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