Category: Trauma

Question Of The Day #68

question of the day
~ Joseph Ciano, USA ~ Leave a comment
Which of the following is the most appropriate next step in management?
  • A) Admit to the hospital for pain management
  • B) CT scan of the chest, abdomen, and pelvis
  • C) Placement of chest tube
  • D) Incentive spirometry

This elderly man presents to the Emergency Department after a mechanical fall down the stairs with left flank pain.  He is on anticoagulation.  His chest X-ray shows 3 lower rib fractures.  The diagnosis of rib fractures is clinical in conjunction with imaging.  A history of rib trauma with pleuritic chest pain, tenderness over the ribs, and skin ecchymoses over the chest all support a diagnosis of rib fracture.  Chest X-ray is often performed as an initial test, but it should be noted that about 50% of rib fractures are not able to be visualized on chest radiography alone.  Bedside ultrasonography and CT scanning are more sensitive in detecting rib fractures than plain radiography.  Treatment for rib fractures is mainly supportive and includes pain management and incentive spirometry (or regular deep inspiratory breaths) to prevent the development of atelectasis or pneumonia as complications.  Many patients with rib fractures can be discharged home with these supportive measures.

Another important part of rib fracture management is evaluation for the complications or sequalae of rib fractures.  This includes pulmonary contusion, pneumonia, atelectasis, flail chest, traumatic pneumothorax or tension pneumothorax, hemothorax, and abdominal viscus injuries.  Elderly patients with multiple rib fractures are more likely to have poor outcomes and should be admitted for close observation.  Admission to the hospital for pain management (Choice A) may be needed in this case, but it is not the best next step.  Placement of a chest tube (Choice C) is not needed in this case as there are no signs of a pneumothorax.  Incentive spirometry (Choice D) is important to prevent atelectasis or pneumonia, but it is not the best next step.  The presence of multiple lower rib fractures (ribs #9-12) as seen in this case should prompt evaluation for abdominal injuries, such as hepatic or splenic lacerations.  Potential abdominal injuries should be of greater concern since this patient is on anticoagulation for his atrial fibrillation.  The best next step is a CT scan of the chest, abdomen, and pelvis (Choice B).

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Question Of The Day #67

question of the day
~ Joseph Ciano, USA ~ Leave a comment
SS Video 2 Large Pericardial Effusion

Which of the following is the most likely cause of this patient’s condition?

  • A) High cardiac preload
  • B) Low cardiac afterload
  • C) Low cardiac output
  • D) High cardiac output

This patient arrives in the Emergency Department after sustaining penetrating chest trauma and is found to be hypotensive, tachycardic, and with a low oxygen saturation on room air. The first step in evaluating any trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.  After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history. 

The FAST exam is a quick sonographic exam that requires the practitioner to look at 4 anatomical areas for signs of internal injuries.  The 4 areas are the right upper abdominal quadrant, left upper abdominal quadrant, pelvis, and subxiphoid (cardiac) areas.  The addition of views for each lung (1 view for each lung) is known as an E-FAST, or extended FAST exam.  The presence of an anechoic (black) stripe on ultrasound indicates the presence of free fluid.  In the setting of trauma, free fluid is assumed to be blood.  The presence of free fluid on a FAST exam is considered a “positive FAST exam”.   This patient’s ultrasound shows fluid in the pericardiac sac which in combination with the patient’s hypotension and tachycardia, this supports a diagnosis of cardiac tamponade.  See the image below for labelling.

Cardiac tamponade is considered a type of obstructive shock.  As with other types of obstructive shock, such as pulmonary embolism and tension pneumothorax, there is a state of reduced preload and elevated afterload.  This causes a reduction in cardiac output (Choice C) which leads to hypotension, tachycardia, and circulatory collapse.  High cardiac preload (Choice A), low cardiac afterload (Choice B), and high cardiac output (Choice D) do not occur in cardiac tamponade.  Treatment for cardiac tamponade includes IV hydration to increase preload, bedside pericardiocentesis, and ultimately, a surgical cardiac window performed by cardiothoracic surgery. Correct Answer: C

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Question Of The Day #66

question of the day
~ Joseph Ciano, USA ~ 1 Comment
40.1 - Pneumothorax 1

Which of the following is the most likely diagnosis of this patient’s condition?

