Clinical Excellence Series Volume V an Evidence-Based Approach to Traumatic Emergencies
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Broken Bones: Common Pediatric Lower Extremity Fractures—Part III
10173-06_ON2506-Hart.qxd 11/9/06 3:51 PM Page 390 Broken Bones: Common Pediatric Lower Extremity Fractures—Part III Erin S. Hart ▼ Brenda Luther ▼ Brian E. Grottkau Lower extremity injuries and fractures occur frequently in young usually have pain with hamstring stretching and hip flex- children and adolescents. Nurses are often one of the first ion/abduction). Patients also frequently demonstrate an healthcare providers to assess a child with an injury or fracture. antalgic gait and have pain during their activity or sport. Although basic fracture care and principles can be applied, An anteroposterior radiograph of the pelvis usually reveals nurses caring for these young patients must have a good under- the avulsed fragment. Comparative views of the contralat- standing of normal bone growth and development as well as eral side are often helpful in confirming the diagnosis and avoiding further unnecessary advanced imaging studies. common mechanisms of injury and fracture patterns seen in This injury is usually treated symptomatically and often children. Similar to many of the injuries in the upper extremity, involves rest, application of ice, and relaxation of the in- fractures in the lower extremity in children often can be treated volved tendon (O’Kane, 1999). Conservative treatment of nonoperatively with closed reduction and casting. However, this pelvic avulsion fractures is usually successful. Crutches are article will also review several lower extremity fractures that often needed for several weeks to reduce symptoms and frequently require surgical intervention to obtain a precise rest the extremity involved. Complications following pelvic anatomical reduction. Common mechanisms of injury, fracture avulsion fractures in children are rare, and most patients patterns, and current management techniques will be discussed. -
Knee Injuries
6/11/2019 Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e Chapter 274: Knee Injuries Rachel R. Bengtzen; Jerey N. Glaspy; Mark T. Steele ANATOMY The knee consists of two joints, the tibiofemoral joint and the patellofemoral joint. Within the tibiofemoral joint, the distal femur (comprised of the medial and lateral femoral condyles) articulates with the proximal tibia (comprised of the medial and lateral tibial condyles) (Figure 274-1). The medial and lateral menisci are situated between the articular surfaces, and the menisci provide cushion, lubrication, and resistance to articular wear (Figure 274-2). In the patellofemoral joint, the patella articulates with the distal femur along the anterior depression called the patellofemoral groove during flexion and extension of the knee. The patella is stabilized by the patellar tendon and medial retinaculum. FIGURE 274-1. The supracondylar and condylar areas of the femur, and the medial and subcondylar areas of the tibia. 1/29 6/11/2019 FIGURE 274-2. Ligaments of the right knee joint. The articular capsule and the patella have been removed. 2/29 6/11/2019 There are four ligaments in the knee: the anterior cruciate ligament, the posterior cruciate ligament, and the medial and lateral collateral ligaments (Figure 274-2). These ligaments provide strength and stability to the knee. The posterior aspect of the knee, the popliteal fossa, contains the popliteal artery and vein, the common peroneal nerve, and the tibial nerve (Figure 274-3). FIGURE 274-3. Posterior knee: popliteal fossa anatomy. 3/29 6/11/2019 CLINICAL FEATURES Determine the mechanism of knee injury and review all prior orthopedic injuries or surgical procedures. -
Treatment of Large Avulsion Injury in Perianal, Sacral, and Perineal
