Head Injury and Limb Trauma Flashcards
(149 cards)
1
Q
what is concussion?
A
mild traumatic brain injury
2
Q
describe coup and contre coup?
A
coup = point of impact
contre coup = opposite to impact
3
Q
what is torque?
A
Brain twist relative to brainstem and stretches regions of brain and affects reticular formation and can cause loss of consciousness
4
Q
what are the red flags for a patient with concussion?
A
Loss of consciousness seizure confusion worsening headache vomiting sensitivity to light
5
Q
what is the treatment for concussion?
A
- 24-48 hours rest
- Memory and concentration may be issue for few weeks
- Sports players should only continue playing when completely symptom free
6
Q
what is primary brain injury?
A
- Injury done at time of injury
- Only cure is accident prevention eg speed limits or damage limitation eg cycle helmets
- Cerebral laceration
- Cerebral contusion
- Dural sac injury
- Diffuse axonal injury
- Skull fractures
7
Q
what is a secondary brain injury?
A
- Damage to brain results from complications after initial injury
- Aim to prevent this happening with ABCDE
8
Q
what are the causes of secondary brain injury?
A
- Hypoxia – ischaemia
- Reduced cerebral blood flow eg bleeding/shock
- Raised intracranial pressure
- Metabolic abnormalities eg hypo and hyperglycaemia
- Infection
- Pyrexia
9
Q
how can head injuries be classified?
A
Severity (mild, moderate, severe)
• Mild GCS 13-15
• Moderate GCS 9-12
• Severe GCS 8 or less
Morphology of skull fracture (vault or skull base)
Intracranial lesion (focal or diffuse)
10
Q
describe the mono-kellie doctrine?
A
skull is closed box
• ICP related to volume of brain + volume blood + volume CSG
• Normal ICP = 10mmHg
11
Q
what is cerebral perfusion pressure and what does it indicate?
A
- CPP = mean arterial pressure – ICP
* CPP used as proxy indicator of cerebral blood flow
12
Q
how does the body respond to increased mass in head eg extra blood?
A
initially system responds by removing venous blood and CSF so compensation occurs and maintains ICP of 10mmHg. After a while no more blood or CSF can be removed which is the point of decompensation and ICP will rise and may result in herniation
13
Q
what are the types of brain herniation?
A
- foramen magnum/tonsillar
- transtentorial (uncal)
14
Q
describe foramen magnum/tonsillar herniation?
A
- Decreased level of consciousness
- Decorticate posturing
- Irregular respirations
- Loss of brainstem reflexes
- Bilateral fixed and dilated pupils
- Cushings response (triad) – high BP, bradycardia and abnormal breathing
15
Q
describe transtentorial (uncal) herniation
A
- Compression of 3rd occulomoter cranial nerve leading to ipsilateral pupillary dilatation then loss of eye movements
- Compression of ipsilateral corticospinal tracts in brainstem leads to contralateral in hemi paresi (corticospinal tract in medulla
16
Q
what aspects of the history are important to clarify in a patient with head injury?
A
- High energy/danerious mechanism of injiry
- History of bleeding or clotting disorders eg liver disease, chronic alocol abuse
- Current anticoagulant therapy
- Current drug or alcohol intoxication
- Loss of consciousness
- Amnesia for events before or after injury
- Persistent headache since injury
- Vomiting episodes since injury
- Seizure since injury
17
Q
describe the clinical features of basal skull fractures?
A
- Panda or raccon eyes
- Battle sign (bruising to mastoid)
- Haemotympanum (bruising/bleeding behind ear drum)
- CSF rhinorrhoea or otorhoea
- Lower motor neurone facial nerve palsy
18
Q
describe the clinical features of depressed/open skull vault fracture?
A
- Visible fracture to skull vault (fracture seen in wound)
* Palpable depression or irregularity in skull
19
Q
what is an extradural haematoma?
A
- Bleeding outside dura
- Middle meningeal artery often involved
- Biconvex or lenticular
- Temporal or temporoparietal most common
- Likely to have skull fracture
- Lucid interval
- Outcome related to status prior to surgery
20
Q
what is a subdural haematoma?
