Trauma Orthopaedics Flashcards by John Darlington

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)

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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

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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

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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

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What is the management of a fracture?

Reduce
- re-aligning the fragments

Retain:

Immobilise the fragments
casts, spints, Slings.

Rehabilitate

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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?

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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

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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

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What kind of etiologies can cause a posterior dislocation of the shoulder?

Seizures

electrocution

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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

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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

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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

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What is Monteggia’s fracture?

Dislocation of the proximal radio-ulnar joint
+
Ulnar fracture

*typically seen fall on outstretched hand with excessive pronation

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What is Galeazzi fracture?

Dislocation of the DISTAL radio-ulnar joint
+
Radial fracture

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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

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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

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What are the radiological features that suggest a distal radial fracture?

<11 mm radial height

<2/23 degree radial inclination

> 11 Degrees volar tilt

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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

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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

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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

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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

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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

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How are finger tip injuries treated:

Dressings only 
or
Trimming of bone and dressings 
or
Terminalisation and primary closure 
or 
Transpositional flap

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What type of degeneration occurs when there is nerve injury during a laceration?

Wallerian degeneration

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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 4. - 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