Trauma Flashcards
what is resuscitation?
the process of correcting physiological disorders in an acutely unwell or injured patient
what does resuscitation involve?
all trauma patients get high flow oxygen
before ABCDE get general impression
major trauma - blood is normally fluid of choice
what are the mechanisms of injury likely to result in resuscitation?
road traffic collisions - account for 1/3 of all major trauma presentations
falls
interpersonal violence
suicide
work place accidents
trauma most common in young men 18-40
vital organ failure can result in cardio-respiratory arrest
What are the aims of treatment in high energy injuries?
e.g. road traffic accidents (RTA) or falling from heights
save life
prevent serious systemic complications
secondary aims (not as important) preventing pain and loss of function from fractures and dislocations
what can quick medical and surgical treatment in the golden hour prevent death from?
airway compromise severe head injuries severe chest injuries internal organ rupture fractures associated with significant blood loss (pelvis and femur)
Airway assessment in trauma
sound of breathing can indicate blockage
ability to speak indicates clear airway
need to protect the C-spine
Breathing and ventilation assessment in trauma
high flow O2 and tight fitting mask for all major trauma patients
pulse oximetry
need to rule out pneumothorax (including tension)
haemothorax
pulmonary contusion
flail chest
Circulation and bleeding control in trauma
pulse and ECG to assess
urinary output for fluid balance (minimum 30ml/hr)
do they look well perfused
all major trauma patients given 2 litres of IV crystalloid initially
get access - bilateral large bore peripheral venous access
Potential circulation issues in trauma
hypovolaemic shock - tachycardia, reduced BP, confusion/lethargy, fluid resuscitation
exsanguinating haemothorax - may need thoracotomy
blunt penetrating abdominal trauma - check for internal bleeding
pelvic fracture - can cause substantial blood loss
obvious external bleeding
major peripheral arterial/venous bleeding - temporary tourniquet
haemorrhagic shock - can be concealed in older people and children
often visible site of injury
Disability assessment in trauma
Glasgow trauma score
15 - best score
3 - worst score
assesses motor response, verbal response and eye opening with a score from 1 to 5
used to prevent secondary brain injury, get early neurosurgical intervention
Exposure in trauma
make sure no injuries are missed - keep warm to avoid hypothermia
warmed IV fluids should be given
what tests are done in major trauma after the primary survey?
trauma series of x-rays log roll patient look for signs of spinal fracture PR exam check c-spine injury urinary catheter NG tube blood tests
what is the secondary survey?
done after the primary survey and when the patient is stable
any deterioration in the clinical condition requires a return to the start of the primary survey - ABCDE
2ndry survey - head-to-toe examination to detect other injuries, may want a whole body CT scan
get more thorough history, PMH and fasting status
What is polytrauma
where more than 1 major long bone is injured or where a major fracture is associated with significant chest/abdominal trauma
need early stabilisation of the long bones - either external fixtures or intramedullary nails needed to avoid SIRS, ARDS and hypovolaemia
all of these issues can lead to MODS (multi-organ dysfunction syndrome) and potential death
what is a fracture?
a break in the bone
can be because of direct trauma (direct blow) but normally indirect trauma e.g. twisting/bending forces
What are the 2 types of fracture?
partial/incomplete e.g. unicortical stress fracture
complete breaks
what kind of mechanisms of injury cause high and low energy fractures?
high energy - RTA, GSW, blast, fall from height
low energy - trip, fall, sports injury
low energy fractures are usually pathological fractures due to an underlying weakness of the bone
Primary bone healing?
occurs when there is a minimal fracture gap (less than 1mm)
bone bridges the gap with new bone formed by osteoblasts
this happens in the healing of hairline fractures and when the fractures are fixed with compression screws and plates
Secondary bone healing?
majority of fractures
gap at the fracture site more than 1mm which needs to be filled temporarily to act as a scaffold for new bone to be laid down
involves an inflammatory response - recruitment of pluropotential stem cells (can differentiate into any cell)
what is the process of secondary bone healing?