A
- Tearing of bridging veins between brain and dura
- Bleeding covers surface of brain
- May be sub acute/chronic eg elderly or alcoholic
- May be trivial or no recognisable injury
- Underlying brain damage more severe than in extradural
- Prognosis is worse than extradural
21
Q
what is an intracerebral haematoma?
A
• Any haemorrhage within substance of brain itself
May be described as
• Coup- when region affected is directly related to site of injury
• Contre coup – when region affected is opposite the site of external injury
Signs and symptoms related to anatomical location and amount of bleed
22
Q
what is diffuse axonal injury?
A
- Reduced consciousness/coma
- Acceleration/deceleration causin shearing forces to neurons
- Microscopic, widely distributed damage
- Motor posturing -decorticate and decerebrate
- Autonomic dysfunction
- Hypertension and hyperpyrexia
- CT scan may appear normal in early stages
23
Q
what are the fundamentals of managing a patient with head injury?
A
- NICE head injury guidelines
- ABCDE
- GCS less than 8 – early involvement with anaesthetics or critical care for airway management
- Ascribe depressed conscious level to intoxication only after a significant brain injury has been excluded
- Pain management - pain can lead to raised ICP
- Written advice to patients when discharged
24
Q
what patients presenting with head injury should be given CT head scan within 1 hour of risk factor identification?
A
- GCS<13
- GCS <15 at 2 hours
- suspect open or depressed fracture
- sign of basal skull fracture
- post traumatic seizure
- focal neurological deficit
- more than one episode of vomiting
25
what patients presenting with head injury should be given CT head scan within 8 hour of risk factor identification?
patients on anticoagulant treatment with no other risk factors
26
what risk factors would require a patient to have a CT scan within 8 hours if they have lost consciousness or amnesia since the head injury?
age >65
history or bleeding/clotting
dangerous mechanism of injury
more than 30 mins retrograde amnesia
27
what are the risk factors for cervical spine injury?
* Age >65
* Known chronic spinal conditions eg ankylosing spondylitis, RA
* Dangerous mechanism of injury
28
head trauma
| give examples of dangerous mechanism of injury
* Fall from heigh
* Axial load to head eg diving, faling onlto head
* High speed motor vehicle collision
* Bicycle collision
* Horse riding
29
what patients with head injury should have full cervical spine immobilisation?
* GCS under 15
* Neck pain or tenderness
* Focal neurological deficit
* Paraesthesia in extremities
* Any other clinical suspicion
30
how can the neck be immobilised?
* Manual in line immobilisaion – held in place by person
| * Hard collar, blocks and tape ‘the holy trinity’
31
when should neurosurgeons be involved in treatment of patient with head injury?
* All patients with new, surgically significant abnormalities on imaging
* Persisting coma after initial resuscitation
* Unexplained confusion for more than 4 hours
* Deterioration in GCS score after admission
* Progressive focal neurological signs
* Seizure without full recovery
* Definite or suspected penetrating injury
* Cerebrospinal fluid leak
32
when should patients with head injuries be admitted?
* GCS not returned to 15 after imaging
* Indications for CT scanning but cannot be done in appropriate period
* Continuing worrying signs eg vomiting, severe headaches
* Other causes of concern eg drug or alcohol intoxication
* Admit for head injury observation
* Patinets whose GCS returned to normal can be discharged
* Patients whose GCS deteriorates can be detected early and further imaging arranged
33
describe safety netting when discharging a patient with head injury?
```
Verbal and written advice
Return to ED if
• Unconscious or lack of full consciousness
• Drowsiness
• Problems understanding or speaking
• Loss of balance or problems walking
• Weakness in one or more arms or legs
• Proplems with eyesight
• Painful headache
• Vomiting
• Seizuires
• Clear fluid coming out of ear or nose
• Bleeding from ears
```
34
what can cause spinal trauma?
```
Falls
assaults
RTCs
sporting accidents
diving into shallow pool
10-20% of patients with spinal fracture will have a second spinal fracture at a different level
```
35
what is the mechanism of actions of spinal traumas?
```
axial loading
flexion
extension
rotation
lateral flexion
distraction
```
36
what is the mechanism of Atlanto-occipital dislocation?
severe traumatic flexion and distraction, most patients die of apnoea or have severe neurological impairment, common casue of death in shaken baby syndrome
37
what are atlas c1 fractures?
