Trauma Flashcards
What does the ABCDE evaluation stand for when managing trauma?
Airway management
Breathing and Ventilation
Circulation ad bleeding control
Disability ( neurological evaluation)
Exposure and Environmental control
What value on the Glasgow coma scale signifies loss of airway control?
8 or lower
Give examples of signs which indicate airway obstruction.
noisy breathing
gurgling
stridor
agitation from hypoxia and hypercapnoea
How do you manage ABCDE evaluation?
A- obstructions must be removed. Oxygen and ventilation can be delivered through the new airway after an emergency cricothyroidotomy if neccessary
B- all major trauma patients should receive high flow oxygen via tight fitting mask. Oxygenation is best assessed with pulse oximetry
C- Patients pulse rate, volume and blood pressure. Cardiac monitor should all be assessed
D- quick neurologic assessment should be performed to establish the level of consciousness
E- Keep patient warm to avoid hypothermia. Adequate patient exposure should ensure no major injuries are missed.
What should be carried out at the end of primary survey?
Trauma series of X-rays (lateral C-spine, chest and pelvis xrays) carried out based on the clinical condition along with X-rays of any other significant MSK injuries
Log roll patient if there is spinal injury and look for signs of spinal fracture
PR examination can be carried out
Urinary catheter should be passed and the nasogastric tube can be passed now
FBC, U&Es, CT scans, US or DPL can be performed now
What is a polytrauma?
Where more than one major long bone is injured or where a major fracture is associated with significant chest or abdominal trauma.
What can unstable major long bone fractures cause?
Ongoing blood loss
Hypovolaemia
Pain
Increased
sympathetic response
Amplification of the inflammatory response
fat embolism
When does Systemic inflammatory response syndrome (SIRS)?
SIRS occurs when there is an amplifaction of inflammatory cascades in response to trauma with pyrexia,tachycardia, tachypnea and leukocytosis
What is the first manifestation of Hypovolaemia?
ii. what follows after?
Tachycardia
ii. Decrease in blood pressure. Confusion or lethargy may also occur
What is the definition of a Fracture?
Medical term for a break in the bone
What is the difference between a direct trauma and indirect trauma?
ii. which causes the majority of fractures?
Direct trauma refers to a direct blow
indirect trauma refers to it being caused by twisting or bending forces
What is the difference between a partial/incomplete fracture and a complete fracture
Partial fracture - not a complete break e.g. stress fracture
complete - complete break in bone
What is the difference between a high energy fracture and a low energy fracture?
High energy - e.g. car accident, gunshot, blast, fall from height
Low energy - e.g. Trip, fall, sports injury
How do bones heal?
Primary healing (1st intention)
secondary healing (2nd intention)
What is primary bone healing?
When there is minimal fracture gap (less than about 1mm) and the bone simply bridges the gap with new bone from osteoblasts.
occurs in the healing of hairline fracture and when fractures are fixed with compression screws and plates
What is secondary bone healing?
- Occurs in majority of fractures
When there is a gap at the fracture site which needs to be filled temporarily to acts a scaffold for new bone to be laid down. Involves the recruitment of pluripotential stem cells which help healingdoocess.
What is the fracture process of secondary bone healing?
- Fracture occurs
- Haematoma occurs with inflammation from damaged tissues
- Macrophages and osteoclasts remove debris and reabsorb the bone ends
- granulation tissue forms from fibroblasts and new blood vessels
- Chondroblasts form cartilage (soft callus)
- Osteoblasts lay down bone matrix (collagen type 1)- endochondral ossification
- Calcium mineralisation produces immature woven bone (hard callus)
- Remodelling occurs with organisation along lines of stress into lamellar bone
How long does it take soft callus to form in secondary bone healing?
2-3 weeks
How long does it take for hard callus to form in secondary bone healing?
6-12 weeks
What does secondary bone healing require?
Good blood supply for oxygen
Nutrients
Stem cells
Little movement - no movement (i.e. internal fixation with fracture gap) is bad
What is a Tranverse fracture?
Fracture of the bone occurs transversely (sideways)
Occur with pure bending force where the cortex on one side fails in compression and the cortex on the other side in tension.
