Trauma Flashcards

1
Q

What does the ABCDE evaluation stand for when managing trauma?

A

Airway management

Breathing and Ventilation

Circulation ad bleeding control

Disability ( neurological evaluation)

Exposure and Environmental control

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2
Q

What value on the Glasgow coma scale signifies loss of airway control?

A

8 or lower

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3
Q

Give examples of signs which indicate airway obstruction.

A

noisy breathing
gurgling
stridor
agitation from hypoxia and hypercapnoea

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4
Q

How do you manage ABCDE evaluation?

A

A- obstructions must be removed. Oxygen and ventilation can be delivered through the new airway after an emergency cricothyroidotomy if neccessary

B- all major trauma patients should receive high flow oxygen via tight fitting mask. Oxygenation is best assessed with pulse oximetry

C- Patients pulse rate, volume and blood pressure. Cardiac monitor should all be assessed

D- quick neurologic assessment should be performed to establish the level of consciousness

E- Keep patient warm to avoid hypothermia. Adequate patient exposure should ensure no major injuries are missed.

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5
Q

What should be carried out at the end of primary survey?

A

Trauma series of X-rays (lateral C-spine, chest and pelvis xrays) carried out based on the clinical condition along with X-rays of any other significant MSK injuries

Log roll patient if there is spinal injury and look for signs of spinal fracture

PR examination can be carried out

Urinary catheter should be passed and the nasogastric tube can be passed now

FBC, U&Es, CT scans, US or DPL can be performed now

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6
Q

What is a polytrauma?

A

Where more than one major long bone is injured or where a major fracture is associated with significant chest or abdominal trauma.

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7
Q

What can unstable major long bone fractures cause?

A

Ongoing blood loss

Hypovolaemia

Pain

Increased

sympathetic response

Amplification of the inflammatory response

fat embolism

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8
Q

When does Systemic inflammatory response syndrome (SIRS)?

A

SIRS occurs when there is an amplifaction of inflammatory cascades in response to trauma with pyrexia,tachycardia, tachypnea and leukocytosis

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9
Q

What is the first manifestation of Hypovolaemia?

ii. what follows after?

A

Tachycardia

ii. Decrease in blood pressure. Confusion or lethargy may also occur

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10
Q

What is the definition of a Fracture?

A

Medical term for a break in the bone

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11
Q

What is the difference between a direct trauma and indirect trauma?

ii. which causes the majority of fractures?

A

Direct trauma refers to a direct blow

indirect trauma refers to it being caused by twisting or bending forces

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12
Q

What is the difference between a partial/incomplete fracture and a complete fracture

A

Partial fracture - not a complete break e.g. stress fracture

complete - complete break in bone

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13
Q

What is the difference between a high energy fracture and a low energy fracture?

A

High energy - e.g. car accident, gunshot, blast, fall from height

Low energy - e.g. Trip, fall, sports injury

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14
Q

How do bones heal?

A

Primary healing (1st intention)

secondary healing (2nd intention)

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15
Q

What is primary bone healing?

A

When there is minimal fracture gap (less than about 1mm) and the bone simply bridges the gap with new bone from osteoblasts.

occurs in the healing of hairline fracture and when fractures are fixed with compression screws and plates

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16
Q

What is secondary bone healing?

A
  1. Occurs in majority of fractures

When there is a gap at the fracture site which needs to be filled temporarily to acts a scaffold for new bone to be laid down. Involves the recruitment of pluripotential stem cells which help healingdoocess.

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17
Q

What is the fracture process of secondary bone healing?

A
  1. Fracture occurs
  2. Haematoma occurs with inflammation from damaged tissues
  3. Macrophages and osteoclasts remove debris and reabsorb the bone ends
  4. granulation tissue forms from fibroblasts and new blood vessels
  5. Chondroblasts form cartilage (soft callus)
  6. Osteoblasts lay down bone matrix (collagen type 1)- endochondral ossification
  7. Calcium mineralisation produces immature woven bone (hard callus)
  8. Remodelling occurs with organisation along lines of stress into lamellar bone
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18
Q

How long does it take soft callus to form in secondary bone healing?

A

2-3 weeks

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19
Q

How long does it take for hard callus to form in secondary bone healing?

A

6-12 weeks

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20
Q

What does secondary bone healing require?

A

Good blood supply for oxygen

Nutrients

Stem cells

Little movement - no movement (i.e. internal fixation with fracture gap) is bad

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21
Q

What is a Tranverse fracture?

A

Fracture of the bone occurs transversely (sideways)

Occur with pure bending force where the cortex on one side fails in compression and the cortex on the other side in tension.

