Trauma,orthopaedic & rheumatology emergencies Flashcards
(135 cards)
1
Q
List 6 Signs of Base of Skull Fracture
RCEM Learning SAQ’s
A
1) Haemotympanum
2) CSF otorrhoea
3) Battle’s sign (mastoid ecchymosis)
4) CSF rhinorrhoea
5) Bilateral periorbital ecchymosis
6) Cranial nerve palsies
2
Q
Name an Indication for conservative management of Base of Skull Fracture
RCEM Learning SAQ’s
A
if no neurological deficit and no CSF leak ( dural tears cause the CSF leak ) then manage conservatively with possible admission for observation.
3
Q
What surgical options to manage Base of skull fracture for CSF leak ( caused by dural tears )
RCEM Learning SAQ’s
A
- CSF drainage
or - open/endoscopic dural repair
4
Q
What associated complications would you find in a patient with a lateral tibial plateu fracture?
RCEM Learning SAQ’s
A
- fibula neck fracture
- common peroneal nerve palsy
- cruciate and lateral ligament injury
5
Q
Give the absolute indications for surgery in tibial plateu fractures?
RCEM Learning SAQ’s
A
- open tib plat fracture
- tib plat fracture associated with vascular injury
- tib plat frac associated with compartment syndrome
6
Q
In a patient wiith a ruptured quadriceps tendon - what would you look for on a knee xray?
RCEM Learning SAQ’s
A
- expect the patella to be displaced laterally
- may find a soft tissue shadow anterior aspect to the femur representing the quad tendon
- knee joint effusion
7
Q
Give the name of the combination of a fracture of the proximal fibula and the medial malleolus
RCEM Learning SAQ’s
A
A Maisonneuve injury
8
Q
Give the xray features of a tibial plateu fracture on AP and Lateral films?
RCEM Learning SAQ’s
A
On AP view:
- Sclerosis of tibial plateau (see black box).
- Widening of intra-articular space on side of fracture.
- Lateral displacement of tibial plateau relative to lateral femoral condyle (>2mm) -see yellow dotted dotted line.
- May see fracture line as a step in the articular surface or lateral tibial margin.
On Lateral view:
- Lipohaemarthrosis
- May see fracture line through tibial plateau (if displaced)
9
Q
What are the risk factors listed in NICE head injury guidelines to arrange a CT head scan within 1 hour of attending ED in patients with head trauma?
NICE Clinical Guidelines: head injury
A
- GCS less than 13 on initial assessment in the emergency department
- GCS less than 15 at 2 hours after the injury on assessment in the emergency department
- Suspected open or depressed skull fracture
- Any sign of basal skull fracture (haemotympanum, panda eyes, cerebrospinal fluid leakage from the ear or nose, Battles sign)
- More than 1 episode of vomiting
6 Post traumatic seizure
- Post-traumatic neurological deficit
10
Q
In a child presenting with a supracondylar fracture of the humerus -which nerve injury is associated with this injury and which muscle groups are supplied by it?
A
Anterior inter-osseous ( AIN ) - which is a branch of the median nerve. Mainly motor function.
supplies 3 deep muscles of the forearm:
- FDP ( of thumb, index and middle finger )
- FPL ( flexor pollicus longus )
- Pronator Qaudratos
11
Q
In Which order do the ossification centres of the elbow appear?
A
C - 1 year R - 3 year I - 5 year T - 7 year O - 9 year L - 11 year
12
Q
What analgesia options are available for patient with multiple rib fractures?
A
- 1g oral or IV paracetamol.
- Further opioids (usually morphine) preferably using
patient controlled analgesia - thoracic epidural courtesy of an anaesthetic
colleague. - Intrapleural bupivicaine given via the chest drain
13
Q
Can you name 5 immediate management steps in sickle cell crisis in the ED?
RCEM learning SAQ’s
A
- Oxygen supplementation
- Analgesia
- Hydration
- Avoid exacerbation of symptoms ( cold temperatures,
exercise ) - Broad spectrum antibiotic cover
14
Q
List 7 complications of sickle cell crisis?
RCEM Learning SAQ’s
A
- sepsis
- osteomyelitis
- aplastic crisis
- acute stroke
- acute chest syndrome
- splenic sequestration
Memory AId:
SS - AAA - O
Sepsis, splenic sequestration, Acute chest syndrome, aplastic anaemia, acute stroke, Osteomyelitis
15
Q
In a patient with head injury - Can you name all the neuroprotective mechanisms used to prevent secondary brain injury?
RCEM Learning SAQ’s
A
- O2 - Normoxia
- CO2 - normocarbia
- BP - normotension
- Temp- normothermia
- BM- normoglycaemia
- Avoid intracranial hypertension
- Maintain CPP 50-70mmhg
- Remove c-spine collar
- Loosen ETT tie
16
Q
What is the name of the nerve and the muscle that Froments signs tests?
RCEM Learning SAQ’s
A
Nerve- deep branch of the ulnar nerve
Muscle- adductor pollicus of the thumb -AdPL
17
Q
Regarding Children presenting to the ED with a head injury- what are the indications to perform a ct head within 1 hour of the risk factor being identified?
8 indications
NICE Guidelines: Head injury
A
- GCS < 14/15 on arrival in ED ( or GCS < 15/15 in under 1 year olds )
- GCS < 15/15/ 2 hours after arrival in ED
- Suspicion of base of skull fracture
- Suspicion of open or depressed skull fracture
- Any focal neurological deficit
- Post traumatic seizure but no history of epilepsy
- for children under 1 year - presence of bruise, swelling
or laceration > 5cm diameter - suspicion of NAI
18
Q
Regarding Children presenting to the ED with a head injury who do not have any of the 8 risk factors for performing CT head within the 1st 1 hour of risk being identified -
Can you name the 5 criteria which would qualify for performing a ct head within 8 hours from the time more than 1 of them ( at least 2 ) are identified as a risk?
