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Summary

This teaching session provides a comprehensive overview of open fractures. Open fractures, formerly known as compound fractures, are defined as fractures associated with a soft tissue injury leading to direct communication of the bone with the external environment. The session emphasizes that these fractures carry a high risk of infection and often require surgical intervention. The speaker stresses the importance of early treatment and assessment, advising medical professionals to follow the BOST (British Orthopaedic Surgeons Trauma) guidelines in order to minimize complications. These guidelines include administering antibiotics within one hour of injury, providing tetanus prophylaxis, taking accurate documentation and photographs of the injury, as well as avoiding any unnecessary actions such as mini washouts in A&Es that may cause further harm. The session is especially useful to early career medical professionals (F1s and F2s) who are likely to encounter and manage open fractures, thus making a significant difference to the patients' outcomes.
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Description

🚑 Join us for the second talk in our ‘Trauma and Orthopaedic Surgery for Finals’ Series: Orthopaedic Emergencies Part I.

🔍 Learn how to identify and manage open fractures and compartment syndrome effectively.

🦴 Delivered by Mr Alex Hinton, ST3 East of England Rotation.

📅 Date: 03/04/2024

🕒 Time: 19:00

👉 Sign-up here: https://share.medall.org/events/orthopaedic-emergencies-part-i

Learning objectives

1. At the end of the lecture, attendees will be able to define 'open fractures', differentiate from other types of fractures, and explain the associated risks. 2. Participants will recognize and understand the importance of immediate first aid and assessment techniques for patients presenting with open fractures. 3. Learners will be able to explain the importance of neurovascular status, how to assess it, and understand what to do if vascular injury is suspected. 4. Attendees will master the Boast guidelines for managing open fractures, being able to explain the do's and don'ts, including the use of intravenous antibiotics within one hour of injury. 5. By the end of this session, participants will understand and explain the Gusti Anderson classification, and will be able to apply it to classify fractures according to their severity.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Uh and then in the next talk we'll go through uh the three things in gray. Er, and then, yeah, if, if you've got a slide with a, a pearl on it, that means it's the sort of take home message. So if you forget everything else, try and remember the, er, the slides of the pearls on. Oh, and there might be some gore in this, I'm afraid. So, open fractures. Uh So the definition is, it's a fracture which is associated with a soft tissue injury, which leads to direct communication of the bone with the external environment. Um, and these used to be called compound fractures. So it's the same thing, but we've moved away from the term compound fracture cos nobody really knew what it meant and people kept getting it confused with comminuted fractures. So we call them open fractures now, er, and sometimes it's really obvious and sometimes it's subtle. So these are both open fractures and you can see that one on the bottom, it's just a tiny sort of five millimeter, er, cut, basically looks quite innocuous. Um, but if that's associated with a fracture underneath and it's uh one of the clues is it's constantly bleeding when you're assessing it, that suggests it's an open fracture. So these need to be treated in a very similar way, even though one looks a lot more severe than the other. And open fractures are relevant because they have a massively increased risk of infection. They've got uh a little bit of an increased compartment syndrome risk which will come on to and then uh you have as associated injuries. So associated vascular injuries and then you ha often have soft tissue defects which might need plastic surgery, reconstruction. It almost always requires some sort of surgery. And then um basically, whatever you do in the first hour affects how these people do later on. So this is the bit when your F ones and F twos, this is the stuff that you're gonna be making a difference to same. How do you assess them? So as always with any injury, these are often high energy injuries. So you need to go through your ACL S and then make sure there's no life threatening injuries that gonna, they're gonna kill them before the fracture. So if you're given a horrible leg like that, the open fractures are like the classic distracting injury. So everybody focuses on the horrible open wound. Um And they ignore the fact that, you know, they've got a massive hemothorax which is stopping them from br breathing, for example. Um I don't know which is more horrible about this picture. Actually the, what the pictures of or the terrible resolution it's in so sorry about that. Um, so immediate first aid. So once you've done ACL S, if there's loads and loads of bleeding coming from it, which most of the time is not the case. To be honest, then you need to, er, control any catastrophic bleeding. So usually that's with direct pressure. Very rarely, you might