MSK, MVA, Trauma

What type of dislocation is Nursemaids elbow? -Epidemiology?

*Radial Head Subluxation*: annular ligament of the radius displaces into the radiocapitellar articulation Girls > boys, 6 mos - 3 yrs

*Secondary* Survey of a Trauma pt: History What does the *AMPLE* mnemonic stand for?

Allergies Meds PMHx Last Meal/drink Events surrounding it (HPI)

Whats the MC source of generalized trauma in the ED? Whats the Goal of trauma mgmt?

Secondary to MVA's/MVC's Goal of Trauma mgmt: 1) to rapidly identify life-threatening injuries 2) to initiate adequate supportive therapy 3) to efficiently orgnize either definitive therapy OR transfer to a facility that provides it

Pics of the following reduction tecnqiues (explain them too) Stimson Captain Morgan Allis Whistler

Stimpson: (lay prone like Jessica Simpson) -Push forward anteriorly -Put traction anteriorly -externally rotate (cuz rember the dislocation is internally rotated) Captains: Pull up and push down on ankle for traction Whistler: Use other knee as a fulcrum to pull anteriorly on hip.

What splints should you do for an Ankle Trimalleolar fx?

Sugar Tong & Posterior Splints

Shoulder Dislocation -define -etiology -S/S -Imaging

The gumeral head is displaced *anterior to glenoid* & *inferior to coracoid* Etiology: Trauma or awkward reach S/S: *"squared off"* shoulder. Imaging: AP & Lateraly & "Y-view" (axial view) -Check for "*ball on tee*" on axial view

*Secondary* Survey of a Trauma pt: History -What do you get?

AMPLE Mechanism -MVA: location in vehicle, location of impact, roll-over, extrication, LOC, restrains (SB, AB, car seat), other passesnger's injured -Motorcycle/Bicycle: helmet, location of impace Timing: how long ago, length of exposure (hot, cold, smoke) Proboking circumstances: seizure, alcohol, syncope, suicide PMH: including allergies, meds, surgery, *Ask about Tetanus*!!!

Circulation: What are signs to recognize shock (3)?

AMS Cyanosis or ashen gray Thready pulse, hypotension

*Primary Survey* of a Trauma pt -What are the ABCDE's?

Airway with attention to *cervical spine control* Breathing Circulation Including evaluation/control of hemorrhage Disability Exposure & Environmental Control

Primary Survey of a Trauma pt: Breathing -Steps/considerations

Adequate breathing requires adequate lung function, chest wall & diaphragm functioning. -Addition of patent airway = *ventilation* Assess: Chest wall expansion, flail chest, ecchymosis, STS, wounds Ausculation: for adequate air movement & adventitious breath sounds (wheezing, rhonchi) Immediate attention to: -tension or open pneumo -flail chest (≥2 rib fxs) -hemothorax

Complications of Hip dislocations

Avascular necrosis Sciatic nerve injury

Which nerve should you check for sensation in a shoulder dislocation?

Axillary nerve!!

*Secondary* Survey of a Trauma pt: What do you assess for in: Back Pelvis Extremities Neurologic

Back: spinous process TTP or deformity, wounds Pelvis: AP or lateral compression pain, perineum/urethra/rectume/vagina Extremities: *reassess vascular status*, palpate for signs of injury Neuro: sensory/motor exams, DTR's, Babinski

Trauma: Gunshot Wounds (GSW) -pathophys of what happens

Bullet penetration (1) crushes & destroys the tissue in its path, creating a permanent cavity & (2) simultaneously imparts a shock wave that radiates outward from its path -shock wave causes tissue to *stretch & shear outward*, followed by subsequent *collapse & reverberation* Tissue density affects where it travels & thru which cavities Hx of incident is frequently inaccurate

*Secondary* Survey of a Trauma pt: *NEXXUS Criteria* for C-spine imaging

Cervical spine imaging is necessary if *any* of the following are present: -Midline C-spine TTP -Altered LOC -Focal neurologic deficits of the extremities -Intoxication -Painful, distracting injury(s) Plain films for low risk, CT for moderate risk

GSW -What assessment is required? -what do GSW's to the head require? -what does an unstable pt with possible thoracic or abd. involvement need?

