Trauma - Level 1/2 Flashcards
Definition of compartment syndrome?
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
Types of compartment syndrome?
o Acute – trauma, intense exercise
o Chronic – exercise, usually return when activity resumed
Affected sites of compartment syndrome?
o Forearm
o Lower limb
o Gluteal
o Abdominal
Causes of compartment syndrome?
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)
Risk factors for chronic compartment syndrome?
o Athletes
Repetitive activities – running, football, cycling, tennis
Acute symptoms of compartment syndrome?
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
Chronic symptoms of compartment syndrome?
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
Diagnosis of compartment syndrome?
Clinical diagnosis
If clinical uncertainty:
o Intra-compartmental pressure measured:
Wick catheter, needle manometry, infusion techniques, pressure transducers
o If unsure: MRI scan
Management of acute compartment syndrome?
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
Management of chronic compartment syndrome?
o Try to reduce offending activity o Deep massage o PRN NSAIDs o Surgery Decompressive fasciotomy
Complications of compartment syndrome?
- Tissue necrosis
- Muscle necrosis leads to fibrosis and shortening, resulting in ischaemic contracture (Volkmann’s ischaemia contracture)
Anatomy of ankle joint?
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
Common injuries of ankle joint?
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
Symptoms of ankle sprains?
o Often running across uneven ground or sudden change in direction
o Pain immediately
o Weight-bearing
o May get swelling
Signs of ankle sprains?
o Deformity o Swelling or bruising o Effusion o Palpate any tenderness o Assess neurovascular compromise
Ottawa ankle rules for XR?
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
When is ankle XR required of ankle sprains?
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
When is foot XR required of ankle sprains?
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?
Management of ankle sprains - initial management?
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
Management of ankle sprains - if unable to weight bear?
o Crutches
o Review in 2-4 days
o Below-knee cast for 10 days
o Follow-up in outpatients
Management of ankle sprains - if badly torn?
surgical repair needed
Definition of Colle’s Fracture?
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
Definition of Smith’s Fracture?
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
Definition of Barton’s Fracture?
o Intra-articular fracture of distal radius with dislocation of radio-carpal joint
Epidemiology of distal radius fracture?
- ¼ of all fractures seen clinically
- Colle’s accounts for 90% of all distal radial fractures
Aetiology of distal radius fracture?
o Fall on outstretched hand (FOOSH)
Risk factors of distal radius fracture?
o Osteoporosis o Age increasing o Female o Prolonged Steroid o Children 5-15
Symptoms of distal radius fracture?
o Episode of trauma
o Immediate pain +/- deformity and sudden swelling
o Weakness and paraesthesia of hand
Signs of distal radius fracture?
o Dinnerfork deformity
- Check scaphoid, distal sensation and pulses in all cases
- Assess joint above and below
Investigations in Colle’s fracture?
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
Investigations in Smith’s fracture?
AP and lateral X-Ray of wrist – Smith’s Fracture
o Distal fragment impacted
o Tilted to point anteriorly and often displaced anteriorly
Investigations in Barton’s fracture?
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
Investigations if planning surgery in distal radius fracture?
- May need MRI/CT if complex or operative planning
Management of distal radius fractures - initial management?
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
Management of distal radius fractures - MUA?
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
Complications of distal radius fracture?
- Malunion – need corrective osteotomy
- Median nerve compression
- Osteoarthritis
Definition of long bones?
humerus, radius, ulna, femur, tibia, fibula
Characteristics of fractures?
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)
Anatomical classification of fractures?
o Intra-articular – fracture line extends within a joint
o Extra-articular – fracture does not extend into joint
Types of fracture - direction - linear?
parallel to bones long axis
Types of fracture - direction - transverse?
right angles to bone’s long axis
Types of fracture - direction - oblique?
diagonal to bone’s long axis
Types of fracture - direction - spiral?
at least one part of bone has been twisted
Types of fracture - direction - compression/wedge?
usually in vertebrae, front portion of vertebra collapses
Types of fracture - direction - impacted?
bone fragments driven into each other
Types of fracture - direction - avulsion?
fragment of bone is separated from mass
Types of fracture - soft tissue involvement - closed?
overlying skin intact
Types of fracture - soft tissue involvement - open?
wounds that communicate with fracture
Types of fracture - displacement - displaced?