Jefferson fracture = burst fracture of both anterior and posterior rings of C1 with lateral displacement of lateral masses due to axial loading
38
what are atlas c2 fractures and what are the different types?
odontoid peg fractures. Type I: fracture through the tip of the peg.
Type II: fracture through the base of the peg.
Type III: fracture through the base of the peg into the lateral masses of C2
39
what is a hangman's fracture?
Fracture of the posterior elements of C2
| Mechanism: hyperextension
40
what are c3-7 fractures?
Fracture - dislocations
41
what are thoracic spine fractures?
Anterior wedge compression injuries/ Mechanism: axial loading with flexion
42
what is the mechanism of burst injuries?
vertical-axial compression
43
what are chance fractures?
Transverse fractures through vertebral body/ Mechanism: flexion about an axis anterior to vertebral column eg from wearing lap belts inappropriately high and not over the pelvic girdle
44
what are the presenting features of spinal trauma?
- General: Neck pain/tenderness, back pain/tenderness, weakness, absent sensation, absent reflexes, urinary incontinence, loss of anal tone. Log roll patient with cervical spine control to examine spine, checking limbs for abnormal neurology
Neurogenic shock: hypotension, bradycardia
Spinal cord syndromes: brown squared syndrome, central cord syndrome, anterior cord syndrome
45
what is brown sequard syndrome?
due to hemisection of spinal cord, results in ipsilateral weakness and sensory deficit with contralateral loss of pain and temp
46
what is central cord syndrome?
due to vascular compromise of spinal cord in distribution of anterior spinal artery usually due to hyperestension injuries and results in upper limb weakness greater than lower limb weakness, cape like sensory deficit
47
what is anterior cord syndrome?
caused by vascular insufficiency of anterior spinal artery, results in bilateral paraparesis and loss of pain and temp with preservation of dorsal column function
48
what investigations are needed in a patient with spinal trauma?
- Dermatomes
- Myotomes
- MRC grading of power – 5=normal down to 0=complete paralysis
- X-rays: neck - AP, lateral and odontoid peg vies / thoracic lumbar spine -AP and lateral views. They can ne normal
- CT
- MRI
49
who is likely to get prolapsed intervertebral disc and typical age of onset?
3% men and 1% women get sciatica related to prolapsed intervertebral disc
Manual workers – heavy lifting
ages 35-55
50
what are the changes seen in prolapsed intervertebral disc?
Herniation of disc tends to occur posterolaterally where annulus is thinner, central disc prolapse can occur and press on combined nerve roots and lead to cauda equina syndrome
Prolapse can occur without spinal root involvement -back pain but not sciatica
Prolapse usually occurs at L4-L5 or L5-S1
51
what are the presenting features of prolapsed intervertebral disc?
Sciatica is symptom of lower lumbar or sacral nerve root irritation.
Sevee pain radiating down leg as far as toes
May be numbess and tingling or weakness of foot
Uncomfortable to sit and either stand or lie down
Coughing and sneezing worsen pain
52
what are the red flag signs of sinister back pain?
age <20 or >55
history of malignancy
present, non mechanical pain
night pain
fever/unexplained weight loss
bladder/ bowel dysfunction
progressive neurology, abnormal gait, saddle anaesthesia
Abnormal posture, stooping to affected side and standing with knee flexed to relieve pressure
Straight leg raising will be positive / crossover sign may be positive
53
what are the clinical features of caudal equine?
- Bladder and bowel dysfunction with possibly urinary retention and saddle anaesthesia due to compression of nerves in cuada equina suppling motor function of bowe and bladder sphincters
- Bilateral leg symptoms suggest impending cauda equina
- Loss of anal tone and reduced perianal sensation of PR
54
what are the diagnostic tests for prolapsed intervertebral disc?
Blood tests especially in elderly to exclude sinister causes
X-rays usually normal but exclude bony pathology such as spondylolisthesis
MRI
55
what is the treatment of prolapsed intervertebral disc?
Conservative – bed rest and physiotherapy with analgesia
Surgical – only indicated for cauda equina syndrome and progressively worsening neurological deficit. Surgery for cauda equina must be done within 24 hours of urinary symptoms
56
who is likely to get spinal infection?
