C Spine And Spinal Injuries,tetanus And Orthopedic Injuries

Question 1

Which parts of the spine are lordotic and which are kyphotic
Look at pictures on the internet to understand better
How many vertebrae are in each spinal region(cervical,thoracic,lumbar,sacrum,coccyx) in all it’ll be 33 vertebrae

Answer 1

The cervical spine curves slightly inward, sometimes described as a backward C-shape or lordotic curve.
The thoracic spine curves outward, forming a regular C-shape with the opening at the front—or a kyphotic curve.

The lumbar spine curves inward and, like the cervical spine, has a lordotic or backward C-shape.

imagine a crunchy breakfast at 7 am (7 cervical vertebrae), a tasty lunch at 12 noon (12 thoracic vertebrae), and a light dinner at 5 pm (5 lumbar vertebrae). 5 for sacrum and 4 for coccyx (SnaCk at 9pm)

Question 2

The vertebrae is made up of?
What is responsible for the stability of the cervical spine ?
How many parts do you have to disrupt for the cervical spine to be unstable?
What is responsible for stability of the thoracolumbar spine and how many parts do you have to disrupt for the thoracolumbar spine to be unstable

Answer 2

Vertebrae = Body + Arch
Vertebral Arch:
Pedicles
Laminae
Processes

Stability:
Anterior column
Posterior column

You have to disrupt both columns to be unstable

Thoracolumbar Spine :
according to Denis Classification-
1.Anterior Column
2.Middle Column
3.Posterior Column

Disrupt 2 columns to be unstable

Question 3

Learn how to read C spine X rays
(ABCDS approach)
What is retrolisthesis and anteriolisthesis

Answer 3

Retrolisthesis is the backward slippage of one vertebral body with respect to the subjacent vertebra. This slippage can lead to spinal nerve root compression or irritation (radiculopathy). Retrolisthesis happens when a vertebral body slips backwards;
Anterior vertebral body of C spine shifts to the posterior part

Anterolisthesis is essentially a misalignment of the spinal vertebrae, referring to the anterior displacement (forward slip) of the vertebral body in the spinal column. Anterolisthesis is a condition where a vertebra in the spine slips forward in relation to the vertebra below it.

Question 4

Flexion injuries involving C1-C2 can cause what type of dislocation
Simple wedge fractures are stable true or false

Answer 4

Flexion injuries involving C1-C2 can cause atlantooccipital or atlantoaxial dislocation, with or without fracture of the odontoid
Atlas = C1, Axis = C2
Unstable due to the location and relative lack of muscle and ligamentous support

True

Question 5

State three examples of c spine flexion injuries,vertical compression injuries
What type of injury is a hangman’s fracture

Answer 5

Flexion Injuries:
Wedge compression fracture*
Flexion teardrop fracture*
Clay Shoveler’s Fracture*
Bilateral Facet Dislocation

Flexion Rotation:
Unilateral facet dislocation

Vertical Compression:
Jefferson Burst Fracture*
Burst Fractures of Lower Cervical Spine*

Hyperextension Injuries:
Avulsion fracture of anterior arch of atlas
Extension teardrop fracture
Posterior arch of atlas fracture
Laminar fracture
Hangman’s Fracture*

Lateral Flexion:
Uncinate Process Fracture

Upper C-spine Injuries:
Occipitoatlantal dissociation

Question 6

State the types of injuries that can happen to the thoracic and lumbar spine
What are chance fractures?

Answer 6

Compression Fractures
Burst Fractures
Flexion Distraction Fractures or chance fractures

Chance fractures also referred to as seatbelt fractures, are flexion-distraction type injuries of the spine that extend to involve all three spinal columns. These are unstable injuries and have a high association with intra-abdominal injuries.

Question 7

What is a complete spinal cord injury?
What about incomplete?
State four types of incomplete spinal cord lesions
Which spinal cord tract is responsible for pain or temperature
Which is responsible for vibration and proprioception?

Answer 7

Complete SCI = No motor or sensory function below injury level
Incomplete SCI = Any Sensory/motor function below level of injury

Spinal Cord Tracts
Corticospinal tract = Descending motor pathway
(Ascending pathway)Spinothalamic tract (anterior)= Pain/Temperature,
(Ascending pathway)Dorsal Column Pathway = Vibratory/Proprioception,two point discrimination

Ascending is sensory stuff and descending is motor stuff
3 main ascending tracts and one main descending tract

Incomplete spinal cord lesions;
Anterior spinal cord syndrome
Posterior spinal cord syndrome
Central Cord syndrome
Brown Sequard Syndrome

Question 8

Pathophysiology of spinal cord trauma

Answer 8

Primary Injury:
Mechanical Injury

Secondary Injury:
Vascular Abnormalities
Free Radicals/Lipid Peroxidation
Excitotoxicity
Electrolyte disturbances
Inflammation

Edema

Question 9

Explain anterior spinal cord syndrome (which tracts are injured and the effects of the injury of those tracts)
State four causes of anterior spinal cord injury

Answer 9

Anterior Spinal Cord Syndrome:
Corticospinal and spinothalamic tracts injured (can’t feel pain and problem with temperature regulation, motor function too is injured)
Preservation of posterior column pathway(so patient still has vibration and proprioception below the level of the injury)

Etiology:
Anterior spinal cord trauma
Flexion of cervical spine causing cord contusion
Thrombosis of anterior spinal artery

Injuries to the lateral corticospinal tract results in ipsilateral paralysis (inability to move), paresis (decreased motor strength), and hypertonia (increased tone) for muscles innervated caudal to the level of injury. The lateral corticospinal tract can suffer damage in a variety of ways. The most common types of injury are central cord syndrome, Brown-Sequard syndrome, and anterior spinal cord syndrome.

