Define an open fracture
A fracture with direct communication to the external environment
List the clinical features of fractures
Pain Loss of function Tenderness Deformity Swelling Crepitus Abnormal movement or position of limb/soft tissues
Describe fracture healing
Haematoma formation + neutrophil infiltration Granulation tissue/woven bone formation Trabecular boney callus Remodelling of cortical bone
Outline the epidemiology of open fractures
Diaphyseal fractures are commoner than metaphyseal Commonest diaphyseal fractures: -Tibia -Femur -Radius and ulna -Humerus
Outline the Gustilo classification of open fractures
I. Low-energy wound <1cm, minimal soft tissue injury, minimal comminution. II. Low-energy wound <10cm, moderate soft tissue injury, moderate comminution. III. High energy injuries irrespective of wound size, or farmyard contamination: A - Adequate local soft tissue coverage B - Inadequate local soft tissue coverage C - Arterial injury needing repair
What should be included in the clinical assessment of open fractures?
Pulses Nerves: motor and sensory Soft tissue integrity Contamination Compartment syndrome
What are the clinical features of acute limb ischaemia?
6 Ps: Pain (early) Pallor (initial), Mottling (later) Pulselessness Paraesthesia (early) Paralysis (advanced) Perishingly cold
Outline the emergency management of open fractures
ABC assessment, cannula, fluids Assessment: neurovascular, soft tissues, photograph Antisepsis: wound swab, wound cover Alignment + splint Anti-tetanus Antibiotics: co-amoxiclav/clindamycin within 3 hours of injury Analgesia: morphine + antiemetic Re-examine neurovascular after alignment + splint Request x-ray after realignment Plan surgery and admit
What skin colour changes are seen with acute limb ischaemia? Explain their appearance
Initial: Pallor due to arterial spasm, causing insufficient arterial perfusion. Later: Mottling (blue/purple reticular pattern) as skin fills with deoxygenated blood.
What are the hard signs of arterial injury, and what do these indicate?
External arterial bleeding Rapidly expanding haematoma Palpable thrill, audible bruit Obvious acute limb ischaemia - not corrected by reduction of dislocation or realignment of fracture These indicate definite injury to an artery ➔ require immediate surgery
What are the soft signs of arterial injury, and what do these indicate?
History of bleeding at the scene Proximity of penetrating wound or blunt trauma to a major artery Diminished unilateral pulse Small non-pulsatile haematoma Neurogenic deficit Probable injury to an artery ➔ may require investigation (duplex USS or angiography)
Which fractures/dislocations have a higher incidence of associated vascular injury?
Supracondylar humerus fracture in children ➔ brachial artery High tibial 'bumper fracture' ➔ anterior tibial artery Dislocation of knee ➔ popliteal artery
How is compartment syndrome assessed following tibia fracture?
Maintain awareness for 48h after injury or fixation by: -Regular assessment and record of clinical symptoms and signs for compartment syndrome -Consider continuous compartment pressure monitoring when clinical symptoms and signs cannot be readily identified (e.g. unconscious or nerve block) -Advice people on how to self-monitor after discharge
Define acute compartment syndrome
Raised pressure within an enclosed fascial space, leading to localised tissue ischaemia. Normal pressure <10mmHg in lower leg.
Describe the clinical features of acute compartment syndrome
Pain out of proportion of physical appearance Swollen tense compartment Paraesthesia or hypoesthesia Pain on passive stretch of compartment
What is the treatment of acute compartment syndrome?
List 3 immediate complications of fractures
Internal bleeding External bleeding Organ injury Nerve or skin injury Vessel injury
List 3 late complications of fractures
Local: skin necrosis/gangrene, pressure sores, infection, non- or malunion, failure of fixation, Volkmann's ischaemic contracture General: venous or fat embolism, PE, pneumonia, renal stones, sepsis, complex regional pain syndrome