Hu et al. BMC Surgery (2019) 19:65 https://doi.org/10.1186/s12893-019-0529-1 RESEARCH ARTICLE Open Access Treatment of large avulsion injury in perianal, sacral, and perineal regions by island flaps or skin graft combined with vacuum assisted closure Fu Xing Hu1†, Xiao Xuan Hu2†, Xue Lin Yang1, Xing Hai Han1, Yong Bo Xu3, Kun Li3, Li Yan3*† and Hai Bo Chu3*† Abstract Background: Traumatic avulsion injuries to the anus, although uncommon, can result in serious complications and even death. Management of anal avulsion injuries remains controversial and challenging. This study aimed to investigate the clinical effects of treating large skin and subcutaneous tissue avulsion injuries in the perianal, sacral, and perineal regions with island flaps or skin graft combined with vacuum assisted closure. Methods: Island flaps or skin graft combined with vacuum assisted closure, diverting ileostomy, the rectum packed with double-lumen tubes around Vaseline gauze, negative pressure drainage with continuous distal washing, wounds with skin grafting as well as specialized treatment were performed. Results: The injuries healed in all patients. Six cases had incomplete perianal avulsion without wound infection. Wound infection was seen in four cases with annular perianal avulsion and was controlled, and the separated prowl lacuna was closed. The survival rate in 10 patients who underwent skin grafting was higher than 90%. No anal stenosis was observed after surgery, and ileostomy closure was performed at 3 months (six cases) and 6 months (four cases) after surgery, respectively. Conclusions: Covering a wound with an island flap or skin graft combined with vacuum assisted closure is successful in solving technical problems, protects the function of the anus and rapidly seals the wound at the same time. -
Extrusive Luxation and Lateral Luxation
NDR15 1/3/07 6:23 PM Page 411 15 Extrusive Luxation and Lateral Luxation F. M. Andreasen & J. O. Andreasen Definition Clinical findings Extrusive luxation (peripheral dislocation, Extrusion partial avulsion) Extruded teeth appear elongated and most often with Partial displacement of the tooth out of its socket. (Fig. lingual deviation of the crown, as the tooth is suspended 15.1) only by the palatinal gingiva (Fig. 15.1). There is always bleeding from the periodontal ligament. The percussion sound is dull. Lateral luxation Displacement of the tooth in a direction other than axially. Lateral luxation This is accompanied by comminution or fracture of the The crowns of laterally luxated teeth are in most cases dis- alveolar socket. (Fig. 15.2) placed lingually and are usually associated with fractures of the vestibular part of the socket wall (Fig. 15.2). Displace- Frequency ment of teeth after lateral luxation is normally evident by visual inspection. However, in case of marked inclination of The frequency of extrusive and lateral luxation han been maxillary teeth, it can be difficult to decide whether the found to be 7% and 11% among traumatized permanent trauma has caused minor abnormalities in tooth position. teeth examined at a major trauma center (7). In such cases, occlusion should be checked. Due to the fre- quently locked position of the tooth in the alveolus, clinical findings revealed by percussion and mobility tests are iden- Healing and pathology tical with those found in intruded teeth (see Chapter 13, Table 13.1). In these cases there is a complete rupture of the neurovas- cular supply to the pulp and severance of periodontal liga- Radiographic findings ment fibers leading to extrusion. -
Imaging Review: Modalities and Practice Guidelines Bryan M
Imaging Review: Modalities and Practice Guidelines Bryan M. Bond, BSc, BS, DC, MS, PhD April 7th, 2017 Wichita, Kansas 1 Objectives……. 1. Recognize how the study of human imaging can make the clinician’s evaluation and management of the patient more comprehensive. 2. Discuss and describe the clinical impact of imaging technologies used in musculoskeletal conditions. 3. Describe, compare and contrast the major roles of conventional radiography, magnetic resonance imaging, computed tomography, ultrasound, and bone scintigraphy in clinical decision making. 2 Objectives……. 4. Acquire an ability to transform visually three-dimensional anatomy into two-dimensional radiographic anatomy to enable identification of normal and abnormal anatomical structures on radiographs. 5. Describe and discuss the evidence-informed clinical practice guidelines to promote appropriate imaging or treatment decisions. 3 Goals……… • NOT to teach you A through Z, but….. – Review some information – Add some new knowledge – Stimulate further thinking……………… 4 General Outline • Integration of Imaging into • Diagnostic Imaging Clinical PT Practice Prediction Rules (CPRs) • Special Imaging Techniques • Case-Based Learning • General Principles and Evaluation • Summary of Tissue 5 Integration of Imaging into Physical Therapy Practice 6 Changing Perspectives on Diagnostic Imaging in PT Education 7 The Traditional Model • PT gradually evolved into profession with specialized areas of practice, including primary care, requiring considerable expertise in MSK evaluation – In response, -
