Musculoskeletal Injury Assessment Quiz

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Questions and Answers

Which of the following is a late complication of fractures?

Compartment syndrome

Avascular necrosis (AVN) (correct)

Fracture blisters

Infection

What anatomical aspect is crucial when describing a fracture on an x-ray?

The history of trauma

The patient’s age

The patient’s activity level

The pattern of fracture (correct)

Which condition does NOT fall under early complications of fractures?

Osteomyelitis (correct)

Fracture blisters

Neurovascular injury

Compartment syndrome

What type of fracture pattern is described as 'curving around the shaft of the bone'?

Spiral Signup and view all the answers

Which of the following complications is considered systemic?

Deep vein thrombosis Signup and view all the answers

What is a key consideration when interpreting pediatric x-rays?

Potential growth centers may mimic fractures Signup and view all the answers

Which of the following should prompt immediate medical action to prevent limb or life loss?

Open fractures Signup and view all the answers

What is the recommended approach when ordering x-ray investigations for fractures?

Request all relevant views for correct diagnosis Signup and view all the answers

What is a primary characteristic of pain associated with compartment syndrome?

Pain that is out of proportion to the injury Signup and view all the answers

What is the most specific sign indicating compartment syndrome?

Pain increased with passive stretch of compartment muscles Signup and view all the answers

Which of the following is NOT a part of the initial management for compartment syndrome?

Performing fasciotomy immediately Signup and view all the answers

What is the common etiological agent in septic joint infections?

Staphylococcus aureus Signup and view all the answers

When investigating osteomyelitis, which examination is least likely to show changes in the early stages?

X-rays Signup and view all the answers

Which of the following symptoms indicates late findings of compartment syndrome?

Polar cold limb Signup and view all the answers

What is the first step in the management of a septic joint?

Emergency decompression Signup and view all the answers

What complication can arise from compartment syndrome due to prolonged muscle necrosis?

Renal failure secondary to myoglobinuria Signup and view all the answers

What does the acronym SEADS represent in the context of a physical examination?

Swelling, Erythema, Atrophy, Deformity, Skin changes Signup and view all the answers

Which statement about the X-Ray rule of 2s is incorrect?

Two images taken at different times are unnecessary for diagnosis. Signup and view all the answers

What should be prioritized when managing an unstable patient?

Management of airway, breathing, and circulation Signup and view all the answers

What is a key reason for performing a neurovascular exam thoroughly during fracture evaluation?

To ensure there is no compromise to blood flow or nerve function Signup and view all the answers

What is the primary purpose of using a splint for a swollen or deformed extremity?

To immobilize the injury and minimize further damage Signup and view all the answers

Which of the following is not a focus of an initial patient assessment?

Identifying potential surgical candidates Signup and view all the answers

What is the first step in managing a patient with a suspected musculoskeletal injury?

Acquiring an AMPLE history Signup and view all the answers

What is an important action to take when encountering a dirty or complex wound?

Cleansing the wound thoroughly with saline Signup and view all the answers

What is the management for a Galeazzi fracture?

Apply a long arm splint and refer for ORIF Signup and view all the answers

Which injury is characterized by a fracture of the proximal ulna with dislocation of the radio-capitellar joint?

Monteggia Fracture Signup and view all the answers

When managing an elbow dislocation, what position should the elbow be held in after closed reduction?

Flexed at 90 degrees Signup and view all the answers

What defines Nursemaid’s Elbow?

Subluxation of the radial head beneath the ligament Signup and view all the answers

What is the recommended initial treatment for a clavicle fracture that is not severely displaced?

Cuff and collar sling and reassurance Signup and view all the answers

What is a common mechanism of injury for a clavicle fracture?

Falling on an outstretched hand (FOOSH) Signup and view all the answers

What type of imaging is required for evaluating elbow dislocations?

X-rays: AP, trans-scapular, axillary lateral Signup and view all the answers

In managing scapula fractures, what is the typical cause of these injuries?

High-impact injuries typically from falls or accidents Signup and view all the answers

What is the immediate management for a non-displaced transverse fracture of the 5th metatarsal?

Apply a short leg splint followed by a short leg cast Signup and view all the answers

Which scenario should always lead to the assumption of a spinal injury?

An unconscious patient who is injured Signup and view all the answers

What is a critical step before moving a patient suspected of having a spinal injury?

Apply an extrication collar Signup and view all the answers

Which of the following is a sign of a possible spinal injury?

Numbness and tingling in the limbs Signup and view all the answers

What does mechanical stability in spinal injury management refer to?

Maintaining alignment under physiologic loads Signup and view all the answers

In a patient with a Lisfranc fracture dislocation, what is the first consideration for further management?

Determine if the fractures are displaced Signup and view all the answers

What is a symptom that could help in diagnosing spinal injuries?

