MINOR TRAUMATIC
INJURIES
OCFP ANNUAL SCIENTIFIC ASSEMBLY
NOVEMBER 24TH, 2011
Phil Moran MD, FRCPC, FACEP
Emergency Physician, MSH
Lecturer, Department of Medicine, University of
Toronto
DISCLOSURES
No financial conflicts of interest.
OBJECTIVES
Case-based approach
Clinical pearls for your primary care practice
Focus on outpatient management
OUTLINE
Minor Head Injuries
Emergency Wound Management
1.
2.
New techniques in Scalp Repair
Minor Orthopedic Injuries
3.
X-ray findings not to miss!
Office Procedures
The Traumatic Eye
Foreign Bodies
4.
5.
Tricks of the trade!
MINOR HEAD INJURIES
2 cases involving minor head injuries
Discussion of CT head rules
What’s new in pediatric CT head rules
Complications
Management
Return-to-Play Guidelines
CASE 1
18 ♂, hockey player
Pushed backwards, hit occiput on ice
CC: H/A and dizziness
What is your approach?
CASE 1
Hx:
Helmet knocked off prior to HI
LOC ~ 1 min
+ nausea, no vomitting
+ amnesia of event
No previous HI
PMH/Meds/Allergies/Social - unremarkable
CASE 1
Physical Exam
Alert & oriented x 3
GCS 15
Neurological exam – no abnormality
H+N – no midline vertebral tenderness, absent
hematoma/hemotypanum/battle sx/raccoon eye
CASE 1
To CT or not to CT…
CANADIAN CT HEAD RULE
Patients with minor head injuries.
Witnessed LOC
Definite amnesia
Witnessed disorientation and GCS 13-15
100% sensitive for assessing need for
neurosurgical intervention, 68.7% specific
Stiell, I, et al. The Canadian CT head rule for patients with minor head
injury. Lancet 2001; 357: 1391-1396.
CANADIAN CT HEAD RULE
Major criteria
GCS<15 @ 2h after injury
Open or depressed skull #
Signs of basilar skull #
Vomit >2x
Age ≥ 65
Plan: Must CT
CANADIAN CT HEAD RULE
Minor Criteria
Amnesia before impact ≥30min
Dangerous mechanism of injury (ped struck, fall>3ft or 5
steps, eject from auto)
Plan: Observe 6hrs + CT
BACK TO CASE 1
Plan: No CT
Diagnosis?
CONCUSSION
Definition:
Direct blow, “impulsive” force transmitted to head.
Rapid onset short-lived impairment in neurologic
function.
Functional disturbance.
May or may not involve LOC.
Normal neuroimaging.
McCrory P., et al. Consensus Statement on Concussion in Sport 3rd International
Conference on Concussion in Sport Held in Zurich, November 2008. Clin J Sport
Med 2009; 19: 185.
CONCUSSION
CONCUSSION
Simple
Most common form of injury.
Complex
symptoms and signs persist beyond 10 days or recur
during rehabilitation,
prolonged loss of consciousness (more than 1 minute),
prolonged cognitive impairment.
SECOND IMPACT SYNDROME
Brain edema leading to herniation within minutes of
second concussion.
Rare and controversial complication.
RETURN-TO-PLAY GUIDELINES
Cornerstone = Rest!
1.
2.
3.
4.
5.
6.
Each step requires 24 hours.
Complete rest. Cognitive and physical.
Light aerobic exercise.
Sport-specific exercise.
Non-contact training drills.
Full contact training after medical clearance.
Game play.
McCrory P., et al. Consensus Statement on Concussion in Sport 3rd International
Conference on Concussion in Sport Held in Zurich, November 2008. Clin J Sport
Med 2009; 19: 185.
BACK CASE 1…
2 weeks later…
Continues to have vague symptoms involving
headache, dizziness, feeling dazed intermittently.
Next step in management?
Post-concussive syndrome
POST-CONCUSSIVE SYNDROME
Definition
Any 3 of the following:
headache, dizziness, fatigue, irritability, impaired
memory and concentration, insomnia, and lowered
tolerance for noise and light.
Resolve within weeks to months.