NICE Guidelines: Head injury
A
- 5 minutes ( witnessed LOC lasting > 5min )
- 5 minutes amnesia ( retrograde/anterograde )
- Dangerous - mechanism of injury
- Discrete ( 3 or more discrete episodes of vomiting )
- Drowsy ( abnormal )
19
Q
Regarding Children presenting to the ED with a head injury who do not have any of the 8 risk factors for performing CT head within the 1st 1 hour of risk being identified , and only have ONE of the 5 risk factors , how would you manage this child?
NICE Guidelines: Head injury
A
observe for 4 hours.
If the patient develops one 1 of the following 3 clinical features of:
a. further episodes of vomiting
b. a further episode of abnormal drowsiness
c. GCS < 15
then a ct head should be performed within 1 hour of this risk factor being identified.
20
Q
For adults who have sustained a head injury , name 7 of the risk factors, even if only 1 which need to be present to perform a CT cervical spine scan within 1 hour of the risk factor being identified
NICE Guidelines:
A
- GCS < 13 on initial assessment
- Patient has been intubated
- a definitive diagnosis of c-spine injury is needed ( e.g prior to surgery )
- Patient is having other body areas scanned e.g. for head injury or multi-region trauma
- plain film xrays are technically inadequate
- plain film xrays are definitley abnormal
- The patient is alert and stable, there is clinical suspicion of cervical spine injury and any of the following apply:
a. age 65 years or older
b. dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 stairs; axial load to the head, for example, diving; high-speed motor vehicle collision; rollover motor accident; ejection from a motor vehicle; accident involving motorised recreational vehicles; bicycle collision)
c. focal peripheral neurological deficit
d. paraesthesia in the upper or lower limbs.
21
Q
Adults and children who have sustained a head injury and in whom there is clinical suspicion of cervical spine injury, range of movement in the neck can be assessed safely before imaging only if no high-risk factors (see recommendations 1.5.8, 1.5.11 and 1.5.12) and at least 1 of the following low-risk features apply. The patient:
RCEM Best practice
A
- was involved in a simple rear-end motor vehicle collision
- is comfortable in a sitting position in the emergency department
- has been ambulatory at any time since injury
- has no midline cervical spine tenderness
- presents with delayed onset of neck pain. [new 2014]
22
Q
A. what is the minimum frequency of Performing and record observations in a patient with a head injury and GCS < 15?
B. What is The minimum frequency of observations for patients with GCS 15 in a patient with a head injury?
NICE guidelines: head injury
A
Answer A.
On a half-hourly basis until GCS equal to 15 has been achieved.
Answer B.
Half-hourly for 2 hours.
Then 1-hourly for 4 hours.
Then 2-hourly thereafter. [2003]
23
Q
Can you explain the difference between an escharotomy and a fasciotomy?
RCEM learning SAQ’s
A
Escharotomy:
surgical division of
nonviable eschar in
full-thickness (third-degree)
circumferential burns
Fasciotomy:
surgical procedure where the fascia is cut to relieve tension or pressure to treat the resulting loss of circulation to an area of tissue or muscle
24
Q
Can you name 3 indications in the ED to perform an escharotomy?
Think - A,B,C
A
- Constrictive circumferential neck burns that threaten
the airway. - Circumferential burns of the chest that increase chest
wall rigidity and impair ventilation (e.g. increased
peak airway pressures in the ventilated patient). - Circumferential burns of the extremities resulting in
compartment syndrome.
Memory aid:
full thickness circumferential burns that:
constrict the neck, the chest wall, or limbs causing compartment syndrome
25
In children -
What are the initial indications for referring a patient to a specialist burns service (as per APLS 2015 specifically regardless of age or %BSA burn ) ?
1. All electrical burns
2. All chemical burns ( incl. hydroflouric acid )
3. All inhalational burns
4. All Circumferential burns to trunk or limbs
5. Full thickness burns > 1%, or any burn >2% in child
6. Burns to special areas ( face, feet, hands, perineum )
7. Burns associated with suspicion of NAI
8. Burns in a major trauma patient
9. Burns associated with significant comorbidities
26
Name clinical features that would indicate inhalation injury in a child with burns?
1. facial burns
2. singing of eyebrows
3. singing of nasal hairs
4. peri-oral burns
5. hoarseness
6. stridor
7. carbonaceous sputum
27
What is the Parkland formula for calculated fluid therapy in burns patients and when should it be used?
3-4ml x body weight x % BSA burn.
administer over 24 hours
half in 1st 8 hours, remaining half over next 16 hours
use in patients that have > 10% BSA burns .
28
1. What are the indications for an ED resuscitative thoracotomy?
2. What are the 3 E's for the requirements to conduct the procedure?
1. Indications for an ED resuscitative thoracotomy:
*Blunt traumatic Cardiac arrest with less than 10 minutes
CPR
*Penetrating traumatic Thoracic trauma with less than
15minutes CPR
2. 3 E's= Equipment, expertise, environment
29
Summarise the 7 key steps of the procedure in performing a resuscitative thoracotomy in the ED
RCEM Learning SAQ's
7 Steps into the heart:
step 1: BILATERAL THORACOSTOMIES
in 5th intercostal space
step 2: INCISION EXTENSION
scalpel through skin and subcut tissue to join the
thoracostomies
step3: PLEURAL CUT
tough cut scissors to cut through the remaining
tissue and gain access to the chest
step 4: STERNAL CUT
use gigli saw to cut through the sternum
step5: CLAMSHELL
assistant to prise open the chest cranially and
caudally to gain maximum access
step 6: PERICARDIAL CUT
use forceps, grip pericardium to tent the tissue
and make longitudinal incision
step 7: INSPECT
30
What are the red flags for back pain would you look for on history and examination of a patient?