need to put a tourniquet on but that causes all sorts of other problems. So try and avoid that unless you really have to. And then in that picture there, it looks like they put a sort of er, hemostatic clip on a vessel. And again, that is something you want to avoid really unless you really have to because you're at risk of causing more damage. Uh You need to get some X rays into your views, which is what orthogonal means. Uh and then you need to assess their neurovascular status and document it properly. So you need to test their nerves, both sensory and motor function and you test the vascularity by testing the pulses or if you can't do that, the cap put refill time. And if you're in any doubt about the vascularity, you get an urgent CT angio. So that's kind of like your immediate stuff. And actually most of the time with these open fractures, they don't have loads and loads of bleeding and most of the time then your vaso stasis is o is ok. But you have to check it and then once you've done that, er, you follow the boast. So I don't know if any of you come across this, I don't think I came across these boast guidelines until I was an F two actually. Um, but basically they're, they are really good, simple to follow guidelines. So, you know, when you have to look up like a nice guideline, it's like pages and pages of tedious, you know, it goes on to points and points and points. These are the exact opposite. So these are all on one side of a four, they're really simple to follow. Um Originally there were only about five of them, but now there's about 30. Um but the open fractures, one was one of the first ones that came out and it's really good and it tells you everything that you want to do. So if you want, you can look up and scan that QR code or you can just Google it. Um But I'm, I've tried to just sort of distill it a bit here into some do s and don'ts. So you need to give IV antibiotics within one hour of injury. So not one hour of presentation to A&E one hour of injury. So actually most of the time that's given by the ambulance crew, um, but if it hasn't been, then you need to make sure that's been done and evidence has shown that if you give it within one hour of injury. Uh It reduces the risk of infection. Uh You need to give tetanus prophylaxis. Um And then you need to get a history about how contaminated the fracture is and what's the mechanism of injury. And the reason why that is important is because that dictates when you have to operate on these people. So what the guideline says is that if they've got any contamination with agricultural waste, uh sewage or aquatic contamination, um and you may think, I mean, when do you ever see this stuff? But actually in, in, in our sort of deaneries east of England into Norfolk and stuff like that, you see this all the time, you know, people are constantly, you know, farmers running themselves over with tractors and people falling off into the broads and stuff like that and getting a aquatic contamination. So it actually happens quite regularly. If they have any of those things, they need an immediate debridement. So if this comes in, in the middle of the night, you need to wash it out that night and then if it's a high energy injury, so car crashes falls from significant height, that kind of thing, it needs to be done within 12 hours. And if it's low energy, so fall from standing or something, it's within 24 hours. Um then you need to assess and document the neurovascular stasis of the limb properly. So I don't mean just writing the notes in the neurovascular intact with no further detail. That's not good enough. You need to uh you know, say if it's a forearm open fracture, you need to document the median radial and ulnar nerve, the motor and the sensory function and then do the pulses as well. And you need to document all that properly. And then if you do any moving around of the fracture, like putting a back slab on it, you need to then repeat it afterwards. Er, you need to take some photos. Er, the official, um, line is you need to go and get the A&E camera from someone and you need to take a photo and upload it to your eno system. But obviously, in reality, everybody just takes it on their phone and whatsapp it to people. Um, so make of that what you will. Um, and basically the main reason you, well, there's two reasons to do that, first of all to make it easy to refer. So if you need to refer on to plastics, you can send them the picture. Er, but secondly, it's so that you can take the photo and then it allows you to, to splint the limb and dress it and it doesn't mean that everyone's gonna redress it e every hour just to look at the wound. So that's really important. And then once you've done all that, you dress the wound with a saline soaked gauze and a, and an inclusive film. So nothing complicated. So literally just squirt some saline on some gauze, stick it on and then get one of those Tegaderm clear dressings and stick that over the top. That's it. You don't need to do anything special and then you need to put a back slab on. So AAA plaster slab er, to um immobilize the fracture basically, and that's to protect the soft tissues. So there is your DS and then there's a few don't, so don't perform mini washouts in EDS. There used to be this trend if you sort of, you have this person in resource and you try and