Assessing the acutely injured Flashcards
1
Q
Define major trauma
A
An injury or combination of injuries that are life-threatening and could be life-changing because it may result in long-term disability.
2
Q
Give some examples of major trauma
A
- Road traffic collisions.
- Injuries from sports or extreme sports or equestrianism.
- Fall from height.
- Assault.
- Workplace related injury.
3
Q
How would the handover be structured in major trauma?
A
iSBAR
ATMISTER (ambulance pre-alert):
- Age and sex of the injured person.
- Time of incident.
- Mechanism of injury.
- Injuries suspected.
- Signs (including vital signs and GCS).
- Treatment so far.
- Estimated time of arrival.
- special Requirements.
IMIST-AMBO (ambulance handover):
- Identification of patient.
- Mechanism of injury or medical complaint.
- Injuries or information related to the complaint.
- Signs (observations).
- Treatment or trends.
Pause for questions
- Allergies.
- Medications.
- Background.
- Other information.
4
Q
Which group of patients should you be cautious with in trauma situations?
A
- Children, young patients and athletes (high physiological reserve, so might not have big drops in BP or raise in HR).
- Elderly (may deteriorate quicker and have large drops in BP).
- Medications e.g. beta blockers.
5
Q
What are the cautions of exposing patients in major trauma?
A
- Hypothermia - can worsen haemorrhage.
- Missing any injuries.
6
Q
Outline resuscitation in major trauma
A
- Protect and secure airway.
- Adequate gas exchange and ventilation.
- Stop the bleeding.
- Blood volume resuscitation.
- Protect from hypothermia.
7
Q
What investigation would you use to assess bleeding from abdominal trauma?
A
- Focused abdominal sonography in trauma (FAST) - to identify the presence of haemoperitoneum.
- CT scan.
8
Q
What is an open book pelvis fracture?
A
Diastasis and/or a fracture of the pubic rami with a posterior pelvic disruption of the sacro-iliac joint - associated with pelvic haemorrhage.
9
Q
Which X-rays would you perform in a primary survey for major trauma?
A
CXR and pelvic x-ray
10
Q
What is the main mode of primary surgery investigation in major trauma?
A
CT scan within 30mins of arrival.
11
Q
Signs of basilar skull fracture
A
- Cerebrospinal fluid rhinorrhoea.
- Haemotympanum.
- Panda eyes.
- Battle’s sign (bruising of the mastoid process of the temporal bone).
- Cranial nerve palsy.
12
Q
Causes of tachypnoea in major trauma
A
- Chest injury (haemothorax, pneumothorax or flail chest).
- Direct airway injury or obstruction.
- Diaphragmatic rupture.
- Shock.
- Acidosis.
- Pain or anxiety.
13
Q
A sucking chest wound is indicative of what?
A
Open pneumothorax (from a penetrating chest injury).
14
Q
Describe a flail chest
A
Where multiple adjacent ribs are fractured in multiple places, a chest section becomes “detached” from the chest wall and moves paradoxically during respiration. While the rest of the chest is expanding during inspiration, decreased pressure pulls the flail segment inwards, and vice versa during expiration. This can cause significant pain, further injury to the lung, and difficulty breathing.
15
Q
What signs might indicate a fracture?
A
- Bruising
- Swelling
- Deformity
- Immobility
- Pain
16
Q
What are the signs of bladder injury?
A
Significant pain and suprapubic tenderness, blood at the urethral meatus, a “high riding” prostate, and haematuria.
17
Q
FATAL TRAUMA to exclude in secondary survey
A
- Flail chest
- Airway compromise
- Tamponade
- Air leaks
- Lung contusion
- Tracheal injury
- Ruptured diaphragm
- Aortic disruption
- Unseen haemorrhage
- Myocardial injury
- Any neurological injury
18
Q
How do you minimise risk of missed injuries?
A
- High index of suspicion.
- Frequent re-evaluation and monitoring.
19
Q
Define crush syndrome
A
- The systemic manifestation of rhabdomyolysis/muscle necrosis caused by prolonged continuous pressure or external compression on muscle tissue.
- It includes crush injury and compartment syndrome.
- It is characterised by hypovolaemic shock and hyperkalaemia.
- It can results in organ dysfunction such as AKI, DIC and metabolic acidosis.
20
Q
Outline the configuration of trauma services in England
A
- Regional trauma network.