Tranverse fractures may not shorten (unless completely displaced) but may angulate or result in rotational malalignment
What is a oblique fractures?
Occur with a shearing force (e.g. fall from height. deceleration).
Their patterns have the benefit of being able to be fixed with interfragmentary screws
Oblique fractures tend to shorten and may also angulate
What is a spiral fracture?
Occur due to torsional forces.
interfragmentary screws potentially can be used.
Spiral fractures are most unstable to rotational forces but can also angulate
What is a comminuted fracture?
Fractures with 3 or more fragments.
Generally a reflection of high energy injuries or poor bone quality.
substantial soft tissue swelling and periosteal damage with reduced blood supply to the fracture site which may impair healing
normally very unstable
What is a segmental fracture?
When the bone fractures in two separate places.
These injuries are very unstable and require stabilisation with long rods
A fracture at the end of a long bone can be described according to what?
site of the bone and also the type of the bone
A fracture at the end of a long bone (metaphyseal/epiphyseal) can be what?
intra-articular (extending into the joint) or extra-articular
Intra-articular fractures have a greater risk of stiffness, pain and post-traumatic osteoarthritis. Especially if there is any residual displacement in an uneven articular surface.
What three factors does a fracture displacement depend on?
Translation
Angulation
Rotation
What does the translation of a distal fragment describe?
Described as anteriorly or posteriorly displaced and medially or laterally translated
can be estimated with reference to the width of the bone. 100% displacement is generally referred to as an “off ended” fracture
What does the angulation of a distal fragment describe?
Direction in which the distal fragment points towards and the degree of the deformity
Can be either posterior/anterior and Medial/lateral
however some exception in description:
lower limb varus ( distal fragment pointing towards the midline)
Lower limb valgus (distal fragment pointing away from the midline)
can be measured in degrees from the longitudinal axis of the diaphysis of a long bone
What can residual displacement or angulation cause?
Deformity
Loss of function
abnormal pressure on joints
all three factors lead to post-traumatic OA
What does the rotation of a distal fragment describe?
Relative to the proximal fragment, it is an important clinical descriptor as a rotational malalignment which poorly tolerated and needs to be corrected when managing fractures.
What are the main clinical features of a fracture?
Pain - if put weight on it
localised bony (marked tenderness)- not diffuse mild tenderness
swelling
deformity
crepitus - from bone ends grafting with an unstable fracture
What should an assessment of an injured limb include?
Whether injury is open or closed
Assessment of the distal neurovascular status (e.g. pulses, cap refill, temp, colour)
whether Compartment syndrome is present
Status of the skin and soft tissue envelope
How do you diagnose fractures?
X-rays
Tomogram - moving X-ray used for images of complex bones e.g. mandibular fractures
CT - helps determine the degree of articular damage
MRI - used to detect occult fractures where there is clinical suspicion but a normal X-ray e.g. hip and scaphoid
Technetium bone scans - can be useful to detect stress fractures. May fail to show up on X-ray until hard callus starts forming
How do you manage Long bone fractures?
Initial management
- clinical assessment of the injured limb
- analgesia ( IV morphine)
- Splintage / immobilisation of the limb with investigation (X-ray)
- Reduction of fracture should be performed before x-ray if there is a clear fracture dislocation
Definitive fracture management;
depends on numerous factors (e.g. which bone affected, age of patient, location of fracture, pattern of fracture, displacement of fracture, stability of fracture, whether it is open or closed, Neurovascular status)
Displaced/angulated fractures where the position is unacceptable required reduction under anaesthetic
(e.g. GA, spinal or Bier’s block)
closed reduction and cast application can also be used. Requires may x-rays to ensure no loss of position
unstable injuries can be treated with surgical stabilisation - use K-wires for small fragments
unstable extra-articular diaphyseal fractures can be fixed with open reduction and internal fixation (ORIF) uses plates and screws with the aim of anatomic reduction and rigid fixation. Should avoid ORIF if the soft tissue is too swollen, where the blood supply to fracture is high energy or where it can cause extensive blood loss.