Fracture occurs
haematoma occurs with inflammation from damaged tissue
macrophages and osteoclasts remove debris and reabsorb the bone ends
fibroblasts and new blood vessels cause the formation of granulation tissue
chondroblasts form cartilage (soft callus, formed by the 2nd/3rd week)
osteoblasts lay down bone matrix (type 1 collagen) - endochondral ossification
immature woven bone (hard callus, takes 6-12 weeks to appear) is formed by calcium mineralisation
remodelling, organisation along lines of stress into lamellar bone
Secondary bone healing needs…
good blood supply for oxygen
nutrients and stem cells
requires little movement or stress (compression or tension)
What causes atrophic non-union to occur?
lack of blood supply
no movement - internal fixation with fracture gap
fracture gap is too big
tissue is trapped in the fracture gap
hypertrophic non-union occurs when
excessive movement (no chance for fracture to bridge the gap) abundant hard callus formation
things that impair fracture healing?
smoking (causes vasospasm)
vascular disease
chronic ill health and malnutrition
what is a transverse fracture?
due to bending force - may angulate or cause rotational malalignment
what is an oblique fracture?
due to sheer force - fall from height, deacceleration
can be fixed by internal fragmentary screws
tends to shorten
may angulate
What is a spiral fracture?
due to torsional (twisting) forces
can be fixed with interfragmentary screws
mostly unstable to rotational forces
can also angulate
what is a comminuted fracture?
fractures with 3 or more fragments
generally due to high energy injury or poor bone quality
may be substantial soft tissue swelling and periosteal damage with reduced blood supply to the fracture site which impairs healing
very unstable
tend to be surgically stabilised
what is a segmental fracture?
bone is fractured into 2 separate places
very unstable
needs stabilised with long rods or plates
what does valgus and varus mean?
valgus - anything which goes away from the midline
varus - anything which goes towards the midline
FOOSH
falling on outstretched hand
- ask about hand dominance
X-ray - look for rough edges, cortex break
fracture can appear more white (bone on bone) or darker (space)
limb fracture management?
reduce - get as close to original position as possible
retain - keep it there
rehabilitate - restore function
Operative options for fracture (least - most invasive)
plaster cast - after reducing it
fixation - K-wire
open reduction and internal fixation - plate and screw
Application of an external fixator - only if infection or too swollen
eventually remove K-wires - leave plates and screws in
intra-articular fracture
look for any reduced joint space (impaction) may need bone graft
why do you want to get fractures involving the joint surface as they were
to avoid OA
BOAST guidelines for open fractures
- limb should be realigned and splinted
- remove gross contamination, dress with saline-soaked gauze and cover with occlusive film
- combined orthoplastic response
- debridement
- definitive soft tissue closure/ coverage within 72 hrs of injury if it can’t be performed at time of the debridement
what is the initial management of a long bone fracture?
clinical assessment of injured limb analgesia (usually IV morphine) splintage/immobilisation of the limb investigation - X ray if fracture is grossly displaced, obvious dislocation or skin damage because of excessive pressure - do reduction of the fracture before waiting for an X-ray
definitive management for undisplaced, minimally displaced and minimally angulated fractures which are considered to be stable long bone fractures
non-operative with splintage/immobilisation then rehab
definitive management for displaced or angulated long bone fractures
reduce under anaesthetic - closed reduction and cast, serial X rays
definitive management for unstable injuries
surgical stabilisation K-wires plates and screws intermedullary nails external fixation
definitive management for unstable extra-articular diaphyseal fractures
open reduction and internal fixation (ORIF) - using plates or screws
ORIF should be avoided when soft tissues are swollen, blood supply to fracture site is weak or
where ORIF may cause extensive blood loss or
plate fixation may be prominent e.g. tibia
Do a closed reduction and internal fixation with intramedullary nail or extenal fixation which aims for 2ndry bone healing - risk of infection and loosening
definitive management for displaced intra-articular fractures
ORIF using wires, screws and plates
may need joint replacement or arthrodesis
definitive management of long bone fractures in elderly people with osteoporosis and dementia
higher risk of complications of surgery
failure of fixation
failure to rehabilitate satisfactorily - elderly patients also tend to have a high functional demand so surgery is usually avoided
early local complications of fractures
compartment syndrome
vascular injury with ischaemia
nerve compression/ injury
skin necrosis
early systemic complications of fractures
hypovolaemia fat embolism shock ARDS acute renal failure SIRS MODS death
late local complications of fractures
stiffness loss of function CRPS (chronic regional pain syndrome) infection non-union mal-union Volkmann's ischaemic contracture post-traumatic OA DVT
late systemic complications
PE
what is compartment syndrome?