- Major trauma centres (treats major trauma).
- Trauma units (treats mild-moderate trauma, but in some locations or circumstances intermediate care in a trauma unit might be needed for urgent treatment of major trauma).
21
Q
Does an extradural or subdural haematoma have a worse prognosis?
A
Subdural haematoma
22
Q
Which type of brain bleeds account for haemorrhagic stroke?
A
- Intracerebral haemorrhage.
- Subarachnoid haemorrhage.
23
Q
How to prevent secondary brain injury
A
Optimal management of airway, breathing and circulation.
24
Q
Why should pain, with regards to head injury, be effectively managed?
A
Because untreated pain can lead to raised ICP,
25
Depressed consciousness can only be ascribed to intoxication only after what?
A significant brain injury has been excluded.
26
What is the primary investigation of choice for detecting an acute clinically important TBI?
CT head
27
Define TBI
Traumatic brain injury - an alteration in brain function, or other evidence of brain pathology, caused by an external force.
28
Define pneumocephalus
The presence of air in the epidural, subdural, or subarachnoid space within the brain parenchyma or ventricular cavities.
29
What are the causes of pneumocephalus?
Head trauma (basal skull or sinus fractures), epidural injections or complications from neurosurgery.
30
Define subcutaneous emphysema
Infiltration of air underneath the dermal layers of skin.
31
What are the causes of subcutaneous emphysema?
Anaerobic infections, trauma to mucosal surfaces and alveolar rupture.
32
Define focal neurological deficit
Neurological problems restricted to a particular part of the body or a particular activity, for example:
- Difficulties with understanding, speaking, reading or writing.
- Decreased sensation.
- Loss of balance.
- Weakness.
- Visual changes.
- Nystagmus.
- Abnormal reflexes.
- Problems walking.
- Amnesia since the injury.
33
Define high-energy head injury
An injury arising from, for example, a pedestrian being struck by a motor vehicle, an occupant being ejected from a motor vehicle, a fall from a height of more than 1 m or more than 5 stairs, a diving accident, a high-speed motor vehicle collision, a rollover motor accident, an accident involving motorised recreational vehicles, a bicycle collision or any other potentially high-energy mechanism.
34
Outline the red flag features of cauda equina syndrome
- Saddle anaesthesia (loss of sensation in the perineum – around the genitals and anus).
- Loss of sensation in the bladder and rectum (not knowing when they are full).
- Urinary retention or incontinence.
- Faecal incontinence.
- Bilateral sciatica.
- Bilateral or severe motor weakness in the legs.
- Reduced anal tone on PR examination.
35
Outline questions to ask for head injury
- Mechanism of injury.
- Loss of consciousness.
- Amnesia before or after injury.
- Vomiting.
- Seziures.
- Visual disturbance, speech disturbance, weakness in limbs, sensory problems.
- Alcohol or illicit drug use.
- PMHx e.g. epilepsy or bleeding disorders.
- Anticoagulant use.
- Any other injury or pain (especially neck).
36
What examination would you perform for a head injury and what signs are you looking for?
- Observations and GCS.
- Pupillary response.
- Assess wounds and bruising.
- Signs for open or depressed skull fracture.
- Signs for basal skull fracture.
- General neurological examination.
- Assessment of neck.
37
How should a head injury be managed?
- Analgesia.
- Wound care.
- CT (if indicated).
- Referral to neurosurgery unit (if indicated).
- Period of head injury observation until GCS returns to normal.
- Written head injury advice when discharged.
38
Outline protective strategies to minimise secondary brain injury
- Intubate patients with a low GCS in order to maintain and protect their airway.
- Avoid hypoxia and maintain PaO2 >13 kPa.
- Aim for PaCO2 in normal range (4.5-5 kPa).
- Tape endotracheal tube in place as opposed to tying them so as not to obstruct venous drainage.
- Avoid excessive intra-thoracic pressures.
- Avoid hypotension and maintain MAP ≥90 mmHg using vasopressors as necessary.
- Avoid hypoglycaemia and replace glucose as necessary.
- Treat seizures; paralyse if necessary.
- Nurse with 30 degrees head-up tilt, neck inline to improve venous drainage and reduce ICP without compromising CPP.
- Avoid cervical collars if possible.
- Consider mannitol 20% 500 ml IV to reduce ICP.