Tranverse fractures may not shorten (unless completely displaced) but may angulate or result in rotational malalignment

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22
Q

What is a oblique fractures?

A

Occur with a shearing force (e.g. fall from height. deceleration).

Their patterns have the benefit of being able to be fixed with interfragmentary screws

Oblique fractures tend to shorten and may also angulate

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23
Q

What is a spiral fracture?

A

Occur due to torsional forces.

interfragmentary screws potentially can be used.

Spiral fractures are most unstable to rotational forces but can also angulate

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24
Q

What is a comminuted fracture?

A

Fractures with 3 or more fragments.

Generally a reflection of high energy injuries or poor bone quality.

substantial soft tissue swelling and periosteal damage with reduced blood supply to the fracture site which may impair healing

normally very unstable

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25
Q

What is a segmental fracture?

A

When the bone fractures in two separate places.

These injuries are very unstable and require stabilisation with long rods

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26
Q

A fracture at the end of a long bone can be described according to what?

A

site of the bone and also the type of the bone

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27
Q

A fracture at the end of a long bone (metaphyseal/epiphyseal) can be what?

A

intra-articular (extending into the joint) or extra-articular

Intra-articular fractures have a greater risk of stiffness, pain and post-traumatic osteoarthritis. Especially if there is any residual displacement in an uneven articular surface.

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28
Q

What three factors does a fracture displacement depend on?

A

Translation

Angulation

Rotation

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29
Q

What does the translation of a distal fragment describe?

A

Described as anteriorly or posteriorly displaced and medially or laterally translated

can be estimated with reference to the width of the bone. 100% displacement is generally referred to as an “off ended” fracture

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30
Q

What does the angulation of a distal fragment describe?

A

Direction in which the distal fragment points towards and the degree of the deformity

Can be either posterior/anterior and Medial/lateral

however some exception in description:

lower limb varus ( distal fragment pointing towards the midline)

Lower limb valgus (distal fragment pointing away from the midline)

can be measured in degrees from the longitudinal axis of the diaphysis of a long bone

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31
Q

What can residual displacement or angulation cause?

A

Deformity

Loss of function

abnormal pressure on joints

all three factors lead to post-traumatic OA

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32
Q

What does the rotation of a distal fragment describe?

A

Relative to the proximal fragment, it is an important clinical descriptor as a rotational malalignment which poorly tolerated and needs to be corrected when managing fractures.

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33
Q

What are the main clinical features of a fracture?

A

Pain - if put weight on it

localised bony (marked tenderness)- not diffuse mild tenderness

swelling

deformity

crepitus - from bone ends grafting with an unstable fracture

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34
Q

What should an assessment of an injured limb include?

A

Whether injury is open or closed

Assessment of the distal neurovascular status (e.g. pulses, cap refill, temp, colour)

whether Compartment syndrome is present

Status of the skin and soft tissue envelope

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35
Q

How do you diagnose fractures?

A

X-rays

Tomogram - moving X-ray used for images of complex bones e.g. mandibular fractures

CT - helps determine the degree of articular damage

MRI - used to detect occult fractures where there is clinical suspicion but a normal X-ray e.g. hip and scaphoid

Technetium bone scans - can be useful to detect stress fractures. May fail to show up on X-ray until hard callus starts forming

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36
Q

How do you manage Long bone fractures?

A

Initial management

  1. clinical assessment of the injured limb
  2. analgesia ( IV morphine)
  3. Splintage / immobilisation of the limb with investigation (X-ray)
  4. Reduction of fracture should be performed before x-ray if there is a clear fracture dislocation

Definitive fracture management;

depends on numerous factors (e.g. which bone affected, age of patient, location of fracture, pattern of fracture, displacement of fracture, stability of fracture, whether it is open or closed, Neurovascular status)

Displaced/angulated fractures where the position is unacceptable required reduction under anaesthetic
(e.g. GA, spinal or Bier’s block)

closed reduction and cast application can also be used. Requires may x-rays to ensure no loss of position

unstable injuries can be treated with surgical stabilisation - use K-wires for small fragments

unstable extra-articular diaphyseal fractures can be fixed with open reduction and internal fixation (ORIF) uses plates and screws with the aim of anatomic reduction and rigid fixation. Should avoid ORIF if the soft tissue is too swollen, where the blood supply to fracture is high energy or where it can cause extensive blood loss.

Displaced intra-articular fractures require anatomic reduction and rigid fixation by ORIF using wires, screws and plates.

