Trauma Ortho Flashcards
How do you describe a radiograph?
What images - when and who is it from.
Type of fracture:
- Complete, transverse, oblique, spiral, comminuted.
- Incomplete, bowling, buckle, greenstick.
- Growth plate injuries.
Location - diaphysis, metaphysis, epiphysis.
Displace - angulation, translation, rotation, distracted, impacted.
Joint involvement - intra-articular, extra-articular.
Another fracture - joint above and below especially forearm and ankle.
What does FOOSH mean?
Fallen on outstretched hand.
What is a fight bite?
Punching injury in which the punchee’s tooth causes a laceration in the 5th MCP as the tooth goes into the joint, inoculating the joint with somebody’s oral bacteria.
This is a surgical emergency as it is septic arthritis until diagnosed otherwise.
How are traumatic fractures examined?
Likely pattern of injury based on age and mechanism.
Distracting injuries.
Zone (area) of injury.
Open or closed (open requires quicker treatment due to infection risk).
Skin integrity.
Assess function, neural and vascular status.
Image, plain radiology and/or CT scan and/or MRI.
What does 0NVD mean?
No neurovascular deficit.
- Don’t say this as many patients have very subtle injuries.*
- To say this you need to understand peripheral innervation of upper and lower limbs and examine sensation and motor for each main peripheral nerve.*
- Usually, unless axial spine is involved this is NOT a check on dermatomes.*
What neurovascular exam of the peripheral nerves of the upper limb should be carried out following a traumatic fracture?
Pressing thumb.
Making a fist and extending digits.
Pressing 5th MCP.
What is compartment syndrome?
Results from interstitial pressure increases in closed osseofascial compartments.
Causes microvascular compromise.
Commonly due to abnormalities in the microcapillary or capillary level not arterial.
Should be treated within 6 hours of onset.
Which people have an increased risk of acute compartment syndrome?
Tibia fractures, especially in male 10-35 years.
Forearm fractures.
IVDAs, comatose prolong lie.
Anticoagulation and trivial trauma.
May not involve a fracture.
Burns.
Which is the commonest compartment that can develop acute compartment syndrome?
Anterior compartment (first and second toes become numb).
Deep posterior compartment - second commonest (foot is tingling).
What are the clinical signs of acute compartment syndrome?
Disproportionate pain.
Pain on passive stretch of muscles in involved compartment.
Paraesthesiae.
What is the treatment of acute compartment syndrome?
Immediate release all dressings/cast to skin.
Do not elevate.
Phone senior help.
Theatre.
Emergency fasciotomy and stitch up again 24-48 hours later.
What is a Weber classification?
Classifies where the ankle fracture is in relation to the syndesmosis.
What is the median age of hip fractures currently?
84 years old.
What information do you need from elderly patients with a hip fracture?
Corroborated history from patient and relatives/friends to gather a baseline.
Anticoagulation status.
Medication changes, full medicines reconciliation - must know if their GP has recently made any changes to medications.
Missed injuries.
Cognitive impairment? Delirium on dementia? Just delirium or was it the analgesia in the ambulance?
MDT medicine for the elderly and friends.
How can you tell if a patient has a broken hip if the xray is normal?
Gently rock the patient’s knee from side to side and if they scream in pain, vomit or give any similar indication the hip is broken until otherwise proven.
Urgent MRI required.
What is the best hip replacement currently?
Ceramic on plastic couple bearing with metal stem and cap.
What should you assess in an open wound?
Location, size of the wound.
Nature of wound (incised or laceration).
Degloving?
Capillary refill?
Pulses.
Tendon damage - wiggle things around.
Who can suffer from a neck of femur (proximal femoral) fracture?
Elderly patients (92%).
Females more likely (73%).
Young adults in high energy trauma.
What are the risk factors for proximal femur fractures?
Risk doubles every 10 years after age 50.
Osteoporosis (3x more common in females).
Smoking.
Malnutrition.
Excess alcohol.
Neurological impairment.
Impaired vision.
What is the blood supply to the femoral head?
Intramedullary artery of the shaft of femur.
Medial and lateral circumflex branches of profunda femoris.
Artery of ligamentum teres (deteriorates as you get older).
What are the consequences of an intra-capsular fracture of femur?
Blood supply is disrupted meaning that healing won’t occur and increased risk of avascular necrosis.
Non-union (20%).
Avascular necrosis (6%).
What are the consequences of an extra-capsular fracture of the femur?
There will be a blood supply on both side of the fracture so it is able to heal and may require surgical fixation.
