Plastics Flashcards
Most common site of hand high pressure soft tissue injuries
Non-dominant index finger, middle finger, palm
Symptoms and signs of high pressure soft tissue injury
Development over 4-6 hours
Pain
Pallor
Swelling
Tenderness
Restricted ROM
Neuromuscular compromise
Complications of high pressure soft tissue injury
Amputation (50% if injected with organic solvents)
Compartment syndrome
Infection
Structure and function of volar plate
Fibrocartilage tissue volar surface of finger PIPJ
Provides anteroposterior joint stability and prevents hyperextension at PIPJ
Complications of unmanaged volar plate injury
PIPJ stiffness
Flexion contracture
Swan neck deformity
Persistent hyper extensibility
At risk group for tendon injury of hand
Male
Working age
Sports - rugby, rock climbing
Food preparation/manual labour - risks of cuts/crush
Rheumatoid arthritis - degenerative rupture
Criteria for conservative management of tendon injuries
Flexor tendons <60% laceration - dorsal blocking splint
Extensor tendons <50% laceration - splint in extension
Hand therapy follow up
Mechanism of injury for UCL thumb
Acute - hyperabduction or hyperextension of thumb
Skier’s thumb
Chronic - repetitive stress, gamekeeper’s thumb
Examination of UCL thumb injury
Xray prior
Valgus stress to MCPJ at full extension and 30 deg flexion
Complete rupture: >30 deg gapping or >15 deg compared to contralateral
Mallet finger mechanism
Forced DIPJ flexion at extended finger
Mallet finger examination
Extensor lag at DIPJ 45 deg
Inability to actively extend
Can be corrected with passive extension
Swelling and tenderness at dorsum DIPJ
Management of mallet finger and complications
Splint in extension for 6-8 weeks full time, then gradually wean over 8 weeks. Don’t allow DIPJ to flex at all, otherwise restart.
Regular hand therapy follow up
Complications - extensor lag, swan neck deformity
Criteria for referral for intraarticular finger fractures
Involvement >30% joint space
Subluxation of joint
Failed reduction
Failed conservative management
Boutonniere deformity cause
Central slip injury, base of middle phalanx button holes between extensor tendons
Trauma
Rheumatoid arthritis/connective tissue disorder
Stages of Boutonniere’s deformity
Stage 1 - PIPJ synovitis and flexion, can be passively corrected, hyperextension DIPJ, normal MCPJ
Stage 2 - 30-40 deg flexion contracture PIPJ, limited passive correction, MCPJ and DIPJ hyperextension
Stage 3 - PIPJ in fixed flexion, radiological changes
Jersey finger mechanism
FDP avulsion from base of distal phalanx:
Forced extension of DIPJ in maximal contraction in flexion
Finger caught in jersey
Contact sports
Jersey finger examination
Swelling and tenderness at volar DIPJ
Loss of active DIPJ flexion
DIPJ rests in extension
Common finger dislocations and mechanisms
PIPJ dorsal dislocation - hyperextension
DIPJ dorsal dislocation - hyperextension
MCPJ thumb - forced hyperextension and abduction
Finger dislocation criteria for referral
Failed reduction
Fracture dislocation
Compound dislocation
Volar dislocation
MCPJ dislocation
Unable to get full ROM after reduction
Collateral instability
Neurovascular compromise
Finger fracture aetiology for age group:
10-29
40-69
70+
10-29 - sports
40-69 - machinery/workplace
70+ - falls
Referral criteria for extraarticular finger fractures
Shortening >2mm
Rotational deformity
Angulated >10 deg + unable to reduce
Displaced fracture
Compound fracture
Multiple fractures
Unstable fracture
How to transfer amputated digit
Wrap in wet gauze in water tight bag
Put bag in container with ice
Referral criteria for base of 1st metacarpal fractures
- Extraarticular with angulation >30 deg
- Bennett’s fracture <1mm displacement (partial intra-articular)
- All Rolando fractures (complete intra-articular)
- Severely comminuted fractures
Most common metacarpal fracture
5th metacarpal
Neck (thinnest bone)
Referral criteria for metacarpal fractures
Head - all intra-articular and displaced
Neck - volar angulation:
Index and middle >10-15 deg
Ring >30-40 deg
Little >50-60 deg
Shaft - volar angulation:
Index and middle >10 deg
Ring and little >20 deg
> 5mm shortening (spiral fractures)
Any shortening for other fractures
Intraarticular
Rotational deformity
Neurovascular compromise
Tendon injury
Compound fracture
Subluxation
Carpal bone fracture mechanisms:
- Capitate
- Hamate
- Trapezium
- Pisiform
Capitate - FOOSH, extension + radial deviation
Hamate - body: punch, hook: direct blow (pain with tight grip)
Trapezium - axial load/hyperextension on adducted thumb, usually intra-articular
Pisiform - FOOSH wrist extension, direct blow
Associated injuries with carpal bone fractures:
- Capitate
- Hamate
- Trapezium
- Pisiform
Capitate - Scaphoid fracture, metacarpal fracture, perilunate dislocation, median nerve injury
Hamate - ulnar nerve injury
Trapezium - radial nerve injury
Pisiform - FCU rupture, ulnar nerve injury at Guyon’s canal
Retrobulbar haemorrhage
- Signs
- Complications
Intraconal haemorrhage:
Proptosis, chemosis, ophthalmoplegia, reduced VA, globe firm to palpate
Compartment syndrome
Irreversible ischaemia in 2 hours
Traumatic optic neuropathy signs
Decreased visual acuity and pupillary reflex
10% have delayed reduced VA
White eye blow out fracture
- Signs
- Complications
Painful restriction eye movement/diplopia
No subconjunctival haematoma
Nausea +/- vomiting
Raised vagal tone
Entrapment of infraorbital nerve
Permanent restriction of ocular movement if not treated within 48 hours
LeFort fracture mechanism
High speed deceleration, midface/maxilla vs stationary object
LeFort I - Straight on/downwards force on upper teeth
LeFort II - Straight on blow lower/mid maxilla
LeFort III - Slight downward force nasal bridge + upper maxilla
LeFort fracture complications
Life threatening haemorrhage
- Epistaxis (II and III)
Upper airway obstruction
Ocular injury
Cribiform plate disruption - CSF leak (II and III)
LeFort fracture pattern
LeFort I - Transverse fracture through maxilla above root of teeth - 3 walls of maxillary sinus, pterygoid process
Unilateral or bilateral
LeFort II - Pyramidal fracture through
bridge of nose, medial + inferior orbit, hard palate and pterygomaxillary buttress.
Usually bilateral
LeFort III - Bridge of nose, medial + inferior + lateral orbit, zygomatic arch ie. craniofacial dissociation
Features of mammalian bite with high infection risk
Dog infection rate 1-20%
High risk: Cats, rodents, bats, humans, monkeys
Hands, feet, genitalia
Delayed presentation >8 hours
Sutured dog bite wounds
Immunocompromised/diabetes/lymphoedema/poor blood supply
Large/dirty wound
Muscle/tendon/joint/bone involvement
Common organisms in bites:
- Dog
- Cat
- Human
+ antibiotic treatment
Dog: Pasteurella multocida, Pasteurella canis, Staphylococcus, Streptococcus, Corynebacterium, Capnocytophaga canimorsus
Tetanus, rabies, mycobacterium - rare
Cat: Pasteurella multocida, Capnocytophaga canimorsus, Staph, Strep
Human: Staph aureus, Strep viridans, Bacteroides, coagulase neg Staph, Fusobacterium, Corynebacterium, Peptostreptococcus
Eikenella corrodens (fist bite)
Augmentin 15-30mg/kg, 625mg tds 7 days
OR
Metronidazole 7.5mg/kg, 400mg tds +
- adults: doxycycline 200mg day 1, 100mg OD day 2-7
- children: co-trimoxazole 24mg/kg BD 7 days
Update tetanus
Venomous bites/stings
Spider - Lactodectus (black widow), antivenom in severe pain + systemic symptoms (<20%)
Toxic fish - Stingray, catfish, lionfish, scorpionfish, weaverfish, stonefish, toadfish, ratfish, rabbitfish, leatherback, some sharks
- Neuro-cardiac toxicity
- Soak in warm water for 30-60mins, surgical removal of barb, antivenoms for some
Blue-ringed octopus, Octopus joubini - releases tetrodotoxin, histamine, serotonin
- Numbness paralysis, hypotension, resp failure
- No anti-venom
Venomous sea snake
- rhabdomyolysis, hyperkalaemia
- Anti-venom
Cone shell - neurotoxicity, 15-20% mortality
- Neostigmine, supportive therapy
Jellyfish (Portugese man of war, box jellyfish, bluebottle) - nematocysts with neurotoxicity
Box jellyfish mortality 15-20%
Bathe in seawater, then vinegar. Avoid water, ETOH (causes nematocyst to discharge). Anti-venom. Supportive care.