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37
Q

Give examples of complications of fractures?

A

Early local complications : compartment syndrome, vascular injury with ischaemia, nerve compression or injury, and skin necrosis

Early systemic complications: hypovolaemia, fat embolism, shock, ARDS, acute renal failure , SIRS and death

Late local complications: Stiffness, loss of unction, chronic regiona pain syndrome, infection, Post traumatic OA and DVT

Late systemic complications : pulmonary embolism - ranges in time taken to form

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38
Q

What is compartment syndrome?

A

When group of muscles are unable to swell caused by bleeding and inflammation exudate from fracture and injury due to it being bound in tight fascial compartments

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39
Q

What are the main clinical features of compartment syndrome?

A
  1. Increased pain on passive stretching of the involved muscle
  2. Severe pain outwith the anticipated severity in the clinical cortext
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40
Q

What are the two main nerve injuries associated with fractures?

A
  1. Neurapraxia - when the nerve has a temporary conduction defect from compression or stretch and resolve over time with full recovery
  2. Axonotmesis - occurs from either sustained compression ,stretch or from a higher degree of force. Long nerve cell axons distal to the point of injury die in a process called wallerian degeneration. recovery varies
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41
Q

What is Neurotmesis?

A

complete transection of a nerve

No recovery will occur unless the affected nerve is surgically repaired

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42
Q

which nerve injury is a colles fracture associated with?

A

Acute median nerve compression/carpal tunnel syndrome

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43
Q

which nerve injury is an anterior dislocation of the shoulder associated with?

A

axillary nerve palsy

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44
Q

Which nerve injury is a humeral shaft fracture associated with?

A

Radial nerve palsy

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45
Q

Which nerve injury is a supracondylar fracture of the elbow associated with?

A

median nerve injury

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46
Q

Which nerve injury is the posterior dislocation of the hip associated with?

A

sciatic nerve injury

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47
Q

Which nerve injury is the “bumper” injury to the lateral knee associated with?

A

common peroneal nerve palsy

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48
Q

What arterial damage can occur from a knee dislocation?

A

popliteal artery can be injured

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49
Q

What arterial damage can occur from a paediatric supracondylar fracture of the elbow?

A

brachial artery injury

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50
Q

what arterial damage can occur from a shoulder trauma?

A

axillary artery injury

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51
Q

Give some examples of signs of reduced distal circulation.

A
  1. Reduced or absent pulses
  2. Pallor
  3. delayed cap refill
  4. Cold to touch
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52
Q

What are the signs and symptoms of a fracture healing?

A

Resolution of pain and function

Absence of point tenderness

no local oedema

resolution of movement at fracture site

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53
Q

what are the clinical signs of non-union in fractures?

A

ongoing pain

ongoing oedema

movement at the fracture site

Bridging callus may be seen x-ray however sometimes not always obvious so use CT scans

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54
Q

What is a non union?

A

serious condition where the fracture fails to heal

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55
Q

what are the cause of hypertrophic non-union?

A

Instability

excessive motion at the fracture site

Infection

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56
Q

What are the causes of atrophic non-union?

A

rigid fixation with a fracture gap

lack of blood supply at the fracture site

chronic disease

soft tissue interposition

infection

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57
Q

Give examples of some fractures which are particularly prone to problems with healing?

A

scaphoid waist fractures

fractures of the distal clavicle

subtrochanteric fractures of the femur

jones fracture of the fifth metatarsal

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58
Q

How do you manage a hypertrophic non union?

A

application of a plate to ensure subsequent union of the fracture

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59
Q

How do you manage atrophic non union?

A

removal of fibrous tissue at the fracture site

restoration of bleeding vone ends

restoration of the medullary canal continuity

bone grafting to stimulate bone formation and to act as a scaffold for new bone to grow

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60
Q

How do you diagnose non union fractures?

A

X-ray

CRP and bacteriological sampling for evidence of infection

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61
Q

How do manage non union fractures if infection is diagnosed?

A

Surgical removal of dead and infected bone is required often with shortening of the bone

special circular frame external fixators may be used with the advantages of applying compression at the fracture site

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62
Q

what is a delayed union?

A

fracture which has not healed within the expected time frame

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63
Q

How can open fractures occur?

A
  1. Inside out injury - spike of fractured bone from within punctures the skin
  2. Outside-in injury - laceration of the skin from tearing or penetrating injury
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64
Q

What factors increase the risk of infection in open fractures?

A
  1. higher the energy of the injury
  2. amount of contamination
  3. any delay in appropriate treatment
  4. problems with wound closure
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65
Q

how do you manage open fractures?