If the corticospinal tract is interrupted in the cerebrum, voluntary movement of the limbs is limited on the contralateral side of the body

Question 10

Explain posterior spinal cord syndrome
State two causes of this syndrome

Answer 10

Posterior Spinal Cord Syndrome:
Rare condition
Injury to dorsal column(patient loses vibration and proprioception)
Preservation of corticospinal and spinothalamic pathways

Etiology:
Penetrating trauma to posterior aspect of cord
Hyperextension injury with vertebral arch fracture

Question 11

Explain central spinal cord syndrome
State two causes of this syndrome

Answer 11

Central Cord Syndrome
Injury preferentially affects central portion of cord
Loss of function of central fibers of corticospinal and spinothalamic tracts
Decreased strength and pain/temperature of upper extremities compared with lower extremities
Etiology
Hyperextension injuries
Central spinal stenosis
Disruption of normal blood flow

Question 12

Explain brown sequard syndrome
State two causes of this syndrome

Answer 12

Brown Sequard Syndrome:
Transverse hemisection of spinal cord
Ipsilateral loss of motor function, proprioceptive/vibratory sensation
Contralateral loss of pain/temperature sensation

Etiology = Penetrating injury or Lateral cord compression

Question 13

What’s the difference between spinal shock and neurogenic
What is the classic triad of neurogenic shock

Answer 13

Spinal Shock: cord hasn’t lost its function it’s just been shocked
Temporary phenomenon characterized by loss of all spinal cord function caudal to level of injury
Symptoms = Flaccid paralysis, Hypotonia, Areflexia, Priapism
Typical duration = 24-72 hours
Resolution = Return of Bulbocavernosus reflex
Outcome = Spastic paresis, hyper-reflexia

Neurogenic Shock
Type of distributive shock characterized by loss of adrenergic tone due to sympathetic denervation
Classic Triad = Hypotension, Bradycardia, Hypothermia
Management = IVF, Vasopressor support, Atropine

Spinal Shock- the flaccidity and loss of reflexes seen after spinal cord injury. The cord may appear destroyed but actually may regain function latter
Neurogenic Shock- destruction of the descending sympathetic pathways of the spinal cord. Results is hypotension and bradycardia. Pts will require vasopressors and atropine as well as fluid.

Question 14

How do you manage C spine and spinal cord injuries ?
When do you immobilize the c spine?

Answer 14

Immobilization
Clinical C-spine Clearance:
When to get images(Nexus criteria + 45 45 degrees turn of neck to clear C spine)

If patient is intoxicated, you’re not sure if patient has c spine injury and in every trauma, immobilize c spine
Make sure patient doesn’t move the head or neck or body till person can get a neck collar

Patient will wear c collar for 2 weeks on discharge with the an NSAID for pain felt in neck (but it’s not midline tenderness) if nothing is seen on CT

Thoracic and Lumbar Spinal Immobilization and Clearance
Management of Cervical and Thoracolumbar fractures without spinal cord injury

Question 15

What are the aims of immobilization?
State the areas for
Immobilization

Answer 15

Prevent further damage - Protect the Cord
Hold the spine in a comfortable, anatomically correct way
Prevent movement of the spine
Allow for safe concurrent management of other injuries

Keep immobilizing till Immobilization of the entire spinal column is necessary in patients until a spinal cord/column injury has been excluded or until the appropriate treatment has been initiated
A combination of rigid cervical collar with supportive blocks on a rigid backboard with straps is effective at achieving safe, effective spinal immobilization for transport
Spinal immobilization devices are effective but can result in patient morbidity. They should be used for safe extrication and transport, but should be removed as soon as definitive evaluation is accomplished or treatment initiated

Anatomical Regions:
Head
Neck
Body

Question 16

How do you immobilize the head?
Methylprednisolone therapy for acute spinal cord injury is controversial with only benefit when administered within 8 hours of injury
True or false

Answer 16

Manual - Hands, Legs
Simple Assist Devices - Sandbags, Towels, Foam Pads
Additional Devices - Straps
Head/Neck immobilizer

Better to immobilize whole body

Question 17

What is used to immobilize c spine

Answer 17

Collars:
Philadelphia
Stiffneck
Other options

Ann Emerg Med 1992; 21: 1185-1188
Compared C collar with Ammerman Halo orthosis, with and without spine board
Photographic comparison during transport
Conclusion:
A rigid cervical collar and a spine board provide significantly better immobilization than the collar alone. Further immobilization is provided by an Ammerman halo orthosis

