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Year 5 Core Conditions > Trauma - Level 1/2 > Flashcards

Trauma - Level 1/2 Flashcards

1
Q

Definition of compartment syndrome?

A

o Increased pressure within closed anatomical space
o Veins compressed and increases hydrostatic pressures, causing fluid to move out of veins
o Traversing nerves are compressed
o Results in temporary or permanent damage to muscles and nerves
o Significant muscle damage can occur if pressures >30/40mmHg

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2
Q

Types of compartment syndrome?

A

o Acute – trauma, intense exercise

o Chronic – exercise, usually return when activity resumed

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3
Q

Affected sites of compartment syndrome?

A

o Forearm
o Lower limb
o Gluteal
o Abdominal

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4
Q

Causes of compartment syndrome?

A 
o	Fractures (forearm and lower leg)
o	Crush injury
o	Burns
o	Infection
o	Prolonged limb compression (plaster cast)
o	Haemorrhage
o	Bleeding disorders
o	Muscle hypertrophy in athlete
o	Iatrogenic (IM injections, anticoagulated patients)
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5
Q

Risk factors for chronic compartment syndrome?

A

o Athletes

 Repetitive activities – running, football, cycling, tennis

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6
Q

Acute symptoms of compartment syndrome?

A

Increasing pain
 Especially with passive movement and stretching
 Tightness of compartment

Sensory deficit in distribution of nerve

Muscle tenderness and swelling

Later – tissue ischaemia, pallor, pulselessness, paralysis, coolness

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7
Q

Chronic symptoms of compartment syndrome?

A

o Severe pain and tightness, hard compartment on examination
 Triggered by exercise, worse as exercise continues and then resolves at rest
o May cause weakness, numbness and tingling

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8
Q

Diagnosis of compartment syndrome?

A

Clinical diagnosis

If clinical uncertainty:
o Intra-compartmental pressure measured:
 Wick catheter, needle manometry, infusion techniques, pressure transducers
o If unsure: MRI scan

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9
Q

Management of acute compartment syndrome?

A

If swollen limb with no cause and risk factors -urgent orthopaedic opinion
 Continuous compartmental pressure monitoring
 High-flow oxygen
 IV fluids
 Morphine PRN
 Urgent Open fasciotomy
• Wound left open for 24-48 hours
• Debridement of any necrosed muscle
 If >8h, severe, muscle necrosis then amputation may be needed

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10
Q

Management of chronic compartment syndrome?

A 
o	Try to reduce offending activity
o	Deep massage
o	PRN NSAIDs
o	Surgery
	Decompressive fasciotomy
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11
Q

Complications of compartment syndrome?

A
  • Tissue necrosis
  • Muscle necrosis leads to fibrosis and shortening, resulting in ischaemic contracture (Volkmann’s ischaemia contracture)
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12
Q

Anatomy of ankle joint?

A

o Tibiotalar joint - articulation is between the lower end of the tibia, the malleoli and the body of the talus. This joint allows dorsiflexion and plantar flexion of the ankle.

o The subtalar joint - articulation is between the talus and calcaneus. This joint allows inversion and eversion of the ankle

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13
Q

Common injuries of ankle joint?

A

o Most frequently in inversion injuries are lateral joint capsule and anterior talofibular ligament
o Increasing injury causes additional damage to calcaneofibular ligament and posterior talofibular ligament

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14
Q

Symptoms of ankle sprains?

A

o Often running across uneven ground or sudden change in direction
o Pain immediately
o Weight-bearing
o May get swelling

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15
Q

Signs of ankle sprains?

A 
o	Deformity
o	Swelling or bruising
o	Effusion
o	Palpate any tenderness
o	Assess neurovascular compromise
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16
Q

Ottawa ankle rules for XR?

A

 Ottawa Ankle Rules for adults:
• Unable to walk 4 steps both immediately after injury and in ED?
• Have tenderness over posterior surface of distal 6cm (tip) of lateral or medial malleolus?
• Adopt lower threshold in elderly or children

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17
Q

When is ankle XR required of ankle sprains?

A

 Ottawa Ankle Rules for adults:
• Unable to walk 4 steps both immediately after injury and in ED?
• Have tenderness over posterior surface of distal 6cm (tip) of lateral or medial malleolus?
• Adopt lower threshold in elderly or children

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18
Q

When is foot XR required of ankle sprains?

A

 Ottawa Foot Rules for adults:
• Tenderness over navicular, base of 5th metatarsal require specific foot X-rays
• Unable to walk 4 steps both immediately after injury and in ED?

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19
Q

Management of ankle sprains - initial management?

A 
PRICE
	Protect
	Rest - for 48-72 hours
	Ice – 10-15 mins, not directly on skin
	Compression
	Elevate
Avoid HARM
	Heat
	Alcohol
	Running
	Massage
Analgesia
Weight-bear as soon as comfortable 
Full recovery ~2-4 weeks
Physiotherapy and exercises when able
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20
Q

Management of ankle sprains - if unable to weight bear?

A

o Crutches
o Review in 2-4 days
o Below-knee cast for 10 days
o Follow-up in outpatients

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21
Q

Management of ankle sprains - if badly torn?

A

surgical repair needed

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22
Q

Definition of Colle’s Fracture?

A

o Radial fracture within 2.5cm of wrist – distal fragment is angulated to point dorsally
o Includes avulsion fracture of ulnar styloid
o Occurs due to fragility fracture in wrist dorsiflexion

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23
Q

Definition of Smith’s Fracture?

