List II - Less common 'know of' conditions Flashcards
1
Q
What is a laceration?
A
- Tearing or splitting of the skin commonly caused by blunt trauma or any incision in the skin caused by a sharp object such as a knife or broken glass
2
Q
How should a person with a laceration be initially managed in terms of referral?
A
- Assess the wound to determine the need for admission or referral
- Admit if the person has signs or symptoms of tetanus (generalised rigidity and spasm of skeletal muscles including lock jaw) and has had a laceration in the previous days or weeks
- Refer to A and E if:
- Vascular damage - arterial bleeding from the wound, loss or pulse, or poor perfusion distal to the injury
- Nerve damage, characterised by loss of light touch or motor function distal to the injury
- Injury to a tendon, including injury to the sheath
- Bony injury or fracture
- Facial laceration for which a good cosmetic repair is important, particularly a laceration that crosses the margins of the lips, nose, or ears
- Laceration of the palm of the hand with any signs of infection
- Laceration associated with cellulitis over a joint
- Laceration is complex, widely gaping, or extensively devitalised
Also refer to A and E if there is tetanus prone wound, which includes:
- Wounds that require surgical intervention which has been delayed for more than 6 hours
- Wounds that have a significant degree of devitalised tissue or a puncture-type injury, particularly if there has been contact with material likely to contain tetanus spores (e.g. soil or manure)
- Wounds containing foreign bodies
- Compound fractures
- Wounds in people who have systemic sepsis
3
Q
How should people with laceration not requiring admission or referral be assessed?
A
- Decide whether it is infected or at risk of infection
- Infected laceration may present with general malaise, fever, rigors, erythema spreading from the laceration, and/or lymphadenopathy
- A laceration is at high risk of infection if it is contaminated with soil, faeces, body fluids, or pus
- Other risk factors for infection include wound length more than 5 cm, age older than 65 years, DBM, stellate shape or jagged wound margins, and presentation more than 6 hours after injury, risk assessment requires clinical judgement but as a guide:
- Single risk factor for infection unless unusally severe, is not likely to be at high risk of infection
- Two or more risk factors, unless these risk factors are unusually mild, is likely to be at high risk of infection
- Although rare, suspect child maltreatment if a child has lacerations, abrasions or scars and the explanation is inconsistent or unreliable
4
Q
What is the management for a laceration with low infection risk?
A
- Clean the wound
- Disinfect around the skin with antiseptic
- Keep hair out of the wound - if necessary, clip the hair around the wound with scissors
- If debriding or exploring the wound, anaesthetise the area - pain from the anaesthetic can be reduced by:
- Using a 25 gauge needle
- Warming the anaesthetic before infiltration
- Infiltrating through the cut edge of the wound into the subdermal tissue
- Infiltrating slowly
- Close the wound
- Suturing with local anaesthetic is preferred for wounds longer than 5 cm or those shorter than 5 cm when:
- Wound is subject to excessive flexing and tension or wetting
- Deep dermal sutures are required to allow low tension apposition of the wound edges
- Tissue adhesives or adhesive strips should be used to close wounds 5 cm or shorter when there are no risk factors for infection, and the wound edges are easily apposed without leaving any dead space and the wound is not subject to excessive flexing, tension or wetting
- Tissue adhesives are not suitable if any risk factors for infection are present
- Always use adhesive strips on pre-tibial flaps (not tissue adhesives or sutures)
- Dress the wound
- Lacerations with minimal exudate, dress with a clear vapour permeable dressing
- Lacerations with modest exudate, dress with a low adherence, absorbent, perforated dressing with an adhesive border - these are also available with a plastic film covering to protect dressings from getting wet
- Check the persons tentanus immunisation status to determine the need for a booster dose of tetanus vaccine
- Provide verbal and written advice to the person including to:
- Seek medical attention if they develop signs and symptoms of infection including increasing pain, redness or swelling spreading from the laceration, fever or generalised malaise
- Take simple analgesia such as paracetamol or ibuprofen if the wound is painful or likely to become painful
- Keep the wound clean and dry
- Arrange follow up appointment to remove stitches
5
Q
What is the advice regarding tentanus vaccine following laceration who is low risk?
A
- Check immunisation status
- Fully immunised person will have had a primary course of three vaccines followed by two boosters spaced 10 years apart
- Administered a booster dose of tetanus vaccine if needed
- If the person is fully immunised, a booster dose is not needed
- If primary immunisation is complete but boosters are incomplete but up to date, a booster dose is not required but administer if the next dose is due soon and it is convenient to do so
- If primary immunisation is incomplete or boosters are not up to date administer a reinforcing dose of the vaccine, and continue with the recommended schedule (to ensure future immunity)
- If the person is not immunised or the immunisation status is unknown or uncertain, give an immediate dose of vaccine followed, if records confirm, by completion of a full five dose course to ensure future immunity
- Prophylaxis with tetanus immunoglobulin is not necessary for a person with a wound that is unlikely to become infected
6
Q
What is the guidance regarding suture removal following laceration?
A
For lacerations closed by sutures, remove stitches after:
- 3-5 days for wounds on the head
- 10-14 days for wounds over joints
- 7-10 days for wounds at other sites
7
Q
What is the guidance regarding removal of adhesive strips following laceration?
A
Advise the person to remove these themselves after:
- 3-5 days for wounds on the head
- 7-10 days for wounds at other sites
8
Q
What is the advice to patients who have had a laceration closed by tissue adhesives?
A
Advise the person that these do not need to be removed as they will slough off naturally after 7-10 days
- Dressings should be removed at the same time as sutures or adhesive strips
- Low adherence absorbent dressings should be replaced if the exudate has cause significant wetting or the dressing
9
Q
How can facial fractures be classified?
