Meditation is a useful skill that helps many patients deal with anxiety, depression and chronic pain.  It is also widely used by millions around just to improve general well-being.

Professor Jon Kabat-Zinn is a professor of medicine in the United States.  He has formulated many courses and written several books on meditation for patients and for business people.  Here are some short meditations from his audiobook Mindfulness for Beginners

Mindfulness meditations just get you to concentrate on something other than your thoughts for 10 minutes, just to give you a break from the incessant mental chatter most of us have in our heads.

Find or create a time you wont be disturbed, sit comfortably and listen to one of these recordings.  Follow his instructions to focus on, for example, your breathing.  Don’t worry if you can’t do it straight away, you get distracted or lose track.  That is to be expected to start with.  Just keep doing the exercise and see what happens.  Just see if there is some lessening of your unpleasant feelings or thoughts.

Focusing on Breathing:

You can download this audio here (right-click and “Save link as” or “Save as”) and put it on your phone or MP3 player.

Focusing on your whole body as you breath:

You can download this audio here (right-click and “Save link as” or “Save as”)
Focusing on Sounds and then Thoughts:

You can download the audio here (right-click and “Save link as” or “Save as”)

Focusing on Nothing:

You can download the audio here (right-click and “Save link as” or “Save as”)

Having trouble getting to sleep or waking up during the night or too early in the morning are very common problems in our society.  Any of the above meditations can be used when you are struggling to sleep.

The meditation below is specifically designed to help people sleep.  It is from The Meditation Podcast.

Falling Asleep

You can download the audio here (right-click and “Save link as” or “Save as”)

Dr Chris Cresswell, MBChB, FACEM

Emergency Physician

Whanganui

New Zealand

The post Meditation for Patients appeared first on EM Tutorials.

This is a simple guide to fracture management, and other common orthopaedic presentations.  It doesn’t cover spinal injuries.

See X-Rays and CTs for New ED Doc for recognition and description of fractures

This guide was first written by (Speedy) Dan Hartwell and myself in 2007. It has been edited by an orthopaedic consultant and continues to be edited and used as a reference in a busy fracture clinic in a tertiary hospital.  It was written because the standard texts weren’t quick or prescriptive enough for new docs.

Don’t try and read the whole of this guide. Just read the introductory paragraphs then use it as a reference when you need to.

Always document whether skin is intact or not and the neurovascular status.

Consider non accidental injuries. Have a low threshold for discussing with paeds reg.

Consider bone strengthening medication for post menopausal women and men over 65 with #s. We can prescribe calcium (eg calcium carbonate 1.5g bd) and vitamin D (eg Colecalciferol 1.25mg once a month). They need to see their GP to obtain bisphosphonates (eg alendronate).

Analgesia/sedation:

Give good doses of oral analgesia eg paracetamol 20mg/kg loading dose, ibuprofen 10mg/kg.

Bier’s blocks: intravenous local anaesthesia of the whole limb (usually upper limb).  Variable availability and protocols.

More often haematoma blocks +/- procedural anaesthesia are more often used in EDs – talk to a senior doc to help with this.

Analgesia: eg fentanyl 1µg/kg IV or 3µg/kg IN,  and Entonox (50% nitrous oxide) or 70% nitrous oxide.

Sedation eg IV midazolam eg 1-2 mg for adults (or 0.5mg in the elderly) or get a senior doc to help with procedural anaesthesia.

Salter Harris classification of physeal injuries.

S slipped SH1
A above SH2
L beLow SH3
T Through SH4
ER er … the mnemonic falls apart – squashed SH5

Usually worse as you go down the list.

Fracture Immobilisation

Fingers, toes, metacarpals 3-4/52

Otherwise generally 6/52 for adults, 5/52 paeds, or less for minor greenstick #s in very young

Follow-up for #s

Generally weekly XR till # thought to be stable eg 3 weeks for adult #s needing manipulation. Occasionally another X-ray at the end of splintage/casting (not usually needed for buckle #s, minor greensticks) to check position, and that the # has healed in, plus likelihood of needing further treatment if some displacement remains.