Complete body assessment is required. All wounds should be documented. Most exit wounds are bigger than entry GSW's to the head: require *intubation & CT scan* Untable pt w thoracic or abd involved: emergency exploratory laparotomy once potential lung inj. is addressed

Whats a Colles fracture?

Distal radius *metaphysis* fx w *dorsal angulation*

Primary Survey of a Trauma pt: *Airway* -steps/considerations

Effective verbal communication is a good sign the airway is intact Stridor dysphonia usually indicates airway involvement Assess oral cavity for swelling or signs of burn/smoke inhalation Assess neck for signs of trauma: ecchymosis, edema, lacerations, or tracheal shift If intubated pre-arrival → assess ETT placement & security *NG tube placement after intubation* Maintain C-spine until cleared (*remember C-spine is a part of airway*)

Colles fracture -Etiology -S/S -Imaging

Etiology: FOOSH S/S: "dinner fork" appearance (of the wrist when looking lateral) Imaging: Wrist lateral view most useful

Smith Fx -Etiology -S/S -Imaging

Etiology: Fall on flexed hand, usually backwards S/S: "*garden spade*" deformity Imaging: Lateral wrist xray is key

Hip Dislocation -Etiology -S/S -Imaging

Etiology: Fall on flexed knee, MVA, prosthetic S/S: Adducted, shortened and *internally rotation* Imaging: AP, lateral

Trauma - Pelvic Fx -Etiology -Complications

Etiology: MVA, motorcycle or pedestrian trauma, fall from height Complications -Hemorrhage (*usually venous* -- remember Venous → penis!) -Concurrent injury of intraabdominal organs (liver, spleen, kidney, bladder), spine or hip

Nursemaids Elbow -Etiology -S/S -Imaging

Etiology: Pull on extended arm or fall & twist (e.g. taking a jacket off of a kid too quickly) S/S: *Adducted, semi-flexed, non-moving arm* Imaging: None unless forceful trauma/swelling (xray)

Knee dislocations -etiology -S/S -Imaging

Etiology: trauma → ligamentous disruption S/S: Visible or reported deformity Imaging: AP & LAteral, *Sunrise view*

Patella Dislocation (it displaces over the *lateral* condyle) -etiology -S/S -Imaging

Etiology: twisting injury. Knee extended. M>W S/S: Usually semi-flexed. Visible patella malalignment Imaging: Usually *Post-reduction* image sufficient (becuz you can obviously see how its misaligned before)

Primary Survey of a Trauma pt: Exposure & Environmental Control -Steps/considerations

Expose everything for thorough eval (e.g. blood from urethral meatus) -Dont forget the back!!! *Log roll to maintain C-spine* Cover pt after exam complete and maintain warm environment Warm IV fluids if indicated Re-Evals frequently: -V/S -Physical exam

*Secondary* Survey of a Trauma pt: What do you assess for in HEENT C-Spine Chst Abdomen

HEENT: scalp STS/lacs, Battles sign/raccoon eyes, CSF leak (clear rhinorrhea), dental injuries C-Spine: midline TPP, STS or deformity, See *NEXUS criteria* Chest: palpate sternum, clavicles, & ribs ofr TTP deformity, crepitus Abdomen: TTP, distention, rebound, guarding, ecchymosis, wounds

GSW: -tx if they are hemo unstable? -Indications for abx

If hemo unstable: plenty of fluids and/or blood ABX: for *all GSW's* EXCEPT extremity injuries without fracture or gross contamination & not related to a shotgun.