Risk factors: Advanced age, Intravenous drug use, Human immunodeficiency virus (HIV) infection, Long-term systemic usage of steroids, Diabetes mellitus, Organ transplantation, Malnutrition, Cancer
IV drug users
Recent dental procedures
57
what causes spinal infection?
Bacteria or fungal infection in another part of body that has been carried into spine via blood stream
Most commonly staph aureus, E.choli
Can occur after urological procedure
58
describe the known changes in spinal infection?
Lumbar region most commonly affected
Progress through the following
1. Severe back pain with fever and local tenderness in the spinal column
2. Nerve root pain radiating from the infected area
3. Weakness of voluntary muscles and bowel/bladder dysfunction
4. Paralysis
59
what are the key presenting features of spinal infection?
Dependent on type of infection
Pain localised initially
In post op patients – wound drainage, redness swelling, tenderness
Intervertebral disc space infections – initially few symptoms then develop severe back pain. Younger patients, children don’t have fever or pain but refuse to flex spines. Post op about 1 month after surgery -alleviated by bed rest and immobilisation and increases with movement gets progressively worse
60
what diagnostic tests are of use in patients with spinal infection?
- ESR
- CRP
- CT
- MRI
61
what are the nonsurgical treatments of spinal infection?
long term IV antibiotic or antifungal and may need extended hospitalisation. Identify organism. Minimum 6-8 weeks
62
what are the surgical treatments of spinal fracture?
non surgical when minimal or no neurological deficits. Morbidity and mortality rate of surgical intervention is high. Surgery indicated in; Significant bone destruction causing spinal instability, Neurological deficits, Sepsis with clinical toxicity caused by an abscess unresponsive to antibiotics, Failure of needle biopsy to obtain needed cultures, Failure of intravenous antibiotics alone to eradicate the infection. Surgery aims to debride, enable adequate blood flow, restore spinal stability and restore function or limit neurological impairment
63
what are the causes of bone fractures?
* Trauma
* Vitamin A deficiency
* Old age
* Low bone density
64
how can fractures be classified?
Position of bone ends
• Non displaced – bone posisiton not moved
• Displaced – bone moves
Completion of break
• Has bone completely fractured
Orientation of break
• Fracture on vertical or horizontal plane
Does it penetrate skin
• Compound – penetrates skin
•Simple – not penetrated
65
describe pathophysiology of bone fractures?
* Bone surrounded by periosteum
* Compact bone and spongy bone
* Blood vessels
* Haematoma: Swelling in minutes after fracture, blood accumulates, death of cells, pain
* Fibrocartilaginous callus formation – few days – vessels regrowing, meshwork forming callous, external callous formed, granulation tissue fills in gap rejoining fracture
* Bone callous formation – few weeks – soft callous becomes bony callous,
* Bone remodelling – months later – bony callous remodelled to become bone, osteoblastic activity increased
66
describe osteomyelitis?
* Bacteria (staphylococcus aeurus) infects bone during fracture of through blood and person gets pain, sweating, and swelling of bone usually affecting ends of long bones.
* Bacteria causes necrosis of bone cells and pus formation which weakens bones
* If untreated it can beceom chronic and affect more bone cells
* Pus formation, peritoneum pushed out and new bone formation occurs
67
describe fracture reduction?
* Aim to correct significant deformity eg angulation, displacement (not always needed)
* Closed reduction– manual manipulation of bones
* Open reduction– reduction under direct visualisation usually followed by internal fixation
68
describe ways to hold a fracture?
* Non rigid – collar and cuff, sling
* Rigid -POP or light weight cast
* Internal fixation-plates, screws, intramedullary nails, wired and tension bands used in intraarticular, allow early mobilisation, pathological fractures. Main complication is osteomyelitis, non union, impant failure, re-fracture after removal
* External fixation – frame and pins fixed to an external frame
69
describe why fracture rehabiliation is needed?
* Why -prevent muscle atrophy, reduce joint stiffness
| * Prevent oedema immediately and gentle movements to retore function
70
describe the process of bone healing?
* Reactive – haematoma formation and osteocyte death -> inflammatory response; osteoblast proliferation and granulation tissue formation
* Reparative – callus formation and bony substitution
* Remodelling – remodelling with osteoclasts, strengthening aong lines of stress
71
what local factors influence bone healing?
* Infection
* Poor alignment
* Disrupted vascular supply
72
what systemic factors influence bone healing?