Question 18

What is used to immobilize the body
State three complications associated with c spine immobilization

Answer 18

Backboards:
Important for transporting patients and keeping them from possibly injuring themselves further

Complications:
Pain- pain can make you not breathe well
Increased risk of pressure sores
Aspiration and limited respiratory function
Increased risk of aspirating emesis while strapped on backboard
Marked pulmonary restrictive effect of appropriately applied entire body spinal immobilization devices

Question 19

When do you get an x ray of the c spine
What is the most common view used in seeing c spine injuries

Answer 19

Patients involved in a traumatic event:
with midline tenderness
With neurologic deficits
Altered level of consciousness
Patients who are intoxicated

Lateral View
Must see to the top of T1 for film to be adequate
May need swimmers view
Will see 90% of cervical spine fractures

Odontoid view
Must include entire process and right and left c1 and c2 articulations

Question 20

When will you want to get a flexion and extension film in spinal cord injuries
When will you do a CT?

Answer 20

Obtained in injured pts without an AMS, and pts who have neck pain without fracture on AP, Lateral and odontoid views
Looking for
Instability
Ligamentous spine injury

CT
More Sensitive
If high suspicion for injury and have inadequate x-ray, CT is warranted

Question 21

How do you clear a C spine injury?

Answer 21

Two studies- NEXUS vs. Canadian C spine

Nexus :
Patients required to meet 5 criteria
No mid-line tenderness
No focal neurological deficit
Normal alertness
No intoxication
No painful, distracting injury

Canadian c spine:

Canadian C Spine Rule:

Is there Any high-risk factor that mandates radiography?
Age more than or equal to 65 years, or dangerous mechanism, or paresthesias in extremities

If No,(if yes, do radiography))

Is there Any low-risk factor that allows safe assessment of range of motion?
Simple rear-end motor vehicle collision, or sitting position inthe emergency department, or ambulatory at any time, or delaved (not immediate) onset of neck pain, or absence of midline cervical-spine tenderness

If Yes(if no do radiography)

Is patient Able to rotate neck actively?
45 degrees left and right

If Yes (so if no,do radiography)

No radiography

Question 22

What are the problems with the nexus rule

Answer 22

Problems:
Management stressors
Failure to discriminate what pain is significant
What is a distracting injury?
How drunk is intoxicated?

Question 23

What are some of the problems of Canadian c spine

Answer 23

The authors conclude that the CCR decision rule is more sensitive than NEXUS for identification of clinically important C-spine injuries and also is more specific, thereby decreasing the number of unnecessary C-spine radiographs

Problems include
Requires active neck rotation (10% excluded)
What is a “Dangerous Mechanism”?

Question 24

State the two main mechanisms of fractures with three examples under each

Answer 24

1.DirectTrauma: Linear
fracture with two fragments and
little or no soft tissue damage
• “Tapping” Fracture–E.g.
Nightstick
• Crush Fracture:
 Comminuted or transverse
fracture
 Extensivesofttissue
damage
• PenetratingFracture: (seen with GSW or missle
wounds). High velocity injuries
with fragmentation
of bone. Bone fragments act
as secondary missiles, causing
cavitation and extensive soft
tissue injury. Also Low
velocity injuries with mild
fragmentation

2.Indirect Trauma
• Traction Fracture:Bone is pulled apart= Transverse fracture
• Angulation Fracture:Bending alongthe long axis
of the bone =Transverse fracturewith concave surface
• Compression
Fracture:Compression
on long axis of the bone from axial loading =T or Y
fractures
• Spiral Fracture:Results
from rotational stress and results in an oblique fracture


Question 25

State the Seven main types of fractures and define each
Which of the types have a high risk for infection
What type of fracture must you suspect when a trivial injury results in a fracture?
What’s the difference between a. Dislocation and a subluxation

Answer 25

Complete Fractures•  Fracture
involving both cortical
surfaces

Incomplete Fractures •  Only
one cortex is disrupted. Has Two
types: a.Torus fracture or Buckle
fracture(Buckling of one cortex). It’s like greenstick fracture. There’s a sort of buckle like a hump or a slight bump on the bone on x ray
b.Greenstick fracture =
Break in one cortex and bending
or bowing of other cortex

Closed Fractures:
•  No communication
with external environment

Open Fractures: Communication
with external environment through break in skin and soft tissue. High risk for infection
(Osteomyelitis)


Pathologic Fractures :Bone
weakness secondary to underlying disease process
Suspect when trivial injury results in fracture. Usually in old people
• E.g. Paget’s disease,Tumor,
Osteogenesis Imperfecta,Rickets,
 Scurvy

Stress Fractures:
• Also termed “march”
or “fatigue” fracture
• Repeat of cyclical stress results in a fracture, typically in lower
 extremities
• Typically accompanied by a
sudden increase in level of
training
usually in military or police

Joint Disruption
• Dislocation =
Complete disruption of articular
surface

• Subluxation =Incomplete
disruption of articular surface


Question 26

What is happening in a Salter Harris fracture
What are salter Harris fractures?
Which age group is it more common in?
Which gender is it common in and why?

