Injuries and Management Tutorial Flashcards
Case 1 - 20F
Fell off her bike, developed immediate severe pain in the left shoulder and deformity
What does the x-ray show?
Dislocated left shoulder - humerus should normally articulate with the glenoid fossa, but the head of the humerus is not there
What normally causes a shoulder dislocation?
How does shoulder dislocation usually present?
Often caused by direct trauma
Presents as:
Pain
Restricted movement
Skinny = obvious dislocation / deformity - loss of normal shoulder contous
What clinical examinations and investigations do you do for a suspected shoulder dislocation?
Examinations =
Assess neurovascular status – axillary nerve
Investigations =
X-ray prior to any manipulation – identify fracture e.g. humeral neck, greater tuberosity avulsion or glenoid
Scapular-Y view/modified axillary in addition to AP
What are the 3 types of shoulder dislocation?
Anterior - commonest type (90%), bimodal distribution (most common in 20-30 year olds), humeral head not overlying glenoid
Posterior - rare (6%), associated with seizures/ shocks, ‘lightbulb sign’ on XR
Inferior - rare (<2-4%), arm held abducted above head, humeral head not articulation correctly
How are shoulder dislocations managed?
Numerous techniques to reduce a dislocated shoulder:
Vigorous manipulation or twisting manipulation should be avoided to avoid fractures
Safest method is to use traction-counter traction +/- gentle internal rotation to disimpact humeral head
Ensure adequate patient relaxation – Entonox; benzodiazepines
If alone could use Stimson method
Undertake in safe environment, especially in elderly e.g. resus, ask for senior/anaesthetic support early on if necessary
Traction OR Stimson method (weights and gravity)
Set-up most important
How was the Case 1 patient’s reduced?
Patient placed into A&E resus (need urgent attention)
Pre-manipulation neurovascular status normal
Sedation provided by anaesthetist colleagues
Shoulder reduced using traction-counter traction method
Reduction felt to be complete clinically with relocation of shoulder and normal appearance of shoulder contour
Patient sent for post reduction films
Plan to check neurovascular status once sedation worn off
What do the x-rays now show?
Hill-Sachs defect and Bankart lesion - a complication of a shoulder dislocation that has been tried to be fixed with traction
What are some shoulder dislocation complications?
When reducing, humerus head gets caught on the glenoid and so -
Hill-Sachs defect = chipped humerus head
Bankart lesion = fragment of humerus head caught in the glenoid fossa
Can cause instability or impingement at joint
The patient returns 6 months later to A&E and they have fallen over again
What does the x-ray show?
Lightbulb sign = posterior dislocation
Case 2 - 82F
Fell onto right hand
Pain
Tenderness over right shoulder
What do the radiographs show?
Proximal humerus fracture
How do proximal humerus fractures normally occur?
How does it present?
Fall onto outstretched hand - although this may also cause wrist fractures
Typically in elderly or those with osteoporosis
Pain
Tenderness
What investigations are usually carried out for suspected shoulder fractures?
How are they usually classified?
Investigation:
Plain x-rays
CT if concern over articular involvement or high degrees of comminution (splintering of bone into more than 2 fragments)
Classification (described by Neer) =
Surgical neck fractures (2 parts)
Avulsion fractures of greater tuberosity (2 parts)
Comminuted fractures (>=3 parts)
What are the management options for proximal humerus fracture?
Collar and cuff = used for 2-part fracture minimally displaced, on patients with high surgical risk / comorbidities, and not compliant with post-operative care
ORIF – plate and screws = used for any fracture with displacement i.e. 2-part+ but not highly comminuted
Arthroplasty = used for large displacement of humeral head and high risk of non-union ness
Reverse arthroplasty = used for unrepairable rotator cuff, previous unsuccessful shoulder replacement, a complex fracture/chronic shoulder dislocation
Case 3 - 50M Right hand dominant - falls onto right arm Immediate pain and gross swelling Limited movement of wrist Neurovascularly intact
What do the radiographs show?