Plan:
CT Head, neurology follow-up
CASE 2
3 ♀,falls from couch, hitting head on floor
Lies stunned for a few seconds, then starts to cry
Vomits once immediately after HI
Within minutes, acting normally
Parents arrive to your office/ER demanding CT scan
Approach?
CASE 2
Additional Hx:
No delayed vomitting
No otorrhea or rhinorrhea
Initially irritable, return to normal behaviour
PMH/Meds/Allergies
Unremarkable
Physical Exam
GCS 15, playful
No signs of basal skull #
Absence of boggy hematoma
MODIFIED GCS FOR INFANTS
Activity
Best Response
Score
Eye Opening
Spontaneous
To speech
To pain
None
4
3
2
1
Verbal
Coos, babbles
Irritable, cries
Cries to pain
Moans to pain
None
5
4
3
2
1
Motor
Spontaneous
movements
Withdraws to touch
Withdraws to pain
Abnormal flexion
Abnormal extension
None
6
5
4
3
2
1
WHO NOT TO CT…
Age, years
Clinical Criteria
<2
Normal mental status
Normal behaviour per caregiver
No LOC
No severe mechanism
No non-frontal scalp hematoma
No evidence of skull #
> 2-18
Normal mental status
No LOC
No severe mechanism
No vomitting
No severe headache
No signs of basilar skull #
Kupperman, N. et al. Identification of children at very low risk of
clinically-important brain injuries after head trauma: a prospective
cohort study. Lancet 2009; 374: 1160.
SKULL FILMS NOT WIDELY RECOMMENDED.
Nearly half of infants with intracranial injury have
overlying skull fractures but…
ED read accuracy is poor.
Sensitivity 76%
Specificity 84%
Chung, S, et al. Skull radiograph interpretation of children younger
than two years. Annals of Emergency Medicine 2004; 43 (6): 71824.
WHO GETS THE CT?
Important in early diagnosis of intracranial
hematomas.
More common, diagnostic yield remains low.
Canadian pediatric ERs
1995 15%
2005 53%
Harmful effects of ionizing radiation.
1 y.o. 1/1500 CA mortality risk
10 y.o. 1/5000 CA mortality risk
Effects on adulthood cognition.
Klassen TP, Reed MH, Stiell IG, et al. Variation in utilization of computed tomography
scanning for the investigation of minor head trauma in children: a Canadian experience. Acad
Emerg Med 2000;7:739-44
MANY DECISION RULES…
CHALICE
CATCH
Children’s Head injury Algorithm for the prediction of
Important Clinical Events
Canadian Assessment of Tomography for Childhood
Head injury
PECARN
Pediatric Emergency Care Applied Research Network
PECARN
Younger than 2
Normal mental status
No scalp hematoma except frontal
LOC less than 5 sec
Non severe injury mechanism
No palpable skull fracture
Acting normally to parents
Sensitivity 100%, specificity 53.7%
PECARN
Older than 2
Normal mental status
No LOC
No vomiting
Non severe injury mechanism
No basal skull fracture
No severe headache
Sensitivity 96.8%, specificity 59.8%
KUPPERMANN N ET AL. IDENTIFICATION OF CHILDREN AT VERY LOW RISK OF
CLINICALLY IMPORTANT BRAIN INJURIES AFTER HEAD TRAUMA: A
PROSPECTIVE COHORT STUDY. THE LANCET 2009 OCT.; 374 (9696):
1160-1170
BACK TO CASE 2
Management:
A. CT Head.
B. No CT and D/C home.
C. No CT. Observation x 4-6 h, D/C home with
instructions.
D. Page radiology and get MRI.
Plan?
No CT.
Observation x 4-6 h.
EMERGENCY WOUND MANAGEMENT
SCALP REPAIR IN YOUR OFFICE!
Case
50 ♂, construction worker, scalp laceration on work site,
steel pipe extending from ceiling.
Hemodynamically stable
4 cm laceration, superficial
Tetanus status: up-to-date
Options for repair?
HAIR APPOSITION TECHNIQUE (HAT)
Perform wound irrigation and examination.
Twist together 3-7 strands of hair on both sides.
Interlock these two hair bundles in a 360-degree
revolution.
Do not tie a knot.
Secure the intertwined hair bundles by applying a
few drops of a tissue adhesive.
Repeat as needed to close the length of the
laceration.
The patient no longer needs to return for staple
removal in 7-10 days.