Answer 26

Salter-Harris Fractures
 Epiphyseal growth plate is
weaker than supporting ligaments.Growth
Plate (Physis) is made up
of cartilage cells that are weaker
than the supporting
ligaments

 Salter-Harris fractures are
fractures involving long
bones in children and involvethe
growth plate or joint
surface

• Most common in children
10-16 (80%)
• More common in males due
to delayed skeletal
maturation and increasephysical
activity compared with
females of same age

May lead to growth complications
• Blood supply to the growth
plate comes through the
epiphysis and the worse
the injury to the epiphysis,
the greater the likelihood
of growth disturbances

These Fractures are categorized on scale 1-5 and increasing number indicates increasing potential for growth complications

Question 27

State the five classifications of Salter Harris fractures and define them
Which type of salter Harris fracture is most common in children more than 10years
Which type of salter Harris fracture is most common in knee and ankle x ray?

Answer 27

Type 1 = Fracture through Epiphyseal Plate. It Results in separation of epiphysis.Good Prognosis

Type 2 = Fracture of Metaphysis
with extension through Epiphyseal plate. Most common type in children >10y/o
• Good
Prognosis

Type3 =Fracture of the Epiphysis
with extension into the
Epiphyseal plate. Totally
Intra-articular fracture. Open
reduction necessary

Type 4 =Fracture through Epiphysis, Metaphysis
and Epiphyseal plate.Complete intra-articular fracture. Open reduction necessary. Growth
disturbance likely if not perfect
reduction

Type 5 = Crush Fracture of
the Epiphyseal plate.Most
common in knee and ankle
X-ray and can be deceptively normal looking.Poor
prognosis because blood supply to epiphysis is
disrupted

How to remember the
classification?
 • SALTER Mnemonic
S = Slip through the growth
plate
 A =Above the level of
thegrowth plate
L = Lower than the growth
plate
T = Through the growth
plate
R = Ram (the whole growth plate is destroyed) the growth
plate


Question 28

State the types of complications of fractures and mention three for each type

Answer 28

A. Immediate Complications: 1.Hemorrhage-Can be extensive
especially with Pelvic
Fractures
2.Vascular Injuries:
• Anterior ShoulderDislocation=Axillary
Artery
• Extension Supracondylar
Fracture =Brachial
Artery
 • Posterior Elbow
Dislocation = Brachial
Artery
• Knee Dislocation =
Popliteal Artery

3.Nerve Injuries
 • Anterior Shoulder Dislocation= Axillary
Nerve Injury
 • Humeral Shaft Fractures=
Radial Nerve Injury
 • Supracondylar Fracture=
Medial, Radial and Ulnar Nerve
Injury
 • Medial Epicondyle =
Ulnar Nerve Injury
• Post Elbow Dislocation =
Ulnar/Medial Nerve
Injury
 • Olecranon =
Ulnar Nerve Injury
 • Acetabular
Fracture= Sciatic Nerve Injury
• Posterior Hip Dislocation= Sciatic Nerve Injury
• Anterior Hip Dislocation
=Femoral Nerve Injury
• Knee Dislocation =
Peroneal/Tibial Nerve
Injury
• Lateral Tibial Plateau Fracture
=Peroneal Nerve Injury

4.Soft Tissue/Visceral Injuries

B. Intermediate Complications: 1.Compartment Syndrome
2. Fat Embolis

C. Long Term Complications:
• Reflex Sympathetic Dystrophy
• Volkmann’s Ischemic Contracture
• Non-union
• Avascular Necrosis
• Angulation Deformities
• Infection
• Joint Stiffness
• Post-traumatic Ossification or Arthritis

Question 29

How is compartment syndrome diagnosed
What causes it
How is it treated

Answer 29

Results from crush injury and
fractures to long bones–
distal radius, tibial shaft
Swelling and bleeding in
compartment increases pressure
to above that able to maintain
normal perfusion of affected
area
Most common = Anterior
Tibial Compartment
Symptoms = Pain, Pallor,
Paresthesias,Pulseness,
Paralysis
(5 P’s)

 Diagnosis
= Compartment
Pressures
• Indication for surgery
=40-50
mmHg
Treatment =Fasciotomy

Question 30

What is the most common type of dislocation seen in the ED
What are the two main classifications of shoulder dislocation and give two examples under each
What are the mechanisms of injury in anterior shoulder dis and posterior shoulder dis
What are the signs and symptoms of anterior shoulder dis and signs and symptoms of posterior shoulder dis
What type of x rays views are done for shoulder dislocation and which type of view is better for a posterior dislocation

Answer 30

Shoulder Dislocation =
Most Common dislocation seen in the
ED


Classification
• Anterior
(95-97%) Subcoricoid, Subglenoid,
Subclavicular, Intrathroracic

