsular neck of femur fractures?
Complications of NOFF
-Mortality (10% at 6 weeks; 30% mortality at 1 year (MAD)
-Avascular necrosis -disruption of blood supply to femoral head → whole joint needs replacing
What is the managment of extracapsular NOF?
usual vs exception
Extracapsular
-General rule is OPEN REPAIR WITH INTERNAL FIXATION ORIF (with DHS)
UNLESS:
- SUB TROCHANERIC (shaft) fracture (do IM nail)
- fracture within 5cm below the lesser trochanter (less risk of AVN (outside capsule) - Four part intertrochanteric fractures
- oblique or transverse
DO IM NAIL INSTEAD>UNSTABLE
Whats the difference between THR and Hemi hip replacement? When would you be more inclined to do a THR?
Total hip replacement-all and socket (active patient, independant) (risk of dislocation)
Hemi hip replacemnt- just the ball (more frail)
Describe the presentation of fat embolism?
Treatment?
Post op a fat embolism can occur at any 3 sites:
Brain (stroke)
Fat (rash)
Lungs (PE)
Treatment: supportive care, ITU if breathless
Whats is less likely to cause AVN (dynamic hip screw or IM nail)?
DHS is good because its less likely to cause AVN
Explain compartment syndrome
Where can you get compartment syndrome (and where is most common)?
Compartment syndrome
swelling of tissue in anatomical compartment>increase pressure>occludes vasculature>hypoxia> acute ischemia and oedema>necrosis
- TIBEA is most common (Commonly lower and upper limb)
- also can get in abdomen, gluteal region
What are the causes of compartment syndrome?
Causes of compartment syndrome
- trauma (fractures, crush injury)
- burns
- infection
- vascular (haemorrhage, reperfusion injury)
- muscle hypertrophy (athletes)
What are some INITIAL signs of acute compartment syndrome? (within 48 hours)
INITIAL signs of acute compartment syndrome (within 48 hours) PAIN PAIN PAIN PAIN PAIN PAIN -on passive stretch -out of proportion -getting worse -on palpation of compartments -despite immobilisation -despite analgesia
May also get sensory deficit in distribution of nerves of compartment
What are some LATE signs of acute compartment syndrome? (within 48 hours)
Late signs Tissue ischaemia (the other 5) – pallor, pulselessness, cold, paraestheia, paralysis (can cause abnormal flexing)
What are the investigations of acute compartment syndrome?
Investigations of acute compartment syndrome
clinical diagnosis
- Bloods
FBC/CK (increased)/UsEs (can cause renal failure) - Intra-compartmental pressure monitoring is diagnostic if unclear
- Wick catheter and needle
Explain the results of the intra-compartmental pressure monitoring
- Difference of > 30mmHg between diastolic BP and compartment pressure = ↑risk of compartment syndrome → surgical decompression + fasciotomy
- If absolute compartment pressure > 40mmHg with clinical symptoms →DIAGNOSTIC → surgical decompression + fasciotomy
Acute MANAGEMENT of compartment syndrome? (5 steps)
Compartment syndrome
- RELEASE any circumferential cast + dressing (↓pressure by 90%)!!! + ELEVATE limb to heart level
- Monitor and control BP
- Urgent surgical DECOMPRESSION (within 1hr) – if symptoms persist FasciOTOMY
- Excise necrotic tissue – FasciECTOMY
- Re-exploration – ALL PATIENTs at ~ 48hours
When should you surgically re-explore a patient after treatment for compartment syndrome?
All patients should get re explored at 48 hours
Complications of compartment syndrome? (3)
Complications of compartment syndrome
1. Tissue necrosis – within 6-12 hours
2. Muscle necrosis → fibrosis + ischaemic contracture (Volkmann’s)
3. Renal failure – rhabdomyolysis from necrosis → ↑CK
(IV Fluids + Acidosis Mx)
Who normally gets Chronic/Exertional compartment syndrome?
How does it present?
Chronic (Exertional compartment syndrome)
-young athletes (football, cycling)
Presentation
- usually both legs
- severe pain/tightness
- rigid legs
- sensory change – numb, tingling
- weakness
- abnormal gait
*worse with exercise and stretch (resolves with rest)
What are investigations for exertion compartment syndrome? What would you expect to see?
Whats the managment?
- Intra-compartmental pressure monitoring (gold standard) – measure before and after exercise
Large difference in pressure confirms
Management
- Limit or stop activity causing pain
- Fasciotomy – for athletes unwilling to modify sport
Differentials of acute and chronic compartment syndrome?
Differential Diagnosis
Acute
-DVT
Chronic
- Stress fracture
- Shin splints
What sling do you need for an acromioclavicular joint injury?
Acromioclavicular joint injury=broad arm sling (shove arm up to reduce the space)
Managment of anterior shoulder disclocation?
What if there is a fracture?
Anterior shoulder dislocation
- MUA to muscle relax (midazolam +/- propofol)
- Re Xray
- Physio
- Immoblisation (broad arm sling)
**if fracture: ORIF!
How do you test for scafoid fracture?
Scafoid fracture
- anatomical snuffbox pain and pain on thumb telescoping
- cast in beer glass position (future splint)
Bring back for CT!
What is the scoring system for fibula fractures?
Webers scoring for fibula fractures
A-below the ligament >cast and send home
B-at the level of ligament
C-above ligament>surgery
What is a Galeazzi fracture?
Galeazzi fracture
- a distal radial fracture with an associated dislocation of the distal radioulnar joint
- direct blow
Radial shaft fracture with associated dislocation of the distal radioulnar joint
Direct blow
What is a Monteggia fracture?
Monteggia fracture
-fracture of the proximal ulna, with an associated dislocation of the proximal radioulnar joint.