Lateral view shows extra articular distal radius fracture
Dorsally displaced distal radius fracture
How are distal radius fractures classified?
Displacement gives its name
e.g.
Extra-articular with dorsal angulation = Colles fracture
Extra-articular with volar (palmar) angulation = Smith fracture
Intra-articular with dorsal angulation = Dorsal Barton
Intra-articular with volar (palmar) angulation = Volar / Reverse Barton
How do distal radius fractures present clinically?
What investigations are carried out for suspected distal radius fractures?
Presentation =
Very common, bimodal distribution
Often present with clear mechanism of falling onto affected area, swelling and visible deformity
Commonest presentation is dorsal displacement due to fall on outstretched hand
Investigation =
Plain radiographs – PA/lateral views to assess fracture type
Thorough clinical examination to avoid associated injuries
How can distal radius fractures be managed?
What is the goal of operative management?
Cast/splint =
Temporary treatment for any distal radius fracture – reduction of fracture and placement into cast until definitive fixation
Definitive if minimally displaced, extra articular fracture
MUA (manipulation under anaesthetics) and K-wire =
For fractures that are extra-articular but have instability, particularly in children that are prone to displacing it later on, MUA in theatre with K-wire fixation can be used. Wires can then be removed in clinic post-op
ORIF (open reduction internal fixation)
Surgery to fix severely broken bones
Any displaced, unstable fractures not suitable for K-wires or with intra-articular involvement may benefit from open reduction internal fixation with plate and screws
Goals = restore articular surface congruency, radial inclination, radial height and volar tilt
Case 4 - 20M
Drunk student fell on his wrist
What does the x-ray show?
Scaphoid fracture
What are the 8 carpal bones?
First row (lateral to medial) = Scaphoid Lunate Triquetrum Pisiform
Second row (lateral to medial) = Trapezium Trapezoid Capitate Hamate
Some Lovers Try Position That They Can’t Handle
If struggling remember ‘trapeziUM under thUMb’
How are scaphoid fractures caused?
How do they present clinically?
Commonest carpal bone injury, usually young patients
Typically a fall backwards onto their hand, but think in any distal radius
Presents clinically as =
Pain
Swelling
What clinical examinations and investigations are carried out for a suspected scaphoid fracture?
What is difficult about scaphoid fractures?
Clinical Examinations =
Anyone with FOOSH or with distal radius fracture should have scaphoid exam
Palpation of anatomical snuffbox, scaphoid tubercle or telescoping of thumb
Investigation =
Plain radiographs difficult to assess – request scaphoid views
Delayed radiographs if normal but clinical suspicion
Consider CT/MRI if still concerned
Often missed as they do not show up on xrays but often have interrupted blood supply of proximal pole leading to avascular necrosis = palpation in the clinical exam v. important
What is the management for a scaphoid fracture?
Displaced fractures =
Retrograde blood supply means high risk of non-union/AVN of proximal pole
Most displaced fractures disrupt this and therefore ORIF usually undertaken
Undisplaced fracture =
Can be treated conservatively in a scaphoid cast
Length of time to heal can be long, some surgeons opt for fixation as a result
Case 5 -
Review after treatment with scaphoid cast
What does the repeat xray show?
What causes this type of injury?
Lateral view - shows perilunate dislocation
Perilunate dislocation part of a broader group of injuries called perilunate instability
Perilunate instability = from disruption to any of the ligament complexes that surround the lunate
Relatively rare - but still often missed 1/4 of the time
Normally radius, lunate and capitate should line up.
How do perilunate and lunate dislocations present on an x-ray?
Perilunate = capitate is displaced to the more dorsal side of the hand in lateral view (AKA capitate sits dorsally to lunate instead of lining up in a straight line)
Lunate = lunate has tipped forward in lateral view (AKA lunate sits more to the palmar side of the hand), tip teacup sign on lateral view shows lunate tipped forward
How are perilunate instability injuries classified?