• Posterior
(2-4%)  Most commonly missed major dislocation of the body. Examples : Subacromial
(98%), Subglenoid, Subspinous

 Mechanism of Injury:
 • Anterior = Abduction, Extension and External Rotation
 • Posterior = Seizure or Electric
Shock. Fall on forward-flexed, adducted and internally rotated arm

 Signs and Symptoms

• Prominence of acromion process and flattening of normal contour of
the (anterior)

• Anterior flatness, posterior
fullness and prominence of the coracoid process (posterior)

 X-rays• Standard Series =
AP Shoulder + Transcapular lateral
or Y view
• Y view is diagnostic in posterior dislocation and without Y view,
may be. missed


Question 31

What will you see on x ray of an anterior shoulder dislocation?
What about a posterior shoulder dislocation Y view x ray
What will you see on a posterior shoulder dislocation AP view x ray
On which X ray view will you see the light bulb sign?
What is the light bulb sign
What technique is used to fix a shoulder dislocation?

Answer 31

Anterior Dislocation: • Inferior
displaced
humerus


Posterior Displacement
• AP = Internal Rotation of
 humerus = “Light bulb sign”

• Y view=Humeral head displaced

External rotation is used to fix a shoulder dislocation but if there’s a fracture in the dislocation, refer to orthopedics
Don’t try to reduce it using external rotation

Question 32

How are shoulder dislocations treated?
State four shoulder dislocation reduction techniques

What must you evaluate and do after dislocation reduction?

Answer 32

Treatment

• Reduction using a variety of
techniques such as Shoulder Reduction Techniques :
1. External Rotation Method (Hennipen Technique)
• Gentle external rotation
• If no success, slowly. lift. abduct. arm, lifting humeral head into joint
2. Traction-Counter traction
3. Scapular Manipulation
4. Stimson or Hanging Weight
5. Kocher method isn’t done anymore 

• Shoulder dislocation with associated fracture should be referred to orthopedics for reduction
• Make sure to evaluate vascular and nerve exam post reduction and obtain
a post-reduction film
• After reduction, patient should be placed in shoulder immobilizer (sling) and
orthopedic follow-up. arranged


Question 33

State five complications of shoulder dislocations
What is Hill Sachs fracture?
How does it occur ?
What’s the difference between Hill Sachs and Bankarts fracture
What’s the most common nerve to be injured in a shoulder dislocation
What injury should you suspect in elderly patients with weak pulse or rapidly expanding hematoma

Answer 33

Complications
• Recurrence = Most common complication. Age related (younger
the patient, the more likely of a reoccurrence)

• Bony Injuries=
  Hill-Sachs Deformity = Compression fracture or groove of
posterolateral aspect of humeral
head • Results from impact of
humeral head on the anterior glenoid
rim as it dislocates or reduces. Avulsion
of greater tuberosity( Increased in
patients > 45 y/o)
  Bankart’s Fracture = Fracture
of the glenoid lip

• Nerve Injuries=  May occur
during dislocation or reduction and most neuropraxias will recover over
time. Axillary nerve( most common)or
Musculocutaneous
nerve

• Rotator Cuff Tears

• Axillary Artery Injury
(rare) – suspect in elderly
patients with weak pulse or rapidly expanding hematoma


Question 34

State the rotator cuff muscles
Uses of these muscles

Answer 34

Rotator cuff
is made up of 4 muscles that insert tendons into the greater and lesser tuberosity of the muscles and allows abduction and internal/external rotation of the shoulder

• SITS
MUSCLES=Subscapularis,
Supraspinatous,Infraspinatous,
Teres minor


Question 35

State the three classification of clavicular fractures. Which of the fractures is most common especially in children?
Which may be associated with ruptured coracoclavicular joint
with medial elevation
Which is the least common?
What is the mechanism of clavicular fractures ?
State two symptoms of clavicular injuries
What imaging technique is cool for it?
How are clavicular fractures treated
State four indications for surgical repair of clavicular fractures

Answer 35

Classification

• Middle 1/3  Most common area
to fracture (especially in children)
• Distal 1/3  May be associated
with ruptured coracoclavicular joint
with medial elevation
• Medial 1/3  Uncommon, requires strong injury forces Consider
intrathoracic injury (i.e. Subclavian
Artery or Vein
Injury)

 Mechanism= Fall on outstretched shoulder or direct clavicle trauma

 Symptoms/Signs = Pain, Swelling
over fractured region

 Imaging= CXR or dedicatedClavicle
films

Treatment:
• Indications for surgical repair
  Displaced distal third
  Open
  Bilateral
  Neurovascular Injury

• Treatment = Sling, OrthopedicFollow-up
 Non-operative management is successful in 90%


Question 36

State the two main types of humeral fractures
What is the mechanism of injury of humeral fractures
Which people is it commonly seen in and what’s the clinical presentation

Answer 36

 Types
• Proximal Humerus Fractures

• Mid-shaft Humerus Fractures

Mechanism of Injury
• Fall on outstretched arm
(most common)
• Direct blow to lateral aspect
of arm
 Clinical Presentation= Upper
arm and shoulder pain after
fall

• Most commonly seen in
elderly


Question 37

What Imaging is used in proximal humerus fracture ?
How do you treat one part fractures and two to four part fractures?
State four complications of humeral fractures
Which nerve injury should you always consider in a humeral fracture and why ?

