MSK Injury Flashcards
What are the red flags for cauda equina syndrome?
Back pain and lower limb weakness
Altered peri-anal or perineal sensation = saddle anaesthesia
Sphincter disturbance
What are the red flags for metastatic spinal cord compression?
Back pain - worse on coughing and lying flat
Leg weakness
Bowel/bladder dysfunction
Reflexes - increased below compression, absent at level of compression, normal above level
What are the red flags for ruptured AAA?
Central umbilical pain radiating to the back
Expansile and pulsatile central abdominal mass
Hypotensive/collapse/shock
Bruising
Acutely unwell
What must you include in your examination of someone presenting with acute back pain?
Gait assessment Spine examination Peripheral nerve examination Peripheral vascular examination Abdominal examination Rectal examination
How can you examine for nerve root pain?
Straight leg test for sciatica (L4, L5, S1)
Femoral stretch test for femoral nerve irritation (L2-L4)
What is the main cause of sciatica?
Lumbar disc prolapse
When is an X-Ray indicated for back pain?
Over 55 Systemically unwell History of trauma or malignancy Infection HIV suspected
What is the management for suspected cord compression?
16mg dexamethasone + PPI
Urgent MRI
Urgent neuro/oncology referral
What are the two joints in the ankle and what movements do they facilitate?
Subtalar joint
- Calcaneus + talus
- Facilitates eversion/inversion
True ankle joint
- Tibia, fibula, talus
- Facilitates dorsi/plantarflexion
What usually causes an ankle ligament strain?
Inversion injury (85%) - injury to the anterior talofibular part of the lateral ligament
What can help you decide if an X-Ray is needed to rule out a fracture in ankle injury?
Ottawa ankle rule:
- Inability to weight bear immediately after injury and in ED
- Pain in malleolar zone plus tenderness over posterior edge of lateral/medial malleolus
How can you manage a simple ankle sprain?
POLICE
Protection from further injury Optimal Loading Ice Compression Elevation
Full recovery can take 4 weeks
Advise to come back if not full weight-bearing by 4 days
Who are distal radial fractures most common in?
Osteoporotic post-menopausal women
What are the most common distal radial fractures? What most commonly causes them?
Colles’ - falling on outstretched hand
Smiths’ - falling on flexed wrist
How does Colles’ fracture present?
Dinner fork deformity
What would be seen on an X-Ray of a Colles’ fracture?
Extra-articular fracture of the distal radius with dorsal displacement of the distal radius
If there is a grossly displaced fracture, how do you treat it?
- MUA (manipulation under anaesthetic) - Bier’s block with IV regional LA
- Apply POP backslab cast and sling
- XRay to check position
When is MUA urgent in a distal radius fracture?
Compound fracture
Nerve compression
How does a neck of femur fracture present?
Pain in hip radiating to knee
Inability to weight-bear
Affected leg is shorter and externally rotated
Adduction of affected leg
What should you check for in an elderly patient with a hip fracture?
Signs of dehydration
Hypothermia
They may have been lying for hours
What is a complication of intracapsular neck of femur fractures?
Disruption of blood supply to femoral head causing avascular necrosis
What is the classification for intracapsular femoral neck fractures?
Garden classification
I - Incomplete undisplaced fracture with the inferior cortex intact
II - Complete undisplaced fracture through the neck
III - Complete neck fracture with partial displacement
IV - Fully displaced fracture
What gives the best outcome in hip fractures if displacement is minimal?
Internal fixation in situ - the risk of displacement, risk of AVN and non-union are reduced
What is the ED management for a hip fracture?
ABCDE
IV access
- Bloods - FBC, U&Es, glucose, crossmatch to prepare for surgery
- IV fluids if hypotension/dehydrated
- IV morphine (titrate up) + antiemetic
- Femoral nerve block
Lateral hip X-ray
Refer to orthopaedic surgery
On a lateral hip X-ray, what indicated a fractured neck of femur?
Interrupted Shenton’s line (imaginary curved line drawn along inferior border of superior pubic ramus to inferomedial border of neck of femur)
What is the most common type of shoulder dislocation?
Anterior dislocation (95%) - due to forced external rotation and abduction of the shoulder
Who does anterior dislocation most commonly affect?
Young males playing contact sports
Elderly patients falling on outstretched hand
What causes a posterior shoulder dislocation?
Trauma to anterior shoulder or fall onto internally rotated arm
What is found on palpation of anterior shoulder dislocation?
Loss of shoulder contour - flattening of deltoid
Anterior bulge from head of humerus - can be palpated anteriorly and in axilla
Step-off deformity at acromion with palpable gap below acromion
How can you test for injury to the axillary nerve?
Loss of sensation over lateral shoulder (badge area)
Lack of contraction of deltoid during attempted abduction
What is posterior shoulder dislocation associated with?
Epileptic seizures
Electrical shocks
Direct blow during trauma
What might occur at the same time as an anterior shoulder dislocation?
Fracture of the humeral head, neck or greater tuberosity
How can you assess the radial nerve?
Weakness of wrist extension and thumb abduction
Reduced sensation on dorsum of hand
Abnormal triceps and brachioradialis reflexes
What changes are seen on an X-Ray in anterior shoulder dislocation?
Humeral head lies inferior to coracoid process on AP view
Head of humerus anterior to glenoid on axillary view
What sign is seen on X-Ray of posterior shoulder dislocation?
Lightbulb sign
What is the most common method to manipulate an anterior shoulder dislocation?
External rotation method
- Patient supine on bed
- Affected arm is adducted and flexed to 90 degrees at elbow
- Arm is then slowly externally rotated
- The shoulder should be reduced before reaching the coronal plane
