Principals of frac management - REDUCE
ie anatomical alignment of a frac or dislocation. reduction allows for:
- tampon add of bleeding @ frac site
- less traction of surrounding soft tissues so less swelling so less comps
- less traction on traversing nerves so less risk of neuro praxis
- less traction of traversing BVs so restoring blood supply
…
- can be done closed (eg MUA) or open (eg ORIF)
- requires analgesia or conscious sedation
- need 3 ppl - 1 to reduce, 1 to counter traction, 1 to apply cast
Principals of frac management - RESTRICT
ie immobilising a fracture
- done via simple splints or plaster casts
- when applying plaster cast remember: it shouldn’t be circumferential for the first 2 wks (one area just w dressing to allow swelling. if not compartment syndrome risk) & if there is axial instability (frac can rotate along its long axis eg? x2) plaster should cross joint above AND below
clinical requirements:
- can pt wt bear?
- do they need thromboprophylaxis?
- have u safety netted w compartment syndrome sx?
Principals of frac management - REHABILITATE
ie the need for intensive period of PT pts need due to reduced use so stiffness
OPEN FRAC what is it?
direct communication between frac site w the external environment
pelvic fracs are internal open fracs - what is this?
OPEN FRAC pathophysiology?
- “in-to-out” injury = ?
- “out-to-in” injury = ?
OPEN FRAC what are the most common fracs?
tibial, phalangeal, ankle, metacarpal
OPEN FRAC outcomes of an open frac?
- skin = small or major ie needs plastics
- soft tissue = “ “
- neurovascular = nerves and BVs maybe be compressed due to limb deformity, go into arteriospasm, develop & initial dissection or transaction all together
- infection
OPEN FRAC clinical features ?
pt present w: pain, swelling, deformity, overlying wound or punctum
OPEN FRAC OE?
- check for neurovascular status!!!, skin or tissue loss
- assess for any contamination
OPEN FRAC investigations ?
- bloods inc clotting and G&S
- xray
- complex? CT
OPEN FRAC management ?
- resuscitation, stabilisation THEN urgent realignment & splinting of limb
- broad spectrum abx
- tetanus vaccination if not up to date w vaccines
- photograph wound & remove gross debris
definitive management : - debride wound ( immediately when? <12-24hrs when?)
- was out wound with A LOt of saline
- ## skeletal stabilisation
SEPTIC ARTHRITIS what is it?
infection of a joint
SEPTIC ARTHRITIS causative organisms ?
staph aureus, strep spp, gonorrhoea (in which pts?) & salmonella (in which pts?)
SEPTIC ARTHRITIS pathophysiology ?
bacteria will seed to the joint from a bacteraemia (eg ? x4), a direct inoculation or spreading from adjacent osteomyelitis
SEPTIC ARTHRITIS risk factors?
inc age, pre existing joint disease, dam, immunosuppression, ckd, prosthetic joint, IVDU
SEPTIC ARTHRITIS clinical features?
single swollen joint causing severe pain + maybe pyre is
SEPTIC ARTHRITIS OE?
red hot swollen joint
pain on active & passive movements
** often joint is rigid and wont tolerate movement at all
SEPTIC ARTHRITIS differentials?
red hot swollen joint? SEPTIC ARTHRITIS should be the main differential
…
oa, haemarthrosis, gout, ra, reactive arthritis, lyme disease
SEPTIC ARTHRITIS investigations?
- bloods inc fbc, crp, esr, irate
- blood cultures
- joint aspirate before abx
- joint fluid analysis for what? x4?
- imaging: xray(no evidence of disease earlier but then can show capsule & soft tissue swelling, fat pad shift or joint space widening), further imaging is rare
SEPTIC ARTHRITIS management ?
- empirical abx treatment
- infected native joint? wash out (irrigation & debridement )may need to happen multiple times
- prosthetic? maybe washout but probs needs a revision surgery
SEPTIC ARTHRITIS comps?
OA, osteomyelitis
COMPARTMENT SYNDROME what is it?
critical pressure increase within a confined compartmental space
- what are the most common sites affected? x6?
COMPARTMENT SYNDROME pathophysiology ?
typically after high energy trauma, crush injuries or fracs that causes vascular injuries. +tight casts, dvt etc
- fasciae compartments are closed & cant be distended so any XS fluid will inc intra compartmental pressure
- inc pressure? veins compressed. therefore inc hydrostatic pressure in them so MORE fluid moves out of veins down gradient inc pressure even more
- now traversing nerves compressed therefore sensory +/- motor deficit in distal distribution. paraesthesia is common
- lastly, intracompartmental pressure = diastolic BP so arterial inflow compromised so ischaemia (what Ps?)
COMPARTMENT SYNDROME clincial features?
- sx in hours
- severe pain disproportionate to injury, not readily improved w initial measure (eg analgesia, elevation to heart level, splitting cast)
- pain made worse by passively stretching muscle bellies of muscles traversing the affected facial compartment
- paraesthesia
- affected compartment may feel tense but will not be generally swollen (why?)
- isnt spotted? ACUTE LIMB ISCHAEMIA (Ps?)