A

Initial management

  1. IV broad spectrum antibiotics e.g. flucloxacilin (gram positive), Gentamicin (gram negative) and Metronidazole ( anaerobes)

antiseptic dressing should be applied to wound

Surgery required ASAP. Debridement is carried out (removal of all contamination and excision of non-viable soft tissue

internal or external fixation required as casts would required constant wound inspections

if wound is not grossly contaminated and all remaining skin and muscle is viable and all can be closed without undue tension - then wound can be closed primarily

skin grafts can be used otherwise if cant be closed primarily

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66
Q

How should you manage mangled extremity?

A

some cases suggest an early amputation may be best choice

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67
Q

what causes dislocations?

A

significant trauma

conditions which cause hyper-mobility (Ehlers danlos and Marfans)

voluntary dislocation e.g. shoulder

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68
Q

How are ligament ruptures graded?

A

grade 1 - sprain

grade 2 - partial tear

grade 3 - complete tear

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69
Q

How do you manage soft tissue injuries?

A

RICE

Rest

Ice

compression

elevation

n.b. some complete ligament ruptures and tendon tears may require surgical repair or graft reconstruction (ligament only)

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70
Q

What are the main causes of spinal cord of nerve cord damage?

A

contusion

compression

stretching

laceration

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71
Q

what is spinal shock?

A

physiological response to injury with complete loss of sensation and motor function and loss of reflexes below the level of the injury

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72
Q

How long does it take for spinal shock to usually resolve?

ii. which reflex is used to signal the end of spinal shock?

A

24 hours

ii. bulbocavernous reflex - reflex contraction of the anal sphincter with either a squeeze of the glans penis, tapping the mons pubis or pulling on a urethral catheter

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73
Q

What is neurogenic shock?

A

occurs secondary to temporary shutdown of sympathetic outflow from the cord from T1 to L2, usually due to injury in the cervical or upper thoracic cord.

74
Q

what does neurogenic shock cause?

A

hypotension and bradycardia

75
Q

how long does it take for neurogenic shock to resolve?

A

24-48 hours

usually treated with IV fluid therapy

76
Q

what is complete spinal cord injury?

A

when there is no sensory or voluntary motor function below the level of the injury. Reflexes however should return

77
Q

How is the level of the injury in a spinal cord injury determined?

A

by the most distal spinal level with partial function (after spinal shock) has resolved as determined by the presence of dermatomal sensation and myotomal skeletal muscle voluntary contraction.

78
Q

what is incomplete spinal cord injury?

A

some neurologic function (sensory and/or motor) is present distal to the level of injury. greater the function = greater the prognosis

79
Q

what does sacral sparing indicate?

A

incomplete cord injury with a better prognosis than a complete injury

signs include perianal sensation, voluntary anal sphincter contraction and big toe flexion (FHL muscle, s1/2)

80
Q

How do you manage spinal cord injury?

A

immobilisation (cervical collar& sandbags, spinal board) helps prevent further damage where an unstable fracture or dislocation exists.

Traction helps reduce dislocations or stabilise unstable cervical spine injuries

surgery used to relieve pressure pressure on the cord or to stabilise unstable injuries

special spinal beds help prevent pressure sores from paralysis

ventilatory support for loss of intercostal muscle function (T1- T12)

81
Q

What is central cord syndrome?

A

common injury pattern and usually occurs with a hyperextension injury in a cervical spine with osteoarthritis.

paralysis of the arms more than the legs occurs due to corticospinal tracts of the upper limbs being more central and those in the lower limbs being more peripheral in the cord

sacral sparing is typically present

82
Q

what is anterior cord syndrome?

A

results in loss of motor function as well as loss of coarse touch, pain and temperature sensation (lateral spinothalamic tract) whist proprioception, vibration sense and light touch are preserved (dorsal columns)

83
Q

what are the signs and symptoms of anterior cord syndrome?

A

loss of movement, pain and temperature

still able to feel position, vibration and touch

84
Q

What is Brown-sequard syndrome?

A

syndrome which occurs from hemisection of the cord usually from penetrating injury e.g. stab wound

signs: ipsilateral paralysis and loss of dorsal column sensation occurs with contralateral loss of pain, temperature and coarse touch sensation

85
Q

what are the main causes of pelvic fractures?

A

younger patients- high energy injuries

older patients - more common to suffer from osteoporosis can sustain pubic rami fractures from low energy injuries

86
Q

what are three main patterns of pelvic fracture?