  • A) Hemorrhagic shock
  • B) Traumatic tension pneumothorax
  • C) Cardiac tamponade
  • D) Traumatic non-tension pneumothorax

This man presents to the Emergency Department with pleuritic chest pain, shortness of breath after a penetrating chest injury. He has tachypnea and low oxygen saturation on exam, but he is not hypotensive or tachycardic.  The first step in evaluating any trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.  After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history. 

This patient should immediately be given supplemental oxygen for his low oxygen saturation.  The history of penetrating chest trauma and hypoxemia also should raise concern for a traumatic pneumothorax, and oxygen supplementation is part of the treatment for all pneumothoraces.  The patient’s chest X-ray shows a large left sided pneumothorax indicated by the absence of left sided lung markings.  There is some left to right deviation of the heart and the primary bronchi.  There is no large left sided pleural effusion in the costodiaphragmatic recess to indicate a pneumo-hemothorax.  There is also no deviation of the trachea, hypotension, or tachycardia to indicate a tension pneumothorax (Choice B).  The patient is hemodynamically stable, so he cannot be in hemorrhagic shock (Choice A) or have cardiac tamponade (Choice C).  Although the pneumothorax is large with mild deviation of the heart, the lack of hemodynamic instability supports the diagnosis of a traumatic non-tension pneumothorax (Choice D).  The treatment for this would include 100% oxygen supplementation and placement of a chest tube.  A CT scan of the chest is more sensitive imaging test than a chest X-ray and should be considered to evaluate for additional injuries (blood vessel injuries, rib fractures, etc.). Correct Answer: D

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Question Of The Day #65

question of the day
~ Joseph Ciano, USA ~ Leave a comment
Longitudinal Orientation

Which of the following is the most appropriate next step in management for this patient’s condition?

  • A) Exploratory laparotomy
  • B) Begin packed red blood cell infusion
  • C) CT scan of the abdomen and pelvis
  • D) Order urinalysis to check for hematuria

This patient arrives in the Emergency Department after an assault with penetrating abdominal trauma and is hemodynamically stable on exam.  The first step in evaluating any trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.  After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history. 

The FAST exam is a quick sonographic exam that requires the practitioner to look at 4 anatomical areas for signs of internal injuries.  The 4 areas are the right upper abdominal quadrant, left upper abdominal quadrant, pelvis, and subxiphoid (cardiac) areas.  The addition of views for each lung (1 view for each lung) is known as an E-FAST, or extended FAST exam.  The presence of an anechoic (black) stripe on ultrasound indicates the presence of free fluid.  In the setting of trauma, free fluid is assumed to be blood.  The presence of free fluid on a FAST exam is considered a “positive FAST exam”.   This patient has no free fluid between the right kidney and liver.  There also is no free fluid above the diaphragm to indicate a hemothorax. The question stem notes that all other FAST exam views are nonremarkable.  Therefore, this patient has a negative FAST exam.  See labelling of the FAST exam image below.

An exploratory laparotomy (Choice A) would be indicated in a patient with penetrating or blunt trauma, a positive FAST exam, and hemodynamic instability. This patient has a negative FAST exam and is hemodynamically stable.  Packed red blood cell infusion (Choice B) would be indicated in the setting of hemodynamic instability and trauma, as this is assumed to be hemorrhagic shock.  This patient is not tachycardic or hypotensive. A urinalysis to check for hematuria (Choice D) may be a helpful adjunctive investigation to evaluate for renal or bladder injury, but it is not the most crucial next step in management. Performing a CT scan of the abdomen and pelvis (Choice C) is the best next step as the patient is hemodynamically stable with a negative FAST exam and a penetrating abdominal injury.  The CT scan will help further evaluate for any internal injuries that may require operative repair.  See the algorithm below for further detail on an abdominal trauma work flow. Correct Answer: C

undifferentiated trauma patient
undifferentiated trauma patient
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Question Of The Day #64

question of the day
~ Joseph Ciano, USA ~ Leave a comment
Left Upper Quadrant

Which of the following is the most appropriate next step in management?

  • A) CT scan of the chest, abdomen, and pelvis
  • B)Exploratory laparotomy
  • C) CT scan of the head
  • D) Bedside diagnostic peritoneal lavage (DPL)

This patient arrives in the Emergency Department after an assault and has pallor (paleness), hypotension, and tachycardia on exam.  The first step in evaluating any trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.  After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history. 

