The Shoulder

 

Examination
Look listen feel - and special tests on ALIEM here. 

The Rotator Cuff
There are muscles you should know - nice picture from medcomic here. 

Shoulder Dislocation
Prone patient. Push the inferior tip of the scapula medially and the superior part laterally. 

Posterior glenohumeral dislocation: applying traction to the arm in a position of 90° abduction and then externally rotating the limb

Consider intra-articular lignocaine for pain free relocation. 

More on RCEMLearning:
https://www.rcemlearning.co.uk/modules/shoulder-and-brachial-plexus/
https://www.rcemlearning.co.uk/reference/shoulder-and-brachial-plexus-injury/ 
https://www.rcemlearning.co.uk/modules/shoulder-injury-dont-miss-this-one/ 
https://www.rcemlearning.co.uk/modules/a-shoulder-to-cry-on/ 
https://www.rcemlearning.co.uk/modules/relocation-relocation-relocation/ 
https://www.rcemlearning.co.uk/foamed/september-2016-new-in-em/ 
https://www.rcemlearning.co.uk/modules/an-unexpected-rugby-injury/ 

Knees

Anatomical Terms: 
VaLgus - L for lateral... lateral part tight. So VaLgus = knock knees. 

Remember the ottawa knee rule
Remember to assess the patella tendon 

Patella dislocation:
Analgesia
Push medially
Extend leg 

RCEMLearning

https://www.rcemlearning.co.uk/modules/the-acutely-injured-knee/
https://www.rcemlearning.co.uk/modules/sounds-like-a-second-injury-in-the-knee/ 
https://www.rcemlearning.co.uk/modules/knee-ding-assistance/
https://www.rcemlearning.co.uk/modules/knee-aspiration-patient-needs-know/ 
https://www.rcemlearning.co.uk/modules/knee-goes-pop/ 
https://www.rcemlearning.co.uk/modules/the-knee-bones-connected-to/ 
https://www.rcemlearning.co.uk/modules/a-shocking-knee/ 
https://www.rcemlearning.co.uk/modules/a-good-knees-up/ 
https://www.rcemlearning.co.uk/modules/wobbly-knees/ 
https://www.rcemlearning.co.uk/modules/triple-trouble/ 
https://www.rcemlearning.co.uk/modules/netball-nasties/ 
https://www.rcemlearning.co.uk/modules/don-t-slip-up/ 
https://www.rcemlearning.co.uk/modules/mini-mono/ 
https://www.rcemlearning.co.uk/foamed/march-2018/ 
https://www.rcemlearning.co.uk/foamed/minor-injuries/ 
https://www.rcemlearning.co.uk/modules/clubbing-in-cambridge/ 
https://www.rcemlearning.co.uk/modules/ortho-induction/ 
https://litfl.com/patellar-dislocation/ 

https://www.aliem.com/splinter-series-locked-knee/
https://www.aliem.com/splinter-series-2-minute-knee-exam/ 
https://www.aliem.com/emrad-adult-knee-cant-miss/ 
https://www.aliem.com/emrad-knee/ 

Ankle Fractures

 

Stable:
Unimalleolar: isolated injury. Can remain stable. Stress-view may help

Unstable:
Bimalleolar: both medial and lateral malleolar. 
 Likely if lateral talar shift is present. 
 Deltoid ligament might be injured

Trimalleolar: also has a posterior tibia fracture 

Masisonneuve fracture: High fibular fracture with syndesmosis disruption. 

Stable fractures - immobilization, elevation and ice as tolerated 
 Cast or boot for 4- 6 weeks 

Unstable - reduction, spliting, ORIF 

Danis-Weber Classification of the fibula (in isolation)
Type A: stable. Distal to the syndesmosis. 
Type B: At the syndesmosis
  Undisplaced = stable = NWB in POP 
  Displaced = unstable 
Type C: Above the joint line
  Unstable 

Wounds

Assessment
Incision - precise
Lacerations - eg. skin torn
Contusion - bruise
Abrasion - scrape 

History features: Poor wound healing possible with smoking, cancer and diabetes. Don't close a wound after 6 hours unless on the face, as blood supply there is excellent 

Cleaning
Irrigation does not mean pouring saline over the wound - you must use some force to decrease the bacterial count. 