• Translated with sideways displacement, angulated, rotated, shortened
Types of fracture - displacement - non-displaced?
No displacement
Types of fracture - fragment - incomplete?
bone fragments partially joined, crack does not completely transverse width of bone
• Greenstick = soft bone bends and breaks, but not into two pieces
Types of fracture - fragment - complete?
bone fragments separate completely
Types of fracture - fragment - comminuted?
bone broken into several pieces
Neer Classification of proximal humerus fracture?
o 1 – Greater tuberosity
o 2 – Lesser tuberosity
o 3 – Humeral head
o 4 – Humeral shaft
Risk factors for fractures?
o Osteoporosis o Old age o Prolonged steroid use o Female sex o Low BMI o Hx of recent falls o Prior fracture
Symptoms of long bone fractures?
o Severe pain
Mild and gradual onset in stress fractures
o Soft-tissue swelling
o Impaired limb function/Inability to weight bear
o Deformity
Assessment of fractured limb?
- 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
Management of long bone fracture - initial management?
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
Management of long bone fracture - orthopaedic referral?
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
Management of long bone fracture - open fractures?
o Antibiotics - IV co-amoxiclav (or cefuroxime + metronidazole)
o Tetanus toxoid if not completed immunisation or over 5 years since booster
Complications of long bone fractures?
- Compartment syndrome
- Fat embolism
- Haemorrhage
- DVT
- Infection
- Delayed or non-union
Complication of hip fracture?
- Can disrupt blood supply to femoral head and cause avascular necrosis from medial circumflex femoral artery which lies on intracapsular femoral neck
Types of femoral head fracture?
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:
- Inter-trochanteric, which are between the greater trochanter and the lesser trochanter
- Sub-tronchanteric, which are from the lesser trochanter to 5cm distal to this point
Risk factors for hip fracture?
o Elderly
o Osteoporosis
o Osteomalacia
o Falls
Symptoms of hip fractures?
o Usually follow a fall onto hip or bottom
o Pain radiates down towards knee
o Affected leg shortened and externally rotated
Signs of hip fractures?
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
XR findings of hip fractures?
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
Further imaging needed of hip fractures?
- If X-ray negative but suspected hip fracturs, offer MRI
Classification of hip fractures?
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
Management of hip fractures - immediate management?
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
Management of hip fractures - further management?
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
Risk factors for hand infections?
o DM
o Immunocompromise
o IVDU
Epidemiology of paronychia?
o 3x more women
Definition of paronychia?
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
Causes of paronychia?
o S.Aureus
o Streptococcus
o Pseudomonas
o Anaerobic – children finger sucking
Risk factors of paronychia?
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
Clinical features of acute paronychia?
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
Clinical features of chronic paronychia?
Affected nail fold is swollen and lifted off nail plate
Nail plate thickens and is distorted with transverse ridges
Management of acute paronychia - general advice?
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
Management of acute paronychia - treatment of minor infection?
Minor infection
• Topical fusidic acid cream
Management of acute paronychia -treatment of moderate infection?
Moderate infections (no incision and drainage or signs of cellulitis and fever)
• 7-day oral flucloxacillin (clarithromycin)
Management of acute paronychia - treatment of abscess?
If fluctuant pus or abscess – incision and drainage in 1o care or ED
Management of acute paronychia -when to take swabs?
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
Management of chronic paronychia?
o Avoid irritants and moisture
o Topical clobetasol for 2-3 weeks
Complications of paronychia?
o Septic tenosynovitis o Spread to whitlow o Nail loss o Osteomyelitis o Septic arthritis o Nail – ridging, discolouration and thickening
Definition of felon (staphylococcal whitlow)?
o Felon = known as staphylococcal whitlow
o Closed-space infection of distal finger
Causes of felon (staphylococcal whitlow)?
o S.Aureus (80%)
o Streptococci
Risk factors of felon (staphylococcal whitlow)?
o Injury to finger tips (BM measurements)
o Untreated acute paronychia
o Immunocompromise
Symptoms of felon (staphylococcal whitlow)?
