Trauma - Level 3 Flashcards
Regions of maxillofacial area?
o Upper face – Frontal bone and frontal sinus
o Midface – nasal, ethmoid, zygomatic and maxillary bones
o Lower face – mandible
Regions of orbit?
o Superior – frontal bone
o Lateral – frontal process of zygomatic bone, zygomatic process of frontal bone and greater wing of sphenoid
o Inferior – maxilla and zygoma
o Floor – roof of maxillary sinus
Blood supply of maxillofacial area?
o Branches of external carotid supply face
Nerve supple of maxillofacial area?
o Facial nerve supply muscles of facial expression
o Trigeminal nerve (ophthalmic, maxillary and mandibular) supply skin innervation
Aetiology of facial injuries?
- Assault
- RTAs
- Falls
- Sporting Injuries
Imaging in facial injuries?
- X-ray
- CT
Symptoms and management of frontal bone fracture?
- Usually due to severe blow to forehead
- Tenderness, crepitus or disruption of supraorbital rim
- Surgery or observation if non-displaced
Classification of Maxillary fractures?
o Le Fort 1
Horizontal fracture across inferior maxilla, alveolar process and hard palate become separated from rest of maxilla and extends through lower nasal septum, lateral maxillary sinus and palatine bones
Present with Facial oedema, loose teeth and mobile hard palate
o Le Fort 2
Pyrimidal-shaped fracture, extends from nasal bridge through frontal process, lacrimal bones and inferior orbit
Presents with facial oedema, epistaxis, subconjunctival haemorrhage, CSF rhinorrhoea, mobile maxilla
o Le Fort 3
Transverse fracture, separation of facial bones from cranial base
Management of maxillary fractures?
o Surgery – Open Reduction and fixation
Symptoms of orbital floor fracture?
o Follows blow from object >5cm
o Periorbital bruising, oedema, surgical emphysema
o Vertical diplopia
o Eye sunken
Management of orbital floor fracture?
Do not blow nose for 10 days
Liase with ophthalmologists and maxillofacial surgeons
Conservative – prophylactic antibiotics and outpatient monitoring
Surgery – if blow-out as child, symptomatic sunken eye, >50% floor involed
Symptoms and management of medial orbital wall fracture?
o Symptoms – subcutaneous emphysema, medial rectus dysfunction
o Management – surgical repair if pain or diplopia
Symptoms and management of orbital roof fracture?
o Common in young children, following blow to brow or forehead
o Symptoms – haematoma of upper lid, periocular ecchymoses, globe inferior displaced
o Management – Close monitoring for CSF leak, large fractures need surgery
Symptoms of mandibular fracture?
abnormal facial contour, tenderness, swelling, redness or haematoma
Management of mandibular fracture?
- Investigations – XR, CT scan, If teeth unaccounted for – CXR in case of inhalation
- Surgery
o Antibiotics given
o Closed/Open reduction
Management of facial lacerations - clean wound?
antiseptic, irrigate with saline
Management of facial lacerations - close wound?
suturing if >5cm or <5cm and excessive flexion/extension, deep, glue or steri-strips if easily opposed edges
Management of facial lacerations - stitch advice?
o Dress wound
o Check need for tetanus prophylaxis
o Remove stitches – 3-5 days on head, 10-14 days over joints, 7-10 days at other sites
o Remove steri-strips – 3-5 days on head, 7-10 days at other sites
o If high risk of infection – dress but don’t close wound and give 5-7 days of flucloaxacillin (co-amoxiclav if contaminated)
Anatomy of shoulder?
o Shoulder = scapula, humerus, clavicle
o Shoulder made up of glenohumeral joint, acromioclavicular joint and sternoclavicular joint
o Glenohumeral joint is ball and socket joint
o Fractures of shoulder usually involve clavicle, proximal humerus and scapula
Symptoms of shoulder fractures?
o Pain o Swelling and bruising o Inability to move shoulder o Crepitus o Deformity
Investigations in shoulder fracture?
o XR of shoulder
o CT
Anatomy of clavicle?