Displaced intra-articular fractures require anatomic reduction and rigid fixation by ORIF using wires, screws and plates.
Give examples of complications of fractures?
Early local complications : compartment syndrome, vascular injury with ischaemia, nerve compression or injury, and skin necrosis
Early systemic complications: hypovolaemia, fat embolism, shock, ARDS, acute renal failure , SIRS and death
Late local complications: Stiffness, loss of unction, chronic regiona pain syndrome, infection, Post traumatic OA and DVT
Late systemic complications : pulmonary embolism - ranges in time taken to form
What is compartment syndrome?
When group of muscles are unable to swell caused by bleeding and inflammation exudate from fracture and injury due to it being bound in tight fascial compartments
What are the main clinical features of compartment syndrome?
- Increased pain on passive stretching of the involved muscle
- Severe pain outwith the anticipated severity in the clinical cortext
What are the two main nerve injuries associated with fractures?
- Neurapraxia - when the nerve has a temporary conduction defect from compression or stretch and resolve over time with full recovery
- Axonotmesis - occurs from either sustained compression ,stretch or from a higher degree of force. Long nerve cell axons distal to the point of injury die in a process called wallerian degeneration. recovery varies
What is Neurotmesis?
complete transection of a nerve
No recovery will occur unless the affected nerve is surgically repaired
which nerve injury is a colles fracture associated with?
Acute median nerve compression/carpal tunnel syndrome
which nerve injury is an anterior dislocation of the shoulder associated with?
axillary nerve palsy
Which nerve injury is a humeral shaft fracture associated with?
Radial nerve palsy
Which nerve injury is a supracondylar fracture of the elbow associated with?
median nerve injury
Which nerve injury is the posterior dislocation of the hip associated with?
sciatic nerve injury
Which nerve injury is the “bumper” injury to the lateral knee associated with?
common peroneal nerve palsy
What arterial damage can occur from a knee dislocation?
popliteal artery can be injured
What arterial damage can occur from a paediatric supracondylar fracture of the elbow?
brachial artery injury
what arterial damage can occur from a shoulder trauma?
axillary artery injury
Give some examples of signs of reduced distal circulation.
- Reduced or absent pulses
- Pallor
- delayed cap refill
- Cold to touch
What are the signs and symptoms of a fracture healing?
Resolution of pain and function
Absence of point tenderness
no local oedema
resolution of movement at fracture site
what are the clinical signs of non-union in fractures?
ongoing pain
ongoing oedema
movement at the fracture site
Bridging callus may be seen x-ray however sometimes not always obvious so use CT scans
What is a non union?
serious condition where the fracture fails to heal
what are the cause of hypertrophic non-union?
Instability
excessive motion at the fracture site
Infection
What are the causes of atrophic non-union?
rigid fixation with a fracture gap
lack of blood supply at the fracture site
chronic disease
soft tissue interposition
infection
Give examples of some fractures which are particularly prone to problems with healing?
scaphoid waist fractures
fractures of the distal clavicle
subtrochanteric fractures of the femur
jones fracture of the fifth metatarsal
How do you manage a hypertrophic non union?
application of a plate to ensure subsequent union of the fracture
How do you manage atrophic non union?
removal of fibrous tissue at the fracture site
restoration of bleeding vone ends
restoration of the medullary canal continuity
bone grafting to stimulate bone formation and to act as a scaffold for new bone to grow
How do you diagnose non union fractures?
X-ray
CRP and bacteriological sampling for evidence of infection
How do manage non union fractures if infection is diagnosed?
Surgical removal of dead and infected bone is required often with shortening of the bone
special circular frame external fixators may be used with the advantages of applying compression at the fracture site
what is a delayed union?
fracture which has not healed within the expected time frame
How can open fractures occur?
- Inside out injury - spike of fractured bone from within punctures the skin
- Outside-in injury - laceration of the skin from tearing or penetrating injury
What factors increase the risk of infection in open fractures?
- higher the energy of the injury
- amount of contamination
- any delay in appropriate treatment
- problems with wound closure
how do you manage open fractures?
