Fm 4 Flashcards
Signs & Symptoms of Limb Threatening Injury - Compartment Syndrome
Compartment syndrome is a serious life- and limb-threatening complication of extremity trauma that occurs when rising pressure in a muscle compartment impairs perfusion to that same muscle compartment. Fractures, crush injuries, burns, and arterial injuries all can result in an acute compartment syndrome. You must have a high clinical suspicion for compartment syndrome, as delay in diagnosis or treatment can ultimately lead to compromised blood supply, nerve damage, and muscle death. Treatment is emergent decompression via fasciotomy.
The 6 P’s (Signs of limb threatening Injury)
Pain
Pallor
Pulselessness
Paresthesia (A skin sensation, such as burning, prickling, itching, or tingling.)
Perishing cold (The inability to regulate one’s body temperature.)
Paralysis
Pain, especially disproportionate pain, is often the earliest sign and clinical hallmark of compartment syndrome. However, the loss of normal neurologic sensation (paresthesia) is the most reliable sign.
Urgent evaluation is required for a patient you suspect of compartment syndrome.
Differential of Acute Ankle Pain Following Inversion Injury 5
Lateral ankle sprains generally present acutely (after trauma) with pain, warmth, and some swelling. Ankle sprains do not create a deformity. If there is a large amount of swelling present, however, it may appear to be a deformity.
Peroneal tendon tear is typically due to an inversion injury and may occur in conjunction with a lateral ankle sprain. Patient may complain of persistent pain posterior to the lateral malleolus. Swelling may or may not be present. Repetitive trauma may cause injury to the peroneal tendons.
Fibular fracture is usually due to a fall, an athletic injury, or a high velocity injury such as motor vehicle accident. Patient may have severe pain, swelling, inability to ambulate, and deformity.
Talar dome fracture is usually due to acute injury. Overall prognosis is related to potential for interruption of the blood supply. Talar dome fracture may occur in conjunction with an ankle sprain, and initial x-rays may miss a talar dome fracture. Repeat imaging may be required if symptoms persist to detect avascular necrosis after talar dome fracture.
Subtalar dislocation occurs in the setting of a high-energy injury involving the talocalcaneal and talonavicular joints. Pain, swelling, and deformity are present.
Mechanism of Injury and Anatomy of Ankle Sprains (plantarflexion and inversion, dorsiflection and eversion)
Plantar flexion and inversion
The most common mechanism of injury in ankle sprains is a combination of plantar flexion and inversion. The lateral stabilizing ligaments, which include the anterior talofibular, calcaneofibular, and posterior talofibular ligaments, are most often damaged.
The anterior talofibular ligament is the most easily injured. Concomitant injury to this ligament and the calcaneofibular ligament can result in appreciable instability.The posterior talofibular ligament is the strongest of the lateral complex and is rarely injured in an inversion sprain.
The anterior drawer test can be used to assess the integrity of the anteriortalofibular ligament, and the inversion stress test can be used to assess the integrity of the calcaneofibular ligament.
Excessive eversion and dorsiflexion
In medial ankle sprains, the mechanism of injury is excessive eversion and dorsiflexion. Medial ankle stability is provided by the strong deltoid ligament, the anterior tibiofibular ligament, and the bony mortise. Because of the bony articulation between the medial malleolus and the talus, medial ankle sprains are less common than lateral sprains.
Grading of ankle sprains (6 plus the different grades)
Grading of ankle sprains takes into consideration:
the presence/absence of a ligament tear
loss of functional ability
severity of pain
presence and/or severity of swelling
presence of ecchymosis
difficulty bearing weight: the ability to take four steps independently
Grade I sprain involves stretching and/or a small tear of a ligament. There is mild tenderness and swelling, slight to no functional loss, and no mechanical instability. No excessive stretching or opening of the joint with stress.
Grade II sprain is characterized as an incomplete tear and moderate functional impairment. Symptoms include tenderness over the involved structures, with mild to moderate pain, swelling, and ecchymosis. In this grade, there is some loss of motor function and mild to moderate instability. Stretching of the joint with stress, but with a definite stopping point.
Grade III sprain is characterized as a complete tear and loss of integrity of the ligament. Severe swelling (greater than 4 cm about the fibula) and ecchymosis may be present, along with inability to bear weight and mechanical instability. Significant stretching of the joint with stress, without a definite stopping endpoint.
Ottawa rules (when to do X-ray of the ankle and foot)
An Ankle X-ray is only required if:
There is any pain in the malleolar zone; and,
Any one of the following:
Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus, OR
Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, OR
An inability to bear weight both immediately and in the emergency department for four steps.
A foot X-ray series is indicated if:
There is any pain in the midfoot zone; and,
Any one of the following:
Bone tenderness at the base of the fifth metatarsal (for foot injuries), OR
Bone tenderness at the navicular bone (for foot injuries), OR
An inability to bear weight both immediately and in the emergency department for four steps.
Physical Exam Maneuvers for Diagnosing Ankle Injury 2
Negative inversion test:
Invert the patient’s ankle. Laxity indicates injury of the calcaneofibular ligament.
Crossed-leg test:
Have the patient cross their legs with the injured leg resting at midcalf on the knee to detect high ankle sprains (syndesmotic injury between the tibia and fibula - can do squeeze test to assess this as well)
Most Effective Compression For Ankle Injury
2 types
A Cochrane review demonstrated that semi-rigid ankle support led to quicker return to sports, work and less instability of the ankle compared to simple wraps and bandages. It also is more helpful with persistent swelling.
There are various braces that may be useful after an ankle sprain. The two most common are a semirigid stirrup (e.g. an Aircast) or a soft lace-up brace.
An Aircast is usually constructed of a hard plastic and has inflatable air chambers inside to provide more stability. It allows for some plantarflexion, dorsiflexion but controls inversion/eversion. This device is appropriate for more severe ankle sprains and not mild ones.
A soft lace-up brace is usually made of canvas and provides more limited support. This may be useful in an individual who has had a previous sprain or is returning to active sport competition.
Pyelonephritis (signs, sxs, rf)
Uncomplicated uti assessment and tx
Pyelonephritis
Symptoms: Fever, chills, severe abdominal or back pain
Signs: Costovertebral angle tenderness
Risk Factors: Recent instrumentation or known anatomic abnormality of the urinary tract
Empiric Treatment for Uncomplicated UTI
young woman with typical symptoms of a UTI and no concern for upper tract infection, you do not need to see both leukocyte esterase and nitrites positive for a presumptive diagnosis of uncomplicated UTI and empiric treatment.
In addition to prior history, it is also important to be aware of resistance patterns in your prescribing area and patient allergy when selecting an antibiotic. Trimethoprim/sulfamethoxazole may be used but if there is greater than 20% resistance you should consider other antibiotic options.
hearing a popping sound followed by immediate pain in the posterior right ankle. On physical exam, the posterior right ankle is edematous and palpation is tender. He is unable to plantarflex his right foot. What is the most likely diagnosis of his current condition?
Achilles’ tendon rupture