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Seal, sea lion bite - Micrococcus infection, tetracycline 2g QID 1/12
Corals - cellulitis + secondary infection (Vibrio, Alteromonas)
Clean with antiseptic, soap + water, hydrogen peroxide
Sponges - irritant dermatitis. Florida fire sponges give toxic rash, erythema multiforme.
- Remove spicule, bathe in vinegar, topical steroid
Sea urchins - secondary infection, some toxic (glycosides, acetylcholine, serotonin)
- Remove spines, treat infection
Starfish (Acanthaster planci) - chronic painful local lesions
Marine bristleworm - irritation, some venemous. Remove spines with tape. Soak in dilute ammonia
Characteristics of burns:
Epidermal
Superficial dermal
Mid dermal
Deep dermal
Full thickness
Epidermal
Red, no blister, normal cap refill, normal sensation, good healing
Superficial dermal
Pale pink, small blisters, normal cap refill, painful, good healing
Mid dermal
Dark pink, large blisters, reduced cap refill, +/- sensation, intermediate healing
Deep dermal
Blotchy red, +/- blisters, no cap refill, no sensation, poor healing
Full thickness
White, no blisters, no cap refill, no sensation, poor healing
Burns at risk of hypovolaemic shock
Fluid resus amount
> 15% TBSA
Normal saline, 1mL x % TBSA /10kg over 1 hour
Burns requiring emergency assessment
Temp >38.9
Hypotension - systolic <90 or <5th percentile for age for children
Diffuse macular erythroderma
Dysfunction of 3+ organ systems
Signs of upper + lower airway burn
Upper:
Perioral burns
Soot in nostrils/sputum
Singed nasal hairs
Pharyngeal oedema
Laryngeal oedema (hoarseness, stridor)
Lower:
Above plus:
Wheeze
Bronchorrhoea
Reduced peak flow
Reduced sats (be wary of carbon monoxide poisoning)
Altered LOC
Management of upper/lower airway burns
Upper:
- Nebulised humidified air/O2 +/- beclomethasone
- Non-patent - tracheal intubation (using smaller ET tube), cricothyrotomy if significant facial trauma
Lower:
- Nebulised salbutamol
- IV fluids: 1mL per %TBSA per 10kg
- Consider abx
Referral criteria for Regional Burns Unit
> 10% TBSA adult, >5% TBSA child
Airway injury
Circumferential burn
Full thickness burn >5%
Burn to hands, feet, face, genitalia, joints
Chemical burns
Electrical burns
Extremes of age
Comorbidities that can affect recovery
Concerns for abuse
Referral criteria for National Burns Unit
> 30% adult, >15% child
Prolonged ventilation requirement
High voltage injuries with underlying tissue damage
Significant chemical burns
Full thickness burns to hands, feet, face, genitalia, joints
Risk factors for poor wound healing
Large, deep wounds
Contaminated wounds/infection
Irregular wound edges, crush, burst wounds
Devitalised tissue, foreign body
Delayed presentation/wound closure
Dependent location (lower limb)
Sutures - too many/too tight
Trauma during suturing
Movement during healing
Elderly
Immunocompromised, peripheral vascular disease, oedema, chronic steroids, diabetes, renal disease, IHD, heart failure
Poor nutrition
Smoking
Obesity
Local anaesthetic toxic dose
Lignocaine 1-2% - 3-5mg/kg
Lignocaine 1% + adrenaline - 6mg/kg
Prilocaine 0.5% - 5mg/kg
Prilocaine 1% + adrenaline - 8mg/kg
Bupivacaine 0.25-0.5% 2mg/kg
Topicaine (lignocaine 4%, adrenaline 0.18%, tetracaine 0.5%) - 0.1mL/kg
More cardiotoxic
Cautions with adrenaline use in LA
End arteries - ears, nose, genitalia, ?fingers
Crush/contaminated wounds
On beta blockers with unopposed alpha receptor stimulation - hypertensive crisis
Peripheral vascular disease
Techniques to reduce pain in LA
Lower concentration
No adrenaline
Warmed
Buffered with NaHCO3 1:10
Small gauge needle - 26-30G
Inject through wound margins
Inject slowly
Inject subdermal
Small volumes (reduce tissue distortion)
Alternatives for local anaesthetic allergy
Diphenhydramine 1%
Benzyl alcohol
Tetracaine (ester)
?SC tramadol
Wound irrigation method
0.9% saline, tap water, 1% povidine iodine
Aiming 1L irrigation
30-60mL syringe
18G needle
Aiming 5-8 PSI
Stingray injuries - use hot saline (<40 deg)
Appropriate wounds for glue
Short (<4cm)
Low tension (<5mm gaping)
Clean