* Age
* Smoking
* Poor nutrition
* Systemic disease
73
how long do fractures take to heal?
Child upper limb fracture will heal in 3-4 weeks double this time for lower limb and adults
74
what are open fractures?
Communication between skin surface and fracture site
75
describe the gustilo classification of open fractures?
Type 1 – simple small (<1cm) wound with minimal soft tissue damage
Type 2 – wound >1cm with moderate soft tissue damage
Type 3 – high energy wound with extensive soft tissue damage
• A- adequate soft tissue to cover wound
• B- inadequate soft tissue to cover wound
• C – arterial injury
76
describe management of open fractures?
Orthopaedic management
• Fracture management
• Prompt debridement
• Wound coverage
```
General
• Document
• Tetanus
• Antibiotics
• Sterile dressing
• Stabilise
```
77
what does the supraspinatus do?
* Abducts
* Pulls humerous into glenoid allowing deltoid to continue abduction
* First 15 degrees of abduction
* Suprascapular C5-6
78
what does the infraspinatus do?
* External rotation
| * Suprascapular C5-6
79
what does teres minor do?
* External rotation
| * Axillary nerve
80
what does subscapularis do?
* Internal rotation
| * Upper and lower subscapular C5-6
81
if all shoulder movement is impaired what is the cause?
frozen shoulder
82
describe some possible shoulder injuries?
Dislocation – axillary nerve injury possible-regimental sensory deltoif
Humeral fracture – radial nerve injury possible– wrist drop, snuff box
Medial epicondyle – ulnar nerve injury possible – FCU weakness and sensory
83
UPPER LIMB NERVE INJURIES
| radial C5-T1
* Fracture midshaft humerus
* Extensors; triceps, supinators, extension of wrist and fingers
* Wrist drop – anatomical snuffbox sensory deficit
* Splint, and nerve studies, is there a fracture?
84
UPPER LIMB NERVE INJURIES
| axillary C5-6
* Dislocation ; humer, neck fracture
* Deltoid arm abduction after supraspinatous initiates
* Deltoid weakness and sensory patch over deltoid -regimental patch
85
UPPER LIMB NERVE INJURIES
| median C5-T1
* Supracondyar fracture, carpal tunne compression
* Forearm flexor except FCU
* LOAF – lateral lumbricals, oppnens policis, abductor ollicis, flexor policis brevis
* Ape hand with weakness of thum, sensory of the 3 ½ lateral fingers
* Benediction sign
86
UPPER LIMB NERVE INJURIES
| ulnar C8-T1
* Medial epicondyle
* FCU flexion, lumbrical 4-5th, finger interossei
* Ulnar claw-loss of sensation over medial 1 ½ (over little finger)
* Ulnar paradox - Higher up the lesion the more normal the hand appears
87
UPPER LIMB NERVE INJURIES
| MCN C5-7
* Upper trunk compression/stab
* Rare
* BBC – biceps, brachialis, coracobrachialis
* Lateral forearm sensory defecit with weakness of flexion of elbow
88
describe the important structures of the knee?
* ACL: lateral condyle of femur to anterior intercondylar tibia
* PCL: medial condyle of femur to posterior intercondylar tibia
* MCL and LCL – prevent valgus and varus opening
* Meniscus -avascular
89
KNEE
| describe ACL injuries?
* sports and skiing,
* unable to walk immediately afterwards
* Symptoms of instability – knee giving way
* Anterior draw test / Lachman test +ve
* MRI – Arhroscopic replacement - hamstring grafting/patella grafting
90
KNEE
| describe PCL injuries?
* Dashboard type injuries
* Less common and less common to get instability
* Posterior draw test and posterior sag
* Isolated complete ruptures are rare
91
KNEE
| what is the unhappy triad?
* MCL rupture
* ACL rupture
* Lateral meniscus rip
* These need surgical repair
92
describe the epidemiology of hip fractures?
* Common
* Post menopausal women over 70
* RF – osteoporosis and risk factors for falls
93
INTRACAPSULAR HIP FRACTURE
1. what is it
2. what are the issues with this
3. what classification system is used
1. Proximal to insertion of hip capsule on femeral head
2. Disrupt retinaculat arteies that run up the neck -> AVN
3. garden
94
what is the treatment for intracapsular fractures?