A
  1. lateral compression fracture - occurs with a side impact where one half of the pelvis is displaced medially
  2. vertical shear fractures - occur due to axial force on one hemipelvis (e.g. fall from height, rapid deceleration) where the affected hemipelvis is displaced superiorly. the leg on the affected side will appear shorter
  3. Anteroposterior compression injury - results in wide wide disruption of the pubic symphysis the pelvis opening up like the pages of a book (open book pelvic fracture). substantial bleeding from torn vessels occurs.
87
Q

How do you manage pelvic fractures?

A

Blood loss is treated with fluid or blood

open book pelvic fractures - promptly reduce the displacement and minimise the pelvic volume to allow tamponade of bleeding to occur

external fixator provides initial stabilisation

ongoing haemodynamic instability may require angiogram and embolisation or open packing of the pelvis if a laprarotomy is required for co-exisiting intra-abdominal injuries

urinary catheterisation for bladder and urethral injuries

PR exam is mandatory to assess the sacral nerve root function and too look for the presence of blood (indicates a rectal tear which means and open fracture)

conservative management required for low energy pubic rami fractures in the elderly

88
Q

what are the main causes of acetabular fractures?

A

high energy injuries

can have low energy in older patients

89
Q

what is the acetabulum?

A

it is the intra-articular section of the pelvis which form the ‘cup’ of the hip joint

where the femur attaches to the pelvis

90
Q

What is the best way to diagnose a acetabular fracture?

A

CT scans better than X-rays as they may be quite difficult to determine

91
Q

how do you manage acetabulum fractures?

A

conservative treatment

anatomic reduction and rigid fixation required in young patients to reduce the risk of post traumatic OA

older patients can be treated with total hip replacements

92
Q

How are hip fractures broadly classified?

A

intracapsular

extracapsular

classified based on the position of the fracture in relation to the hip capsule - relevance is the likelihood of disruption the femoral head blood supply

93
Q

What is an intracapsular hip fracture?

A

bone fracture located within the joint capsule.

when the arterial supply of the femoral head can be disrupted and there is a risk of avascular necrosis of the femoral head an non-union of the fracture

94
Q

How do you manage Intracapsular hip fractures?

A

femoral head replacement via hemi-arthroplasty (removing femoral head only) or total hip replacement

Total hip replacement has higher risk of dislocation but gives better movement - give to higher functioning hip fracture patient

95
Q

What is an extracapsular hip fracture?

A

bone fracture located outside the joint capsule.

should not cause avascular necrosis and have high union rates

96
Q

How do you manage extracapsular hip fractures?

A

internal fixation as avascular necrosis wont occur

either do it by compression or dynamic hip screw

97
Q

What causes femoral shaft fractures?

A
  1. usually occurs as high energy injuries - risk of concomitant fracture elsewhere
  2. osteoporotic bone, metastatic disease, patients with paget’s disease can lead to stress fractures of the femoral shaft
98
Q

What can occur due to displaced femoral shaft fractures?

A

substantial blood loss

99
Q

how do you manage femoral shaft fractures?

A

initial management :

  1. analgesia with a femoral nerve block
  2. thomas splint - minimises further blood loss and fat embolism

Definitive management:

closed reduction and stabilisation with an intramedullary nail

minimally invasive plate fixation can also be used

100
Q

What causes true knee dislocations?

A
  1. high energy injuries

2. severe hyperextension and/or rotational forces with a sporting injury

101
Q

How do you manage knee dislocations?

A

Obvious dislocations should be reduced urgently

further investigation: doppler, duplex scan or angiogram

revascularisation

if the knee is very unstable then external fixator can be required

multi-ligament reconstruction is usually required as knee dislocations usually tear multiple ligaments

102
Q

what are the causes of patellar dislocations?

A
  1. direct blow

2. contraction of the quadriceps with a rotational force with the patella not engaged in the trochlea

103
Q

what are the risk factors for patellar dislocations?

A
  1. adolescents ( mainly females)
  2. Generalised ligamentous laxity
  3. valgus alignment of the knee
  4. rotational malaignment
  5. Shallow trochlear groove
104
Q

How do you manage patellar dislocation?

A

further dislocations can occur in first time dislocation patients

further dislocations can be prevented by temporary splintage followed by physiotherapy

may require surgical stabilisation sometimes

105
Q

What type of fracture is the proximal tibia fracture?

A

intra-articular fractures with either a split in the bone, a depression of the articular surface or both

106
Q

What are the causes of proximal tibia fractures?

A

high energy injuries - associated with neurovascular injury or compartment syndrome

low energy injuries in osteoporotic bone

107
Q

How do you manage proximal tibia fractures?