Answer 37

Plain film=x-ray imaging

 Treatment
• One part fractures=Immobilization with shoulder immobilizer sling and
swath,Analgesia, Ortho follow-up
• Two/Three/Four Part fractures =
Immobilize and emergent orthopedic
referral.Many will require surgical repair

 Complications
 • Adhesive capsulitis = Frozen
Shoulder = Most Common
 –Prevent with early mobilization

• Neurovascular Injuries = Axillarynerve
and artery, brachial plexus

• Posterior Dislocations = Will frequently accompany lesser tuberosity
fractures

• Avascular necrosis of humeralhead
especially with anatomic neck
fractures

Consider axillary nerve injury cuz the nerve lies close to it?
Axillary nerve injury manifests as erbs palsy,klumpkes palsy
Radial nerve injury causes wrist drop

Question 38

What part of the humeral shaft does the mid shaft humerus involve?
State the three mechanisms of injury of mid shaft humeral injuries and state the most common mechanism
Which mechanism is more common is patients with breast cancer
What’s the clinical presentation of mid humeral injuries

Answer 38

Mid-shaft Humerus Fractures
 Classification
 • Typically involve middle 1/3 of the
humeral shaft
 Mechanism of Injury
 • Direct Blow (Most common)
 • Fall on outstretched arm or elbow
• Pathologic Fracture (especiallyBreast
Cancer)

 Clinical
Presentation
• Pain and deformity over affected
region
 • Associated Injuries
1. Radial Nerve injury= Wrist Drop = Inability of extend wrist, fingers,
thumb, Loss of sensation over dorsal
web space of 1st digit
 • Neuropraxia at time of injury will
often resolve spontaneously
• Nerve palsy after manipulation or
splinting is due to nerve entrapment and must be immediately explored by
orthopedic surgery
 2.Ulnar and Median nerve injury (less
common)
 3. Brachial Artery Injury

Question 39

State two complications of mid humeral shaft
How is mid humeral shaft treated

Answer 39

Imaging = Standard x-ray imaging

 Treatment
1• Most managed non operatively(either):
 a.Coaptation splint (sugar tong) plus sling and swath
 b.Hanging cast
2• Operative management for patients:
 Neurovascular compromise, pathologic fractures

 Complications
• Delayed union
• Adhesive capsulitis



Question 40

What is a galeazzi fracture
What is the mechanism of injury of this fracture. ?
State one complication and how it’s treated

Answer 40

Distal Radius Fracture
 • Distal radio-ulnar dislocation

Mechanism of Injury
 • Direct blow to back of wrist
 • Fall on outstretched hand

 Complication=
Ulnar nerve injury

 Treatment
=ORIF
Open reduction and internal fixation

Question 41

What is monteggias fracture
What is the mechanism of injury of this fracture. ?
WhT imaging is done for it?
What is the associated nerve injury for
Monteggias fracture
State how it’s treated in adults and how it’s treated in children

Answer 41

Proximal 1/3 Ulnar Fracture
• Dislocation of radial head

 Mechanism of Injury =
Direct blow to posterior
aspect of ulna• Fallon outstretched
hand

 Imaging=
Elbow/Forearm x-rays
• Radial head dislocation missed in 25% of cases

• Carefully examine the alignment of radial head

 Associated Injury= Radial
Nerve Injury

 Treatment
• ORIF(Adults)
(open fracture reduction and internal fixation)
• Closed Reduction/Splinting(Children)


Question 42

What does the Acronym GRUM mean?

Answer 42

Galeazzi Radial fracture Ulnar fracture Monteggias

Meaning G causes distal radial fracture but results in ulnar nerve injury while M causes proximal ulnar fracture but results in reading nerve injury

Question 43

What is a forearm fracture
What is it’s mechanism of injury
How is it treated

Answer 43

Isolated fracture of ulnar
Shaft

 Mechanism = Direct blow to
ulna with patient raising forearm
to protect face

 Treatment
• Non-displaced =Immobilization
in cast
• Displaced:
 >10 degrees
angulation or displacement >
50% of ulna
 Orthopedic referral-ORIF

Question 44

What kind of injury will cause Fracture of both ulnar and
radius
state two associated injuries with this fracture of both ulnar and radius
State two complications of this fracture

Answer 44

This type of fracture is Usually
displaced fracture

 Mechanism of Injury=
Direct blow to forearm

 Associated Injury
• Peripheral Nerve Deficits
• Development of compartment
syndrome

 Treatment:
• Non-displaced
(rare) = Immobilization in bivalved cast
• Displaced – ORIF. Closed
reduction may be possible in
children