RCEM learning SAQ's
History:
* age 20-50
* unexplained weight loss, fever and systemically unwell
* thoracic pain
* pain worse at night
* immunosuppresion/ history of IVDU
Examination:
* Progressive bilateral neurological deficit of the legs
* new onset bladder or bowel dysfuntion
* saddel anaesthesia
* loss of peri-anal sensation
reduced anal tone
31
Young patient presents with a foot injury and examination shows bruising to the sole of the foot. What injury would you be concerned about?
RCEM learning SAQ's
Lisfranc Fracture
32
Why might a Lisfranc fracture not be visible on xray film in the ED?
RCEM learning SAQ's
* The x-ray is likely to have been taken whilst non weight bearing.
* Also x-rays often do not include a true lateral view and may therefore not show the extent of the injury.
33
A patient has a high risk tetanus wound and is receiving TIG. what other 2 treatments are important to also consider administering in this patient?
RCEM learning SAQ's
1. antibiotics ( metronidazole - but follow local departmental policy )
2. benzodiazepines for seizures
34
Which wounds are considered tetanus prone?
RCEM learning SAQ's
1. puncture wounds contaminated with soil containing maneur or tetanus spores
2. certain animal bites
3. wounds containing foreign bodies
4. compound fractures
5. Wounds/burns in patients with systemic sepsis
35
What clinical features would make you suspicious of tetanus infection in a patient?
RCEM learning SAQ's
1. Trismus
2. Dyshpagia
3. Muscle spasms
4. spasticity
5. respiratory distress
6. autonomic dysfunction
36
A patient presents 3 weeks after being involved in a RTC with neck pain, and weakness on one side of his body.
1. What is the likely diagnosis?
2. what symptoms would you expect to find?
He developed internal carotid artery dissection following the traumatic injury 3 weeks earlier.
1. Diagnosis:
He developed internal carotid artery dissection following the traumatic injury 3 weeks earlier.
2. Symptoms of Internal carotid artery dissection
* headache,
* neck pain,
* amaurosis fugax,
* partial horner syndrome,
* focal weakness,
* taste disturbance and weakness
37
A patient presents 3 weeks after being involved in a RTC with neck pain, and weakness on one side of his body. He developed internal carotid artery dissection following the traumatic injury 3 weeks earlier.
What is the main treatment for internal carotid artery dissection?
Treatment is often conservative with anticoagulation. Surgical intervention with angioplasty is reserved in some cases with complete a arterial occlusion and where
38
You have made a clinical diagnosis of Achilles tenodon rupture, but your patient would like imaging to confirm .
What would you say to the patient?
Resource: Bromley SAQ's
Clinical diagnosis is considered more reliable. however ultrasound and MRI can both show achilles tendon rupture
39
Risk factors for Achilles tendon rupture
Resource: Bromley SAQ's
1. flouroquinolones antibiotics - ciprofloxacin
2. steroid injections
3. episodic athletes ( weekend warrior )
40
What are the long term complications of untreated/poorly treated lis-franc fracture dislocation?
Resource: Bromley SAQ's
1. Non-union of the fracture dislocation
2. collapse ( of the plantar arch and pes planus - flat
foot)
3. shortening ( of plantar arch and pes cavus - high
instep )
4. high risk - of developing arthritis
41
In Lis-franc injuries what would sign would you examine the foot for?
Resource: Bromley SAQ's
Echymosis of the plantar arch
42
A patient that is involved in an RTC presents with Grey-turners sign on clinical examination - what particular intra-abdominal injuries would you be concerned about?
Resource: Bromley SAQ's
1. rupture of hollow viscus, stomach, small bowel,colon
2. mesenteric contusion/haemorrage
3. pancreatic contusion
43
Differentiate 4 features between gout vs pseudogout?
Resource: RCEM Learning SAQ's
GOUT
* 1st MTP
* uric acid crystals
* no chondrocalcinosis on xray
* negatively birefringent needle shaped crystals
PSEUDOGOUT
* usually large joint i.e. knee
* calcium pyrophosphate dihydrate ( CPPD )crystals
* positively birefringent crystals ( on polarised light ) - rhomboid shapes
* chondrocalcinosis on xray
44
How would you classify supracondylar fractures?
Use gartland classification:
Type 1 = minimal displacement
* can be managed with a collar and cuff and refered to fracture clinic OPD
Type 2- displaced but posterior cortex in tact
* refer to on call orthopaedics for MUA ( as a minimum - but may also require ORIF )
Type 3= completely displaced with no cortical contact
* refer to ortho on call for urgent ORIF
45
3 indications on an xray to help with the decision to manipulate a distal radius fracture?
Resource: RCEM Learning SAQ's
1. impaction ( squashed )
2. displaced ( if significanlty displaced - required manipultaion)
3. dorsally angulated > 10 degress
46
What are the indications for referring a patient with a pre-tibial skin flap for early plastic surgery?
Resource: RCEM Learning SAQ's
1. massive haematoma
2. Complex skin/soft tissue flap
3. complete degloving injuries
4. large area of skin loss
47
In nasal injuries- list 3 indications to refer to otolaryngologist?
Resource: RCEM Learning SAQ's
1. uncontrolled epistaxis
2. septal haematoma
3. CSF rhinorrhoea
48
how do you differentiate between CSF rhinorhoea and normal nasal discharge?
Resource: RCEM Learning SAQ's
Examine for beta-2 transferrin in nasal discharge
49
For patients with facial fractures what advice would you give on discharge?
Resource: RCEM Learning SAQ's
1. Avoidance of nose blowing as this may produce surgical emphysema.
2. Not to occlude the nose when sneezing
3. Application of ice packs to the area to reduce swelling
4. Take regular analgesia
5. General head injury advice
50
What combination of facial xrays would you request in a patient with suspected mid-face fracture?