- Articulates with acromion process of scapula laterally and manubrium of sternum medially
- More common in children
Mechanism of clavicle fracture?
o Pain, swelling and tenderness around clavicle
o Deformity
Symptoms of clavicle fracture?
o Pain, swelling and tenderness around clavicle
o Deformity
Investigations of clavicle fracture?
o Neurovascular exam of upper limbs
o AP XR of clavicles
o CXR if pneumothorax suspected
o CT/MRI if joints involved
Allman classification of clavicle fracture?
o Group 1 – middle 1/3 of clavicle (shaft), most common, medial fragment tends to be displaced upwards
o Group 2 – Lateral 1/3 of clavicle (acromial end)
Type 1 – non-displaced, intact ligaments hold fragment together
Type 2 – displaced, coracoclavicular ligaments ruptured and medial segment displaces upwards
Type 3 – Articular surface involving AC joint
o Group 3 – Medial 1/3 (sternal end)
Management of clavicle fracture - group 1?
o Sling arm
o Analgesia – paracetamol, opiates
Immobilisation using sling, figure-of-eight bandage and straps
Displaced fractures may need surgery
Management of clavicle fracture - group 2?
o Sling arm
o Analgesia – paracetamol, opiates
Type 1 & 3 – immbolisation
Type 2 – surgery (intramedullary screws or nails and plate fixation of clavicle)
Management of clavicle fracture - group 3?
o Sling arm
o Analgesia – paracetamol, opiates
Displaced need surgery
Anatomy of humerus - articulation, neck, bicipital groove, nerve?
o Humeral head articulates with glenoid fossa of scapula
o Anatomical neck separates greater and lesser tuberosities
o Long head of biceps runs in bicipital groove
o Radial nerve runs posteriorly around middle 1/3 of humeral shaft in spiral groove
Mechanism of humeral fractures?
o Falls or direct trauma
o Classed into proximal, humeral shaft and distal humeral fracture
Cause of proximal humeral fractures?
o Usually due to FOOSH from standing, seizures, electric shock, direct trauma
o Middle age/Elderly women most common
Symptoms of proximal humeral fractures?
Pain, swelling and tenderness around humerus
Deformity
Assessment of proximal humeral fractures?
Neurovascular assessment
Peripheral pulses
Investigations of proximal humeral fractures?
X-rays
CT
Management of proximal humeral fractures?
Immobilisation
Analgesia – paracetamol, opioids
Non-operative – sling or shoulder immoboliser & physiotherapy
If displaced – surgery (closed reduction with percutaneous fixation, open reduction and internal fixation or proximal head replacement)
Management of humeral shaft fracture?
Immobilisation
Analgesia – paracetamol, opioids
Non-operative – sling or shoulder immobiliser & physiotherapy
If vascular compromise – open reduction and plates/screws or intramedullary fixation/nailing
Definition of anterior shoulder dislocation?
- Results from forced external rotation/abduction of shoulder
- Humeral head lies anteriorly and slightly inferior to glenoid
Definition of posterior shoulder dislocation?
o Results from blow onto anterior shoulder or a fall onto internally rotated arm
o May occur during seizure or electric shock
Definition of luxatio erecta dislocation?
o Rare inferior dislocation of humeral head
Most common shoulder dislocation?
- Anterior most common dislocation
Symptoms of anterior shoulder dislocation?
o Step-off deformity at acromion with palpable gap below acromion
o Humeral head palpable antero-inferiorly to glenoid
o Complications: distal pulses reduced and decreased sensation over lateral aspect of shoulder (badge sign) supplied by axillary nerve
Symptoms of posterior shoulder dislocation?
o Shoulder internally rotated, pain, reduced ROM
Symptoms of luxatio erecta shoulder dislocation?
o Arm held above head
o May be neurovascular problems
XR findings in anterior shoulder dislocation?
o X-ray before reduction to exclude associated fractures (document before and after)
o X-ray
o Loss of congruity between humeral head and glenoid
o Humeral head displaced medially and inferiorly on an AP shoulder X-ray
XR findings in posterior shoulder dislocation?
o AP shoulder X-ray
May be normal
Abnormally symmetrical appearance of humeral head (‘light bulb sign’)
Loss of congruity between humeral head and glenoid
o Modified axial view
Confirm posterior dislocation of humeral head
Management of anterior shoulder dislocation - reduction?
o Analgesia and support in temporary sling
o Reduce under sedation/analgesia with full monitoring
External rotated method
Kocher’s Method
Modified Milch Method
Management of anterior shoulder dislocation - post reduction?