Ortho Clinical Decision Rules -Ottawa Knee Rules to indicate an xray

If ≥1 of the following, the xray indicated: Patella Tenderness Fibular head tenderness Inability to flex 90 degrees Inability to bear wt Age > 55

Tx of Pelvic Fx with *Hemorrhage*

Immediate application of *Pelvic binder* if: -hemodynamically unstable -positive FAST in setting of pelvic trauma *Interventional* radiology to identify & embolization of bleeding source Pelvic packing may be necessary Aggressive fluid & blood administration Eventual surgical fixation may be required

Finger IP Joint Dislocations are describes as dorsal, volar, or lateral. -Which joints are MC? -etiology -S/S -Imaging

Joint MC: *PIP* > DIP (MCP's are hard to dislocate & more likely to me a fx) Etiology: usually hyperextension, fall, ball S/S: Visible deformity at joint -inability to flex/etend Imaging: Minimum 2 view to look for fx's

What are the 6 spots of the E-FAST exam?

L & R Chest (in B-mode for lung sliding) RUQ LUQ Heart (*subxiphoid*) Pelvis (Transverse)

Trauma W./u -labs -diagnostics

Labs: CBC, CMP, coag's DAU-8 (toxicology), UA/Pregnancy, type & screen EKG: arrhythmia, MI, tamponade Radiology: C-spine, CXR, pelvis U/S: FAST bedside exam CT: head, chest/avd/pelvis with *IV contrast* only

Smith Fracture - what is it?

Less common than colles. AKA "Reverse Colles" -- there is *volar angulation* of the distal radius fx

Cardiac tamponade EKG findings

Low voltage electrical alternans

Mandlible can have anterior, posterior, lateral, or superior dislocation. -which is MC? -etiology? -S/S? -Imaging?

MC mandible dislocations: *Anterior & bilateral& MC Etiology: trauma (e.g. punch), yawning, hypermobility syndrome. S/S: TMJ pain, malocclusion (teeth not lined up or cant close mouth) Imaging: *Panorex* or *Mandible*

Elbow Dislocation -Which type is MC? -Frequently ass'd with what? -Etiology -S/S -Imaging

MC → *Posterior MC* Frequently ass'd with fractures Etiology: Fall on outstretched hand (FOOSH) - gives a posterior dislocation S/S: Elbow helf in *45° flexion* -assess distal N/V status Imaging: AP & Lateral views

Patella Dislocation -Method of reduction -sedation -Disposition

Method of reduction: Extending leg while applying valgus force to patella -usually quick w *no sedation needed* Disposition: Immobilizer. Crutches for partial wt bearing. Ortho referral -Quadriceps strengthening exercises. -Rarely surgical intervention

Ankle Trimalleolar Fx -Method of reduction -Sedation? -Disposition

Method of reduction: Opposing forces to heel & lower leg IV analgesics &/or conscious sedation needed (three bones broken is gonna hurt) Disposition: *Sugar tong & posterior splints* then *Surgery* (cuz they're gonna wanna screw it together)

Shoulder Dislocation -Method of reduction -Analgesia -Disposition

Method: -traction-countertraction -*Milch* (think Milchlaughlin -- this is internal rotation & flexion) -"Kocher" -Scapular manipulation Sedation is normally not needed as long as pt isnt anxious or nervous Disposition: *immobilizer x1-4 wks* then PT

Elbow dislocation -reduction method -sedation? -Disposition & when can they use ROM again?

Method: *Distal traction* or *interlocking hands* Sedation necessary Disposition: Splint in 90° w/ a sling. *ROM in 1-2 wks*

Colles fracture -Method of reduction (& indications for reduction) -sedation? -Disposition

Method: *inline traction*→ push distal radius volarly -or reduction indicated if >20° angulate Sedation: Hematoma block (lidocaine) and/or sedation needed Disposition: Volar splint, sling, ortho F/U

Smith Fx -Method of reversal? -Disposition

Method: Same as colles but pressure volar to dorsal Disposition: Splint, ortho f/u

Finger IP Jt dislocations -Method of reversal (if dorsal vs. if volar) -Sedation? -Disposition (what type of splint & how long?)

