5.1 R Trauma Extremity Trauma Em Cam P 109

Front 1

What are the life threatening complications of fractures?

Back 1

Haemorrhage
Sepsis
Compartment syndrome
Crush syndrome
Fat embolism

Front 2

Regarding extremity trauma which is incorrect
1 tense white skin over a closed fracture is an orthopaedic emergency requiring urgent reduction, before imaging
2 no splint should remain in situ more than 8 hours without removal/reassessment
3 patients with a higher likelihood of complications include delayed presentations >6/24, head injured, immunocompromised and alcoholics
4 hand dominance is an important part of history
5 full active range of movement in a joint is not sensitive for excluding dislocation

Back 2

5 incorrect - almost never dislocated

Front 3

Regarding extremity trauma which is incorrect
1 lipohaemarthrosis in joint aspirate or on XR may indicate occult fracture
2 angiography may be both diagnostic and therapeutic, and is indicated in knee dislocation and limb injuries with distal vascular compromise
3 CT is not frequently indicated for fractures, but indications may include tibial shaft fractures, tarsal and carpal injuries
4 emergency MRI is not indicated for limb trauma

Back 3

1 true - appears as radio opaque effusion
2 angiography may be used in limb amputation with poorly controlled haemorrhage
3 INCORRECT - tibial PLATEAU esp posteriorly, (and tarsal and carpal)

Front 4

Regarding the management of limb trauma which is CORRECT
1 control of visible haemorrhage by external pressure is part of the secondary survey
2 severely contaminated wounds should receive tetanus immunisation and urgent theatre debridement
3 NNT with antibiotics to reduce infection rates is 13 in open fractures
4 a loose dressing should be applied to open wounds to facilitate reexamination

Back 4

1 incorrect - PRIMARY
2 incorrect - tetanus IMMUNOGLOBULIN
3 CORRECT - very good evidence for systemic ab's
4 incorrect - avoid re-examination increases chance infection; consider photo and sterile dressing to remain undisturbed

Front 5

A nice classification of analgesia for fracture - see over

Back 5

Pharmacological
- local
- general

Nonpharmacological
- splint
- reduce

Front 6

Regarding management of extremity injury which is incorrect
1 there is good evidence fat embolism is reduced by early splinting
2 role of splint includes communication, tissue protection, facilitating transport
3 a limb cannot be adequately assessed while splint is in place
4 any suspected penetrating joint injury should be reviewed under anaesthesia for assessment/lavage
5 compound fracture and contaminated wounds are time critical emergencies where time to theatre is related to infection rates and skin necrosis

Back 6

1 incorrect - poor evidence
2 communication e.g. I think this means take care, pt has injury

Front 7

Regarding wound management which is incorrect
1 povidine iodine has been shown to decrease wound healing and increase chronic infection rates
2 wound irrigation is best achieved with a pressure of 7-10psi (48-69kpa)
3 wound irrigation pressures are best achieved with a 20g needle and 50mL syringe
4 tense haemarthroses should be drained under sterile technique

Back 7

3 INCORRECT a 19g needle and 20ml syringe

4 true, symptom relief, may reveal lipohaemarthrosis (& hence fracture), facilitates joint assessment,

Front 8

Regarding complications of extremity wounds which is CORRECT
1 risk of permanent damage in arterial ischaemia occurs >6/24
2 the presence of a distal pulse excludes arterial injury
3 bruit is an immediate sign of arterial injury
4 axonotmesis results in regeneration over months along intact nerve sheath
5 neurological deficits are due to nerve injury until proven otherwise

Back 8

1 incorrect, 4-6 hours
2 incorrect, injury may be incomplete
3 incorrect, delayed
4 correct see below
5 incorrect - must exclude ischaemia

Neuropraxia - transient change conduction following crush, contusion or stretching, recovers in days to 8 weeks
Axonotmesis - complete denervation, sheath INTACT, regeneration over months
NEUROTMESIS - complete division nerve and sheath. Spontaneous regeneration does not occur, surgery required

Front 9

Compartment syndrome true false
1 may be lethal
2 lethality is due to potassium, hydrogen ion and myoglobin release
3 peripheral pulses are lost early
4 ischaemia muscle pain is difficult to control and out of proportion for the injury - cardinal finding
5 it worsens with active flexion/extension distal digits
6 causes include reperfusion of arterial ischaemia, electric shock
7 causes include snakebite, exercise and hyperthermia
8 common sites include hand, buttocks and arm
9 normal pressures are 20mmhg
10 fasciotomy is indicated with pressure >40mmhg

Back 9

1 t
2 t via cardiac arrhythmia, acute renal failure
3 f late sign
4 t
5 f - PASSIVE
6 t
7 t
8 f - these occur, but commonly all compartments of leg, quadriceps of thigh and forearm compartments
9 f 4-8
10 t

Front 10

Regarding fat embolism syndrome which is incorrect
1 causes include closed cardiac massage, liver injury, bone marrow transplantation and liposuction
2 skin petechiae are typical
3 self limiting and treatment is supportive
4 usually occurs 3-4 days after long bone fracture

Back 10

1 correct, and of course long bone fractures
2 correct, skin and conjunctival petechiae, altered conscious state and ARDS-like respiratory syndrome with hypoxaemia are all part of syndrome
4 incorrect 6-48 hours

Front 11

Regarding crush syndrome in extremity trauma
1 briefly describe the pathophysiology
2 why are pre-extrication/pre-hospital fluids important?
3 list causes of rhabdomyolysis other than crush injury
4 local and systemic clinical findings
5 most urgent initial investigation
6 CK level predictive of acute renal failure and death

Back 11

1 muscle cells rupture releasing K, H, and CK resulting in life threatening arrhythmias, metabolic acidosis and acute renal failure
2 may preempt renal injury and death by improving volume state before release of toxic mediators
3 heat stroke, severe exhaustion, cocaine and amphetamine use, serotonergic syndrome, snake bites
4 local - tense hard tender muscles, bruised/blistered skin (same as compartment syndrome). Systemic - hypothermia, shock, dark urine, myoglobin
5 ECG to identify hyperkalaemia
6 75000

Front 12

Principles of treatment of crush syndrome

Severe crush injury - fluid requirements in first 48 hours

Back 12

1 aggressive normal saline loading prior to extraction, plus calcium gluc/hco3 to protect against hyperkalaemia
2 IVF 12L in 48 hours if severe
3 cardiac monitoring
4 art line, IDC, central line
5 alkaline (hco3) mannitol diuresis, UO 2ml/kg/hour
6 fasciotomy if compartment syndrome
7 dialysis may be required to manage hyperkalaemia or fluid overload and pulmonary oedema