Minor Injury Management Flashcards
- Hand, Fingers, & Wrist
- Elbow
- Shoulder
History Taking
10 Points
- Presenting Complaint.
- History of Presenting Complaint (traumatic or atraumatic)
- Self-management / OTC Analgesia
- Unwell? / Fever? / Pain?
- Hand Dominance
- If wound(s), ask tetanus status
- Past Medical History
- Drug History
- Allergies
- Social History (Lives Alone? / Frail?)
Opening Of Each OSCE
4 Points
- Wash hands
- Introduce myself, including role
- Patient name and DOB
- Explain examination and gain informed consent
Hand, Fingers, & Wrist
Look
7 Points
- Skin appearance, colour change
- Deformity
- Wounds
- Erythema
- Swelling
- Bruising
- Scars
Hand, Fingers, & Wrist
Feel
3 Points
- Temperature (Warmth)
- Bony Tenderness: DIPJ, PIPJ, MCPJ / Wrist / Elbow (INCLUDING BONY STRUCTURES IN BETWEEN)
- If atraumatic, check for crepitus.
Hand, Fingers, & Wrist
Move
4 Points
- Test ROM (Active or Passive)
- Wrist - Extension & Flexion
- Finger - Extension & Extension
- Thumb Flexion / Extension / Abduction / Adduction / Opposition
Hand, Fingers, & Wrist
Special Tests
6 Points
- ASB Tenderness / Scaphoid Tubercle Tenderness / Pain on Axial Compression of the Thumb
- FDS
- FDP
- Extensor Tendons & Collateral Ligaments
- Carpal Tunnel: Tinels Test
- Flexor Pollicis Longus (FPL) / Extensor Pollicis Longus (EPL) / Extensor Pollicis Brevis (EPB) / Abductor Pollicis Longus (APL)
Hand, Fingers, & Wrist
Neurovascular
4 Points
- CRT
- Pulse (Radial & Ulna)
- Sensation (First Web Space)
- Radial, Medial, & Ulna Nerves: Kumar’s Test
Colles Fracture (Common) – Over 65 Management
- Non-operative management unless severe deformity or NV compromise
Colles Fracture (Common) – Under 65 Management
- Consider surgery for intra-articular involvement, dorsal tilt, and patient needs
- Manipulation for >10mm dorsal angulation or >5mm shortening of radius
- Pain relief: IV regional anaesthesia (gold standard); local hematoma block with gas and air if IV anaesthesia not feasible
- Apply back slab while in traction
- Perform recheck of NV status and re-x-ray
- Referral to fracture clinic
Elbow
Look
8 Points
- Whole Limb
- Deformity
- Wounds
- Erythema
- Swelling
- Bruising
- Scars
- Carrying Angle
Elbow
Feel
4 Points
- Temperature (Warmth)
- Bony / Ligament Tenderness
- Crepitus
- Joint Above / Below
Elbow
Move
4 Points
- Active Or, if needed, Passive ROM
- Flexion 135 degrees
- Extension 0 degrees
- Pronation/Supination 180 degrees
Elbow
Special Tests
3 Points
- Tests for Lateral / Medial Epicondylitis
- Tennis Elbow: Pain Increases Over Lateral Epicondyle On Passive Stressing of Wrist Flexion with Elbow Extension
- Golfer’s Elbow: Pain Increases Over Medial Epicondyle On Passive Wrist Extension With Elbow Extension
Elbow
Neurovascular
3 Points
- Pulses (Radial / Brachial)
- CRT
- Sensation to Limb
Fractured Radial head / Neck
Management
3 Points
- Collar & Cuff
- Surgery if displaced #
- Pain relief
Olecranon Fracture
Management
4 Points
- Refer to Orthopaedics same day
- May advise collar & cuff and return to fracture / elbow clinic
- May be for non-urgent theatre if closed #
- Pain relief
Supracondylar Fracture
Management
3 Points
- Pain Management
- Above Elbow Back Slab
- Refer to Orthopaedics immediately – as Theatre Likely
Elbow Dislocation
Management
3 Points
- Reduction Under Sedation
- Perhaps Surgery if Unstable Due to Complete Joint Capsule Rupture
- Pain Management
Elbow