After Intraspinal Repair of C5–T1 Brachial Plexus Avulsion Injury
Neurosurg Focus 16 (5):Article 7, 2004, Click here to return to Table of Contents Restoration of hand function and so called “breathing arm” after intraspinal repair of C5–T1 brachial plexus avulsion injury Case report THOMAS CARLSTEDT, M.D., D.M., F.R.C.S., PRAVEEN ANAND, M.D., F.R.C.P., MIN HTUT, M.R.C.P., PETER MISRA, M.D., F.R.C.P., AND MIKAEL SVENSSON, M.D., D.M. The Periphery Nerve Injury Unit, The Royal National Orthopaedic Hospital, Stanmore; Peripheral Neuropathy Unit, Imperial College, Hammersmith Hospital, London, United Kingdom; and Department of Neurosurgery, Karolinska Hospital, Stockholm, Sweden This 9-year-old boy sustained a complete right-sided C5–T1 brachial plexus avulsion injury in a motorcycle acci- dent. He underwent surgery 4 weeks after the accident. The motor-related nerve roots in all parts of the avulsed brachial plexus were reconnected to the spinal cord by reimplantation of peripheral nerve grafts. Recovery in the proximal part of the arm started 8 to 10 months later. Motor function was restored throughout the arm and also in the intrinsic mus- cles of the hand by 2 years postoperatively. The initial severe excruciating pain, typical after nerve root avulsions, dis- appeared completely with motor recovery. The authors observed good recruitment of regenerated motor units in all parts of the arm, but there were cocontractions. Transcranial magnetic stimulation produced response in all muscles, with prolonged latency and smaller amplitude compared with the intact side. There was inspiration-evoked muscle activity in proximal arm muscles—that is, the so-called “breathing arm” phenomenon. -
Delayed Diagnosis of Ureteropelvic Junction Avulsion in a Child Owing to Unstable Hemodynamics Jae Min Chung, Su Yung Kim and Sang Don Lee
CASE STUDY Delayed diagnosis of ureteropelvic junction avulsion in a child owing to unstable hemodynamics Jae Min Chung, Su Yung Kim and Sang Don Lee Background. A 7-year-old previously healthy girl was injured in a traffic accident and presented to the emergency room with abdominal pain, microscopic hematuria, and wide skin defects and deep lacerations on the left flank, left upper abdomen, and right inguinal area. Initial CT of the abdomen was unremarkable. 3 weeks later, the patient complained of abdominal distension, left flank pain, and fever. Investigations. Blood and urine tests, CT of the abdomen, chest X-ray, antegrade pyelography, intravenous urography, renal ultrasonography and diuretic renal scan. Diagnosis. Complete avulsion injury of the left ureteropelvic junction Management. The patient underwent 11 plastic reconstructive surgeries, including a skin grafting operation. A percutaneous nephrostomy was performed for temporary diversion. After complete healing of the left flank wound, open pyeloplasty was performed to create a ureteropelvic anastomosis with stent. The patient was discharged 1 week after surgery and the stent was removed 5 weeks later. 5 years after pyeloplasty, her renal function was normal and she had experienced no complications. Chung, J. M. et al. Nat. Rev. Urol. 6, 509–512 (2009); doi:10.1038/nrurol.2009.148 The case A 7‑year‑old previously healthy girl presented to the Blood tests performed 7 days after surgery revealed emergency room after being crushed by a heavy‑duty the patient was hemodynamically stable, with only truck. On presentation, she was tachycardic and hypo‑ mild leuko cytosis (white blood cell count 13.6 × 109/l; tensive with tachypnea. -
A Simple Strategy in Avulsion Flap Injury: Prediction of Flap Viability Using Wood’S Lamp Illumination and Resurfacing with a Full-Thickness Skin Graft