A

Volar angulation of distal fragment of extra-articular fracture of distal radium
o (reverse of Colle’s)
o Caused by landing on dorsal surface of wrist

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24
Q

Definition of Barton’s Fracture?

A

o Intra-articular fracture of distal radius with dislocation of radio-carpal joint

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25
Q

Epidemiology of distal radius fracture?

A
  • ¼ of all fractures seen clinically

- Colle’s accounts for 90% of all distal radial fractures

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26
Q

Aetiology of distal radius fracture?

A

o Fall on outstretched hand (FOOSH)

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27
Q

Risk factors of distal radius fracture?

A 
o	Osteoporosis
o	Age increasing
o	Female
o	Prolonged Steroid
o	Children 5-15
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28
Q

Symptoms of distal radius fracture?

A

o Episode of trauma
o Immediate pain +/- deformity and sudden swelling
o Weakness and paraesthesia of hand

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29
Q

Signs of distal radius fracture?

A

o Dinnerfork deformity

  • Check scaphoid, distal sensation and pulses in all cases
  • Assess joint above and below
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30
Q

Investigations in Colle’s fracture?

A

AP and lateral X-Ray of wrist – Colle’s Fracture
o Posterior and radial displacement (translation) of distal fragment
o Angulation of distal fragment to point dorsally
o Impaction and shortening of radius

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31
Q

Investigations in Smith’s fracture?

A

AP and lateral X-Ray of wrist – Smith’s Fracture
o Distal fragment impacted
o Tilted to point anteriorly and often displaced anteriorly

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32
Q

Investigations in Barton’s fracture?

A

AP and lateral X-Ray of wrist – Barton’s Fracture
o Involves dorsal or volar portion of distal radius
o Fragment slips, so fracture is unstable

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33
Q

Investigations if planning surgery in distal radius fracture?

A
  • May need MRI/CT if complex or operative planning
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34
Q

Management of distal radius fractures - initial management?

A 
o	Analgesia
o	Discharge if undisplaced fracture
o	Displaced fractures – closed reduction or MUA
	Repeat XR in 1 week
o	Immobilise in backslap POP
o	Elevate in sling
o	Fracture clinic follow-up 
o	Advise patient to keep moving fingers, thumb, elbow, shoulder
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35
Q

Management of distal radius fractures - MUA?

A

o Grossly displaced fractures
o Loss of normal forward radial articular surface tilt on lateral wrist XR
o Either urgent or within a couple of days

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36
Q

Complications of distal radius fracture?

A
  • Malunion – need corrective osteotomy
  • Median nerve compression
  • Osteoarthritis
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37
Q

Definition of long bones?

A

humerus, radius, ulna, femur, tibia, fibula

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38
Q

Characteristics of fractures?

A

o Acute – caused by sudden overload of forces on healthy bone

o Stress – gradual overload of force on healthy bone, leads to inability to repair itself over time

o Pathological – occurs in area of diseased bone

o Insufficiency – normal force load but fracture due to low density (osteoporosis)

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39
Q

Anatomical classification of fractures?

A

o Intra-articular – fracture line extends within a joint

o Extra-articular – fracture does not extend into joint

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40
Q

Types of fracture - direction - linear?

A

parallel to bones long axis

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41
Q

Types of fracture - direction - transverse?

A

right angles to bone’s long axis

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42
Q

Types of fracture - direction - oblique?

A

diagonal to bone’s long axis

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43
Q

Types of fracture - direction - spiral?

A

at least one part of bone has been twisted

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44
Q

Types of fracture - direction - compression/wedge?

A

usually in vertebrae, front portion of vertebra collapses

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45
Q

Types of fracture - direction - impacted?

A

bone fragments driven into each other

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46
Q

Types of fracture - direction - avulsion?

A

fragment of bone is separated from mass

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47
Q

Types of fracture - soft tissue involvement - closed?

A

overlying skin intact

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48
Q

Types of fracture - soft tissue involvement - open?

A

wounds that communicate with fracture

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49
Q

Types of fracture - displacement - displaced?

A

• Translated with sideways displacement, angulated, rotated, shortened

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50
Q

Types of fracture - displacement - non-displaced?

A

No displacement

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51
Q

Types of fracture - fragment - incomplete?

A

bone fragments partially joined, crack does not completely transverse width of bone
• Greenstick = soft bone bends and breaks, but not into two pieces

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52
Q

Types of fracture - fragment - complete?

A

bone fragments separate completely

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53
Q

Types of fracture - fragment - comminuted?

A

bone broken into several pieces

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54
Q

Neer Classification of proximal humerus fracture?

A

o 1 – Greater tuberosity
o 2 – Lesser tuberosity
o 3 – Humeral head
o 4 – Humeral shaft

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55
Q

Risk factors for fractures?

A 
o	Osteoporosis
o	Old age
o	Prolonged steroid use
o	Female sex
o	Low BMI
o	Hx of recent falls
o	Prior fracture
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56
Q

Symptoms of long bone fractures?

A

o Severe pain
 Mild and gradual onset in stress fractures
o Soft-tissue swelling
o Impaired limb function/Inability to weight bear
o Deformity

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57
Q

Assessment of fractured limb?

A
  • Assessment of neurovascular status
  • Bloods – FBC, cross-matching
  • X-ray
    o At least two 90o orthogonal x-rays (AP, lateral) with inclusion of joints proximal and distal to site of injury
  • Non-contrast CT scan
  • MRI limb
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58
Q

Management of long bone fracture - initial management?