The FAST exam is a quick sonographic exam that requires the practitioner to look at 4 anatomical areas for signs of internal injuries.  The 4 areas are the right upper abdominal quadrant, left upper abdominal quadrant, pelvis, and subxiphoid (cardiac) areas.  The addition of views for each lung (1 view for each lung) is known as an E-FAST, or extended FAST exam.  The presence of an anechoic (black) stripe on ultrasound indicates the presence of free fluid.  In the setting of trauma, free fluid is assumed to be blood.  The presence of free fluid on a FAST exam is considered a “positive FAST exam”.   This patient has free fluid between the left kidney and spleen in combination with hypotension and tachycardia.  This patient is in hemorrhagic shock until proven otherwise and needs prompt operative management.  See labelling of the FAST exam image below.

us image showing bleeding
us image showing bleeding

 

A CT scan of the chest, abdomen, and pelvis (Choice A) and a CT scan of the head (Choice C) may be helpful in the evaluation of this patient, but this patient is hemodynamically unstable.  Radiographic tests that require the patient to leave the Emergency Department should be avoided if the patient is unstable.  The specific location or cause of the hemodynamic instability can be diagnosed in the operating theater where there are opportunities to control the intraperitoneal bleeding (i.e., splenectomy, vessel ligation or cautery, etc.).  Bedside diagnostic peritoneal lavage (Choice D) is not indicated in penetrating abdominal trauma when there is a negative FAST exam and CT scanning is available.  This patient sustained blunt abdominal trauma, so a DPL is less informative.  The best next step for this patient is exploratory laparotomy (Choice B) in the operating theater.  Hemodynamically unstable patients with a positive FAST exam should always go to the operating theater for further diagnosis and treatment.  See the algorithm below for further detail.

 

undifferentiated trauma patient
undifferentiated trauma patient

 

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Question Of The Day #63

~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management for this patient’s condition?

  • A) CT scan of head and cervical spine without contrast
  • B) CT scan of head without contrast only
  • C) Endotracheal intubation
  • D) Neurosurgical consultation

This patient presents to the Emergency Department after a high-speed motor vehicle accident in the setting of alcohol intoxication.  On examination, he is intoxicated with a GCS of 14 (normal GCS is 15).  The first step in evaluating any trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.

After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history.  This patient is intoxicated but is awake with a patent airway. Endotracheal intubation (Choice C) is not indicated.  Neurosurgical consultation (Choice D) is also not indicated at this stage as there is no concrete information to indicate a surgical emergency.  CT imaging may demonstrate a cervical spine fracture or intracerebral bleeding, but these results are not provided by the question stem.  A CT scan of the head without contrast (Choice B) is a reasonable test for this patient given his significant mechanism of injury and intoxication on exam.  However, both a CT scan of the head and cervical spine (Choice A) should be ordered due to the patient’s intoxication creating an unreliable physical exam.  Alcohol intoxication or drug use can alter a patient’s ability to sense pain and provide accurate information.  The presence of intoxication should always raise awareness for possible occult injuries. 

Of note, intoxication and altered mental status are indications to perform a CT scan of the cervical spine based on a well-validated decision-making tool known as the NEXUS criteria (National Emergency X-Radiography Utilization Study).  Other criteria on the NEXUS tool that support CT cervical spine imaging are midline spinal tenderness, the presence of a focal neurologic deficit, or the presence of a distracting injury (i.e., femur fracture). The Canadian C-Spine Rule and Canadian CT Head Rule are other validated decision-making tools to help a clinician decide on whether or not to order CT head or cervical spine imaging. Correct Answer: A

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Question Of The Day #62

~ Joseph Ciano, USA ~ Leave a comment
627.15 - Figure 15 - lentiform epidural hematoma in the right hemisphere

Which of the following is the most likely diagnosis for this patient’s condition?

  • A) Subdural hemorrhage
  • B) Intraparenchymal hemorrhage
  • C) Epidural hemorrhage
  • D) Subarachnoid hemorrhage

This patient presents to the Emergency Department after a high-speed motor vehicle accident.  On examination, he is tachycardic, mildly tachypneic, and has an altered mental status (somnolent).  The first step in evaluating this trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.

After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history.  A noncontrast CT scan of the head is a reasonable test for this patient given his significant mechanism of injury and altered mental status on exam.  The CT scan shows a hyperdense (white) biconvex area on the right side of the brain.  This white area indicates the presence of fresh blood on the CT scan.  Keep in mind that CT scans are read as if you are looking up from the patient’s feet to their head.  This means left-right directionality is reversed.  See image below.