Animal bites especially cat bites penetrate more deeply 

Old blood must be removed

Wounds healing stages:

Haemostasis - coagulation, platelet aggregation

Proliferation - epithelization

Inflammation- macrophages, neutrophils, granulocytes

Recognising wound failure to heal:

Dry wound bed - needs moisturiser, and moisture retaining dressing

No change in size or depth for 2 weeks - pressure or trauma to the area, poor nutrition, infection. Make sure patient assessed for local or systemic problems. 

Increase in size or depth of wound - may need debridement, may have infection. 

Necrosis - may be due to ischaemia. Needs debridement. 

Pus - maybe autolytic or enzymatic debridement, or infection. 

Tunnelling - protect pressure sores. 

Wound drainage descriptors

Serous - clear or light yellow, thin and watery
Sanguineous - red (with fresh blood), think
Serosanguineous - pink to light red, thin, watery
Purulent - creamy yellow, green, white or tan. Thick and opaque.

Wound Ulcers
Venous - ankle to midcalf, especially medial. Irregular, dry, crusted or moist slightly macerated borders. Need to control the oedema with gravity, compression bandages - ?Unna's boot. 

Arterial - tips of toes, corners of nail beds on toes. Well-demarcated. Pale and dry wound base. Need vascular review. Protect the wound and keep it dry. 

Lymphatic - arms, legs, ankles. Limb elevation

Dependent rubor - chronic arterial insufficiency. 

Further Reading 

https://www.rcemlearning.co.uk/foamed/paediatric-wound-management/ https://twitter.com/jamesnchlsn/status/1299276919184252928?s=09
https://www.rcemlearning.co.uk/reference/soft-tissue-and-skin-injury-descriptions-in-the-emergency-department/
https://www.rcemlearning.co.uk/lessons/context-126/
https://www.rcemlearning.co.uk/foamed/boxing-and-facial-injuries/ https://calgaryguide.ucalgary.ca/AcuteWoundHealing

Colles Fractures

After an embarrasing handover situation, it turns out that there are guidelines for when to pull Colles fractures. I can't believe I didn't know that!

Anyway, there are normal angles to know. If the fracture doesn't meet these - it needs pulling!

Elbow Fractures

Radiographs

 

1.    Anterior and posterior fat pads
 - If the anterior is elevated treat it as abnormal
 - If there is a posterior fat pad at all, treat as abnormal as 75% have fractures.

2.    Anterior humeral line
 On the lateral, draw a line down the anterior surface of the humerus. 1/3 of the capitellum should lie above the line.

3.    Radiocapitellar line
Draw a line through the centre of shaft of radius on either view. It should cut through capitellum on AP + lateral views.

4.    Ossification centres

As well as the bones, children have an added layer of complexity because of the ossification centres. The ossification centres tend to appear at these ages NOT fuse at these ages.

5.    Radial head, olecranon, distal humerus

Supracondylar Fractures: Ortho or # Clinic

Remember a displaced anterior fat pad, any posterior fat pad or an abnormal anterior humeral line are indications of an undisplaced supracondylar fracture (or a radial head fracture) and should be treated as such with either an above elbow POP or a broad arm sling if pain is not a significant feature.

Brachial artery injury in 5-10% Type II and Type III injuries. 

Radial (~25%) and ulnar (~15%) nerve damage unlikely. 60% of median nerve damaged. Mostly just motor branch, damaging intrinsic hand muscles so can't flex thumb IP joint.

In your clinical examination include:

-  a ‘pinch’ (medial nerve / AION),

-  ‘thumbs up’ (radial nerve), and

-  ‘give me four’ (finger abduction against resistance – ulnar nerve).

 

Complications include:

• Cubitus varus (gun stock deformity)
  
• Malunion and stiffness
  
• Myositis ossificans
  
• Nerve injury (most commonly median nerve)
  
• Brachial artery (due to stretch and posterior displacement)
  
• Volkmann’s ischaemic contracture (due to compartment swelling)
   

Olecranon Fractures: Ortho or #Clinic
Manage conservatively with POP. If significant displacement, discuss with orthopaedics.

Elbow dislocation: Ortho



Elbow dislocations are surprisingly common, comprising 10 - 25% of all elbow injuries
The radial head may dislocate from the capitulum of the humerus on its own or in combination with dislocation of the ulna from the trochlea. The latter is usually straightforward to identify, but radial head dislocations may be more subtle - check the radiocapitellar line.