Work and sport post injury

Generally avoid injury after ROP or removal of sling for same length of time as was in cast/sling (ie generally

6/52 adults, 5/52 kids)

COMPLEX REGIONAL PAIN SYNDROME = REFLEX SYMPATHETIC DYSTROPHY (Sudeck’s Atrophy)

- consider in any patient with pain or swelling/stiffness/parathesia/hyperasthesia/cyanosis persisting after the first few days

- even if symptoms due to ? tight plaster needs review at 24 hours post CHOP to ensure symptoms resolving

- ortho review if not settling

-Intensive physio is the mainstay of treatment

Abbreviations

AEPOP – above elbow plaster

AKPOP – above knee cast

BAS – broad arm sling

BEPOP – below elbow plaster

BKPOP – below knee plaster

BKWPOP – below knee walking plaster

C+C – “collar and cuff” sling

CHOP – change of plaster (often from FG reinforced POP to a FG only cast)

COP – completion of plaster (reinforce split POP with layer of FG)

COD – change of dressing

FG – fibreglass plaster

FOOSH – fell on outstretched hand NIX – nurse-initiated x-ray

MUA – manipulation under anaesthetic

NAI – non-accidental injury

NBA – no bony abnormality (NBI – no bony injury)

NWB – non weight bearing

ORIF – open reduction internal fixation

POP- plaster of Paris plaster

PTB – patella bearing cast

PWB – partial weight bearing

ROM – range of movement

ROM brace – range of movement knee brace

ROP – removal of cast

ROS – removal of sutures/ or removal of splint

SKB – Scott knee brace

SNOH – surgical neck of humerus

STI – soft tissue injury

SI – shoulder Immobiliser

TA – tendo Achilles

TWB – touch weight-bearing

XROA – x-ray on arrival

SHOULDER INJURIES

AC JOINT INJURY

There are a total of six grades of severity of AC separations. Grades I-III are the most common.
grade I: sprain of joint without a complete tear of either ligament (no displacement)grade II: tear of AC ligaments w/ coracoclavicular ligaments intact; will not show marked elevation of lateral end of clavicle; (50% displaced)

grade III: in this injury both AC & CC ligaments are torn; – 100% displacement of A-C joint

grade IV: distal clavicle impaled posteriorly into trapezial fascia; – check on axial x-ray

grade V This is type III but with more vertical displacement of the clavicle from the coracoid 100-300% greater than the normal side, with the clavicle in a subcutaneous position. (Ruptured through the deltotrapezial fascia)

ACJT displacement of grade VI This is a rare injury. This is type III with inferior dislocation of the lateral end of the clavicle below the coracoid.

Grade 1-2 -GP follow up – BAS for a couple of weeks until swelling settles

Grade 3 – BAS with 2/52 ROM. Consider discuss grade 3 with Reg if dominant side – refer if overhead activities/athlete (Plumber/ Electrician/ Tennis player) – BAS

Grade 4-6 – BAS and refer to on-call Reg for inpatient Surgical treatment

http://www.physiotherapyassociates.com.au/index.php/conditions/conditions-of-the-shoulder/ac-joint-sprain/

CLAVICLE #

BAS (no collar and collar)

2/52 ROM check – check swelling and skin over #/ XR check position

6/52 XR ROM Check to ensure callous formation (if not settling at 6/52 refer to consultant)

See again at 10/52 if no callous

100% displaced with > 2.5cm shortening refer to consultant, or skin tenting or not settling at 6/52

DISLOCATED SHOULDER

Must have AP/axial/lat as standard views + axial/AP post-reduction

Anterior

Multiple methods of reduction. 2 low trauma methods are scapula rotation and Cunningham and its variants.

For all techniques use eg IV fentanyl 100µg, midazolam 1mg (0.5mg in elderly) + entonox or procedural anaethesia with a senior doctor.

Scapula rotation: patient prone, arm hanging over side of bed. One person provides downward traction on arm, another person pushes tip of scapula medially.

Cunningham: patient sits with affected hand on your shoulder holding onto your clothes. You stand, link your hands over patient’s elbow, bend at the waist and gently pull down on the elbow. May take 1-5 minutes to reduce, and may reduce without you or the patient noticing.

Supine Cunningham: patient lying on bed. Doc stands on bed. Flex shoulder to 45° and apply gentle steady longitudinal traction. Shoulder reduces over 1-5 minutes.

If this doesn’t work keep traction on and proceed to Kocher’s (towel pulling humerus out). If this doesn’t work -> MUA.

Test for reduction: patient is able to touch opposite shoulder with affected hand.

1st dislocation

- BAS 2-3 weeks if < 25 years old and active ref to consultants to consider surgery subsequent dislocations – some consultants immobilise 2-3 weeks – if > 2-3 dislocations with proven radiological dislocation then refer consultant clinic for stabilisation

if unreduced > 3/52 then danger of rupture of brachial artery during reduction and should be admitted

Ensure axial and lateral views of shoulder.

