Trauma surgery Flashcards
OVERVIEW
i) what % of deaths happen in mins, hours, day-weeks and give a cause for each?
ii) what is the golden hour?
iii) what are the first two things that need to be done when a trauma patient presents?
i) mins = 50% (sp cord, severe brain injury, great vessel lesion)
hours = 30% (airway, blood loss, thoracic trauma, liver/spleen injury, pelvic fractures)
days-weeks = 20% (sepsis, multi organ failure)
ii) time following a traumatic injurt when prompt medical treatment has the highest likelihood to prevent death
iii) primary survey and resuscitation of vital functions
PRIMARY TRAUMA SURVEY
i) what must ultimately be protected in A?
ii) what is assessed in B? (5)
iii) what is assessed in C? (3)
iv) what is assessed in D? (3)
i) C spine protection
ii) resp rate, chest movement, air entry, o2 sats, adequate oxygen/ventilation
iii) level of conc, skin colour and temp, pulse rate and character
iv) GCS, pupils BM
CONSIDERATIONS
i) name four leading pulmonary injuries
ii) what needs to be assessed at the extremities? (4)
iii) name five things about neurologic brain and spine that need to be asssessed
i) rib frac/flail segment, pulmonary contusion, simple pneumothorax, tension pneumothorax, haemothorax
ii) contusion, deformity, pain, perfusion, periph neurovasc status, xrays
iii) GCS, pupil size/reaction, lateralising signs (onset of epileptic seizures), motor and sensory exam, reflexes
HAEMATOMA
i) which artery is implicated in an epidural haematoma?
ii) which vessels are implicated in subdural haematoma?
i) middle meningeal artery
ii) bridging veins
FRACTURE MANAGEMENT
i) what should first be done if it is a high energy injury? what three step process is then followed for fractures?
ii) what is reduction? who should perform it? what does it allow for (3) what does it try to correct? which type of fractures are usually reduced?
iii) what does the hold phase involve? what needs to be considered? what two things may be used to hold the fracture? what must be done if there is a plaster cast?
iv) what is axial instability? what needs to be done for these fractures? what two other questions needs to be asked?
v) what do most patients need post fracture? what advise should be given? what may be needed for frail patients?
i) REDUCE, HOLD, REHABILITATE
- if high energy injury > resus following ATLS
ii) Reduce - by orthopaedic specialist
* restore the anatomical alignment of frac/disloc of deformed limb
* allows for tamponade of bleeeding, reduction in traction on surrounding tissues (and swelling), reduc in traction on surrounding nerves (and neurpraxia), reduced pressure on blood vessels (restoring blood supp)
* correct the deforming forces from the injury
* usually reduced closed but some can be done open/intraop
* painful > needs analgesia (regional or local)
* may do short period of concious sedation
* manoeuvre requires two people and third to apply plaster
iii) Hold
* Immobilise the fracture
* consider whethr traction is needed (muscle pull across fracture site is strong and fracture is unstable) eg fem shaft, acetabular, pelvic
* simpl splint or plaster cast
* plaster cast > not circumferential for first two weeks and must have space for fracture to swell > if not = risk of compartment synd
iv) axial instab (can rotate aalong long axis eg tib fib) > needs to cover joint above and below (most fracs only need distal joint covered)
* can the pt weight bear? do they need thromboprophylaxis?
v) Rehabilitate - most patients need intense periods of physio
* advise to move non immobilised unaffected joints from outset
* fractures occ in frailty and make pt unable to weight bear > ability to cope at home
* home adaptations
PATELLA FRACTURES
i) which age group are they most prevalent in? do they occ more in men or women? what are they usually caused by? what type of bone is the patella? what is found on its posterior surface?
ii) what may be seen following injury? name two mechs of injury? name two other symptoms? how may the knee look OE?
iii) what main imaging is done? which three views? what is skyline view not possible in patella fracture? what is the classification used?
iv) which two fracture types can be conservatively managed? what mech needs to be functional for cons mx? what can be done for cons mx?
