List I - Core Conditions Flashcards
What are the presenting symptoms of an ankle sprain?
- Pain around the affected joint
- Tenderness
- Swelling
- Bruising
- Functional loss (for example pain on weight bearing)
- Mechanical instability (if the sprain is severe)
How can ankle sprains be divided?
- High ankle sprain
- Syndesmosis injury (ligament connecting the tibia and fibula)
- 1-10% of all ankle sprains
- Low ankle sprains
- Involving anterior-talofibular ligament (ATFL) and calcaneofibular ligament (CFL)
- > 90% of ankle sprains
How common are ankle sprains?
- Most common reason for missed athletic participation
* Most common injury in dancers
What are the risk factors for ankle sprains?
- Patient
- Limited dorsi-flexion
- Decreased propioception
- Balance deficiency
- Environmental related
- Indoor court sports have highest risk (basketball, volleyball)
What is the mechanism of an ankle sprain?
- Often inversion type of ankle injury on a plantar flexed foot
- Recurrent ankle sprains can lead to functional instability
What is the prognosis of an ankle sprain?
- Pain decreases rapidly during the first 2 weeks after injury
- 5-33% reports some pain at 1 year
- Increased risk of a sprain to ipsilateral and contralateral ankle
Which anatomical structures are involved in an ankle sprain?
- Anterior talo-fibular ligament is most commonly involved in low ankle sprains
- Mechanism is plantar flexion and inversion
- Physical exam shows draw laxity in plantar flexion
- Calcaneofibular ligament is the second most common ligamental injury in lateral ankle sprains
- Mechanism is dorsi-flexion and inversion
- Physical exam shows drawer laxity in dorsi-flexion
- Subtalar instability can be difficult to differentiate from posterior ankle instability because the CFL contributes to both
- Posterior- talofibular ligament is less commonly injured
How is ankle sprain classified?
- Grade 1
- Ligament disruption - None
- Ecchymosis and swelling - Minimal
- Pain with weight bearing - Normal
- Grade 2
- Ligament disruption - Stretch without tear
- Ecchymosis and swelling - Moderate
- Pain with weight bearing - Mild
- Grade 3
- Ligament disruption - Complete tear
- Ecchymosis and swelling - Severe
- Pain with weight bearing - Severe
What is the talar-tilt test?
- Excessive ankle inversion (>15 degrees) compared to contralateral side indicated injury to ATFL and CFL
Following an ankle injury what can be used to decide on whether the patient needs an x-ray?
- Ottawa ankle rules recommend x-ray in the following cases, if there is pain in the malleolar zone, and one of the following:
- Inability to bear weight (walk four steps) immediately after the injury and when examined
- Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus
- Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus
Exclusion criteria
- Chronic +10 days
- Pregnant
- <18 years age
- Unable to follow test
What is the treatment for ankle sprain?
- Grade I, II, III - RICE
- Initial immobilisation
- May require initial short period of weight bearing immobilisation in a walking boot, but early mobilisation facilitates better recovery
- Grade III sprains may benefit from 10 days of casting and non-weight bearing
- Progressive therapy
- Early - motion exercises, progresses to strengthening, propioception and activity specific exercises
- Strengthening phase - once swelling and pain have subsided and patient has full range of motion begin neuromuscular training with focus on peroneal muscles strength and proprioception training
HARM
- Heat
- Alcohol
- Running
- Massage
What are the indications for operative management of ankle sprain?
Anatomic reconstruction
- Grade I - III that continue to have pain and instability despite extensive non-operative management
- Grade I - III with a bony avulsion
Arthroscopy
- Recurrent ankle sprains and chronic pain caused by impingement lesions
- Anterior-inferior tibiofibular impingement
- Posteriormedial impingement lesion of ankle
- Often used prior to reconstruction to evaluate for intra-articular pathology
When can the patient with ankle sprain return to play/normal activities?
- Grade I - 1-2 weeks
- Grade II - 1-2 weeks
- Grade III - Few weeks
- High ankle immobilisation - several weeks
- High ankle (screw fixation) - whole season
What are the complications of ankle sprain?
- Ongoing pain and instability - up to 30%
- Risk factors for chronic pain include:
- Missed fractures
- Osteochondral lesion
- Injuries to the peroneal tendons
- Injury to the syndesmosis
- Tarsal coalition
- Impingement syndromes
- Stretch neuropraxia
- Neuropathic pain in the distribution of the affected nerve
What is a Colle’s fracture?
- Extra-articular fracture of the distal radius with dorsal angulation of the distal fragment
- Frequently associated with an ulna styloid fracture and volar angulation of the fracture apex
How does a Colle’s fracture present?
- Usually due to a fall onto outstretched hand
* Described as a dinner fork deformity
What are the 3 classical features of a Colle’s fracture?
- Transverse fracture of the radius
- 1 inch proximal to the radio-carpal joint
- Dorsal displacement and angulation
What is a reverse Colle’s fracture?
- (also known as a Smith’s fracture)
- Volar angulation of distal radius fragment (Garden spade deformity)
- Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed
How should a Colle’s fracture be reported?
- Degree of dorsal angulation
- Degree of impaction
- Degree and direction of dis-impaction
- Location of the medial fracture line - does it involve the radio-ulnar joint
- Presence of intra-articular fractures
- Other fractures
- Ulnar styloid
- Carpal bones
What are the management options for a person with a Colle’s fracture?