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
Management of felon (staphylococcal whitlow) -when to admit?
o Admit to hospital if sepsis apparent
Management of felon (staphylococcal whitlow) -if tense or fluctuant?
o Same-day incision and drainage if tense or fluctuant
1o care or ED
Management of felon (staphylococcal whitlow) -if incision and drainage not required?
7-day course of flucloxacillin (erythromycin or clarithromycin)
Swab if:
• Recurrent, immunosuppressed, not responded to treatment within 2-3 days
Management of felon (staphylococcal whitlow) - general advice?
Keep finger elevated
Apply moist heat 3-4x per day to alleviate pain and hasten drainage
PRN paracetamol and ibuprofen
Complications of felon (staphylococcal whitlow)?
o Tenosynovitis o Tissue necrosis o Osteomyelitis o Scarring of finger pad o Septic arthritis o Sepsis
Definition of herpetic whitlow?
Herpes simplex infection typically appears on distal phalanx of fingers
Causes of herpetic whitlow?
o HSV- 1 – sucking fingers
o HSV-2 – autoinoculation from genital herpes
Risk factors of herpetic whitlow?
o Exposure to oral secretions (dentists, GP)
o Presence of herpetic lesions
o Immunocompromise
Symptoms of herpetic whitlow?
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
Management of herpetic whitlow?
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
Complications of herpetic whitlow?
o Ocular spread
o Scarring of fingers
o Increased sensitivity or numbness
o Lymphangitis
Prognosis of herpetic whitlow?
o Self-limiting and resolves in 1-3 weeks, can remain dormant in nerve ganglia and be reactivated by stress, illness
Definition of tenosynovitis?
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
Types of tenosynovitis - trigger digit grading?
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
Types of tenosynovitis - trigger finger grading?
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
Types of tenosynovitis - De Quervain’s disease?
Tendonitis of abductor pollicis longus and extensor pollicis brevis tendons
Risk factors of tenosynovitis?
o Women 50-60
o Dominant hand
o IDDM
Symptoms of tenosynovitis?
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)
Investigations of tenosynovitis?
o US
Effusion, tendon sheath thickening and hyperaemia
Management of tenosynovitis?
o NSAIDs
o Splinting
o Corticosteroid injections
o Surgery
Causes of human bites?
o Biting injuries
o Fight bites – clenched fist punches person’s teeth
o Mostly occur on hand
Organisms of human bites?
o Streptococcus o S.Aureus o Haemophilus o Eikenella corrodens o Bacteroides
Complications of human bites?
o Tenosynovitis o Septic Arthritis o Abscess o Osteomyelitis o Sepsis
Management of human bites - determining risk of tetanus?
Significant puncture in contact with soil
Foreign body
Compound fracture
Sepsis
Management of human bites - determining risk of blood-bourne infection?
Check status of person bitten – vaccines
Offer testing for HepB, HepC, HIV
Management of human bites - managing wound?
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)
Management of human bites - when to give tetanus vaccine?
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)
Causative organisms of dog bites?
o S.aureus
o Pasteurella canis
o P.multicida
Causative organisms of cat bites?
o Pasteurella multocida
o Cat scratch disease
Caused by Bartonella henselae – mild infection 3-14 days after injury
Lymphadenopathy, fever, malaise and poor appetite
Management of animal bites - determining risk of tetanus?
Significant puncture in contact with soil
Foreign body
Compound fracture
Sepsis
Management of animal bites - assessing risk of rabies?
Country bitten and origin of animal (UK no risk)
Broken skin
Abnormal behaviour of animal
Management of animal bites - management?
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)
Management of animal bites - tetanus injection?
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)
Definition of osteomyelitis?
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
Types of osteomyelitis?