A

Surgery used for the aim of reduction of the articular surface and rigid fixation

Plates and screws are used for fixation

CT scans useful for planing surgical fixation

Can be substantial soft tissue swelling therefore a temporary external fixator to allow for the swelling to resolve. then use internal fixation and definitive open reduction

can have definitive external fixation using a ring fixator and fine wires

total knee replacement also common

108
Q

What are the causes of tibial shaft fractures?

A

Indirect force along with:

  1. bending- transverse fracture
  2. rotational energy- spiral fracture
  3. compressive force from deceleration- oblique fracture
  4. combination of these forces or from high energy injuries- comminuted fractures
109
Q

tibia fractures are the commonest cause of compartment syndrome true or false?

A

true - particularly the anterior compartment of the leg

110
Q

How do you manage tibia shaft fractures?

A

Non operative: up to 50% displacement and 5 degrees of angulation in any plane can accepted with conservative management in an above knee cast

operative: internal fixation removes need for a cast

open fractures require surgical stabilisation - intramedullary nailing commonest method

compartment syndrome requires urgent fasciotomies and surgical stabilisation of the fracture

non unions may require bone grafting of special circular frames

111
Q

what are the names of the lateral ankle ligaments?

A

anterior & posterior talofibular ligaments

calcaneofibular ligaments

commonplace for sprains to occur in the ankle

112
Q

which criteria is used to identify suspected ankle fracutres?

A

ottawa criteria

113
Q

what signifies that an ankle may need an x ray if they have a suspected fracture?

A

severe localised tenderness - bony tenderness in the distal tibia or the fibula

inability to weight bear for four steps

114
Q

what does ORIF mean?

A

open reduction and internal fixation

115
Q

What is classed as a stable ankle fracture and how do you manage them?

A

Isolated distal fibular fractures with no medial fracture or rupture of the deltoid ligament

treatment - walking cast or splint for around 6 weeks

116
Q

What is classed as an unstable ankle fracture and how do you manage them?

A

Distal fibular fractures with the rupture of the deltoid ligament

treatment - ORIF

117
Q

what is talar shift?

A

observed on a mortise AP view xray with the foot slightly internally rotated

when there is a asymmetric increased space around the the talus within the ankle mortise. signifies that the deltoid ligament must be ruptured if there is no medial malleolar fracture

causes ankle pressure to increase and increase risk of Post OA

can also lead to fracture-dislocation of the ankle

118
Q

How do you manage talar shift?

A

anatomic reduction and rigid internal fixation

119
Q

what type of fracture is a bimalleolar fracture?

A

fracture to both medial and lateral malleoli - unstable and require ORIF

120
Q

What are the causes of the fracture of the 5th metatarsal base ?

A

inversion injury with an avulsion fracture at the insertion of the peroneus brevis tendon

121
Q

how do you manage 5th metatarsal fractures?

A

require a walking cast, supportive bandage or wearing a of a stout boot for 4-6 weeks

122
Q

what is a jones fracture?

A

when the 5th metatarsal fractures in the region of the proximal diaphysis - can be more problematic due to poor blood supply and have a higher risk of non unions.

require fixation with a screw.

non union will also require a bone grafting

123
Q

what type of fracture is the 2nd metatarsal a common site for?

A

stress fractures - occur spontaneously or after a period of exercise. can sometimes not be visible so may require a bone scan

use cast for treatment

124
Q

what is the most common pattern of a humeral neck fracture?

A

Fracture of the surgical neck of the humerus with medial displacement of the humeral shaft due to pull of the pectoralis major muscle

the greater and less tuberosisites may also be pulled away

it is associated with axillary nerve injury - resulting in weakness and numbness over the upper lateral aspect of the arm.

There is no visible gap immediately below the acromion is unlike in shoulder dislocation

125
Q

How do you manage humeral neck fractures?

A

minimally displaced proximal humerus fractures are treated conservatively with a sling

internal fixation for persistently displaced fractures

humeral head splitting fractures require shoulder replacement unless patient is young

126
Q

which is more common anterior or posterior shoulder dislocations?

A

anterior dislocations

127
Q

What are the causes of anterior shoulder dislocations?

A

excessive external rotational force

fall onto the back of the shoulder

seizures - bilateral dislocations

ligamentous laxity

connective tissue disorders e.g. ehlers - danlos and marfan’s syndrome

128
Q

what can anterior shoulder dislocations lead to?