A

Immobilisation & Splint
o If neurovascular compromise or inability to splint
 Gentle in-line traction

Analgesia
o Morphine sulfate 2.5-10mg SC/IM/IV every 2-6 hours or IVI titrated to response

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59
Q

Management of long bone fracture - orthopaedic referral?

A

o External Fixation OR Open reduction and internal fixation
o Serial x-rays to verify healing and alignment
o EXOGEN is low-intensity pulsed US for healing non-union fractures

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60
Q

Management of long bone fracture - open fractures?

A

o Antibiotics - IV co-amoxiclav (or cefuroxime + metronidazole)
o Tetanus toxoid if not completed immunisation or over 5 years since booster

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61
Q

Complications of long bone fractures?

A
  • Compartment syndrome
  • Fat embolism
  • Haemorrhage
  • DVT
  • Infection
  • Delayed or non-union
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62
Q

Complication of hip fracture?

A
  • Can disrupt blood supply to femoral head and cause avascular necrosis from medial circumflex femoral artery which lies on intracapsular femoral neck
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63
Q

Types of femoral head fracture?

A

Intra-capsular – from the subcapital region of the femoral head to basocervical region of the femoral neck, immediately proximal to the trochanters

Extra-capsular – outside the capsule, subdivided into:

  1. Inter-trochanteric, which are between the greater trochanter and the lesser trochanter
  2. Sub-tronchanteric, which are from the lesser trochanter to 5cm distal to this point
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64
Q

Risk factors for hip fracture?

A

o Elderly
o Osteoporosis
o Osteomalacia
o Falls

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65
Q

Symptoms of hip fractures?

A

o Usually follow a fall onto hip or bottom
o Pain radiates down towards knee
o Affected leg shortened and externally rotated

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66
Q

Signs of hip fractures?

A

o Tenderness over hip or greater trochanter, particularly on rotation
o Suspect in elderly: sudden inability to weight-bear, unstable and pain in knee, gone off her feet

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67
Q

XR findings of hip fractures?

A

X-Ray (need AP and lateral)
o Shenton’s line disruption: loss of contour between normally continuous line from medial edge of femoral neck to inferior edge of superior pubic ramus
o Lesser trochanter more prominent due to external rotation
o Sclerosis in fracture plane
o Bone trabeculae angulated
o Fractures of femoral neck not always visible

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68
Q

Further imaging needed of hip fractures?

A
  • If X-ray negative but suspected hip fracturs, offer MRI
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69
Q

Classification of hip fractures?

A

Garden Classification for intracapsular
o 1 – non-displaced incomplete fracture
o 2- non-displaced complete fracture
o 3 – partially-displaced complete fracture
o 4 – completely-displaced complete fracture

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70
Q

Management of hip fractures - immediate management?

A

o IV access
o Bloods – FBC, U&Es, glucose and cross-match
o IV fluids if indicated
o IV analgesia plus antiemetic (morphine + metoclopramide/cyclizine)
o ECG for arrhythmias
o CXR consider
o Admit to orthopaedic ward

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71
Q

Management of hip fractures - further management?

A

o Rapid optimisation of fitness for surgery
o Surgery – on day or day after admission
o Encourage mobility and independence when possible
o Physiotherapy if unsteady

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72
Q

Risk factors for hand infections?

A

o DM
o Immunocompromise
o IVDU

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73
Q

Epidemiology of paronychia?

A

o 3x more women

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74
Q

Definition of paronychia?

A

o Inflammation of folds of tissue surrounding nails
o Can develop either suddenly for a few days (acute) or for >6 weeks (chronic)
o Acute paronychia = localized, superficial infection or abscess, causing painful swelling

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75
Q

Causes of paronychia?

A

o S.Aureus
o Streptococcus
o Pseudomonas
o Anaerobic – children finger sucking

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76
Q

Risk factors of paronychia?

A 
o	Manicuring
o	Artificial nail placement
o	Excessive hand washing
o	Chemical irritant
o	Finger sucking or nail biting
o	Ingrown nail
o	Obesity, DM, immunosuppression
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77
Q

Clinical features of acute paronychia?

A

 Pain and swelling at base of fingernail/toenail and nail folds
• Usually one finger, may be history of trauma
 Nail folds – red, tender, swollen and may have pus
 Extension of proximal nail edge (eponychium) and abscess formation
 Floating nail

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78
Q

Clinical features of chronic paronychia?

A

 Affected nail fold is swollen and lifted off nail plate

 Nail plate thickens and is distorted with transverse ridges

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79
Q

Management of acute paronychia - general advice?

A

 Apply moist heat 3-4x a day – alleviate pain, localize infection and hasten draining
 Paracetamol and/or ibuprofen PRN
 Keep area dry and clean
 Avoid biting nails
 If work in moist environment – wear gloves

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80
Q

Management of acute paronychia - treatment of minor infection?

A

 Minor infection

• Topical fusidic acid cream

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81
Q

Management of acute paronychia -treatment of moderate infection?

A

 Moderate infections (no incision and drainage or signs of cellulitis and fever)
• 7-day oral flucloxacillin (clarithromycin)

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82
Q

Management of acute paronychia - treatment of abscess?

A

 If fluctuant pus or abscess – incision and drainage in 1o care or ED

83
Q

Management of acute paronychia -when to take swabs?

A 
	Enlarging or recurrent paronychia
	Inflammation of surrounding tissue
	Not responded to treatment within 2-3 days
	Systemically unwell
	Hx of contact with MRSA
	Immunosuppressed
	Diabetes
84
Q

Management of chronic paronychia?

