Ambulatory Injuries

Question 1

What are the potential complications of an off-ended, closed clavicle fracture?

Answer 1

Peripheral neurovascular complications
May not heal (non-union) > pain and loss of function
Mal-union

Question 2

What is the management of an off-ended, closed clavicle fracture?

Answer 2

Early
- Splint > sling
- Adequate analgesia
Definitive
- Surgical fixation

Question 3

What are the Ottawa ankle rules?

Answer 3

Ankle x-ray needed if pain in malleolar zone AND any of
- Bone tenderness at posterior edge/tip of lateral malleolus
- Bone tenderness at posterior edge/top of medial malleolus
- Inability to bear weight both immediately after injury and in ED
Foot x-ray only needed if pain in malleolar zone AND one of
- Bone tenderness at base of 5th metatarsal
- Bone tenderness at navicular
- Inability to bear weight both immediately after injury and in ED

Question 4

What is the initial management of the sprained ankle?

Answer 4

RICE
- R = rest
- I = ice
- C = compression > also splinting > sometimes need plaster if too sore
- E = elevation
Analgesia
If improving, continue with their activity level
May need physiotherapy to strengthen muscles of ankles, and proprioceptive exercise

Question 5

What is the commonest carpal bone to fracture?

Answer 5

Scaphoid

Question 6

What commonly causes a scaphoid fracture?

Answer 6

Fall on outstretched hands > axial and rotation

Question 7

What other fractures are common with a fall on outstretched hands?

Answer 7

Radius fracture

Lunate dislocation > scapho-lunate ligament disruption

Question 8

What are the major complications of a scaphoid fracture?

Answer 8

Avascular necrosis
- Proximal scaphoid most in danger
- Because of retrograde blood supply
Intra-articular fracture > joint fluid effusion > washes away fracture haematoma

Question 9

What other bones are prone to avascular necrosis?

Answer 9

Lunate
Head of femur
Talus
Naviculum

Question 10

What are the clinical features of scaphoid fractures?

Answer 10

Tenderness
Paraesthesia in distribution of median nerve
Swelling

Question 11

What would you do if the clinical features of a fracture are present but the x-ray does not show a fracture?

Answer 11

Splint suspected area and sling
Analgesia
Rest
Come back in a week for another x-ray
If still doesn't show, can do MRI = gold standard

Question 12

What is the classical presentation of an Achilles tendon rupture?

Answer 12

Very painful ankle
Medial malleolus pressing on overlying skin > very pale
Heel drawn up
Foot plantar flexed
Significant bruising and swelling > bones intact

Question 13

What is the immediate management of a dislocated ankle?

Answer 13

Analgesia/anaesthesia
Reduce dislocated joint ASAP
Splinting
Further imaging to confirm reduction
Referral for further management

Question 14

How do you decide whether an ankle fracture requires operative management?

Answer 14

Absolute indication (for any fracture)
- Open fracture
- Neovascular compromise
Relative indication
- Talar shift >5 mm
- Fracture moved a certain amount
- Irregular/incongruent joint space
- Intra-articular fracture

Question 15

What is the Canadian C-spine rule?

Answer 15

Any high risk factors mandating radiography?
- >65 years
- Fall from >1 m/5 stairs
- Axial load
- MVA >100 km/hr, rollover or ejection from vehicle
- MVA involving recreational vehicle
- Bicycle collision
If yes > imaging
If no > any low risk factor allowing safe range of motion assessment?
- Simple rear-end MVA
- Sitting position in ED
- Ambulatory at any time
- Delayed onset of neck pain
- Absence of midline cervical spine tenderness
If no > imaging
If yes > able to actively rotate neck?
- 45 degrees to left and right
If no > imaging
If yes > no imaging needed