- Closed reduction
* Open reduction and internal fixation (ORIF)
What is closed reduction approach to managing Colle’s fracture, when is it indicated?
- Manipulation without surgery (closed)
- Cast immobilisation - cast extends from below the elbow to the metacarpal heads and holds the wrist somewhat flexed and in ulnar deviation
Indications - Extra-articular
- <5 mm radial shortening
- Dorsal angulation <5 degrees or within 20 of contralateral distal radius
When is ORIF indicated for Colle’s fracture?
- When the fracture is unstable and/or unsatisfactory closed reduction is achieved (i.e. >5-10 degrees dorsal angulation >5 mm shortening; significant comminution)
What are the potential complications of a Colle’s fracture?
- Malunion resulting in dinner fork deformity
- Mediam nerve palsy and post traumatic carpal tunnel syndrome
- Reflex sympathetic dystrophy
- Secondary osteoarthritis, more frequently seen in patients with intra-articular involvement
- EPL tendon tear
When should surgery be conducted for distal radius fractures?
- Within 72 hours of injury for intra-articular fractures
- Within 7 days of injury for extra-articular fractures
- When surgery is needed for re-displacement of distal radius fractures, perform surgery within 72 hours of the decision to operate
What is the recommended definitive treatment of distal radius fractures in adults (skeletally mature)?
- Consider manipulation and a plaster cast in adults with dorsally displaced distal radius fractures
- When surgical fixation is needed for dorsally displaced radius fractures in adults (skeletally mature):
- Offer k-wire if:
- No fracture of the articular surface of the radial carpal joint is detected or
- Displacement of the radial carpal joint can be reduced by closed manipulation
- Consider open reduction and internal fixation if closed reduction of the radial carpal joint surface is not possible
What is the recommended definitive treatment of distal radius fractures in children (skeletally immature)?
- In children (skeletally immature) with dorsally displaced distal radius fractures (including fractures involving a growth plate) who have undergone manipulation, consider:
- A below elbow plaster cast or
- K-wire fixation if the fracture is completely displaced (off-ended)
What is the recommended pain management to children (under 16) with suspected long bone fractures of the legs (femur, tibia, fibula) or arms (humerus, radius or ulna)?
- Offer
- Oral ibuprofen or oral paracetamol, or both for mild to moderate pain
- Intranasal or IV opioids for moderate to severe pain (use IV opioids if IV access has been established)
What is the recommended pain management to adults (16 and over) with suspected long bone fractures of the legs (tibia, fibula) or arms (humerus, radius or ulna)?
- Offer
- Oral paracetamol for mild pain
- Oral paracetamol and codeine for moderate pain
- IV paracetamol supplemented with IV morphine titrated to effect for severe pain
(Use IV opioids in caution in frail or older adults)
(Do not offer NSAIDs to frail or older adults with fractures)
How should pain be managed for children (under 16) with suspected displaced femoral fractures?
- Consider a femoral nerve block or fascia iliac block in the ED
What pain management should be used when reducing a dorsally displaced distal radius fracture in adults (16 and over)?
- Consider IV regional anaesthesia (Bier’s block) in the ED
- Can be performed by health care practitioners trained in the technique (not necessarily anaesthetics)
- Do not use gas and air (nitrous oxide and oxygen) on its own
How should all children (skeletally immature) with femoral shaft fractures be managed?
- Admit all and consider 1 of the following according to age:
- Prematurity and birth injuries - simple padded splint
- 0 to 6 months - Pavlik’s harness or Gallows traction
- 3 to 18 months (but not children over 15 kg) - Gallows traction
- 1 to 6 years - straight leg skin traction (impractical in children over 25 kg) with possible conversion to hip spica cast to enable early discharge
- 4 to 12 years (not children over 50 kg) - elastic intra-medullary nail
- 11 years to skeletal maturity (weight more than 50 kg) - elastic intra-medullary nails supplemented by end-caps, lateral entry ante-grade rigid intra-medullary nail or sub-muscular plating
What is the weight bearing advice regarding distal femoral fractures?
- Consider advising immediate unrestricted weight bearing as tolerated for people who have had surgery for distal femoral fractures
How should long bone fractures of the leg be managed in the pre-hospital setting?
- In the pre-hospital setting, consider the following for people with suspected long bone fractures of the legs:
- Traction splint of adjacent leg splint if the suspected fracture is above the knee
- Vacuum splint for all other suspected long bone fractures
What is the definitive treatment of proximal humerus fractures in adults (skeletally mature) ?
- For adults (skeletally mature) with displaced low energy proximal humerus fractures:
- Offer non-surgical management for definitive treatment of uncomplicated injuries
- Consider surgery for injuries complicated by an open wound, tenting of the skin, vascular injury, fracture dislocation or a splint of the humeral head
How does a hip fracture typically present?
- Common site of fracture especially in osteoporotic, elderly females.
- Blood supply to the femoral head runs up the neck and thus avascular necrosis is a risk in displaced fractures
- Pain
- Classical signs are a shortened and externally rotated leg
How is hip fracture classified?
- Location
- Intra-capsular
- Extra-capsular
- Garden system
- Type I
- Type II
- Type III
- Type IV
What is an intra-capsular hip fracture?
