Trauma Orthopaedics Flashcards
What are the clinical features of a posteriorly dislocated hip?
and what is a major cause?
And how should it be managed?
Shortened
Adducted
Internally rotated
Passenger in RTC - dashboard pushed up into their femur
Management:
- ABCDE
- Analgesia
- Reduced within 4 hours (risk of AVN)
What is the immediate management of a open fracture?
Examination for other injuries and control bleeding
Reduction if possible + analgesia
IV antibiotics
Photograph wound
Saline soaked gauze and impermeable dressing
*debridement is mainstay but is done in theater
+
*external fixation
What urgent investigation should be done into Knee dislocations?
Angiogram
The injury should be reduced early and embolized to reduce damage to the popliteal artery
How is compartment syndrome diagnosied?
and managment:
Usually made clinically but if patient has reduced GCS then intracompartmental measurement:
5cm away from source.
>40mmHg is diagnostic
Management:
- remove bandages and casts
- neutralise leg
- IV analgesia
- IV fluids (Rhamdo)
- Oxygen therapy
- fasciotomies
- left open for 24 - 48 hours
What is the management of a fracture?
Reduce
- re-aligning the fragments
Retain:
- Immobilise the fragments
- casts, spints, Slings.
Rehabilitate
How should you assess a fracture?
Soft tissue injury
- is there neurovascular injury?
Fracture location
- near organs?
Fracture configuration
- transverse
- spiral
- communicated
- segmental
- oblique
- avulsion
Fracture displacement
- how far apart have the two opposing ends moved?
Fracture stability
Open
Intra-articular?
What are the gradings of an open fracture?
Gustilo grading:
I: <1cm and clean
II: 1-10cm and clean
IIIa: >10cm, soft tissue is okay
IIIb: >10cm, soft tissue damage
IIIc: >all injuries with vascular damage
What is the management of an open fracture?
ABCDE
- reduce if possible
- Broad spectrum antibiotics
- Tetanus shot
- Photograph wound
- Saline gauze packing
*don’t repeatedly examine the wound
Surgical theatre:
- Surgical debridement
- Retainment
- Vascular/ Plastic input
- IIIb = plastics
- IIIc = plastics and vascular
What kind of etiologies can cause a posterior dislocation of the shoulder?
Seizures
electrocution
Name two associated injuries seen with dislocations of the shoulder:
Hill- Sachs defect
- impact injury to the posterior/ superior portion of the humerous
Bankart lesions
- avulsion of the anterior labarum and glenohumoral ligament
What is the management of a shoulder dislocation and Name a method of reducing a shoulder dislocation:
ABCDE
Analgesia
Reduction
- hippocratic method
Surgical if fixation if associated injuries
What is a complex injury that can occur with elbow dislocations?
The terrible triad:
- Lateral collateral ligamental disclocation
- Radial head fracture
- Coronoid fracture of the ulnar
What is Monteggia’s fracture?
Dislocation of the proximal radio-ulnar joint
+
Ulnar fracture
*typically seen fall on outstretched hand with excessive pronation
What is Galeazzi fracture?
Dislocation of the DISTAL radio-ulnar joint
+
Radial fracture
What are the features of a Colle’s fracture?
*extra-articular
Transverse fracture of radius
1inch proximal from radio-carpal joints
Dorsal displacement and angulation
- *dinner fork deformity
- *fall onto outstretched hands
What are the features of Smith’s fracture?
Volar angulation of distal radius
**garden spade deformity
**caused by falling onto palmer inward facing hands or backwards
What are the radiological features that suggest a distal radial fracture?
<11 mm radial height
<2/23 degree radial inclination
> 11 Degrees volar tilt
What the symptoms of a scaphoid fracture and what is the most sensitive diagnostic test for them?
Tenderness/ pain in anatomical snuff box
Swelling
Pain on movement of wrist
Pain on longitudinal compression of thumb
Initial investigation: - x-ray *if negative but clinical suspicion bring back in 10-14days if still negative then: - MRI
*MRI is most sensitive
What are Ottawa ankle rules?