a serious complication and surgical emergency
groups of muscles are bound in tight fascial compartments with limited capacity for swelling
pathology of compartment syndrome
rising pressure compresses the venous system causing congestion within the muscle and secondary ischaemia as oxygenated arterial blood can’t supply the congested muscle
what are the symptoms and signs of compartment syndrome
severe pain
parasthesiae
sensory loss
increased pain on passive stretching of the involved muscle
severe pain outwith the anticipated severity of the clinical context
limb will be tensely swollen and the muscle tender to touch
What does loss of pulses mean in compartment syndrome?
end-stage ischaemia - diagnosed too late
what is the treatment for compartment syndrome?
removal of any tight bandages for temporary relief
emergency fasciotomies involving incisions through skin and fascia to relieve contraction
open wound is left for a few days before 2ndry closure
what happens if compartment syndrome is left untreated?
ischaemic muscle will necrose causing fibrotic contracture (Volkmann’s ischaemic contracture)
poor function
what are the nerve injuries associated with a fracture?
neurapraxia
axonotmesis
what is neurotmesis?
complete transection of a nerve requiring surgical repair for any chance of recovery of function
what is neurapraxia?
temporary conduction defect from compression/ stretch
resolves over time with full recovery (can take up to 28 days)
what is axantmesis?
nerve injury sustained due to compression/ stretch or from a higher degree of force with death of the long nerve cell axons distal to the point of injury die
what nerve injury is associated with a colles fracture
acute medial nerve compression (carpal tunnel syndrome)
anterior dislocation of the shoulder
axillary nerve palsy
humeral shaft fracture
radial nerve palsy (in spiral groove)
supracondylar fracture of the elbow
median nerve injury (usually anterior interosseous branch)
posterior dislocation of the hip
sciatic nerve injury
‘bumper’ injury to lateral knee
common peroneal (fibular) nerve palsy
what are the vascular injuries which can be associated with fractures
uncommon but with significant causes
can happen with both blunt and penetrating trauma
vessels can be transected, torn, stretched or compressed
partial tears affecting the arterial intima - can thrombose forming arterial occlusion
haemorrhage from arterial/venous injury causing hypovolaemic shock
potential management of a vascular injury caused by a fracture
may need an urgent angiography
emergency can make temporary restoration of circulation with vascular shunt/repair with bypass graft or endoluminal stent
need to do skeletal stabilisation with internal/external fixation to protect repair from shearing force
vascular risk with knee dislocation
risk of popliteal artery injury
vascular risk with paediatric supracondylar fracture of the elbow
risk of brachial artery injury
vascular risk with shoulder trauma
risk of axillary artery injury
vascular risk with pelvic fractures
risk of life-threatening haemorrhage from arterial/ venous bleeding
ongoing haemorrhage can be controlled by angiographic embolisation performed by interventional radiologists
skin and soft tissue problems which can be caused by skin and soft tissue problems
especially affected by high energy injuries and if skin is fragile
protruding spike of bone/tension can cause devitalisation and necrosis with skin breakdown
if fracture is causing excessive pressure on skin may see tenting of the skin and blanching - fracture should be reduced - emergency to avoid necrosis
shear force - can cause degloving, can result in skin ischaemia, no blanching under pressure and can be insensate - skin graft/flap may be needed
high energy injury - more soft tissue swelling and bruising (contusion)
inflammatory exudates causing lifting of the epidermis can cause fracture blisters
surgical wound is not recommended
how do you describe a fracture of the long bone?