Initial management
- IV broad spectrum antibiotics e.g. flucloxacilin (gram positive), Gentamicin (gram negative) and Metronidazole ( anaerobes)
antiseptic dressing should be applied to wound
Surgery required ASAP. Debridement is carried out (removal of all contamination and excision of non-viable soft tissue
internal or external fixation required as casts would required constant wound inspections
if wound is not grossly contaminated and all remaining skin and muscle is viable and all can be closed without undue tension - then wound can be closed primarily
skin grafts can be used otherwise if cant be closed primarily
How should you manage mangled extremity?
some cases suggest an early amputation may be best choice
what causes dislocations?
significant trauma
conditions which cause hyper-mobility (Ehlers danlos and Marfans)
voluntary dislocation e.g. shoulder
How are ligament ruptures graded?
grade 1 - sprain
grade 2 - partial tear
grade 3 - complete tear
How do you manage soft tissue injuries?
RICE
Rest
Ice
compression
elevation
n.b. some complete ligament ruptures and tendon tears may require surgical repair or graft reconstruction (ligament only)
What are the main causes of spinal cord of nerve cord damage?
contusion
compression
stretching
laceration
what is spinal shock?
physiological response to injury with complete loss of sensation and motor function and loss of reflexes below the level of the injury
How long does it take for spinal shock to usually resolve?
ii. which reflex is used to signal the end of spinal shock?
24 hours
ii. bulbocavernous reflex - reflex contraction of the anal sphincter with either a squeeze of the glans penis, tapping the mons pubis or pulling on a urethral catheter
What is neurogenic shock?
occurs secondary to temporary shutdown of sympathetic outflow from the cord from T1 to L2, usually due to injury in the cervical or upper thoracic cord.
what does neurogenic shock cause?
hypotension and bradycardia
how long does it take for neurogenic shock to resolve?
24-48 hours
usually treated with IV fluid therapy
what is complete spinal cord injury?
when there is no sensory or voluntary motor function below the level of the injury. Reflexes however should return
How is the level of the injury in a spinal cord injury determined?
by the most distal spinal level with partial function (after spinal shock) has resolved as determined by the presence of dermatomal sensation and myotomal skeletal muscle voluntary contraction.
what is incomplete spinal cord injury?
some neurologic function (sensory and/or motor) is present distal to the level of injury. greater the function = greater the prognosis
what does sacral sparing indicate?
incomplete cord injury with a better prognosis than a complete injury
signs include perianal sensation, voluntary anal sphincter contraction and big toe flexion (FHL muscle, s1/2)
How do you manage spinal cord injury?
immobilisation (cervical collar& sandbags, spinal board) helps prevent further damage where an unstable fracture or dislocation exists.
Traction helps reduce dislocations or stabilise unstable cervical spine injuries
surgery used to relieve pressure pressure on the cord or to stabilise unstable injuries
special spinal beds help prevent pressure sores from paralysis
ventilatory support for loss of intercostal muscle function (T1- T12)
What is central cord syndrome?
common injury pattern and usually occurs with a hyperextension injury in a cervical spine with osteoarthritis.
paralysis of the arms more than the legs occurs due to corticospinal tracts of the upper limbs being more central and those in the lower limbs being more peripheral in the cord
sacral sparing is typically present
what is anterior cord syndrome?
results in loss of motor function as well as loss of coarse touch, pain and temperature sensation (lateral spinothalamic tract) whist proprioception, vibration sense and light touch are preserved (dorsal columns)
what are the signs and symptoms of anterior cord syndrome?
loss of movement, pain and temperature
still able to feel position, vibration and touch
What is Brown-sequard syndrome?
syndrome which occurs from hemisection of the cord usually from penetrating injury e.g. stab wound
signs: ipsilateral paralysis and loss of dorsal column sensation occurs with contralateral loss of pain, temperature and coarse touch sensation
what are the main causes of pelvic fractures?
younger patients- high energy injuries
older patients - more common to suffer from osteoporosis can sustain pubic rami fractures from low energy injuries
what are three main patterns of pelvic fracture?
