Week 4

Question 1

Types of forces

Answer 1

Direct- forces in physical contact, blunt or penetrating
Penetrating- high or low velocity
Indirect

Question 2

Effects of age on injury

Answer 2

Osteoporosis
Soft tissues generally weaker
Slower healing
Altered physiological responses
Associated medical problems/drugs

Question 3

How does upper limb get injured

Answer 3

Trips
Sporting
Work related- crush etc
Assaults

Question 4

Injury mechanisms FOOSH

Answer 4

Fall on outstretched hand

Question 5

What can get injured

Answer 5

Bones-fractures
Joints- dislocation and subluxation
Blood vessels- axillary, brachial, radial and ulnar
Nerves- brachial plexus, radial, axillary, ulnar and median
Muscle
Ligaments

Question 6

Assessment of injury- history

Answer 6

Injury mechanisms
Complaints
-pain , swelling, loss of function, neurological, vascular symptoms
Previous health/medications
Allergies

Question 7

Musculoskeletal assessment of injury

Answer 7

Look:
-deformity, scarring, swelling, colour
Feel:
-tenderness, crepitus(presence of air in soft tissues), temperature
Move:
-active movement, passive movement

Question 8

Soft tissue injury

Answer 8

Vast majority of injuries
Principles of management:
-rest: slings, splints, plaster
-ice
-elevation: to decrease swelling
-analgesia
-early mobilisation

Question 9

Dislocated shoulder

Answer 9

“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

Question 10

Fracture clavicle

Answer 10

FOOSH
Fractures in middle 1/3
Complications: few, lump often persists

Question 11

Fractured humerus

Answer 11

Usually following a fall
If shaft, rotation a problem
Radial nerve damage

Question 12

Principles of fracture management

Answer 12

Reduction if needed
Immobilisation
-plaster
-fixation: internal/external
Internal fixation: plates and screws, nails

Question 13

Injuries around elbow

Answer 13

Most due to fall on elbow
Indirect force FOOSH mechanism
Elbow effusion-fluid in the joint, usually indicates a fracture

Question 14

Displaced supracondylar fracture

Answer 14

Risk to brachial artery check pulse+ circulation

Question 15

Dislocated elbow

Answer 15

Usually follows a fall
Deformity obvious
Reduced under sedation
Can have ass fractures
Plaster support
Doesn’t recur as frequently as shoulder dislocations

Question 16

Buckle fractures

Answer 16

In younger children
Heal rapidly

Question 17

“Greenstick” fracture fracture in children

Answer 17

Bend more then snapped
One side of bone covering intact
Usually remodelled well
Treatment
Rest in plaster

Question 18

Colles fracture

Answer 18

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

Question 19

Fractured 5th metacarpal- Boxers fracture

Answer 19

Can also occur from a fall
Treated with strapping

Question 20

Neighbour or buddy strap

Answer 20

Used for many finger injuries
Fingers work together
Stay mobile

Question 21

Metacarpal fractures

Answer 21

Extra articular rarely require ORIF
Boxers fracture
Mobility of the 4th and 5th rays
No rotational malalignment

Question 22

Finger fracture

Answer 22

If alignment is maintained most do well with simple strapping

Question 23

Rotational deformity

Answer 23

Due to uncorrected axial rotation

Question 24

Dislocated finger

Answer 24

Common injury
Ligament torn
Reduce with ring block
Occ “stuck” needs op
Treated with buddy strapping
Long term
Occ swelling
Ligaments may be lax

Question 25

Penetrating injury

Answer 25

Depends on location of injury
Injury to skin and underlying structures
-nerves
-blood vessels
-tendons

Question 26

Infective (septic) arthritis

Answer 26

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

Question 27

Consequence of untreated infection

Answer 27

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

Question 28

Gout

Answer 28

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

Question 29

Osteoarthritis

Answer 29

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

Question 30

Rheumatoid arthritis

Answer 30

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

Question 31

Nature of pain determines if degenerative or inflammatory condition

Answer 31

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