1
Q
When someone has been involved in a high energy trauma, what would your immediate management/primary survey be?
A
ATLS (advanced trauma life support) *Basically A to E with a few added extras:
- Airway + C spine
- Breathing
- Circulation + haemorrhage control
- Disability
- Exposure
2
Q
Following your primary survery (ATLS) of a pt involved in major trauma, what would be included in your secondary survey?
A
- History: AMPLE
- Head to toe physical examination
- Continue to assess vital signs
- Specialist diagnostic tests
3
Q
What framework can you use to structure your history in an emergency situation to ensure you get the information you need?
A
+ symptoms & signs
4
Q
What are the 3 principles of fracture management in orthopaedics?
A
- Reduce
- Hold
- Rehabilitate
5
Q
Reduction means restoring the anatomical alignment of a fracture or dislocation. State 5 benefits of reduction/why reduction is important
A
- Tamponade of bleeding at fracture site
- Reducing in traction on surrounding tissues which in turn reduces swelling
- Reduction in traction on traversing nerves reducing risk of neuropraxia
- Reduction of pressures on traversing blood vessels restoring any affected blood supply
- Pain control
6
Q
There are numerous methods of reduction, however what is the key principle in any reduction?
A
- To correct the deforming forces
- Some clinicians may suggest an initial exageratioin of the fracture before the definitive reduction manouevre as this can help to uncouple the proximal and distal fracture segments
7
Q
Fracture reduction can be ______ or _______
A
- Open: involves making incision in skin
- Closed: no incision in skin
8
Q
Reduction is painful therefore you must provide pt with…?
A
Analegisa (e.g. regional or local blockade if available) or conscious sedation (e.g. entonox or penthrox)
9
Q
How many people does it generally require to reduce a fracture or dislocation?
A
Usually three:
- One to perform reduction manoeuvre
- One to provide counter traction
- One to apply plaster
10
Q
Holding a fracture means immbolising the fracture. There are lots of options availabe for holding a fracture; state some
A
- Splints or plaster casts/back slabs
- External fixators
- Internal fixation
- Plates & screws
- IM nail
- Solid
- Flexible
11
Q
When initially deciding how to hold/immobilise a fracture it is important to consider whether traction is also needed:
- What is traction?
- When might traction be needed?
A
- Traction: technique for realigning a broken bone or dislocated part of the body using weights, pulleys, and ropes to gently apply pressure and pull the bone or injured body part back into position
- May be needed when muscular pull across fracture site is strong rendering fracture unstable:
- Subtrochanteric #NOF
- Displaced acetabular fractures
- Pelvic fractures
12
Q
Why is a plaster cast not circumferential for the first 2 weeks?
A
To allow forfracture swelling and reduce risk of compartment syndrome
13
Q
When there is axial instability (fracture is able to rotate along its long axis e.g. combined radius & ulna metaphyseal fractures) how must you apply the plaster?
A
- Axial instability: must cross joint above & below to prevent limb rotating on it’s long axis
- For most other fractures plaster only needs to cross joint immediately distal to it
14
Q
Discuss 3 considerations you must be aware of regarding fracture immobilisation
A
- Can the pt weight bear? Ensure pt knows.
- Do they need thromboprophylaxis? If immobilised in cast & cannot weight bear it’s common to provide thromboprophylaxis.
- Have you provided advice about compartment syndrome?
15
Q
What is involved in the rehabilitate section of fracture management?
A
- Most pts have intense physiotherapy
- Occupational therapists may be involved if pt unable to weight bear and doesn’t have adequete support at home
*NOTE: pts should be encouraged to move non-immbolised joints from the start!
16
Q
What is meant by an open fracture?
A
There is a direct communication between the fracture site and external environment. This is most commonly through the skin however some fractures e.g. pelvic fractures may be internallly open (having penetrated into the vagina or rectum)
17
Q
Fractures may become open via:
- In to out injury
- Out ot in injury
… explain the difference
A
- In to out: bone penetrates skin from beneath
- Out to in: high energy injury penetrates skin
18
Q
What are the most common open freactures?
A
- Tibial
- Phalangeal
- Forearm
- Ankle
- Metacarpal
19
Q
State some key factors which can influence the outcome of an open fracture
A
- Skin: how much tissue loss there is; do plastics need to be invovled?
- Soft tissues: any muscle, tendon, ligament loss which requires reconstruction. Is reconstruction possible?
- Neurovascular injury: nerves & vessels may be compressed due to limb deformity, go into ateriorspasm, develop intimal dissections or be transected
- Infection: high rate of infection following open fracture due to direct contamination, reduced vascularity and need for insertion of metal work/surgical intervention
20
Q
What do you need to ensure you assess on examination of someone with open fracture?
A
- Neurovascular status
- Overlying skin for tissue loss
- Any evidence of contamination
- Identify if plastic surgery input will be required (doing this early allows both to be present at first operation to avoid multiple procedures)
21
Q
What classification can be used to classify open fractures?
Describe this classification
A
NOTE: type 1 must be clean, type 2 can be clean-moderate contamination
22
Q
What investigations will be required for open fractures?