To minimise unnecessary ankle x-rays, a person should only get an x-ray if:
- unable to weight bare more than 4 steps
- pain distal of fibula
- pain distal of tibia
Explain the importance of early reduction in ankle fractures and high those likely to get surgery:
An ankle fracture should be reduced quickly.
- this is because pressure of the bone over the skin can cause necrosis.
- also because blood supply to the foot can be compromised.
Weber Type B and C are likely to need surgery, usually internal fixation with plates.
Weber type A can be placed into boot and weight bare what is bearable
When assessing finger tip injuries - what consideration needs to be taken into account for reattachemnet:
Viability of the tissue
Amount of bone
- without bone the soft tissue won’t do well
Nail loss
>50% loss of nail better to shorten finger
What are the levels of amputation that can occur to the upper limb?
Finger tip
Finger - distal to Flexor digitorum superficialis
Finger - proximal to FDS
- this is because the PIPJ is likely to be damaged making the finger non-functional
Hand
Forearm
Arm
How are finger tip injuries treated:
Dressings only or Trimming of bone and dressings or Terminalisation and primary closure or Transpositional flap
What type of degeneration occurs when there is nerve injury during a laceration?
Wallerian degeneration
What x-rays should be conducted in suspected C-spine injury?
Anterior - posterior
Lateral
Peg
What are the indications for a CT scan following a spinal injury:
High impact
Suspected spinal cord injury
More than 1 column involved
How are cervical injuries managed?
Stable:
- Collar
+
- Analgesia
Unstable:
- HALO jacket
+/-
- Open reduction internal fixation
What is the definition of major trauma?
Any trauma which has the potential to cause long term disability or death
- Injury severity of >15
What is the diagnostic choice for meniscal tears?
MRI
or
Arthroscopy
What classification system is used for intracapsular hip fractures?
Garden Classification:
1:
- non displaced
- incomplete fracture
2:
- Non displaced
- complete fracture
3:
- Partial displaced
- complete fracture
- Displaced
- Complete fracture
What are some differentials for a hip fracture?
Pubis ramus fracture
Femoral fracture
Dislocation
What are the treatment options for a hip fracture:
Intracapsular/displaced/ elderly:
- Hemiarthroplasty
Intracapsular/displaced/young/ active:
- Total hip arthroplasty
Extracapsular/ un-displaced:
- Dynamic hip screws
- Cannulated screws
Subtrochanter fracture
- Intramedullary screws
What are some of the management strategies of high impact pelvic fractures?
Pelvis Binder
- taped around trochanters
- not tightened beyond normal pelvis size
Imaging:
FAST Scan
- assess for free flui
CT scan
Definitive:
- surgical intervention
- Radiological embolization
What are the classification of fractures in paediatrics?
Salter - Harris Classification:
I - Across the physis II - Above III- Below IV - Through V - Crush
What are the findings of a medial meniscus tear?
*occurs in a twisting movement on weight baring
- Pain
- Effusion - usually begins a few hours after injury, not immediately
- Held in flexed position
- Locking of the joint - most common with bucket injury
Name two clinical tests which can be done to identify ACL damage?
Lachmann’s test
Anterior Draw Test
What are the management options for a ankle fracture?
Immediate reduction and fixation via a below the knee black slab should be done.
- this is to prevent necrosis of skin
Conservative management:
- Weber A
- Non displaced
- not open
Weber B:
- internal fixation usually required - depending on mechanism of injury
Open reduction and internal fixation
- Weber C
- Displaced
- complicated fractures
What are the different types of nerve injuries that can occur?
Neuropraxia
- sensory deficits
- damage to myelin sheath usually through compression
Axonotmesis
- sensory and motor deficits
- surgery may be required
- Epineurium and perineurium still intact
Neurotmesis
- Disruption/ severing of nerve
- requires surgery
- complete transection through all layers
List the complications that can occur with fractures:
Compartment syndrome
Infection
Mal-union
Delayed union
Embolisms
- including fat embolisms
What is the lesion that can occur with anterior shoulder dislocation?
Bankart lesion
What internal fixation device can be used for closed reduction and name some properties of it:
K wires
- not as strong as plates or screws
- easily removed
Specifically what nerve allows us to do the “OK” sign with the hands, and when should it be tested? What other sign may be seen with this nerve injury?
