Minor Injuries
Kim Kilmurray Senior Clinical Teaching Fellow Objectives
Provide an overview of common presentations to the minor injuries unit Refresh your memory of joint examination Identify rules that will help with deciding whether imaging is needed Increase awareness of classification systems for fractures Increase confidence in plain film interpretation Outline the management of common injuries What do we see in ED?
Sprains Fractures Dislocations Wounds Burns Corneal abrasions & foreign bodies Foreign bodies in ears, noses, genitals
Joint Examination
Look Positioning Gait Deformity Muscle wasting Erythema Swelling Wounds/Scars Symmetry Joint Examination
Feel Temperature Bony tenderness Swelling Crepitus Move Active Passive Special Tests Knee : Ligaments – anterior draw, posterior draw, medial and lateral stress Shoulder : Rotator cuff Case 1
26 year old male Inversion injury to right ankle whilst playing football Unable to weightbear immediately, but now partially weightbearing On examination: Neurovascularly intact Swollen Mildly reduced ROM-active and passive No bony tenderness
Does he need an ankle x-ray?? Ottawa ankle rules Ankle x-ray only required if there is pain in the malleolar area and any of: Bony tenderness along the distal 6cm posterior edge of tibia or tip of medial malleolus Bony tenderness along the distal 6cm posterior edge of fibula or tip of lateral malleolus Unable to weightbear immediately and in ED (4 steps) Ankle anatomy Soft Tissue Injury Discharge Advice
RICE Rest Ice Compression Elevation Patient information leaflet Worsening advice
Case 2
22 year old female Sustained an inversion injury to her left ankle whilst dancing at a nightclub Unable to weightbear On examination NVI – palpable dorsalis pedis and posterior tibial pulses with normal sensation Swollen++ over lateral malleolus Tender++ over lateral malleolus Markedly reduced ROM
Does she require an x-ray? X-ray Management
Below knee POP backslab Elevation Analgesia Orthopaedic referral Weber Classification System Based on the location of a fibula fracture in relation to the ankle joint (syndesmosis). Weber A Below the level of the talar dome. Usually stable. Weber B Distal extent at the level of the talar dome. May extend proximally. Weber C Above the level of the talar dome. Unstable and usually requires an ORIF (open reduction and internal fixation).
Weber Classification System X-rays Signs of a fracture
Swelling Deformity Point tenderness Pain on movement Loss of function
How to describe fractures Remember
Always examine for & document neurovascular status Obtain 2 views Document hand dominance in all upper limb injuries Injury patterns Examine lumbar spine in calcaneal fracture Examine entire spine if any spinal fractures Childhood injuries Torus Greenstick Salter Harris
Remember
Always examine the joint above and below Ankle fractures may have associated proximal fibula fractures MAISONNEUVE Wrist fractures may have associated proximal or distal dislocations & multiple fractures GALEAZZI MONTEGGIA
Maisonneuve fracture Galaezzi A fracture of the radius associated with distal ulnar dislocation
Monteggia
A fracture of the ulna with radius head dislocation
Case 3
56 year old female Slipped on ice and sustained a right FOOSH injury She is complaining of pain in her right wrist Right hand dominant On examination NVI U√ M√ R√ AIN√ Swollen ++ No wounds Obvious ‘dinner fork deformity’ Tender++ over distal radius & ulna Wrist X-ray How to describe a fracture
Location Bone Distal, middle or proximal Type Oblique, transverse, comminuted, torus, greenstick, spiral, avulsed, impacted Compound? Displaced or undisplaced? Medial, lateral, dorsal, volar, ulnar, radial Angulation Dorsal or volar Management
Manipulation under sedation Forearm POP backslab Elevation in sling Analgesia Referral to fracture clinic Case 4
2 year old boy Wrestling with his older brother earlier tonight Stopped using his right arm & now guarding it by his side Crying whenever it is touched On examination: NVI No obvious deformity or bony tenderness Refusing to move arm actively On passive movement cries++ when hand supinated What’s the diagnosis? Pulled Elbow Radial head subluxation Management
Analgesia Explain reduction technique to parents Forced supination & flexion of elbow Will feel a click when it reduces Should start using arm again within about 30 minutes Advise parents to avoid swinging child or pulling the arm as likely to happen again Childhood injuries
Salter Harris fractures Foreign bodies in ears and nose Pulled elbow Torus fracture Greenstick fracture REMEMBER Non-Accidental Injuries
Salter Harris Fractures
Describe epiphyseal plate fractures Important as they may cause premature closure with resulting growth disturbance or limb shortening 5 types – I- V SALTR
Bone parts Salter Harris Fractures I - Slipped Fracture plane passes all the way through the growth plate. II - Above Fracture passes across most of the growth plate and up through the metaphysis. III - Lower/below Fracture passes across most of the growth plate and down through the epiphysis. IV - Transverse Fracture passes through metaphysis, growth plate and epiphysis. V - Rammed/Ruined Crushing type injury that causes compression of the growth plate.
Sometimes it is easier to visualise X-rays Why is this important?
Prognosis worsens from I to V I and II have a good prognosis V has the worst prognosis In type III to V the proliferative and reserve zones of the growth plate are damaged
Case 5
4 year old girl 2 day history of right ear pain No discharge from the ear Systemically well You have a look with the auroscope…. Here’s what you see Now what? Management options
Suction with a fine bore catheter Crocodile forceps ENT referral Crocodile forceps Case 6
4 year old boy Was eating dinner & told his parents that he has put something up his nose No difficulty breathing You have a look….. Examination How are you going to get it out? Management options
Mother’s kiss Suction with fine bore catheter Crocodile forceps ENT if unable to remove or not tolerating Case 7
27 year old female Poked in right eye by her toddler Now complaining of a painful, watery eye with blurred vision
How are you going to examine her? Examination equipment Examination
Local anaesthetic drops x2 Visual acuity Right 6/12, Left 6/6 Pupil reaction PEARL Eye movements Full & painless Slit lamp exam Clear light: scleral erythema++ with conjunctival swelling, no FB on eyelid eversion Fluorescein & blue light Fluorescein exam Management
Chloramphenicol 1% ointment Analgesia Referral to Ophthalmology if visual impairment, large abrasion or pain on eye movement Wounds
Location Length/Diameter Depth Function of area Neurovascular status Contaminated or clean ?FB Hand dominance Tetanus status Always x-ray a wound if caused by glass Laceration closure options
Secondary intention Glue Steristrips Sutures Clips
Sutures Suture kit Summary
Provided an overview of common presentations Refreshed your memory of joint examination Identified rules that will help with deciding whether an x-ray is needed Increased awareness of classification systems for fractures Increased confidence in x-ray interpretation Outline the management of common injuries
Thank you A brief, whistle stop tour of minor injuries
Any Questions?