Week 4 Flashcards
Types of forces
Direct- forces in physical contact, blunt or penetrating
Penetrating- high or low velocity
Indirect
Effects of age on injury
Osteoporosis
Soft tissues generally weaker
Slower healing
Altered physiological responses
Associated medical problems/drugs
How does upper limb get injured
Trips
Sporting
Work related- crush etc
Assaults
Injury mechanisms FOOSH
Fall on outstretched hand
What can get injured
Bones-fractures
Joints- dislocation and subluxation
Blood vessels- axillary, brachial, radial and ulnar
Nerves- brachial plexus, radial, axillary, ulnar and median
Muscle
Ligaments
Assessment of injury- history
Injury mechanisms
Complaints
-pain , swelling, loss of function, neurological, vascular symptoms
Previous health/medications
Allergies
Musculoskeletal assessment of injury
Look:
-deformity, scarring, swelling, colour
Feel:
-tenderness, crepitus(presence of air in soft tissues), temperature
Move:
-active movement, passive movement
Soft tissue injury
Vast majority of injuries
Principles of management:
-rest: slings, splints, plaster
-ice
-elevation: to decrease swelling
-analgesia
-early mobilisation
Dislocated shoulder
“Squared off” appearance
Initial management principles:
-pain relief: support, entonox “gas and air”, morphine IV
-assessment
-X-ray
-definitive treatment- reduction
Complications: recurrence, axillary nerve damage, associated fracture, stiffness, instability
Fracture clavicle
FOOSH
Fractures in middle 1/3
Complications: few, lump often persists
Fractured humerus
Usually following a fall
If shaft, rotation a problem
Radial nerve damage
Principles of fracture management
Reduction if needed
Immobilisation
-plaster
-fixation: internal/external
Internal fixation: plates and screws, nails
Injuries around elbow
Most due to fall on elbow
Indirect force FOOSH mechanism
Elbow effusion-fluid in the joint, usually indicates a fracture
Displaced supracondylar fracture
Risk to brachial artery check pulse+ circulation
Dislocated elbow
Usually follows a fall
Deformity obvious
Reduced under sedation
Can have ass fractures
Plaster support
Doesn’t recur as frequently as shoulder dislocations
Buckle fractures
In younger children
Heal rapidly
“Greenstick” fracture fracture in children
Bend more then snapped
One side of bone covering intact
Usually remodelled well
Treatment
Rest in plaster
Colles fracture
Distal end of the radius
‘Dinner fork deformity’
Management:
Reduction- return to acceptable position: open(surgical) vs closed(manipulation)
Fixation-keeping it in that position: plaster immobilisation, internal fixation with plates
Complications: malunion(persistent angulation), pain, weak grip-twisting movements, limited movement, carpal tunnel syndrome, reflex sympathetic dystrophy, arthritis
Fractured 5th metacarpal- Boxers fracture
Can also occur from a fall
Treated with strapping
Neighbour or buddy strap
Used for many finger injuries
Fingers work together
Stay mobile
Metacarpal fractures
Extra articular rarely require ORIF
Boxers fracture
Mobility of the 4th and 5th rays
No rotational malalignment
Finger fracture
If alignment is maintained most do well with simple strapping
Rotational deformity
Due to uncorrected axial rotation
Dislocated finger
Common injury
Ligament torn
Reduce with ring block
Occ “stuck” needs op
Treated with buddy strapping
Long term
Occ swelling
Ligaments may be lax
Penetrating injury
Depends on location of injury
Injury to skin and underlying structures
-nerves
-blood vessels
-tendons
Infective (septic) arthritis
Inflammation of a joint caused by infection usually bacterial
Loss of joint space, erosions and new bone formation
Can affect any age group more common in children and elderly
Risk factors: breach of the skin barrier, immunosuppression for any cause, extremes of age, underlying inflammatory arthritis, joint replacement
Aspiration always done in acute hot swollen joint, not in joint replacement as it can introduce infection
Investigation, microscopy and culture synovial fluid
Consequence of untreated infection
Rapid joint destruction often with infection of surrounding bone (osteomyelitis)
May drain to skin surface (sinus)
Bacterial spread to blood stream (sepsis)
Stimulation of excess bone formation leading to fusion of joint- loss of function
Gout
Crystal induced arthritis in which the deposition of Uric acid (monosodium urate) crystals in joints leads to inflammation
Monoarticular or oligoarticular (asymmetrical at first)
May become polyarticular and symmetrical later
Incidence:
-more common in men (middle aged on)
-post menopausal women
Increased uric acid production (secondary): eg alcohol consumption or high purine intake in diet or high turnover in cells eg treatment of leukaemia, some rare genetic causes
Reduced uric acid excretion (primary ideopathic): kidney disease, drugs reducing uric acid excretion
Pathological changes:
- Cartilage degeneration
-synovial hyperplasia and erosion of bone
-secondary degenerative change (osteoarthritis)
-tophaceous deposits (calcified uric acid) in skin and secondary arthritis
Crystals can be seen on polarised microscopy
Osteoarthritis
Predominantly degenerative tissue
Dysregulation of normal tissue turnover and repair
Incidence: age related major cause disability and inability to work over 60
Aetiology: primary, secondary (eg complication of other joint disorders, inflammatory joint disease, trauma to joints, congential joint deformities)
Pathological changes: involve cartilage, bone, synovium and joint capsule with secondary effects on muscle due to diuse, damage bone loss of articular cartilage small amount inflammation
Radiological: joint space narrows, subchrondral bone sclerosis and cysts, marginal osteophyte formation
Bony swellings typically affects larger joints
Rheumatoid arthritis
Chronic symmetrical erosive inflammatory joint disease polyarthritis
Female more then male
Between 35-45 years
Autoimmune
Clinical manifestation: symmetrical deforming polyarthritis, widespread small joint involvement (hands and feet), medium to large also involved may be associated with non-articular disease
Pathological changes: synovial hyperplasia and inflammatory infiltration resulting in pannus formation (abnormal layer vascular fibrocollagenous tissues), invasion and destruction of articulation cartilage, focal destruction of bone
Soft tissue swelling, joint space narrowing, osteopenia (reduced bone density), erosions
Nature of pain determines if degenerative or inflammatory condition
Inflammatory:
- pain more prominent in morning, long morning stiffness, swelling softer, very tender, redness, warm
Degenerative:
- pain more prominent with moving better with rest, short morning stiffness, tender not red and not warm