A

o Avoid irritants and moisture

o Topical clobetasol for 2-3 weeks

85
Q

Complications of paronychia?

A 
o	Septic tenosynovitis
o	Spread to whitlow
o	Nail loss
o	Osteomyelitis
o	Septic arthritis
o	Nail – ridging, discolouration and thickening
86
Q

Definition of felon (staphylococcal whitlow)?

A

o Felon = known as staphylococcal whitlow

o Closed-space infection of distal finger

87
Q

Causes of felon (staphylococcal whitlow)?

A

o S.Aureus (80%)

o Streptococci

88
Q

Risk factors of felon (staphylococcal whitlow)?

A

o Injury to finger tips (BM measurements)
o Untreated acute paronychia
o Immunocompromise

89
Q

Symptoms of felon (staphylococcal whitlow)?

A

o Usually history of penetrating injury or untreated paronychia
o Thumb or index finger
o Initial tight feeling or pricking pain
o Rapid onset of very severe, throbbing pain
o Redness and swelling of entire distal pulp

90
Q

Management of felon (staphylococcal whitlow) -when to admit?

A

o Admit to hospital if sepsis apparent

91
Q

Management of felon (staphylococcal whitlow) -if tense or fluctuant?

A

o Same-day incision and drainage if tense or fluctuant

 1o care or ED

92
Q

Management of felon (staphylococcal whitlow) -if incision and drainage not required?

A

 7-day course of flucloxacillin (erythromycin or clarithromycin)
 Swab if:
• Recurrent, immunosuppressed, not responded to treatment within 2-3 days

93
Q

Management of felon (staphylococcal whitlow) - general advice?

A

 Keep finger elevated
 Apply moist heat 3-4x per day to alleviate pain and hasten drainage
 PRN paracetamol and ibuprofen

94
Q

Complications of felon (staphylococcal whitlow)?

A 
o	Tenosynovitis
o	Tissue necrosis
o	Osteomyelitis
o	Scarring of finger pad
o	Septic arthritis
o	Sepsis
95
Q

Definition of herpetic whitlow?

A

Herpes simplex infection typically appears on distal phalanx of fingers

96
Q

Causes of herpetic whitlow?

A

o HSV- 1 – sucking fingers

o HSV-2 – autoinoculation from genital herpes

97
Q

Risk factors of herpetic whitlow?

A

o Exposure to oral secretions (dentists, GP)
o Presence of herpetic lesions
o Immunocompromise

98
Q

Symptoms of herpetic whitlow?

A

Usually no injury

Current or recent herpes

History of fever or malaise

Previous history

Any part of finger
 Prodromal pain, paraesthesia of affecting finger
 Abrupt onset oedema, redness and localised tenderness of infected finger
 Vesicles with clear fluid
 Pulp soft and not swollen

Systemic – fever, malaise, lymphadenopathy

99
Q

Management of herpetic whitlow?

A 
	PRN paracetamol and ibuprofen
	Avoid touching area
	Ensure clean and dry
o	Aciclovir if within 48 hours of onset of symptoms
o	DO NOT INCISE AND DRAIN
o	Recurrent – prophylactic aciclovir
100
Q

Complications of herpetic whitlow?

A

o Ocular spread
o Scarring of fingers
o Increased sensitivity or numbness
o Lymphangitis

101
Q

Prognosis of herpetic whitlow?

A

o Self-limiting and resolves in 1-3 weeks, can remain dormant in nerve ganglia and be reactivated by stress, illness

102
Q

Definition of tenosynovitis?

A

o Group of diseases involving extrinsic tendons of hand and wrist and retinacular sheaths
o Usually start as tendon irritation and progress into catching and locking when gliding fails

103
Q

Types of tenosynovitis - trigger digit grading?

A

 Grade 1 (pre-trigger) – pain, catching but normal motion on examination
 Grade 2 (active) – catching present on examination, full extention possible
 Grade 3 (passive) – locked digit in flexion or extension, full motion achieved passively
 Grade 4 (contracture) – fixed flexion of PIP joint

104
Q

Types of tenosynovitis - trigger finger grading?

A

 Grade 0 – mild crepitus in non-triggering finger
 Grade 1 – no triggering but uneven movement
 Grade 2 – triggering is actively correctable
 Grade 3 – usually correctable by other hand
 Grade 4 – digit locked

105
Q

Types of tenosynovitis - De Quervain’s disease?

A

 Tendonitis of abductor pollicis longus and extensor pollicis brevis tendons

106
Q

Risk factors of tenosynovitis?

A

o Women 50-60
o Dominant hand
o IDDM

107
Q

Symptoms of tenosynovitis?

A

o Pain increased with motion
o Painful popping sensation with finger extension/flexion (trigger finger)
o Pain, tenderness and swelling of radial side of wrist (de Quervains)

108
Q

Investigations of tenosynovitis?

A

o US

 Effusion, tendon sheath thickening and hyperaemia

109
Q

Management of tenosynovitis?

A

o NSAIDs
o Splinting
o Corticosteroid injections
o Surgery

110
Q

Causes of human bites?

A

o Biting injuries
o Fight bites – clenched fist punches person’s teeth
o Mostly occur on hand

111
Q

Organisms of human bites?

A 
o	Streptococcus
o	S.Aureus
o	Haemophilus
o	Eikenella corrodens
o	Bacteroides
112
Q

Complications of human bites?

A 
o	Tenosynovitis
o	Septic Arthritis
o	Abscess
o	Osteomyelitis
o	Sepsis
113
Q

Management of human bites - determining risk of tetanus?