Radial Head: Fracture Clinic
These injuries usually follow a fall onto an outstretched wrist or direct trauma. Radial head fractures usually occur in adults and account for 30% of all adult elbow fractures. It is the second most common elbow fracture in children. Examination may reveal local bruising and swelling. In some cases pain may only be evident with palpation of the radial head during passive forearm pronation. Elbow extension is usually restricted. Assessment of the wrist should be performed due to the possibility of an Essex-Lopresti fracture-dislocation, consisting of a comminuted radial head fracture with subluxation of the distal end of the ulna.

Undisplaced fractures can be managed with a collar and cuff sling and orthopaedic outpatient follow-up. Radial neck fractures: greater than 20° of angulation in the adult or 30° in the child requires reduction.

Medial epicondyle avulsion injury: Fracture Clinic
These injuries tend to occur in adolescents due to valgus stress during a fall on an outstretched hand. There may be associated ulna nerve damage and sometimes dislocation. Undisplaced avulsions can be managed conservatively while displaced fragments should be referred for reduction.

Pulled elbow: No follow up
The radial head dislocates from the annular ligament. In 50% of cases there is no history of a pull on the arm. The x-ray is normal and therefore not necessary if clinical suspicion is high prior to attempted manipulation.

There are 2 methods for reduction;
1. Supination of the forearm followed by flexion of the elbow
2. Hyperpronation of the wrist followed by flexion of the elbow - thought to be less painful. Elbow can start at 90, or be extended. Position one hand with the thumb over the radial head.

References
http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_upper_limb/elbow_fracture_x-ray.html

http://www.enlightenme.org/knowledge-bank/cempaedia/elbow-injuries
http://www.enlightenme.org/learning-zone/pinch-me-thumbs-and-give-me-four
http://lifeinthefastlane.com/elbow-dislocation/
http://academiclifeinem.com/tricks-of-the-trade-nursemaid-elbow-reduction/
http://radiopaedia.org/articles/elbow-dislocation
http://journals.lww.com/em-news/blog/theproceduralpause/pages/post.aspx?PostID=8
http://emupdates.com/2009/09/19/emcard2054/
http://radiopaedia.org/articles/pulled-elbow-syndrome
http://emergencyeducation.net/1/post/2014/03/pulled-elbow.html
http://bestbets.org/bets/bet.php?id=123
http://pedemmorsels.com/nursemaids-elbow-feel-like-mr-miyagi/
http://www.ozemedicine.com/wiki/doku.php?id=elbow_pulled
http://academiclifeinem.com/tricks-of-the-trade-nursemaid-elbow-reduction/
http://radiopaedia.org/articles/supracondylar-fracture
http://emrems.com/tag/supracondylar/
http://lifeinthefastlane.com/bone-and-joint-bamboozler-007/
http://radiopaedia.org/articles/supracondylar-fracture-classification-1
http://radiopaedia.org/cases/supracondylar-process-of-humerus-1
http://radiopaedia.org/articles/olecranon-fractures-1
http://radiopaedia.org/cases/olecranon-fracture-2
http://radiopaedia.org/cases/olecranon-and-radial-head-fracture
http://radiopaedia.org/articles/radial-head-fractures

Forearm Fractures

It's difficult to separate the radius from the ulnar as you progress up the forearm but isolated fractures can occur. Forearm fractures frequently seen in school aged children after a fall.  Adult fractures may be markedly displaced with little or no bony contact between the fragments. ORIF needed

Isolated ulnar fracture
Rare but can happen if the arm is in a defensive position, as in martial arts. POP. If displaced or angulated, for ORIF.

Isolated radial fracture
Very rare

Monteggia Fracture

    

Ulnar fracture and radial dislocation. You need to look carefully at the radiocapitella line. If it does not transect the middle of the capitlellum, there is a radial head dislocation. Occurs by forced pronation of the outstretched forarm. Urgent ORIF needed.

The Hume fracture is related - anterior dislocation of the radial head + olecranon fracture.

Galeazzi - radial fracture, dislocation at distal radioulnar joint. This occurs in teenagers and is very rare.

http://www.pemcincinnati.com/blog/fracture-fridays-monteggiazzi/

Remember by:
" MUGR (Mugger): Monteggia Fracture = Ulnar fracture with radial head dislocation; Galeazzi Fracture = Radius fracture with DRUJ dislocation."