- Ensure adequate analgesia to avoid rises in ICP.
- Aim for normothermia.
39
Which bones are vulnerable to avascular necrosis, impaired healing and non-union?
- The scaphoid bone.
- The femoral head.
- The humeral head.
- The talus, navicular and fifth metatarsal in the foot.
40
What are the 2 important principles to remember when applying a plaster cast?
- For the first 2-weeks, plasters are not circumferential (not always the case in children). They must have an area which is only covered by the overlying dressing, to allow the fracture to swell; if this principle is not adhered to, the cast will become tight (and subsequently painful) overnight, and if left the patient is at risk of compartment syndrome.
- If there is axial instability (whereby the fracture is able to rotate along its long axis), such as combined tibia-fibula metaphyseal fractures or combined radius-ulna metaphyseal fractures, the plaster should cross both the joint above and below. These are usually termed ‘above knee’ or ‘above elbow’ plasters, respectively, preventing the limb to rotate on its long axis; for most other fractures, the plaster need only cross the joint immediately distal to it.
41
Describe the anatomy of the wrist
The radiocarpal (wrist) joint is a synovial joint formed by the distal articular surface of the radius and the articular disc with the scaphoid, lunate and triquetrum.
42
Name two extra-articular and one intra-articular wrist fractures
- Extra-articular: Colle’s and Smith’s.
- Intra-articular: Barton’s.
43
When does a fracture need surgical fixation?
If it is intra-articular, severely displaced, significantly comminuted or significant shortening.
44
As a general rule, how are volar angulated wrist fractures managed?
Open reduction and plate fixation - because they are inherently unstable.
45
What is the MOA of bisphosphonates?
Reduce osteoclast activity, preventing bone reabsorption.
46
Name the side effects of bisphosphonates
- Reflux and oesophageal erosions.
- Atypical fractures (e.g. atypical femoral fractures).
- Osteonecrosis of the jaw.
- Osteonecrosis of the external auditory canal.
47
How can tibial plateau fractures arise?
Valgus or varus forces.
48
What is the time frame for hip fracture surgery?
Within 48 hours
49
Why are intra-capsular hip fractures at risk of AVN of femoral head?
Because the fracture can damage the retinacular vessels supplying the femoral head, causing ischaemia and necrosis.
50
Management of displaced intra-capsular neck of femur fractures?
Hemiarthroplasty or total hip replacement.
51
What is the main blood supply to the femoral head?
Retinacular vessels
52
Which artery supplies the femoral epiphysis, but becomes obliterated in adult life?
Foveal artery
53
Define lisfranc injury
A Lisfranc injury is a tarsometatarsal fracture dislocation characterised by traumatic disruption between the articulation of the medial cuneiform and base of the second metatarsal.
54
The medial meniscus is attached to what?
The MCL.
55
Which tests were previously used for meniscal tears?
- McMurray’s test involves the patient lying supine. The examiner takes the leg and flexes the knee. While internally rotating the tibia (by turning the foot inwards) and applying varus pressure to the knee (applying outward pressure to the inside of the knee), carefully extend the knee. Pain or restriction indicates lateral meniscal damage. Repeating the flexed to extended movement with external rotation of the tibia and valgus (inward) pressure on the knee tests for medial meniscal damage.
- The Apley grind test involves the patient lying prone and flexing the knee to 90 degrees with the thigh flat on the couch. Downward pressure is applied through the leg into the knee, and the tibia is internally and externally rotated at the same time. Pain indicates a positive result, suggesting meniscal damage. The pain is localised to the area of damage (e.g., medial or lateral meniscus).
56
How do ACL injures typically occur?
Sudden change of direction twisting the flexed knee.
57
Which fracture of pathognomic of an ACL tear?
Segond fracture (bony avulsion of the lateral proximal tibia).
58
What is the ‘terrible triad’ for knee injury?
Tear of ACL, medial meniscus and MCL.
59
Management of patella fracture
- Conservative if non-displaced or minimally displaced - brace or cylinder cast.
- Surgery if significant displacement or compromise to extensor mechanism - open reduction and internal fixation with tension band wiring.
60
Name 2 complications of a patella fracture
- Loss of range of motion in knee.
- Secondary OA.
61
Define subluxation
Partial dislocation
62
Which nerve roots does the axillary nerve originate from?