Loss of bladder or bowel control Signup and view all the answers

What procedure is indicated for displaced fractures of the 5th metatarsal?

ORIF (Open Reduction and Internal Fixation) Signup and view all the answers

Study Notes

Referred Symptoms

When referring patients with musculoskeletal injuries, utilize the AMPLE history to gather crucial information.
AMPLE stands for Allergies, Medications, Past medical history, Last Eaten, Events leading to the injury.

Physical Examination

Examine the affected limb for SEADS (swelling, erythema, atrophy, deformity and skin changes).
Assess active and passive range of motion of the affected joint, including the joints above and below.
Conduct neurovascular tests to evaluate pulse, sensation, reflexes, and power (0 to 5).

Investigations

Plain x-ray: obtain anteroposterior (AP), lateral, and oblique views for accurate diagnosis, using the "X-Ray rule of 2s":
- 2 sides: bilateral views are essential, especially in children.
- 2 views: obtain AP and lateral views for comprehensive evaluation.
- 2 joints: include views of the joint above and the joint below the injury.
- 2 times: repeat x-rays before and after reduction of the fracture or dislocation.
Blood: perform complete blood count (CBC) and blood grouping.
Aspiration: aspirate fluid from the joint for analysis.
Ultrasound: may be considered when deemed appropriate.

Basic Fracture Evaluation & Management

Start with the ABCs (Airway, Breathing, Circulation), followed by primary and secondary surveys.
Conduct a thorough examination of the fracture site, including the location along the bone's length (proximal, middle, or distal third), whether it's open or closed, and if there is an associated dislocation.
Perform a complete neurovascular exam to assess circulation, sensation, and motor function.
Order appropriate imaging studies to confirm the diagnosis.
Rule out any potential associated injuries like chest or abdominal trauma.
Obtain an AMPLE history and provide analgesics as needed.
Immobilize the injured limb with proper splinting before moving the patient.
If a reduction is performed, assess neurovascular status before and after the procedure.
Refer the patient for further management when necessary.

Complications of Fractures

Local Complications:
- Early:
  - Compartment syndrome
  - Neurovascular injury
  - Infection
  - Fracture blisters
- Late:
  - Malunion or nonunion
  - Avascular necrosis (AVN)
  - Osteomyelitis
  - Post-traumatic arthritis
  - Reflex sympathetic dystrophy (RSD)
Systemic Complications:
- Sepsis
- Deep vein thrombosis (DVT)
- Pulmonary embolism (PE)
- Acute respiratory distress syndrome (ARDS)
- Hemorrhagic shock

Pediatric X-Rays

Pediatric x-rays can be challenging to interpret due to the ongoing growth process, as normal gaps between bones (growth centers) may be mistaken for fractures.
When in doubt, compare with the contralateral side.

Describing Orthopedic X-Rays

When describing orthopedic x-rays, include the following points:
- Anatomic Location: specify the bone and location within the bone.
- Pattern of Fracture:
  - Transverse: Fracture perpendicular to the long axis of the bone.
  - Oblique: Fracture at an angle from the long axis of the bone.
  - Spiral: Fracture that curves around the shaft of the bone.
  - Comminuted: Fracture with more than two bone fragments.
- Impacted, Compressed, Depressed: Indicate whether the bone fragments are compressed, driven into each other, or pushed inward.
- Displacement: Describe the degree to which the fragments are shifted in relation to each other.
- Angulated: Indicate the angle between the longitudinal axes of the bone fragments.
- Intra-articular: Specify if the fracture extends into the joint.

Acute Orthopedic Emergencies

These conditions require immediate and timely intervention to prevent potential limb loss or life-threatening complications:
- Open fractures
- Multiple long bone fractures
- Pelvic fractures
- Major joint dislocations (e.g., knee, hip)
- Fractures and dislocations with neurovascular compromise
- Compartment syndrome
- Septic joint
- Osteomyelitis
- Cauda Equina Syndrome

Compartment Syndrome

It's characterized by increased interstitial pressure within an anatomic compartment.
Interstitial pressure exceeding capillary perfusion pressure leads to muscle necrosis (within 4-6 hours) and eventually nerve necrosis.
Clinical Presentation: 6 Ps
- Pain out of proportion to the injury
- Pain unrelieved by analgesics
- Pain increased with passive stretch of compartment muscles (most specific)
- Pallor (pale skin)
- Paresthesia (numbness or tingling)
- Polar: Cold limb (late finding)
- Paralysis (late finding)
- Pulselessness (late finding)
Management
- Remove all constrictive dressings (casts, splints).
- Elevate the limb.
- Reassess in 20 minutes.
- Urgent referral for fasciotomy to decompress compartmental pressure.
Complications: Rhabdomyolysis, renal failure due to myoglobinuria, Volkmann's ischemic contracture.