like, you know, wash a few bags of saline through their wound and stuff like that, don't do it. You're just gonna cause more damage. You're not in a proper sterile environment, it's a waste of time. So, the only thing you do is remove, you know, if there's a big, big rocks or something in the wound or like vegetation or something, then remove it, but that's it. And then we'll get onto this in a bit more detail, but don't try and manage injuries that require plastic surgery coverage in a hospital which doesn't have plastic surgery, uh, which sounds obvious, but you'd be surprised. But these people, if you think, no, this wound is too big, we're never going to be able to close it. It needs plastic surgery. You should just transfer them from A&E once you've got your x rays and stuff to the major trauma center that's got plastics in vascular and then don't take any swabs of the wound when they initially present cos it'll grow all sorts of stuff and it'll just confuse things. Um, you know, if later down the line, 23 weeks down the line it gets infected, then, I mean, even then some people would argue it's not worth taking swabs, but then you can just about justify it cos it might grow something significant. But if you swab it on admission, it's just gonna grow about 10 things and it's gonna be useless, right? Um I think so these are classified with something called the Gusti Anderson classification. You do not need to know all the details of this classification. If you just know the name that is a lot more than is expected um at your stage. Uh I don't know if you can see the chat but there's just a quick question that's probably quicker for you to answer now. Oh Yeah. Go ahead. When do you culture the antibiotics? So, uh yeah. So, so when you're giving your antibiotics uh on admission, you're gonna follow the local guidelines. OK. Uh So you go on micro guide or whatever your app is and you'll do what it says. Uh So you start off with a broad spectrum antibiotic. Um So, and that's what you stick with basically. Uh And then if it does get infected later on, then that's when you swab it. Um And then you can change your antibiotics if need be. But basically all of these people just get broad spectrum antibiotics. Cool. Does that answer the question? I hope that helps and if it doesn't um just message again. Yeah. So, because if you think about it, if so say somebody's fallen in, uh let's say they've broken their ankle and they've fallen in the sea. Ok. If you take a swab of that wound, when they arrive, it will literally grow like 10 different things, right? And you won't know which of those might cause infection or some of them might not. So you just give a broad spectrum antibiotic and then if it does get infected later down the line, then you try and find out what the actual organism is. Ok. Um So yeah, Gracila Anderson. So just be aware that it exists, you don't need to know all the classifications. Uh But basically, it's divided into three. one is very, very small, two is a bit bigger and three is bigger than 10 centimeters. Um If it's high energy, it automatically becomes a three b because it will have periosteal stripping if it's high energy and then if there's a vascular injury, it automatically becomes a three C. Now, the, the important thing to remember about this other than the fact it exists is that it's assessed post debridement. Ok. So that's really important and a lot of people get that wrong. So, what that means is that if you have a wound. So these, this is the same leg. Ok. So the one on the left is pre debridement. And you'd probably say if you just looked at that, you'd say it's probably a Castillo Anderson two because it's bigger than one centimeter, but it's more than 10 centimeters. But once you've debrided it all of a sudden, actually, that's probably bigger than 10 centimeters, you can see there's some periosteal stripping here, there's three bits of bone. So actually, what you thought was a Gillo and two is probably a three B. Uh So you assess it post bride. OK? And then in terms of what debridement actually is. So this is obviously something that your senior is gonna be doing, but it's a good, it's a good thing to be aware of so that you know what they're actually gonna do. Um So debridement. So you start by extending the wound along the fasciotomy line. So we'll talk about fasciotomies later in the talk. But you can see on this one. Can you see that, that they've, they've, er, that's how it started and they've done a cot down here basically and a cot down here. So they haven't just taken a border around the whole thing like you would, if it was a skin cancer or something, they've done it in this specific, along these fasciotomy lines. Cos that means if you do have to do a fasciotomy later on which is very common. You can just continue the exci incision, then you're gonna excise anything that is devitalized all dead. And that includes skin mu and muscle. And it also includes bone. And the way you assess bone is to do something called a tug test, which is you grab one of these bits of bone with a pair of forceps and give it a little tug. And if it comes away, then that basically means there's so little periostal attachment to it that it will have no blood, blood supply. And if you just left it there, it would definitely die and it would just become a focus