Trauma Flashcards
What does the ABCDE evaluation stand for when managing trauma?
Airway management
Breathing and Ventilation
Circulation ad bleeding control
Disability ( neurological evaluation)
Exposure and Environmental control
What value on the Glasgow coma scale signifies loss of airway control?
8 or lower
Give examples of signs which indicate airway obstruction.
noisy breathing
gurgling
stridor
agitation from hypoxia and hypercapnoea
How do you manage ABCDE evaluation?
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.
What should be carried out at the end of primary survey?
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
What is a polytrauma?
Where more than one major long bone is injured or where a major fracture is associated with significant chest or abdominal trauma.
What can unstable major long bone fractures cause?
Ongoing blood loss
Hypovolaemia
Pain
Increased
sympathetic response
Amplification of the inflammatory response
fat embolism
When does Systemic inflammatory response syndrome (SIRS)?
SIRS occurs when there is an amplifaction of inflammatory cascades in response to trauma with pyrexia,tachycardia, tachypnea and leukocytosis
What is the first manifestation of Hypovolaemia?
ii. what follows after?
Tachycardia
ii. Decrease in blood pressure. Confusion or lethargy may also occur
What is the definition of a Fracture?
Medical term for a break in the bone
What is the difference between a direct trauma and indirect trauma?
ii. which causes the majority of fractures?
Direct trauma refers to a direct blow
indirect trauma refers to it being caused by twisting or bending forces
What is the difference between a partial/incomplete fracture and a complete fracture
Partial fracture - not a complete break e.g. stress fracture
complete - complete break in bone
What is the difference between a high energy fracture and a low energy fracture?
High energy - e.g. car accident, gunshot, blast, fall from height
Low energy - e.g. Trip, fall, sports injury
How do bones heal?
Primary healing (1st intention)
secondary healing (2nd intention)
What is primary bone healing?
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
What is secondary bone healing?
- 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.
What is the fracture process of secondary bone healing?
- Fracture occurs
- Haematoma occurs with inflammation from damaged tissues
- Macrophages and osteoclasts remove debris and reabsorb the bone ends
- granulation tissue forms from fibroblasts and new blood vessels
- Chondroblasts form cartilage (soft callus)
- Osteoblasts lay down bone matrix (collagen type 1)- endochondral ossification
- Calcium mineralisation produces immature woven bone (hard callus)
- Remodelling occurs with organisation along lines of stress into lamellar bone
How long does it take soft callus to form in secondary bone healing?
2-3 weeks
How long does it take for hard callus to form in secondary bone healing?
6-12 weeks
What does secondary bone healing require?
Good blood supply for oxygen
Nutrients
Stem cells
Little movement - no movement (i.e. internal fixation with fracture gap) is bad
What is a Tranverse fracture?
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
What is a oblique fractures?
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
What is a spiral fracture?
Occur due to torsional forces.
interfragmentary screws potentially can be used.
Spiral fractures are most unstable to rotational forces but can also angulate
What is a comminuted fracture?
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
What is a segmental fracture?
When the bone fractures in two separate places.
These injuries are very unstable and require stabilisation with long rods
A fracture at the end of a long bone can be described according to what?
site of the bone and also the type of the bone
A fracture at the end of a long bone (metaphyseal/epiphyseal) can be what?
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.
What three factors does a fracture displacement depend on?
Translation
Angulation
Rotation
What does the translation of a distal fragment describe?
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
What does the angulation of a distal fragment describe?
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
What can residual displacement or angulation cause?
Deformity
Loss of function
abnormal pressure on joints
all three factors lead to post-traumatic OA
What does the rotation of a distal fragment describe?
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.
What are the main clinical features of a fracture?
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
What should an assessment of an injured limb include?
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
How do you diagnose fractures?
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
How do you manage Long bone fractures?
Initial management
- clinical assessment of the injured limb
- analgesia ( IV morphine)
- Splintage / immobilisation of the limb with investigation (X-ray)
- 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.
Give examples of complications of fractures?
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
What is compartment syndrome?
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
What are the main clinical features of compartment syndrome?
- Increased pain on passive stretching of the involved muscle
- Severe pain outwith the anticipated severity in the clinical cortext
What are the two main nerve injuries associated with fractures?
- Neurapraxia - when the nerve has a temporary conduction defect from compression or stretch and resolve over time with full recovery
- 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
What is Neurotmesis?
complete transection of a nerve
No recovery will occur unless the affected nerve is surgically repaired
which nerve injury is a colles fracture associated with?
Acute median nerve compression/carpal tunnel syndrome
which nerve injury is an anterior dislocation of the shoulder associated with?
axillary nerve palsy
Which nerve injury is a humeral shaft fracture associated with?
Radial nerve palsy
Which nerve injury is a supracondylar fracture of the elbow associated with?
median nerve injury
Which nerve injury is the posterior dislocation of the hip associated with?
sciatic nerve injury
Which nerve injury is the “bumper” injury to the lateral knee associated with?
common peroneal nerve palsy
What arterial damage can occur from a knee dislocation?
popliteal artery can be injured
What arterial damage can occur from a paediatric supracondylar fracture of the elbow?
brachial artery injury
what arterial damage can occur from a shoulder trauma?
axillary artery injury
Give some examples of signs of reduced distal circulation.
- Reduced or absent pulses
- Pallor
- delayed cap refill
- Cold to touch
What are the signs and symptoms of a fracture healing?
Resolution of pain and function
Absence of point tenderness
no local oedema
resolution of movement at fracture site
what are the clinical signs of non-union in fractures?
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
What is a non union?
serious condition where the fracture fails to heal
what are the cause of hypertrophic non-union?
Instability
excessive motion at the fracture site
Infection
What are the causes of atrophic non-union?
rigid fixation with a fracture gap
lack of blood supply at the fracture site
chronic disease
soft tissue interposition
infection
Give examples of some fractures which are particularly prone to problems with healing?
scaphoid waist fractures
fractures of the distal clavicle
subtrochanteric fractures of the femur
jones fracture of the fifth metatarsal
How do you manage a hypertrophic non union?
application of a plate to ensure subsequent union of the fracture
How do you manage atrophic non union?
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
How do you diagnose non union fractures?
X-ray
CRP and bacteriological sampling for evidence of infection
How do manage non union fractures if infection is diagnosed?
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
what is a delayed union?
fracture which has not healed within the expected time frame
How can open fractures occur?
- Inside out injury - spike of fractured bone from within punctures the skin
- Outside-in injury - laceration of the skin from tearing or penetrating injury
What factors increase the risk of infection in open fractures?
- higher the energy of the injury
- amount of contamination
- any delay in appropriate treatment
- problems with wound closure
how do you manage open fractures?
Initial management
- 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
How should you manage mangled extremity?
some cases suggest an early amputation may be best choice
what causes dislocations?
significant trauma
conditions which cause hyper-mobility (Ehlers danlos and Marfans)
voluntary dislocation e.g. shoulder
How are ligament ruptures graded?
grade 1 - sprain
grade 2 - partial tear
grade 3 - complete tear
How do you manage soft tissue injuries?
RICE
Rest
Ice
compression
elevation
n.b. some complete ligament ruptures and tendon tears may require surgical repair or graft reconstruction (ligament only)
What are the main causes of spinal cord of nerve cord damage?
contusion
compression
stretching
laceration
what is spinal shock?
physiological response to injury with complete loss of sensation and motor function and loss of reflexes below the level of the injury
How long does it take for spinal shock to usually resolve?
ii. which reflex is used to signal the end of spinal shock?
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