- Intra-capsular
- Sub-capital: from the edge of the femoral head to the insertion of the capsule of the hip joint
What is an extra-capsular hip fracture?
- Extra-capsular
- Can either be trochanteric or subtrochanteric (lesser trochanter is the dividing line)
What is the Garden classification system in terms of hip fracture?
- Type I - Stable fracture with impaction in valgus
- Type II - Complete fracture but undisplaced
- Type III - Displaced fracture, usually rotated and angulated, but still has boney contact
- Type IV - Complete boney disruption
- Blood supply disruption is most common following types III and IV
What is the management of an un-displaced intra-capsular hip fracture?
- Un-displaced hip fracture
- Internal fixation, or hemi-arthroplasty if unfit
What is the management of a displaced intra-capsular hip fracture?
- Displaced hip fracture
- Young and fit i.e. <70 years - reduction and internal fixation (if possible)
- Older and reduced mobility - hemi-arthroplasty or total hip replacement
NB offer total hip replacement rather than hemi-arthroplasty to patients with a displaced intra-capsular hip fracture who:
- Were able to walk independently out of doors with no more than the use of a stick and
- Are not cognitively impaired and
- Are medically fit for anaesthesia and the procedure
What is the management of an extra-capsular hip fracture?
- Extra-capsular hip fracture
- Dynamic hip screw
- If reverse oblique, transverse or sub-trochanteric intra-medullary device
What are the imaging options in occult hip fracture (x-ray negative)?
- MRI
* CT if MRI not available within 24 hours
What is the weight bearing advice regarding hip fractures following surgery?
- Operate on patient with the aim to allow them to fully weight bear (without restriction) in the immediate post-operative period
What is the rehabilitation programme offered to patients as part of their discharge provided the patient is medically stable and has the mental ability to participate in continued rehabilitation, is able to transfer and mobilise short distances and has not yet achieved their full rehabilitation potential, as discussed with the patient, carer and family?
- The Hip Fracture Programme!
What are the different types of head injury / traumatic brain injury?
- Primary brain injury
* Secondary brain injury
What are the different types of primary brain injury?
- Focal - contusion or haematoma
* Diffuse - diffuse axonal injury
What are can be the mechanism of a diffuse axonal injury?
- Result of mechanical shearing following deceleration, causing disruption and tearing of axons
What are the different types of intra-cranial haematomas?
- Extradural
- Subdural
- Intra-cerebral
What are the different types of contusion injuries to the brain?
To the side of impact:
- Adjacent to (coup)
- Contra-lateral to (contre-coup)
When does a secondary brain injury occur?
- When cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation exacerbates the original injury
- Normal cerebral auto regulatory processes are disrupted following trauma rendering the brain more susceptible to blood flow changes and hypoxia
What is the Cushing’s reflex?
- Hypertension and bradycardia - often occurs late and is a pre-terminal event
What is an extra-dural (epidural) haematoma?
- Bleeding into the space between the dura mater and the skull
- Often results from acceleration-deceleration trauma or a blow to the side of the head
- Majority of epidural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery
Features:
- Raised intra-cranial pressure
- Some patient may exhibit a lucid interval
What is a subdural haematoma?
- Bleeding into the outermost menigeal layer most commonly occurs around the frontal and parietal lobes
- Risk factors include older age, alcoholism and anti-coagulation
- Slower onset of symptoms than epidural haematoma
- May be fluctuating confusion/consciousness
What is a subarachnoid haemorrhage?
- Classically causes a sudden occipital headache
- Usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may be seen in association with other injuries when a patient has sustained a traumatic brain injury
What is the clinical presentation of an extra-dural haematoma?
- Collection of blood between the skull and the dura
- Caused by low impact trauma
- Classically presents with:
- Loss of consciousness
- Lucid interval then rapid decline in consciousness
- Mass effect on the brain will cause uncal herniation and a fixed, dilated pupil due to third cranial nerve compression
What are the typical CT features of an extra-dural haematoma?
- CT imaging will show hyperdense (bright)
- Biconvex (or lentiform) collection around the surface of the brain
- Definitive management is craniotomy and evacuation of the haematoma
What is the clinical presentation of an acute subdural haematoma?
- Fresh collection of blood under the layer of the dura mater of the meninges
- Most commonly caused by trauma but can be caused by vascular lesions e.g. arteriovenous malformations
- Typically caused by high speed injuries or acceleration-deceleration injuries and is therefore commonly associated with other brain injuries
- Spectrum of severity of clinical presentation from an asymptomatic patient to severely comatose
What are the typical CT features of an acute subdural haematoma?
- CT imaging will show hyperdense (bright) cresenteric collection surrounding the brain that is not limited by suture lines
- Definitive treatment is a decompression craniotomy
What is the clinical presentation of a chronic subdural haematoma?
- Old collection of blood that is under the layer of the dura mater of the meninges
- More common in elderly patients, alcoholics, people on anti-coagulation or in infants due to fragility and/or predisposition of the bridging veins to bleed
- Patients typically present several weeks after a mild head injury with progressive confusion, loss of consciousness, weakness or higher cortical function
What are the typical CT features of a chronic subdural haematoma?
- CT imaging will show a hypodense (dark), cresenteric collection around the surface of the brain that is not limited by suture lines
- In symptomatic patients, definitive treatment is burr hole drainage
What is the clinical presentation of intra-cerebral haemorrhage?