* Key – displacement
* Displaced – head excised and replaced / arthroplasty
* Non displaced – head is saved and may be fixed with screws
95
what are the complications of hemiarthroplasty?
infection, dislocation, wear through acetabulum
96
what are the classifications of screw fixation?
non union, loss of position, femoral head AVN
97
what is extra capsular hip fracture and what are the types?
Distal to insertion of hip capsule on femeral head
intertrochanteric and subtrochanteric
no risk of AVN
98
describe intertrochanteric extra capsular fractures?
* Usually failry stable
* Treat with dynamic hip screw
* If complex with lots of pieces may also need intramedullary nail
99
describe subtrochanteric extra capsular fractures
Not stable
| Treat with intramedullary nail and screw
100
describe medical treatment of hip fractures?
* Prevent VTE - LMWH
* Prevent pressure sores
* Early mobilisation
* Bone protection (with geriatrician advice) - bisphosphonates
* Usually elderly patients with high mortality
101
what is syndesmosis?
Ring holding fibula, tibia and talus together
| made up of several ligaments (deltoid ad anterior taco-fibular)
102
what classification system can be used for ankle fractures?
weber (A, B. C)
103
describe gout?
* Acute onset
* Extremely painful
* Asymmetrical inflammatory joint pain
* Uric acid -purine metabolism, deposition in joints
* Local inflammatory reaction
* Decreased excretion or increase production
* testing– serum urate, aspirate negatively birefringent needle shaped
* acute: indomethacin – COX inhibitor
* colchine
* allopurinaol
* probenecid
104
what is the mechanism of action of colchine?
colchine binds to tubulin and inhibits microtubes polymerisation, inhibits neutrophil migration and antiinflammtory cause diarrhoe
105
what is the mechanism of action of allopurinol?
xanthine oxidase inhibitor
106
what is the mechanism of action of probenecid?
increases uric acid excretion in urine
107
describe pseudo gout?
* Elderly usually larger joints – knee, shoulders
* Calcium pyrophosphate crystals within joint space
* Rhomboid shaped positely birefringent
* X-ray – calcium infiltration in meniscus
108
describe septic arthritis?
* Patient will be septic, mono-arthropathy
* Hot , swollen joint with disease ROM
* Hematogenous spread – direct spread/trauma – post op
* Increased WBC, ESR, CRP
* Staph aureus, group A strep, Neisseria gonorrhoea
* Aspirate, IVABS, washout, MC&S further review
109
what features suggest fracture?
* History of injury (pathological fractures)
* Deformity of limb
* Tenderness of bone – palpate areas that aren’t painful first
* Pain with remote force
* Abnormal mobility at injury site
* Patient protects and supports limb
* When fracture is immobilised pain improves
110
describe conservative treatment of fractures?
* Manipulation
* Immobiise in plaster (POP – plaster of paris not POT)
* Stay in POP for 4 weeks at least (usually 6 weeks)
* Wrist is then stiff
* May need physiotherapy
111
describe operative treatment of fractures?
* Wires or plate
* Less immobiilsation
* Risk of infection
* Risk of non-union
* May need physiotherapy
* Patients over 65 don’t usually benefit from surgery
112
what other injuries should be considered in a patient with fracture?
* Skin – cut and bruised
* Fat - indented
* Muscle. Weak or wasted
* Ligaments – unstable joint
* Arteries – ischaemia
* Nerves – decreased sensation and power
* Veins - engorgement
* Joint surfaces – cartilage -poor ability to repair – X-ray irregularity
113
what is rugger jersey injury?
ring finger tendon pulled off bone
114
describe flexor tendon injury?
* Active movement not passive movement is impaired
* Site of injury indicates the likely tendon injured
* Assessment difficult due to pain
115
describe flexor digitorum profundus injury?
* Flexes MP, PIP and TIP
* If this tendon injured inisolation there is loss of flexion of TIP. The PIP and MP can still be flexed by flexor digitorum superficialis tendon
* FDP function – hold finger straight and see if they can bend tip of finger
116
describe flexor digitorum superficialis injury?
* Tendon flexes MP and PIP
* Its action is independent of adjacent fingers and can flex the finger when the adjacent fingers are held in an extended position
* If only the FDS is severed and FDP is intact then the finger cannot be flexed while the adjacent fingers are held in extended position. FDP is not able to flex the isolated finger
117
describe fallout sign?
both flexor tendons are severed
118
describe extensor tendon injury?