for, for infection. So all of that needs to come out as well and it is better to do an aggressive over debridement than a cautious under debridement because remember what you're trying to avoid is infection, um particularly of the bone and osteomyelitis. So if in doubt, take out a bit more and the defect that you leave, whether it's soft tissue or whether it's bone can be sorted out later down the line in another operation. Um So you might have to do something called shotgunning the limb, which is this. So like a uh like a shotgun, you basically bend the limb in half, which will present the bone ends to you allowing you to debride them. And the only thing you don't debride is nerves and blood vessels. So sometimes you even have to skeletonize the neurovascular bundle. So you're literally taking everything away aside from the neurovascular bundle itself. And then that's just kind of left floating in air. And then you've gotta work out with the plastic surgeons later on how you cover that up, you're gonna give it a wash with Saline. It's supposed to be about 6 to 9 L. Um But the important thing is it's just low pressure through a normal giving set. So, you know, if you're just giving someone an IV drip, you just use one of them to basically gently wash it with saline. What you don't do if any of the, you've been in a hip replacement or anything and you've seen the, um, what I call the water gun, the, er, pulse lavage that high pressure stuff. You don't wanna do that cos that's just gonna push everything deeper into the tissues. So you just want low pressure saline wash, keep it simple. And then again, this is from the Bose guidelines so that they say the debridement should be done as a combined orthoplastic approach. So what that means is that you should have an orthopedic consultant there and a plastic surgery consultant there and they both together are deciding what needs to be debrided. Uh Now, in reality, that's something that only happens with the bigger wounds. Um, and it obviously can only happen in major trauma centers where they've got plastics. Um, so often the smaller open fractures are not do not have a combined orthoplastic approach, although officially they should. And then once you've done your debridement, you've got to decide how do you close the defect that you've made? So you basically got three options. Ok. So the first and most simple is direct, primary closure. So can you just stitch the two wounds, two wound ends back together? Um, if you can't do that, then they need to go to a major trauma center because they need plastics coverage. Ok. Um, now sometimes it's really obvious and you'll go, yeah, I can definitely close that or no, I definitely can't close that. Sometimes it's not quite clear and the really difficult ones are the ones where you go. Oh yeah, I think I can close that and then you take them to theater, do the debridement and then you find out, oh, actually I can't close it. So those are difficult ones. So you need to try and predict before you take them to the theater for their debridement. Am I going to be able to close this defect? And actually that can be really hard. So if in doubt, refer them to a tertiary center, um then if you're in a tertiary center, you have all of these options. So you have the plastic surgery recon ladder. So it starts with direct closure that we just talked about and it goes up through skin graft all the way up to free flap. So literally taking a chunk of tissue and skin disconnecting it from the blood vessels, uh and plumbing it in uh to cover the defect. And then your last option is a temporary measure, which is a vac dressing. So it's a negative pressure dressing. So it's basically a bit of cling film uh that you put over the wound and you attach that to a little vacuum pump that is constantly sucking all of the liquid out. Um And those you can leave on for probably a maximum of about two weeks. So that is a temporizing measure. And I've importantly, I'll put here, I'll get onto this in a second, but that does not count as definitive coverage when you're thinking about fixation. So, fixation. So this, you can divide into two options, ok? So you've got a fracture if you think you can achieve tissue coverage at the time of the operation. So either you can directly close it or you've got plastic, you've got a plastic surgeon next to you who says, yeah, I can put a free flap on that. Now today, if that is the case, then you can use your normal internal fixation like you would with any other fracture. So you can use in some dolly nails. You, you can use open reduction, internal fixation with plates and screws. You can do all your normal stuff. Um But to keep it all clean, you've gotta to kind of treat it as a new clean procedure. So once you've done your debridement, you all rere up, you re drape the patient, you get all new instrument sets. Now, if you can't achieve tissue coverage. So usually this will be, if you're in a district general hospital, you've done your debridement, you've realized actually, I can't close this, then you can't put in this traditional internal fixation metalwork because that metal will then be exposed to the outside world for a period of time. And that is pretty much guaranteed, deep metalwork and deep bone infection. So if that is the case, you can't achieve tissue coverage, you