Malunion.
Non-union.
How are intracapsular fractures of the femur classified?
There is the Garden classification but most say whether it is displaced or undisplaced.
What types of extra-capsular fractures of the femur are there?
Basicervical.
Intertrochanteric.
Subtrochanteric.
What history and signs are suggestive of a proximal femoral fracture?
History (fall, pain, unable to weight-bear).
Signs (shortening, external rotation).
What investigations are used in diagnosing proximal femoral fractures?
Xray (Shenton’s line).
MRI.
What is Shenton’s line?
Shenton line is an imaginary curved line drawn along the inferior border of the superior pubic ramus (superior border of the obturator foramen) and along the inferomedial border of the neck of femur. This line should be continuous and smooth.
Interruption of this line indicates either fractured neck of femur or developmental dysplasia of the hip.
What are the principles of management of hip fracture?
Return patient to pre-fracture level of function.
Usually by operation followed by mobilisation.
Early mobilisation is done to avoid complications of recumbency (which can lead to pneumonia, UTIs, DVTs, pressure sores).
What xray views do you do for suspected proximal femur fractures?
AP.
Lateral.
What is the management of proximal femoral fractures if both sides of the fracture are vascular (have a blood supply)?
Fix the fracture with screws, etc.
What is the management of proximal femoral fractures if only one side is vascular (have a blood supply)?
Total hip replacement.
What are the key elements of good care of fragility fractures?
Prompt admission to orthopaedic care.
Rapid comprehensive assessment – medical, surgical and anaesthetic.
Minimal delay to surgery.
Accurate and well-performed surgery.
Prompt mobilisation & prevention of complications.
Early multidisciplinary management rehabilitation.
Early supported discharge.
Secondary prevention including falls and bone health assessments.
What are the current standards required for hip fracture care pathway?
- Be transferred from the ED (emergency dept) to the orthopaedic ward within 4 hours.
- Have the ‘Big Six’ interventions in the ED.
- Receive the ‘Inpatient Bundle of Care’ within 24h.
- Undergo surgery with 36h of admission.
- Not be fasted repeatedly and should be given fluids up to 2 hours before surgery.
- Have a cemented hemiarthroplasty unless otherwise indicated.
- Receive geriatric assessment within 3 days of admission if frail.
- Receive early mobilisation by end of first day after surgery and physiotherapy assessment by end of day 2 after surgery.
- Receive occupational therapy assessment by end of day 3 following admission to ward.
- Receive assessment of bone health prior to leaving acute orthopaedic ward.
- Have recovery optimised by MDT so can be discharged within 30 days of admission.
During the initial admission of a hip fracture what should be done in the emergency department before the patient is admitted to the orthopaedic ward?
Rapid triage through A&E.
rapid X-rays.
Minimise delays in reaching orthopaedic ward (unless indicated to stay for essential interventions).
Avoid long uncomfortable periods on trolleys.
What are the ‘big six’ interventions that should be done before a patient with a hip fracture leaves the emergency department to go to the orthopaedic ward?
Analgesia (especially for xrays).
Early warning score.
Pressure area inspection.
Blood tests.
Fluid therapy.
Delirium screening.
What analgesia is given pre-op for a hip fracture?
Local nerve blocks (into the fascia).
Can last intraoperatively and post-op.
Delivered in A&E.
What is delirium?
Acute confusion.
What is the management of delirium?
Predisposing factors e.g. age, dementia.
Precipitating factors e.g. pain, drugs, constipation.
Propagating factors e.g. change in environment, constipation, infection.
Treat the underlying cause.
Non-pharmacological methods e.g. ensure, same nursing team, use families.
What are the criteria used to identify delirium and what is the tool used?
Confusion assessment method.
Acute change/fluctuating cognitive level.
Inattention.
Altered conscious level or disorganised thinking.
4AT tool helps identify delirium.
What is the inpatient bundle of care that every patient with a hip fracture should receive within the first 24 hours of admission?
Cognitive screening.
Nutritional (MUST) screening.
Pressure area screening.
Falls screening.
How long does it take for pressure ulcers to develop?
They can start to develop within 30 mins of lying on a hard surface e.g. A&E trolley or floor at home.
In which patients are pressure ulcers more likely?
Delays in surgery.
Frail/malnourished patients.
Failure to mobilise early.
Who’s involved in the assessment for a patient with a hip fracture awaiting surgery?
Orthopaedic surgeon (review patient and films and produce an appropriate management plan).