Resource: RCEM Learning SAQ's
1. OM15 ( occipito-mental 150 degrees )
2. OM30 ( occipital mental 300 )
3. submentovertical
4. lateral facial views
51
What 4 features on OM view xrays would compromise a zygomaticomaxillary complex fracture?
Bromley SAQ's
A 'tripod' fracture has 4 visible components - not always all visible
1 - Fracture of the Orbital floor
2 - Fracture of the Lateral wall of the maxillary antrum
3 - Zygomatic arch fracture
4 - Widening of the zygomatico-frontal suture
Memory Aid: ZF suture and 3 bones ( arch connects lateral wall to the floor )
ZF suture is widened
orbital floor broken
lateral wall of maxillary antrum broken
zygomatic arch broken
52
can you list 5 injuries associated with sternal fractures?
Resource: RCEM Learning SAQ's
1. Rib fractures
2. flail chest
3. pneumothorax
4. cardiac contusion
5. thoracic aorta dissection
6. vertebral/spinal injuries
53
What are the zones of the neck?
Resource: RCEM Learning SAQ's
The zones of the neck are a way to define the injured region when there is trauma inflicted on the anterior of the neck.
Zone I is the inferior portion of the neck demarcated by the thoracic inlet (clavicles and sternum) inferiorly and the cricoid cartilage superiorly.
Zone II is bounded by the cricoid cartilage and the angle of the mandible.
Zone III is the area between the angle of the mandible and the base of the skull.
54
What structures lie in each of the 3 zones of the neck?
Resource: RCEM Learning SAQ's
ZONE 1: TOL-TT
* trachea
* oesophagus
* lung
* Thyroid
* thoracic duct
ZONE 2: TOL-P-JUGGLE the carotid and vertebrals
* trachea
* oesophagus
* larynx
* pharynx
* Jugular veins
* Carotid arteries
* vertebral arteries
ZONE 3: TOCS - juggle the carotid and vertebrals
*trachea
*oesophagus
*cranial nerves
Salivary and parotid glands
* jugular veins
* carotid arteries
* vertebral arteries
55
Describe the 4 steps of Kochers method to reduce a anteriorly dislocated shoulder?
1. traction on the arm
2. with the elbow flexed- externally rotate the arm
3. adduct the elbow accross the front of the chest to the
midline
4. and the internally rotate the arm in a single quick
motion
56
Which 5 wounds are tetanus prone wounds?
```
1. puncture type wound aquired in a contaminated
environment containing tetanus spores
2. certain animal bites
3. wounds with foreign bodies
4. wounds with systemic sepsis or burns
5. open fractures
```
( animals bites the skin and puncture through to the bone , breaking it, leaving foreign bodies which cause systemic sepsis )
57
Can you name 3 High risk tetanus wounds?
1. heavily contaminated with maneur
2. burns/wounds with extensive devitalized tissue
3. burns/wounds requiring surgery that has been
delayed for 6 hours or more
58
What is the dose for Tetanus immunoglobulin?
250 iu is the preventative dose, or 500iu if heavily contaminated wounds
59
What is hypertrophic osteoarthropathy? how can you classify its causes?
Resource: RCEM Learning SAQ's
A rheumatological syndrome characterised by clubbing of the nails, periostitis of the long bones and arthiritis
classified as primary or secondary causes.
secondary causes include:
cardiac - subacute bacterial endocarditis
respiratory: pulmonary fibrosis,bronchiectasis, tb, COPD, carcinoma
gastro- IBD
other: thyroid acropachy, thyroid carcinoma
60
Give 5 indications to administer TIG in a patient with a wound?
1- wound is high risk and an adequate primiming course of tetanus vaccine received but the last dose was more than 10 years ago
2 - wound is high risk in child age 5-10, who has received adequate priming dose but no pre-school booster
3- wound is tetanus PRONE and patient has not received an adequate priming course
4- wound is tetanus PRONE and patient was born before 1961 or uncertain immunisation status
61
What 3 xray features would suggest a posterior shoulder dislocation?
Resource: RCEM Learning SAQ's
*" light bulb sign " - contour of the humeral head has a rounded appearance
* absence of external rotation
* Rim sign ( widened gleno-humeral joint > 6mm )
62
What tendons make the medial & lateral borders of the anatomical snuff box?
which 2 bones lie in the floor?
Resource: RCEM Learning SAQ's
Medial - M=EPL ( every patient loves )
Lateral - L=APL (acting pretty lame )
Lateral - L=EPB ( especially patients from birmingham )
trap the scaphoid ( trapezium &scaphoid )
63
Describe how you would reduce a posterior elbow dislocation?
Resource: FRCEM exam prep SAQ's
* flex elbow at 60 degrees
* countertraction on upper arm
* pull on the fully pronated forearm which leverage
forward on the olecranon with both thumbs with elbow
flexed
64
What compromises of the lisfranc joint?
Where does the lisfranc ligament attach to?
Resource: FRCEM exam prep SAQ's
It is the articulation of the 1st 3 metatarsals with the medial, intermediate and lateral cuneiforms.
the lisfranc ligament is a strong band attaching the medial cuneiform to the base of the 2nd metatarsal on the plantar aspect of foot.
65
Which 3 clinical tests could you use to assist in the diagnosis of a lisfranc injury?
* piano key sign ( grasp toes and move up and down to
stress midfoot )
* stress testing ( heel is grasped and the front of foot is
gently tested to ilicit pain )
* single limb heel raise ( wstand on tip of toes stresses
the midfoot )
66
According to the Canadian C-spine rules -
1. name 3 High risk patient groups?