The hair will unravel on its own after a week.
HAT
MODIFIED HAT (SHORT HAIR)
ABSORBABLE SUTURES
No benefit in using non-absorbable sutures for
facial or extremity lacerations in children
Rapid absorbing gut identical to non-absorbable in
the face re: keloid formation, scarring, infection rate
and wound dehiscence.
• Luck, R. et al. Cosmetic outcomes of absorbable versus
nonabsorbable sutures in pediatric facial lacerations.
Pediatric Emergency Care 24(3): 137-142
MINOR ORTHOPEDIC INJURIES
Review of 4 minor orthopedic injury cases.
Review of important elbow x-ray rules/lines
Discussion of subtle radiograph findings in commonly
missed injuries
Outpatient management
CASE 1
2♀ , unattended, fell from bed onto L elbow in
flexion
Crying inconsolably, tender and edematous elbow
Painful range of motion
Radial/ulnar pulses palpable
CASE 1
ELBOW RADIOGRAPH RULES
Effusion – seen on lateral view.
Anterior fat pad – “sail” sign
Posterior fat pad – presence = abnormal!
Radio-Capitellar Line – should transect the
capitellum.
(if not radial head dislocation)
Anterior Humeral Line – line through middle third of
capitellum.
(if not supracondylar #)
ELBOW OSSIFICATION CENTRES
“CRITOE”
C – capitellum
R – radial head
I – internal (medial) epicondyle
T - trochlea
O- olecranon
E – external (lateral epicondyle)
Appear at 1, 3, 5, 7, 9, 11 years (in that order)
NORMAL X-RAY
Radio-capitellar line
Anterior humeral line
BACK TO CASE 1
SUPRACONDYLAR FRACTURE
Common injury in children
Important to clear neurovascular status
Varus/valgus deformity unacceptable
Management:
Undisplaced/minimal AP angulation:
posterior slab with follow-up
Significant AP angulation or valgus/varus angulation:
slab and ortho consult immediately
TRAUMATIC ELBOW EFFUSIONS
No effusion on x-ray = unlikely acute #
Consider status of growth plates
Open Growth Plates:
Likely occult supracondylar # (subtle or Salter I)
Posterior slab and ortho F/U in 1-2 weeks
Closed Growth Plates (adults):
Likely occult radial head #
Sling, ROM exercises, ortho follow-up
Posterior slab if significant pain
CASE 2
3 ♂, previously healthy
Swinging from parent’s
hands
Refuses to use R arm
In no apparent distress
Denies trauma
RADIAL HEAD SUBLUXATION
RADIAL HEAD SUBLUXATION
AKA nursemaid’s or pulled elbow
Common injury, ages 1-4 years.
Flexed at elbow, forearm pronated.
Radiographs not needed unless history atypical or
point tenderness.
Must remind parents to avoid linear traction on arm.
Increased risk of recurrence.
TECHNIQUES FOR REDUCTION
CASE 3
24 ♂, rollerblader fell backwards on his
outstretched right hand. No wrist guards.
The wrist is very tender but does not show signs
suggesting fracture of the radius or scaphoid.
TRIQUETRUM FRACTURE
Two Types:
1.
2.
Body fracture
Chip fracture of dorsal triquetrum
(5x more common)
Common in children
Ulnar styloid chisel hypothesis
Rich vascular supply
Not associated with ligamentous joint instability
CARPAL BONE ANATOMY
MANAGEMENT
Body fractures
Short arm cast until signs of union
3-6 weeks
Chip Fractures
Symptomatic treatment
Removable splint
Provide cushioning, limit flexion and extension
Follow-up
CASE 4
22 ♀, fall while skiing.
CC: R thumb pain
PMHx/Meds/All: unremarkable
Social Hx: RHD, Graphic
Designer, plays piano
CASE 4 - PHYSICAL EXAMINATION
Swelling and
ecchymosis
Maximal point
tenderness at ulnar
aspect MCPJ
Decreased ROM –
extension, abduction
CASE 4
ULNAR COLLATERAL LIGAMENT INJURIES
Fall on outstretched
thumb, forcible
abduction
Gamekeeper’s or
skiier’s thumb
Abduction Stress
Testing
Radial collateral
ligament injuries –rare
(bull-rider’s thumb)
ABDUCTION STRESS TESTING
MANAGEMENT OF UCL INJURIES
Plastics referral recommended for all cases with:
Pincer weakness, and/or,
Laxity in flexion and extension
Slight laxity or minimally displaced avulsion # thumb spica splint
Gross laxity requires surgical intervention in 50%
due to Stener lesion
THE TRAUMATIC EYE
Eye Trauma Classification
1.
