discussing the details of limbs injuries of upper and lower limbs

1. AHMAD SALADDIN SULTAN
M.B.Ch.B, M.R.C.E.M, F.J.M.C.H.S.(A&E)
Specialist Emergency Medicine

2. I Dr. AHMAD SULTAN
DO NOT have a financial interest/arrangement or
affiliation with anyone in relation to this
program/presentation/organization that could be
perceived as a real or apparent conflict of interest
in the context of the subject of this presentation.

3. -Reviewing common injuries presented to PHCC.
-Recognizing the complicated types of fractures
and how to deal with according to the PHCC
policy.
-Indications for radiology use in some injuries.
-Reviewing some maneuvers for reduction.
-Indications for referral to ED or for outpatient
follow up.

4. Is a medical condition where the continuity of the
bone is broken.
Caused either by trauma or medical problems
majority are caused by trauma.
It is one of the commonest presentations to ED
and WIC in PHCC.

6. Classifications:

7. Classifications:

9. The important elements of history should focus on:
Traumatic or non-traumatic.
When, where and how the injury occurred.
Establish mechanism of injury
Pain(SOCRATES)
Swelling
Bruising/redness
Wounds
Reduced or loss of function
instability
Deformity/dislocation or muscle wasting

10. The clinical examination should include:
a) Inspection.
b) Palpation.
c) Movement.
d) Special tests including muscle power, vascular and neurological
examination.
e) Examination of joint above and joint below.
Investigations:
Imaging: X ray, CT and MRI.

12. Clinical Approach:
History.
Examination.
Imaging.
Management.

13. 1- Clavicle Fracture.

17. -Non displaced: If applicable apply figure 8
sling, analgesia and follow-up with general
clinic, otherwise refer to ED.
-Displaced: Analgesia, sling and referral to ED.

18. 2- Proximal Humerus Fracture

20. 3- Shoulder Dislocations.
1-Mechanism and types.
2-Presentation.
3-Examination.
4-Imaging.
5-Management, complications and disposition.

32. -Reduction with external rotation or alternatively scapular rotation and
prone traction. Analgesia for pain.
-Posterior dislocation: Analgesia, immobilization with sling and referral
to ED maybe a preferred option.

35. -Neurological
-Vascular
-Mechanical

36. Indications for referral to ED:
-All fractures should be referred acutely to ED.
-Refer all patients on anticoagulation therapy to the Emergency department.
-Dislocations.
-Pathological Fractures.
Review Red Flags of Shoulder Disorders
-Trauma, (sever pain, fracture, dislocation, sudden loss of function or
paralysis) .
- Sign of infection or malignancy .
-Acute shoulder dysfunction without trauma .
-Acute sign of inflammation/Arthritis.
-Acute shoulder problem with progressing upper arm neurological findings .
-Acute shoulder problem with disruption of upper arm circulation.

38. A-Dislocation.

39. -Commonly occur in the 2 – 6 age groups, usually caused by pulling of
the child’s arm through swinging the child by the arms, the child
falling while being held by the hand or a pull by an older
person/sibling.
-history of sudden pull, supination and pronation is difficult, no
swelling, bruising, warmth or erythema is found. X-rays only if diagnosis
is in doubt.
-Provide simple analgesia.
-Reduction techniques.
• If attempted reduction unsuccessful refer to ED.

42. 1-Olecranon Fracture.
2-Lateral condyle fracture.
3-Radial head Fracture.
4-Supracondylar Fracture.

51. 1- Monteggia Fracture.
2- Galeazzi Fracture.
3- Colle’s Fracture.
4- Isolated Radial Styloid Fracture.

52. 1- Monteggia Fracture.

53. 2- Galeazzi Fracture.

54. 3- Colle’s Fracture.

55. 3- Colle’s Fracture.

58. 4- Isolated Radial Styloid Fracture.

59. 1- Scaphoid bone Fracture.
2- Boxer’s Fracture.
3- Bennet Fracture.
4- Gamekeeper Thumb.

60. 1- Scaphoid Bone Fracture.

61. 2-Boxer’s fracture

62. 3-Bennet Fracture.

63. 4-Gamekeeper thumb.

64. • Severe trauma
• Displaced fracture
• Multiple fractures
• Acute tendon rupture

66. The important elements of history should focus on:
Identifying the joint position at the time of injury.
When, where and how the injury occurred.
Establish mechanism of injury
Pain(SOCRATES)
Swelling
Bruising/redness
Wounds
Ask whether the patient could weight bear immediately after the injury
instability
Deformity/dislocation

67. The clinical examination should include:
Observe where possible patients gait, balance, mobility, ability to
weight bear prior to examination.
a) Inspection.
b) Palpation.
c) Movement.
d) Special tests including Muscle power, vascular and neurological
examination.
Investigations:
Imaging: X ray, CT and MRI.

68. 1- Hip Fractures.
2- Hip Dislocation.
3- Femur Shaft fractures.

69. 1- Femur Fracture.

70. 2-Hip Dislocation

71. 1- Fractures.
2- Dislocation.
3-ligamentous injuries.

72. 1- Knee Fractures.
1-History.
2- Examination special tests and Ottawa Knee rule.
3-Imaging.
4-Types: Distal Femur Fracture, Proximal Tibial fractures,
Proximal Fibular Fractures, Patellar Fracture.

73. Ottawa Knee rule
-Age ≥55 years.
-Isolated tenderness of patella .
-Tenderness at the head of the fibula.
-Inability to flex the knee to 90 degrees.
-Inability to bear weight both immediately and in the
emergency department.