v) when is surgery implicated? (2) what is the aim? (2) what is the most common surgical approach? what does this do for the patella?
vi) what may be done if simple vertical or transverse fracture? when may a pallectomy be done? name two complications of pat frac?
i) most prevalent in 20-50yrs (x2 common in males)
* usually occ as result of direct trauma to the patella but can also be due to rapid eccentric contraction of quads
* patella = large sesamoid bone formed within quad tendon > att to patella ligament inferior
* post surface - medial and lateral facets > artic with femoral condyles
ii) * anterior knee pain following injury eg hard blow to the patella (RTA) or strong contract of quads
* pain made worse with movement and may not be able to weight bear
* pt unable to straight leg raise due to damage to the extensor mechnaism
* OE - knee swollen and bruised
iii) mainstay is plan film radiograph - three views = antero-post, lateral and skyline (cant do in pat frac as req knee flexion to 30 degrees - cant do)
* can do CT if comminuted fracture
* AO foundation classification > extra articular/avulsion fracture, partial articular fracture, complete articular fracture
iv) Conservative if non displaced or minimally displaced patella
- if vertical fracture if extensor mechanism remains functional
- place pt in brace or cylinder cast and ensure early weight bearing in extension > then increase flexion incrementally
v) Surgery indicated if significant displac or compromise to the extensor mechanism
* aim is to obtain anatomical reduction, adequate fixation and resoration of extensor mech
* open reduc and int fixation (ORIF) with tension band wiring is most common > convert tensile force applied to the patella via ext mech into a compression force to assist with fracture reduc and healing
vi) screw fixation with no wires if simple certicle or TV fracture with healthy cancellous bone
* if ORIF isnt possible > can do partial or totally pallectomy
- complications - loss of range of motion is primary complication
* secondary OA at patellofemoral joint
TIBIAL SHAFT FRACTURE
i) which three areas can the tibia be fractured in? what type of injury is the shaft vulnerable to? what syndrome is it associated with higher risk of? why?
ii) name four symptoms? what may be seen OE? what exam must also be done? what should be suspicious if pain out of proportion to injury or worse on passive stretch?
iii) what should be done for a pt that present with major trauma? what imaging should be done? when may a CT be done?
iv) what should be done to treat ASAP? does it req exact anatomical reduction? what can be used to control rotation? name a way to mitigate compartment syndrome? what can be done for non sx management?
v) name three indications for urgent surgery? what is the most common method of fixing? when can pts weight bear post op? what may a prox/distal/extending to joint end require?
vi) what should be done for assoc fib fractures? name four complications of tib shaft fracture?
i) one of most common long bones to be fractured > can be frac prox, distally or along its shaft
* shaft is vulnerable to both direct injury from all or from direct blow and indirect injury from twisting or bending
* lack of signif soft tissue envelope > risk of open fracture and compartment syndrome are greated
ii) history of trauma
* severe pain in lower leg and inability to weight bear
* OE - clear deformaty and signif swelling/bruising
* carefully inspect the skin to look for poss of open fracture
* full neurovasc exam for concurrent vascular/peripheral nerve damage
* high risk of CS so any pain out of proportion to injury/worse on passive stretch > suspicious
iii) f pt presents with major trauma > ATLS and urgent bloods - co ag and G&S
* full AP and lateral plain film radiograph of tib and fib (inc knee and ankle)
* CT in case of intra articular extension
* suspect spiral fracture of distal tibial > CT to asses fracture of post malleolus
* may also be assoc fib fracture (often due to high energy mech)
iv) realign tib soon as possible (in A&E under sedation or analgesia)
* doesn’t require exact anatomical reduction but bring to approx length and rotation
* do above knee backslab (plaster slab) to control rotation
* elevate limb immed and closely monitor for CS
* post manip radiograph should be done as well as neurovasc status of limb reassess
* non surgical mx with a sarmiento cast for closed stable tibial fractures
v) Surgery > urgent if acute CS, ischaemic limb or open fracture
* intramedullary nailing is most common method of fixing > stable construct with minimal invasive approach > high sucess rate
* post op patients can usually fully weight bear immed
* prox/distal/extend to joint fracture may require ORIF with locking plates
* multiple injuries > temp internal fixation if not stable enough for definitive sx
vi) assoc fib fractures can be left alone as they heal well once tib has been stablised
complications -
* compartment syndrome
* ischaemic limb
* open fracture
* malunion (healed in wrong position) if fractures not operated on
TIBIAL PLATEAU FRACTURE
i) when does it most commonly occur? what causes it? when can it also less commonly occur? what type of deforming fource is seen? which side is more likely to fracture? what does it often occur alongside? what happens if there is significant injury?
