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