A hyperdense area with a sickled or crescent-shaped appearance would indicate an acute subdural hemorrhage (Choice A).  This is caused by tearing of the cerebral bridging veins.  Hyperdense areas throughout the brain tissue itself would indicate an intraparenchymal hemorrhage (Choice B).  Hyperdense areas around the sulci of the brain and a starfish appearance would indicate a subarachnoid hemorrhage (Choice D). Subarachnoid bleeding is caused by rupturing of a brain aneurysm or an arteriovenous (AV) malformation.  Subarachnoid bleeding can also be associated with trauma. 

This patient’s CT image shows an epidural hemorrhage (Choice C), indicated by the biconvex lens shaped area of blood.  This is caused by tearing of the middle meningeal artery.  Treatment of all types of intracranial bleeding involves general supportive care, airway management (i.e., endotracheal intubation for GCS < 8), elevating the head of the bed to 30 degrees to lower intracranial pressure (ICP), managing pain and sedation (lowers ICP), blood pressure maintenance (goal SBP <140mmHg), reversal of coagulopathy, neurosurgical evaluation for possible operative intervention, and providing ICP lowering treatments (mannitol or hypertonic 3% NaCl) when concerned about elevated ICP or brain herniation.

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Question Of The Day #61

~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management for this patient’s condition?

  • A) Administer packed red blood cells
  • B) Auscultate both lungs
  • C) Remove the patient’s clothes to evaluate for occult injuries
  • D) Perform a FAST exam (Focused Assessment with Sonography in Trauma)

This patient arrives to the hospital after penetrating trauma to the right chest.  His initial examination reveals hypotension, tachycardia, tachypnea, and a low oxygen saturation.

All medical and trauma patients that arrive to the Emergency Department, especially those who are ill-appearing or with abnormal vital signs, should undergo the “ABCs”.  This is also known as the primary survey.  The primary survey aims to create a step-wise initial approach to patients where all life-threatening conditions are identified and treated early in the encounter with the patient.  The primary survey should be conducted prior to taking a full history.  In trauma patients, the primary survey is extended to include the “ABCDEFs”.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam.  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition. 

Airway assessment involves checking for airway patency (clear voice, stridor, blood or vomitus in mouth, etc.) and applying cervical spine immobilization if needed.  Endotracheal intubation or a surgical airway may need to be placed during this step.  Breathing assessment involves auscultation of the lungs, checking the oxygen saturation, and providing supplemental oxygen to the patient if needed.  Abnormalities in the breathing exam (absent unilateral lung sounds, tracheal deviation, etc.) may prompt the placement of a chest tube or needle decompression.  It is during the breathing step that a pneumothorax, tension pneumothorax, or hemothorax is identified and treated.  Circulation assessment involves checking the heart rate and blood pressure, palpating all peripheral pulses, establishing IV access, and administering IV fluids or blood products.  It is during the circulation step that hemorrhage and shock is identified and controlled (pressure dressing applied to bleeding extremity wound, tourniquet applied to slow bleeding at amputated limb, etc.).  Disability assessment involves checking the patient’s neurologic status.  This involves calculating a GCS (Glasgow Coma Score), measuring the patient’s glucose level, and performing a focused neurologic exam.  Exposure involves removing all the patient’s clothes which may be obstructing view of other injuries.  This step involves rolling the patient to the lateral decubitus position to check the back and perineal areas for trauma.  The last step of the primary survey in trauma is the FAST exam (Focused Assessment with Sonography in Trauma).  The FAST exam is a quick sonographic exam that requires the practitioner to look at 4 anatomical areas for signs of internal injuries.  The 4 areas are the right upper abdominal quadrant, left upper abdominal quadrant, pelvis, and subxiphoid (cardiac) areas. 

The question stem provides information regarding the airway of the patient, which is stated to be patent.  The next step in the “ABCDEFs” should be evaluation of the ‘Breathing’.  Administration of packed red blood cells (Choice A) is considered part of the “Circulation” assessment.  Removing the patient’s clothes to evaluate for occult injuries (Choice C) is important, but the “Breathing” assessment should be performed prior to the patient’s “Exposure” step.  Performing a FAST exam (Choice D) is also an important part of the primary survey, but it should be performed after the “Breathing” step is completed.  Auscultation of both lungs (Choice B) is the best next step, as this is part of the “Breathing” step after the “Airway” assessment.  During this step, the patient should be given supplemental oxygen and evaluated for abnormal or absent unilateral lung sounds.  This is important as this patient is at risk for a large pneumothorax, tension pneumothorax, or hemothorax after his penetrating trauma.   