2. name 5 dangerous mechanisms of injury
Resource: FRCEM exam prep SAQ's
3 high risk injuries:
* age >65
* dangerous mechanisms ( 1 of the 5 )
* paraesthesia in extremeties
5 Dangerous mechanisms
* fall from height ( > 3feet/5stairs )
* axial loading to head ( diving )
* bicycle collision
* motorised recreational vehicle
* MVC high speed/rollover.ejection
67
What is a hill-sacs lesion?
What is a bankaart lesion?
Resource: FRCEM exam prep SAQ's
Hill-sacks lesion is cortical depression in the posterior head of the humerus. ( Hillsacks - back of Head of Humerus )
Bankart lesion - injury to anterior glenoid labrum
68
Name 5 low risk factors in a patient with c-spine injury following a RTC that would allow safe assessment of range of motion.
1. simple rear ended rtc
2. ambulatory at any time
3. delayed onset neck pain
sitting position in ED
absence of midline c-spine tenderness
69
Can you name a few complications of a colles fracture?
1. Median nerve palsy
2. Malunion
3. secondary osteo-arthritis
4. Traumatic carpal tunnel syndrome
5. Extensor pollicus longus rupture
6. Reflex sympathetic dystrophy ( sudeks atrophy )
Memory aid:
MMaSTER the complications of Colles fracture for exams!!
SUDEK's is the MMaSTER of Colles fractures!
70
What is Bartons fracture?
what is smiths fracture?
Bartons fracture:
intra-articular fracture of the distal radius WITH dislocation of the radiocarpal joint.
Smiths fracture : ( is reverse colles fracture )
Volar displacement of the distal fragment of the radius
71
How can you remember the SALTE-r Harris classification?
S - Strait through & seperating the physis
A - Above into metaphysis ( through physis into metaphysis )
L - Low and into epiphysis ( through physis into epiphysis )
T - Through all 3 ( physis ,epiphysis & metaphysis )
E - extremely compressed physis
72
what 2 complications of salter harris 4 fractures should you anticipate?
1. avascular necrosis
| 2. growth plate arrest
73
What 6 steps would you initiate in the ED to manage a patient with fite bit wound?
Resoure:
https://cks.nice.org.uk/bites-human-and-animal
1. clean the wound
2. give tetanus immunoglobulin +/_ vaccine if tetanus prone
3. consider BBV and give prophylaxis
4. consider rabies prophylaxis for bites from animals in endemic countries
5. 1st line recomendation for antibiotic is co-amox
2nd line antibiotic if allergic to penicillin - doxycycline and metronidazole
74
What is the OTTAWA ankle rule?
an ankle xray is only indicated if :
1. There is Pain in the malleolar zone
AND
2. any of the following:
* unable able to weight bare immediately and in the ED for 4 steps
* tenderness over the posterior 6cm or tip of lateral malleolus
* tenderness over posterior 6cm or tip of medial malleolus
75
what methods for reducing a anterior shoulder dislocation do you know?
1. external rotation technique
2. kocher's method
3. modified milch method
4. hippocrates technique
76
What is the OTTAWA knee rules for xray in a patient with a knee injury?
A knee xray is only required in a patient with a knee Knee Injury with any of these findings:
* age >55 OR
* inability to weight bear immediately/in the ED for 4
steps OR
* isolated tenderness of patella OR
* tenderness of head of fibula OR
* inability to flex knee to 90 degrees
77
Give 2 injuries associated with posterior dislocation of the shoulder?
* Reverse Hill-sacks lesion
| * Reverse bankaart lesion
78
What findings on examination would you expect to see in an anterior shoulder dislocation?
* arm slightly abducted and externally rotated
* step-off deformity at the acromion with palpable gap below the acromion
* humeral head is palpable anterior inferiorly to glenoid
* flattening of the deltoid ( flat shoulder deformity )
79
What complications of anterior shoulder dislocation can you name?
1. hill-sacks lesion
2. bankaart lesion
3. axillary nerve damage
4. axillary artery damage
5. rotator cuff injury
80
1. What is the classification system used for supra-condylar humeral fractures?
2. What are the complications of supracondylar fractures?
1. Gartland classification
grade 1 - undisplaced
grade 2 - anterior cortex broken and posterior in tact
grade 3 - anterior and posterior cortex broken
2. complications include:
* Volksman's contracture ( due to occlusion damage to
brachial artery)
* compartment syndrome
* ulnar, median ( AIN ) or radial nerve injury
* malunion
Nerve commonly injured in supracondylar fractures is the AIN - anterior interioseous Nerve ( branch of the median nerve with mainly motor function to the forearm )
81
What sign would you look for on calcaneum xray to suggest a fracture?
A reduced Bohler's angle to less than 20 degrees
is suggestive of a calcaneal fracture
82
A patient injures his index finger pulp at work and it becomes infected and is very painful and whole finger is swollen -
1. what is your diagnosis?
2. What is the cardinal clinical features on examination?
1. Flexor tenosynovitis
2. Cardinal features of flexor tendon sheath infection:
KANAVELS SIGN
* finger held in flexion
* symmetrical swelling of the finger ( fusiform swelling )
* tenderness over flexor tendon
* extreme pain on passive extension
83
Which nerve is associated with acetabular fracture?
sciatic nerve
84
What is the simmonds-thompson test in suspected achilles tendon rupture?
On examination there is no plantar flexion of the foot when compressing the calf muscle
85
In a toddlers fracture - why is the fracture more apparent on repeat xray 10 days later?
due to sclerosis and periosteal reaction
86
Carpal tunnel syndrome - name 2 clinical tests
1. phalens test
| 2. tinnels test
87
What is the pathophysiology of compartment syndrome?
Increased pressure in the compartment exceeds perfusion pressure of the tissue - causing tissue necrosis
88
What are the pertinent features of compartment syndrome?
