the case.
A 2 year old infant is bought to your ED with a painful right hand. She claims to be have been bitten by the family dog 2 days earlier… [Read more…]
concerning extension…
the case.
You receive a BAT call about a 31 year-old male who has come off his bicycle after running into a stationary car at ~30 km/hour. Bystanders report that he was thrown 3-5m and had a loss of consciousness of ~3 minutes without witnessed seizure activity. [Read more…]
Quick Case #01
A 24 year old male rugby player presents to your ED with a severely painful, swollen left hand which occurred during a tackle and subsequent ruck.
These are his x-rays….
Carpometacarpal Dislocation
- The carpometacarpal (CMC) joints form the base of the metacarpal arch of the hand.
- The metacarpal bases articulate with each other & with the distal carpal row.
- This is a complex structural configuration.
- Supported by volar, dorsal and interosseous ligaments.
- Reinforced by broad insertions of wrist flexors and extensors as well as the deep transverse metacarpal ligament.
- The ring & little finger MCs articulate with the hamate.
- These are more mobile and hence more susceptible to dislocation (5th >> 4th digit).
- Dislocations of the carpometacarpal (CMC) joints are rare.
- Often the diagnosis is missed.
- Most commonly a dorsal dislocation.
- Commonly associated with fractures.
- Clinically;
- Occurs as a result of MVAs, falls, crush injuries and closed-fist trauma.
- Marked swelling and deformity with pain over the dorsum of the hand.
- Thorough neurovascular examination is mandatory.
- Assess deep motor branch of ulnar nerve
- Passes adjacent to hook of hamate & can be directly injured.
- Beware of compartment syndrome.
- Radiologically;
- Fractures may be subtle on x-ray.
- Superimposed carpal & metacarpal bones.
- Extra-oblique films may be helpful.
- Management;
- Analgesia & limb elevation initially.
- Closed reduction can be attempted (following adequate sedation +/- regional anaesthesia)
- Traction & flexion with simultaneous longitudinal pressure on the MC base.
- Followed by extension of the MC head.
- Requires Hand-Surgeon referral & will likely need surgical fixation (K-wire).
- Volar dislocations are very rare and require Hand-Surgery involvement.
- Complications;
- Arthritis
- Weakness.
- Rosenʼs Emergency Medicine. Concepts and Clinical Approach. 7th Edition
- Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.
- Wheeless’ Textbook of Orthopaedics
in with a chance…
the case.
a 19 year old female arrives to your resuscitation bay following a high-speed rollover MVA where she was the restrained passenger.
- she has a clinically fractured mandible with some oropharyngeal bleeding, but a GCS of 15. she is able to use a yankauer-sucker and intermittently suction her own mouth. you are happy with her airway for now
- she is tachycardia at 125/min, and had a transient episode of hypotension (systolic of 85 mmHg) which resolved without intervention.
- with some analgesia her pulse settles to 110/min.
- her abdomen is exquisitely tender on the left side and she has a positive seat-belt sign.
- she has free fluid on FAST exam (LUQ)
- she has midline spinal tenderness in the upper lumbar region…
A joint decision with the Trauma surgeons is made; and we head to radiology for a pan-CT. This revealed the following…
- Mandible fracture.
- Splenic laceration
- and this….
httpv://www.youtube.com/watch?v=9B1YMOr9LK0&feature=youtu.be
- Acute L2 Chance-type fracture.
Chance Fracture.
A flexion-distraction injury of the lumbar spine.
It represents failure of both the posterior and middle spinal columns under tension forces generated by flexion and distraction (from a fulcrum focus anterior to the vertebral body).
- The anterior column may partially fail (under compression, acting as a hinge) or may completely disrupt (hinge failure).
This is an unstable fracture involving all three spinal columns.
There is significant distractive disruption of middle & posterior ligamentous structures (50% of cases).