C5 & C6
63
What is the apprehension test?
The apprehension test is a special test to assess for shoulder instability, specifically in the anterior direction. It is likely to be positive after previous anterior dislocation or subluxation of the shoulder. This may be performed after recovery from any acute injuries.
The patient lies supine. The shoulder is abducted to 90 degrees, and the elbow is flexed to 90 degrees. The shoulder is then slowly externally rotated in this position while watching the patient. As the arm approaches 90 degrees of external rotation, patients with shoulder instability will become anxious and apprehensive, worried that the shoulder will dislocate. There is no pain associated with the movement, only apprehension.
64
The ‘light bulb sign’ suggests what type of dislocation?
Posterior shoulder dislocation
65
Why should shoulder relocations occur as soon as safely possible?
Because muscle spasm occurs over time, making it harder to relocate the shoulder and increasing the risk of neurovascular injury during relocation.
66
What is a rotator cuff tear?
Injury to the tendons of the rotator cuff muscles. The tendon may be partially or fully torn.
67
Name the function of the rotator cuff muscles
- Supraspinatus – abducts the arm.
- Infraspinatus – externally rotates the arm.
- Teres minor – externally rotates the arm.
- Subscapularis – internally rotates the arm.
68
Symptoms of rotator cuff tear
- Shoulder pain.
- Weakness and pain with specific movements relating to the site of the tear.
69
Management of rotator cuff tears
- Conservative: rest, NSAIDs, physiotherapy.
- Surgery e.g. arthroscopic rotator cuff repair.
70
Clinical features of clavicle fracture
- Sudden-onset localised pain.
- Open fracture or tenting of skin.
71
Management of clavicle fractures
- Non-surgical: sling.
- Surgical for open fractures.
72
What is the major complication from clavicle fractures?
Non-union
73
What is an AC joint separation?
Dislocation of clavicle from acromion.
74
What can cause AC joint separation?
From a fall directly onto shoulder.
75
Why can flexion of elbow still remain during a biceps tendon rupture?
Due to action of the brachialis and supinator muscles.
76
List the differentials for septic arthritis
- Rheumatoid arthritis.
- Osteoarthritis.
- Gout (joint fluid shows urate crystals that are negatively birefringent of polarised light).
- Pseudogout (joint fluid shows rod-shaped calcium pyrophosphate crystals that are positively birefringent).
- Drug-induced arthritis.
- Haemarthrosis (bleeding into the joint, usually after trauma).
- Reactive arthritis (typically triggered by urethritis or gastroenteritis and associated with conjunctivitis).
- Lyme disease.
77
Outline treatment of nerve damage
- Non-surgical: analgesia, braces/splints, electrical stimulation, physiotherapy.
- Surgery e.g. peripheral nerve graft, peripheral nerve transfer.
78
Outline treatments for arterial damage
- Surgery: resection and anastomosis, resection and graft, embolisation, direct vascular suture, bypass, vessel ligation.
79
Recognise fractures in children that might lead to abnormalities in growth and deformity
Growth plate fractures (most commonly in fingers, forearm and lower leg).
Aka metaphyseal fractures.
80
Evaluate the possibility of fractures as an indicator of non-accidental injury including domestic violence
- Metaphyseal fractures.
- Posterior rib fractures or occult rib fractures.
- Multiple fractures at different stages of healing.
- Spiral fractures.
- Humeral, radial or femoral fractures.
81
Outline risk factors for fractures
- Advancing age.
- Previous fractures.
- Falls/trauma.
- Steroid use.
- Osteoporosis.
82
Describe approaches to prevent fractures
- Maximise bone strength (bisphosphonates, vitamin D, calcium).
- Preventing falls (home adaptions, correct eyewear and footwear).
- Physiotherapy.
- Exercise.
83
Describe features of an elbow dislocation
- Present following a high-energy fall.
- Painful and deformed joint.
- Swelling and decreased function (difficulties in full extension).
- Potential ulnar nerve injury.
84
How would you manage an elbow dislocation?
- Analgesia +/- sedation.
- Closed reduction via in line traction method or via manipulation of the olecranon.
- Post-reduction X-ray to confirm.
- Short period of immobilisation.
- Early rehabilitation.
85
How could tell if there was soft tissue damage following an elbow dislocation?
- If the lateral collateral ligament is damaged the elbow will be more stable in pronation.