A
  1. bankart lesion - detachment of the anterior glenoid labrum and capsule
  2. Hill-sachs lesion - when the posterior humeral head impacts on the anterior glenoid producing an impaction fracture of the posterior head
  3. axillary nerve can be stretched as it passes through the quadrilateral space
129
Q

what are the clinical features of a anterior shoulder dilsocation?

A

loss of symmetry with loss of roundness of the shoulder

arm supported by the patients other unaffected arm. It is held externally rotated and slightly abducted

tears of the rotator cuff are common in the elderly

The acromion becomes prominent with a visible gap below it

loss of sensation in the ‘regimental badge area’ - main sign of axillary nerve injury

XRAY useful in diagnosis

130
Q

How do you manage anterior shoulder dislocations?

A

closed reduction under sedation/anaesthetic

sling - 2-3 weeks to allow detached capsule to heal

physiotherapy

ORIF if greater tuberosity still displaced

131
Q

How do you calculate the risk of recurrent dislocation of the shoulder?

A

age of the patient at the time of initial dislocation

younger you are, the greater the risk

132
Q

what are the causes posterior shoulder dislocations?

A

posterior force on the adducted and internally rotated arm

133
Q

What are the clinical features of the posterior shoulder dislocation?

A

humeral head may be palpated posteriorly

xray - main sign where the excessively internally rotated humeral head looks symmetrical like a light bulb on AP view - LIGHT BULB sign

134
Q

how do you manage posterior shoulder dislocations?

A

closed reduction and a period of immobilisation

physiotherapy

135
Q

what are the three main ways the ACJ joint can be injured?

A
  1. sprained
  2. subluxed (partial dislocation)
  3. dislocation
136
Q

what happens if the ACJ Joint is subluxed?

A

acromioclavicular ligaments are ruptured

137
Q

what happens if the ACJ is dislocated?

A

acromioclavicular ligaments are ruptured

coracoclavicular ligaments are ruptured

138
Q

how do you manage ACJ injuries?

A

conservative management - sling and physio

surgery is reserved for chronic pain

139
Q

what are the main causes for humeral shaft fractures?

A

direct trauma - results in comminuted or transverse fractures

fall with or without twisting - oblique or spiral fracture

140
Q

what signifies that the radial nerve injured due a humeral shaft fracture?

A

wrist drop and loss of sensation in the first dorsal web space

141
Q

how do you manage humeral shaft fractures?

A

most cases treated non op with a functional humeral brace

internal fixation allows for quicer recovery however

non unions are rare (10%) and require plating and bone grafting

142
Q

what are the main clinical features of an ulnar shaft fracture ( nightstick fracture)?

A

normally due to a direct blow

many cases a dealt with by conservative management can have ORIF however

143
Q

how do you manage a fracture of both bones of the forearm?

A

ORIF with plates and screws

anatomic reduction is required to maximise function and prevent deformity

children can have plaster casts only as the small degree of angulation will remodel as they grow

MUA and plaster can be used if the fracture has an intact periosteum and are only unstable in one direction

144
Q

What is a monteggia fracture dislocation?

A

where there is a fracture of the ulna along with the dislocation of the radial head at the elbow

difficult to see on forearm xray

Requires ORIF of the ulna fracture

145
Q

what is a galazzi fracture dislocation?

A

where there is a fracture of the radius along with dislocation of the ulna at the distal radioulnar joint

difficult to see on forearm xray

requires ORIF of the radius

146
Q

What does FOOSH stand for?

A

Fall onto an outstretched hand

147
Q

What is a colles fracture?

A

dorsaly displaced or angulated extra-articular fracture of the distal radius within an inch of the articular surface

148
Q

what causes colles fractures?

A

FOOSH with the wrist extended

149
Q

how do you manage colles fractures?

A

depends on the degree of displacement or angulation, the presence of dorsal comminution and the functional demand of the patient

  1. Minimally displaced or angulated fractures- splintage
    or
    angulation is past neutral - manipulation
  2. holding:

plaster cast

or

the fracture has dorsal comminution or is felt to be very unstable then percutaneous wires or ORIF with plate and screws can be used

150
Q

what is a late local complication which is specific to colles fractures?

A

extensor pollicis longus tendon can rupture

manage with a tendon transfer

151
Q

what is a smith’s fracture?

A

volarly displaced or angulated extra-articular fracture of the distal radius

152
Q

what causes a smith fracture?

A

falling onto the the back of a flexed wrist

153
Q

how do you manage smith’s fracture?

A

ORIF with playe and screws

they are highly unstable injuries

154
Q

what are Barton’s fractures?

