Trauma / Orthopaedics Flashcards
1
Q
Describe the injuries associated with anterior shoulder dislcoation
A
Hills-sachs deformity: on humeral head Bankart lesion: of glenoid labrum with avulsion fracture Greater tuberosity fracture Axillary nerve injury Axillary vessel injury
2
Q
Describe 3 reduction techniques for shoulder dislocation
A
Cunningham: seated, arm adducted and flexed. voluntary scapular retraction, gentle forearm pressure. massage trap/deltoid/bicep.
Spaso: lying flat. flexion of shoulder to 90 deg with straight arm, gentle traction, some external rotation.
Stimson: prone. arm hanging down with weight for 15-20 min. scapular rotation.
3
Q
Describe signs of occult elbow fracture on x-ray
A
Elbow joint effusion: anterior sail sign, any posterior fat pad Radiocapitellar line (AP and lateral) Anterior humeral line: through middle third of capitellum
4
Q
Ossification centres and age of appearance in the elbow joint
A
Capitellum - 1 yr Radial head - 3 yrs I, medial epicondyle - 5 yrs Trochelar - 7 yrs Olecranon - 9 yrs E, lateral epicondyle ** If trochelar present, check medial condyle also present
5
Q
Management of lateral condyle elbow fracture
A
> 2 mm separation needs operative fixation
6
Q
Indications for surgical management with radial head fracture
A
Displacement > 2 mm with mechanical block or complex fracture.
7
Q
Describe a monteggia fracture
A
Proximal ulnar fracture with radial head dislocation
8
Q
Describe a Galleazzi fracture
A
Distal radial fracture with ulnar dislocation / subluxation
9
Q
Indications for reduction of a distal radius / ulnar fracture
A
Visible deformity Loss of volar tilt beyond neutral Loss of > 5 deg radial inclination (normal 20 deg) Intraarticular step > 2 mm Radial shortening > 2-3 mm
10
Q
Factors associated with failure of reduction maintenance in distal radius / ulnar fractures
A
- Intraarticular component
- Shearing fractures (barton - dorsal or volar, or hutchinson - radial styloid)
- Volar displacement - smith type
- Greater amount of displacement / comminution
11
Q
Signs of lunate dislocation on x-ray
A
triangle lunate shape on AP
Lateral x-ray: C shaped lunate
12
Q
Signs of perilunate dislocation on x-ray
A
Dorsal displacement of carpal bones
Lunate articulating with radius
13
Q
Scapholunate dislocation
A
Scapholunate space > 4 mm
Signet ring sign (distal scaphoid appears round due to rotation)
14
Q
Describe the classification of pelvic fractures
A
Young and Resnick
- Lateral compression.
- 1: stable, intact ligaments
- 2: iliac wing #, SI joint and pubic rami #
- -3: associated anterior distruption
- APC
- 1: pubic diastasis < 2.5 cm
- 2: diastasis >2.5 cm, rupture sacral ligaments
- -3: all ligaments disrupted, lateral disconnection of hemi-pelvis
- Vertical sheer
15
Q
Classification of femoral neck fractures
A
Garden classification
1: incomplete, impacted, trabeculae congruous in part
2: undisplaced complete fracture
3: complete fracture, partial displacement
4: total displacement
16
Q
Methods for reduction of hip dislocation
A
Whistler: knee at 90 deg, hip at 45 deg. arm under leg and stabilised on contralateral leg. traction by elevation of arm.
Allis. Supine, counter traction. longtitudinal traction with flexed knee. Internal / external rotation.
Zero position. Abduction 30 deg, external rotation 30 deg. rotatory rocking with gentle traction.
17
Q
Ottowa knee rule
A
x-ray for acute knee injury if any of:
- age > 55
- isolated patella tenderness
- isolated fibula head tenderness
- unable to flex knee to 90 deg
- unable to take 4 steps immediately and in ED
18
Q
classification of tibial plateau fracture
A
Schatzker classification 1-3: lateral tibial plateau - 1: < 4 mm depression - 2: > 4 mm depression - 3: depression only without wedge # 4 - medial tibial plateau 5-6 - both tibial plateaus - 5: wedge fractures - 6: tibial metadiaphyseal fracture
19
Q
Diagnosis of compartment syndrome
A
Clinical
- pain, out of proportion, with passive movement
- paraesthesia
- pallor / pulseless; irreversible
Compartment pressure > 30 mmHg or < 30 mmHg below diastolic
- indicated if uncertain or unreliable patient (ie obtunded)
20
Q
Describe a Maisonneuve fracture
A
Proximal fibular fracture, with medial malleolus / detolid ligament injury (unstable)
21
Q
Ottowa ankle / mid foot rules
A
- Bony tenderness over posterior and inferior aspect of medial malleolus
- bony tenderness over posterior and inferior lateral malleolus
- isolated navicular tenderness
- isolated base of 5th tenderness
- unable to bear weight for 4 steps immediately and in ED
22
Q
Describe the classification of ankle fractures
A
Tibial
- uni, bi and trimaleolar fractures
Fibular = Webber
A: Distal to syndesmosis
B: at level of syndesmosis
C: proximal to syndesmosis
23
Q
Describe findings of a calcaneal fracture on x-ray
A
Bohler angle: cephalad point on tuberosity to highest point on posterior facet, with line from posterior facet to posterior process.