Posterior

Reduce by longitudinal traction, start pulling along the line of the humerus in what ever position the shoulder is in, aim to be pulling with arm abducted at 90°. One reduced immobilise in “gunslinger splint” from orthotics (this is the only thing orthotics will supply after hours)

BICEPS DISTAL TENDON RUPTURE

Operative repair. Refer to consultant. Proximal usually non-operative, unless young and physically active (<40yrs)

HUMERAL INJURIES

HEAD OF HUMERUS

Greater tuberosity #. -Minimally displaced.(5mm or less) -BAS -XR weekly for 3/52, then 6/52 -Moderately/grossly displaced (>5mm)

-d/w reg ?for ORIF

Head # involving joint surface

-d/w reg ? need CT

Check for signs of head split (double shadow of head) – refer

SURGICAL NECK OF HUMERUS

-markedly displaced(> 1cm)/angulated(?>45º) d/w nurses re acceptability, if they’re not sure d/w reg. May need handing cast to traction. May need ORIF (rare)

-always collar and cuff – not BAS

- weekly XR for 3/52, change to C+C

-6/52 ROM XR

HUMERAL SHAFT

Collar and cuff

Kids Rx as adults but require less time in cast. Displaced midshaft d/w ortho reg

Proximal #

- Hanging POP 5-6/52 with weekly XR for first 3 weeks

Mid-Distal shaft#

- undisplaced require Rose splint (U slab with outer part extending to shoulder tip (prevents humerus hinging at top of u slab) Check XR. XR 1/52, then 2/52ly visits.

- Once callus visible change to clam shell = plastic removable splint from orthotics

- displaced discuss with reg

DISTAL HUMERUS

Medial epicondyle

- AEPOP unless displacement > 5mm -> ORIF

- may need XR comparison with other elbow

- CRITOL sequence of ossification of elbow growth centres: capitellum (“the capitellum is the cap that sits on the radial head”), radial, internal (medial), trochlea, olecrenon, lateral. It’s the medial epicondyle that is typically avulsed and missed. See Accident and Emergency Radiology. A Survival Guide in House Surgeons room in bone shop (chained to desk)

Lateral Epicondyle

- difficult to diagnose. Refer reg if uncertain.

- if displaced can be a serious injury. Some consultants admit for ORIF. Others AEPOP pronation f/u clinic 4-5 weeks

Supracondylar # (kids)

- Grade 1 (minimal displacement) – AEPOP elbow flexed at least 90° (backslab 1/52 then softcast) 3-4/52, or collar and cuff and flexed >90 degrees.

- Grade 2 (attached but displaced, angulated but no translation) – MUA/? Reduction under sedation -> cast high up arm elbow flexed >90˚ Check n.v. status afterwards. AEPOP 5/52. Refer to Reg

- Grade 3 ( 100% displaced/translated/rotated) – beware NV deficit. ORIF

ELBOW HAEMARTHROSIS

- look for sail signs: elevated anterior fat pad or any posterior fat pad seen on XR, ?radial head #

- Consider aspiration if large and tense + very painful

- if no # seen recheck in 1/52 +/- repeat XR if still has decresed ROM

ELBOW

DISLOCATED ELBOW

- Lots of analgesia/sedation. Reduce: one person applies lateral traction, another holds distal humerus from behind and uses thumbs to push olecrenon. Backslab 10/7 to 2/52

- 1-person reduction: pt supine with arm overhead: traction on forearm use thumbs to reduce olecranon

Pulled elbow

- radially deviate wrist (to push radius proximally), supinate, pronate, supinate. Feel click. Leave child for 10 mins. Obseve child using arm.

- discharge

Any Fracture plus dislocation

- refer ? ORIF

FOREARM #

RADIAL HEAD #

- unless significantly displaced( ≤3mm) or > 1/3 articular surface can be Rx conservatively in BAS

- key clinical question is ensure no mechanical hindrance to pronation or supination.