 Complications
• Compartment
Syndrome
• Malunion

Question 45

What is Colle’s fracture (under distal forearm or wrist fractures)
What is the mechanism of injury?
Which age group is it mostly common in
What will you see on examination of someone with this fracture
State two associated injuries
Explain how it’s treated

Answer 45

Collesʼ Fracture
• Transverse fracture of distal
radius withdorsal displacement
of distal fragment

• Mechanism=
Fall on outstretched hand

• Most common fracture in
adults > 50 years old

• Exam = Classic Dinner Fork
Deformity

• Associated Injuries
 Ulnar styloid fracture
 Median Nerve Injury

• Treatment:
 Non-displaced Fracture:
• Sugar Tong Splint, Referral to Orthopedic Surgery

 Displaced Fracture :
• Prompt reduction–Finger traps and manipulation under conscious sedation or with hematoma block
• Immobilization in Sugar tong splint
• Referral to Orthopedic Surgery

Question 46

What is another name for Smith fracture?(under distal forearm or wrist fractures)
What is a Smith fracture?
What is the mechanism of injury for this fracture?
What is the associated injury or complication ?
How is it treated?

Answer 46

Smith Fracture (Reverse Colles)

• Transverse fracture of distal radius with volar displacement

• Mechanism=Fall on outstretched
arm with forearm in supination

• Associated Injury= Median Nerve
Injury

• Treatment
 Reduction with finger traps and
manipulation
 Immobilization in sugar tong
or long arm splint
 Orthopedic referral


Question 47

What is paronychia?
What is the usual causative agent for paronychia? How is it treated? State one complication

What is felon? What is the usual causative agent for felon? How is it treated? State two complications
Another name for felon is ?

Answer 47

Paronychia: Infection of lateral nail
fold. Staph/Step usual causative
agents

• Treatment
 Incision and Drainage
 Warm soaks
 Antibiotics if surrounding cellulitis

• Complications=Felon

 Felon • Infection of pulp space of
fingertip • Staph aureus is typical causative agent

• Treatment– I+D at point of
maximal tenderness
 Packing for 48-72 hours
 Warm soaks
 Antibiotics

• Complications= Flexor tenosynovitis,
osteomyelitis


Question 48

What is Flexor Tenosynovitis
What are the causative agents ?
How is it diagnosed?
How is it treated?

Answer 48

An infection of flexor tendon sheath that typically results from a puncture
wound on volar surface.  Causative
agents typically Staph Aureus or
Strep

 Diagnosis= 4 Cardinal Kanavel
Signs
• Finger held in slight flexion
• Symmetric swelling of finger(termed diffuse fusiform swelling)
• Tenderness along proximal flexor
sheath
• Pain with passive extension of
finger

 Treatment
• Hospitalization and Emergent Orthopedic Consult
• Surgical Drainage
• IV antibiotics
• Elevation and Splinting
• Tetanus update


Question 49

What is the cause of a human bite injury ?
This type of injury has a high potential for what ?
Any wound over which joint is considered a fight night until proven otherwise
State three causative organisms of human bite injuries
How is it managed?

Answer 49

Human Bite (Fight Bite)
 Injury results from punching another
person in the mouth • High potential for severe infection
 Infected wounds have potential
for spread to deep palmar space
infections, functional loss and need
for amputation
 Any wound over MCP joint (Metacarpophalangeal joint) is
considered a fight bite until proven
otherwise–patients will often lie about cause of injury

 Causative agents
• Anaerobes (especially Eikenella
corrodens)
• Staph aureus
• Neisseria species

 Treatment
• DO NOT SUTURE –
Secondary intention healing
• Consult Orthopedic Surgeon
• X-rays to r/o fracture
• Irrigate wound
• Splint and elevate the hand
• Hospitalize the patient and treat with IV Antibiotics (Unasyn)


Question 50

How do you preserve amputated digits ?
State the criteria for reimplantation of the amputated digit
State the absolute and relative contraindications to reimplantation of amputated digits

Answer 50

Amputated Digits
 Preservation of Amputated Digit
• Irrigate amputated part with normal saline to remove gross contamination
• Wrap in sterile gauze moistened with
saline
• Place in sterile water tight container
• Store the container in ice water. Make sure the ice doesn’t come into contact with the amputated part 

 Criteria for Re-implantation
• Young, healthy patient with normal
vital signs
• Sharply incised wound with minimal
associated tissue destruction
• Amputated thumb
• Multiple digit amputation
• Hand or forearm amputation
• Amputation in child

 Contraindications to reimplantation

• Absolute Contraindications
 Unstable patient with severe life threatening injuries
 Severe crush injury

• Relative
 Severely damaged part
 Severely contaminated part
 Single digit amputation
• other than thumb
 Avulsion Injury
 Serious underlying medical illness
that would impair wound healing
 Prolonged warm ischemia (>12hrs)
 Prior injury to affected part
 Emotionally unstable patient


Question 51

State seven associated injuries of pelvic fractures
How much blood can be collected in the retroperitoneum when there’s a pelvic fracture
What is the most commonly associated injury of pelvic fractures?
Which of the associated injury is eight times more likely in a pelvic fracture