Haematogenous osteomyelitis
Infection resulting from blood bacterial seeding from remote source
Direct (contiguous) osteomyelitis
Direct contact of infected tissue – surgical procedure or trauma
Epidemiology of osteomyelitis?
o Most common site is distal femur and proximal tibia in children and cancellous bone in adults
Causes of osteomyelitis?
o S.aureus (most common) o H.influenzae o Streptococcus o E.coli o Proteus o Pseudomonas
Risk factors of osteomyelitis?
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
Clinical features of osteomyelitis?
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
Investigations of osteomyelitis?
o FBC (WCC raised) o ESR/CRP raised o Blood cultures o Culture pus, joint effusion o Bone cultures (gold standard for diagnosis)
Imaging of osteomyelitis?
o MRI – gold standard
o XR film
Management of osteomyelitis?
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
Complications of osteomyelitis?
o Bone abscess o Sepsis o Fracture o Septic arthritis o Loosening prosthetic joint o Chronic infection
Definition of necrotizing faciitis?
o Necrotizing infection involving any layer of deep soft tissue compartment (dermis, subcutaneous tissue, fascia or muscle)
Classifications of necrotizing faciitis?
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
Risk factors of necrotizing faciitis?
o Skin injury o Alcohol abuse o IVDU o CKD/CLD o DM o Malignancy o Immunosuppressed
Presentation of necrotizing faciitis?
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
Diagnosis of necrotizing faciitis?
o Clinical diagnosis – need exploratory surgery o FBC (high WCC) o U&E o CRP (raised) o Blood culture o Plain XR or CT
Management of necrotizing faciitis?
o Resuscitation and IV fluids o Urgent Surgical exploration & debridement May need to repeat o Antibiotics IV broad spectrum antibiotics
Life threatening thoracic injuries?
- Airway obstruction
- Tension pneumothorax
- Open chest wound
- Massive haemothorax
- Flail chest
- Cardiac tamponade
GCS - severity assessment?
o 13-15 is minor
o 9-12 is moderate
o 3-8 is severe
o <8 considered a coma
GCS score - eye opening?
o 4 = Spontaneous
o 3 = To Speech
o 2 = To Pain
o 1 = None
GCS score - verbal response?
o 5 = Orientated o 4 = Confused o 3 = Inappropriate Words o 2 = Sounds o 1 = None
GCS score - motor response?
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
ABCDE Management of multi-system trauma - Airway?
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)
ABCDE Management of multi-system trauma - breathing and ventilation?
- Optimise oxygenation
- Needle/ tube thoracocentesis or Pericardiocentesis
- Resuscitative thoracotomy
- Consider the need for intubation
ABCDE Management of multi-system trauma - circulation - assessment?
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)
ABCDE Management of multi-system trauma - circulation - haemorrhagic shock?
“On the floor and four more” • External wounds • Chest cavity • Abdominal cavity • Pelvic Cavity • Long-bone fracture
ABCDE Management of multi-system trauma - circulation - trauma triad of death?
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
ABCDE Management of multi-system trauma - circulation - management?
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
ABCDE Management of multi-system trauma - disability - assessment?
- 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
ABCDE Management of multi-system trauma - disability - management?
- 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
ABCDE Management of multi-system trauma - exposure - spinal injury assessment?
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
ABCDE Management of multi-system trauma - exposure - management?
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
Management of MSK trauma in multi-system trauma?
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
Resuscitation phase of multi-system trauma event?
- After ABCDE primary assessment
- Treatment is continued
- Practical procedures (oro/nasopharyngeal tube, chest drain, urinary catheter)
- May need immediate damage control surgery
What is secondary survey in multi-system trauma?
- Head to toe examination to identify other injuries – accompanied by other imaging and treatment
Treatment principles in trauma - airway control?
o Basic manoeuvres to open airway, apply O2
o If still obstructed then may need advanced airways
Treatment principles in trauma - oxygen?
o High-flow to all patients
o If hypoventilating then may need bag and mask prior to tracheal intubation
Treatment principles in trauma - cervical spine control?
o Manual immobilisation – hands either side of head and holding steady
o Apply cervical collar, sandbags and adhesive tape to fix cervical spine
Treatment principles in trauma - IV fluids?
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
Treatment principles in trauma - analgesia and antibiotics?