- Intra-cerebral or intra-parenchymal haemorrhage is a collection of blood within the substance of the brain
- Causes include:
- Hypertension
- Vascular lesion - e.g. aneurysm or arterio-venous malformation
- Cerebral amyloid angiopathy
- Brain tumour or infarct (e.g. in stroke patients undergoing thrombolysis)
- Patients present similarly to ischaemic stroke - therefore crucial to obtain a CT head in all stroke patients prior to thrombolysis or with decrease in consciousness
What are the typical CT features of an intra-cerebral haematoma?
- CT imaging will show hyperdense (bright lesion) within the substance of the brain
- Treatment is often conservative under the care of stroke physicians
- Large clots in patients with impaired consciousness may warrant surgical evacuation
What are the presenting clinical features of SAH?
- SAH is a bleed into the subarachnoid space which is deep to the subarachnoid layer of the meninges
- Most common cause is trauma
- In non-traumatic (spontaneous) SAH, the most common cause is a ruptured aneurysm but can be caused by an arteriovenous malformation, mycotic aneurysm, pituitary apoplexy or can be idiopathic
- Classical presentation of spontaneous SAH is a sudden onset severe headache, neck stiffness and photophobia
What are the typical CT features of an SAH?
- CT imaging will show hyperdensity within the cisterns or the brain and the sulci
- In cases where the clinical diagnosis is certain but the Ct imaging is inconclusive, a lumbar puncture should be performed after 12 hours to look for xanthochromia
- Treatment is directed at the cause of the bleed
What are the presenting clinical features of an intra-ventricular haemorrhage?
- Intra-ventricular haemorrhage is a collection of blood within the ventricular system of the brain
- In children it can occur due to the prematurity of the periventricular vascular structures
- In adults it may be caused by an extension of SAH, vascular lesions (e.g. aneurysms or arteriovenous malformations) or tumours
- In neonates the vast majority of IVH occur in the first 72 hours after birth - mechanism suggested is result of birth trauma combined with cellular hypoxia and delicate neonatal CNS
What are the typical CT features of an intra-ventricular haemorrhage?
- CT imaging appears as hyper-density within the dark CSF spaces within the ventricles
- Patients with intra-ventircular haemorrhage at risk of obstructive hydrocephalus and this would require surgical CSF diversion
What are the risk factors that trigger telephone advice services (111 or emergency department helplines) to refer patients who have had a head injury to a hospital emergency department?
If patients have any of the following:
- Any loss of consciousness (knocked out) as a result of the injury from which the person has now recovered
- Amnesia for events before or after the injury (problems with memory)
- Persistent headache since the injury
- Any vomiting episodes since the injury
- Any previous brain surgery
- Any history of bleeding or clotting disorders
- Current anticoagulant therapy
- Current drug or alcohol intoxication
- Any safe guarding concerns (e.g. non accidental injury or a vulnerable person is affected)
- Irritability or altered behaviour (easily distracted, not themselves, no concentration, no interest in things around them) particularly in infants and children under 5 years
- Continuing concern by helpline staff about the diagnosis
In community health services e.g. GP and NHS minor injury clinics, what is the referral criteria to the emergency department for patients who have had a head injury?
If any of the following are present, refer to the emergency department:
- GCS <15 on initial assessment
- Any loss of consciousness as a result of the injury
- Any focal neurological deficit since the injury
- Amnesia for events before or after the injury
- Persistent headaches since the injury
- Any vomiting episodes since the injury
- Any seizure since the injury
- Any previous brain surgery
- A high energy head injury
- Any history of bleeding or clotting disorders
- Current anti-coagulant therapy
- Current drug or alcohol intoxication
- Safeguarding concerns
- Continuing concern by the professional about the diagnosis
In the absence of any risk factors following head injury presenting to community services, what other factors should be considered and if present could indicate referral to the emergency department dependent on severity?
- Irritability or altered behaviour, particularly in infants and children aged under 5 years
- Visible trauma to the head
- No one is able to observe the injured person
- Continuing concern by the injured person or their family or carer about the diagnosis
For patients with head injury, what are the risk factors for deciding on full cervical spine immobilisation?
- Attempt full cervical spine immobilisation for patients who have sustained a head injury and present with any of the following risk factors (unless other factors prevent this):
- GCS less than 15 in initial assessment by the healthcare professional
- Neck pain or tenderness
- Focal neurological deficit
- Paraesthesia in the extremities
- Any other clinical suspicion of cervical spine injury
(Maintain cervical spine immobilisation until full risk assessment including clinical assessment (and imaging if necessary) indicates it is safe to remove the immobilisation device
What is focal neurological deficit?
- Problems restricted to a particular part of the body or a particular activity, for example, difficulties with understanding, speaking, reading or writing, decreased sensation, loss of balance, general weakness, visual changes, abnormal reflexes and problems walking
What is a high-energy head injury?
- For example, pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from a height of greater than 1 metre or more than 5 stairs, diving accident, high speed motor vehicle collision, rollover motor accident, accident involving motorised recreational vehicles, bicycle collision, or any other potentially high energy mechanism
What is a base of open or depressed skull fracture or penetrating head injury?
- Signs include clear fluid running from the ears or nose, black eye with no associated damage around the eyes, bleeding from one or both ears, bruising behind one or both ears, penetrating injury signs, visible trauma to the scalp or skull of concern to the professional
Upon arrival at the emergency department following head injury how should patients be assessed?