A

 Significant puncture in contact with soil
 Foreign body
 Compound fracture
 Sepsis

114
Q

Management of human bites - determining risk of blood-bourne infection?

A

 Check status of person bitten – vaccines

 Offer testing for HepB, HepC, HIV

115
Q

Management of human bites - managing wound?

A

 Remove foreign body, encourage wound to bleed, irrigate with warm running water
 PRN paracetamol and ibuprofen
 Refer to ED for wound closure if needed
 Prophylactic antibiotics all bites under 72 hours old + infected bites
• Co-amoxiclav for 7 days (metronidazole + clarithromycin)

116
Q

Management of human bites - when to give tetanus vaccine?

A

Tetanus injection 250IU IM injection or 500IU if >24 hours (tetanus prone wound)

  • If vaccine over 10 years old
  • 5-10 without preschool booster
  • Not received any vaccine (any wound)
117
Q

Causative organisms of dog bites?

A

o S.aureus
o Pasteurella canis
o P.multicida

118
Q

Causative organisms of cat bites?

A

o Pasteurella multocida
o Cat scratch disease
 Caused by Bartonella henselae – mild infection 3-14 days after injury
 Lymphadenopathy, fever, malaise and poor appetite

119
Q

Management of animal bites - determining risk of tetanus?

A

 Significant puncture in contact with soil
 Foreign body
 Compound fracture
 Sepsis

120
Q

Management of animal bites - assessing risk of rabies?

A

 Country bitten and origin of animal (UK no risk)
 Broken skin
 Abnormal behaviour of animal

121
Q

Management of animal bites - management?

A

 Remove foreign body, encourage wound to bleed, irrigate with warm running water
 PRN paracetamol and ibuprofen
 Refer to ED for wound closure if needed
 Prophylactic antibiotics all bites under 72 hours old + infected bites
• Co-amoxiclav for 7 days (metronidazole + doxycycline)

122
Q

Management of animal bites - tetanus injection?

A

 Tetanus injection 250IU IM injection or 500IU if >24 hours (tetanus prone wound)
• If vaccine over 10 years old
• 5-10 without preschool booster
• Not received any vaccine (any wound)

123
Q

Definition of osteomyelitis?

A

o Infection of bone marrow which may spread to bone cortex and periosteum via Haversian canals
o Causes destruction of bone and necrosis
o Dead bone becoming detached from healthy bone = sequestrum

124
Q

Types of osteomyelitis?

A

Haematogenous osteomyelitis
 Infection resulting from blood bacterial seeding from remote source

Direct (contiguous) osteomyelitis
 Direct contact of infected tissue – surgical procedure or trauma

125
Q

Epidemiology of osteomyelitis?

A

o Most common site is distal femur and proximal tibia in children and cancellous bone in adults

126
Q

Causes of osteomyelitis?

A 
o	S.aureus (most common)
o	H.influenzae
o	Streptococcus
o	E.coli
o	Proteus
o	Pseudomonas
127
Q

Risk factors of osteomyelitis?

A 
o	Trauma (surgery, open fracture)
o	Prosthetic orthopaedic device
o	DM
o	PAD
o	Joint disease
o	Alcoholism
o	IVDU
o	Steroid use
o	Immunosuppression
o	HIV/AIDS
o	Sickle Cell Disease
128
Q

Clinical features of osteomyelitis?

A

o Acutely febrile
o Painful, immobile limb
o Swelling, extremely tender, erythematous and warm over area
o Pain exacerbated by movement of effusion of adjacent joints
o Malaise and fatigue

129
Q

Investigations of osteomyelitis?

A 
o	FBC (WCC raised)
o	ESR/CRP raised
o	Blood cultures
o	Culture pus, joint effusion
o	Bone cultures (gold standard for diagnosis)
130
Q

Imaging of osteomyelitis?

A

o MRI – gold standard

o XR film

131
Q

Management of osteomyelitis?

A

o Immobilise leg
o Analgesia
o 6-week flucloxacillin IV with oral switch after 2 weeks
 Add fusidic acid or rifampicin for initial 2 weeks
 Clindamycin if penicillin allergic
 Vancomycin for suspected MRSA
o Surgical Debridement of dead bone

132
Q

Complications of osteomyelitis?

A 
o	Bone abscess
o	Sepsis
o	Fracture
o	Septic arthritis
o	Loosening prosthetic joint
o	Chronic infection
133
Q

Definition of necrotizing faciitis?

A

o Necrotizing infection involving any layer of deep soft tissue compartment (dermis, subcutaneous tissue, fascia or muscle)

134
Q

Classifications of necrotizing faciitis?

A

o Type 1 (polymicrobial) – aerobic and anaerobic bacteria, usually immunocompromised or chronic disease patients
o Type 2 (Group A strep) – Any age and in otherwise well patients
o Type 3 (Gram-negative) – marine organisms Vibrio and aeromonas hydrophila from seawater contamination of wounds, can be fatal
o Type 4 (fungal) – zygomycetes after traumatic wounds, candida in immunocompromised patients

135
Q

Risk factors of necrotizing faciitis?

A 
o	Skin injury
o	Alcohol abuse
o	IVDU
o	CKD/CLD
o	DM
o	Malignancy
o	Immunosuppressed
136
Q

Presentation of necrotizing faciitis?

A

Day 1-2
 Local pain, swelling and erythema (mimics cellulitis but deep so not visible)
• Disproportionately severe pain – compared to physical signs
 Margins of infection poorly defined
 No response to antibiotics
 Malaise, fever, dehydration
 Usually extremities, perineum or trunk

Day 2-4
 Area develops tense oedema, bullae, skin discolouration and grey necrosed skin
 Wooden-hard feel to subcutaneous tissue
 Crepitus due to gas

137
Q

Diagnosis of necrotizing faciitis?