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
Treatment principles in trauma - tetanus?
o Prophylaxis given to most patients
Treatment principles in trauma - DIC?
Control primary cause to avoid total depletion
Expert advice about replacement with platelets, FFP, prothrombin complex concentrate, heparin and blood
Investigations to perform in trauma - bloods and vital signs?
- 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
Investigations to perform in trauma - imaging?
- 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
What is canadian C-spine rule?
- Patient with suspected spine injury should be assessed as having high, low or no risk of C-spine injury
High risk criteria in Canadian C-spine rule?
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
Low risk criteria in Canadian C-spine rule?
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
No risk criteria in Canadian C-spine rule?
One of low-risk factors
Able to rotate neck 45o to left and right
When to perform imaging in Canadian C-spine rule?
High-risk factor OR
Low-risk factor and unable to actively rotate neck 45o left and right
What imaging to perform in Canadian C-spine rule?
Children (under 16) – MRI
Adults – CT
MAnagement of fracture pre-hospital - long bone fracture of leg?
Traction splint or adjacent leg as splint if above knee
Vacuum splint if all other long bone fractures
MAnagement of fracture pre-hospital - non long bone fracture?
Oral paracetamol for mild pain
Oral paracetamol and codeine for moderate pain
IV paracetamol with IV morphine titrated to effect for severe pain
MAnagement of fracture pre-hospital - open fracture?
o IV morphine
o Prophylactic IV antibiotics within 1 hour
o Transfer to specialist centre or trauma unit ED
MAnagement of fracture pre-hospital - high energy pelvic fracture?
IV morphine
If active bleeding, apply pelvic binder
Assessment in fractures?
- 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
When to use whole body CT in fractured limb?
o If 16 and over with blunt major trauma and suspected multiple injuries
o Use clinical findings to direct CT of limbs
What are Ottawa knee rules for XR?
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
What are Ottawa ankle rules for XR?
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
What are Ottawa foot rules in XR?
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
Pain relief in patients with a fracture?
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
Further management of fractures - radial - under 16s?
- Surgery within 72 hours of injury for intra-articular fractures and within 7 days of injury for extra-articular
- Below-elbow plaster cast
Further management of fractures - femur - under 16s?
- 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
Further management of fractures - tibia - under 16s?
• Definitive management within 24 hours if intra-articular distal tibial fractures
Further management of fractures - ankle - under 16s?
• 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
Further management of fractures - ankle - adult?
- Non-surgical if uncomplicated injury
* Surgery – open wound, tenting of skin, vascular injury, fracture dislocation or split humeral head
Further management of fractures - radius - adult?
- 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
Further management of fractures - femur adult?
• Immediate unrestricted weight-bearing as tolerate once surgery for distal femoral fracture
Further management of fractures - pilon adult?
• Definitive management within 24 hours if displaced pilon fractures
Further management of fractures - ankle adult?
• 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
Management of calcaneal fracture?
o Intra-articular – lateral foot XR, need open reduction and internal fixation
o Extra-articular – Compression dressing, rest, ice and elevation with follow up
Management of metatarsal fracture?
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
Management of toe fracture?
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
Management of ankle fracture?
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
Surgery in neck of femur fracture - depending on locations?
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
What is a Pott’s fracture?
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
What is Bennett’s Fracture?
Fracture to base of 1st MCP, which extends into carpometacarpal joint
What is Monteggia’s Fracture?
Fracture of proximal 1/3 of ulna, with dislocation of radial head
What is Galaezzi’s Fracture?
Fracture of distal 1/3 of radius with dislocation of distal radioulnar joint
What is a Hill-Sachs lesion?
Associated with anterior shoulder dislocation
Head of humerus impacts on anterior edge of glenoid bone
What is a fat embolism?
Embolic fat pass into small vessels of lungs and other sites
Risk factors of fat embolism?
Closed fracture of long bone
Orthopaedic procedures - intermedullary nailing, hip or knee replacements
Symptoms of fat embolism?
Mild headache, confusion
SOB, tachycardia, hypoxia, pyrexia
Petechial rash - upper anterior part of trunk, arms, neck and conjunctiva