- Stabilisation of ABC is done before attention to other injuries
- Patients with impaired consciousness GCS <15 should be assessed immediately
- GCS 8 or less should ensure early involvement of anaesthetist or critical care physician for definitive airway management (ET tube)
- Trained member of staff should assess all patients presenting to the ED with a head injury within a maximum of 15 minutes or arrival at hospital - part of this assessment should establish whether they are high risk or low risk for clinically important brain injury and/or cervical spine injury
What is the criteria for performing a CT head scan within 1 hour following head injury in adults?
- Any of the following risk factors present following head injury in adults, perform a CT head scan within 1 hour of the risk factor being identified:
- GCS less than 13 on initial assessment in the emergency department.
- GCS less than 15 at 2 hours after the injury on assessment in the emergency department.
- Suspected open or depressed skull fracture.
- Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
- Post-traumatic seizure.
- Focal neurological deficit.
- More than 1 episode of vomiting
A provisional written radiology report should be made available within 1 hour of the scan being performed.
What is the criteria for performing a CT head scan within 8 hours of the head injury for adults?
- Any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury, perform a CT head scan within 8 hours of the head injury:
- Age 65 years or older.
- Any history of bleeding or clotting disorders.
- Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs).
- More than 30 minutes’ retrograde amnesia of events immediately before the head injury
A provisional written radiology report should be made available within 1 hour of the scan being performed.
What is the criteria for performing a CT head scan within 1 hour following head injury in children?
- Any of the following risk factors present following head injury in children, perform a CT head scan within 1 hour of the risk factor being identified:
- Suspicion of non-accidental injury
- Post-traumatic seizure but no history of epilepsy.
- On initial emergency department assessment, GCS less than 14, or for children under 1 year GCS (paediatric) less than 15.
- At 2 hours after the injury, GCS less than 15.
- Suspected open or depressed skull fracture or tense fontanelle.
- Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
- Focal neurological deficit.
- For children under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head.
A provisional written radiology report should be made available within 1 hour of the scan being performed.
- For children who have sustained a head injury and have more than 1 of the following risk factors perform a CT head scan within 1 hour of the risk factors being identified:
- Loss of consciousness lasting more than 5 minutes (witnessed).
- Abnormal drowsiness.
- Three or more discrete episodes of vomiting.
- Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 metres, high-speed injury from a projectile or other object).
- Amnesia (antegrade or retrograde) lasting more than 5 minutes
A provisional written radiology report should be made available within 1 hour of the scan being performed.
What is the criteria for observing children for a minimum of 4 hours after the head injury but performing a CT head scan within 1 hour if during observation any of the risk factors are identified?
Observe for a minimum of 4 hours after the head injury, if during observation any of the following risk factors are identified, perform a CT head scan within 1 hour:
- GCS less than 15.
- Further vomiting.
- A further episode of abnormal drowsiness
A provisional written radiology report should be made available within 1 hour of the scan being performed. If none of these risk factors occur during observation, use clinical judgement to determine whether a longer period of observation is needed.
What is the guidance regarding patients having anti-coagulation treatment who have sustained a head injury (adults and children)?
- For patients (adults and children) who have sustained a head injury with no other indications for a CT head scan and who are having anticoagulant treatment, perform a CT head scan within 8 hours of the injury. A provisional written radiology report should be made available within 1 hour of the scan being performed.
What is the criteria for performing a CT cervical spine scan in adults with head injury?
For adults who have sustained a head injury and have any of the following risk factors, perform a CT cervical spine scan within 1 hour of the risk factor being identified:
- GCS less than 13 on initial assessment.
- The patient has been intubated.
- Plain X-rays are technically inadequate (for example, the desired view is unavailable).
- Plain X-rays are suspicious or definitely abnormal.
- A definitive diagnosis of cervical spine injury is needed urgently (for example, before surgery).
- The patient is having other body areas scanned for head injury or multi-region trauma
- The patient is alert and stable, there is clinical suspicion of cervical spine injury and any of the following apply:
- Age 65 years or older
- Dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 stairs; axial load to the head, for example, diving; high-speed motor vehicle collision; rollover motor accident; ejection from a motor vehicle; accident involving motorised recreational vehicles; bicycle collision)
- Focal peripheral neurological deficit
- Paraesthesia in the upper or lower limbs.
A provisional written radiology report should be made available within 1 hour of the scan being performed
What is the criteria for performing 3 view cervical spine x-rays within 1 hour for adults with head injury?
For adults who have sustained a head injury and have neck pain or tenderness but no indications for a CT cervical spine scan, perform 3 view cervical spine x-rays within 1 hour if either of these risk factors are identified:
- It is not considered safe to assess the range of movement in the neck
- Safe assessment of range of neck movement shows that the patient cannot actively rotate their neck to 45 degrees to the left and right
The x-rays should be reviewed by a clinician trained in their interpretation within 1 hour of being performed.
When can range of movement in the head and neck be assessed following head injury in children and adults?
- Range of movement in the neck can be assessed safely before imaging only if no high risk factors and at least one of the following low risk features apply, the patient was:
- Involved in a simple rear end motor vehicle collision
- Comfortable in a sitting position in the emergency department
- Has been ambulatory at any time since injury
- Has no midline cervical spine tenderness
- Presents with delayed onset of neck pain
What is the criteria for performing a CT cervical spine scan in children with head injury?