Septic Joint and Osteomyelitis

Septic Joint:
- Infection within the joint space.
- Usually caused by direct inoculation or hematogenous spread.
- Common organisms include Staphylococcus (staph) or Streptococcus (strep) species, potentially Gonorrhea (GC).
- Characterized by localized joint pain with warmth, swelling, and restriction of active and passive range of motion.
Investigations:
- Blood tests: Complete blood count (CBC), Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and blood culture.
- Joint aspirate: examine for frank pus or turbid fluid.
Management:
- Emergency decompression and thorough irrigation in the operating room.
- Intravenous antibiotics.
Osteomyelitis:
- Etiology: Staphylococcus aureus is the most common causative organism. Neonates and immunocompromised individuals are susceptible to gram-negative bacteria.
- Clinical Presentation: Localized extremity swelling with pain and fever.
- Investigations:
  - Complete blood count (CBC - leukocytosis), Erythrocyte sedimentation rate (ESR), Blood culture.
  - Aspirate cultures (cultures obtained from fluid aspirated from the affected area).
  - X-rays: changes may not be visible initially and require 1-2 weeks to manifest.
- Management:
  - Emergency surgical decompression and washout.
  - Intravenous antibiotics.
  - Urgent referral is required.

Galeazzi Fracture

Definition: Fracture of the distal radial shaft with disruption of the distal radio-ulnar joint.
Management: Apply a long arm splint and refer for Open Reduction and Internal Fixation (ORIF).

Monteggia Fracture

Definition: Fracture of the proximal ulna with dislocation of the radio-capitellar joint.
Management: Apply a long arm splint and refer for ORIF.

Elbow, Arm and Shoulder Injuries:

Nursemaid's Elbow:
- History of being swung by the arm.
- Peak age range: 1-4 years old.
- Forearm held flexed and pronated, with reluctance to move.
- Subluxation of the radial head beneath the ligament.
- Management: Reduce the subluxation by supinating the forearm and flexing the elbow.
Elbow Dislocation:
- Majority of dislocations are posterior.
- Be vigilant for potential neurovascular injuries.
- Management: Immediate closed reduction (CR) under sedation with a long arm splint in neutral forearm rotation, elbow flexed at 90 degrees. Start early range of motion (ROM) exercises (90 degrees).
Shoulder Dislocation:
- Usually anterior.
- Most common in young adults.
- “Square off” shoulder: Arm held in slight abduction, external rotation, and internal rotation is blocked.
- Investigations: X-rays: AP, trans-scapular, axillary lateral.
- Treatment: Closed reduction by traction/counter-traction under IV sedation and muscle relaxation as soon as possible. Sling for 3 weeks.

Clavicle Fractures

Mechanism: Fall on an outstretched hand (FOOSH).
Locations: Medial third, distal third.
Management:
- Non-operative treatment is typical unless the fracture is open or severely displaced.
- Cuff and collar sling.
- Figure-of-eight bandage.
- Pain medication.
- Reassurance.
- Refer for complications.

Scapula Fractures

Result from high-impact injuries.

Foot Injuries

Transverse fracture of the 5th metatarsal (Jones' Fracture)
Lisfranc Fracture Dislocation: Fracture of the metatarsal base and dislocation of the metatarsal.
Management:
- Non-displaced fractures: Initially apply a short leg splint followed by a short leg cast.
- Displaced fractures: May require ORIF.

Spinal Injuries

Emergency Care of Spinal Injury Patients:
- General Principles:
  - Prioritize ABCs (Airway, Breathing, Circulation) with cervical spine immobilization.
  - Assume spine injury in unconscious injured patients.
  - Immediately provide gentle longitudinal support to the cervical spine.
  - Apply an extrication collar before transporting the patient.
  - Maintain cervical support until the patient is secured on a spine board.
  - Utilize log rolling and splint the patient before moving them.
Diagnosis of Spinal Injuries:
- History:
  - Violent impacts to the head, neck, or pelvis.
  - Sudden acceleration or deceleration accidents.
  - Falls from heights where the patient lands on their head or feet.
  - Gunshot wounds to the neck or trunk.
- Physical Signs and Symptoms:
  - In conscious patients, pain over the spinous processes, with or without deformity.
  - Numbness, tingling, or weakness in the limbs.
  - Pain over the spine with movement.
  - Tenderness over the spine.
  - Absent or weak reflexes.
  - Paralysis or anesthesia.
  - Loss of bladder or bowel control.
Concept of Spinal Stability:
- Mechanical Stability: Maintain alignment under physiologic loads without significant onset of pain or intolerable deformity.
- Neurologic Stability: Prevent neural signs or symptoms under anticipated loads.

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Description

Test your knowledge on the assessment of musculoskeletal injuries, focusing on the AMPLE history, physical examination techniques, and necessary investigations. Explore essential concepts like the SEADS assessment and the X-Ray rule of 2s to ensure accurate diagnosis and patient care.