- (if patient will not secondary to pain may require aspiration of haemarthosis and LA injection

- ROM check at 2/52 +/- 4/52 if not back to normal

RADIAL NECK #

- treat conservative in AEPOP unless > 20˚ displacement which should be discussed with Reg

SHAFT FOREARM # KIDS

Often moulded (gently manipulated) in plaster with entonox +/- oral morphine (0.2mg/kg)

Displaced

- admit for MUA/ORIF

Nondisplaced transverse crack with no joint disruption

- AEPOP with f/u as per Colles’ – no repeat x-rays

Greenstick

- AEPOP/BEPOP 4/52, no repeat x-rays

SHAFT FOREARM # ADULTS

Midshaft radius and ulna or isolated midshaft ulna (night stick)(check it’s not a Monteggia) #

-If minimally displaced (<25%)/angulated (<10°) AE cast. f/u as for Colles’

-otherwise admit for ORIF

GALLEAZZI #

- Radius # causes distal radio-ulna joint disruption

- ORIF

MONTEGGIA #

- # thru proximal ulna causes dislocation radial head

- ORIF

WRIST INJURY

BUCKLE #

- backslab/soft cast 2/52. GP follow up (soft cast can be unwrapped – doesn’t require cast cutter). No x-ray

GREENSTICK #

Single Cortex, minor angulation

- BEPOP 3-5/52 depending on severity and age (kids heal quickly)

- Soft cast for very young

Both Cortex radius but no/minor angulation

- BEPOP 4-5/52

- can angulate therefore check XR 1,2,3/52 with CHOP and remould at 2-3/52 – if loose on x-ray

DISPLACED/ANGULATED COLLE’S/DISTAL RADIUS #

Generally all Colles’ manipulated but may accept volar or neutral angulation (of end of distal radius as seen on lateral), < 1mm shortening of medial end of distal radius relative to adjacent surface of ulna, < 1mm articular step. Kids under 12: Generally admit for MUA unless over 7 where Bier’s block may be considered (or haematoma block + IV analgesia + entonox). Then into AEPOP (below elbow if # within 2cm of wrist) 12 – 50ish: Biers block by anaesthetic SHO. If anaesthetic SHO not available may need to bring patient back next day (haematoma block and back slab overnight) or proceed under haematoma block etc as below (but use 1mg instead of 0.5mg midazolam). Then manipulate (see below) in BEPOP. Cast split before discharge >50ish: Haematoma block 10ml ropivocaine or bupivocaine 0.5% (max 3mg/kg) + 100µg fentanyl + 0.5mg midazolam + entonox. Then manipulate (see below) in BEPOP. Cast split before discharge

Manipulation: Traction (assistant holds upper arm, elbow flexed at 90°, shoulder abducted at 90°, you pull hand) for a few minutes. Extend wrist (to disimpact) if needed, then flex, palpate dorsum of wrist to ensure relocated. Very elderly and very comminuted fractures may be better with just traction rather than flexion (which may just impact volar lip) and casted in neutral position. Hold thumb and maintain traction while nurse plasters. Nurse then takes thumb, still tractioning. Dr moulds cast till it sets: pressure with palms on volar surface of forearm just proximal to # & dorsal surface just distal to #, wrist flexed c. 30° & ulnar deviation (ulnar deviation occurs naturally with traction on thumb).

Follow up 1/52: COP and XR

2/52: XR

3/52: CHOP + XR (consider CHOP to BEPOP in kids)

6/52: ROP and XR

SMITHS #

- reduce with opposite movements and moulding to Colles’, immobilise in AEPOP in supination with follow up as per Colles’. May CHOP to BE at 3/52 if bone not too crumbly.

- admit for ORIF if post reduction films inadequate

RADIAL STYLOID = CHAFFEUR’S #

Assess for ulna impingement symptoms. Consider scapho-lunate ligament injury (need bilateral clenched fist views if considering scapho-lunate dissociation)

Usually undisplaced. Treat with Colles’ cast

>2mm intraarticular displacement

- discuss with ortho reg ?admit for ORIF, ? attempt reduction (traction and ulna deviation) and refer consultant clinic

BARTON = DORSAL LIP #

Attempt reduction as for Colles’ with traction and flexion of wrist. Follow-up same as Colles’. May need ORIF.

SCAPHOID#

Any FOOSH with scaphoid tenderness POP for 10/7 and re xray scaphoid.

Or if they are employed patient can be sent for private MRI. Needs to have B/Slab applied – as needs to be removed for MRI. Patient needs to be told to return in afternoon before 1600 if MRI in a.m., or next a.m. if MRI in afternoon. This allows time for report of scan to be done. Ensure patient phone number and ACC number on forms – and questionnaire for MRIs is completed.

