ABSTRACT
Te ta
nu ss
ta tu
s (C
on tin
ue d)
• Sc
ap ho
id fr
ac tu
re •
Te nd
er o
ve ra
na to
m ic
al sn
uff bo
x •
Pa in
a nd
sw el
lin g
in ra
di al
a sp
ec t
of w
ris to
ve rs
ca ph
oi d
tu be
rc le
an
d on
th um
b te
le sc
op in
g •
Po or
g rip
• An
al ge
sia •
Fu tu
ra w
ris ts
pl in
to rp
la ste
ro fp
ar is
• Re
vi ew
in 1
d ay
sw ith
fo llo
w -u
p X
-r ay
(n ot
a lw
ay sv
isi bl
e in
iti al
ly )
• C
om pl
ic at
io n:
a va
sc ul
ar n
ec ro
sis :
• Su
sp ec
ti fp
er sis
te nt
p ai
n/ te
nd er
ne ss
at
fo llo
w -u
p •
Re qu
ire sb
on e
sc an
if fo
llo w
-u p
X -r
ay
no rm
al a
nd st
ill c
lin ic
al su
sp ic
io n
of
fra ct
ur e
• R
ad ia
lh ea
d/ ne
ck
fra ct
ur e
• El
bo w
e ffu
sio n
• In
ab ili
ty to
fu lly
e xt
en d
an d
fle x
el bo
w •
Te nd
er ne
ss o
ve rr
ad ia
lh ea
d on
pa
lp at
io n
pr on
at io
n/ su
pi na
tio n
• An
al ge
sia •
C ol
la ra
nd c
uff •
Im m
ob ili
ze in
p la
ste ro
fp ar
is if
di sp
la ce
d an
d el
ev at
e in
h ig
h ar
m sl
in g
• Fr
ac tu
re c
lin ic
• M
ay n
ee d
se da
tio n
an d
m an
ip ul
at io
n or
in
te rn
al fi
xa tio
n if
di sp
la ce
d D
• C
la vi
cl e
fra ct
ur e
• Te
nd er
ne ss
o ve
rc la
vi cl
e •
C he
ck n
eu ro
va sc
ul ar
st at
e an
d ov
er ly
in g
sk in
fo r t
en tin
g/ w
ou nd
s •
Ex am
in e
fo ra
ss oc
ia te
d sp
in al
in
ju rie
s
• An
al ge
sia •
Br oa
d ar
m sl
in g
• Fr
ac tu
re c
lin ic
(r ar
el y
ne ed
fi xa
tio n)
HIP FRACTURE
• Pain, exacerbated by: • Weight bearing • Movement of affected hip; flexion, extension, internal and external
rotation
• Patients may complain of knee pain (referred to as pain via obturator nerve)
• Bloods: • FBC: baseline Hb in case blood transfusion is necessary • U&E: assess renal function (many elderly patients are dehydrated) • Glucose: to exclude cause of fall if unknown (hypoglycaemia) • Clotting profile: to assess bleeding risk and in preparation for theatre • Group and save • Cross-match 2 units (prepare patient for theatre)
problems (such as a concurrent chest infection)
the morning
FEMORAL SHAFT FRACTURE
• High-energy trauma: • Fall from height • Crush injuries • Severe road traffic accident
open fracture • Multiple injuries:
• Complications: • Hypovolaemic shock (severe blood loss) • Cardiogenic shock (chest injuries: pneumothorax) • Compartment syndrome
• Plain radiograph of hip and full length femur: two views (anterior-posterior and lateral)
more proximal • Immobilize in Thomas splint, then order plain radiograph of femur • Refer to orthopaedics for repair (commonly intramedullary nail)
ANKLE FRACTURE
• Plain radiograph of ankle according to Ottawa ankle rules (see MICRO-print)
• Talar shift (gap between medial mallelous and talus) requires orthopaedic intervention
immediately under sedation/analgesia prior to radiology to prevent neurovascular compromise
compression bandage • Larger fractures: immobilization/NWB and orthopaedic referral • May require open reduction and internal fixation
Immediate • Open fracture • Skin loss or compromise • Nerve palsy • Vascular injury: ischaemia
• Bleeding • Hypovolaemic
shock
Early • Compartment syndrome • Infection
• DVT • Fat embolus
Late • Delayed union and non-union
• Joint stiffness • Chronic osteomyelitis
• Poor mobility
COMPARTMENT SYNDROME