Stages 1-4
Stage 1 = Scapho-lunate dissociation = widening of scaphoid and lunate due to scapholunate ligament disruption
Stage 2 = Lunocapitate disruption = lunate remains normally aligned with distal radius, remaining carpal bones dislocated
Capitate and lunate widening
High association with scaphoid fractures
Stage 3 = Lunotriqeutral disruption = capitate and lunate are not aligned with distal radius
Lunate-triquestral ligament disrupted
High associated with triquetral fractures
Stage 4 = Lunate dislocation = dislocation of lunate with a ‘tipped’ teacup’ sign
Dorsal radiolunate ligament injury
How are perilunate instability injuries managed?
Non-operative =
Closed reduction and casting has no indication and often poorer outcomes compared to operative management
High risk of recurrent dislocation
Operative =
Acute injury (<8 weeks): Open reduction, ligament repair and fixation
Good functional outcomes
Non-acute (>8 weeks): Proximal row carpectomy
Converts wrist into simple hinge type
Chronic injuries: Arthrodesis of wrist
reduction of pain especially if degenerative changes
Case 6 - 32F
Head on collision
Intubated on scene
What does the trauma survey’s pelvic radiograph show?
Right superior and inferior pubic rami fractures
Left superior pubic rami / pubic tubercle fracture
Disruption of iliopubic line
Fracture of sacrum = widening of sacroiliac joint
What are the causes of a pelvic fracture?
Usually a result of high energy trauma
Patients can become very unstable – a lot of visceral organs and vasculature are adherent to the pelvis
What clinical examinations and investigations are carried out for a suspected pelvic fracture?
Examinations =
ABCDE approach = don’t forget to examine the perineam/urethral opening
Digitate – PV (per vaginal) or PR (per rectal) examinations – check for visceral damage or bleeding
Investigations =
Plain radiographs
Urethrogram
CT +/- angiography
How are pelvic fractures classified?
Lateral compression
Anterior posterior compression
Vertical shear
What is the management for a pelvic fracture?
Always stick to ATLS and ABCDE principles
Hypovolaemia is common = IV access and resuscitate the patient, think of major haemorrhage protocols early
Pelvic binders are used as a tamponade device but need to placed accurately (over greater trochanters)
Ongoing instability should suggest surgical intervention - laparotomy or angiographic embolisation
Definitive treatment via a specialist centre with pelvic surgeons
Principle = to restore integrity of pelvic ring and alignment of sacroiliac joints
Internal fixation with plate and screws
External fixation if patient unstable and not suitable for invasive surgery
Case 7 - 72M
Found on the floor by carers
PMH of dementia
What does the radiography show?
Disruption of shenton’s line - suggests proximal femur pathology
Patient has neck of femur fracture (also called ‘hip’ fracture)
What is the issue of neck of femur fracture?
Rare in young, only usually from high energy major trauma
Common in elderly often as a result of osteoporosus and minimal trauma = many other co-morbidities within these patients
V. frail patients = worse mortality rate than breast cancer:
10% can die within a month
30% die within a year
50% of patients will not return to their pre-injury level of independence
How do these ‘neck of femur’ fractures occur?
How do they present?
In elderly = fairly inconspicuous history of a minor fall
Presents =
Report of groin, thigh or buttock pain
Want to ask about preceding symptoms, always think of pathological causes for a fall e.g. MI, TIA/stroke, seizure,
How should suspected proximal femur fractures be examined and what investigations should be undertaken?
Examinations =
MSK – look, feel, move
Thorough secondary survey and top-to-toe examination to look for other injuries
Investigations =
Plain radiographs
CT if not identified but high suspicion
How are these managed pre-op / initial ED (emergency department) management?