- Typically interspinous ligament, ligamentum flavum, facet capsule, posterior annulus & thoracodorsal fascia are involved.
- The other 50% result from fracture through bone.
It is unusual, in that the fracture line extends through the spinous process, pedicle and into the vertebral body.
** Subtype of Flexion-Distraction Injuries – Image taken from Denis (1983) **
Most commonly associated with seat-belt injuries (especially isolated lap belts only).
- Also associated with pedestrian-vs-car injuries and falls.
This is often misdiagnosed as an anterior compression fracture.
Chance fractures are strongly associated with intraabdominal injuries. These result from rapid deceleration of intraabdominal contents against the lap belt, or compression against the anterior spine. There is also subsequent increased intraluminal pressure in hollow viscus structures.
- Associated intraabdominal injuries.
- Small bowel
- Spleen
- Large bowel
- Kidney
- Pancreas
- Omentum & mesentery
- Liver
- Stomach
- Adrenal glands
- Large vessel.
- Hollow viscus injury occurs in ~22% of Chance fractures.
- However; in patients with identified intra-abdominal injuries, 65% have hollow viscus injury.
- Have high index of suspicion for more than one injury.
- Abdominal wall contusions (“seat-belt sign”) in combination with Chance fracture is very suggestive of intraabdominal pathology (50-68%) and increased need for laparotomy (50-72%).
- The absence of abdominal wall contusions drops the likelihood of intraabdominal pathology and need for laparotomy to 14% & 9% respectively.
- Spinal cord injury may accompany up to 25% of Chance fractures.
- Associated with high-grade posterior element dissociation.
- Abdominal aortic injuries (particularly dissection) have been known to occur in paediatric trauma patients with Chance fractures.
CT scan is the preferred initial diagnostic modality of choice in the haemodynamically stable patient with a Chance fracture. It is however important to recognise its limitations particularly in the diagnosis of small bowel injury.
Remember to treat this injury like any other unstable spinal injury.
Our patient remained haemodynamically stable. Her MRI spine showed no evidence of epidural haematoma, canal or foramina narrowing. There was however ligamentous injury posteriorly, mainly at L1-2.
Whilst her mandible was repaired on Day 2, her splenic injury was managed conservatively.
This was her final operative repair prior to discharge home….
- Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.
- Current Diagnosis & Treatment: Surgery, 13th Edition.
- Wheeless’ Textbook of Orthopaedics.
- Denis, F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 8(8), 817–831.
- Tyroch, AH et al. The association between Chance fractures and intra-abdominal injuries revisited: a multicenter review. The American surgeon, 71(5), 434–438.
- Chapman JR et al. Thoracolumbar Flexion-Distraction Injuries: Associated Morbidity and Neurological Outcomes. Spine (Phila Pa 1976). 2008 Mar 15;33(6):648-57.
- Inaba K et al. Blunt abdominal aortic trauma in association with thoracolumbar spine fractures. Injury. 2001 Apr;32(3):201-7.
- Choit RL et al. Abdominal aortic injuries associated with Chance fractures in pediatric patients. J Pediatr Surg. 2006 Jun;41(6):1184-90.
a swollen face…
The Case.
A 36 year old male presents through your sub-acute area with increasing facial pain & swelling. He reports a simple trip and fall 18 hours earlier (no alcohol on board, recalls all events), where his right cheek struck a concrete step. He had no LOC at the time, and has no historical features concerning for intracranial injury.
He is worried today as the swelling ‘just keeps getting worse’.
On examination he has obvious marked right zygomatic/maxillary swelling and ecchymoses. His cranial nerves are ok (particularly extra-occular movements and facial sensation). When you palpate his facial bones, for find something unexpected which leads you to expediting his CT scan….
Interpretation & Progress.
This CT demonstrates a comminuted, depressed maxillary fracture involving the orbital floor and lateral orbital wall (a ‘blow-out’ type fracture), with extension into the maxillary alveolar process.
