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Emergency Med > 2 - Digital Trauma > Flashcards

2 - Digital Trauma Flashcards

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1
Q

Objectives for digital trauma

A
  • Recognize and understand basic principles of nail trauma and digital fractures.
  • Recognize the mechanisms of injury and make appropriate treatment recommendations
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2
Q

Topics in digital trauma

A
  • Emergent Care
  • History
  • Physical Exam
  • X-rays
  • Lab
  • Treatment
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3
Q

Mechanism of trauma

A
  • Mechanism of trauma is usually direct or indirect trauma most commonly caused by falling objects or stubbing injuries.
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4
Q

Sagittal plane digital injury

A
  • Most frequently observed
  • Direct trauma, injury 2nd hyperextension or hyperflexion
  • Comminuted type injury
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5
Q

Transverse plane digital injury

A
  • Very frequent
  • Abduction - adduction force
  • Results in transverse or short oblique fractures
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6
Q

Frontal plane digital injury

A
  • Least frequent
  • Predominantly transverse or sagittal plane
  • Injury with assoc. rotational or inversion - eversion injuries
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7
Q

Clinical presentation of digital trauma

A
  • Acute Pain
  • Discomfort with shoe gear & ambulating
  • Ecchymosis and edema present within 2-3 hours
  • May see dislocation
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8
Q

Digital fractures

A
  • Fractures of all proximal phalanges are usually oblique or comminuted.
  • Transverse pathologic fractures may occur in diseased bone
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9
Q

Treatment of digital injuries Closed injuries

A
  • R.I.C.E.
  • Closed Reduction
  • Immobilization
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10
Q

Treatment of digital injuries Closed reduction

A
  • Distraction of the digit or fracture, then put it back into alignment
  • Then splint or wrap it to keep it in place
  • The point of this is to achieve correct alignment of the fracture line before the initiation of bone healing
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11
Q

Treatment of digital injuries Open injuries

A
  • Surgical emergency
  • Assess neuro-vascular status
  • Tetanus & antibiotics if indicated
  • Address soft tissue initially
  • Address fracture secondary
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12
Q

Sesamoid fractures

A
  • Not very common
  • Need to rule out bifurcate or bipartite
  • A mis-step may lead to soft tissue injury of the sesamoids
  • Commonly sagittal plane injuries
  • Crush injury (comminuted)
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13
Q

Predisposing factors to sesamoid fractures

A
  • Cavus foot
  • Metatarsus primus equinus
  • Sport activities (repetitive flexion trauma)
  • High-heeled shoes
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14
Q

Clinical presentation of sesamoid fractures

A
  • Acute or chronic pain
  • Edema & ecchymosis
  • Pain w/weightbearing or dorsiflexion
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15
Q

Treatment of sesamoid fractures

A
  • Radiographs
  • Relieving direct or indirect pressure
  • Surgical intervention
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16
Q

CASE STUDY 1

- A 27 year old female gives the history of kicking a dog gate while upset and inebriated

A

What is the mechanism of injury?
o Oblique fracture

What should be considered when treatment this injury?
o Comminuted, displaced intra-articular fracture

Why surgical intervention vs conservative treatment?
o Surgical intervention with fixation is the best treatment option due to the comminuted displaced intra-articular fracture
o The patient is young and healthy, so she is a good candidate for surgery

17
Q

CASE STUDY 2

  • 35 year old female presents in the office with a painful right 2nd toe
  • Patient gives a history of running 10 miles, but started feeling pain in the toe after 6 miles
  • There is a hematoma present under the skin at the proximal nail
A
  • There is redness and swelling, likely due to mechanical trauma, but infection is a possibility
  • If the patient presents with this the day of or after the run, it is likely from mechanical trauma
  • If the patient presents 3-5 days after the run, it is more likely to be an infection and you could start an antibiotic
  • Culture is not necessary in a young healthy patient and prophylactic antibiotics can be started without culture, but if there is an odor or more than blood in the drainage from the hematoma
18
Q

CASE STUDY 3

- Open fracture of 1st left digit with exposed bone

A
  • Need to look for intact vasculature to determine whether or not you can save the digit
  • Cap fill time will give the most information on whether or not blood supply is present in the digit
19
Q

Nail anatomy

A
  • Nail matrix
  • Nail root
  • Cuticle
  • Nail plate
  • Distal edge of nail plate
  • Hyponychium
  • Nail bed
20
Q

MALAY CLASSIFICATION SYSTEM

A 
A = Primary onycholysis
B = Subungual hematoma 
C = Simple nail bed laceration 
D = Complex nail bed laceration 
E = Nail bed laceration with phalangeal fracture
21
Q

A = Primary onycholysis

A
  • Separation of nail plate

- Posterior nail fold friction injury (bleeding and sepsis)

22
Q

Treatment of onycholysis (A)

A
  • Removal of nail plate
  • Antisepsis
  • Antibiotics as needed
23
Q

B = Subungual hematoma

A
  • Blood clot
  • Must check for fractures
  • Treat injury as an open fracture
24
Q

Treatment of subungual hematoma (B)

A
  • X-rays

- Removal

25
Q

C = Simple nail bed laceration treatment

A
  • Antibiotics
  • Tetanus
  • Surgical cleansing and irrigation
  • Align the root and nail bed (repair w/ 6.0 absorbable on a traumatic
  • Nail plate may be reused if avulsed
26
Q

D = Complex nail bed laceration

A
  • Same as simple laceration with proximal nail fold defect
27
Q

Complex nail bed laceration treatment (D)

A
  • Addition of a rotational flap
28
Q

E = Nail bed laceration with phalangeal fracture treatment

A
  • Same as complex laceration with reduction of subungual fractures
  • Removal of bone spicules and nail fragments
29
Q

Level of tissue loss

A
  • Zone I: Distal to bony phalanx
  • Zone II: Distal to the lunula
  • Zone III: Proximal to distal end of lunula
30
Q

Directional planes of tissue loss

A
  • Dorsal (oblique)
  • Transverse
  • Plantar (oblique)
  • Axial (tibial or fibular oblique)
  • Central (Gouge)
31
Q

Treatment of zone I injuries

A
  • Allow wound to granulate

- STSG or FTSG

32
Q

Treatment of zone II injuries

A
  • Pedicle flaps (direction or plane of injury dictates type of flap)
  • Atasoy - type plantar
  • Kutler - type biaxial
33
Q

Look at pictures and know these types of closure flaps

A
  • Atasoy plantar V-Y
  • Atasoy-type plantar V-Y
  • Kutler type bi-axial V-Y
34
Q

Treatment of zone III injuries

A
  • Requires primary amputation

- Possible preservation of distal interphalangeal of interphalangeal joint

Emergency Med (14 decks)

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