Monteggia Fracture Dislocation
Management
3 Points
- Closed Reduction in Paediatrics Usually
- Open reduction and Internal Fixation (ORIF) of the Ulna in Adults
Above Elbow Backslab - Pain Management
Elbow
Galeazzi Fracture Dislocation
Management
3 Points
- Open reduction and Internal Fixation (ORIF) of the Distal Radius followed by Stability of the Distal Radioulnar Joint (DRUJ), possibly DRUJ Pinning or ORIF of the DRUJ
- Above elbow backslab
- Pain Management
Elbow
Isolated Ulna Fracture
Management
4 Points
- Below Elbow Dorsal Backslab
- Pain Management
- Refer to Orthopaedics / Fracture clinic – usually no immediate assessment needed
- Safeguarding Referral if Appropriate
Pulled Elbow
Management
1 Point
- Manipulation is performed by actively supinating the forearm with the elbow flexed and whilst palpating the radial head. A click and pain are followed, by a return to active movement when successful
Elbow
Bicep Injuries
Management
- Proximal rupture- usually conservative
- Distal rupture- REFER to ortho same day – for surgery
Lateral / Medial Epicondylitis
Management
- Not for immobilisation
- Avoid oversuse
- Rest
- Ice
- Pain relief
- NSAID’s if not contraindicated
Shoulder
Look
- Whole Limb
- Skin Appearance, including Skin Tenting
- Deformity - Normal and Symmetrical Contour?
- Winged Scapula
- Wounds
- Erythema
- Swelling
- Bruising
- Scars
- Bicep Contour
Elbow
Feel
- Temperature (Warmth)
- Bony Tenderness
- Ligament / Joint Line Tenderness
- Joint Above & Below: C-Spine & Elbow
- Bicep / Triceps tendon Assessment
Shoulder
Move
- Test ROM (Active or Passive)
- Flexion / Extension / Abduction / Adduction / External Rotation / Internal Rotation
- Resisted Tests
- Look out for Crepitus / Impingement
Elbow
Special Tests
- Rotator Cuff
- Empty can
- Resisted external rotation in abduction
- Hornblowers
- Lift off
Shoulder
Neurovascular
- Pulses (Radial / Brachial)
- CRT
- Sensation to limb - Axial Nerve and Distal Limb
Shoulder
Clavicle Fractures
Management
- Poly sling
- Pain relief
- Surgery dependent upon fracture position
- Mid shaft - surgery more likely and need same day discussion with ortho
Shoulder
Acromioclavicular Joint (ACJ) Disruption
Management
- Usually managed conservatively dependent on grading of the disruption
- May need surgery
- Physio
- Collar & Cuff
- Pain Management
Shoulder
Humeral fracture-Proximal
Management
- Usually managed conservatively
- High arm collar & cuff giving traction to the #
- Physio & rehab
- Maintain patient safety on discharge ?social assessment
- Adequate pain relief
Shoulder
Humeral fracture-mid shaft
Management
- Ensure NV intact
- Usually conservative unless comminuted
- Hanging U Cast
- Surgery if vascular/brachial plexus injury, open #, floating segment
- Pain Management
Shoulder
Scapula Fracture
Management
- Senior review and same day ortho referral
- CT
- Pain Management
Anterior Shoulder dislocation
Management
- Check axial nerve, radial pulse, CRT!
- Variety of reduction methods
1. Leverage
2. Traction-semi-supine position, abduction and flexion, slow continuous traction - Some need reduction under sedation if difficult or Hill-Sach’s lesion
Shoulder
Supraspinatus Tendonitis
Management
- Steroid injection
- Pain relief
- Physio
Knee
History Taking
- How can I help?
- SOCRATES
- Any previous injuries?
- How do you feel in yourself?
- What have you tried to help with the pain?
- Would you like any pain relief now?