- lateral compression fracture - occurs with a side impact where one half of the pelvis is displaced medially
- vertical shear fractures - occur due to axial force on one hemipelvis (e.g. fall from height, rapid deceleration) where the affected hemipelvis is displaced superiorly. the leg on the affected side will appear shorter
- Anteroposterior compression injury - results in wide wide disruption of the pubic symphysis the pelvis opening up like the pages of a book (open book pelvic fracture). substantial bleeding from torn vessels occurs.
How do you manage pelvic fractures?
Blood loss is treated with fluid or blood
open book pelvic fractures - promptly reduce the displacement and minimise the pelvic volume to allow tamponade of bleeding to occur
external fixator provides initial stabilisation
ongoing haemodynamic instability may require angiogram and embolisation or open packing of the pelvis if a laprarotomy is required for co-exisiting intra-abdominal injuries
urinary catheterisation for bladder and urethral injuries
PR exam is mandatory to assess the sacral nerve root function and too look for the presence of blood (indicates a rectal tear which means and open fracture)
conservative management required for low energy pubic rami fractures in the elderly
what are the main causes of acetabular fractures?
high energy injuries
can have low energy in older patients
what is the acetabulum?
it is the intra-articular section of the pelvis which form the ‘cup’ of the hip joint
where the femur attaches to the pelvis
What is the best way to diagnose a acetabular fracture?
CT scans better than X-rays as they may be quite difficult to determine
how do you manage acetabulum fractures?
conservative treatment
anatomic reduction and rigid fixation required in young patients to reduce the risk of post traumatic OA
older patients can be treated with total hip replacements
How are hip fractures broadly classified?
intracapsular
extracapsular
classified based on the position of the fracture in relation to the hip capsule - relevance is the likelihood of disruption the femoral head blood supply
What is an intracapsular hip fracture?
bone fracture located within the joint capsule.
when the arterial supply of the femoral head can be disrupted and there is a risk of avascular necrosis of the femoral head an non-union of the fracture
How do you manage Intracapsular hip fractures?
femoral head replacement via hemi-arthroplasty (removing femoral head only) or total hip replacement
Total hip replacement has higher risk of dislocation but gives better movement - give to higher functioning hip fracture patient
What is an extracapsular hip fracture?
bone fracture located outside the joint capsule.
should not cause avascular necrosis and have high union rates
How do you manage extracapsular hip fractures?
internal fixation as avascular necrosis wont occur
either do it by compression or dynamic hip screw
What causes femoral shaft fractures?
- usually occurs as high energy injuries - risk of concomitant fracture elsewhere
- osteoporotic bone, metastatic disease, patients with paget’s disease can lead to stress fractures of the femoral shaft
What can occur due to displaced femoral shaft fractures?
substantial blood loss
how do you manage femoral shaft fractures?
initial management :
- analgesia with a femoral nerve block
- thomas splint - minimises further blood loss and fat embolism
Definitive management:
closed reduction and stabilisation with an intramedullary nail
minimally invasive plate fixation can also be used
What causes true knee dislocations?
- high energy injuries
2. severe hyperextension and/or rotational forces with a sporting injury
How do you manage knee dislocations?
Obvious dislocations should be reduced urgently
further investigation: doppler, duplex scan or angiogram
revascularisation
if the knee is very unstable then external fixator can be required
multi-ligament reconstruction is usually required as knee dislocations usually tear multiple ligaments
what are the causes of patellar dislocations?
- direct blow
2. contraction of the quadriceps with a rotational force with the patella not engaged in the trochlea
what are the risk factors for patellar dislocations?
- adolescents ( mainly females)
- Generalised ligamentous laxity
- valgus alignment of the knee
- rotational malaignment
- Shallow trochlear groove
How do you manage patellar dislocation?
further dislocations can occur in first time dislocation patients
further dislocations can be prevented by temporary splintage followed by physiotherapy
may require surgical stabilisation sometimes
What type of fracture is the proximal tibia fracture?
intra-articular fractures with either a split in the bone, a depression of the articular surface or both
What are the causes of proximal tibia fractures?
high energy injuries - associated with neurovascular injury or compartment syndrome
low energy injuries in osteoporotic bone
How do you manage proximal tibia fractures?