Definite # (mid-waist or distal #s)

- BEPOP (or FG if minimal swelling) no need to include thumb

- 1/52 CHOP to FG if initially in POP

-6/52 ROP XR

-> 6/52 check tenderness settling, if still uncomfortable CT to check % of healing

Clinical #

- BEPOP 2/52 with ROP + XR. If # confirmed FG cast and f/u as above.

Scaphoid tubercle #

- BEPOP 4-5/52 for comfort

Proximal scaphoid # – refer for ORIF (and displaced #s)

Mr Beadel would like his scaphoid #s referred to his next clinic for consider of operative vs non-operative management. If the MRI scan demonstrates a partial scapholunate ligament injury or an extrinsic dorsal ligamentous injury then the patient is to be treated with a Tubigrip bandage, given a referral for a removable splint and Hand Therapy for a rehab programme. They should be prescribed a NSAID if medically appropriate and not contra-indicated. If the MRI scan demonstrates an acute complete scapholunate ligament rupture then the patient is to be left in their cast and referred to the Hand Consultant’s next clinic for an opinion.

HAND INJURY

Use ring blocks before any manipulations. Use Entonox when putting in ring block

BASE of 1ST METACARPAL # (Bennetts)

(Rolando # = comminuted/3 part # base with intra-articular component)

Displaced/> 30°/intraarticular (ensure true AP and Lat films)

- closed manipulation: median & radial nerve blocks + haematoma block, tape on end of thumb so it can be tractioned in cast, pressure on radial aspect of base of 1st MC with pressure on ulna aspect of distal 1st MC and 1st metacarpal in maximum extension in thumb spica 4/52

- if good reduction weekly XR for next 2 weeks as can slip early. Cons clinic f/up

- Poor reduction -> ORIF (hands team)

Minimally displaced (30° angulation of extraarticular # acceptable)

- Thumb spica 4/52 (usually split POP as quite swollen)

METACARPAL #’s

- Ensure no rotational deformity clinically

- Moulded volar slab with buddy strap (applied with MCPJs at > 60’ and IPJs at almost full ext)

- 1/52 CHOP to FG “volar cast” (circumferential cast from proximal forearm to MC heads) + buddy strapping for further 2-3 weeks

- 3-4/52 ROP and XR (total 3-4/52 in cast)

- Recheck for rotational deformity before discharge

Spiral #

- 5mm shortening acceptable, less at neck if spike is prominent

Neck of 5th Metacarpal

- if able to actively extend to neutral and no rotational deformity then reduction not necessary (but often done anyway). Neighbour strap for 2-3/52.

- otherwise reduce in POP by direct pressure over volar aspect of head 5th MC and dorsum of metacarpal

Transverse # 4th Metacarpal

- High incidence shortening cosmetically disfiguring

- check line of metacarpal heads on AP.

- If head of 4th MC is more proximal than 5th MC head then d/w Hands Reg

FINGER DISLOCATIONS

Dorsal DIP dislocations

- reduce, immobilise in 20-30 degrees of flexion (short Zimmer splint) to prevent resubluxation for 2-3/52

- ROM check at 2/52

Dorsal PIP dislocations – Hand therapy ASAP

- reduce, immobilise in dorsal blocking splint 30 degrees of flexion to prevent resubluxation for 2/52

- splint extends MCPJ to fingertip along dorsum of finger with flexion at PIPJ. Tape over prox phalanx

ensuring finger can flex from PIPJ but not reach full extension

- ROM check at 2/52 and until full ROM

Volar dislocations

- result in boutonniere deformity and must be referred to hand clinic

THUMB MCPJ UCL INSTABILITY/RUPTURE

- examine X-ray before stressing ligament to ensure no avulsion #. If avulsion displaced >2mm refer to Hands

Complete Rupture

- inject local anaesthetic before testing. If confirmed refer to hand team for repair

Laxity with end point

- Thumb spica 3 – 6/52 until non-tender. Consider USS “?stener lesion” if unsure. No stener lesion spica 6/52, stener lesion needs surgery.

THUMB MCPJ RCL STRAIN

- Thumb spica 2-3/52 for pain relief

MALLET DEFORMITIES

No Associated Avulsion #

- Hyperextend distal phalanx with mefix, then place into Mallet splint (may need padding) 6/52

- refer to Hand Therapy (Physio Dept @ CPH or private) for custom made mallet splint.