- Occupation
- Tetanus Status (If Wound(s))
- PMH
- DH
- Allergies
- SH (Particularly If Elderly & Lives Alone)
- Atraumatic specifics
Any new or repetitive movements e.g. DIY/ new or increased sporting activities - Specifics of the mechanism of the injury- valgus or varus strain, hyperextension, direct impact?
- Did the knee swell? Immediate or delayed?
- Does it ‘click’?
- Does it ‘lock’?
- Does it ‘give way’?
Knee
Look
- Whole Limb
- Skin Appearance
- Deformity
- Wounds
- Erythema
- Swelling - Effusion, Bursitis, Bakers Cyst
- Bruising
- Scars
- Valgus/Varus Deformity?
- Quad Contour / Muscle Wastage
- Drop Foot?
Knee
Feel
- Temperature (Warmth)
- Bony Tenderness
- Ligament / Joint Line Tenderness
- Joint Above & Below: Hip, lower limb, foot & ankle
- Effusion tests: Patella tap and sweep tests
Knee
Move
- Test ROM (Active or Passive)
- Flexion / Extension
- Resisted Tests
- Look out for Crepitus
Knee
Special Tests
- Valgus Stress Test For Medial Collateral Ligament (MCL)
- Varus Stress Test For Lateral Collateral Ligament (LCL)
- Lachmans For Anterior Cruciate Ligament (ACL)
- Posterior Draw For Posterior Cruciate Ligament (PCL)
- Straight Leg Raise - patella & quad tendons
Knee
Neurovascular
- Popliteal pulse
- CRT
- Sensation to Limb - First Web Space
Knee
Anterior Cruciate Ligament (ACL) Injury
Management
- Does not heal when torn- requires surgical reconstruction.
Useful info: Meta- analysis trends favour early surgery for optimum rehab
Average surgical age between 2013-2021 is 30
Anterior drawer test (Lachman tests)
Knee
Posterior Cruciate Ligament (PCL) Injury
Management
- If in isolation Grade 1 &2 managed conservatively.
Useful Info: Posterior Drawer Test
Knee
Medial Collateral Ligament (MCL) Injury Management
- Management Several methods
- Rest
- Patellar/soft tissue mobilisations and frictional massage, gait training, cold therapy etc.
- Rarely surgical intervention is necessary.
Useful info: VaLgus stress (foot Leaves the midline)
Knee
Lateral Collateral Ligament Injury
Management
- Usually manged conservatively is in isolation
Useful info: VaRus stress (foot Returns to the midline)
Quadricep Tendon Injury
Management
- Compete rupture = surgical repair
- Partial tear = immobilization 3-6 weeks
Patella Tendon Injury
Management
- Early surgical repair is favored
Knee
Meniscal injury
Management
- Dependent of location, severity, patient individual
Patella Fractures
Management
- Often conservatively
- Surgically if displaced
Patella Dislocation
Management
- Reduction on scene usually
- Physio
Knee
Femoral Condyle Fractures
Management
- Surgical fixation or conservative depending on severity
Knee
Tibial Plateau Fractures
Management
- CT /MRI
- Surgery – Managed externally then later open reduction and internal fixation (ORIF)
Knee
Atraumatic Septic Arthritis
Management
- Immediate referral
- Bloods, infection markers, cultures, cannula, IV ABX. ?Joint aspiration
Knee
Loose Bodies
Management
- Request a ‘tunnel view’ if suspicious of
- Non-immediate referral for investigation ?orthoscopy/ wash out
Knee
Reiter’s Syndrome- Reactive Arthritis
- Steroids, ABX, NSAIDs
- Treatment of the primary infection
- Bloods for infection markers
- Can take 6 months to improve
Knee
Bursitis
Management
- Treat possible infection
- Conservative management preferred
- Aspiration usually not indicated
Chondromalacia Patella
Management
- Education and physio
- Usually conservative management- -stretching and strengthening the relevant muscles
- If conservative fails- numerous surgical interventions
What are the OTTAWA Knee Rules?
- Age ≥55
- Isolated tenderness of the patella
- Tenderness at the fibular head
- Unable to flex knee to 90°
- Unable to bear weight both immediately and in ED