Surgery used for the aim of reduction of the articular surface and rigid fixation
Plates and screws are used for fixation
CT scans useful for planing surgical fixation
Can be substantial soft tissue swelling therefore a temporary external fixator to allow for the swelling to resolve. then use internal fixation and definitive open reduction
can have definitive external fixation using a ring fixator and fine wires
total knee replacement also common
What are the causes of tibial shaft fractures?
Indirect force along with:
- bending- transverse fracture
- rotational energy- spiral fracture
- compressive force from deceleration- oblique fracture
- combination of these forces or from high energy injuries- comminuted fractures
tibia fractures are the commonest cause of compartment syndrome true or false?
true - particularly the anterior compartment of the leg
How do you manage tibia shaft fractures?
Non operative: up to 50% displacement and 5 degrees of angulation in any plane can accepted with conservative management in an above knee cast
operative: internal fixation removes need for a cast
open fractures require surgical stabilisation - intramedullary nailing commonest method
compartment syndrome requires urgent fasciotomies and surgical stabilisation of the fracture
non unions may require bone grafting of special circular frames
what are the names of the lateral ankle ligaments?
anterior & posterior talofibular ligaments
calcaneofibular ligaments
commonplace for sprains to occur in the ankle
which criteria is used to identify suspected ankle fracutres?
ottawa criteria
what signifies that an ankle may need an x ray if they have a suspected fracture?
severe localised tenderness - bony tenderness in the distal tibia or the fibula
inability to weight bear for four steps
what does ORIF mean?
open reduction and internal fixation
What is classed as a stable ankle fracture and how do you manage them?
Isolated distal fibular fractures with no medial fracture or rupture of the deltoid ligament
treatment - walking cast or splint for around 6 weeks
What is classed as an unstable ankle fracture and how do you manage them?
Distal fibular fractures with the rupture of the deltoid ligament
treatment - ORIF
what is talar shift?
observed on a mortise AP view xray with the foot slightly internally rotated
when there is a asymmetric increased space around the the talus within the ankle mortise. signifies that the deltoid ligament must be ruptured if there is no medial malleolar fracture
causes ankle pressure to increase and increase risk of Post OA
can also lead to fracture-dislocation of the ankle
How do you manage talar shift?
anatomic reduction and rigid internal fixation
what type of fracture is a bimalleolar fracture?
fracture to both medial and lateral malleoli - unstable and require ORIF
What are the causes of the fracture of the 5th metatarsal base ?
inversion injury with an avulsion fracture at the insertion of the peroneus brevis tendon
how do you manage 5th metatarsal fractures?
require a walking cast, supportive bandage or wearing a of a stout boot for 4-6 weeks
what is a jones fracture?
when the 5th metatarsal fractures in the region of the proximal diaphysis - can be more problematic due to poor blood supply and have a higher risk of non unions.
require fixation with a screw.
non union will also require a bone grafting
what type of fracture is the 2nd metatarsal a common site for?
stress fractures - occur spontaneously or after a period of exercise. can sometimes not be visible so may require a bone scan
use cast for treatment
what is the most common pattern of a humeral neck fracture?
Fracture of the surgical neck of the humerus with medial displacement of the humeral shaft due to pull of the pectoralis major muscle
the greater and less tuberosisites may also be pulled away
it is associated with axillary nerve injury - resulting in weakness and numbness over the upper lateral aspect of the arm.
There is no visible gap immediately below the acromion is unlike in shoulder dislocation
How do you manage humeral neck fractures?
minimally displaced proximal humerus fractures are treated conservatively with a sling
internal fixation for persistently displaced fractures
humeral head splitting fractures require shoulder replacement unless patient is young
which is more common anterior or posterior shoulder dislocations?
anterior dislocations
What are the causes of anterior shoulder dislocations?
excessive external rotational force
fall onto the back of the shoulder
seizures - bilateral dislocations
ligamentous laxity
connective tissue disorders e.g. ehlers - danlos and marfan’s syndrome
what can anterior shoulder dislocations lead to?
