Regarding the diagnosis of compartment syndrome, which ONE of the following statements is TRUE?
Answer: A: The initial symptom of compartment syndrome in an awake patient is pain and this becomes excessive and out of proportion to the extent of the injury. Pain has an usual onset within a few hours from the injury. However, the onset can be delayed up to 48 hours. Both active and passive stretching of the affected muscles cause excessive pain. Accompanied with pain are the symptoms secondary to dysfunction of the nerves in the compartment, especially paraesthesia in the nerve distribution occurs. Motor dysfunction can occur but this is usually late. Permanent nerve damage can occur within approximately 8 hours. Limb ischaemia is a late feature, therefore the limb may be warm to touch and there could be an easily palpable pulse in the early stage.
In compartment syndrome irreversible damage to the nerves and muscles occur 8 hours after the onset. Functional impairment can be prevented by prompt diagnosis and treatment within 6 hours.
Reference:
Regarding an elderly patient with a fractured neck of femur, which of the following is the MOST appropriate ED management?
Answer: C: A fractured neck of femur in the elderly is associated with high mortality and morbidity. The aims of ED management in these patients are: early diagnosis; detailed medical evaluation to identify and stabilize concurrent medical issues such as associated acute myocardial infarction, cardiac arrhythmia, stroke, sepsis and dehydration; provision of adequate analgesia; and prevention of complications such as pressure sores, hypoxia and deep venous thrombosis or pulmonary embolism. Delay to surgery beyond 48 hours has been identified as a compounding factor affecting survival in these patients and is associated with an increased major complication rate. As early surgery is recommended in most patients, detailed medical assessment should be done to identify and stabilize associated medical conditions. In the ED a three-in-one femoral nerve block is recommended as an effective method of providing analgesia (NHMRC grade A recommendation). In this method, in addition to the femoral nerve, the obturator nerve and the lateral cutaneous nerve of the thigh are blocked because these nerves substantially supply the hip joint.
Preoperative skin or skeletal traction is not useful because there is no evidence to support its use (Grade A recommendation). There is some evidence to support the use of oxygen therapy in these patients (Grade B). A regular pulse oxymetry check should be performed and oxygen should be provided as required in the ED. In addition, the patient should be placed on a pressure-relieving mattress and appropriate measures should be taken to prevent pressure sores (Grade A). The patient should be wearing pressure-gradient stockings (Grade A).
References:
An 82-year-old woman presents 3 days after a mechanical fall at home. She has mild dementia. Since the fall she is able to walk but with considerable right hip pain. Her leg is not shortened or externally rotated. On examination, she has some tenderness in the right inguinal region and has restricted active range of movement due to pain.
She has almost full passive range of movement with pain in that hip. Her pelvis X-ray and AP and lateral right hip X-rays appear normal. Regarding an occult neck of femur fracture, which ONE of the following is TRUE?
Answer: A This is a relatively frequent scenario where an elderly patient presenting to the ED with hip pain and inability to fully weight-bear but has normal-appearing pelvic and hip radiography. In this scenario, a thorough examination is necessary to exclude other possible injuries such as a missed femoral shaft fracture. Hip radiographs should be examined for subtle signs of a nondisplaced neck of femur fracture. These subtle signs of a nondisplaced fracture include a:
To prevent delay in the diagnosis of an occult fracture and complications such as avascular necrosis, and late displacement associated with it, the best approach would be to proceed to either CT or MRI. MRI is more sensitive than CT in detecting occult fractures. When subtle signs of occult fractures are present on plain radiography, CT is useful to confirm the fracture. However, in a patient with clinical findings that are suggestive of a fracture, if the CT is normal, a further MRI may be necessary to exclude a fracture. MRI is able to identify an alternative injury such as a pelvic fracture, intertrochanteric fracture or soft tissue injury. Diagnosis of a hip sprain or contusion in an elderly patient should be made only after a careful exclusion of an occult fracture. Bone scans are not frequently used as an imaging modality to exclude occult neck of femur fractures. Although a bone scan could detect fracture (sensitivity 90–95%), it takes 3–5 days for new bone formation at the fracture site and hence a bone scan will be negative until that time. Bone scans are relatively non-specific because other conditions may cause abnormal uptake.
Regarding hip dislocation, which ONE of the following statements is INCORRECT?
Answer: B: About 90% of hip dislocations are posterior and 10% are anterior. Anterior dislocations can be anterior superior or anterior inferior. Acetabular and femoral head fractures are frequently associated with hip dislocations. These fractures may not be easily identifiable on initial X-rays and therefore should be evaluated using a post-reduction X-ray, especially Judet views or CT scans.
Any delay in reduction of a dislocated hip increases the rate of avascular necrosis of the femoral head, therefore all hip dislocations should be reduced within 6 hours either in the ED or in the OT. Interposition of the capsule or tendons in the joint may interfere with easy reduction in the ED. Numerous repeated attempts at reducing the hip in the ED should be avoided and emergent closed reduction should be arranged in the OT under general anaesthetic.
Regarding collateral ligamentous injuries of the knee, which ONE of the following statements is INCORRECT?
Answer: B: Injuries to the medial collateral ligaments are more common than lateral ligaments as in most instances the forces such as abduction, flexion and internal rotation of the femur on the tibia are applied to the medial side. There could be a sprain, partial tear or complete tear involving the collateral ligaments. During examination laxity should be elicited with valgus and varus strain, first at a 30-degree knee flexion and then with the knee fully extended. Examination findings should be compared with the normal knee. When the knee is flexed at 30 degrees, and there is no laxity but pain is produced, the injury can be considered a sprain. If the laxity is <1 cm and it stops with a firm end point the injury is likely to be a partial tear. If the laxity is >1 cm and there is no end point it is a complete tear. If the laxity is present in full extension of the knee it indicates a more severe injury to the knee, with involvement of the capsule and cruciate ligaments.
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