C Spine And Spinal Injuries,tetanus And Orthopedic Injuries Flashcards
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
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)
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
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
Learn how to read C spine X rays
(ABCDS approach)
What is retrolisthesis and anteriolisthesis
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.
Flexion injuries involving C1-C2 can cause what type of dislocation
Simple wedge fractures are stable true or false
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
State three examples of c spine flexion injuries,vertical compression injuries
What type of injury is a hangman’s fracture
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
State the types of injuries that can happen to the thoracic and lumbar spine
What are chance fractures?
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.
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?
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
Pathophysiology of spinal cord trauma
Primary Injury:
Mechanical Injury
Secondary Injury:
Vascular Abnormalities
Free Radicals/Lipid Peroxidation
Excitotoxicity
Electrolyte disturbances
Inflammation
Edema
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
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
Explain posterior spinal cord syndrome
State two causes of this syndrome
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
Explain central spinal cord syndrome
State two causes of this syndrome
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
Explain brown sequard syndrome
State two causes of this syndrome
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
What’s the difference between spinal shock and neurogenic
What is the classic triad of neurogenic shock
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.
How do you manage C spine and spinal cord injuries ?
When do you immobilize the c spine?
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
What are the aims of immobilization?
State the areas for
Immobilization
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
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
Manual - Hands, Legs
Simple Assist Devices - Sandbags, Towels, Foam Pads
Additional Devices - Straps
Head/Neck immobilizer
Better to immobilize whole body
What is used to immobilize c spine
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
What is used to immobilize the body
State three complications associated with c spine immobilization
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
When do you get an x ray of the c spine
What is the most common view used in seeing c spine injuries
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
When will you want to get a flexion and extension film in spinal cord injuries
When will you do a CT?
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
How do you clear a C spine injury?
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
What are the problems with the nexus rule
Problems:
Management stressors
Failure to discriminate what pain is significant
What is a distracting injury?
How drunk is intoxicated?
What are some of the problems of Canadian c spine
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”?
State the two main mechanisms of fractures with three examples under each
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
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
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
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?
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
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?
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
State the types of complications of fractures and mention three for each type
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
How is compartment syndrome diagnosed
What causes it
How is it treated
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
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
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
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?
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
How are shoulder dislocations treated?
State four shoulder dislocation reduction techniques
What must you evaluate and do after dislocation reduction?
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
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
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
State the rotator cuff muscles
Uses of these muscles
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
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
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%
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
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
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 ?
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
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
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
State two complications of mid humeral shaft
How is mid humeral shaft treated
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
What is a galeazzi fracture
What is the mechanism of injury of this fracture. ?
State one complication and how it’s treated
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
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
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)
What does the Acronym GRUM mean?
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
What is a forearm fracture
What is it’s mechanism of injury
How is it treated
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
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
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
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
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
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?
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
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 ?
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
What is Flexor Tenosynovitis
What are the causative agents ?
How is it diagnosed?
How is it treated?
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
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?
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)
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
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
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
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
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
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
Which group of people usually suffer femur fracture
What is the clinical presentation
How is it treated?
State three complications
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
What does the football triad result in?
Explain the unhappy triad in football
What is the clinical presentation?
How is it treated?
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
Explain the OTTAWA KNEE AND ANKLE RULES (what it’s used for and what it involves?
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
What is the Danis-Weber classification of ankle fracture and what is it based on?
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
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