ii) why is mechanism of injury important? name three symptoms? what may be seen OE? why does neurovasc status need to be checked?
iii) what imaging is done? when is CT done? what classification is used?
iv) which type of fractures can be managed conservatively? how are these treated? when may surgery be done? (3)
v) what is the main surgical appraoch taken? what is fitted post op? how long until patient can weight bear? name a complication
i) most common following high energy trauma such as fall from height or RTA
* occ due to impaction of femoral condyle on tibial plateau
* less commonly occ in elderly following a fall (osteoporosis)
* varus derforming force - lateral tib plat is more freq fractured tan medial side
* often occ alongside other bony and soft tissue injury eg meniscal tear/cruciate/collat lig injury
* signif injury > rapid degen change in the knee
ii) mech of injury is important as injury through axial loading or high impact injurt > inc likelyhood of tib plat frac
* sudden onset pain, unable to weight bear and swelling
* OE - signif swelling alongside temderness on medial or lat aspect of prox tibia
* may get ligament instability
* check periph neurovasc status as injuries like popliteal vessel dissec/common fib nerve damage may be assoc with high grade injury
iii) plain film radiograph (AP and lateral) > features are often subtle
* CT in almost all cases apart from undisplaced fractures
* Schatzker classication
iv) Conservative
* if uncomplicated tib plat fractures (no evidence of ligamentous damage, subluxation or articular step <2mm)
* tx with hinged knee brace for 8-12 weeks alongside physio and analgesia
Surgical
* if complicated fracture, open fracture or CS
* any form of medial tib plat frac even if undisplaced as they are more likely to displace
v) ORIF is mainstay > aim to restore joint surface congruence and stability
* post op - hinged knee brace fitted with early passive range of movement but non weight bear for 8-12weeks
complication - post traumatic OA
NECK OF FEMUR FRACTURE
i) what can they be caused by? (2) where is the neck of femur located? which parts are intracapsular and which are extracapsular?
ii) how does the blood supply flow? which artery supplies it? what happens if blood supply is disrupted? what therefore needs to be done?
iii) what is the leading symptom? name three places may may be felt? how will the leg appear on exam? (2) name another symptom? are distal NV deficits common or rare?
iv) what imaging is usually done? what shoul dbe done if suspicious of pathol fracture? name three other investigations that may be done?
i) caused by low energy injury such as fall in frail pt or high energy eg RTA, fall from height
* NOF = anywhere from subcapital region to femoral head to 5cm distal to lesser troch
* intracapsular = from fem head to femoral neck prox to trochanters
* extra capsular > inter and sub trochanteric
* inter troch - between breater and lesser troch
* sub troch - from lesser troch to 5cm distal
ii) blood supply is retrograde - distal to proximal along fem neck to fem head via medial circumflex femoral artery which lies on the tra capsular fem neck
* if blood supply is disrupted (intracapsular) then head will undergo avasc necrosis > need to replace head > joint replacement rather than fixation
iii) eading symptom is trauma (low energy) followed by pain and inability to weight bear
* pain in groin, thigh or knee in elderly
* OE - leg is shortened and ext rotated due to pull of short ext rotators
* pain on pin rolling the leg and axial loading
* distal neurovasc deficits are rare but do full neurovasc exam
iv) plain film radiograph (AP) and lateral of affected hip and AP pelvis
* full length femoral radioraph if suspic of a pathol fracture
* basic bloods - FBC, UE, coag screen, G&S, if fall do CK
* urine dip, CXR, ECG
NECK OF FEMUR FRACTURE TX
i) what is initially done to stabilise the patient? name two types of analgesia that can be given? what is definitive mx?