For children who have sustained a head injury, perform a CT cervical spine scan only if any of the following apply (because of the increased risk to the thyroid gland from ionising radiation and the generally lower risk of significant spinal injury):
- GCS less than 13 on initial assessment.
- The patient has been intubated.
- Focal peripheral neurological signs.
- Paraesthesia in the upper or lower limbs.
- A definitive diagnosis of cervical spine injury is needed urgently (for example, before surgery).
- The patient is having other body areas scanned for head injury or multi-region trauma.
- There is strong clinical suspicion of injury despite normal X-rays.
- Plain X-rays are technically difficult or inadequate.
- Plain X-rays identify a significant bony injury.
The scan should be performed within 1 hour of the risk factor being identified. A provisional written radiology report should be made available within 1 hour of the scan being performed.
What is the criteria for performing 3 view cervical spine x-rays within 1 hour for children with head injury?
For children who have sustained a head injury and have neck pain or tenderness but no indications for a CT cervical spine scan, perform 3-view cervical spine X-rays before assessing range of movement in the neck if either of these risk factors are identified:
- Dangerous mechanism of injury (that is, fall from a height of greater than 1 metre or 5 stairs; axial load to the head, for example, diving; high-speed motor vehicle collision; rollover motor accident; ejection from a motor vehicle; accident involving motorised recreational vehicles; bicycle collision).
- Safe assessment of range of movement in the neck is not possible (see recommendation 1.5.10).
- The X-rays should be carried out within 1 hour of the risk factor being identified and reviewed by a clinician trained in their interpretation within 1 hour of being performed.
What are the problems with hand infections?
- Can cause severe problems even after the infection has resolved, such as stiffness, loss of strength and loss of tissues such as skin, nerve and bone
What is a felon?
- Type of hand infection that involves painful throbbing of the pulp of the fingertip
What is acute paronychia?
- Type of hand infection that involves the para-onychium which is the area around the fingernail
What are the potential causes of hand infection?
- Atypical mycobacterial infections
- Bite wound infections
- Cellulitis
- Deep space infections
- Felon
- Herpetic whitlow
- MRSA
- Necrotising fasciitis
- Paronychia
- Septic arthritis/osteomyelitis
- Tendon sheath infection (infectious tenosynovitis)
What are the features of atypical mycobacterial infections to the hand?
- More common types are mycobacterium marinum infection
- Can develop after puncture wounds from fish spines or contamination of a simple wound or abrasion from stagnant water
- Develop gradually and may be associated with swelling and stiffness without much pain or redness
- Surgical removal of infected tissue may be necessary and is helpful to determine which medicine will help treat the infection
- Patients with impaired immunity are more susceptible to atypical mycobacterial infections
What are the features of bite wound infections to the hand?
- Bacteria from the skin or from the mouth can cause infection in the case of human or animal bites
- Thorough washing, soaking or even surgical drainage of the bite wound is needed to clear the infection and wounds are often left open so that any infection can drain
- “Fight bites” to the joint of the hand sometimes result in a chipped tooth being left in the joint of the hand, the tooth needs to be removed to prevent infection of the joint
- Rabies infection from an animal may be serious or even fatal, so it is important to seek treatment as soon as possible after a bite wound
What are the features of cellulitis as a skin infection to the hand?
- Can cause redness, warmth and pain
- May include fever or sickness
- Usually happens due to a break in the skin
- Antibiotics are needed immediately and some people need to be admitted to hospital for treatment
What are the features of a deep space infection of the hand?
- Hand is divided into many separate compartments or deep spaces
- One or more space can become infected even from a small puncture wound
- An abscess can form in the muscle area at the base of the thumb (thenar space), the palm (deep palmar space), or the web spaces between the fingers
- These infections can spread to other areas, even to the wrist and the forearm - need to be drained by surgery
What are the features of a felon in a hand infection?
- Painful throbbing infection of the pulp of the finger is called a felon
- Closed space is separated into many small compartments, each of which fills with infection and pus
- Felon can occur after gardening or other activities that involve sharp objects near the finger tip
- Some felons will resolve with soaks and oral anti-biotics but many also need to be drained
- If not treated early, destruction of the soft tissues and even bone can occur
What are the features of a herpetic whitlow as an infection in the hand?
- Herpetic whitlow is a viral hand infection usually on the fingers, caused by a herpes virus
- More commonly seen in healthcare workers whose hands may be exposed to the saliva of patients carrying herpes
- Condition is characterised by small, swollen, painful blood tinged blisters and sometimes numbness
- Typically treated conservatively and usually resolves in several weeks without many after effects
What are the features of an MRSA infection to the hand?
- Bacteria resistant to methicillin
- Present in health care, nursing homes, gyms, dorms, houses and day care centres
- Skin infections usually look like boils or collections of pus
- Sometimes need draining
- Immediate treatment is important to prevent infection spreading
What are the features of necrotising fasciitis in the hand?
- Very rare but severe infection
- Streptococcus pyogenes or other flesh eating bacteria enter the body through a cut
- Bacteria toxins destroy skin, mucous and other soft tissue
- Emergency - can be life threatening - very strong IV anti-biotics are required to treat it
- Urgent surgery is required to remove the dead tissue
What are the features of paronychia as an infection of the hand?