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Focused Assessment with Sonography in Trauma (FAST): An Overview

~ Maryam Bagherzadeh, Canada ~ Leave a comment

Traumatic injuries are one of the leading causes of death, and intraperitoneal bleeds occur in approximately 12% of blunt traumas [1]. A quick assessment of trauma and detection of intraperitoneal fluid is increasingly essential in trauma patients’ assessment. The implementation of point-of-care ultrasound (POCUS) has had a significant impact on patient management, especially in a trauma setting. POCUS is easy to use at the bedside, non-invasive and inexpensive.

The Focused Assessment with Sonography in Trauma (FAST) is an ultrasound protocol used to assess hemoperitoneum and hemopericardium [2]. The FAST protocol is sensitive and specific for detecting intraperitoneal free fluid. According to previous studies, sensitivity ranges from 75-100%, and specificity ranges from 88-100% [3]. The FAST exam is rapid and can be completed in less than 5 minutes. It also has multiple advantages, including decreased time to interventions like surgery and length of stay at the hospital [4]. The Extended FAST (eFAST) protocol, which involves examinations of each hemithorax for hemothorax and pneumothoraces, has recently been introduced by several institutions [2].

Regions Examined

The FAST exam assesses the pericardium and multiple potential spaces within the peritoneal cavity for free fluid. The patient is often assessed in the supine position.

The right flank or right upper quadrant (RUQ) view assesses the hepatorenal recess (also known as Morrison’s pouch), as well as the right paracolic gutter, the hepato-diaphragmatic area, and the caudal edge of the left liver lobe [2]. The pericardial view, also known as the subcostal or the subxiphoid, is usually assessed next. The liver is commonly used as a sonographic window of the heart to evaluate pericardium. Ultrasound can detect little pericardial fluid with sensitivity and specificity approaching 100% [5]. The pericardial view also helps to differentiate between pleural and pericardial effusions and visualize right ventricular collapse during diastole [2]. Next, the left upper quadrant (LUQ) is used to visualize the splenorenal recess, the subphrenic space and the left paracolic gutter. If the eFAST protocol is being conducted, the RUQ and LUQ views are also used to examine the left and right hemithorax. Lastly, the pelvic or the suprapubic view is used to assess for free fluid in the rectovesical pouch in males and rectouterine and vesicouterine pouches in women [2]. The bladder acts as a sonographic window for this view.

https://www.researchgate.net/figure/Trauma-FAST-exam-views-abdominal-and-pelvic_fig1_276498248

Complications

While there are no complications related to the FAST exam itself, the use of ultrasound does have some limitations, one of which is the requirement for at least 150-200 cc of intraperitoneal fluid for an ultrasound to be able to detect. This can lead to false negatives when free fluid is in fact present [6]. False positives in the FAST exam may also occur and can be due to the presence of ascites, pre-existing pleural or pericardial effusions unrelated to the trauma, ruptured ovarian cysts or ruptured ectopic pregnancies [2]. Healthcare workers should be aware that POCUS and the FAST protocol have limitations dependent on the provider’s experience and the patient’s body habitus.   

Further Reading and Free Online Course

References

  1. Poletti, P. A., Mirvis, S. E., Shanmuganathan, K., Takada, T., Killeen, K. L., Perlmutter, D., Hahn, J., & Mermillod, B. (2004). Blunt abdominal trauma patients: can organ injury be excluded without performing computed tomography?. The Journal of Trauma, 57(5), 1072–1081. https://doi.org/10.1097/01.ta.0000092680.73274.e1
  2. Bloom, B. A., & Gibbons, R. C. (2020). Focused Assessment with Sonography for Trauma. https://www.ncbi.nlm.nih.gov/books/NBK470479/
  3. Brenchley, J., Walker, A., Sloan, J. P., Hassan, T. B., & Venables, H. (2006). Evaluation of focussed assessment with sonography in trauma (FAST) by UK emergency physicians. Emergency Medicine Journal, 23(6), 446–448. https://doi.org/10.1136/emj.2005.026864
  4. Melniker, L. A., Leibner, E., McKenney, M. G., Lopez, P., Briggs, W. M., & Mancuso, C. A. (2006). Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Annals of Emergency Medicine, 48(3), 227–235. https://doi.org/10.1016/j.annemergmed.2006.01.008
  5. Mandavia, D. P., Hoffner, R. J., Mahaney, K., & Henderson, S. O. (2001). Bedside echocardiography by emergency physicians. Annals of emergency medicine, 38(4), 377–382. https://doi.org/10.1067/mem.2001.118224
  6. Von Kuenssberg Jehle, D., Stiller, G., & Wagner, D. (2003). Sensitivity in detecting free intraperitoneal fluid with the pelvic views of the FAST exam. The American journal of emergency medicine, 21(6), 476–478. https://doi.org/10.1016/s0735-6757(03)00162-1
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Acromioclavicular Joint Injuries Illustrations