- @ 6 weeks wean off splint over next 6 weeks – see pamphlet

Associated Avulsion #

If volar subluxation or joint surface incongruent will need admission for reduction and K wire. Otherwise treat as for no #, but XRay @ 6/52

In children with Mallet deformity check nail bed involvement prior to Rx

BOUTONNIERE AND CENTAL SLIP EXTENSOR TENDON INJURIES

“Circumferential finger base splint” from Hand Therapy. If after hours Zimmer splint in extension and go to Hand Therapy next working day

PHALANGEAL SHAFT#

- Check rotational deformity clinically

Undisplaced out to length fractures without rotational deformity

- Zimmer splint (foamy aluminium thingy, attached to finger without traction) 4/52 – if sagittal displacement. (If coronal displacement or rotation buddy-strapping +/- Zimmer splint)

Displaced/shortened/rotated

- Southhampton traction splint 4/52 (aluminium strip along volar surface of hand and with finger taped to end of splint, splint and finger flexed at MTPJ to provide longitudinal traction). Weekly XR 2-3/52.

- Beware circulation to finger can be compromised

Greenstick # base of proximal phalanx – often little finger

- occasionally can put in digital block. Often offer Entonox and put tip of pen between #ed finger and neighbouring finger and use pen as fulcrum to assist finger reduction. Buddy strap and re-xray

INTRAARTICULAR # IPJ’s

Condylar #/ collateral ligament avulsions

- displaced: call hand reg ? ORIF

- Nondisplaced: Buddy strap and refer hand clinic

Dorsal Avulsion Base Middle Phalanx

- displaced: hand reg for ORIF

- nondisplaced: splint in extension for 4/52 with check XR 1 wk and needs hand clinic

Volar Avulsion Base Middle Phalanx

If > 20% area then unstable so extensor blocking splint from Hand therapy (or Zimmer extensor blocking splint out of hours) and refer to hand clinic

FINGER TIP INJURIES

Open wounds shouldn’t be seen in bone shop but be aware that nail avulsions and subungal haematoma > 50% of nail area may require nail removal and nail bed repair. D/W hands reg.

PHALYNGEAL TUFT #

- finger cot splint. GP follow up.

- NB if displaced transverse # will not reduce contact hand reg ? nail bed caught in #

KNEE

(As per Mr Vincent’s knee teaching session)

Most of the diagnosis is in the history. The following questions help with the diagnosis:

- What was the mechanism of injury?

- Did you hear a noise?

- Any direct impact to the knee?

- Any swelling, and how quickly did the knee swell?

- Did you end up on the ground?

- Did you finish playing?

- How did you get off the court/pitch?

ACL injuries

Often missed in OOPD

Classic history is landing from a jump, pivoting to change direction, orside-stepping, e.g. in netball/soccer/rugby/touch.

If the patient heard a “pop”, with a knee effusion, the injury involves the ACL until proven otherwise (differential diagnosis is meniscal injury or dislocated patella, but less common)

The knee swells within the first hour, indicating a significant injury.

Usually unable to weight-bear

O/E: effusion, often pain/tenderness laterally. Try to assess co-existing collateral ligament injury.

X-ray: often normal. Flake of bone off lateral tibial plateau (segond lesion) is pathogenic of ACL lesion.

Treatment: Tubigrip, RICE, WB as able, physio early

Follow-up at 2 weeks: if examination positive for ACL injury, refer to Consultant clinic.

Patella Dislocation

Need x-rays of knee and skyline patella (which may show # to medial patella). Should be treated with patella orthosis (neoprene splint) NOT a ROM brace.

Early physio

Follow-up at 3-4 weeks to ensure good progress and not missing another injury.

If 1st dislocation – continue physio.

If 2nd or 3rd consider referral to Consultant clinic for discussion re possible surgery – if skeletally mature, and patient wants to discuss potential surgery. If patient definitely doesn’t want to have an operation – don’t refer, just continue with surgery.

MCL Injury

The patient has to have had direct impact to their knee, e.g. tackle to lateral knee

Knee usually doesn’t swell as injury is extra-articular

Pain medially

The patient will often try to play on, but too sore. Usually manages to walk off field.

ROM for grade III MCL injuries only, to prevent valgus deformity

Meniscal Injury

History of sideways twisting injury, often in a middle-aged patient, with pain medially – many have a medial meniscal injury.

Often an effusion

Tender medial knee and pain on valgus stress, often misdiagnosed as MCL injury

Locked knee indicates bucket handle meniscal tear

Patient usually squatting/flexed knee, then unable to straighten knee. Patient can often wiggle leg to straighten it. May hear a clunk.