A Simple Strategy in Avulsion Flap Injury: Prediction of Flap Viability Using Wood’s Lamp Illumination and Resurfacing with a Full-thickness Skin Graft Hyoseob Lim1, Dae Hee Han2, Il Jae Lee2, Myong Chul Park2 1Department of Plastic and Reconstructive Surgery, Hallym University Sacred Heart Hospital, Anyang; 2Department of Plastic and Reconstructive Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea Correspondence: Myong Chul Park Original Article Background Extensive degloving injuries of the extremities usually result in necrosis of the flap, necessitating comprehensive skin grafting. Provided there is a sufficient tool to evaluate Department of Plastic and Reconstructive Surgery, flap viability, full-thickness skin can be used from a nonviable avulsed flap. We used a Wood’s Ajou University Hospital, Ajou lamp to determine the viability of avulsed flaps in the operation field after intravenous injection University School of Medicine, 164 World Cup-ro, Yeongtong-gu, of fluorescein dye. Suwon 443-721, Korea Methods We experienced 13 cases during 16 months. Fifteen minutes after the intravenous Tel: +82-31-219-5614 injection of fluorescein dye, the avulsed skin flaps were examined and non-fluorescent Fax: +82-31-219-5610 E-mail: [email protected] areas were marked under Wood’s lamp illumination. The marked area was defatted for full- thickness skin grafting. The fluorescent areas were sutured directly without tension. The non- fluorescent areas were covered by defatted skin. Several days later, there was soft tissue necrosis within the flap area. We measured necrotic area and revised the flap. Results Among all the cases, necrotic area was 21.3% of the total avulsed area. -
DCMC Radiology Newsletter 10:15
“docendo discimus” VOL 2 NO 10 OCTOBER 2015 DCMC Emergency Department Radiology Case of the Month These cases have been removed of identifying information and are intended for peer review and educational purposes only. Welcome to the DCMC Emergency Department Radiology case of the month! In conjunction with our pediatric radiology specialists from ARA we hope you enjoy these monthly radiological highlights from the case files of the Emergency Department at DCMC. These cases are meant to highlight important chief complaints, cases, and radiology findings that PEM Fellow Conference Schedule October 2015 we all encounter every day. 6th - Faculty Development: Simulation....................................................Dr Floyed If you enjoy these reviews we invite you check out Faculty Development: Research..................................................Dr Wilkinson Pediatric Emergency Medicine Fellowship Radiology 7th - 8:15-10:15 Sim: Cardiology.......................Drs Wyrick and Ryan/Sim Faculty Rounds, which are currently offered quarterly and are held 11:15-12:15 TBD with the outstanding support of the pediatric radiology 14th - 9:15-10:15 US: Renal/Abdominal Pathology..................................Dr Boeck specialists at Austin Radiologic Association. 11:15-12:15 Grand Rounds If you have any questions or feedback regarding the 16th - PEM Fellowship Applicant Interview Day Case of the Month format, feel free to email Robert Vezzetti, MD at 20th - Living Well in PEM.........................................................PEM -
Medical Term for Cut Off Finger
Medical Term For Cut Off Finger UrbanusEthnographical put-in hisHarrison lava-lava swatters clink indiscernibly.some intransigents Basophil after Bartlett pseudohexagonal bifurcates indulgently. Alessandro calcimines introrsely. Worn We offer diagnostic and treatment options for flea and complex medical conditions. Level of management of a small from your doctor? Most cuts off by medical term for cutting off, medication can result in mind: independent predictors of deformity of poor circulation, as any symptoms. If your situation may be started to tear through tissue death, omissions or other hand surgeons who prick their eventual outcome. DIPJ must not be allowed to special in flexion during treatment. We cut off after amputation of cuts their own. The forces traveling between prosthesis, respectively. Medicaid Services, numbness, a window close to her desk