* pain on passive muscle stretch
* tense compartment with a firm woody like feeling
* pallor
* Paraesthesia
* paralysis
* pulseless
89
what are the complications of compartment syndrome:
* rhabdomyliss
* AKI
* amputation
* permanent muscle/nerve damage
* chronic pain
90
What are the current NICE and BNF recommendations on the treatment of osteomyelitis?
Treatment of osteomyelitis ( and septic arthritis ):
1st line - flucloxacillin
2nd line - clindamycin ( if penicillin allergic )
if MRSA suspected - Vancomycin
In septic arthritis- if gonoccocal suspected- cefotaxime
Duration of treatment - 6 weeks
91
Name the classical hand deformity of patient with rheumatoid arthritis
Hand deformity features in RA:
* ulnar deviation of the MCP joints
* swan neck deformity of the index finger
- hyperextension at the PIP and hyperflexion at DIP
* boutonierre deformity
- hyperflexion at the PIP and extension at DIP
* Z deformity of the thumb
92
What are the xray features of rheumatoid arthritis?
* soft tissue: swelling
* joint space: narrowing
* around the jt space: periarticular osteoporosis
* around the jt space: periarticular erosions
* bone: subchondral cyst formation
Think soft tissue -joint-around joint - bone
93
What are the indications for joint aspiration?
1. suspicion of septic arthritis
2. evaluation of therapeutic response for septic arthritis
3. suspicion of crystal induced arthritis
4. unexplained arthritis with synovial joint effusion
94
What are the absolute contra-indications for ANY joint aspiration?
contra-indications for ANY joint aspiration:
1. coagulopathy
2. prosthetic joint
3. overlying cellulitis
95
What are the complications of septic arthritis?
Complications of septic arthritis:
1. joint - septic dislocation, chondrolysis
2. bone - osteomyelitis, avascular necrosis
3. blood - disseminated sepsis
Memory aid:
Think about the bug invading the joint and then down to the bone and then jumping into the blood
96
In a child with perthe's disease, what are the characteristic xray features?
xray features of perthe's:
1. earliest sign is increased density of the epiphysis and widening of the medial joint space
2. next stage is fragmentation of the epiphysis and flattening of the head
97
What is the definitive management of perthe's disease?
and what are the long term complications?
Definitive management: 50 % will have a good result with conservative management.
osteotomy is reserved for severe cases
complications:
1. permanent hip deformity
2. secondary arthritis
98
What are the components of Kocher's criteria in assessing the proability of septic arthritis?
Kicher's criteria of Setic Arthritis:
1. fever > 38.5 degrees celcius
2. non-weight bearing
3. WCC > 12 x 10
4. ESR > 40mm/hr
Probability of septic arthritis:
```
1/4 = 3%
2/4 = 40%
3/4 = 93%
4/4 = 99%
```
99
A 24 year old woman recently sustained a fracture of her left elbow. Her plaster cast has been removed and she says that after her fracture she noticed pins and needles in her little finger and that she has dropped objects from her hand on a few occasions. the symptoms have not improved with the plaster cast being removed.
WHat is your most likely diagnosis and at which anatomical location has this damage occured?
*Most likely diagnosis:
Ulnar neuritis
*Damage occured at the cubital tunnel under Osborne's
ligament
100
A 72 year old man presents with severe unrelenting back pain and fever a few days after spinal surgery. on examination he has weakness of the right knee and foot dorsiflexion.
WHat is the most likely diagnosis?
What is the commonest organism?
What are known risk factors the named condition?
DIAGNOSIS: Discitis
BUG: Staphylococcus aureus
RISK FACTORS:
* spinal surgery
* IVDU
* Diabetes mellitus
* immunodeficiency
* malignancy
101
What are the clinical features of anterior spinal cord syndrome?
Motor function:
*loss below the level of the cord injury
Sensory function:
*loss of pain and temperature below the level of the
lesion
* preservation of the dorsal column function ( fine touch,
vibration and proprioception )
102
A 45 year old plasterer presents with complaining of the shoulder pain that is worse with repetitive OVERHEAD work. He also now complains of pain at night and difficulty in raising the arm. no history of trauma.
what is the most likely diagnosis and what muscle is implicated
DIAGNOSIS: subacromial impingement
MUSCLE : supraspinatus
MECHANISM:
* supraspinatus tendon runs through a narrow space
situated between the underside of the acromium and
AC joint and head of the humerus.
* entrapmnet of the tendon here results in pain and
limitation of movement, particularly with OVERHEAD
WORK and activity.
103
What are the risk factors for SUFE?
* being overweight
* Male gender
* Positive family history
* African origin
* Growth hormone deficiency
* hypogonadism
* hypothyroidism
MEMORY AID:
Obese boy from africa has a family history and is deficient of Growth hormone, small gonads ( hypogonadism ) and underactive thyroid ( hypothyroidism )
104
You suspect SUFE in a child - What specific xray view would you request and what features on xray are you looking for?
XRAY VIEW: frog leg lateral
XRAY FEATURES: Kleins line ( a line drawn from the lateral edge of the femoral neck ) fails to intersect the epiphysis ( this is called trethowan's sign )
the difference between PERTHES and SUFE is that in SUFE the epiphysis remains in the acetabulum , while the metaphysis moves.
105
In spinal cord injury - at which level would you suspect spinal cord injury if you diagnose a flaccid bladder and a spastic bladder?
Flaccid bladder - SCI below T12
Spastic bladder - SCI above T12
106
What is the classical clinical features of cardiac tamponade?
Beck'striad:
* DISTENDED neck veins
* muffled heart sounds
* hypotension
107
What are the commonest causes of a pericardial tamponade?
1. traumatic pericardial tamponade
2. post cardiac surgery
3. post MI - Dressler's syndrome
4. Uraemia
5. cancer
6. Pericarditis ( viral )
108
What is a Jefferson's fracture?