Anterior interosseous nerve
- branch of the median nerve
- this is due to weakness of the flexor pollicis longus and flexor digitorum profundus
During a Distal radial fracture (Colles, smiths)
other sign is:
- in ability to flex the index finger and weakness of the middle. this is because the medial aspect of the flexor digitorum profundus is suppled by the ulnar nerve
What nerve supplies the dorsal surface of the 1st web space?
Radial nerve
What nerves do you want to test following a distal radial fracture and how are they tested?
Median
Radial
Ulnar
Median:
- Abduction of thumb
- OK sign
What are the differentials for a scaphoid fracture?
Distal wrist fracture
Bennet’s fracture
De Quervains tenosynovitis
Wrist sprain
How should scaphoid fractures be managed?
Plain x-ray
- even if negative placed in splint
followed up 10-14days later, if still clinical suspicion then MRI should be conducted.
Undisplaced:
- reduction and immobilization
Displaced fractures@
- ORIF with k wire
When should intra-compartment pressure monitoring be conducted in a patient?
Low GSA or unreliable patient
Polytrauma
Inconclusive examination findings
What is not recommended with compartment syndrome?
Anticoagulation
- this can make it worse
Which artery is at risk of injury following an elbow fracture?
Brachial artery
What test can be done to establish if there has been trauma to the joint (arthromy) during an open knee fracture?
Saline solution load test
List some common complications associated with open fractures:
Infection
Osteomyelitis
Neurovascular injury
Compartment syndrome
Name a complication following compartment syndrome of the forearm:
Volkmann’s ischemic contracture
- hand held in a flexed position looking like a claw
How should a high energy pelvis fracture be managed and contrast this to a low energy fracture:
High:
- pelvis binder (place on at scene, around trochanters, as tight as normal anatomy)
- FAST scan
- CT scan
- Surgery
Low:
- mobilization
- analgesia
(usually low isn’t enough to have caused internal damage)
What things should be assessed on an AP ankle x-ray?
Cross-over of the tibia and fibula
Talus separation from mortise - <4mm
Smoothness and dome shape of talus
What is a fracture called when there is ankle dislocation and a fracture at proximal area of fibula?
Maisonneuve fracture
*presents with ankle injury and upper leg pain
What is a fracture that can occur on the 5th metatarsal associated with excessively loading, often seen in young athletes? What is its differential and how is it treated and how does this compare to the differential?
Jone’s fracture
- fracture of the distal aspect of the 5th met
Differential:
- Avulsion fracture
Intramedullary screw, whereas evulsion is rest and boot
What type of LA block can be done to the extremities to allow for reduction?
Bier’s block
- so sedation or analgesia is not needed
What are the types of pelvic fractures and what is the immediate management?
Type A:
- stable
Type B
- Vertical stable
- Horizontally/ rotational unstable
Type C:
- vertically unstable
- Rotational unstable/ horizontally unstable
CABCDE approach
- resuscitate as needed
- pelvic binder
- urine testing for blood (catheter usually done after CT)
- Trauma CT
Surgical intervention
Interventional radiology intervention
- embolism bleeding vessels
What are the indications for surgery of a pelvic fracture and list some long term complications following a pelvic fracture:
Indications:
- major haemorrhage
- Unstable fracture
- Open fractures
- Urological associated injuries
Long term - Complications of a pelvic fracture:
- Urological injury
- VTE
- Long standing pelvic pain
What options are available for pain relief following a hip fracture?
Morphine
Entanox
Facial-iliac block
What is the mortality following a hip fracture?
1 year 30% mortality rate
List some signs that may be seen of a pelvic fracture?
Ecchymosis in the perineum
LLD
Scrotal/ labia haematoma
PV bleeding
PR examination
- palpate the fracture
- PR bleeding
- High riding/ boggy prostate
What are some immediate complications following giving blood during a massive haemorrhage?
Hypothermia
- blood is cooled to 2-6 Celius for storage
Hypocalcaemia
- the citrate in the stored blood
Hypomagnesium
- defects in Ca2+ can lead to changes in Mg2+ levels