need to use an external fixator to fix the bone from the outside. And then as per the boost, you need to get your formal coverage within 72 hours. So that means once you put your X fix on, you need and put, then put a vac on to cover the wound, you've then got to ship them urgently to the major trauma center who can then do the flap coverage plus the er internal fixation. Ok. So just to recap. So if you can achieve tissue coverage, you can do an internal fixation like this. So that's an intima dolly nail going through. I think someone's tibia and that's fine because they're about to put a free flap on this to cover it all up. If you can't achieve tissue coverage, then you need to put an X fix on which is what this is. And then they would then put a vac dressing over that wound there. Uh I hope that all makes sense. Um So this is a case. Um So I don't know if anyone wants to pipe up and talk through these images. Thi so this is a lady, er, who actually came to my hospital about a month ago, she gave me the permission to use these pictures, which was nice for her. Um, so she's a 65 year old lady. She, er, was in the pub and fell off the bar stool and sustained this injury. Er, this did get me out of bed at about, at about one in the morning. Um Does anyone wanna go through this, er, or otherwise I can go through it? No silence? Ok, so I'll go through it. So I'll, I'll go through this, how I would present it. So I'd say right. So first on the left, we've got um, a clinical photograph of a right ankle. Uh I can see there's about a 10 centimeter um, open wound over the medial malleolus with exposed bone. And then we've got er, ap and lateral radiographs of the right ankle which show a bimalleolar fracture because both the lateral malleolus and the medial malleolus are broken. Um, and it's a fracture dislocation because this is the talus here and it is completely dislocated from under the tibia where it should be. Um, and just to sort of orientate you a little bit, uh, that is the medial malleolus, which has basically stayed where it should be next to the talus, but it's been left behind as the entire rest of the tibia has dived medially and then that's the bit that's sticking out of the skin that we can see here. Yeah. Um, and then that's the natural view which doesn't really show much more and you can see, er, she's in some sort of splint already here. I think that was one of those ambulance, er, splints that basically just stop the ankle falling off, doesn't really do much more than that. Um, so I went to see her, I, er, they put her to sleep with a bit of propofol and, um, I reduced it. Er, so I suppose a little feed, little tips for reducing things like this if you ever have to do this. Um, first of all, if you look back at the X ray, can you see how this Talus, the corner of that? Talus is kind of right up against the corner of the tibia. So I think if you just try to push this foot majorly and push the talus laterally, this would probably hit this and it just wouldn't go. So for this one, I exaggerated the injury slightly just to tilt the talus down so that the, it wasn't getting stuck on that corner and then I could slide it underneath if that makes sense. Um, so that's so the X ray looks a bit better. Um And then I also just grabbed before I went and did this, I grabbed these little, um, it's just an artery clip, but all I wanted was something with a bit of a curve on the end. Basically, that was sterile because this little bit of skin I anticipated getting stuck on this. So I just want something to hook onto that bit of skin so I could hook it over the bit of bone to sort of get it all back in. So that's all I use that for. And you can see now, actually, it looks a lot smaller. Um And I was looking at this and I was thinking actually, I think we probably could close that in theater here. Um Cos you can kind of think, yeah, are those skin inches gonna come together? They probably will actually with sutures. Um And then this is like the most common open fracture you see, especially in elderly patients, they have like paper thin skin over the medial side of the ankle. So this is, this is a very common open fracture we get. Uh so she went on to um I don't have the POSTOP images I'm afraid, but they basically gave it a good wash out. They put a plate on the fibula along here, they put two screws into the medium malleolus and they were able to close this directly and she's done very well. Actually, a question from the chart, Alex Um So Sandy says we x-rayed before and after reduction. But when would you decide not to reduce, would it just be neurovascular compromise? So, uh no. So if there's neurovascular compromise, then it's even more important to reduce because the, the by far the most common cause of um not having a pulse to the foot, say in this circumstance would be an artery being kinked or something uh because of the position of the ankle. So it being stretched over a bit of bone. It was very unusual for an artery to literally be completely transected. So most of the time if you reduce it, um the pulses will actually come back. So in fact, it's even the case where say, say, say if you presented with this, no x-rays have been done, the foot was cold and white. Your first step would be to attempt a reduction even without any x rays at all. Uh put it in a cast and see