Anaesthetist (suitability for type of anaesthetic; assessment of cardio-respiratory system).
Medical (assess fluid status, comorbidities; start fluids; manage comorbidities; address any acute cause of falls; medication review).
Which patients may not receive a cemented hemiarthroplasty implant as standard?
Patients who had a very high independence level of living before admission.
What are the frailty syndromes?
Falls (e.g. collapse, legs gave way, ‘found lying on the floor’).
Immobility (e.g. sudden change in mobility, ‘gone off legs’, ‘stuck in toilet’).
Delirium (e.g. acute confusion, muddledness, sudden worsening of confusion in someone with previous dementia or know memory loss).
Incontinence (e.g. change in continence).
Susceptibility to side effects of medication (e.g. confusion with codeine, hypotension with antidepressants).
What is the CSHA Clinical Frailty Scale?
A classification of the spectrum of frailty:
- Very fit.
- Well.
- Well, with treated comorbid disease.
- Apparently vulnerable.
- Mildly frail.
- Moderately frail.
- Severely frail.
What is the post-op management of pain in hip fractures?
WHO pain ladder is the recommended treatment post-operatively.
What is the pragmatic appropriate of post-op analgesia following hip fractures in patients identified as frail?
Paracetamol regularly oral of IV.
Codeine starting small dose (15mg) but can be increased.
Morphine as required or regular; oxycodone if confused on morphine (small doses of both).
When should a post-op hip fracture patient be assessed by physiotherapy?
Mobilisation should have begun by the end of the first day after surgery and every patient should have physiotherapy assessment by the end of day 2.
When should a post-op hip fracture patient be assessed by occupational therapy?
Patients with a hip fracture should have an OT assessment by the end of day 3 post-operation.
What is resuscitation?
The process of correcting physiological disorders in an acutely unwell patient.
Why do people undergo cardiorespiratory arrest?
Failure of one of the vital organs due to lack of oxygen.
What is the pathophysiology of cardiac arrest?
Inadequate oxygen delivery to organs leading to organ failure.
Vital organ failure can lead to cardiorespiratory arrest.
What are required for oxygen delivery to organs?
Airway.
Breathing.
Circulation.
What is the approach to treating the acutely unwell patient?
Recognition.
Structured assessment.
Structured correction of the abnormal pathophysiology.
Treat the underlying cause.
What are the clinical indicators of deterioration before hospital cardiac arrest?
Tachypnoea.
Tachycardia.
Hypotension.
Reduced conscious level.
Look for trends in clinical observations.
What is involved in a rapid assessment of a patient with acute illness?
General impression.
Airway assessment.
Breathing assessment.
Circulatory assessment.
Disability (neuro).
Exposure.
What is involved in an airway assessment?
Open or closed.
Is it obstructed (foreign body; swelling, jaw being loose and occluding airway, blood)?
Is action required?
Do you need an adjunct (head lift, chin tilt, oropharyngeal or nasopharyngeal airway)?
Do I need anaesthetic support?
What is involved in an assessment of breathing?
Present or absent? - if absent the bag and mask and start CPR.
Adequate ventilation?
Oxygen source and means of delivering oxygen.
When are the 2 age peaks in which children are more likely to suffer a fracture?
Around age 7.
Around age 13.
What are the Salter-Harris fractures?
Type I - Straight across.
Type II - Above.
Type III - Lower.
Type IV - Through Everything.
Type V - cRush.
What directions can an elbow dislocate?
Posterior.
Anterior.
Medial/lateral (divergent).
What is the mechanism of injury in a pulled elbow causing a radial head dislocation which may be associated with an elbow dislocation?
To test motor function ask a child to make a starfish (ulnar nerve), point (radial nerve), an O (median nerve).
What is the management of interphalangeal joint dislocation?
Closed reduction under digital or metacarpal block.
Open reduction rarely required.
2 weeks in neighbour strapping.
Volar slab in the Edinburgh position if unstable (image shows this).
What is a ring block?
Anaesthetic is injected into the web space of the dorsal and volar aspect of the affected finger.
What is the Q-angle?
Line drawn from ASIS to the midpoint of the patella and a second line is drawn from the tibial tubercle to the midpoint of the patella.
The Q-angle is the angle between these 2 lines.
Can be measured on appropriate xrays.
Why does the patella dislocate laterally instead of medially?
Patella has a tendency to move laterally is the medial retinaculum and medial structures are damaged or lax.
In which directions can the knee dislocate?
Posterior (potential to injury popliteal artery).
Anterior.
Medial, lateral and rotatory.