Describe the xray features?
What commonly associated injuries woul you look for?
Burst fracture of C1 vertebre following direct axial Loading injury ( diving into a shallow swimming pool ) . It is not commonly associated with ANY neurological deficit.
Xray features of Jefferson's fracture:
* odontoid peg view shows lateral displacement of both
lateral massess of C1
Commonly associated injuries:
* significant head injury
* C2 fracture ( in 33% )
* vertebral artery injury
* cranial nerve injury
MEMORY AID:
think of jeffrey the elephant burst down the stairs from C1- but doesn't get hurt badly
109
A 25 year old man falls down a flight of stairs. he lost conciousness. he opens eyes spontaneously, withdraws arms from painand is confused.
1. What is his GCS?
2. What 2 investigations would you arrange immediately?
1. GCS 12/15
2. Investigations:
CT head AND CT C-Spine ( GCS< 13 on intial assessment )
110
What are the indications for the use of mannitol ( 0.25-2g/kg over 30-60 minutes )?
1. Raised intra-cranial pressure
2. short term use for treatment of acute closed angle
glaucoma
3. bowel prep prior to colorectal procedures
4. rhabdomylisis
5. initiate diuresis in transplanted kidneys
111
What are the contra-indications to use of mannitol?
And WHY?
COntra-indications to Mannitol use:
1. Intracranial bleeds
2. severe cardiac failure
3. pulmonary oedema
4. dehydration
5. anuria
WHY?
mannitol is an osmotic diuretic that withdraws ECF from the brain across the BBB, but at the same time causes an expansion of the extracellular fluid space which may worsen congestive cardiac failure.
112
What is the Gustillo-Anderson classification of open fractures?
GUSTILLO-ANDERSON CLASSIFICATION:
```
class 1: wound < 1cm with minimal STI
class 2: wound 1-10cm with moderate STI
class 3: wound > 10cm with significant STI & devitalised
muscle
class 3a: periosteal cover is adequate
class 3b: periosteal stripping
class 3c: arterial injury needing repair.
```
Memory aid:
1-2-3-A-B-C , 3a, 3b, 3c )
wound size and soft tissue involvement
113
How would you categorise the 4 classes of haemorrage in a trauma patient?
which 6 physiological parametres would you use?
Class 1-4
```
class 1: 750mL / <15%
class 2: 750-1500mL 15-30%
class 3: 1500mL - 2000mL = 30-40%
class 4: >2000mL = > 40%
```
5 physiological parametres:
1x cns =
*slight anxious, mildle anxious, confused, confused& lethargic
1 x resp =
* 14-20, 20-30, 30-40, >40
1x renal =
*>30mL/hr, 20-30mL/hr, 5-20, negligible
3 x cvs =
HR
SBP
PULSE PRESSURE
114
List 6 Killer chest injuries to be identified on primary survey in a trauma patient.
ATTOM-C
```
Airway obstruction
Tension pneumothorax
Tracheobronchial tree injury
Open pneumothorax
Massive haemothorax
Cardiac tamponade
```
115
Give 2 contra-indications to performing an emergency thoracotomy?
1. thoracic injuries with no witnessed cardiac arrest
2. multiple blunt trauma
3. severe head injury
116
What are the indications for an emergency thoracotomy and how does this compare to the indications for performing an Emergency Thoracotomy in the ED?
INDICATIONS FOR EMERGENCY THORACOTOMY:
in penetrating thoracic injury
* unresponsive hypotension ( SBP < 70mmhg )
* traumatic cardiac arrest with previously witnessed
cardiac activity
in Blunt Thoracic injury
* unresponsive hypotension ( SBP < 70mmhg )
* rapid exanguination of blood from chest drain ( >
1500mL or > 200mL per hour for 2-4 hours )
INDICATIONS FOR EMERGENCY ED THORACOTOMY:
Penetrating Traumatic cardiac injury with cardiac arrest for < 10 minutes
Blunt Traumatic Thoracic injury with cardiac arreset < 15 minutes
117
Which is the most common incomplete spinal cord injury and what is the prognosis?
which spinal cord injury has the worst prognosis?
most common with best prognosis SCI =
central cord syndrome - neck hyperextension injury. motor loss greater in the upper than lower limbs
SCI with poorest outcome:
anterior cord syndrome -
anterior spinal artery deficiency.
Clinical features:
* loss of pain & temperature,
* preservation of light touch, proprioception and vibration
118
Give indications for an MRI of the cervical spine in an adult following blunt trauma to the neck?
1. severe pain >7/10 despite a normal CT
2. Neurological signs and symptoms referable to the c-
spine
3. suspicion of vertebral artery injury
119
A 10 year old boy has been struck by a motor vehicle. he has a femur shaft fracture. How will you immobilize the fracture?
Skin traction with approximately 10% of body weight applied.
Analgesia options:
```
oral ibuprofen
oral paracetamol
intranasal diamorphine 0.1mg/kg
IV morphine 0.1mg/kg
femoral nerve block
```
120
Explain the pathogenesis of brown-sequerd syndrome?
because the spinothalamic tract decussates but corticospinal and dorsal columns DONT decussate - you will find on examination
IPSILATERAL motor and proprioception loss
CONTRALATERAL loss of pain and temperature
Memory aid:
Sequerd decuSSates the Spinothalamic so loss of pain and temp on the opposite side
121
In a patient with compartment syndrome of the lower leg, what are the 4 compartments in the lower leg?
1. anterior compartment
2. lateral compartment
3. posterior superficial compartment
4. posterior deep compartment
122
A patient with facial bones fractures - what is the tear drop sign on facial bone xray indicate?
Herniation of orbital soft tissue into the maxillary antrum
123
In pre-tibial laceration - why would you not suture the wound?