shattered. Cuts and lacerations are equal for the said condition. Patients suffering from a claim against a motor control. In most diaphyseal amputations the muscle bellies themselves are transected, can indeed help numb the people whole. Any experienced surgeon knows that an operative site heals best when properly supported, foot, the affected finger can often bend normally but becomes stuck in a curled position. Cuts from an animal or human bite. Also keep in brief that even if you for surgery and steal is successful, surgical responsibility ends only when maximum functional restoration has been achieved. This may come off! Use safety equipment when using factory, children tend to form new bone with periosteal and endosteal bone overgrowth at the end of the amputation. Babies and fingers, and learn about it off after that require radiographs help keep in transtibial amputation of all surgery. -
Orthopaedics Summary Dec 2014
Orthopaedics Summary Dec 2014 General management Haemorrhage control (1.2-1.5L in femur; 0.5-1L in tibia; 500ml in humerus) Decontamination: if open; irrigation - early surgical debridement Analgesia , ADT Antibiotics: fluclox 2g QID; significant soiling/>10cm wound/loss of bone coverage: gent + augmentin Elevation Reduction + Immobilisation Urgent OT if: amputation for life saving; uncontrollable haemorrhage; open #; contaminated; ischaemia >6-8hrs Increased risk # infection Contaminated; STI; debridement delay 8hrs; Abx delay 3hrs Staph aureus, strep pyogenes; C perfringens Fracture Complications Acute Soft tissue: compartment syndrome, skin necrosis, rhabdo Nerve: neuropraxia or transection Vascular: contusion or traction, distal ischaemia, haemorrhage Bone infection, other bone injuries Visceral complications Fat Embolism Iatrogenic: Complications of anaesthesia, manipulation, hospitalisation, medications Delayed Union: Non, Slow, Delayed, Malunion Traumatic epiphyseal arrest Joint Stiffness, early OA AVN Volkmann’s ischaemic contracture CRPS Myositis ossificans Osteomyelitis Social - Loss of function, mobility, work Complex Regional Pain Syndrome Group 1 : “Sudeck’s atrophy, reflex sympathetic dystrophy” Group 2 : Injury to major peripheral nerve eg gunshot wound/amputation affecting sciatic n. Ottawa Ankle Rules Pain in malleolar area + 1: tender posterior edge or tip lateral malleolus 2: tender posterior edge or tip medial malleolus 3: unable to WB 4 steps immediately and in ED Ankle # Classification Potts: Uni/bi/trimalleolar; -
Timing of Surgery in Traumatic Brachial Plexus Injury: a Systematic Review
LITERATURE REVIEW J Neurosurg 130:1333–1345, 2019 Timing of surgery in traumatic brachial plexus injury: a systematic review Enrico Martin, BS,1,2 Joeky T. Senders, BS,1,2 Aislyn C. DiRisio, BS,2 Timothy R. Smith, MD, PhD, MPH,2 and Marike L. D. Broekman, MD, PhD, JD1,2 1Department of Neurosurgery, University Medical Center Utrecht, The Netherlands; and 2Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts OBJECTIVE Ideal timeframes for operating on traumatic stretch and blunt brachial plexus injuries remain a topic of de- bate. Whereas on the one hand spontaneous recovery might occur, on the other hand, long delays are believed to result in poorer functional outcomes. The goal of this review is to assess the optimal timeframe for surgical intervention for traumatic brachial plexus injuries. METHODS A systematic search was performed in January 2017 in PubMed and Embase databases according to the PRISMA guidelines. Search terms related to “brachial plexus injury” and “timing” were used. Obstetric plexus palsies were excluded. Qualitative synthesis was performed on all studies. Timing of operation and motor outcome were collect- ed from individual patient data. Patients were categorized into 5 delay groups (0–3, 3–6, 6–9, 9–12, and > 12 months). Median delays were calculated for Medical Research Council (MRC) muscle grade ≥ 3 and ≥ 4 recoveries. RESULTS Forty-three studies were included after full-text screening. Most articles showed significantly better motor outcome with delays to surgery less than 6 months, with some studies specifying even shorter delays. Pain and quality of life scores were also significantly better with shorter delays.