If < 20 deg indicates fracture.
24
Q
Describe the difference between a jones and base of 5th metatarsal avulsion fracture and their management
A
Jones - transverse fracture into articulation between 4th and 5th metatarsal. NWB cast 6-8 weeks if undisplaced, or surgical mx if displaced.
Avulsion - transverse fracture of tip of 5th metatarsal base. WBAT.
Growth plate is oblique.
25
Typical organisms for osteomyelitis
Staph aureus
Streptococcus
Gram Neg (enterobacter)
Newborn: Staph, GAS / GBS
Older child: GAS, strep pneumoniae, kingell, Haemophilus influenza
26
Diagnostic criteria for acute rheumatic fever
Modified Jones Criteria
2 major, or one major and 2 minor
Plus evidence of GAS
Major
- Carditis
- Chorea
- Polyarthritis
- Subcutaneous nodules
- Erythema marginatum
Minor
- Fever
- Polyarthralgia
- ESR or CRP > 30
- Long PR interval on ECG
27
Differential diagnosis of hip pain / limp in pre or primary school aged child
```
Occult fracture (young child)
Transient synovitis
Septic arthritis / osteomyelitis
Perthes
Inflammatory arthritis or bone tumour
```
28
Differential diagnosis of hip pain / limp in preadolescent / adolesecent
```
Septic arthritis / osteomylitis
Perthes
SUFE
Inflammatory arthritis
Bone tumour
```
29
Features suggesting bacterial infection in child with acutely irritable hip
```
NWB
Fever > 38.5
WCC > 12 x 10^9
ESR > 40
CRP > 20
```
30
Describe the trauma team activation criteria
Mechanism: ie MVA > 60 kms/hr, ejection/roll over, fall > 5 m, explosion
Injury: serious injuries to head, chest, abdomen, pelvis, groin or axilla.
Signs: RR < 10 or > 30, SBP < 100, O2 < 90%
Interventions: airway, chest, failure of haemostasis
Other: pregnancy, significant comorbidity
31
Describe the physiological changes in pregnancy affecting trauma care
Airway: oedema, reflux
B: high diaprhagm, tachypneoa, resp alkalosis
C: Blood volume inc by 1.5L, SBP < 20 mmHg in 2nd trimester, LAD, IVC compression
Abdo: displacement of organs, encorgement of spleen, peritoneal stretching, 600 mls/min to uterus
32
Potential pregnancy related complications in trauma
Placental abruption
Uterine abruption
Feto-maternal haemorrhage
33
Describe management of pregnant women with trauma
Negative FAST, minor injuries - CTG, obs RV and DC at 4 hrs.
Negative FAST, complex injuries - admit with CTG and obs review prior to cessation
Positive FAST, no peritoneal signs, haemodynamically stable - CT to determine abdominal injuries
Positive FASt and haemodynamically unstable - urgent OT for laparotomy
34
Describe the canadian head CT rule
```
GCS 13-15 with head trauma
High risk criteria (neurosurgical intervention)
- GCS < 15 at 2 hrs
- Suspected open / depressed skull #
- Vomiting >= 2 episodes
- Signs of base of skull fracture
- Age >= 65
--> sensitivity 99%, specificity 48-77%
```
Medium risk (clinically important brain injury)
- Amnesia > 30 min
- Dangerous mechanism
- -> sensitivity 80-100%
35
Describe the clinical syndrome of uncal herniation
Occurs due to expanding unilateral mass.