74. A-Distal Femur Fracture:

75. B-Proximal Tibial Fracture:

76. C-Fibular Fracture:

77. D-Patellar Fracture:

78. E-Special type:

79. 2- Knee Dislocations.
1-Patellar Dislocation.
2- Knee Dislocations.

80. A-Patellar Dislocation:

81. B- Knee Dislocation:

82. B- Knee Dislocation:

83. 3-Ligamentous injuries.
1-Medial Collateral Ligament injury.
2-Lateral Collateral Ligament injury.
3-Anterior Cruciate Ligament injury.
4-Posterior Cruciate Ligament injury.
5-Meniscal Tear

84. • All knee fractures warrant immediate referral to Emergency
Department.
• Immediate referral is also required for a locked knee due to suspected
meniscal entrapment, or where the diagnosis is in doubt.
• All Patellar dislocations need immediate referral if unable to reduce. Or
needs fracture clinic referral if a recurrent issues post reduction.
• All Suspected ligament rupture needs immediate referral.
• Patients with a delayed presentation of suspected meniscal injury
should be referred to Fracture clinic or with severe symptoms needs
referral to emergency department.

86. 1- Fractures.
2- Dislocation.
3-ligamentous injuries.

87. a- Ankle Fractures.
1-History.
2-Examination and Ottawa Ankle rule.
3-Imaging.
4-Managements.

89. 1- Maisonneuve fracture:

90. 2- Trimalleolar Ankle Fracture:

91. b- Ankle Dislocations.

92. c-Ligamentous injuries.
Ankle Sprain
1-Mechanism.
2-Presentation( History, Types).
3-Investigation.
4-Mangements.

93. Ankle Sprain
1-Mechanism.

94. Ankle Sprain
2-presentation and clinical evaluation:
History
- Evaluation of an injured ankle requires a careful history. It is
important to determine:
*The mechanism of injury in order to direct the rest of the examination
(Whether or not the patient could walk after the injury in order to help
stratify risk of fracture).
*Whether or not the ankle had been previously injured, as people who
sprain ankles are more likely to reinjure the same ankle.

95. Ankle Sprain
Types
• Grade I sprain: mild stretching and some damage to fibers with no
laxity on examination.
• Grade II sprain: moderate injury, frequently partial tearing of the
ligament. If the ankle joint is examined and moved in certain ways,
abnormal looseness (laxity) of the ankle joint occurs.
• Grade III Sprain: Complete tear of the ligament. If the examiner pulls
or pushes on the ankle joint in certain movements, gross instability
occurs.
2-presentation and clinical evaluation:

96. Ankle Sprain
3-Investigations:

97. a) Mild Sprain (Grade 1 Sprain) able to weight bears.
• Treated with RICE protocol (Rest, Ice, Compressive Dressing (splint),
and Elevation).
• Anti-inflammatory medications (if tolerated) can provide significant
improvement in the pain associated with ankle sprains and soft tissue
injuries.
but encourage them to gently weight-bear as soon as they are able
to do so.
• Exercise sheets if available. Begin weight bearing as soon as
symptoms allow
.
4- Management :

98. 4- Management :
b) Moderate sprain(Grade 2 Sprain) able to weight bear.
• Treated with RICE protocol (Rest, Ice, Compressive Dressing (splint),
and Elevation).
• Immobilization with an ankle braces if available or use tubi grip.
but encourage them to gently weight-bear as soon as they are able
to do so.

99. c) Severe Sprain (Grade 3 Sprain) unable to weight bears.
• Treatment requires immobilization in a short leg cast.
• Refer to Fracture clinic for further review or if severe may need to
be referred to Emergency Department for further assessment
• Grade 3 sprains can potentially go on to gross instability that
requires long term bracing, rehabilitation, or surgical reconstruction.
4- Management :

100. • All ankle fractures MUST be reviewed with Orthopedics, either emergently
(if indicated) or urgently (i.e. within the week at Fracture Clinic).
• Persistent ankle pain following injury which is suspicious for occult
fracture.
• Ankle sprain with ligament injury not responding to conservative
treatment.
• Recurrent ankle sprains should be referred routinely to Orthopedics via
Primary health care
• All Achilles tendon rupture should be referred to Emergency Department.
• Any fractures identified on X-ray should be reviewed with the Orthopedic
Surgeons/ Fracture clinic.

101. 1-History.
2- Examination special tests and Ottawa rule.
3-Imaging.
4-Types: Calcaneus fracture, Jones fracture, Fifth
Metatarsal Avulsion Fracture, Lisfranc Fracture-Dislocation.

102. 1- Calcaneus fracture :
Calcaneus Fracture: Bohler Angle. The Bohler angle is formed by the intersection of lines drawn
tangentially to the anterior (A) and posterior (B) elements of the superior surface of the calcaneus (C). A
normal angle is approximately 20 to 40 degrees.

103. 1- Calcaneus fracture :

104. 1- Calcaneus fracture :

105. 2- Jones fracture and Fifth Metatarsal Avulsion
Fracture :

106. 3- Lisfranc Fracture-Dislocation :

107. • All foot fractures MUST be reviewed with Orthopedics, either emergently
(if indicated) or urgently (i.e. within the week at Fracture Clinic).
• All Calcaneal fracture should be referred to orthopedic team immediately.
• All open fractures, compound fractures and crush injuries should be
referred to orthopedic team immediately.
• Severe metatarsal injuries may need admission for further assessments
• Recurrent foot sprains should be referred routinely to Orthopedics via
Primary health care.
• All fractures identified on X-ray should be reviewed with the Orthopedic
Surgeons/ Fracture clinic.

109. References
Atlas of Emergency medicine 4th edition, 2016
PHCC Policy Database
https://lifeinthefastlane.com
https://www.uptodate.com
https://radiopaedia.org/
https://emedicine.medscape.com