- bankart lesion - detachment of the anterior glenoid labrum and capsule
- Hill-sachs lesion - when the posterior humeral head impacts on the anterior glenoid producing an impaction fracture of the posterior head
- axillary nerve can be stretched as it passes through the quadrilateral space
what are the clinical features of a anterior shoulder dilsocation?
loss of symmetry with loss of roundness of the shoulder
arm supported by the patients other unaffected arm. It is held externally rotated and slightly abducted
tears of the rotator cuff are common in the elderly
The acromion becomes prominent with a visible gap below it
loss of sensation in the ‘regimental badge area’ - main sign of axillary nerve injury
XRAY useful in diagnosis
How do you manage anterior shoulder dislocations?
closed reduction under sedation/anaesthetic
sling - 2-3 weeks to allow detached capsule to heal
physiotherapy
ORIF if greater tuberosity still displaced
How do you calculate the risk of recurrent dislocation of the shoulder?
age of the patient at the time of initial dislocation
younger you are, the greater the risk
what are the causes posterior shoulder dislocations?
posterior force on the adducted and internally rotated arm
What are the clinical features of the posterior shoulder dislocation?
humeral head may be palpated posteriorly
xray - main sign where the excessively internally rotated humeral head looks symmetrical like a light bulb on AP view - LIGHT BULB sign
how do you manage posterior shoulder dislocations?
closed reduction and a period of immobilisation
physiotherapy
what are the three main ways the ACJ joint can be injured?
- sprained
- subluxed (partial dislocation)
- dislocation
what happens if the ACJ Joint is subluxed?
acromioclavicular ligaments are ruptured
what happens if the ACJ is dislocated?
acromioclavicular ligaments are ruptured
coracoclavicular ligaments are ruptured
how do you manage ACJ injuries?
conservative management - sling and physio
surgery is reserved for chronic pain
what are the main causes for humeral shaft fractures?
direct trauma - results in comminuted or transverse fractures
fall with or without twisting - oblique or spiral fracture
what signifies that the radial nerve injured due a humeral shaft fracture?
wrist drop and loss of sensation in the first dorsal web space
how do you manage humeral shaft fractures?
most cases treated non op with a functional humeral brace
internal fixation allows for quicer recovery however
non unions are rare (10%) and require plating and bone grafting
what are the main clinical features of an ulnar shaft fracture ( nightstick fracture)?
normally due to a direct blow
many cases a dealt with by conservative management can have ORIF however
how do you manage a fracture of both bones of the forearm?
ORIF with plates and screws
anatomic reduction is required to maximise function and prevent deformity
children can have plaster casts only as the small degree of angulation will remodel as they grow
MUA and plaster can be used if the fracture has an intact periosteum and are only unstable in one direction
What is a monteggia fracture dislocation?
where there is a fracture of the ulna along with the dislocation of the radial head at the elbow
difficult to see on forearm xray
Requires ORIF of the ulna fracture
what is a galazzi fracture dislocation?
where there is a fracture of the radius along with dislocation of the ulna at the distal radioulnar joint
difficult to see on forearm xray
requires ORIF of the radius
What does FOOSH stand for?
Fall onto an outstretched hand
What is a colles fracture?
dorsaly displaced or angulated extra-articular fracture of the distal radius within an inch of the articular surface
what causes colles fractures?
FOOSH with the wrist extended
how do you manage colles fractures?
depends on the degree of displacement or angulation, the presence of dorsal comminution and the functional demand of the patient
- Minimally displaced or angulated fractures- splintage
or
angulation is past neutral - manipulation - holding:
plaster cast
or
the fracture has dorsal comminution or is felt to be very unstable then percutaneous wires or ORIF with plate and screws can be used
what is a late local complication which is specific to colles fractures?
extensor pollicis longus tendon can rupture
manage with a tendon transfer
what is a smith’s fracture?
volarly displaced or angulated extra-articular fracture of the distal radius
what causes a smith fracture?
falling onto the the back of a flexed wrist
how do you manage smith’s fracture?