- If the medial collateral ligament is disrupted the elbow will be more stable in supination.
86
Describe the terrible triad of elbow dislocation
(1) lateral collateral ligament injury
(2) radial head fracture
(3) coronoid fracture
87
What is a complication of untreated compartment syndrome?
Tissue necrosis
88
What causes acute compartment syndrome?
- Cush injures
- Fractures
89
What are the 5 P’s for compartment syndrome?
- Pain “disproportionate” to the underlying injury, worsened by passive stretching of the muscles
- Paresthesia
- Pale
- Pressure (high)
- Paralysis (a late and worrying feature)
90
Outline management of compartment syndrome
- Escalating to the orthopaedic registrar or consultant
- Removing any external dressings or bandages
- Elevating the leg to heart level
- Maintaining good blood pressure (avoiding hypotension)
- Emergency fasciotomy within 6 hours
- Debride any necrotic muscle tissue
91
Burns vs. Scalds
- A burn is an injury caused by exposure to thermal (heat), electrical, chemical, or radiation energy.
- A scald is a burn caused by contact with a hot liquid or steam.
92
What are the burns red flags for non-accidental injury?
- Explanation for the injury is absent or unsuitable.
- The person is not independently mobile.
- The injury is on any soft tissue area that would not be expected to come into contact with a hot object in an accident (for example, the backs of hands, soles of feet, buttocks, or back).
- The injury is in the shape of an implement (for example, a cigarette or iron from a contact burn).
- The injury indicates forced immersion, for example, scalds: To the buttocks, perineum, and lower limbs. To limbs in a glove or stocking distribution. To limbs with a symmetrical distribution. With sharply delineated borders.
93
What are two complications from eschar?
Constrictive eschar on the leg may cause limb ischaemia, and around the chest causes respiratory distress.
94
Why are skin grafts used in the treatment of burns?
To prevent hypertrophic scars and contractures forming.
95
Skin graft vs. Skin flap
- Skin graft receives its blood supply from the recipient site though the vascular bed.
- Skin flap brings its blood supply from the flap donor site.
96
What risks are associated with electrical burns?
Arrhythmia and myoglobinuria
97
What is the most important initial management for chemical burns?
Immediate irrigation of the affected area, using warm water for at least 30 mins.
98
How can up you reduce the risk of Curling’s ulcer forming?
PPIs
99
What is the cauda equina?
The collection of nerve roots after the spinal cord terminates at L2/L3.
100
What is the name for when the spinal cord tapers down at the end before the cauda equina?
Conus medullaris
101
What is the function of the cauda equina?
- Sensation to the lower limbs, perineum, bladder and rectum.
- Motor innervation to the lower limbs and the anal and urethral sphincters.
- Parasympathetic innervation of the bladder and rectum.
102
Is cauda equina an UMNL or LMNL?
LMNL
103
Metastatic spinal cord compression vs cauda equina syndrome
- Metastatic lesion compresses the spinal cord (not compression of cauda equina).
- Presents with back pain and motor and sensory signs and symptoms. A key feature is back pain that is worse on coughing or straining.
- UMNL signs e.g. increased tone, brisk reflexes and upping plantar responses.
- Treatment: high dose dexamethasone, analgesia, surgery, radiotherapy, chemotherapy.
104
Define gangrene and its types
Localised necrosis of bodily tissues, commonly occurring at the extremities, due to hypoperfusion or a serious infection.
- Dry: tissue is dry. Usually evidence of shrunken, black, necrotic tissue. Often from ischaemia (lack of blood supply).
- Wet: tissue is wet. Usually evidence of oedema, ulceration, and exudate. Often due to a necrotising infection.
105
What is the organism in cat scratch disease?
Bartonella henselae
106
Investigations for animal bites?
- X ray of affected region.
- Bloods.
- Swabs if purulent.
107
Management of animal bites?
- Clean wound with normal saline and consider need for debridement.
- Tetanus booster.
- Assess risk of rabies.
- Oral antibiotics (co-amoxiclav) if broken skin.
108
What is the investigation of choice for suspected cauda equina syndrome?
Urgent MRI spine
109
What is the most common cause of cauda equina syndrome?
Herniation of an intravertebral disc
110
What are the other causes for cauda equina syndrome?