A

intra-articular fractures of the distal radius involving the dorsal or volar rim, wherere the carpal bones of the wrist joint sublux with the displaced rim fragment.

either classified as:

Volar barton’s fracture - an intra-articular smith fracture

Dorsal Barton’s fracture - an intra-articular colles’ fracture

155
Q

how do you manage Barton’s fracture?

A

ORIF

156
Q

what causes scaphoid fractures?

A

FOOSH

157
Q

what are the clinical features of the scaphoid fracture?

A

Tenderness in the anatomic snuff box (between APB/EPB & EPL tendons)

pain on compressing the thumb metacarpal

Diagnosis:

Difficult to visualise on x-ray can sometimes show up later after resorption of the fracture ends. Repeat them 10-14 days after as this will allow time for bone resorption which will make it easier to view

CT scan to see if union as occured

complications: non unions and Avascular necrosis of the proximal pole

158
Q

how do you manage scaphoid fractures?

A

undisplaced fractures use a plaster cast

displaced fractures - special compression screw sunk into the bone to avoid non-union CT

non union - screw fixation and bone rafting

159
Q

What do dorsal injuries of the hand risk causing?

A

damage to the extensor tendons

160
Q

what do volar injuries of the hand risk

A

damage to the flexor tendons, digital nerves and digital arteries

161
Q

how do you manage tendon injuries?

A

complete or significant partial tendon injuries require surgical repair

162
Q

what is a mallet finger?

A

avulsion of the extensor tendon from its insertion into the terminal phalanx and is caused by forced flexion of the extended DIPJ (often due to a ball from sport)

163
Q

how do mallet finger patients present?

A

drooped DIPJ of the affected finger and inability to extend at the DIPJ

164
Q

how do you manage mallet fingers?

A

mallet splint holding DIPJ extended which should be worn for 4 weeks

165
Q

how are extensor tendon injuries of the hand managed?

A

surgical repair with splintage

166
Q

how are flexor tendon injuries of the hand managed?

A

fingers splinted in a flexed position

167
Q

How are metacarpal fractures managed?

A

3rd,4th and 5th metacarpals are usually treated conservatively

3rd and 4th metacarpals have strong inter-metacarpal ligaments proximally and distally giving stability to these fractures

168
Q

what is the main cause of 5th metacarpal fractuers?

A

punching injury

treatment: neighbour strapping of the affected digit to the adjacent finger and early motion to maintain function

any overlapping of the fingers when making a fist should be corrected by manipulation with neighbour strapping or k-wire stabilisation

169
Q

what is a ‘fight bite’ and how may it cause a laceration?

A

term describe a laceration sustained to the puncher’s hand from the punchee’s tooth.

Injury could potentially penetrate the MCP joint and disrupt the extensor tendon

septic arthritis can also occur from the intra-oral organisms from the tooth infecting the finger

170
Q

How are phalangeal fractures treated?

A

neighbour strapping or splintage

significantly displace or angulated fractures may require manipulation under anaethetic

unstable fractures require k wire or fixation with small screws

171
Q

How are hip fractures (fractured neck of the femur) is presented?

A

shortened fractured leg which is externally rotated

172
Q

How are dislocated hips presented?

A

internally rotated leg

head of femur lies posterior to acetabulum

173
Q

what is the role of the NEXUS criteria?

A

sees whether a patient with a C spine injury can be cleared for mobililsation

174
Q

what are the criteria part of NEXUS?

A
  1. focal neurological deficit present
  2. midline spinal tenderness present
  3. altered level of consciousness present
  4. intoxication present
  5. distracting injury present

if none of the above are present then the patient can safely be considered for clinical clearance of the C spine

175
Q

what is pre-patellar bursitis?

A

often called carpet layer’s knee or nun’s knee

most likely due to repetitive knee trauma

NSAIDs for non septic bursitis

septic bursitis: antibiotics and drainage

176
Q

which tendon is the most common to be effected by rotator cuff tear?

A

supraspinatus tendon

177
Q

which nerve is most likely to be effected by anterior dislocation of the shoulder or fractures of the surgical neck of the humerus?

A

axillary nerve

178
Q

which nerve is most likely to be effected by a mid-shaft fracture of the humerus?

A

Radial nerve

179
Q

which nerve is most likely to be entrapped in the carpal tunnel?

A

median nerve

180
Q

which nerve can be entrapped in the cubital tunnel?

A

Ulnar nerve

181
Q

A 35-year-old man falls and sustains a fracture to the medial third of his clavicle. Which vessel is at greatest risk of injury?

A

subclavian vein