Week 5 - G - General Trauma (5) - Open fractures, soft tissue injuries and septic arthritis

Question 1

The skin acts as a vital barrier to bacteria however once breached bacteria (including normal skin bacterial flora) can enter a wound and cause infection. Which type of fracture are more likely to become infected?

Answer 1

Open fractures are more likely to become infected

Question 2

What are the factors that increase the risk of infection in an open fracture?

Answer 2

The higher the energy of injury,

the degree of contamination,

delay in appropriate treatment and

wound closure

Question 3

Initial management in the Accident & Emergency department includes IV broad spectrum antibiotics

What is typically given to cover: Gram positive organisms? Gram negative organsisms? Anaeorbic organisms?

Answer 3

Gram positive organisms - flucloxacillin

Gram negative organisms - gentamicin

Anaerobic organisms - metronidazole - if there is soil contamination

A sterile or antiseptic soaked dressing should be applied to the wound to prevent further contamination before the fracture is splinted.

Question 4

In general, open fractures require fairly prompt surgery (as soon as possible or first on the next day trauma list if during the night)

What does surgical involvement of the open fracture involve?

Answer 4

It involves debridement to remove the dead or contaminated tissue and internal or external fixation

Question 5

Additionally an unstable fracture may produce haematoma and what may this cause?

Answer 5

This acts as a perfect breeding ground for bacteria to cause infection

Question 6

Again, what is the treatment of an open fracture as it may be contaminated?

Answer 6

Open fractures are usually stabilized with internal or external fixation providing an early and thorough debridement is performed.

Question 7

In the case of mangled extremity from extensive bone and soft tissue damage (eg crushing), poorer outcomes occur in higher energy injuries, injuries associated with prolonged ischemia and/or neurological injury, injuries occurring with hypovolaemic shock and increasing age of the patient.

What may be wiser to perform as treatment in a mangled extremity instead of numerous surgeries?

Answer 7

Amputation

Question 8

Any dislocation should be reduced as soon as possible. Is the preffered method of reduction open or closed?

Answer 8

Closed reduction is the preffered method

Question 9

When are closed reductions used in fractures?

Answer 9

If the fracture is minimally displaced and angulated, and is regarded stable - then close reduction and stabilsation/immbolization

Question 10

If there are bony fragements preventing closed reduction of the dislocation or soft tissue entrapment in the bone, what may be required instead of closed reduction?

Answer 10

Open reduction and internal fixation of the dislocatin

Question 11

Ligaments and tendons can be sprained (intra‐substance tearing of some fibres), partially torn or completely ruptured. Muscle tears can also occur with rapid resisted contraction.

What are the 3 gradings of ligament ruptures?

Answer 11

a - Grade 1 - sprain

b - Grade 2 - partial tear

c - Grade 3 - complete tear (rupture)

Question 12

What is the mainstay treatment of soft tissue injuries?

Answer 12

RICE followed by early movement to prevent stiffness

Rest Ice Compression Elevation

Question 13

Some complete ligament ruptures result in joint instability and may need repair, tightening (advancement) or graft reconstruction. WHat are examples of complete tears of tendons that require surgery?

Answer 13

Quadriceps tendon and patellar tendon

Also hip adductor tendn

Question 14

What is septic arthritis and what are the presenting features?

Answer 14

Septic arthritis is the infection of a joint and an important orthopaedic diagnosis.

It presents as an acute onset of severely painful red, hot, swollen and tender joint with severe pain on any movement

Question 15

In most cases, how does the offending pathogens spread to the affected joint in septic arthritis?

Answer 15

In most cases, the offending pathogens spread to the joint via the blood or from an infection of adjacent tissues

Question 16

What are different risk factors for septic arthritis?

Answer 16

Similar to osteomyeleitis

* Pre-existing joint disease eg RA

* Young

* Elderly

* PWIDs/IVDUs

* Recent joint surgery

* Immunocompromised

Question 17

Although septic arthritis is relatively uncommon in adults, such is the importance of early detection and intervention that it should be excluded with any unexplained acute monoarthritis Bacterial infections are commonly found to cause septic arthritis

What can these infections cause to the joint?

Answer 17

These infections can irreversibly damagae hyaline articular cartilage within days and therefore septic arthritis is considered an emergency to try to avoid chronic arthritic damage.

Question 18

What are the common bacteria that are found to cause septic arthritis? * most common cause * second most common cause * common cause in sexually active people * common in elderly, IV drug users and immunocompromised

Answer 18

* Staphylococcys aureus is the most common cause in adults

* Streptococci is the second most common cause

* Neisseria gonorrhoea is a common cause in sexuallya ctive peoplle

* Escherichia coli is a common cause in elderly, IV drug users and immunocompromised

Question 19

What investigation should any joint suspected of septic arthritis undergo? Should you give antibiotics before diagnosis?

Answer 19

Any joint suspected of septic arthritis should be aspirated for synovial fluid microscopy and culture under aseptic technique

* before antibiotics are given to confirm the diagnosis and to identify the causative organism such that appropriate antibiotic therapy can be targeted at the responsible bacteria. -

* single antibiotic dose can lead to a falsely negative gram stain and culture

Question 20

What from the aspirate would indicate septic arthritis as the picture?

Answer 20

If frank pus is aspirated,

the clinical picture fits with obvious septic arthritis or

a positive Gram stain is found,

Question 21

What is the treatment of septic arthritis? What is the empirical antibiotic given once aspirates have been taken for synovial fluid microscopy and culture?

Answer 21

Treatment is usually surgical washout via open surgery or using arthroscopic techniques

Empirical intravenous antibioitc therapy is then commenced - usually IV flucloxacillin is started

Question 22

What is response to the treatment of septic arthritis based on?

Answer 22

Response to treatment is based on clinical findings and serial CRP.