MUST treat what CAUSED the fall
Rule out any other injury/pathology causing fall
Involvement of orthogeriatricians/medical team early
Pain relief – consider fascia iliaca block in ED if necessary
Catheterise – limited mobility
Blood tests,
ECG/Chest X-ray if >55
Pre-operative optimisation – fluids, transfusion?
How are ‘hip’ / ‘neck of femur’ fractures classified?
Intra-capsular = compromised vasculature:
Subcapital
Transcervical
Basicervical
Extra = usually not compromised vasculature:
Intertrochanteric
Subtrochanteric
Reverse oblique
Why is classifcation important?
Determines management options
e.g. no need for replacement if minor - just require cannulated screws
Intracapusular: - Total hip arthroplasty = Mobile with <1 walking stick outdoors No cognitive impairment Medically suitable for procedure and anaesthetic
- Hemiarthroplasty
Mobile with >1 walking stick outdoors
Reduced AMTS
Comorbidities or reduced baseline not benefiting from THR - Cannulated screws
Undisplaced fractures where vessels unlikely to be disrupted
Young patients
Compliant with non-weightbearing while fracture heals
Extracapsular:
- DHS (dynamic hip screw)
For 2-, 3- and 4-part intertrochanteric fractures
Provides compression as prosthesis is perpendicular to fracture line
- IM nail (intramedullary)
Subtrochanteric fractures are unstable due to pull of hip girdle
Reverse oblique pattern not amenable to DHS as fracture line not perpendicular
Most = joint replacement - total or hemi
How is it decided whether a patient gets a total or hemi hip replacement?
Medical suitability - anaesthetics and post op
Criteria for total =
Mobile with <1 walking stick outdoors
No cognitive impairment
Medically suitable for procedure and anaesthetic
Criteria for hemi = Mobile with >1 walking stick outdoors Reduced AMTS Comorbidities or reduced baseline not benefiting from THR Cognitive disturbance
What is the post-op management for neck of femur fractures?
MDT approach is absolutely vital!
Geriatrician input from admission = Bone health Medical optimisation Secondary fall prevention Physiotherapy
Prevent leading causes of death – hospital acquired infections, DVTs/PEs by early mobilisation
Occupational Therapy/Social Worker = help with post-operative care needs, package of care and assistance or aids at home
Case 8 - 42M
High speed road traffic collision
Extricated by fire department
Leg in splint - currently complaining of pain
What does the radiograph show?
Midshift femoral fracture - fragmented (multiple fragments)
Posteriorly displaced distal femur according to lateral x-ray view
What are femoral shaft fractures caused by?
Femur is the largest bone in the body and a significant force is required to fracture it e.g. high speed trauma
What examinations and investigations should be carried out for a suspected femur?
Clinical examinations =
Assessment of neurovascular status of the affected limb
Investigations =
Imaging using X-rays = take X-rays of the joints above and below to look for fractures or dislocation
What is the management for a femoral shaft fracture?
A high incidence of concomitant life threatening injuries can exist – always assess using ABCDE and ATLS protocol
Resuscitate patients as necessary – hypovolaemia is not uncommon as long bone fractures can bleed a lot!
Traction is useful in the first instance as a way of temporarily reducing both pain and bleeding
Operative fixation:
Intramedullary nailing – can be either antegrade (from the hip) or retrograde (from the knee) as surgeon preference, injury pattern, or existing prostheses dictates
Open reduction and internal fixation can be used if nailing unsuitable e.g. a segmental fracture, knee or hip replacements
Case 9 - 28M
Presents with right knee pain in A&E for the last 6 hours
Thinks he fell over when intoxicated
Tenderness across joint line
What do the radiographs show?
Tibial plateau fracture
What causes a tibial plateau fracture?