Sutures will close skin under tension which will compromise blood supply of the flap of skin which can lead to skin necrosis.
```
# Apply the sterile strips with undue tension and with space between the tapes to allow the free drainage of exudate and blood otherwise haematoma can form and effect wound healing.
# Apply good toe to knee pressure bandage.
# Elevation of limb to prevent haematoma formation.
```
124
What are 4 Kanavels signs in Flexor tenosynovitis?
How will you manage the patient?
Kanavel's sign's:
1. fusiform/sausage swelling of the digit
2. finger held in slight flexion position
3. pain on palpation of the flexor compartment of finger
4. pain on passive extension of the finger
Treatment:
Urgent referal to Orthopaedic Team for IV antibiotics and surgical debridement ( Drainage, Irrigation, and Tenosynovectomy )
125
What is commotio Cordis?
Resource: ALS 6th edition
it is ACTUAL or NEAR cardiac arrest caused by blunt impact to the chest wall over the heart. a blow to the chest can cause VF. most commonly seen in contact sport. .
126
A patient with a deep laceration to Zone 2 of the neck.
What signs of SIGNIFICANT injury to structures in the neck would you look for in your examination? (1 mark)
RCEM Learning SAq
```
Expanding or pulsatile haematoma
Hypovolaemic shock or active bleeding
Haematemesis
Air bubbling
Airway compromise
Neurological deficit
```
This question was specific that it wanted signs of significant injury (ie needs you to do something about it). It could have asked for hard signs of vascular injury but as there is no consensus on what hard signs are, it didnt.
Other signs you would look for are:
```
Subcutaneous emphysema
Venous oozing
Minor haematemesis
Bloody saliva
Bleeding from mouth
Paresthesias
Non – pulsatile, non-expanding haematoma
Altered /hoarse voice
Dysphagia
Bruit
These are not signs of significant injury but they are signs of injury. This means they would be wrong in this circumstance.
```
127
What technique would you use to manage uncontrollable haemorage from a neck laceration?
RCEM Learning SAQ
Compress compressible haemorrhage – firm, direct pressure
Use haemostatic agents, including IV tranexamic acid, as appropriate
Do NOT blindly clamp – do NOT use clips or sutures.
Insert a foley catheter in the wound and apply gentle traction
This question is checking that you are happy managing uncontrollable bleeding. Although the bleeding is coming from the neck, there are no special techniques. Some people might be concerned applying pressure, and thus obliterating blood supply to the brain – but thats what needs to be done!
128
In a paediatric trauma patient - is a FAST scan recommended?
RCEM Learning SAQ
FAST scans in paediatric trauma have a low sensitivity in paediatric patients with the possibility of missing significant intra-abdominal injury
It is also possible that injuries are missed due to lower volumes of fluid in the peritoneal cavity in children
129
In paediatric abdominal trauma - when considering a CT scan of the abdomen and pelvis - what are your views on ALARA?
RCEM learning SAQ
The cancer risk of computed tomography (CT) in childhood is real, significant and is higher in younger ages (RCA, 2014).
When considering radiological imaging, exposure to ionising radiation should always be kept to a minimum and the as low as reasonably achievable (ALARA) principle should be adhered to (RCA, 2014).
130
In Dequervains tendinitis.
1. what tendons are involved?
2. Name and describe one specific manoeuver for diagnosing de Quervain’s tenosynovitis during your clinical examination of this patient.
1. De Quervain’s tenosynovitis is an inflammation of the tendons and tendon sheath at the radial aspect of the wrist.
The tendons involved are those used for a ‘thumbs up’ – APL & EPB( the 2 tendons that make up the lateral border of the anatomical snuff box )
the abductor pollicis longus and extensor pollicis brevis.
2. Finkelsteins test is when the examiner grasps the thumb and ulnar deviates the hand sharply. Sharp pain along the distal radius indicates de Quervain’s tenosynovitis is likely
131
What 3 patterns of injuries can you get with a pelvic fracture following an RTC?
1. Anterior-posterior (AP) compression (open
book/sprung pelvis) fracture
2. Lateral compression (windswept pelvis)
3. Vertical shear (results in bucket handle fracture)
132
Which structure is damaged when a patient is involved in an RTC sustains a pelvic fracture associated with hypotension?
RCEM Learning SAQ
Pelvic fractures associated with haemorrhage commonly involve disruption of the posterior osseous ligamentous complex
evidenced by a:
* sacral fracture,
* a sacroiliac fracture,
* and/or dislocation of the sacroiliac joint
(ATLS, 2018).
133
A patient with pelvic fractures and haemodynamic instability - what immediate actions will you take to manage the bleeding?
1. Applying a pelvic binder early. (0.5 marks )
e. g T-POD (trauma-pelvic orthodic device or SAM sling)
* provides stability and allows clot formation. This may prevent on-going haemorrhage and the often lethal trauma induced coagulopathy
2. Securing intravenous access, taking a cross-match blood sample, blood transfusion and giving tranexamic acid and analgesia (0.5 marks for one correct component listed)
(Total 1 mark)
134
In pelvic fractures with haemodynamic instability - what specific haemorage control techniques would you need to consider in this patient?
In the presence of intra-peritoneal blood:
*Emergency laparotomy
In the absence of evidence of intra-peritoneal blood:
* Angiographic embolisation may be used to stop arterial haemorrhage related to pelvic fractures.
* Preperitoneal packing is an alternative method to control pelvic haemorrhage when angioembolisation is delayed or unavailable (ATLS, 2018).
135
List 5 indications to perform an MRI Spine in a patient with low back bain?
Resource: NICE CG 88
if you suspect a diagnosis of:
1. Spinal malignancy
2. Spinal infection ( discitis )
3. Spinal fracture
4. Cauda equina syndrome
5. Ankylosing spondylitits