How are pelvic fractures treated ?
State four complications of pelvic fractures

Answer 51

Associated Injuries

• Hemorrhage
 1st cause of death from pelvic fracture
 Up to 6Lof blood in
retroperitoneum

 50% of patients require
transfusion

• Urethral and Bladder Injuries
 Mostcommonly associated
injuries

• Vaginal Laceration or rupture

• Nerve Injury

• Ruptured Diaphragm

• Rectal Injuries

• Thoracic AorticRupture
 8 times more likely in patients with pelvic fractures

 Treatment
• Evaluation for secondary
injuries
• Avoid excessive movement
• Antishock pelvic clamp
in patients with evidence of
fracture and instability

Pelvic binders for open book fractures.

• Type I – Conservative
treatment

• Type 2–Single Ring Fractures
 Conservative
treatment

• Type 3 – Double Ring Fractures
 Unstable, Immobilize, External or Internal Fixation, Orthopedic Consultation, Embolization of hemorrhage

• Type 4 –Acetabulum fracture =
Displaced fractures require surgical repair

 Complications
• Sepsis
• Thromboembolic complications
• Malunion or Delayed Union
• Chronic Pain

Question 52

State the two types of hip dislocation
Which type is more common ?
What is the mechanism of injury of anterior hip dislocations
What are the clinical features?
What indicates need for immediate
reduction?
State two complications of anterior hip dislocation

What is the mechanism of injury of posterior hip dislocations
What are the clinical features and physical findings?
State two complications of posterior hip dislocation
How is it treated

Answer 52

Anterior Hip Dislocation
(10%)
• Mechanism of Injury = Extreme abduction pushes femoral head out
through tear in anterior capsule from
auto accident or fall

• Clinical Features = Slight abduction,
external rotation

• Associated vascular injuries with
diminished femoral or distal pulses indicates need for immediate
reduction

 Posterior Hip Dislocation
(80-90%)

• Mechanism of Injury = Majority are
due to auto-accidents with direct force
applied to flexed knee, pushing
femoral head through the posterior
capsule

• Clinical Features = Shortened,
Adducted and Internally Rotated

• Associated Physical Findings
 Acetabular or Femoral Fractures
 SciaticNerveInjury
 Knee Injury

 Treatment
• Early reduction to avoid Avascular necrosis of the femoral head
• Closed Reduction should be attempted in ED, operative
repair if unsuccessful.
It’s difficult to reduce a hip dislocation in the ED

 Complications
• Anterior dislocation = Femoral Artery,
vein, nerve injury
• Posterior dislocation = Sciatic Nerve
injury

Question 53

Which group of people usually suffer femur fracture
What is the clinical presentation
How is it treated?
State three complications

Answer 53

Femur Fracture  Typically, male
patients suffering fall or MVA(motor vehicle accident injury)

 Clinical Presentation –
Severe pain, unable to bear weight

 Treatment
 . Hair Traction Splint
• Orthopedic Consultation
• ORIF

 Complications
• Hemorrhage
• Neurovascular Injury
• Fat Emboli


Question 54

What does the football triad result in?
Explain the unhappy triad in football
What is the clinical presentation?
How is it treated?

Answer 54

Football Triad Injury
 Football triad results from lateral
aspect of the knee

 Results in:
• Medial Collateral Ligament Tear
• Medial Meniscus
• ACL Tear

The unhappy triad, also known as a blown knee, refers to a sprain injury which involves 3 structures present in the knee joint. These structures include; anterior cruciate ligament (ACL), medial meniscus and tibial (medial) collateral ligament.

 Clinical Presentation: Swelling or
pain around knee with moderate
to severe pain

 Treatment
• Knee Immobilization
• Surgical Repair

Question 55

Explain the OTTAWA KNEE AND ANKLE RULES (what it’s used for and what it involves?

Answer 55

Ottawa Knee Rules
 Patient needs an x-ray of knee
if:
• Age > 55 y/o
•Isolated tenderness of patella

• Tenderness at head of fibula
• Inability to flex 90 degrees or inability
to bear weight in the ED (at least 4 steps)

• Rules are valid in children or adults

ANKLE RULES:
Patients need ankle x-rays if:

• Inability to bear weight
  Either after injury or in ED
• Bony tenderness along posterior edge of distal 6cm of lateral or
medial malleolus
• Point tender over navicular bone

Question 56

What is the Danis-Weber classification of ankle fracture and what is it based on?

Answer 56

It is a classification of ankle fractures Based on the level of
fracture of the fibula

 Type A - Fracture of fibula below the syndesmosis
 Type B – Fibular fracture at the level of the syndesmosis

 Type C-Fibular fracture above the level of the syndesmosis

Higher level = Greater disruption of syndesmosis – Greater instability

Look at a picture of it on the slide

Question 57

Ankle joint is a ring which is maintained in stability by bony structures and ligaments

 Disruption of one part of the ring allows for continued stability of the joint
 Disruption of two parts of the ring results in instability of the joint

True or false