* Dividion of extensor tendon of a digit on the dorsum of the hand results in drooping of the digit when the hand is held palm down
* Loss of active extension of MP joint
* Boutonniere deformity – hold PIP extended for 6 weeks
* Mallet finger deformity – stubbing finger, drooping of tip of finger – hold finger in full extension for 6 weeks
119
describe nerve innervation of hand?
* Ulnar – skin of ulnar third of palm, palmar and dorsal surfaces of little and ulnar half of ring fingers
* Median nerve supplies palmar surfaces of the thumb, index, middle and radial half of ring finger
* Radial – supplies same are on dorsum of the same digits
120
what should you be cautious of in shoulder injury?
* Beware rotator cuff tear
* Axillary nerve injury
* Check peripheral pulses
121
describe differences in shoulder injury in old people compared to old people?
* Young people = dislocate
* Old people = break
* Consider soft tissue injuries
* Young people - mobilise
* Old people- early mobilisation
122
what are the risk factors for femoral neck fracture?
* Increasing age
* Osteoporosis
* Osteomalacia
* Falls
* Instability
* Lack of core strength
* Gait disturbance
* Sensory impairment
123
describe examination findings of a femoral neck fracture?
* Hip pain radiate to knee
* Inability to bear weight
* Affected leg may be shortened and adducted with external rotation
* External roation is painful
124
how is femoral neck fracture diagnosed?
* AP pelvis and lateral hip x-rays
* CT helpful n determining displacement and degree of comminution
* MRI in suspected hip fractures but not seen in AP pelvic and lateral hip x-rays do not show a fracture
* MRI usedul in ruling out occult fracture
* If MRI unavailable within 24 hours request a CT
125
describe the initial management for femoral neck fracture?
* ATLS, mental score, DVT assessment
* FBC, U&Es, G&S, cross match, glucose
* ECG
* IV access if indicated – hydrate – may develop kidney problems if dehydrated
* Adequate analgesia
* Early assessment for cognitive impairment
* Catheter
126
describe secondary management for femoral neck fracture?
* Patient dependent: displacement, age and premorbid health/moility
* Surgery – hemiarthroplasty or total for intracapsular fractur
* Dynamic hip screw fixation for extracapsular fracture
* Cannulated screw fixation for undisplaced intracapsular or extracapsular fraction
127
what is a femoral fracture most likely due to?
Almost always due to high energy trauma
• RTA, gunshot injury, fall
• Pathologic fractures occur at metaphyseal/diaphyseal junction
• If degree of trauma inconsistent with fracture, rule out pathological
128
what are the clinical features of femoral fracture?
* Pain
* Swelling
* Deformity
* Shortening of lower limb and complete external rotation deformity
* Severe blood loss
* Shock - unconsciousness, pallor, cold nose, tachycardia, cold and clammy skin, hypotension etc
129
describe femoral fracture in children?
* Exclude none accidental injury
* Skin traction (up to 2 years for 4-6 weeks
* Hip spica
* Older children; external fixation, plate or elastic nails can be used
* Epiphyseal injuries are classified according to salter are fixed if displaced
130
give examples of acute knee injuries?
* Acute patellar dislocation – brace for 2-4 weeks then physio
* Collateral ligament rupture, if knee is lax, brace followed by physio
* Contusion
* Meniscus injury
* Anterior cruciate ligament injury
* Rest, MRI scan
131
what are the causes of tibia and fibula fractures?
* RTA-37%
* Sports 25%
* Assaults – 5%
* Rest – falls
132
what is the treatment for tibia and fibula fractures?
Closed reduction under GA and long leg cast application
Conservative management Indication; closed fracture, undiscplaced facture, low energy trauma, low energy trauma, young adults, minor or moderate
Surgical treatment: open reduction and internal fixation induction
• Tibial fracture with vascular or neural injuries
• Segmental fracture
• Inadequate reduction
• Displaced intraarticular distal tibia plafond fracture or proximal tibia
133
what are the complications of tibia and fibula fractures?