- Tumours: primary or metastatic
- Infection: abscess, discitis
- Trauma
- Haematoma
111
First-line management of an open fracture
IV antibiotics and surgical debridement
112
What is the management for a grade 1/2 AC joint injury?
Conservative with rest and sling
113
Management of ankle fractures
- Weber A: 99% of times CAM boots with weight bearing.
- Weber B: need radiograph (mortis view) to assess syndesmosis + mortis for ankle stability. It there is instability as ligaments are affected, then surgery. If not, then CAM boot.
- Weber C: 99% of times fracture will involve syndesmosis -> ankle instability -> required surgery (ORIF).
114
What is the main neurovascular structure compromised in a scaphoid fracture?
Dorsal carpal branch of the radial artery.
115
What are the signs of a scaphoid fracture?
- Point of maximal tenderness over the anatomical snuffbox.
- Wrist joint effusion.
- Pain elicited by telescoping of the thumb (pain on longitudinal compression).
- Tenderness of the scaphoid tubercle (on the volar aspect of the wrist).
- Pain on ulnar deviation of the wrist.
116
What is the initial management of a scaphoid fracture?
Immobilisation with a Futuro splint or standard below-elbow backslab.
117
What is the orthopaedic management for a scaphoid fracture?
- Undisplaced: cast for 6-8 weeks.
- Displaced: surgical fixation.
- Proximal scaphoid pole fractures: surgical fixation.
118
What is the most common cause of knee pain, particularly in runners?
Iliotibial band syndrome
119
Severe acute limb pain that is worsened on both active and passive movement, along with an inability to weight bear following trauma should raise suspicion of what?
Compartment syndrome
120
Compartment syndrome is most commonly associated with which fractures?
Supracondylar fractures and tibial shaft fractures.
121
What is the name for when the scaphoid and lunate bones move out of alignment?
Scapholunate dissociation
122
Galeazzi fracture?
Fracture of the middle to distal one-third of the radius associated with dislocation or subluxation of the distal radioulnar joint.
123
Monteggia fracture?
Fracture of the proximal ulna associated with a dislocation of the radial head.
124
Name for an isolated fracture of the ulnar shaft?
Nightstick fracture
125
Where is the most common site for osteomyelitis in adults and children?
- Adults: epiphysis
- Children: metaphysis of long bone
126
What is the most common type of intracapsular fracture of the proximal femur?
Subcapital fracture
127
A 22-year-old male presents to the emergency room with pain in the left knee following a twisting injury during a rugby match. He states that it has gradually swollen over the past 24 hours, and he is unable to fully extend it. On examination you note tenderness over the medial joint line, a joint effusion, and the joint is held in a flexed position. There is no laxity on valgus stress test.
What is the most likely diagnosis?
Medial meniscus tear
128
If a rib fracture isn’t controlled by normal analgesia (e.g. paracetamol, NSAIDs, morphine), what else can be done to manage the pain?
Nerve blocks
129
Diagnostic test for rib fractures?
CT scan
130
A 56-year-old man undergoes a low anterior resection with legs in the Lloyd-Davies position. Post operatively he complains of foot drop.
Peroneal nerve
131
A 23-year-old man complains of severe groin pain several weeks after a difficult inguinal hernia repair.
Ilioinguinal nerve
132
A 72-year-old man develops a foot drop after a revision total hip replacement.
Sciatic nerve
133
What is the most common complication of fracture of mid shaft of the humerus?
Radial nerve injury
134
Supracondylar fracture of humerus
- Posterior displacement of distal fragment is most common.
- Varus deformity following malunion is common.
- Neurological complications are transitory.
135
Which muscle makes it difficult to maintain reduction of Bennett's fracture because of its pull?
Abductor pollicis longus
136
What is the commonest cause of a loose body in the knee joint?
Meniscus tear
137
What are the triad of symptoms for fat embolism?
- Respiratory e.g. tachycardia, tachypnoea, pyrexia.
- Neurological e.g. confusion, agitation, retinal haemorrhages.
- Petechial rash (tends to occur after the first 2 symptoms).
138
A hyper-extension knee injury commonly results in what?
ACL rupture
139
What is a boxers fracture?
Fracture of the neck of the fourth or fifth metacarpal with volar displacement of the metacarpal head.
140
What is a Bennett’s fracture?
Intra-articular fracture at the base of the thumb metacarpal
141
What is a Barton’s fracture?