if the pulses came back and most of the time they would and if they didn't come back, that's when you'd send them for a CT angio. Does that make sense? Cos if something's hanging off like this, you're not gonna make it any worse by trying to reduce it. The, the vast majority of the time that by reducing it, you're gonna restore the pulses. Yeah. Hope that helps on it. Yeah. Any other questions before I move on to compartment syndrome? Um I've got one. yeah. Do you have any tips, any personal or when you think that you could direct primary closure? What, as in, how to decide as in, as in, when you see a wound and you think, I think I could do that but you don't want to get in a situation where you get there and you're like, actually I can't, do you have any tips for? So it's really difficult for this lady. I actually, I told her when she woke up, I said uh we might be able to do it here but we might have to send you to the tertiary center. Er, and I'm gonna discuss it with my consultant and see what they want to do. Cos I actually wasn't sure. I think you could argue either way. I think if you were strictly following the bo guidelines, we would have sent this to uh the Tertiary Center. Um, but the thing, the thing around, basically, if you look at that wound, if you look very, I don't know how good your screens are and I don't think I can zoom in. But um can you see it around here? There's, we know there's no skin loss, we know that you can see around the sides of the laceration, there's wrinkles which suggests that that has been pulled back and it suggests you can stretch it and you can even just, uh with your, with two fingers, just try and pull it back together and see, will it go? So it is kind of one of those you get an impression, er, and sometimes it's really obvious you can sometimes really obvious you can't. And then this one is a bit borderline and it kind of depends on, you know, but when it's a bit borderline, you just ask your consultant and they've got more experience than you. So they'll, they'll be able to make a decision. Yeah, makes sense. Ok. Um So camal syndrome, uh so this is raised pressure inside a fascial compartment which exceeds the perfusion pressure of that compartment. So basically, the pressure gets more and more and more until it cuts off the arterial supply and then your muscle starts to die inside that compartment and it's a vicious cycle. So when your muscle starts to die, it swells up and the pressure, the pressure gets even more. Um And this is, this is like the classic orthopedic emergency. It really doesn't happen very often. Um But it's really important. So if you leave it, you get irreversible muscle and neurovascular ischemia and you can't even lose the limb. Uh so it can affect any fascia compartment. But by far the most common is the lower leg. So what I mean by that is uh the calf basically. So between the knee and the ankle. Um and then the next most common in order are the thigh, the forearm, the hand and the foot. But I think about 60% of the time. It's, it's the lower leg. Um So the risk factors are obviously fractures is the number one risk factor. And then surgery on those fractures also increases the risk and then open fractures have a slightly increased risk. Uh And so do combined fractures. So, fractures in more than two pieces. Um, cross injuries are high risk because uh they um there's so much associated soft tissue damage as well as the fracture. Um then it can be caused by really tight casts or bandages around the limb. It can be caused by people having long LS. Uh So again, that causes muscle death, rhabdomyolysis and that starts the process of compartment syndrome. Um You can have local pressure, pressure effect from hematomas or extravasation of IV medications and then uh burns is another one. But by far, the most common is fractures and then in terms of which fractures are worst. Um Again, the tibial shaft is by far the worst. Um Then it's the distal radius apparently according to what I looked up, although uh I've never actually heard of it happening in the distal radius, but apparently that's the next most common. Then the femur, then the tibial plateau, then the distal tibia, then the hand and then the foot and you can see the tibia is, is, is very up there. And the reason why is if you think about your tibia, um the skin around it, if you look at yourself is really tight around the tibia and there's just not a lot of room for expansion and you never compare it to something like the thigh. Um, so how do you assess it? So this is our, it's our little M TQ. Uh jo, so if you want to pop up that pole. Um, so here's a question for you. So, er, you've got a patient who had a tibial shaft, er, intima dolly nailing for a fracture two hours ago. Uh You called to see him because the nurse had given him maximum dose morphine, but he's still screaming in pain. Uh They got on their leg, uh A boloney back slab and then woolen crepe. So what is your initial management? It's one of those annoying questions where it asks, what is your initial management? So a do you call the registrar to do an urgent fasciotomy? B? Do you measure the compartment pressures? C release all circumferential dressings, elevate the limb, then reassess d feel the distal pulses and test sensation if normal, continue giving analgesia until it settles