* Compartment syndrome – need releasing
* Delayed union -bone grafting
* Non union – right internal fixation with compression palting and bone grafting
* Malunion - osteotomy
* Shortening
* Infection
* Joint stiffness
* Refracture
* DVT
* Fat embolism
134
what classification system is used for ankle fractures?
```
Classification - Danis weber
Based on mechanism of injury, usually triping over curb
Three fracture types defined by location
• A-below tibiotalar joint
• B – at level of tibiotalar joint
• C – above tibiotalar joint
```
135
what is the management of ankle fractures?
* ABC, localised swelling and tenderness in malleolar region
* Undisplaced fracture can be treated below knee cast for 6 weeks
* Displaced fracture with diastasis, talar shift indicates disruption of syndesmosis and often require anatomical reduction and immobilisation for 6 weeks in plaster
* Fractures – lateral
136
describe pilon fractures the ankle?
* Axial compression
* Talus driven into plafond
* Usually comminuted and displaced with extensive soft tissue swelling
* Look for associated injuries
* Calcaneus, femoral neck, acetabulum, lumbar vertebrae
* Management – ortho consult
137
describe tarsal, metatarsal and phalangeal fracture?
* Due to fall or sports injury
* Tarsometatarsal injuries often hard to diagnose, CT scan will help
* Undisplaced fractures can be treated in boot or cast for 6-12 weeks and displaced injuries require fixation
* Neighbout strapping supports the toe fracture for 3 weeks
* Metatarsal fracture are treated in boot of cast for 4-6 weeks
138
give examples of common types of fractures?
* Transverse
* Spiral
* Oblique
* Convoluted
* Segmental
139
what are the potential complications of diaphysial fractures?
* Bed sores
* Pneumonia
* DVT and PE
* Systemi inflammatory response to injury
* Non union or malunion
* Ulcers
* Muscle wasting
* Joint stiffness
* RSD
* Painful scar
* Infection
* Nerve injury
140
describe conservative management of fractures?
* Supervised neglect
* Crutches
* Rest in sling
* Cast immobiisation
* Skin traction
* Skeletal traction
141
describe operative management of fracture?
```
Intra-medullary
• Kirshner wires
• Elastic/flexible nails
• Non locked nails
• Locked nails
Extramedullary
• Plate and screw
• Circlage wires
External fixation
• Mono/bi/poly axial
• Circular frames
• Hybrid frames
```
142
describe the treatment of undisplayed intra-articular fractures?
maintain anatomical reduction
• Until stable then mobilise avoiding displacement
• Prevent fracture disease
143
describe the treatment of displayed intra-articular fractures?
* Obtain anatomical reduction with rigin fixation to allow early mobiisatin
* If unlikely to heal then replac (NOF)
* If impossible to fix then ; consider replacement, treat as bag of bones with supervised neglect
144
describe oblique fractures?
Oblique fractures are complete fractures that occur at a plane oblique to the long axis of the bone. Like transverse fractures, the term is predominantly used in the context of describing a fracture in a long bone.
Oblique fractures are particularly prone to angulation in the plane of the fracture.
Caused by sharp blow coming from an angle
145
describe transverse fractures?
Transverse fractures are complete fractures that traverse the bone perpendicular to the axis of the bone. The fracture involves the cortex circumferentially and there may be displacement.
The term is predominantly used in the context of fractures of long bones although other types of bones may have transverse fractures, e.g. transverse fracture of the temporal bone.
Transverse fractures of long bones are at risk of displacement, like any other long bone fracture
Trauma from falls, car, motorcycle accidents. Severe and sudden twisting or bending
146
describe longitudinal fractures?
longitudinal fractures are fractures that occur along (or nearly along) the axis of the bone. This is most often used in the context of a long-bone fracture although traditional classification of temporal bone fractures also used this term.
147
describe comminuted fractures?
Comminuted fractures are fractures where more than 2 bone components are created.
The problem with the term is that it includes a very heterogeneous group of fractures from a 3 part humeral head fracture to a multi-part fracture of the femur following a high-energy road traffic acciden
148
Describe spiral fractures?
Spiral fractures are complete fractures of long bones that result from a rotational force applied to the bone. Spiral fractures are usually the result of high energy trauma and are likely to be associated with displacement.
149
describe impacted fractures?
An impacted fracture occurs when the broken ends of the bone are jammed together by the force of the injury.