- Infection of the paronychium which is the area around the fingernail
- In acute paronychia, bacteria can cause the skin around the nail to be red, swollen and tender
- Early treatment with soaks and oral antibiotics can cure the infection
- If pus is formed under the skin, surgery to drain the pus is needed
- Chronic paronychia is caused by fungus - usually occurs in people whose hands are frequently wet
- Cuticle area becomes mildly red and swollen, without drainage and only mild tenderness
What are the features of septic arthritis/osteomyelitis in the hand?
- Wound near a joint can cause septic arthritis
- Can even be caused by a small needle used to drain a cyst at a joint
- Urgent surgical drainage and antibiotics are needed
*
What are the features of tendon sheath infection (infectious tenosynovitis) of the hand?
- Tendons that bend the fingers run from the wrist, through the palm, up the palm side of the fingers, especially near a joint on the palm side, the canal that the flexor tendon runs through can get infected
- Can cause stiffness or even destroy and pop the tendon
- A finger with a tendon sheath infection is swollen, red, and tender over the palm side of the finger and the finger stays slightly bent and is painful to extend
- This infection usually requires that the patient be admitted to the hospital for IV antibiotics, soaks and possible surgical drainage
What are the features of an animal bite?
- Majority involve cats and dogs
* Generally polymicrobial but the most common isolated organism is Pasteurella multocida
What is the management of animal bite?
- Cleanse wound
- Puncture wounds should not be sutured closed unless cosmesis is at risk
- Current BNF recommendations are:
- Co-amoxiclav or
- If penicillin allergic - doxycycline + metronidazole
What the organisms involved in human bites?
- Commonly cause multimicrobial infection, including both aerobic and anaerobic bacteria
- Common organisms include:
- Streptococci spp
- Staphylococcus aureus
- Eikenella
- Fusobacterium
- Prevotella
- Risk of viral infections such as HIV and hepatitis C should also be considered
What are Kanaval signs?
Relating to flexor tenosynovitis are 4 signs on physical examination:
- Flexed posturing of the involved digit
- Tenderness to palpation over the tendon sheath
- Marked pain with passive extension of the digit
- Fusiform swelling of the digit
How should multi-system trauma be approached initially?
- ABCDE approach
- Airway maintenance with cervical spine protection
- Breathing and ventilation
- Circulation with haemorrhage control
- Disability (neurological status)
- Exposure and environmental control (completely undress the patient but avoid hypothermia)
What is the guidance regarding airway management in the pre-hospital setting following major trauma?
- Aim to perform RSI within 45 minutes of the initial call to emergency services for patients who cannot maintain their airway and/or ventilation
What is the management of major trauma patients in the pre-hospital setting who cannot maintain their airway but RSI cannot be performed at the scene?
- Consider using a supraglottic device if the patients airway reflexes are absent
- Use basic airway manoeuvres and adjuncts if the patients airway reflexes are present or supra-glottic device placement is not possible
- Transport the patient to a major trauma centre for RSI provided the journey time is 60 minutes or less
- Only divert to a trauma unit for RSI before onward transfer if a patent airway cannot be maintained or the journey time to a major trauma centre is more than 60 minutes
How should chest trauma be managed in the pre-hospital setting?
- Assess for the diagnosis of pneumothorax for the purpose of triage or intervention
- Consider use of eFAST to assist assessment if the equipment is available
- Negative eFAST does not exclude pneumothorax
- Perform chest decompression in a patient with suspected tension pneumothorax if there is haemodynamic instability or severe respiratory compromise
- Use open thoracostomy instead of needle decompression if the expertise is available, followed by a chest drain via the thoracostomy in patients who are breathing spontaneously
- Observe patients after chest decompression for signs of recurrence of the tension pneumothorax
- Patients with an open pneumothorax:
- Cover with a simple occlusive dressing and
- Observe for the development of a tension pneumothorax
How should chest trauma be managed in the hospital setting?
- In patients with tension pneumothorax, perform chest decompression before imaging only if they have either haemodynamic instability or severe respiratory compromise
- Perform chest decompression using open thoracostomy followed by a chest drain in patients with tension
What type of imaging should be used to assess chest trauma in the hospital setting?
- Imaging for chest trauma patients should be performed urgently
- Consider immediate chest x-ray and/or eFAST as part of the primary survey to assess chest trauma in adults with severe respiratory compromise
- Consider immediate CT for adults with suspected chest trauma without severe respiratory compromise who are responding to resuscitation or whose haemodynamic status is normal
- Chest x-ray and/or USS first line for chest trauma in children
What can be used to control active bleeding in patients with major trauma?
- Simple dressings to control external haemorrhage
- Tourniquet in patients with major limb trauma if direct pressure has failure to control life threatening haemorrhage
- Pelvic binders if active bleeding is suspected from a pelvic fracture after blunt high energy trauma:
- Apply a purpose made pelvic binder or
- Consider an improvised pelvic binder (if purpose made not available)
- IV tranexamic acid as soon as possible in patients with major trauma and active or suspected active bleeding - do not use IV TXA >3 hours after injury in patients with major trauma
- Rapidly reverse anticoagulation - Use prothrombin complex concentrate immediately in adults with major trauma who have active bleeding and need emergency reversal of a vitamin K antagonist (do not use plasma to reverse a vitamin K antagonist)
- Use physiological criteria to activate the major haemorrhage protocol (bleeding leads to a HR >110 bpm and/or systollic bp <90 mmHg
- Use peripheral IV access or IO access
How should access be gained for patients with major trauma?