Recheck pulses and sensation
Obtain CXR to check
Immobilise in collar and cuff and body bandage
Analgesia and arrange follow-up
Management of posterior shoulder dislocation - reduction?
o Reduce
Manipulate under sedation by applying traction and external rotation to upper limb at 90o to body
o If difficult, refer for reduction under GA
Management of posterior shoulder dislocation - post reduction?
Recheck pulses and sensation
Obtain CXR to check
Immobilise in collar and cuff and body bandage
Analgesia and arrange follow-up
Definition of trigger finger?
o Stenosing flexor tenosynovitis
o Finger or thumb click/lock when in flexion, preventing return to extension
o Preceded by repetitive movements leading to inflammation of tendon and sheath
Associated conditions of trigger finger?
o Rheumatoid Arthritis
o Amyloidosis
o Diabetes Mellitus
o Increasing age
Symptoms of trigger finger?
o Painless clicking/snapping/catching when trying to extend finger (most commonly middle/ring finger)
o May become painful and lock in flexion
Management of trigger finger?
o Mild – splinting
o If not responding or severe – steroid injections
o Surgical management – percutaneous trigger finger release via needle under LA
Severe – Surgical decompression of tendon tunnel
Definition of Dupuytren’s Contracture?
o Contraction of longitudinal palmar fascia caused by fibroblastic hyperplasia and thickening
o Leading to fibrous cords and flexion contractures at MCP and IP joints
o Reduce digital movements
Epidemiology of Dupuytren’s Contracture?
o Men 6x
o Ulnar digits most common (ring and little finger)
Risk factors of Dupuytren’s Contracture?
o Smoking
o Alcoholic liver cirrhosis
o Diabetes
o Vibration tools or heavy manual labour
Symptoms of Dupuytren’s Contracture?
o Reduced range of movement and nodular deformity
o Complete loss of movement
Signs of Dupuytren’s Contracture?
o Thickened band of firm nodule adherent to skin
o Skin blanching on extension
o Digits in contracture
o Hueston’s Test – flexion at MCP joint, patient unable to place palm and fingers flat on hard surface
Investigation sof Dupuytren’s Contracture?
o Clinical diagnosis
o Bloods – LFTs, HbA1c
Management of Dupuytren’s Contracture?
o Conservative Management
Hand exercises, multiple stretching exercises
Injectable Clostridium Histiolyticum (Xiapex)
o Surgical Management (function impaired)
Refer to hand surgeon or orthopaedic surgery
Fasciectomy under LA/GA
Techniques – regional fasciectomy (entire cord removed), segmental fasciectomy (short segment of cord removed), dermofasciectomy (cord and overlying skin removed then skin graft), closed fasciotomy, finger amputation
Definition of scaphoid fracture?
o Most common carpus fracture
o Scaphoid has three parts: proximal pole, waist, distal pole
o Blood Supply – dorsal branch of radial artery enters via distal pole and travels in retrograde fashion towards proximal pole
o Fractures can compromise blood supply
Epidemiology of scaphoid fracture?
o Men aged 20-30
Symptoms of scaphoid fracture?
o Trauma prior, often high energy
o Sudden onset wrist pain and bruising
Signs of scaphoid fracture?
o Tender anatomical snuffbox
o Pain on palpation of scaphoid tubercle
o Pain on abduction of thumb
Investigations of scaphoid fracture?
o XR of wrist – Scaphoid series (AP, lateral and oblique views)
o If suspicion despite negative imaging – wrist immobilised in thumb splint and repeat in 10-14 days
o MRI scan used if still doubt
Management of scaphoid fracture?
o Undisplaced fracture – strict immbolisation in plaster with thumb spica splint
o Displaced fracture – surgical fixation using percutaneous variable-pitched screw
Complications of scaphoid fracture?
o Avascular necrosis (30% of cases), risk increased the more proximal fracture is
o Non-union failing to heal properly
Definition and grading of knee sprain?
Sprain is stretch and/or tear of ligament
o Grade 1 – mild stretching of ligament without joint instability
o Grade 2 – partial rupture of ligament without joint instability
o Grade 3 – complete rupture of ligament with instability of joint
Definition of strain and grading?