The proximal tibia comprises a key weightbearing surface as part of your knee joint, articulating with the distal femur
Tibial joint surface is relatively flat and comprises of both medial and lateral plateaus with a central tibial spine acting as an insertion point for ligaments
Any extreme valgus/varus force or axial loading across the knee can cause a tibial plateau fracture, with impaction of the femoral condyles causing the comparatively soft bone of the tibial plateau to depress or split
Concomitant ligamentous or meniscal injury is not uncommon
How are tibial plateau fractures classified?
Lateral:
Type 1 = split
Type 2 = split and depression
Type 3 = depression
Medial:
Type 4 = medial plateau
Medial and lateral:
Type 5 = bicondylar
Type 6 = metaphyseal-diaphyseal dissociation
What is the management for a tibial plateau fracture?
Non-operative =
Only truly undisplaced fractures with good joint line congruency assessed on CT or high fidelity imaging
Operative =
Predominance of treatment will be operative
Restoration of articular surface using combination of plate and screws
Bone graft or cement may be necessary to prevent further depression after fixation
Case 10 - 62F
Tripped over tree trunk when walking her dog
Deformed ankle on site - possible dislocation
Swollen by neurovascularly intact
What do the radiographs show?
Trimalleolar fracture =
Medial malleolus fracture
Posterior malleolus fracture
Oblique fiibular fracture (lateral malleolus)
What is found at the ankle joint and what is required for ankle joint stability and function?
Ankle joint comprised of talus articulating with tibia and fibula
Joint stability necessary for function and provided by:
Ligaments =
- Medially: talofibular and calcaneofibular ligaments
- Laterally: deltoid ligament
Bone projections =
- Medially: medial malleolus of tibia
- Laterally: lateral malleolus of fibula
- Posteriorly: posterior malleolus of tibia
How can ankle fractures occur?
How do they present clinically?
Can occur with twisting or axial
Presentation =
Often have extensive soft tissue swelling and inability to weightbear
What clinical examinations and investigations are carried out for a suspected ankle fracture?
Clinical examination = to identify tenderness over ligament complexes
Investigation = X-ray to ascertain talar shift are important to assess stability
How are ankle fractures classified?
Based on level of syndesmosis (fibrous joint held together by ligaments)
Weber A fractures = below the level of the syndesmosis, therefore ligament disruption and joint instability unlikely
Weber B fractures = at the level of the syndesmosis, therefore ligament disruption and joint stability possible and stress testing or weightbearing assessment for talar shift necessary
Weber C fractures = above the level of the syndesmosis, therefore ligament disruption and joint instability likely
What is the management for ankle fractures?
Non-operative =
Non-weightbearing below knee cast for 6-8 weeks, can transfer into walking boot and then physiotherapy to improve range of motion/stiffness from joint isolation
Weber A i.e. below syndesmosis and therefore thought to be stable
Weber B if no evidence of instability (no medial/posterior malleolus fracture and no talar shift)
Operative =
Soft tissue dependent – patients need strict elevation as injuries often swell considerably
Open reduction internal fixation +/- syndesmosis repair using either screw or tightrope technique
Syndesmosis screws can be left in situ but may break after some time so therefore can be removed at a later date if necessary
Weber B (unstable fractures – talar shift/medial or posterior malleoli fractures)
Weber C i.e. fibular fracture above the level of the syndesmosis therefore unstable
Case 11 - 32M
Football injury to ankle
Tenderness and swelling over medial ankle
Generalised pain throughout leg
What does the radiograph show?
Medial malleolus fracture (AKA on tibia)
+
High fibula fracture
= Maisonneuve fracture
What is a maisonneuve fracture?
Twisting injury disrupts the syndesmosis and causes a high fibula fracture
What clinical examinations and investigations should be carried out for a suspected maisonneuve fracture?
Clinical examination = check for proximal tenderness in ankle fractures, patients may have distracting pain and be unaware
Investigations =
Request long length X-rays to visualise the full fibula and ensure no missed fracture
If there is widening of the syndesmosis on radiographs but no obvious fibula fracture always think about a Maisonneuve fracture – energy has to dissipate somewhere