• Increased pressure in a muscle compartment due to bleeding, oedema or infection leading to reduced blood flow and further increased pressure and ischaemia
• Most common: • Lower leg (tibial fractures) • Forearm
• Less common: • Hand • Foot • Upper arm
− Fractures − Crush injuries − Compartment syndrome
• Amputation may be needed if the limb cannot be saved • Consider palliative care
COMMON NERVE INJURIES
each other
SHOULDER
Spine • Vertebral wedge compression fracture
• Thoracic back pain • Follows minor injury • Loss in height • Kyphotic spine deformity
Wrist • Colles’ fracture • (See upper limb fractures) Hip • Neck of femur fracture • (See hip fractures)
• Confirm neurovascular status of upper limb: − Distal pulses − Sensation in region of axillary nerve (regimental badge)
• Plain radiograph of shoulder (two views): • Anterior:
− Humeral head lies anterior and inferior to glenoid • Posterior:
− ‘Light bulb’ sign − Abnormal symmetry between humeral head and glenoid
ANKLE
sterile saline and dressing
positioning of the foot • Re-examine for distal sensation and pulses • Urgent referral to orthopaedics
SOFT TISSUE INJURY
13.8 KNEE INJURIES Ottawa knee rules can be used to decide whether radiographic imaging is required or not: • Inability to weight bear immediately at time of injury or unable to take four
steps in the ED • Fibular head tenderness • Inability to flex knee to 90° • Age >55 years old • Isolated patella tenderness
RUPTURED ANTERIOR CRUCIATE LIGAMENT
• Conservative: • Rest • Ice • Elevation
MENISCAL TEAR
locked knee
• Bladder/bowel changes • Unexplained weight loss • Thoracic or non-mechanical • Age <16 and >50 years • Bilateral leg pain with neurological symptoms • Night pain • History of active or previous malignancy • Perianal paraesthesia • Expansile mass • Chronic steroid use • Intravenous drug use • Immunocompromise • Recent or active infection
• Blood tests: • FBC: raised WCC in infection and/or inflammation • U&E: deranged in renal colic • Calcium levels: raised in bony destruction e.g. myeloma • Inflammatory markers: raised ESR and CRP
CAUDA EQUINA SYNDROME
• Characteristic pattern of neurological and urogenital symptoms due to acute compression of lumbar-sacral nerve roots below the conus medullaris where the spinal cord terminates
CORD COMPRESSION
• Lower motor neurone (LMN) signs at level of lesion: • ↓ Reflexes • ↓ Tone • Fasciculations
• Upper motor neurone (UMN) signs below lesion: • Spasticity • Weakness • Hyper-reflexia • Upgoing plantars
• Immediate referral to orthopaedics/neurosurgeons for urgent decompressive surgery within less than 24 h of symptom onset
• Permanent neurological damage: • Paraplegia • Incontinence • Weakness • Impotence
MECHANICAL BACK PAIN
• Pain: • Lower back • Exacerbated on movement • ± Down one leg
AETIOLOGY
SEPTIC ARTHRITIS
• Bloods: • FBC: ↑ WCC
• Joint aspiration: • Microscopy for crystals and cell count • Gram stain for organisms • Culture
ACUTE GOUT
• Acute inflammatory arthritis with elevated serum uric acid that crystallizes and is deposited into joints
• Bloods: • FBC: raised WCC in inflammation and infection • U&E: check renal function • Inflammatory markers: raised ESR and CRP • Serum uric acid levels (levels may be normal or low in acute attack)