ORIF with playe and screws
they are highly unstable injuries
what are Barton’s fractures?
intra-articular fractures of the distal radius involving the dorsal or volar rim, wherere the carpal bones of the wrist joint sublux with the displaced rim fragment.
either classified as:
Volar barton’s fracture - an intra-articular smith fracture
Dorsal Barton’s fracture - an intra-articular colles’ fracture
how do you manage Barton’s fracture?
ORIF
what causes scaphoid fractures?
FOOSH
what are the clinical features of the scaphoid fracture?
Tenderness in the anatomic snuff box (between APB/EPB & EPL tendons)
pain on compressing the thumb metacarpal
Diagnosis:
Difficult to visualise on x-ray can sometimes show up later after resorption of the fracture ends. Repeat them 10-14 days after as this will allow time for bone resorption which will make it easier to view
CT scan to see if union as occured
complications: non unions and Avascular necrosis of the proximal pole
how do you manage scaphoid fractures?
undisplaced fractures use a plaster cast
displaced fractures - special compression screw sunk into the bone to avoid non-union CT
non union - screw fixation and bone rafting
What do dorsal injuries of the hand risk causing?
damage to the extensor tendons
what do volar injuries of the hand risk
damage to the flexor tendons, digital nerves and digital arteries
how do you manage tendon injuries?
complete or significant partial tendon injuries require surgical repair
what is a mallet finger?
avulsion of the extensor tendon from its insertion into the terminal phalanx and is caused by forced flexion of the extended DIPJ (often due to a ball from sport)
how do mallet finger patients present?
drooped DIPJ of the affected finger and inability to extend at the DIPJ
how do you manage mallet fingers?
mallet splint holding DIPJ extended which should be worn for 4 weeks
how are extensor tendon injuries of the hand managed?
surgical repair with splintage
how are flexor tendon injuries of the hand managed?
fingers splinted in a flexed position
How are metacarpal fractures managed?
3rd,4th and 5th metacarpals are usually treated conservatively
3rd and 4th metacarpals have strong inter-metacarpal ligaments proximally and distally giving stability to these fractures
what is the main cause of 5th metacarpal fractuers?
punching injury
treatment: neighbour strapping of the affected digit to the adjacent finger and early motion to maintain function
any overlapping of the fingers when making a fist should be corrected by manipulation with neighbour strapping or k-wire stabilisation
what is a ‘fight bite’ and how may it cause a laceration?
term describe a laceration sustained to the puncher’s hand from the punchee’s tooth.
Injury could potentially penetrate the MCP joint and disrupt the extensor tendon
septic arthritis can also occur from the intra-oral organisms from the tooth infecting the finger
How are phalangeal fractures treated?
neighbour strapping or splintage
significantly displace or angulated fractures may require manipulation under anaethetic
unstable fractures require k wire or fixation with small screws
How are hip fractures (fractured neck of the femur) is presented?
shortened fractured leg which is externally rotated
How are dislocated hips presented?
internally rotated leg
head of femur lies posterior to acetabulum
what is the role of the NEXUS criteria?
sees whether a patient with a C spine injury can be cleared for mobililsation
what are the criteria part of NEXUS?
- focal neurological deficit present
- midline spinal tenderness present
- altered level of consciousness present
- intoxication present
- distracting injury present
if none of the above are present then the patient can safely be considered for clinical clearance of the C spine
what is pre-patellar bursitis?
often called carpet layer’s knee or nun’s knee
most likely due to repetitive knee trauma
NSAIDs for non septic bursitis
septic bursitis: antibiotics and drainage
which tendon is the most common to be effected by rotator cuff tear?
supraspinatus tendon
which nerve is most likely to be effected by anterior dislocation of the shoulder or fractures of the surgical neck of the humerus?
axillary nerve
which nerve is most likely to be effected by a mid-shaft fracture of the humerus?
Radial nerve
which nerve is most likely to be entrapped in the carpal tunnel?
median nerve
which nerve can be entrapped in the cubital tunnel?
Ulnar nerve
A 35-year-old man falls and sustains a fracture to the medial third of his clavicle. Which vessel is at greatest risk of injury?
subclavian vein