ii) what needs to be done if blood supply is compromised? what is involved in total hip arthroplasty?
iii) what is done in subcapital (intracapsular) fracture? what is done for inter trochanteric/basocervical fracture?
iv) what is done for sub trochanteric fracture? what is needed early after surgery?
v) name three post op complications? name three later complications?
i) A-E approach to stabilise patient
* adequate analgesia - opioid or regional (fascia ilial block)
* definitive mx is surgical - dep on type of fracture
ii) if bs compromised > replace femoral head (hemiartho replac femoral head and bone but not acetabulum)
* total hip arthroplasty - remove fem head and acetabulum
iii) displaced subcapital - hip hemi arthro (replace fem head and neck fixed to prox femur)
* inter troch and basocervival > dynamic hipp screw
* non displace intra cap - cinnulated hip screws (three parallel screws in inverted triangle formation)
iv) sub troch - anterigrade intramedull fem nail (titanium rod placed through femus for stab)
* conversative managment is rarely considered
* post op - need early rehab through physio and OTs
v) Post op
* pain, bleeding, leg length discrep, neurovasc damage
long term
* joint disloc, aseptic loosening, periprosthetic fracture, deep infection
FEMORAL SHAFT FRACTURE
i) name four common causes? what is the femur supplied by? what can happen if it is fractured?
ii) name four symptoms? will deformity be obious? what position is the proximal fragment pulled into? (2) by which muscles? (3) what other exam should be done?
iii) what classificaiton is used? what imaging is done routine? what is done if polytrauma?
iv) what approach is taken to stabilise pt? which two methods of pain relief can be done? name three things that need to be done for open fractures? what need to be done immediately? (2) what does this allow?
v) what can be done if patient isnt suitable for surgery? what time period should sx be done it? what are most pt treated with surgically? what do bilateral fractures increase risk of? (2)
vi) name five complications? which nerve is most likely to be damaged?
i) common in high energy trauma, fragility fracture, pathol fracture, bisphos related frac
* supplied by branches of profunda femoris > large vol of blood can extravasate if fractured
ii) pain or swelling in thigh
* hip, knee pain and unable to weight bear
* deformity will usually be obvious from end of the bed
* prox frag is pulled into flexion and ext rotation (by illipsoas/glut med/min)
* full NV exam of lower limbs to check for vasc or periph nerve injury
iii) winquist and hansen classification
* follow major trauma ATLS protocol
* routine bloods - coag and group and save
* if pathol - do calcium etc
* plain film radiograph (AP and lateral of entire femur inc hip and knee)
* may do CT if polytrauma
iv) A-E assess > stabilise and fluid resus
* pain relief > opioids/ regional block
* open frac need abx prophylax, tetanus and medical photography
* immed reduc and immob > reduce to near antomic alignment in lne traction to allow haematoma formation and reduce pain
v) most need surgery but may do long leg cast for undisplac frac if pt not suited to sx
* surgically fix in 24-48hrs
* most can be treated with antegrade intramedullary nail
* external fixation prior to definitive fixation
* need early mobilisation to reduce complications
* if bilateral > increased rates of pulm complications/inc mortality tates
vi) nerve of vasc injury (pudendal injury)
* mal union, delayed union or non union
* infection (open frac)
* fat embolism
* VTE
* long term - hip flexor/knee extensor weakness
OLECRANON BURSITIS
i) what is it? why is this area prone to inflam? what can cause it? name three less common causes?
ii) name two symptoms? what can be seen initially? what can this progress to? is range of motion affected? why?
iii) what bloods should be done (3) what is plain film radiograph used for? what gives a definitive diagnosis?