Ipsilateral 3rd nerve palsy
- aniscoria, ptosis, impaired eye movement
Ipsilateral peduncle compression
- contralateral upward babinski
- contralateral hemiparesis (or ipsilateral)
Altered consciousness, decerebrate posturing, respiratory and CVS changes
36
Describe the clinical syndrome of transtentorial herniation
Bilateral central compression on brainstem
Decrease consciousness, pinpoint pupils
Bilateral motor weakness
Increased muscle tone, bilateral babinski
midpoint pupils and loss of response
Altered respiratory pattern (yawns), Decorticate posturing
Bilateral decorticate and then spontaneous decerebrate posturing
37
PECARN CT brain rule for children < 2
CT if
High risk (4.4% risk cTBI)
- GCS <= 14, altered mental status
- palpable skull fracture
Intermediate risk (1% risk cTBI)
- Occipital, parietal or temporal haematoma
- LOC > 5 sec
- Severe mechanism
-- ped/cyc vs car, fall >1m, high impact strike
- Not acting normally
--> if multiple, worsening, or age < 3 months then CT. if not, observe in hospital
38
PECARN CT brain rule for children > 2 yrs
```
CT if
High risk (4.3% risk cTBI)
- GCS <= 14 or altered mental status
- signs of base of skull fracture
Intermediate risk (1% risk cTBI)
- LOC
- Vomiting
- Severe mechanism
-- Ped/cyc vs car, fall >2 m, high impact strike
- Severe headache
--> CT if multiple findings or worsening symptoms, otherwise observe in hospital
```
Isolated vomiting (0.2% risk cTBI)
39
General indications for CT brain
```
Signs of base of skull fracture
Focal neurological deficit
GCS < 8 or persistently < 13
Suspected NAI
Delayed seizure (>2 min post impact)
Suspected open or depressed skull fracture
```
40
Describe the Le Forte fractures
Describe midface fractures involving the pterygoid plates
1: horizontal fracture through maxillae and bony nasal septum
2: through posterior maxillary sinuses, infraorbital foramina, lacrimals and ethmoids to bridge of the nose
3: through the superior orbital fissure, ethmoid and nasal bones, sphenoid and frontozygomatic arches.
41
Describe the classification of dental fractures
Ellis classification
1: enamel
2: yellow dentin, painful, occlusive cover
3: pink pulp, painful, early dental RV
42
Zones of neck trauma
1: Cricoid cartilage to sternal notch
2: cricoid cartilage to angle of mandible
3: above angle of mandible to BOS
43
Hard signs of penetrating neck trauma
```
Rapidly expanding or pulsatile haematoma
Massive haemoptysis
Bubbling air
Stridor / hoarseness
Vascular bruit or thrill
Cerebral ischaemia
+/- massive subcut emphysema
```
44
Soft signs of penetrating neck trauma
```
minor haemoptysis
haemtemesis
dysphonia / dysphagia
subcut / mediastinal air
non-expanding haematoma
oropharyngeal bleeding
neurological findings
wound proximity
```
--> if none: near zero risk of significant injury
45
signs of impending airway compromise in neck injury
Expanding neck haematoma
Upper airway haemorrhage / haematoma
Voice changes
Significant subcutaneous emphysema
46
Investigation and management of penetrating neck trauma
Zone 2 & unstable --> OT
Zone 1 & 3 --> imaging
Zone 2 - imaging first if stable
47
Specific issues in managment of spinal trauma
A: aspiration due to passive reflux with LOS tone loss, poor cough
B: diaphragm paralysis
C: bradycardia with pharyngeal stimulation (atropine)
D:
E: poikilothermia, hyperthermia, priapism
Urinary retention
48
Describe flexion and extension teardrop fractures
Both anterior inferior part of vertebrae
Flexion.
- very unstable.
- ALL ruptured, discoligamentous distruption, PLL rupture and posterior distraction with injury to intersinous and ligamentum flavum.