Treatment: RICE, physio

If locked knee – don’t need to try to unlock it in OOPD, as will unlock itself

OK to ride a bike, don’t run

Takes 6-8 weeks to settle

LCL injury

Lateral knee pain, is often non-specific

LCL injury is often caused by hyperextension of the knee, or pedestrian hit by a car. If lateral ligament laxity – needs to be dealt with acutely i.e. call on-call Registrar.

Fractured Patella

Displaced – D/W registrar as need surgery

Undisplaced (<3mm diplaced, < 2mm articular step)

- 4/52 scott knee brace/ROM brace locked extension

- then 2/52 0-30 degrees flexion

- at 6 weeks can increase to full ROM and wean off splint

KNEE SPRAINS

Often knee injuries are hard to assess on the first visit. If in doubt treat in a ROM brace (from orthotics), unlocked except for for patellas, and review 2/52.

Likely Ligament injury

- ROM BRACE unlocked (or Scott Knee Brace short term) and crutches

- review 2/52

- refer consultant clinic if definite significant laxity

Minor knee sprains

- Tubigrip, crutches and GP follow up

LOWER LEG

TIBIAL PLATEAU #

-Look for widening of tibia on AP (eg EHS7622 31/3/07). If suspicious request an oblique XR.

- if minimally displaced: tubigrip with ROM brace in extension. XR and ROM 2/52

- otherwise d/w reg re ORIF

TIBIAL SHAFT

Spiral undisplaced

Hang lower leg off end of bed while casting.

Baby to toddler

- AKsplitPOP 4/52 with COP/CHOP at 1/52

5-10 years

- AKPOP 5-6/52 with COP/CHOP at 1/52 if required. Consider PTB for further 2/52

10+ years

Consider admission for elevation and analgesia

- AKPOP 6/52 then CHOP to PTB cast 4/52 if signs radiographic union

TIBIAL # – displaced

- ortho reg ?IM nail/ORIF

TIBIAL CRACK #

- AKPOP 2-3/52 then PTB until 6/52

SHAFT FIBULA #

- ensure isolated injury eg direct blow

- check ankle ? ligament injury with interosseous ligament involvement

- softcast (or just tubigrip if not too sore) 4/52, weight bear as tolerated

ANKLE INJURIES

ANKLE FRACTURES

Weber system describes the position of the fracture line on the medial side of the fibula

Weber A # (# fibula distal to talo-tibial jt line)

- very stable. BKPOP 4/52. WB in cast from 1-2/52 or avulsion # very small consider moonboot/tubigrip – dependant on pt age

Weber B # (# fibular @ talotibial jt line)

- BKsplitPOP, COP + XR (including mortice view) at 1/52, XR 2/52, CHOP + XR 3/52, ROP + XR 6/52. Partial WB with cast shoe for last 10/7 only

- D/w ortho ? ORIF if

1) medial malleolar tenderness on exam

2) talar shift

-if talar shift reduce: consider haematoma block. Good IV and inhaled analgesia. Reduce by pressure on lateral malleolus and medial mid lower leg. Place into full cast –(bivalved prior to admission – see note below in # dislocation heading). If posterior malleolus as well: support heel and let tibia drop backwards to help reduce posterior malleolar #. Reg will decide on further Mx after viewing pre and post reduction film.

Weber C # (fibular # above ankle joint, but not from direct blow on fibula)

- ORIF

# Dislocation

- Consider haematoma block. Good IV and inhaled analgesia. Reduce. Place into full cast, (which is bivalved to enable swelling check on ward prior to ORIF – but helps avoid redislocation). If posterior malleolus as well: support heel and let tibia drop backwards to help reduce posterior malleolar #

- ORIF

Minor Avulsions

- weight bearing BKPOP 2-4/52 (backslab 1/52 if swelling)

Medial malleolar # (except small avulsions)

-ORIF in Christchurch

TA Rupture

Conservative = 10- 12% rupture rate at 1 year

= 3/12 rehab (2/52 equinus cast, 4/52 moon boot only taken off for seated shower or bath (NWB)(full plantar flexion to 20 degrees plantar flexion), 4-6/52 heel raisers and physio – patient can be discharged to physio/GP at 6/52, with referral back if there are any problems)

Operative = NOT FOR SMOKER/PVD/OLD/DM

= Treatment of choice for delayed presentation

Week 0-2 post-op gravity equinus cast till Consultant wound check

Week 2-6 Moonboot hinged with ROM from full plantar flexion to 20 degrees plantar flexion.