The most striking feature of this CT-series is the abundance of subcutaneous emphysema, and of particular concern to me was the extent to which it had traveled (to contralateral carotid sheath, SCM & masseter, submandibular space & of most concern to me, the retropharyngeal space at the level of the epiglottis).
Whilst a bony injury of this magnitude requires little further ED work-up & can usually be referred to your Plastics/Maxillofacial surgeons as an outpatient, the amount of soft-tissue air in this case made us reluctant to simply discharge him home.
Subcutaneous emphysema in the setting of facial and neck trauma raises the suspicion & should prompt the consideration of an aero-digestive injury. Our patient in this case had a single isolated blow to the right cheek & no evidence of anterior neck injury (and gave excellent recollection of the events). He had no dysphagia, dysphonia or neck pain, but did report a recent runny nose. Regardless, we elected to pursue this further by asking our ENT colleagues to review him.
In short, he was admitted for observation & commenced on IV antibiotics. The ENT registrar performed a nasendoscopy in the ED revealing a macroscopically normal airway to the level of the cords. He was discharged home 48 hours later with no further sequelae from his injury.
Orbital Fractures.
The most common simple fracture of the orbit is the ‘blow-out’ fracture of the orbital floor.
Assessment:
* Bony fragments & orbital contents can sag/herniate into the maxillary sinus.
* Enophthalmos vs Exophthalmos (more likely to occur with medial wall involvement)
* Assess for diplopia & EOM (particular inferior rectus function)
* Pic courtesy of Otolaryngology Houston
* Assess function of infraorbital nerve.
* Pic courtesy of Zygomatic Complex & Nasal Injury
* Retrobulbar haematomas (or malignant orbital emphysema) can create an ocular compartment syndrome leading to blindness from acute ischaemic optic neuropathy. (Suggested by exophthalmos, reduced visual acuity & increased IOPs).
Management.
- Non-displaced or minimally displaced fractures can be handled as an outpatient with definitive repair delayed by up to 7 days.
- Antibiotics are required for open fractures and fractures that violate sinuses. Amoxicillin-clavulanate is sufficient.
- Lateral canthotomy is required for suspected or confirmed retrobulbar haematomas.
- Check out Broome Docs 7th Podcast for more information…
Lastly; avoid sneezing and don’t blow your nose !! This can force air from the sinuses into soft tissues...
As it turns out, our man had a simple case of man-flu just prior to his injury and in the 12 hours prior to his ED arrival had been vigorously blowing his nose in attempt to clear his nostrils !!
hard & soft…
The Case.
A 22 year old male is retrieved to ED after a nasty workplace accident where he was pinned between a truck and wayward forklift. He had sustained injuries to his head/face, upper thorax and perineum, however our most significant concern was regarding his right lower limb. He had a displaced, angulated compound femur fracture that required sedation and pre-hospital reduction. There were reports of significant bleeding at the scene.
No immediate interventions were required following his primary survey, but his right limb revealed a nasty tissue defect and open fracture (now splinted). There was no active blood loss, but his leg distal to the injury was pale and cold with no appreciable dorsalis pedis or posterior tibial pulses.
Here are his initial xrays….
As there was concerns regarding intraabdominal and pelvic injuries; he was taken to radiology for CT, including angiography of his lower limbs….
httpv://www.youtube.com/watch?v=P8jIf50wnQw&feature=youtu.be
He went straight to theatre from radiology, and unfortunately underwent an above-knee amputation.
Whilst the decision making process was rather straight forward in this case, it did lead me to revisit the ED-based evaluation of suspected peripheral vascular injury….
peripheral vascular injury…
Typically these injuries are divided into blunt vs penetrating, however they generally result in a similar spectrum of vascular injuries (including laceration, transection, entrapment, avulsion, intimal tears/flaps, pseudoaneurysm, AV-fistulas, thrombosis & spasm).