iv) what does treatment depend on? what analgesia should be given? what can be done if swelling is large? what is done if there are systemic symptioms and infection?
v) what can be done for prolonged/untreatable cases? name two complications?
i) inflammatory pathology of the elbow
* prone to inflam due to superficial position and vulnerability to pressure and trauma
* usually dev due to repetitive flexion extension movement > irritates brusa
* less common causes = gout and RA
* less common = bursa can become infection through skin abrasion or puncture (s aureus)
ii) pain and swelling over olecranon
* may be small swelling initially then increase in size/discomfort/erythema
* range of motion usually preserved as joint capsulse not involved (min discomfort in extreme movement) (septic arth causes pain with any movement)
iii) routine bloods - FBC and CRP
* serum urate levels for gout, look for rheum causes
* plain film radiograph wont confirm but can rule out bony injury
* defintive dx = fluid aspiration > send for microscopy and culture (look for infection and presence of crystals) > can also provide symptomatic relief for some patients
iv) dep on whether there is an infection
* swellings without infection > tx with analgesia (NSAID) and rest
* may splint elbow for short period of time
* if swelling is large > high levels of discomfort > washout in theatre
* systemic symp and infection > IV abx and surgical drainage
v) *septic arthritis
* osteomyelitis
COMPARTMENT SYNDROME
i) what is it defined as? name four commonly affected areas? what does it occur after? name three other causes?
ii) why does it happen in fascial compartments? what happens to cause CS in relation to compartments, veins, nerves? at what pressure will arterial flow be compromised? how will limb appear if this happens?
iii) how quickly do symptoms usually present? how long after the insult may they present? what is key feature? what is pain made worse by? what symptom is common? how may it feel compared to contralateral side? what can happen if symptoms are missed?
iv) how is a dx made? what test is used if there is clinical uncertainty? what blood marker may be elevated?
v) what is essential in CS? (2) name three things that may be done in initial mx? what pain relief is given? what surgical procedure is done? what happens after this? function of which organ should be close monitored? why? (2)
i) defined as critical pressure increase within confined compartmental space
* any fascial compartment can be affected - most common sides are leg, thigh, forearm, foot, hands and buttock
* occ following high energy trauma crush injuries or fractures that cause vasc injury
* can also be caused by iatrogenic vasc injury, tight cast or splint, DVT and post reperfusion swelling
ii) fascial comparts are closed and cant be distended > any fluid that is depos will cause an increase in intracompartmental pressure
* inc in pressure > veins compressed > increases hydrostatic pressure > fluid moves down gradient and out veins into the compart > further inc pressure
* then traversing nerves are compressed > causes sensory and or motor deficit in the distal disb (paraesthesia is common symptom)
* if intra compartmental pressure reaches BP then arterial inflow will be compromised > ischaemia = cool pale pulsness distal limb (late sign)
iii) symptoms present within hours > can dev up to 48hrs post insult
* severe pain dispropotionate to injury not improbed with analgesia, elevation to heart level and splitting in a tight cast)
* pain made worse by passively stretching muscle bellies of muscles traversing the compart
* distal paraesthesia is common
* compart may feel tense comapred to contralat side but wont be swollen as compart is only minimally distenable
* if symptoms are missed > acute arterial insufficiency (5Ps) > pain, pallor, perishingly cold, paralysis, pulseness
iv) clinical dx based on symptoms and RFs
* high degree of clinical suspic in post op patients
* most reliable dx test > intra compartmental pressure monitor > use when clinically uncertain
* CK may be elevated
v) need early recog and immed surgical treatment (urgent fasciotomy)
* initial mx - keep limb at neutral level to pt, improve oxygen delivery with high flow oxygen, fluid bolus to keep BP
* remove all dressing, splint, casts down to the skin (don’t leave any dressing circumferentially)
* treat with opioid analgestics
* surgery = fasciotomy > leave skin incisions open and re look in 24-48hrs to assess for dead tissue that may need to be debrided
* monitor renal function closely due to effects of rhabdomyolysis or reperfusion injury