A
- Lower third
- Middle third
- Upper third
10
Q
What is the lower third of the face?
A
- Made up of the mandible and its teeth
* Mandible forms a ring with the temporo-mandibular joint and the base of the skull
11
Q
What are the potential fractures of the lower third of the face?
A
- Mandible often breaks in more than one place - ring is difficult to break
- Often has little impact on the airway, unless there is gross displacement
- Gross displacement can cause bleeding that can cause a large sublingual haematoma producing airway compromise (similar to Ludwigs’ angina)
- Roots of the teeth act as a natural weak point in the mandible, teeth are often in the fracture line and can become displaced, loosened, or avulsed
12
Q
What is the middle third of the face?
A
- Made up of the maxilla, zygoma and lower half of the naso-orbito-ethimoidal complex
- This part of the face houses the eyes, the nasal airway, maxillary sinuses and maxillary teeth
13
Q
What are the potential fractures of the middle third of the face?
A
- Mid face acts as a crumple zone to protect the brain from injury and is frequently involved in facial injuries
- Can also result in airway compromise
- Can result in significant haemorrhage and immediate life saving measures may involve placement of Epistats, Rapid Rhinos, Foley catheters or equivalents and bite blocks such as McKesson’s to splint the maxilla and tamponade bleeding points
- Le Fort classification are common patterns of injury - patterns were produced on cadavers therefore not as precise in vivo
14
Q
What is Le Fort I?
A
- Maxilla is fractured from the rest of the face and is often not as freely mobile as one might expect
- Only in high energy transfer does the maxilla become loose and at risk to the airway
15
Q
What is Le Fort II?
A
- Involves the maxilla and nasal complex fracturing from the facial bones and mobility is often more than Le Fort I
16
Q
What is Le Fort III?
A
- Injuries are more significant and involve the whole mid-face dissociating from the base of the skull and facial bones
- Frequently Le Fort injuries will occur in combination and involve the mandible
17
Q
What is the upper third of the face?
A
- Made up of the frontal bone, sphenoid and upper half of the naso-orbito-ethimoidal complex
- Contains the eyes and more of the paranasal sinuses (frontal, anterior and posterior ethmoids and sphenoids)
- Frontal bone’s weakness is the frontal sinus and the extent of pneumatisation varies considerably between individuals
18
Q
What are the potential fractures of the upper third of the face?
A
- When sinuses are large the frontal bone may fracture and involve the anterior skull base
- These fractures may be associated with dural tears, cerebrospinal fluid leak and, therefore, the risk of ascending infection
- Upper third fractures often require anaesthetist input because it is commonly necessary for tubes to be placed into the nose (Foley catheters, nasogastric tubes, and temperature probes)
- Due to fracture displacement and difficult clinical circumstances they can end up in the frontal lobe - it is important to understand that the nasal floor is horizontal when upright and caution is needed
19
Q
What are the different areas of the shoulder that can be fractured?
A
- Clavicle fractures - most common and results from a fall
- Scapula fractures - rare and usually result from high energy trauma such as motor vehicle accidents or far fall
- Proximal humerus fractures - upper part of the arm and more common in older (>65 years) population
20
Q
Which classification system can be used for fractures of the proximal humerus?
A
- Neer classification system
- Based on the anatomical relationship of 4 segments
- Greater tuberosity
- Lesser tuberosity
- Articular surface
- Shaft - surgical neck
21
Q
Which type of shoulder fracture is the most common?
A
- Proximal humerus
- Often seen in older patients with osteoporotic bone following a simple ground level FOOSH
22
Q
What are the treatment options for proximal humerus fracture?
A
- Most are treated with a sling non-operatively
- Indications for non operative treatment include:
- Minimally displaced surgical and anatomic neck fractures
- Greater tuberosity fracture displaced <5 mm
(>5 mm displacement will result in impingement with loss of abduction and external rotation) - Operative
- Closed reduction percutaneous pinning (CRPP)
- ORIF
23
Q
What is the most commonly injured carpal bone in the hand?
A
- Scaphoid - base of the thumb region
- Usually the result of a fall onto outstretched hand
- Most commonly axial load across a hyper-dorsi-flexed, pronated and ulnarly-deviated wrist
- Common in contact sports
24
Q
What is the main risk of an untreated scaphoid fracture?
A
- Avascular necrosis
- Without treatment the risks are as follows:
- Proximal 5th AVN rate of 100%
- Proximal 3rd AVN rate of 33%
25
Q
Which classification can be used for scaphoid fracture?
A
- Type A - stable, acute fractures
- Type B - unstable, acute fractures (distal oblique, complete waist, proximal pole, trans-scaphoid and perilunate associated fractures)
- Type C - delayed union characterised by cyst formation and fracture widening
- Type D - non-union
26
Q
What is a positive clinical test for scaphoid fracture?
A
- Anatomical snuffbox tenderness dorsally
27
Q
What is the recommended imaging for scaphoid fracture?
A
- X-ray in the following views:
- Neutral rotation and lateral, semi-pronated (45 degree) oblique view
- Scaphoid view, 30 degree wrist extension, 20 degree ulnar deviation
28
Q
What is the management if the radiographs are negative (27%) and there is high clinical suspicion of scaphoid fracture?
A
- Repeat radiographs in 14-21 days
29
Q
What is the management of scaphoid fracture?
A
- Non-operative
* Operative
30
Q
What are the indications for non-operative management of scaphoid fractures?
A
- Stable non-displaced fracture (majority)
- If patient has normal radiographs but there is high suspicion can immobilise in thumb spica and re-evaluate in 12 to 21 days
- Scaphoid fractures with <1 mm displacement have union rate of 90%