Distal radius fracture (Colles'/Smith's) with associated radiocarpal dislocation.
142
Describe the features of Osteochondritis dissecans
- Knee pain and swelling, typically after exercise
- Knee catching, locking and/or giving way: more constant and severe symptoms are associated with the presence of loose bodies
- Feeling a painful 'clunk' when flexing or extending the knee - indicating the involvement of the lateral femoral condyle
- Joint effusion
- Tenderness on palpation of the articular cartilage of the medial femoral condyle, when the knee is flexed
- Wilson's sign for detecting medial condyle lesion - with the knee at 90° flexion and tibia internally rotated, the gradual extension of the joint leads to pain at about 30°, external rotation of the tibia at this point relieves the pain
143
Sudden popping sound during athletic activity leading to knee pain, swelling and instability
ACL injury
144
What is the most commonly injured knee ligament?
ACL
145
What are the common mechanisms of injury for ACL injury?
- Lateral blow to the knee.
- Skiing.
- Non-contact injuries (e.g. sudden twisting or awkward landing).
146
Limb shortening and internally rotated leg
Posterior hip dislocation
147
Presentation of anterior hip dislocation?
Leg abducted and externally rotated
148
Name a complication of a posterior hip dislocation
Sciatic nerve injury
149
What is Simmonds' Triad of tests for Achilles tendon rupture?
Palpable gap, examining the angle of declination at rest and the calf squeeze test.
150
First line investigation for occult hip fractures?
MRI
151
Name risk factors for avascular necrosis of femoral head
- Long-term steroid use
- Chemotherapy
152
Colles’ fracature
Dorsally Displaced Distal radius → Dinner fork Deformity
153
What is a common complication of Colles’ fracture?
Median nerve injury
154
How can compartment syndrome lead to an AKI?
Increased pressure in the fascial compartment may lead to muscle breakdown and release of myoglobin into the bloodstream, due to rhabdomyolysis. Deposition of myoglobin in the renal tubules causes an AKI, with myoglobinuria causing dark, brown urine, which dips positively for blood.
155
A 23-year-old male with no past medical history presents to the emergency department immediately after a high-speed motor vehicle accident. He was found on the side of the road after his motorbike collided with a car.
He has received morphine for analgesia and 500ml 0.9% NaCl as an IV bolus. He is alert and complaining of pain in his abdomen and back from the accident.
His heart rate 53 beats per minute, respiratory rate of 20 breaths per minute and blood pressure 83/45 mmHg. Heart sounds one and two are present with no added sounds. There are vesicular breath sounds throughout the chest, with equal air entry bilaterally. He is peripherally warm with a capillary refill time <2 seconds. No external signs of haemorrhage are seen on full exposure.
A point-of-care ultrasound examining the liver, spleen, kidney and heart demonstrated no abnormalities. Electrocardiogram demonstrates normal sinus rhythm with no ST-segment or T-wave abnormalities.
What is the most likely aetiology of his shock?
Neurogenic shock - spinal cord transection after trauma - bradycardia.
156
Fluctuating confusion/consciousness after head injury
Subdural haematoma
157
A 19-year-old sportswoman presents with knee pain which is worse on walking down the stairs and when sitting still. On examination there is wasting of the quadriceps and pseudolocking of the knee.
Chondromalacia patellae
158
A tall 18-year-old male athlete is admitted to the emergency room after being hit in the knee by a hockey stick. On examination his knee is tense and swollen. X-ray shows no fractures.
Dislocated patella
159
An athletic 15-year-old boy presents with knee pain of 3 weeks duration. It is worst during activity and settles with rest. On examination there is tenderness overlying the tibial tuberosity and an associated swelling at this site.
Osgood Schlatters disease
160
What is the most common site of osteomyelitis in children?
Metaphysis - highly vascular area.
161
What is the recommended first line method of analgesia for a NOF#?
An iliofascial nerve block
162
Presentation of cauda equina syndrome
Lower back pain, sciatica, reduced perianal sensation
163
What is a late sign in cauda equina syndrome?
Urinary incontinence
164
Weakness of hip abduction and foot drop, no specific reflex lost
L5 radiculopathy
165
Sudden popping sound during athletic activity → knee pain, swelling and instability
?ACL injury
166
What is the first-line investigation for a suspected osteoporotic vertebral fracture?
X-ray of the spine