the site of the bone - proximal, middle, distal 3rd
type of bone involved - diaphyseal (shaft), metaphyseal, epiphyseal
intra-articular fracture
fracture at the end of the long bone (metaphyseal/epiphyseal) which extends into the joint
greater risk of stiffness, pain and post-traumatic OA esp. if residual displacement resulting in an uneven articular surface or extra-articular
translation fracture displacement
of the distal fragment
can be described as anteriorly or posteriorly (volar/palmar or dorsal in the forearm and hand)
medially or laterally (ulnar and radial in the forearm)
can be estimated in relation to the width of the bone 25% etc
100% displaced - an off-ended fracture
angulation fracture displacement
direction in which the distal fragment points towards and the degree of deformity
can be described as anteriorly or posteriorly or medially or laterally
measures in degrees from the longitudinal axis of the diaphysis of the long bone
gives info of the direction of forces involved in the injury and info about the reversed
direction of forces required to reduce a fracture
residual displacement and angulation can cause deformity - loss of function and abnormal pressure leads to post-traumatic OA
minor degrees of displacement/ angulation may be alright depending on the bone involved and the site of fracture
rotation displacement of fracture
of distal fragment relative to the proximal fragment
clinically important
rotational malalignment is poorly tolerated and needs to be corrected
fracture is more unstable
what is optimum fracture management dependent on?
site of fracture
position
stability
related to the fracture pattern and degree of initial displacement
what are the clinical signs of a fracture?
localised bony (marked) tenderness NOT diffused mild tenderness
swelling
deformity
crepitus (bone ends grating with an unstable fracture)
when to x ray a suspected fracture?
if a patient can’t weight bear on an injured lower limb then x-ray painful area
x-ray if any clinical signs
How is a fracture assessed?
radiographs (X-rays) - diagnose majority of fractures - usually an AP and lateral view, 2 views are always required, oblique views can be useful for complex shaped bones
Tomogram - moving X-ray, takes images of complex bones not really used anymore except for diagnosing mandibular fractures
CT - assess fractures of complex bones can help to determine the degree of articular damage and help surgical planning for complex intra-articular fractures
MRI - used to detect occult fractures where there is a clinical suspicion but a normal X-ray
Technetium bone scans: used to detect stress fractures, usually fail to show up on an X-ray until a hard callus begins to appear
signs a fracture is healing?
resolution of pain/function
no point tenderness
no local oedema
resolution of movement at fracture site
signs of fracture non-union?
ongoing pain/function ongoing oedema movement at fracture site may see bridging callus on X-ray may need CT to confirm
what is a delated union?
fracture that has not healed within the expected time
many factors affect the rate of healing
- tibia is one of the slowest healing bones
- femoral shaft fractures take 3-4 months to heal, metaphyseal fractures tend to heal more quickly than cortical fractures
infection can delay union
antibiotics might help union - might not
what is hypertrophic non-union?
due to instability and excessive motion at the fracture site
what is atrophic non-union?
due to rigid fixation with a fracture gap, lack of blood supply to the fracture site, chronic disease or soft tissue interposition
what can cause fracture non-union?
infection
some fractures are prone to problems with healing due to poor blood supply e.g. scaphoid wrist
fractures, distal clavicle fractures, subtrochanteric fractures of the femur, Jones fracture of the
fifth metatarsal
Some intra-articular fractures may not unite due to synovial fluid inhibiting healing if a fracture
gap exists (intracapsular hip fracture, scaphoid fracture)
who is likely to get a local DVT?
after pelvic/major lower limb fractures with a period of immobility
prophylaxis (LMWH) to all at-risk patients
suspected DVT needs duplex scanning and anticoagulation
what is fracture disease?
Stiffness and weakness due to the fracture and splintage in cast, self-limiting
may need physiotherapy
where does AVN occur post fracture?
fractures in the femoral neck, scaphoid and talus
not all cases are symptomatic but many cases need surgery (THR if hip, athrodesis)
what is post-traumatic OA?
can occur due to intra-articular fracture
ligamentous instability or fracture malunion
treated with analgesia
bracing/splinting
arthrodesis
joint replacement
what is CRPS?
heightened chronic pain response after injury
burning/throbbing
sensitivity to stimuli that’s not usually painful
chronic swelling
stiffness
painful movement
skin colour changes
Type 1 - caused by a peripheral nerve injury
Type 2 - not caused by a peripheral nerve injury, most cases
what is the management of CRPS?
anlagesics antidepressants anticonvulsants steroids TENS machines physio lidocaine patches sympathetic nerve blocking injections
how is infected fracture fixation managed?
antibiotics with/without surgical washout
may need surgery to remove implants and for debridement of the infected bone
causes of open fractures
spike of fractured bone from within puncturing the skin
laceration of the skin from tearing/penetrating injury
why is treatment of an open fracture to avoid infection is so important
Infection can result in non-union, and is difficult to get rid off
Bone infection of open fracture of a long bone often needs extensive removal of bone with
shortening which may require complex surgery to lengthen the bone
Some infected non-unions lead to amputation (presence of vascular injuries increases the risk
of amputation)
how is infection of an open fracture prevented initially?