The moonboot can be removed for showering and at night, but patient should remain

NWB

advantages: same 3/12 rehab total

reduced 1 year rerupture rate 1 year of 3-5%

disadvantages: scar problems/neuroma

1% chance infection (devastating)

FOOT INJURIES

TALUS FRACTURES (other than minor avulsion)

- Backslab, admit for CT.

SUBTALAR DISLOCATION

- Don’t need admission or operation, but do need reduction.

- NWB in cast.

- 6/52 ROP and XR

CALCANEAL FRACTURES – may need CT to assess
Consider acetabular and spinal #s

extraarticular Os Calcis #

- backslab. Don’t need admission.

- various recommendations re weight bearing (PWB from a week – NWB 6/52)

- 1+2/52 XR

Intrarticular Os Calcis #

- ortho reg

METATARSAL #

- NWB first 2/52

- BKPOP Backslab 1/52. CHOP XR at 1/52. ROP XR 4/52.

- Lis franc for reg review – need WB x-rays to consider this diagnosis ? other imaging

GREAT TOE

Proximal phalanx #

- Toe Spica CHOP XR at 1/52, ROP 3/52

Bony Mallet

- Toe Spica CHOP XR at 1/52, 2/52 XR, 4/52 ROP

OTHER TOES

- treat # and dislocations with buddy strap

Enjoy

(Speedy) Dan Hartwell and Chris Cresswell

June 2007

Edited by Mr Malone October 2010

Wrist # image from: http://www.orthopaedicsone.com/pages/viewpage.action?pageId=82116701

The post Fracture management appeared first on EM Tutorials.

Between a rock and a hard place.

Audio:

64M with exacerbation of CCF with angina at rest. Hx 50% LAD stenosis 3 years ago -> no intervention, CCF with EF 25%, pulmonary hypertension with RV dysfunction, COPD on home O2, chronic AF on warfarin (therapeutic + d-dimer negative).

He was on frusemide 40mg bd, sprinolactone, warfarin, digoxin and several inhalers.

In slow AF. BP 110 systolic, JVP to ear lobes, fine creps both bases, pitting oedema to knees.

Responded well to GTN

Given a GTN patch to be removed the next evening, started on low dose ACEI (cilazapril 0.5mg) and frusemide increased from 80mg/day to 120mg/day.

Kept in ED overnight and apparently looked good the next morning and discharged.

Woke from a nap @ 1400 same day with headache, feeling faint, SOB.

HR 75, BP 75 systolic, sats 85% on 5L Hudson, JVP to ear lobes, fine creps both bases, pitting oedema to the knees.  GFR had dropped from 47 -> 31 over night.

He’d been given 300ml of saline in the ambulance but his BP had dropped further.

Shite

Caught between a rock and a hard place.  Over-loaded and hypotensive.

In retrospect all those vasodilators dropped his RV filling too much given his pulmonary hypertension.

Hmm.  Frusemide or GTN will drop his BP worse.  Pressor might worsen his left heart failure.

The ambos have already tried a fluid load which appears to make things worse (Amal Mattu says to consider PE in anyone who behaves this way.  This patient is on therapeutic warfarin and had a negative d-dimer the day before).

In these circumstances we usually reach for dobutamine.  Traditionally starting at 2.5 mcg/kg/minute.  This was started peripherally then a central line was put in.

Central lines are easy in patients like this because of the dilated central veins.  The patient can have the central line put in with them sitting enough so that they can breath. The vein stays dilated with them sitting up, and with a raised CVP there is no chance of sucking air into their vein (so long as the JVP is still visible at the ear lobes)

High flow oxygen and dobutamine titrated up to 6.5mcg/kg/min improved his heart failure and got him peeing out his excess fluid. Unfortunately when they tried to wean him of dobutamine he deteriorated again and was transferred to a tertiary unit in the hope another angiogram might find a treatable lesion.

So in recent times we have moved away from frusemide to greater use of GTN and ACEI, and we are frequently able to treat and discharge from ED with close GP follow up. Unfortunately patients with right heart failure sometimes do poorly with this strategy. This patient would probably done better with just diuretics, and triple therapy was too aggressive for him.

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Rock and a hard place images from http://www.tumblr.com/tagged/rock%20and%20a%20hard%20place

Music: “What’s happened to Soho” by the Correspondents https://itunes.apple.com/nz/album/whats-happened-to-soho-ep/id427171298

The post When Vasodilators Are Not So Good For Heart Failure appeared first on EM Tutorials.