or e do you get an urgent DVT ultrasound? Uh Let me know when we've had a few responses to that. So we've got 55 at the moment, all C at the moment. OK. See if you can get to 10 responses. Maybe we're on seven at the moment. We've got another, we've got one for B now. OK. Nice bit of variation. Just had another 150 this time. Oh, ok, great. I think that's enough time. So it's c ok. So it sounds like most of you got it right. Um, so I'll go through it now and hopefully it'll all become clear why it's c if you're not sure. Um, so the classic signs of compartment syndrome that certainly, I was taught when I was at medical school. I'm not sure if they still tell you this is the six ps pain paresthesia poikilothermia, which means it's colder, but of course cold as you would see, er pallor paralysis and pulselessness. Um but the thing about this is that those three signs are quite late as in the compartment syndrome has to have been around for quite a long time for those things to develop. And if paralysis and pulselessness are developing, it basically means that limb is dying. It, this is really late. It's too, you know, if the pressure in the compartment is so high that it's cutting off the arterial supply, that is really bad news. Ok. So the signs of compartment syndrome really are uh pain six times. OK. This is the most important thing. And if you wanna get a bit more specific, you can say it's pain with minimal or no response to analgesia. So this guy in the M CQ, he'd had max dose morphine, uh then it's pain out of proportion. So that's important, right? Because anyone with a fracture, it is gonna be painful. So they are going to need morphine, morphine that's normal and to be expected. But is it out of proportion? Are they in even more pain than you'd expect? And then this is really the key one, it's pain on passive stretch. So what that means is um uh when you stretch a muscle that is in the compartment that you're worried about, does it cause loads and loads of pain? So an example of that would be so say someone's got a tibial fracture. Uh You're worried about compartment syndrome in the lower leg. The most common compartment for compartment syndrome is the anterior compartment. So the way you're gonna passively stretch, that is that you're gonna flex so bend downwards the big toe. Ok? Because that is gonna stretcher extensor Haasis longus, which is in the anterior compartment. Um and that's gonna cause pain. So the way I do it is um I go to the patient, I wiggle their toe up and down. So when I'm wiggling it down, I'm testing for compartment syndrome in the anterior dear compartment cos that's the muscle, I'm stretching. If I wiggle it up, I'm testing for compartment syndrome in the posterior compartment, the deep posterior compartment. Ok? And then you can also move that ankle around, which does the other two compartments. Ok? Um So, pain or passive stretch that's really important. Um And you'll be glad to know there's also a boast on how to assess compartment syndrome um So you're gonna go and see the patient, you're gonna elevate the limb properly to the level of the heart. So usually, uh when you're doing that, it means it looks a bit comical because you've got to really put their leg up really, really high. You're gonna remove all circumferential dressings down to skin. So you're gonna remove everything, bandages, you're gonna, um, if they're in a back slab, so ie if there's any plaster on the back and it's open at the front, then you can leave that on. But I would pull it apart a bit to loosen it. If they're in a circumferential cast that goes all the way round, then you need to cut it and break it open and you even need to take down the wool. And if they've got a stocking it on, you cut through that. So literally everything is cut through down to the skin and the skin is open to you and then, uh you're gonna reassess them within 30 minutes. And if you go back and nothing is better, then you're gonna take them for an emergency, fasciotomy or you're gonna call your senior to do that. So the point is it's a clinical diagnosis. Uh, it's one of those annoying things. Unfortunately, one of the, well, one of the few things remaining in medicine where you can't just scan them or do a blood test and it gives you the answer. This is a clinical diagnosis Um Now I know at least one of you who answered. Um we get on to that second. So uh the fasciotomy just so your aware of what that means. So it's a fascy. So something to do with the fascia and there's an otomy which means make a hole. So you're making a hole in the fascia. So if this, so if this is someone's uh lower leg, um these dotted green lines are basically the palpable borders of the tibia. So you can feel it on yourself. And then this is the medial side here. So you're gonna do a two incision, fasciotomy and each incision is gonna release two compartments. OK? So this is your posteromedial incision. So you're gonna cut through skin and then that will give you access. So you're coming in here that will give you access to the deep posterior compartment and the superficial posterior compartment. So you're gonna go through your skin and then you're gonna cut the fascia all the way down in both of these compartments. Uh And then you're gonna do your second cut, which is the other side of the tibia, which is your