Week 5 - C - General Trauma (1) - Trauma procedure, fracture process and healing

Question 1

With any high energy injuries (eg RTA, fall from height) the priorities are to save life and prevent serious systemic complication ahread of preventing pain and loss of function from fractures or dislocations What is the term where early death can arise and what are the potential causes of this?

Answer 1

The golden hour

Early death within the golden hour after injury from airway compromise, severe head injuries, severe chest injuries, internal organ rupture and fractures associated with substantial blood loss (pevis/femur) can be avoided with rapid resusictation and prompt, approproiate medical and surgical care

Question 2

The principles of ATLS guidelines involve an initial primary survey where a quick assessment of vital functions is made What does ATLS stand for? Following the initial survery, appropriate management is carried out. What follows this?

Answer 2

Advanced trauma life support

Following the initial primary survery and appropriate management, a secondary survey involves a head to toe inspection for other injuries

Question 3

How is the primary survery in advanced trauma life support carried out?

Answer 3

Carried by assessing ABCDE

* Airway management with cervical spine control

* Breathing & ventilation

* Circulation & bleeding control

* Disability (neurological evaluation)

* Exposure & environmental control

Question 4

If a patient is able to speak, what does this tell you about their airways?

Answer 4

They have airway control

Question 5

In all ABCDE examinations, what should be checked for?

Answer 5

Look to make sure airways are patent

Question 6

All major trauma patients should receive high flow Oxygen via a tight fitting mask. Oxygenation is best assessed with pulse oximetry. What is given to patients who have low O2 sats on pulse oximetry in an acute situation?

Answer 6

Non rebreather mask 15l/min high flow oxygen (100%)

Question 7

When assessing breathing, what should you check the trachea for?

Answer 7

Check trachea to make sure the airway is patent

Question 8

How would a tension pneumothorax be treated?

Answer 8

Emergency management involved needle decompression with a large bore needle in the 2nd intercostal space, midclavicular line before a chest drain is inserted

Question 9

An initial assessment of adequacy of circulation and perfusion is performed by assessing the patients pulse rate and volume as well as blood pressure. What is inserted into the patient at this stage and what are all major trauma patients given at this point?

Answer 9

Bilateral large bore peripheral venous access is achieved and all major trauma patients are given 2L of IV cystalloid initially

Question 10

When should the secondary survery be carried out?

Answer 10

The secondary survey should only proceed after the primary survey is completed and the patient is stable.

Any deterioration in the clinical condition requires a return to the start of the primary survey.

Question 11

Polytrauma is where more than one major long bone is injured or where a major fracture is associated with significant chest or abdominal trauma. Early stabilization of major long bone fractures should be performed to optimize the patient’s condition and help prevent what?

Answer 11

Systemic inflammotry response syndrme (SIRS),

Acute Respiratory Distress Syndrome (ARDS),

Multi-Organ Dysfunction Syndrome (MODS)

and death

Question 12

What is the medical term for a break in the bone?

Answer 12

A fracture

Question 13

Very low injury fractures are usually due to an underlying weakness of the bone resulting in a pathologic fracture. Bone can heal through primary or secondary healing, when does it heal through primary healing?

Answer 13

This is where there is a minimal fracture gap (less than 1mm) and osteoblasts formation fills the gap

Question 14

When does primary bone healing occur?

Answer 14

This occurs in hairline fractures and when bones are fixed with compression screws and plates

Question 15

Secondary bone healing: In the majority of fractures, there is a gap at the fracture site which needs to be filled temporarily to act as a scaffold for new bone to be laid down This process occurs in different stages? (explain the stages - fracture then, blood, osteo, blood, chrondro, osteo, calcium remodeland bone)

Answer 15

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Question 16

What is granulation tissue?

Answer 16

This is new connective tissue and microscopic blood vessels formed on the surface of a wound to promoted healing

Question 17

Step 1 of secondary healing is inflammation What occurs here?

Answer 17

Hameatoma occurs with inflammation from damaged tissue

Macrophages and osteoclasts remove debris and resorb bone rend

Question 18

Step 2 of the secondary healing is soft callus formation What occurs here?

Answer 18

Granulation tissue forms from fibroblasts and new blood vessels form

Chondroblasts form cartilage (soft callus)

Question 19

Step 3 is the formation of the hard callus What happens here?

Answer 19

Osteoblasts lay down bone matrix (collagen type 1)– Enchondral ossification

Calcium mineraliation produces immature woven bone

Question 20

Step 4 is the remodelling of the bone What happens here?

Answer 20

In this step

The bone undergoes remodelling where the body replaces old bone with new to make the bone stronger into lamellar bone

Question 21

Run through the stages of secondary bone healing one more time

Answer 21

Fracture - haematoma occurs with inflammation from damaged tissue - macrphages and osteoclasts remove debri and resorb bone ends - granulation tissue forms from fibrolasts and new blood vessels form - chorndroblasts form cartilage (soft callus) - osteoblasts lay down matrix (type 1 collagen) (endochondrial ossification) - calcium mineralization produces immature woven bone (hard callus) - remodelling occurs with organization along lines of stress into lamellar bone

Question 22

Which stage is the soft and hard callus formed?

Answer 22

Soft callus - chondroblasts form cartilage (soft callus) - step 2

Hard callus - calcium mineralization produces immature woven bone - step 3

Question 23

One more time, talk through the stages of secondary healing of bone

Answer 23

fracture - haematoma forms with inflammation of damaged tissue - macrophages and osteoclasts remove debris and resorb bone ends (1)

• granulation tissue forms from fibroblasts and new blood vessels form - chondroblasts form cartilage (soft callus) (2)
• osteoblasts lay down bone matrix (type 1collagen) (endochrondrial ossification) - calcium mineralization forms immature woven bone (hard callus) (3)

Remodelling of bone along stress line to form lamellar bone (4)

Question 24

Soft callus in bone is usually formed by around 2-3 weeks How long does it take for the hard callus to appear?

Answer 24

Hard callus is usually fomed by around 6-12 weeks

Question 25

Lack of blood supply, no movement (internal fixation with fracture gap), too big a fracture gap or tissue trapped in the fracture gap may result in an atrophic non‐union What may severely impair fracture union due to vasospasms?

Answer 25

Smoking

Question 26

So, how does primary healing work?

Answer 26

Works when there is a limited fracture gap (less than 1mm) and the osteoblasts lay down bone to fill it, usually occurs in hairline fracture and fixed compression with screws and plates

Question 27

When is a soft callus usually formed and when is the hard callus usually formed?

Answer 27

Soft callus usually formed by 2-3 weeks

takes around 6-12 weeks for hard callus to form

Question 28

Run through the process of secondary healing

Answer 28

Fracture - haematoma with inflammation from damaged tissues -

macrophages and osteoclasts remove debris and resorb bone ends -

granulation tissue forms from fibroblasts and new blood vessels form -

chondroblasts form cartilage (soft callus) -

osteoblasts lay down matrix (type 1 collagen) (endochondrial ossification) -

calcium mineralization forms immature woven bone (hard callus) -

remodelling occurs with organization along stress lines to form lamellar bone

Question 29

What accounts for most of the organic composition of bone?

Answer 29

Type 1 collagen

Question 30

What condition is it where there is an autosomal dominant causing defect in the maturation and organisation of type 1 collagen?

Answer 30

Osteogenesis imperfecta

Question 31

What is osteogenesis imperfecta known as and what are features of the disease?

Answer 31

It is known as birttle bone disease

Features are blue sclera, hearing loss, multiple childhoof fractures and spinal deformity