A 
o	Clinical diagnosis – need exploratory surgery
o	FBC (high WCC)
o	U&E
o	CRP (raised)
o	Blood culture
o	Plain XR or CT
138
Q

Management of necrotizing faciitis?

A 
o	Resuscitation and IV fluids
o	Urgent Surgical exploration & debridement
	May need to repeat
o	Antibiotics
	IV broad spectrum antibiotics
139
Q

Life threatening thoracic injuries?

A
  • Airway obstruction
  • Tension pneumothorax
  • Open chest wound
  • Massive haemothorax
  • Flail chest
  • Cardiac tamponade
140
Q

GCS - severity assessment?

A

o 13-15 is minor
o 9-12 is moderate
o 3-8 is severe
o <8 considered a coma

141
Q

GCS score - eye opening?

A

o 4 = Spontaneous
o 3 = To Speech
o 2 = To Pain
o 1 = None

142
Q

GCS score - verbal response?

A 
o	5 = Orientated
o	4 = Confused
o	3 = Inappropriate Words
o	2 = Sounds
o	1 = None
143
Q

GCS score - motor response?

A

o 6 = Obeys Commands
o 5 = Localises to pain
o 4 = Withdraws from pain
o 3 = Abnormal Flexion (decorticate - arms adducted and flexed, wrists and fingers flexed on chest - damage to corticospinal tracts)
o 2 = Abnormal Extension (decerebrate - arms adducted and extended, wrists pronated and fingers flexed - damage to upper brainstem)
o 1 = None

144
Q

ABCDE Management of multi-system trauma - Airway?

A

Assess adequacy:

  • are there signs of obstruction or airway injury?
  • are there injuries which could compromise the airway:

Manage inadequate airway immediately:

  • Improve oxygenation
  • Airway maintenance techniques
  • Definitive airway techniques

Cervical spine protection
o Immobilised when a hard collar, tape and blocks are applied, or when there is manual in-line stabilisation
o Sized using fingers measuring from the top of the patient’s trapezius to the point of the chin
o Used against the sizing posts on the cervical collar which is then adjusted to the correct size (measure from the hard plastic at the bottom to the hole)

145
Q

ABCDE Management of multi-system trauma - breathing and ventilation?

A
  • Optimise oxygenation
  • Needle/ tube thoracocentesis or Pericardiocentesis
  • Resuscitative thoracotomy
  • Consider the need for intubation
146
Q

ABCDE Management of multi-system trauma - circulation - assessment?

A

o Hands (temperature/sweating/capillary refill time)
o End organ perfusion (Conscious levels /urine output)
o Pulse (Rate/quality/regularity)
o Blood pressure (Hypotension* late sign)

147
Q

ABCDE Management of multi-system trauma - circulation - haemorrhagic shock?

A 
	“On the floor and four more”
•	External wounds
•	Chest cavity
•	Abdominal cavity
•	Pelvic Cavity
•	Long-bone fracture
148
Q

ABCDE Management of multi-system trauma - circulation - trauma triad of death?

A

 Major haemorrhage leads to tissue hypoperfusion and decreased O2 delivery (Shock) – decreased heat generation
 Leads to decreased CO, SVR and induce coagulopathy
 Anaerobic respiration leads to lactic acidosis

149
Q

ABCDE Management of multi-system trauma - circulation - management?

A

o Optimise oxygenation
o Splints/ Tourniquet/ Direct pressure for active haemorrhage
o 2x large bore IV access in the antecubital fossae
o Fluid resuscitation
 Crystalloid (warm)
 Blood
o IV Tranexamic acid if haemorrhaging
o Consider activation of the massive transfusion protocol
o Definitive haemostasis

150
Q

ABCDE Management of multi-system trauma - disability - assessment?

A 
-	Assess adequacy
o	are there signs of head injury?
	Facial or scalp bruising or haematoma
	Scalp or facial lacerations
o	Pupils size and reaction
o	Capillary glucose 
o	GCS
151
Q

ABCDE Management of multi-system trauma - disability - management?

A 
-	Manage neuro-disability immediately
o	Optimise oxygenation
o	Maintain cerebral perfusion (Blood pressure>90mmHg)
o	Avoid hypoglycaemia
o	Avoid pyrexia 
o	Definitive imaging and treatment
152
Q

ABCDE Management of multi-system trauma - exposure - spinal injury assessment?

A

 Assess adequacy
• are there signs of spinal injury?
• Diaphragmatic breathing
• Evidence of neurogenic shock
• Responds to pain only above the clavicles
• Priapism
• Flexed posture of upper limbs or flaccid areflexia
• Patient complains of loss of sensation or function
• Spinal tenderness, bruising or swelling on log-roll

153
Q

ABCDE Management of multi-system trauma - exposure - management?

A 
	Optimise oxygenation
	Ensure adequate ventilation
	Maintain spinal cord perfusion (avoid hypotension)
	Maintain immobilisation
	Document thorough spinal cord examination
	Urinary catheterisation and NG tube
	Definitive imaging
	Early specialist advice
154
Q

Management of MSK trauma in multi-system trauma?

A 
	Optimise oxygenation
	Maintain tissue perfusion (avoid hypotension)
	Apply splints (reduce blood loss, pain and improve alignment)
	Analgesia
	IV antibiotics?
	Monitor for complications:
•	Compartment syndrome
•	Skin necrosis
•	Nerve compression
155
Q

Resuscitation phase of multi-system trauma event?