- Anterior cord injury
Extension
- Stable in flexion, unstable extension
- ALL pulled off anterior inferior vertebrae. ligamentum flavum buckles into cord
- Central cord syndrome
49
Describe evaluation for atlanto-occipital dislocation
Basion-axis interval > 10-12 mm
Basion-dens interval > 12 mm
Powers ratio > 1
- basion to posterior arch atlas : anterior arch of atlas- opistion
50
Describe a hangmans fracture
C2 fracture
Hyperextension and abrupt deceleration (distraction)
Bilateral pedicle fracture +/- dislocation
Unstable fracture
51
Describe a jefferson fracture
C2 fracture
Unstable, burst fracture - anterior and posterior arch fractures
Predental widening on lateral film (>2.5-3, child 5mm)
52
Describe anterior cord syndrome
```
Compression of anterior spinal artery
flexion injury
Bilateral motor involvement
Bilateral pain/temp loss
Intact proprioception
```
53
Describe central cord syndrome
Hyperextension injury with buckling of ligamentum flavum into cord
UL > LL, distal > proximal
Bilateral Motor, pain and temperature and proprioceptive loss
54
Describe posterior cord syndrome
Penetrating trauma or posterior arch injury
Loss of ipsilateral proprio/vibr
Intact motor
Intact pain and temperature
55
Cord level tested with basic reflexes
Biceps: C5/6
Tricepts: C7/8
Knee: L2-4
Ankle: S1
56
Describe the nexus C-spine rule
Low risk criteria, sensitivity 99.6%, NPV 99.8%
- normal alertness
- no focal neurological deficit
- not intoxicated
- no painful distracting injury
- no midline tenderness
57
Describe the canadian c-spine rule
```
Sensitivity 99.4%, NPV 100%
High risk = CT
- Age > 65
- Dangerous mechanism (fall >1m, axial load, MVA > 100 km/hr, roll/eject, cyclist)
- paraesthesia
Low risk factor --> ROM assessment
- Rear end MVA
- Sitting in ED
- Ambulatory at any time
- Delayed onset pain
- No midline tenderness
Able to rotate 45 deg L and R --> no CT
```
58
How do you identify physiolocial subluxation of C2/3 in children
Swischucks line
- join spinolaminar line of C1-C3
- C2 should be within 2 mm
59
Indications for thoracotomy
```
Initial drainage of > 20 mls/kg blood
Persistent bleeding > 7 mls/kg/hr
Increasing haemathorax on XR
Hypotension without other cause and with adequate blood replacement
Decompensation after initial response
```
Urgent: Drainage > 1.5L (>15 mls/kg) on insertion or > 200 mls/hr for 3 hrs (1-2 mls/kg/hr).
60
Indications for resuscitative thoracotomy
Penetrating wound with pericardial tamponade
Penetrating trauma with signs of life in previous 10 min
Blunt trauma with clear evidence of tamponade
In ED if no perfusion or unresponsive due to shock
In OT if perfusion present, responsive or improvement with aspiration
61
CXR signs of aortic injury
```
Wide mediastinum
Loss/abnormal aortic knob
Depression of left mainstem bronchus
tracheal/oesphageal deviation to right
Left pleural cap
Left haemothorax
Upper rib fractures
```
62
Indications for immediate laparotomy
Evisceration
Gunshot wound
Stab wound with compromise, peritoneal signs, left diaphragm injury
Frank peritonism
Free gas
Ruptured diaphragm
Haemodynamic instability despite replacement of EBL and other sites controlled.
63
Young and resnick / burgess classification of pelvic trauma
Lateral compression: 1-3, 1: sacral compression, 3: contralateral hemipelvis externally rotated (dissociation)
AP compression. 1-3, 1: symphysis < 2.5cm, 2: > 2.5 cm, 3: complete disruption of hemipelvis.
Vertical sheer.
64
Indications for intubation/ventilation in burns
Airway burns suspected
Severe inhalational lung injury (pulmonary oedema, hypoxia)
Extensive burns (>60-70%)
Full thickness burns to chest (compromise chest wall movement)
65
Factors making a wound “tetanus prone”
```
Compound fracture
Deep penetrating wound
Wounds with foreign bodies
Crush injuries / extensive tissue damage
Contaminated by soil / horse manure
Wound cleaning delayed > 3-6 hrs
```
66
Patients requiring dPTa
Had 3 does of tetanus toxoid, but > 5-10 yrs from last dose with tetanus prone wound
Had 3 doses of tetanus toxoid, but > 10 yrs since last dose with clean/minor wound
Uncertain
< 3 doses of tetanus toxoid
67
Patients requiring tetanus immunoglobulin
Uncertain, or < 3 doses vaccine with tetanus prone wound
| Humoral immune deficiency with tetanus prone wound (ie HIV)
68
Principles of massive transfusion
Early recognition of blood loss
Maintain tissue perfusion and oxygenation by restoring blood volume
Arrest bleeding with early surgical / radiological intervention
Judicious use of blood components to correct coagulopathy
69
Targets/parameters of massive transfusion
```
Temp > 35
PH > 7.2, BE > -6, Lactate < 4
ICa > 1.1 mmol/L
Hb - none
Platelets > 50
PT / APTT < 1.5 x normal
IRN <= 1.5
Fibrinogen > 1.0
```
70
Criteria for activation of MTP
Actual or anticipated use of 4 blood units RBC in 4 hrs AND unstable +/- anticipated ongoing bleeding
Severe thoracic, abdominal, pelvic or multiple long bone fracture
Major obstetric, GI or surgical bleeding
71
Response to platelets < 50 in MTP
1 adult dose platelets
72
Response to INR > 1.5 With MTP
FFP 15 mls/kg
73
Response to Fibrinogen < 1.0 with MTP
Cryoprecipitate 3-4 g
74
Management of warfarin with massive bleeding
Vitamin K 5-10mg IV
Prothrombinex 50 units/kg
OR FFP if ptx not available, 15 mls/kg