A
- Urgent routine bloods (do this in ATLS): FBC, U&Es, Clotting, crossmatch or group & save
- Plain film radiograph of affected area(s)
- Consider CT (if complex)
23
Q
Discuss the immediate management of open fractures
A
- ATLS
- Analgesia if required
- Re-align limb (ensure reassess neurovascular status after)
- Remove gross debris from wound
- Photograph wound (various stages e.g. first presentation, before debridement and at other key stages of management)
- Dress with saline soaked sterile gauze and cover with occlusive film. *Mini washouts prior to theatre are NOT indicated
- Splint limb (and repeat neurovascular examination)
- Broad spectrum IV antibiotics ASAP (ideally within an hour)
- Tetanus vaccination (if pt not fully up to date)
- Arrange investigations e.g. plain film radiograph
24
Q
Discuss the definitive management of open fractures
A
- Surgical debridement of wound to remove all devitalised tissue
- Wash wound with copious volumes of saline
- Ensure definitive skeletal stabilisation using internal fixation
- Ensure plastics are involved if soft tissue coverage required
- Ensure vascular surgeons involved if vascular compromise
25
Debridement is required for all open fractures however the time frame in which it needs to happen varies. State the time frame for debridement in following sitations:
* Contaminated wounds (e.g. with agricultural, aquatic or sewage) or if there is associated vascular compromise
* Solitary high energy open fracture
* Low energy open fracture
* Contaminated wounds (e.g. with agricultural, aquatic or sewage) or if there is associated vascular compromise= **immediately**
* Solitary high energy open fracture**= within 12hrs**
* Low energy open fracture**= within 24hrs**
26
What broad spectrum abx may be used in open fractures?
* **Co-amoxiclav** (1.2g, 8 hourly)
* **Cefuroxime** (1.5g, 8 hourly. Ok if mild penicllin allergy)
* **Clindamycin** (600mg, if penicillin anaphylaxis)
27
What is compartment syndrome?
Critical increase in pressure within a confined compartmental space. This pressure can decrease blood flow which prevetns blood from reaching nerve and muscle cells.
28
Discuss the pathophysiology of compartment syndrome
Fascial compartments are closed and cannot be distended; hence, any fluid deposition in compartments will lead to increase in intra-compartmental pressure
* As pressure increases **veins are compressed**
* Increases hydrostatic pressure in veins causing **fluid to move out of veins**, into the compartment, down pressure gradient
* This **further increases intra-compartmental pressure**
* **Traversing nerves are then compressed** resutling in sensory +/- motor deficit
* Lastly, when **intra-compartmental pressure reaches disatolic BP arterial inflow will be compromised leading to ischaemia** (THIS IS A LATE SIGN OF MISSED COMPARTMENT SYNDROME)
29
State some causes of compartment syndrome
* High energy trauma
* Crush injuries
* Fractures that cause vascular injury
* Iatrogenic vascular injury
* Tight casts or splints
* DVT
* Post-reperfusion swelling
30
State some clinical features of compartment syndrome
* Tends to develop in hours but can be up to 48hs post insult
* Severe pain disproportionate to injury
* Pain worsened by passively stretching the muscle bellies of muscles in affected compartment
* Distal parasthesia
* Affected compartment feels tense- but not generaly swollen
* If compartment syndrome missed then will develop 6 p's of ischaemia
31
What investigations may be done if you suspect compartment syndrome?
Mostly a **clinical diagnosis** therefore don't delay treatment if clinical certainty. If uncertain can do:
* Intra-compartmental pressure monitor
* Creatine kinase level may aid diagnosis if elevated or trending upwards
32
Discuss the management of compartment syndrome, consider:
* Initial management pre definitive management
* Definitive management
_Initial_
* Early recognition
* Notify orthopaedics
* Keep limb at neutral level
* High flow oxgyen (to improve O2 delivery to limb)
* Increase BP by giving IV crystalloid fluids
* Remove all dressings/splints/casts down to skin
* Analgesia (usually opiod IV)
_Defintive_
* Urgent fasciotomies
* Skin incisions left open
* Surgeons re-look 24-48hrs later to assess for dead tissue which needs debriding
* Wouds can be closed (but fascia is often left open)
* Monitor renal function closely (due to rhabdomyolysis & reperfusion injury)
33
What is osteomyelitis?
Infection of bone & bone marrow
34
Which bones are most commonly affected by osteomyelitis in:
* Adults
* Children
* Adults: spine, hip
* Children: long bones
35
Osteomyelitis is usually acute and bacterial in origin; although it can be chronic and can rarely be caused by fungi. State 3 ways in which osteomyelitis can occur/how infection got there
* **Haematogenous spread**
* **Direct inoculation** of micro-organisms into the bone (such as following an open fracture or penetrating injury)
* **Dire****ct spread from nearby infection** (such as a contiguous joint)
36
State the most common causative organisms for osteomyelitis
* **S.aureus**
* H.Influenza
* Enterobacteur spp.