Detection & treatment of vascular injuries must take place within the context of overall resuscitation of a patient. This also includes the control of active bleeding.
The assessment of peripheral vascular injury can be divided into three categories;
- Hard findings
- Soft findings
- High-risk asymptomatic wounds (based on mechanism of injury).
Hard Findings of Vascular Injury.
- Pulsatile bleeding
- Loss of distal pulses
- Audible bruit or palpable thrill (indicative of AVF)
- Expanding or pulsatile haematoma
- Overt distal ischaemia (the 6 P’s)
The incidence of arterial injury is > 90% if any of these are present !! Surgical exploration is required.
Soft Findings of Vascular Injury.
- Palpable, but diminished pulse
- Isolated peripheral nerve injury (due to common proximity to vessels)
- History of severe haemorrhage in the field
- Unexplained hypotension
- Large, non-pulsatile haematoma
- ?delayed capillary refill (in combination with other signs).
Up to 35% of patients with soft-signs will have positive angiographic findings !!
High-Risk Injuries.
- Proximity of wound to a neurovascular bundle (< 1cm)
- Includes; axillary, brachial, common femoral & popliteal arteries.
- Bites from large dogs or other animals.
- Severely displaced fractures.
- Crush injuries.
- Major joint dislocations (especially knee).
Meticulous examination is required to look for the above hard & soft signs. Surprisingly, these are relatively dependable (Sensitivity 92%, Specificity 95%).
- False positive findings can occur in shock, preexisting vascular disease, arterial spasm or compression. (Occurs in ~ 10-27% of cases).
- False negative findings can result from pulse transmission through a soft clot, past an intimal flap or via collateral circulation. Distal pulses can persist in 6-42% of patients despite significant arterial injury.
Diagnostic investigations.
These must be tailored to the patient & their injury, and should never delay a definitive treatment to an obvious arterial injury (especially if the clock is approaching the all-important 6 hour warm ischaemia time).
Modalities include plain radiography, pulse-oximetry, hand-held Doppler, ultrasound (including colour-flow and duplex), CT & MRI. CT-angiography is now the most commonly used primary diagnostic study for the evaluation of penetrating lower extremity vascular injury.
The investigation that I wanted to focus on is Arterial-Pressure Index, as I feel it can be easily done at the bedside as an extension to your physical examination.
- Measured with a manual BP-cuff and hand-held Doppler, the systolic blood pressure is measured and compared between the injured and the contralateral unaffected limb.
- An API of < 0.90 increases the likelihood of vascular injury and should prompt further investigation (like CT-angiography).
- Sensitivity 95% / Specificity 97%.
- PPV 100%
- NPV 95%
- API of 0.90-0.99 = observation for 24 hours with repeated examination.
- Normal examination and API = discharge home !!
- If both normal = 100% negative predictive value.
Caution w/ API: Limited usefulness in deep arteries (profunda femoris, profunda brachii & peroneal arteries) which do not produce palpable pulses & with shot-gun wounds which often cause multiple small arterial injuries.
Summary.
- Hard signs = surgical exploration. No need for angiography unless there is an associated skeletal or shotgun injury.
- Patients (without hard signs) who have abnormal physical examination &/or API < 0.90 should have further evaluation to rule out vascular injury.
- Normal physical examination and API > 0.90 = Discharge home !!
References.
- Rosenʼs Emergency Medicine. Concepts and Clinical Approach. 7th Edition
- Levy BA et al. Screening for extermity arterial injury with the arterial pressure index. Am J Emerg Med. 2005 Sep;23(5):689-95.
- Sadjadi J et al. Expedited treatment of lower extremity gunshot wounds. J Am Coll Surg. 2009 Dec;209(6):740-5.
- Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: Prospective study. J Trauma 2004; 56:1261.
- Fox, N et al. Evaluation and management of penetrating lower extremity arterial trauma: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma. 73(5):S315-S320.