Traumatic limb/joint pain/deformity

Question 1

basic approach to fractures?

Answer 1

4Rs

• resuscitation (+ analgesia, NV status, Abx)
• reduction (if displaced)
• restriction (immobilisation)
• rehabilitation (early movement, physios and OT)

Question 2

what is reduction and how is it done?

Answer 2

• manipulation (closed reduction, may be done under GA if complex/painful)
• traction
• open reduction (surgery, often for intra-articular)

Question 3

when is restriction needed, and how is it done?

Answer 3

• if fracture may displace again after reduction (unstable fracture)
• if stable but at risk of being knocked
• splint
• sling
• cast
• bracing
• internal fixation
• external fixation
• continuous traction

Question 4

complications of fractures?

Answer 4

immediate:
• bleeding
• NV injury
• muscle damage
• fat embolism (esp long bone injuries)

nerve injury
• neuropraxia (stretched, temporary)
• axonotmesis (Wallerian degeneration, recovers if cause removed)
• neurotmesis (cut, irrepairable)

early
• compartment syndrome
• infection
• bed rest: DVT, pneumonia, UTI, pressure sores

late
• poor union
• avascular necrosis
• pain
• reduced use
• growth impairment in kids

Question 5

patient with femoral fracture presents with SOB, CNS Sx, and petechial rash?

Answer 5

fat embolism
(esp in long bone injuries)

Question 6

what could cause poor union?

Answer 6

• NV injury (vascular)
• infection
• high energy impact
• poor reduction
• PVD, DM
• smoking
• steroids

Question 7

how to Tx major trauma?

Answer 7

• “C” ABC (catastrophic haemorrhage)
• direct pressure/tourniquets, pelvic binders
• fluid resusc 1:1:1 rbcs, platelets, FFP
• tranexamic acid IV
• rapidly reverse anticoag
• surgery +/- IR

Question 8

Ix major trauma?

Answer 8

• immediate CXR
• immediate CT
• surgery for penetrating trauma

Question 9

Sx: patient presents with leg pain out of proportion to appearance, with altered sensation +/- (late) weakness, rhabdomyolysis, vascular compromise?

Ex: swollen, red, warm leg

Answer 9

compartment syndrome

Question 10

what causes compartment syndrome?

Answer 10

bleeding or inflammation within a closed muscle compartment, leading to muscle and nerve ischaemia

mostly following (tibial) fracture

Question 11

Tx compartment syndrome?

Answer 11

• position limb at level of heart and remove any bandaging or cast
• ***surgical fasciotomy