A
  • After ABCDE primary assessment
  • Treatment is continued
  • Practical procedures (oro/nasopharyngeal tube, chest drain, urinary catheter)
  • May need immediate damage control surgery
156
Q

What is secondary survey in multi-system trauma?

A
  • Head to toe examination to identify other injuries – accompanied by other imaging and treatment
157
Q

Treatment principles in trauma - airway control?

A

o Basic manoeuvres to open airway, apply O2

o If still obstructed then may need advanced airways

158
Q

Treatment principles in trauma - oxygen?

A

o High-flow to all patients

o If hypoventilating then may need bag and mask prior to tracheal intubation

159
Q

Treatment principles in trauma - cervical spine control?

A

o Manual immobilisation – hands either side of head and holding steady
o Apply cervical collar, sandbags and adhesive tape to fix cervical spine

160
Q

Treatment principles in trauma - IV fluids?

A

o 2 large bore cannulae into ACF, can go IO
o IV fluids 0.9% saline (or Hartmann’s) 500mL boluses, repeated to 2L
o If >2L, consider urgent blood transfusion and look for sources of bleeding

161
Q

Treatment principles in trauma - analgesia and antibiotics?

A

o IV morphine titrated in small increments to response
o IV cyclizine 50mg given
o Others: regional nerve blocks, splintage, immobilisation)

o Prophylactic IV antibiotics for compound fractures and penetrating injuries to head, chest or abdomen
o Usually broad spectrum – cefuroxime

162
Q

Treatment principles in trauma - tetanus?

A

o Prophylaxis given to most patients

163
Q

Treatment principles in trauma - DIC?

A

 Control primary cause to avoid total depletion

 Expert advice about replacement with platelets, FFP, prothrombin complex concentrate, heparin and blood

164
Q

Investigations to perform in trauma - bloods and vital signs?

A
  • Done in all patients – group and save/cross match, BMG, XR, ABG
  • SpO2
  • Bloods
    o FBC, U&E, glucose on all patients
    o If significant haemorrhage suspected – cross match
    o Clotting screen – haemorrhage or those at risk
    o FFP and platelets for those haemorrhage
  • Urinalysis
    o If suspicion of abdominal injury (microscopic haematuria)
  • ABG
165
Q

Investigations to perform in trauma - imaging?

A
  • XR
    o CXR and pelvis XR as minimum
  • ECG
    o IF >50 or chest trauma
  • CT
    o Used to assess injuries but need to be haemodynamically stable
  • USS FAST scan
    o Focused assessment with sonography from trauma (FAST) used to identify free fluid
    o 4 cavities – Morrison’s pouch (hepatorenal recess), splenorenal recess, Pouch of Douglas (pelvis) and pericardium
166
Q

What is canadian C-spine rule?

A
  • Patient with suspected spine injury should be assessed as having high, low or no risk of C-spine injury
167
Q

High risk criteria in Canadian C-spine rule?

A

 Age >65
 Dangerous mechanism of injury (fall from height over 1m/5 stairs, axial load to head, rollover motor accident, ejection from motor vehicle, horse riding accident)
 Paraesthesia in upper or lower limbs

168
Q

Low risk criteria in Canadian C-spine rule?

A

1 or more

	Minor rear-end motor vehicle collision
	Comfortable sitting
	Ambulatory at any time since injury
	No midline cervical spine tenderness
	Delayed onset neck pain
	Unable to actively rotate neck 45o to left and right
169
Q

No risk criteria in Canadian C-spine rule?

A

 One of low-risk factors

 Able to rotate neck 45o to left and right

170
Q

When to perform imaging in Canadian C-spine rule?

A

 High-risk factor OR

 Low-risk factor and unable to actively rotate neck 45o left and right

171
Q

What imaging to perform in Canadian C-spine rule?

A

 Children (under 16) – MRI

 Adults – CT

172
Q

MAnagement of fracture pre-hospital - long bone fracture of leg?

A

 Traction splint or adjacent leg as splint if above knee

 Vacuum splint if all other long bone fractures

173
Q

MAnagement of fracture pre-hospital - non long bone fracture?

A

 Oral paracetamol for mild pain
 Oral paracetamol and codeine for moderate pain
 IV paracetamol with IV morphine titrated to effect for severe pain

174
Q

MAnagement of fracture pre-hospital - open fracture?

A

o IV morphine
o Prophylactic IV antibiotics within 1 hour
o Transfer to specialist centre or trauma unit ED

175
Q

MAnagement of fracture pre-hospital - high energy pelvic fracture?

A

 IV morphine

 If active bleeding, apply pelvic binder

176
Q

Assessment in fractures?

A
  • Assessing vascular injury in fracture:
    o Signs – palpable pulse, continued blood loss or expanding haematoma
    o Immediate surgical exploration if hard signs persist after restoration of limb alignment and joint reduction
    o If de-vascularised limb in long bone fracture – vascular shunt before vascular reconstruction
    o Neurological function
    o Pulses
177
Q

When to use whole body CT in fractured limb?

A

o If 16 and over with blunt major trauma and suspected multiple injuries
o Use clinical findings to direct CT of limbs

178
Q

What are Ottawa knee rules for XR?

A 
	Age >55
	Isolated tenderness of patella
	Tender at fibular head
	Unable to flex knee to 90o
	Unable to weight bear both immediately and in ED (4 steps, limping okay)
	If 1 or more met, x-ray recommended
179
Q

What are Ottawa ankle rules for XR?