IV broad spectrum antibiotics in A&E
flucloxacillin for gram +ve organisms
gentamicin for gram -ves
metronidazole for anaerobes (if soil contamination)
Sterile/antiseptic soaked dressing before fracture is splinted
Open fractures usually require prompt surgery, involves debridement
Unstable fracture may produce haematoma which acts as a culture medium for bacteria, may
cause more necrosis
Open fractures are often high energy and delayed union is more common
how is an open fracture managed ongoingly?
Need frequent wound inspections (so difficult to treat with plaster cast)
Open fractures are usually stabilised with internal/external fixation
Wounds may require skin graft
Skin graft will NOT take on bare tendon, bone or any exposed metalwork, also might not take
fat (due to poor vascularisation)
Muscle, fascia, granulation tissue, paratenon and periosteum can accept a skin graft
If there is doubt over viability of soft tissues/if the wound is heavily contaminated then leave the
wound open to allow ongoing infection to drain out and then return to theatre for further
debridement in 48 hrs (necrotic tissue will have declared itself by this time)
what is a mangled extremity?
limb with injury to 3/4 systems in the extremity
many damaging outcomes
may need early amputation
how should dislocations be managed?
Any dislocation should be REDUCED as soon as possible.
Most are done by closed manipulation under sedation and analgesia/sometimes general/local
anaesthetics.
Delayed presentations (e.g. in alcoholics) increases the risk of needing an open reduction and
recurrent instability.
who gets dislocations?
May occur after significant trauma but people with hyper mobility (inc. Ehlers Danlos and
Marfan’s) might get a dislocation with an innocuous injury, some can voluntarily dislocate joints
(e.g. shoulder).
Dislocations can occur with associated injuries: tendon tears, nerve injury, vascular injury,
compartment syndrome.
management of recurrent dislocation?
soft tissue repair/reconstruction or bony surgical procedures
how to manage fracture-dislocations?
may reduce with closed reduction
ORIF may be needed if reduction cannot be achieved due to a bony fragment preventing congruent reduction or joint instability
grading ligament ruptures
grade 1 - sprain
grade 2 - partial tear
grade 3 complete tear
how to treat soft tissue injuries
RICE rest Ice compression elevation followed by early movement to prevent stiffness
tendon tears able to be conservatively treated?
Achilles tendon, rotator cuff, long
head of biceps brachia, distal biceps) though may need repair to restore function
complete tears of… need surgical repair
tendons fundamentally for function
quadriceps tendon
patellar tendon
tendon injuries in the hand - need surgical repair
what is septic arthritis?
an emergency
Bacterial infections can irreversibly damage hyaline cartilage within days
who gets septic arthritis?
Uncommon in adults but important so should be excluded with any unexplained acute mono
arthritis
Young, elderly, IVDUs and immunocompromised patients are most prone to infection
can evolve from metphyseal osteomyelitis in some joints - neonates and infants
What is the pathology of septic arthritis?
pathogens usually spread to the joint via the blood/from infection of adjacent
tissues
Suspect endocarditis esp. if more than one joint/bone is involved (due to septic emboli)
how does septic arthritis present?
acute onset severe painful red hot swollen and tender joint severe pain on any movement sometimes history of direct penetration with a sharp object, can also occur following intra-articular surgery
pathogens causing septic arthritis
Staph aureus = most common cause in adults
Streptococci = second most common cause
Haemophilus influenzae = most common in children though now there’s a vaccine
Nesseria gonorrhoea = in young adults, rare
Escherichia coli - in the elderly, IVDUs, very ill patients
how is septic arthritis diagnosed?
aspirate under aseptic technique before giving antibiotics to confirm it and to
identify causative organism (single dose of antibiotics can lead to a falsely negative gram stain
and culture), frank pus aspirated and positive gram stain are indicators of septic arthritis
how is septic arthritis treated?
surgical washout either via open surgery or arthroscopically, can do repeat
aspirations esp. in children, response to treatment is based on clinical findings and serial CRP