Strain is stretch and/or tear of muscle fibres and/or tendon
o 1st -degree (mild) – few muscle fibres stretched or torn, normal strength but power may be limited
o 2nd-degree (moderate) – several injured fibres and more severe muscle pain, mild swelling, loss of strength and bruise
o 3rd-degree (severe) – muscle tears all way through, may have ‘pop’ sensation, loss of motor function, swelling and visible bruise
Risk factors of knee sprains and strains?
o Sports (contact, sprinting) o Poor exercise technique o Inappropriate footwear o Inadequate warm up o Muscle fatigue o Sudden trauma o Overweight or obese o Previous sprain or strain
Symptoms of knee sprain?
- Pain around joint
- Tenderness
- Swelling
- Bruising
- Loss of function
- Instability
Symptoms of knee strain?
- Muscle pain
- Weakness
- Inflammation
- Haematoma
What are the Ottawa XR rule for Knee?
o One or more of following: Inability to bear weight (walk 4 steps) at time of injury and when examined Age >55 Tender head of fibula Isolated patella tenderness Inability to flex knee to 90o
When to refer knee problem to ED?
o Fracture, dislocation, damage to nerves, tendon rupture, known bleeding disorder, septic arthritis, complete muscle tear
Management of knee strains and sprains - analgesia?
Paracetamol or NSAIDs (ibuprofen gel)
Codeine
Management of knee strains and sprains - advice?
Sprains – severe sprains
Strains – 1st few days, crutches in severe injuries
Management of knee strains and sprains - immobilisation?
Sprains – severe sprains
Strains – 1st few days, crutches in severe injuries
Management of knee strains and sprains - referral to orthopaedic surgeon?
Recovery slower than expected, worsening symptoms or out of proportion to degree of trauma
Management of knee strains and sprains - prevention?
Warm up properly
Cool down
Use proper equipment, technique, footwear
Schedule regular days off from exercise
Healthy weight
Prognosis of knee strains and sprains?
- Mild – few weeks with conservative treatment
- Moderate – few weeks, high risk of further injury in first 4-6 weeks
- Severe – month to heal, may require surgery
Red flags for knee pain?
o Infection – red, swollen, heat, rapid onset, one joint, fever
o Tumour – persistent, bone pain, pain at night/at rest, unexplained weight loss, previous cancer, hard mass
Ligaments of knee and their function?
- MCL – prevents lateral movement of tibia on femur, runs between medial epicondyle of femur to anteromedial tibia
- LCL – prevents medial movement of tibia on femur, runs between lateral epicondyle of femur to head of fibula
- ACL – prevents forward movement of tibia in relation to femur, runs from anterior tibial plateau and posterolateral intercondylar notch of femur
- PCL – prevents forward sliding of femur, runs from posterior part of tibial plateau to medial intercondylar notch of femur
Mechanism of injury to ACL?
o Hyperextension, marked internal rotation of tibia, pure deceleration
Mechanism of injury to PCL?
o Hyperflexion of knee
Grading of ligament injury?
o Grade 1 – mild stretching of ligament without joint instability
o Grade 2 – partial rupture of ligament without joint instability
o Grade 3 – complete rupture of ligament with instability of joint
Imaging in knee injury?
- XR
- MRI
Management of knee ligament injury - analgesia?
Paracetamol or NSAIDs (ibuprofen gel)
Codeine
Management of knee ligament injury - advice ?
Protect from further injury Rest (avoid activity for 48-72h) Ice (ice wrapped in damp towel for 15-20 minutes, every 2-3 hours during 1st 48-72h) Compression (elastic bandage) Elevation Avoid heat, alcohol, running, massages
Management of knee ligament injury - immobilisation?
Non-weight-bearing crutches
Management of knee ligament injury - referral to orthopaedic surgeon?
Recovery slower than expected, worsening symptoms or out of proportion to degree of trauma
Management of knee ligament injury - prevention?
Warm up properly
Cool down
Use proper equipment, technique, footwear
Schedule regular days off from exercise
Healthy weight
Management of ACL tear - conservative?
hinged brace
Management of ACL tear - surgical?
Usual method of treatment with reconstruction or grafting
Management of PCL tear ?
o Crutches and long leg brace if conservative
o Surgery if fracture, or other ligaments affects too, or failed conservative measures
What are the meniscus?