A

 Pain in posterior 6cm tip of lateral/medial malleolus
 Unable to weight-bear both immediately and in ED (unable to take 4 steps)
 Ankle series X-ray if pain in area

180
Q

What are Ottawa foot rules in XR?

A

 Pain in , base of 5th metatarsal or navicular
 Unable to weight-bear both immediately and in ED (unable to take 4 steps)
 Foot series if pain in area

181
Q

Pain relief in patients with a fracture?

A

 Oral paracetamol for mild pain
 Oral paracetamol and codeine for moderate pain
 IV paracetamol with IV morphine titrated to effect for severe pain
 Regional Bier’s block – when reducing dorsally displaced distal radial fracture

182
Q

Further management of fractures - radial - under 16s?

A
  • Surgery within 72 hours of injury for intra-articular fractures and within 7 days of injury for extra-articular
  • Below-elbow plaster cast
183
Q

Further management of fractures - femur - under 16s?

A
  • 0-6 months – Pavlik’s Harness
  • 3-18 months – Gallows traction
  • 1-6 years – straight leg traction with conversion to spica cast
  • 4-11 years – elastic intramedullary nail
  • 11 years or over – elastic intramedullary nails supplemented by end-caps
184
Q

Further management of fractures - tibia - under 16s?

A

• Definitive management within 24 hours if intra-articular distal tibial fractures

185
Q

Further management of fractures - ankle - under 16s?

A 
•	Non-surgical
o	Immediate unrestricted weight-bearing
o	Orthopaedic follow-up within 2 weeks
o	Return for review if symptoms not improving 6 weeks after injury
•	Surgery on day of injury or next day
186
Q

Further management of fractures - ankle - adult?

A
  • Non-surgical if uncomplicated injury

* Surgery – open wound, tenting of skin, vascular injury, fracture dislocation or split humeral head

187
Q

Further management of fractures - radius - adult?

A
  • Surgery within 72 hours of injury for intra-articular fractures and within 7 days of injury for extra-articular
  • Offer K-wire fixation
  • Open reduction and internal fixation if closed reduction not possible
188
Q

Further management of fractures - femur adult?

A

• Immediate unrestricted weight-bearing as tolerate once surgery for distal femoral fracture

189
Q

Further management of fractures - pilon adult?

A

• Definitive management within 24 hours if displaced pilon fractures

190
Q

Further management of fractures - ankle adult?

A 
•	Non-surgical
o	Immediate unrestricted weight-bearing
o	Orthopaedic follow-up within 2 weeks
o	Return for review if symptoms not improving 6 weeks after injury
•	Surgery on day of injury or next day
o	Open reduction and internal fixation
191
Q

Management of calcaneal fracture?

A

o Intra-articular – lateral foot XR, need open reduction and internal fixation
o Extra-articular – Compression dressing, rest, ice and elevation with follow up

192
Q

Management of metatarsal fracture?

A

 Analgesia, backslap plaster cast, K-wire fixation and occasionally open reduction and internal fixation
 Non-displaced fractures and of 2nd to 4th metatarsal can be treated conservatively with weight-bearing cast show for 4-6 weeks

193
Q

Management of toe fracture?

A

o Referral indicated if circulatory compromise, open fractures, soft tissue injury, dislocations
 Reduction and immobilisation
o Stable toe fracture – strap to adjacent toe and rigid-sole shoe

194
Q

Management of ankle fracture?

A

 Reduce fracture if displaced or neurovascular compromise
 Cover with wet, sterile dressing – open fractures
 Elevate limb
 Conservative Management
• Backslab Casting for 4-6 weeks
• Serial XR to ensure reduction, joint congruity and healing (after reduction, 48 hours, 7 days and 2-weekly)
 Operative Treatment
• Open reduction and internal fixation if displaced, talar subluxation, joint incongruent

195
Q

Surgery in neck of femur fracture - depending on locations?

A

Displaced subcapital/intracapsular - hip hemiarthroplasty/total hip replacement (if were able to walk independently outdoors with no more than stick/medically fit & no cognitive impairment)

Non-displaced intracapsular - Cannulated hip screw

Inter-trochanteric & basocervical - Dynamic hip- screw

Sub-trochanteric - Intermedullary femoral nail

196
Q

What is a Pott’s fracture?

A

Bimalleolar ankle fracture

Abduction and external rotation from eversion force (tackle)

Medial deltoid ligaments tears off medial malleolus, talus moves laterally, shearing off lateral malleolus

197
Q

What is Bennett’s Fracture?

A

Fracture to base of 1st MCP, which extends into carpometacarpal joint

198
Q

What is Monteggia’s Fracture?

A

Fracture of proximal 1/3 of ulna, with dislocation of radial head

199
Q

What is Galaezzi’s Fracture?

A

Fracture of distal 1/3 of radius with dislocation of distal radioulnar joint

200
Q

What is a Hill-Sachs lesion?

A

Associated with anterior shoulder dislocation

Head of humerus impacts on anterior edge of glenoid bone

201
Q

What is a fat embolism?

A

Embolic fat pass into small vessels of lungs and other sites

202
Q

Risk factors of fat embolism?

A

Closed fracture of long bone

Orthopaedic procedures - intermedullary nailing, hip or knee replacements

203
Q

Symptoms of fat embolism?

A

Mild headache, confusion

SOB, tachycardia, hypoxia, pyrexia

Petechial rash - upper anterior part of trunk, arms, neck and conjunctiva

Year 5 Core Conditions (55 decks)

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