- Peripheral IV cannula or IO
For patients who have haemorrhagic shock and traumatic brain injury how should they be managed in terms of volume resuscitation?
- If haemorrhagic shock is the dominant condition, continue restrictive volume resuscitation or
- If traumatic brain injury is the dominant condition, use a less restrictive volume resuscitation approach to maintain cerebral perfusion
When resuscitating with blood for active bleeding what ratio of plasma to RBCs should be used to replace fluid volume?
- FFP:RBC 1:1
* Follow the hospital major haemorrhage protocol
How should the injured limb be assessed?
- Look
- Feel
- Move
- Special test
- Neuro-vascular status (pre and post manipulation and x-ray)
- X-ray (pre and post manipulation)
How should a fracture be described?
- Site
- Bone
- Proximal, mid-shaft, distal
- Articular
- Configuration
- Transverse
- Oblique
- Spiral
- Segmental
- Multi-fragmentory
- Displacement
- Translation
- Angulation
- Rotation
- Shortening/impaction
- Soft tissue
- Open
- Compromised
- Tenting
- Blisters
- Firm/woody
- Distal status - sensation, motor
- Vascular (pulses, cap refil)
What is an open fracture?
- Break in the skin and underlying soft tissue leading directly into or communicating with the fracture and its haematoma
Which parts of the body are open fractures more common in?
- Lower limb 3.7%
- Upper limb 3.3%
(More common in young adult males and elderly females) - Vast majority of proximal and distal tibial fractures present with a significant soft tissue injury hence additional complexity when managing the injury
How are open fractures classified?
- Gustilo Anderson Classification
* Type 1, 2, 3a, 3b, 3c
What is a type 1 GA open fracture?
- Wound length <1 cm
- Minimal soft tissue damage, contamination and comminution
- Periosteum intact
- Adequate soft-tissue coverage
- Vasculature intact
What is a type 2 GA open fracture?
- Wound length >1 cm
- Moderate soft tissue damage, contamination, or comminution
- Periosteum intact
- Adequate soft-tissue coverage
- Vasculature intact
What is a type 3a GA open fracture?
- Extensive wound
- Extensive soft tissue damage, contamination, or comminution, segmental fracture
- Periosteal stripping
- Adequate soft-tissue coverage
- Vasculature intact
What is a type 3b GA open fracture?
- Extensive wound
- Extensive soft tissue damage, contamination, or comminution, segmental fracture
- Periosteal stripping
- Inadequate soft-tissue coverage
- Vasculature intact
What is a type 3c GA open fracture?
- Extensive wound
- Extensive soft tissue damage, contamination, or comminution, segmental fracture
- Periosteal stripping
- Inadequate soft-tissue coverage
- Arterial damage
What are the principles of management of the open fracture?
- Manage soft tissue injury
- Minimise the risk of infection
- Stabilise and repair the skeletal injury
- Restore function of affected extremity
How should the patient initially be assessed when suspected open fracture?
- ATLS
- Common secondary to high velocity trauma - Check concomitant injuries
- Thorough examination of all limbs
- Neuro-vascular status of affected limbs
- Compartment syndromes
- Bleeding control
- Vascular damage should be addressed surgically within 3 to 4 hours of injury, but may be delayed to 6 hours in warm limbs
- Ascertain extent of injury by considering mechanism
- Extent of environmental contamination
What is the guidance from the BOAST standards regarding open fracture debridement?
- Debridement should be performed using fasciotomy lines for wound extension where possible
- Timing is advised as follows:
- Immediately for highly contaminated wounds (agricultural, aquatic, sewage) or when there is an associated vascular compromise (compartment syndrome or arterial disruption producing ischaemia)
- Within 12 hours of injury for other solitary high energy open fractures
- Within 24 hours of injury for all other low energy open fractures
When should closure of the wound be performed for patients with open fractures?
- Definitive soft tissue closure or coverage should be achieved within 72 hours of injury if it cannot be performed at the same time of debridement
When can internal stabilisation be performed for patients with open fractures?
- Should only be carried out when it can be immediately followed with definitive soft tissue cover
What are the reasons for immediate surgical exploration on a patient with an open fracture?
- Gross contamination of the wound
- Compartment syndrome
- Devascularized limb
- Multiply injured patient
How is wound debridement performed?
- Initially a limb is washed and alcoholic chlorhexidine tournique is prepped
- Tissues are assessed systematically in turn, from superficial to deep (skin, fat, muscle, bone) and from the periphery to the centre of the wound
- Non-viable skin, fat, muscle and bone are excised
- If definitive treatment is not to be performed in a single step then a vacuum foam dressing (or anti-biotic bead pouch if there is significant segmental bone loss) is applied until definitive surgery is performed
What is the BOAST guideline advice regarding antibiotics for patients with open fractures?
- IV antibiotics should be administered as soon as possible, ideally within 1 hour of injury
- Continue to be administered until primary closure of the wound, or for 72 hours whichever is sooner
What are the potential complications of open fractures?
- Infection
- Non-union
- Chronic regional pain syndrome
- Amputation