* P.aeruginosa (especially in IV drug users)
* Salmonella spp. (especially in sickle cell pts)
37
Discuss the pathophysiology of osteomyelitis
* Bacteria enter bone tissue and express adhesins to bind to bone tissue and produce ECM
* This allows pathogens to spread further into tissue
* In **chronic cases, devascularisation** of affected bone occurs resulting in subsequent **necrosis and resorption of surrounding bone**
* Leads to a 'floating' piece of dead bone called a **sequestrum**
* Sequestrum acts as **reservoir for infection** as it is not penetrated by abx as it is avascular
* **Involucrum can also form following sequestrum formation**; region becomes encased in thick sheath of periosteal bone
38
State some risk factors for osteomyelitis
* Open fractures
* Orthopaedic operations, particularly with prosthetic joints
* Diabetes, particularly with diabetic foot ulcers
* Peripheral arterial disease
* IV drug use
* Immunosuppression
39
Describe clinical features of osteomyelitis
* Severe pain *(or no pain if peripheral neuropathy as in diabetic pts)*
* Low grade pyrexia
* Tender on plapation
* Swelling
* Erythema
* +/- unable to weight bear
* Potential source of infection
The presentation of osteomyelitis can be quite non-specific, with generalised symptoms of infection such as fever, lethargy, nausea and muscle aches.
40
What investigations are required for osteomyelitis?
* **Blood tests:**
* FBC
* CRP
* ESR
* Blood cultures
* **Bone cultures**
* **Plain film radiographs** *(BUT have poor accuracy for osteomyelitis. Only show signs 7-10 days following initial infection)*
* **MRI = GOLD STANDARD**
41
What might you see on an x-ray if there is osteomyeltis?
* Osteopenia
* Periosteal thickening/reaction
* Focal cortical bone loss
* Endosteal scalloping
42
Discuss the management of osteomyelitis
* Long term IV abx (\>4 weeks)
* Empirical e.g. flucloxacillin
* Then tailor to blood culture
* Surgery may be required if deterioration or progressive bone destruction
* E.g. surgical debridement
* If prosthetic joint may need complete replacement of prosthesis
43
State some potential complications of acute osteomyelitis
* Sepsis
* Growth distrubances in children due to premature physeal closure
* Recurrence
* Chronic ostemomyelitis
44
For chronic osteomyelitis, discuss:
* Presentaion
* Investigation results
* Management
_Presentation_
* Localised ongoing bone pain
* Non-specific infection symptoms e.g. fever, malaise
* Draining sinus tract
* Difficulties in mobility
_Investigation results_
* Normal inflammatory markers
* Negative blood cultures (positive cultures from any sinus tracts are often contaminants)
_Managment_
* Bone and soft tissue debridement
* Long term abx therapy (\>3 months)
* Staged reconstruction
* Prolonged rehabilitation
* OR amputation could be considered
45
For Potts disease, discuss:
* What it is
* Presentation
* Gold standard investigation
* Management
* **Infection of vertebral body and intervertebral disc** by **Mycobacterium Tuberculosis;** usually in thoraco-lumbar region
* Present with:
* Back pain
* +/- neurological features
* Low grade fever
* Non-specific infective symptoms
* Gold standard= MRI
* Prolonged course of anti-TB medication +/- surgery to abscess drainage
46
State some common causative organisms of septic arthritis
* **S.aureus**
* **Streptococcus spp.**
* **Gonorrhoea**
* **Salmonella spp**. (sickle cell)
47
Remind yourself what investigations should be sent for sepic athritis
* **Joint aspiration** (prior to abx) and senf for gram stain, leucocyte count, polarising microscopy & fluuid culture
* Bloods:
* **FBC**
* **CRP**
* **ESR**
* **Urate**
* **Blood cultures**
* **X-ray**
* ? MRI or CT to assess extension
48
Discuss the management of septic arthritis; include any differences for naive or prosthetic joints
* ALL= antibiotics- initially empirical
* Initially IV (2 weeks)
* Oral (further 2-4 weeks)
Native and prosthetic joints are managed differently:
* Native joints:
* Surgical irrigation & debridement (washout)= GOLD STANDARD- may be required multiple times
* Prosthetic joints:
* Washout may be done but revision surgery is typically needed
49
State some potential causes of an acutely swollen joint
* Septic arthritis
* Gout
* Pseudoout
* RA
* Spondyloarthropatheis
* Traumatic haemathrosis
50
Define degenerative joint disease
Clinical synrome of joint pain acommpanied by functional limitation & reduced quality of life
51
What scoring systems can be used to evaluate hip & knee OA?
Oxford hip score
Oxford knee score
52
For each of the cardinal signs of OA on x-ray state whey they happen
* Decrease joint space: loss of hyalien cartilage
* Osteophytes: bone tries to increase distribution of weight by forming more bone
* Subchondral sclerosis: more stress to joint, bone adapts to become stronger
* Cysts: microfractures & synovial fluid can then pass through microfratures to form cysts in bones
53
Briefly explain why OA can occur following trauma
* Malignement
* Wearing down of joints occurs earlier
* Post-traumatic OA presents ~15yrs after injury