anterolateral incision, which you go through here. And again, that gives you access to the anterior compartment and the later or the lateral compartments they put in a perineal compartment, but I call it the lateral compartment. Um And that's what fasciotomy is. Um And then you er basically leave that open and you can dress it again with the vac dressings that we talked about with open fractures um for a few days and then you go back in 48 72 hours for a rook, see if any of the muscle has died cos of the compartment syndrome. If so debride it. And then if you can at that stage, you can close the skin but you leave the fascia open. So that's fasciotomy again. You don't need to know the details of this. Just know what a fasciotomy is, but you don't need to know all the anatomy in detail, right? Compartment, pressure monitoring. So I know at least one of you said you wanted to do this for the, for the last er for the M CQ. So that's what it looks like. So it, it's actually, it's actually quite simple. Um It's basically something that's a bit similar to an ABG syringe. Um and you just stick this needle in the leg, but you've got to measure all four compartments, you can't just stick it in one. Um and it gives you a reading. Now, this only has a role for obtunded patients. So if they're unconscious in ICU and they can't tell you they're in pain or patients who have had like nerve blocks after an operation. Now, if there's any risk of compartments, injury with an operation. So if you're doing a tibial nail, you should say to the anesthetist. No, I don't want you doing a nerve block because it's gonna cover up compartments in June. So this shouldn't really be a thing. OK? And then I've put here maybe if it's diagnostic uncertainty. But I would argue, most people would argue if you're in doubt um just tape to theater and do a fasciotomy because the the consequences of getting it wrong are too great. So basically, what I want you to remember is the only role of compartment pressure monitoring is for obtunded patients. Now, if you do have to do it again, you don't, you don't need to know these numbers um until you're going for uh you know, ST three interviews. But basically, there's a relative, a relative cut off and an absolute cut off. So your relative cut off if you is if you measure it and there's uh the difference between the compartment pressure and the diastolic BP is less than 30 millimeters of mercury. Uh So ie if those two values are too close together, then you worry or if the absolute compartment pressure is above 40. Um But like I said, this has a very limited use. That's what I want you to remember. Uh 99% of the time it's clinical diagnosis. Uh So what I want you to remember is I want you to follow the BO and II still look them up occasionally, you just look them up. Um And they are really good guidelines for both compartment syndrome and for open fractures, uh open fractures, a distracting injury. So don't forget about ATL S before you start getting excited about the gory er fracture compartment syndrome is a clinical diagnosis. Uh The main sign is pa pain or passive stretch, which I talked about and the compartment pressure monitoring, it has a very, very limited use. So uh it will rarely be the answer to an empty cube. Fine. Any questions was asking me to answer the M CQ answer later, right? Really, really great talk, Alex. Thank you. Um I can't see any questions in the chat at the moment. Great. Uh People who put questions in chat earlier. Are you happy with my answers? Yes, I know. It's presumably if you, if you get compartment syndrome somewhere else, the management is exactly the same. All the changes just where you make the incisions. Uh Yeah, exactly. Um So yeah, so that, that's part of the reason why I say don't worry too much about the anatomy and I can tell you for a fact. So I, so I've never been in a fasciotomy uh for a tibia. I've been in one for a forearm, er, when I was working with the plastic surgeons and their very senior registrar had to look up the incisions beforehand, er, to remind herself cos it just, it just doesn't happen all that often. So you definitely don't need to uh remember where they are at all. So if you just remember it's a you make two incisions and through those you release all four compartments that is more than enough. Yeah. And it, it's interesting you say that the distal radius is the second most common because it's something that at least I've never really heard anyone talk about it. Everyone talks about the leg. Big deal. Yeah. So I mean, like I said, I think the leg, the lower leg is about 60%. Um I think probably the distal radius is a bit uh skewed. So I think like as a percentage of distal radius fractures, I imagine it's tiny but because a lot more people break their distal radius than they do their tibia. Um I suspect that pushes up the numbers a bit if you know what I mean. Yeah, it doesn't look like there are any questions coming in if there are. I think people can start a thread on the QT S page. Um Oh, can they? Ok. I think so. Yeah, I think. Good. Fine. Ok. Yeah, great. Well, thanks everybody. Don't forget to see the feedback, right? Great. Thanks everyone. Hope to see you all at the next one in a couple of weeks time. Thanks again, Alex. Really, really good talk. Yeah, no problem. Great. Thanks. See you. Bye bye.