Method: Traction (need to pull) -if dorsal: hyperextension -if volar: hyperflexion Sedation: Digital block Disposition: Aluminum splint 1-2 wks

Knee dislocation -Methods of reduction -Disposition

Methods: Traction & ant. or post. manipulation -usually easy secondary to joint derangement Disposition: Knee immobilizer. -*Post-reduction arteriography to r/o popliteal injury*

What GSC level should you intubate

if GCS < 8 then intubate

Complications of Pelvis Fracture: Hemorrhage (usually venous) -Whats the normal pelvic volume (it expands with unstable fx) -Normal size of retroperitoneal space (L) -what are 2 other potential spaces

Normal pelvic volume: *1.5 L* *Retro*petrioneal space: *5 L* Peritoneum or thighs also potential spaces

Hip Dislocation -which is MC → posterior or anterior?

Posterior 80-90% Anterior is only 10% i.e. most are posterior dislocations

Knee dislocation - which is MC? (anterior, posterior, lateral)

Posterior MC (spontaneous reductions may occur)

Trauma - Pelvic fracture: Whats an open-book fracture? & when should you suspect it?

Pubic symphysis widening or rami fracture *PLUS* *Posterior pelvic fx* or ligamentous injury Suspect when pubic symphysis widening *>2.5 cm*

Primary Survey of a Trauma pt: Circulation -Steps/considerations

Recognize shock External hemorrhage control with *direct pressure* Suspect internal hemorrhage w S/S of shock Ensure adequate vascular access

Hip dislocation -Reduction methods -Disposition (what braces should they use? How long non-wt bearing?

Reduction methods: -Allis -Stimson -Captain Morgan -Whistler Disposition: Abductor pad or knee immobilizer, admit, non wt bearing for 2-3 wks -mat require OR reduction or open surgical reduction

Nursemaids elbow -method of reduction -sedation -Disposition

Reduction: *Hyperpronation w elbow at 90°* -Supination then flexion is less successful Sedation: None Disposition: Full use should return quickly -Avoid pulling/twisting mechanism (have them reach to grab a toy to make sure its back in place)

Primary Survey of a Trauma pt: Disability -Steps/Considerations

Refers to neurologic evaluation (*Glasgow coma scale*) -assesses *Eye opening*, *Verbal response*, *Motor response* AMS may be secondary to shock of head injury Pupil size and reactivity Lateralizing signs suggestive of CVA or spinal injury

Dislocations -How are they described? -What type of anesthesia/analgesia do they need before relocating? -what makes them more difficult to relocate after time has passed? -What do you always do post-reduction

They are described in terms of distal bone in relation to proximal bone Most require some degree of anesthesia or analgesia: local anesthetic, nerve block, parenteral analgesics, or conscious sedation The longer the joint is dislocated → the more difficult it is to relocate d/t *muscle spasm* Always get a post-reduction xray & perform neurovasc check.

What is *Mortise widening* on a trimalleolar fracture

This is a lateral malleolus fx with subluxation of the talus (the talus slid over and broke the lateral malleolus) It puts widening between the talus and the tibia

*REBOA* (Resusciative Endovascular Balloon Occlusion of the Aorta) -What is it?

This is temporary hemorhage control of the chest, abd, and pelvis

Ankle Trimalleolar Fractures-What is this a fracture of (3)

Tibia malleoli (medial & posterior) (in the picture - the posterior tib fx is behind so you'd need a lateral view) Fibula malleolus

Salter-Harris Classification of a Fracture -Type I-IV

Type I: Thought the growth plate (straight across) Type II: Through growth plate & metaphysis (*MC*) Type III: Through plate & epiphysis Type IV: Through all 3 Type V: Crush injury of growth plate

Mandible Dislocation -Method for reduction -Analgesia? -Disposition

Wrap thumbs with guaze Intraoral pressure down & back Analgeisa: *Conscious sedation* required for most -*Intra-articular lidocaine* can help Disposition: soft diet x2wks. Oral surgery for nerve deficit.

Ankle Trimalleolar fx -Etiology -S/S -Imaging

etiology: Stepping into a hole, MVC, tackle (soccer) S/S: Moderate swelling & deformity Imaging: *AP, Lat, & Oblique* (remember these *3* views cuz its *Tri* fx)

Elbow dislocation distal traction

or you can do interlocking fingers -- where you interlock fingers with the pt and slide your forearms foreward