- Two menisci in each knee, crescent shaped pads of cartilage tissue
- Function – tibiofemoral load transmission, shock absorption, lubrication of knee joint and improve stability
Mechanism of injuring menisci?
o Twisting or pivoting
Symptoms of meniscal injury?
- Acute pain
- Popping/Catching/Locking of knee
- Swelling and effusion
Management of meniscal injury - analgesia?
Paracetamol or NSAIDs (ibuprofen gel)
Codeine
Management of meniscal injury - advice?
Protect from further injury Rest (avoid activity for 48-72h) Ice (ice wrapped in damp towel for 15-20 minutes, every 2-3 hours during 1st 48-72h) Compression (elastic bandage) Elevation Avoid heat, alcohol, running, massages
Management of meniscal injury - refer to orthopaedic surgeon?
Urgently if locking of knee and meniscal injury suspected
Routine if meniscal injury suspected and symptoms persist or interfere with ADLs
Techniques – repair or partial meniscectomy (total possible)
• Functional activities within 7-8 days, running from 2 weeks
Definition of pelvic fracture?
- Fracture of any part of bony pelvis
Definition of acetabular fracture?
Pelvic fractures, which involve ilium, ischium and/or pubis
Types of pelvic fracture?
o High-energy trauma – significant fractures
o Stable fractures – less severe
o Avulsion fracture from sporting events where muscle detaches from insertion point
Symptoms of pelvic fracture?
- Tenderness, bruising, swelling of pubis, iliac bones, hips and sacrum
- Haematuria
- Rectal bleeding
- Haematoma
- Loin bruising
- Unstable hip adduction and pain on hip motion
Imaging of pelvic fracture?
- X-Ray of hip
o Destruction of Shenton’s Lines, asymmetry, widening of pubic symphysis or SI joints - CT pelvic
o Whole-body if blunt major trauma or suspected multiple injuries
Tile classification of pelvic fractures - type A?
Stable injuries Avulsion fractures occurring at points of muscle attachments • AIIS – rectus femoris • ASIS – sartorius • Ischial tuberosity – hamstrings
Tile classification of pelvic fractures - type B?
Rotationally unstable but vertically stable
Openbook fractures
Tile classification of pelvic fractures - type C?
Rotationally and vertically unstable
Pelvic ring disrupted in two or more places
Associated with blood loss
Management of pelvic fracture - if haemodynamically unstable?
o Immediate transfer to major trauma centre for definitive treatment
o Pelvic Binding
Remove if no fracture, mechanically stable, no further bleeding
o Avoid rolling patient
Management of pelvic fracture -if active arterial pelvic bleeding?
o Interventional radiology
o Pelvic packing if emergency laparotomy needed for abdominal injuries
Management of pelvic fracture - pain relief?
o IV morphine
o 2nd line –ketamine
Management of pelvic fracture - stable fractures?
o Surgery not usually needed
o Refer to orthopaedics for analgesia, bed rest then mobilisation
o Crutches or walker used
o Venous thromboprophylaxis
Management of pelvic fracture - surgery?
o Surgery on day of, or day after admission
Internal/External fixation
Aim to fully weight bear immediately post-operative
If displaced intracapsular hip fracture – replacement arthroplasty
o Physio and mobilisation on day of surgery and then at least once a day
Definition of Ilizarov-Frame surgery?
- External fixation apparatus used in orthopaedic surgery
USes of Ilizarov-Frame surgery?
Lengthen or reshape limb bones
Distraction osteogenesis
• Bone is cut during surgery or fractured bone, device pulls 2 pieces of bone apart slowly and lengthens bone
• Used in unequal leg length
Fracture non/mal-union
Limb-sparing technique in complex/open bone fractures
Infected non-unions of bones
What is an Ilizarov-Frame?
o Stainless steel rings are fixed to bone via stainless steel wire pins (Kirschner wires)
o Rings are connected to each other with threaded rods attached through adjustable nuts
o Allows early weight bearing
Theory behind Ilizarov-Frame?
o Theory of tension
o The top rings of Ilizarov (fixed to healthy bone) allow force to be transferred through external frame (vertical metal rods), bypassing fracture site
o Force is transferred back to healthy bone through bottom ring and tensioned wires
o Both immobilises fracture site and relieves stress
Procedure of Ilizarov-Frame surgery?
o Under GA o Need to wear for at least 3 months – usually 6-12 months o Complications Pain Infection
