Trauma of the musculoskeletal system

Question 1

What comprises the primary survey in advanced trauma life support?

Answer 1

1. Airway and C-spinal control
2. Breathing and ventilation
3. Circulation and haematologic control
4. Disability and AVPU
5. Exposure and environmental control

Question 2

What comprises the secondary survey in advanced trauma life support?

Answer 2

1. Head-to-toe examination
2. Detailed history
3. x-rays, blood tests

Question 3

What is the possible blood loss within first 2 hours when these bones experience haemorrhage:

1. tibia/fibula
2. femur
3. pelvis

Answer 3

1. ~500 mL
2. ~500mL
3. ~2000mL

Question 4

What is the most common source of bleeding when there is haemorrhaging as a result of a pelvic fracture?

Answer 4

85% of haemorrhages affect posterior pelvic venous plexus and bleeding from cancellous bone surfaces
10% from arterial bleeding

Question 5

How is a pelvic fracture stabilised? What is the result if it is not fixed properly? What is the mortality rate from pelvic fractures?

Answer 5

External fixation left for 8 weeks (if possible)
Malunion if not dealt with properly
10-20% mortality

Question 6

What soft tissue injuries can occur in:

1. skin
2. muscle
3. blood vessels
4. nerves
5. ligaments

Answer 6

1. open fractures; degloving; ischaemic necrosis
2. crush and compartment syndrome
3. vasospasm + arterial laceration
4. neurapraxia; axonotmesis; neurotmesis
5. joint instability; dislocation

Question 7

What is neurapraxia?

Answer 7

Nerve injury where there is no axonal discontinuity

Question 8

What is axonotmesis?

Answer 8

Nerve injury where there is axon disruption, but the endoneural sheath is still intact

Question 9

What is neurotmesis?

Answer 9

Nerve injury where the axon is disrupted, there is loss of tubules and support cells are destroyed

Question 10

When is traction used in fracture reduction?

Answer 10

When fractures/dislocations require slow reduction

Question 11

When would open reduction of a fracture be used? What are the risks/disadvantages?

Answer 11

When very accurate (anatomic) reduction is required
usually done when internal fixation is needed
risk of infection
can slow healing if it is too rigid

Question 12

How may a reduction be held in place? (semi-rigid/rigid?)

Answer 12

Semi-rigid: plaster

Rigid: internal fixation

Question 13

What are the absolute indications for operative treatment of a fracture?

Answer 13

1. displaced intra-articular fractures
2. open fractures
3. fractures with vascular injury or compartment syndrome (pathological fractures, non-unions)

Question 14

What are the relative indications for operative treatment of a fracture?

Answer 14

1. loss of position with closed method
2. poor functional result with non-anatomical reduction
3. displaced fracture with poor blood supply

Question 15

What is the radiographic definition of fracture union?

Answer 15

When 3 out of 4 cortices have healed on 2 views

• may seen bridging callus formation
• the fracture line is still often present
• might see lucency as a result of remodelling

Question 16

Compare the fracture healing times of the upper and lower limb between adults and children.

Answer 16

Upper limb

• Adults: 6-8 weeks
• Children: 3-4 weeks

Lower limb

• Adults: 12-16 weeks
• Children: 6-8 weeks

Question 17

What are the general complications of musculoskeletal trauma + healing?

Answer 17

Early:

• other injuries
• PE
• fat embolism syndrome/ acute respiratory distress syndrome

Late:

• chest infection
• UTI
• bed sores

Question 18

What are the complications of bone trauma + healing?

Answer 18

Early:
- infection

Late:

• non-union
• mal-union
• AVN

Question 19

What are the complications of soft tissue trauma + healing?

Answer 19

Early:

• plaster sores
• wound infection
• neurovascular injury
• compartment syndrome

Late:

• tendon rupture
• nerve compression
• volkmann contracture

Question 20

What is fat embolism syndrome? What organs are most affected?

Answer 20

This is when a fat embolus is released into circulation, usually after physical trauma
- fat may enter for mechanical and biomechanical reasons and basically it just comes down to fat being released from bone marrow into the VENOUS system

*important to emphasise that it is the venous system that is affected, as the lungs are always affect by FES, followed by the brain

Question 21

What is the clinical triad indicating FES?

Answer 21

1. hypoxaemia
2. neurological issues (agitation, delirium, coma)
3. petechial rash

Can also have haematological problems such as low platelets and anaemia

Question 22

How should FES be treated?

Answer 22

oxygen
hydration (maintain intravascular volume)
albumin (may decrease fatty acids by binding them)

Question 23

What are the 6 Ps of the musculoskeletal assessment?

Answer 23

1. Pallor
2. Pain
3. Pulseless
4. Paraesthesias
5. Paralysis
6. Polar

Question 24

What is the normal pressure within tissues?

Answer 24

0-10 mmHg

Question 25

At what pressure will capillary blood flow in a compartment become compromised?

Answer 25

> 20 mmHg

Question 26

At what pressure will muscles and nerve fibres within a compartment become at risk to ischaemic necrosis?

Answer 26

30-40 mmHg

Question 27

What is delta pressure? (i.e. what is it, what is the value)

Answer 27

Diastolic blood pressure - intracompartment pressure = delta pressure
Normal value >30 mmHg
if <30 mmHg this indicates need for fasciotomy

Question 28

If the delta pressure of a compartment is <20mmHg, what should be done?

Answer 28

Delta pressure of <20mmHg is a DEFINITIVE indication for fasciotomy

Question 29

What are the other indications for fasciotomy (apart from delta pressure)?

Answer 29

• clinical signs of acute compartment syndrome
• absolute pressure is >30 mmHg and clinical picture is consistent with compartment syndrome
• arterial perfusion has been interrupted for 4+ hours