~ Murat Yazici, Turkey ~ Leave a comment

Acromioclavicular joint (AC) injuries are associated with damage to the joint and surrounding structures.

ANATOMY

The acromioclavicular joint, together with the sternoclavicular joint, connects the upper limb to the skeleton.

The support of the acromioclavicular joint is provided by the ligament and muscle surrounding the joint. The capsule surrounding the acromioclavicular joint is strengthened by the acromioclavicular ligaments. The joints are acromioclavicular ligaments that provide horizontal stability.

The coracoclavicular ligaments consist of two parts, the lateral trapezoid, and the medial conoid, and connect the distal lower clavicle to the coracoid process of the scapula. The coracoclavicular ligament is the main stabilizing ligament of the upper limb.

Acromioclavicular joint injuries occur at all ages, but are most common in the 20-40 year age group, 5x times more common in men than women. It is a common contact sports injury in young male athletes (1).

There are two main mechanisms of acromioclavicular joint injury; direct and indirect (2). A direct blow or fall to the shoulder results in a superior force on the acromion with restricted clavicular movement in the joint, the acromion is forcibly pushed down and medially relative to the clavicle. It can occur indirectly as a result of a fall on the hand or elbow, causing the humerus to be pushed into the acromion, resulting in lower-grade injuries that typically protect the coracoclavicular ligament.

Imaging can be used to classify acromioclavicular injuries and is the most widely used Rockwood classification. 

ROCKWOOD CLASSIFICATION

References and Further Reading

  1. Dyan V. Flores, Paola Kuenzer Goes, Catalina Mejía Gómez et-al. Imaging of the Acromioclavicular Joint: Anatomy, Function, Pathologic Features, and Treatment. (2020) RadioGraphics. 40 (5): 1355-1382.
  2. Vanhoenacker F, Maas M, Gielen JL. Imaging of Orthopedic Sports Injuries. (2006)
  3. Tintinalli’s Emergency Medicine, A Comprehensive Study Guide 9th edition. ( 2019)

  4. Rockwood classification of acromioclavicular joint injury

  5. Acromioclavicular injury

 

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iEM Image Feed: Star shape wound on forehead

iem image feed
~ iEM Education Project Team ~ Leave a comment
Star shaped wound

A 17-year-old female patient presented to ED after hitting a metal piece on the wall.

How would you like to suture this patient?

Here is one clue!

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iEM Image Feed: Scaphoid fracture

iem image feed
~ iEM Education Project Team ~ Leave a comment
87 - Figure 6 - Fracture of the proximal pole of the scaphoid
  • Falling on an Out-Stretched Hand (FOOSH) is the most common mechanism of wrist injuries, with the wrist in extension.
  • Immature, weaker epiphyseal plate or metaphysis of the radius in children are more likely to sustain injuries, sparing the still-cartilaginous carpal bones.
  • Young adults with active lifestyles are more likely to be injured with greater forces.
  • In the elderly, especially in women with some degree of osteoporosis, distal radial metaphysis is more fragile resulting in Colles fracture.
  • “Anatomic snuffbox’’ on the dorsum of the wrist is an important landmark. Because the scaphoid is palpable with its triangle by styloid, extensor pollicis brevis tendon and the extensor pollicis longus tendon. Tenderness in this area may indicate a scaphoid fracture. The image above shows scaphoid fracture.
  • The examination should include assessment of neurovascular status motor and sensory function of the median, radial and ulnar nerves. Because acute median nerve compression is a common occurrence, the sensation of thumb and index fingers is important, especially with severely displaced fractures. In all injuries to the wrist, radial and ulnar pulses should be evaluated.

Further reading

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