Open or closed globe injury
2.
Visual acuity
3.
Afferent pupillary defect
4.
Area of injury (cornea, exposed sclera or
posterior to lid margins)
Pieramici D. Et al., “A System for Classifying Mechanical Injuries of the
Eye,” American Journal of Ophthalmology. June 1997; 123: 820-831.
CASE
40♂, FB sensation to R eye while playing with
children at the beach
Non-contact lens wearer
Td status up-to-date
+FB sensation with watery discharge
Absence of photophobia, diplopia, blurred vision
O/E:
Closed globe injury, VA OS 20/20, OD 20/20
N EOM, PERL
No RAPD
No FB seen on lid eversion
Fluorecein applied
FLUORECEIN UPTAKE
CORNEAL ABRASION MANAGEMENT
Consider tetanus status
Contact lens wearer
Patching is out!
Meta-analysis of 7 trials
showed similar healing rates between patching and no
patching.
Cochrane database of systematic review article
11 trials - total of 1014 participants.
eye patching did not reduce pain or improve wound healing.
possible loss of binocular vision and possible increased
pain
Flynn CA, D'Amico F, Smith G. Should we patch corneal abrasions? A meta-analysis. J Fam
Pract. Oct 1998;47(4):264-70.
Le Sage N, et al. Efficacy of eye patching for traumatic corneal abrasions: a controlled
clinical trial. Ann Emerg Med. Aug 2001;38(2):129-34
MANAGEMENT
Topical NSAIDs useful in reducing pain.
As effective as analgesics.
Return to work times shorter.
Topical antibiotics = mainstay but no evidence!
Ointment preferred (lubricant effect).
Erythromycin ointment QID x 3-5 days.
Calder LA, et al. Topical nonsteroidal anti-inflammatory drugs for corneal
abrasions: meta-analysis of randomized trials. Acad Emerg
Med. May 2005;12(5):467-73
Goyal R, et al. Randomised controlled trial of ketorolac in the
management of corneal abrasions. Acta Ophthalmol
Scand. Apr 2001;79(2):177-9.
FOREIGN BODIES – TRICKS OF THE TRADE
FOREIGN BODIES
“ORGANIC” FOREIGN BODIES
EAR FOREIGN BODIES
CASES
4 ♂ , eating cornflakes for breakfast, crushed as
many cornflakes as he could into his ear.
50 ♀ , living in cockroach infested apartment, feels
something moving in her ear.
Use of oil to coat material and then syringe with water.
Kill the insect first with Auralgan, lidocaine or mineral oil,
then syringe.
Caution in syringing organics; may swell and become
impossible to remove
NASAL FOREIGN BODIES
Nasal FBs
Hx of putting object in nose, usually visible in anterior
nares
Techniques for Removal
Standard – curette, alligator forceps, suction, right-angle
hook
Alternative – nasal positive pressure (parent’s kiss),
magnetic removal, glue, stovepipe wire (Lee Valley
Tools)
SUCTION AND PEDIATRIC CATHETERS
CYANOACRYLATE GLUE
PREPARATION
Adequately restrain child – bundle
Topical anesthetic
Headlight, nasal speculum
Avoid pushing into posterior nasopharynx – risk of
aspiration
PARENT’S KISS
THE PARENT’S KISS
Effective way of removing foreign bodies.
Prospective study in British ER/ENT departments.
31 pediatric participants < 5 years old.
Primary outcome success of parent’s kiss.
Secondary reduction of general anesthetics required.
Results
Primary parent’s kiss successful 20/31 (64.5%).
Secondary 1/31 (3%) required general anesthetic
compared to rate of 32.5% in preceding 6 months.
Parent’s kiss made FB more visible when not successful.
Ann R Coll Surg Engl. 2008 Jul;90(5):420-2.
Mother performing
the “parent’s kiss.”
“THE PARENT’S
KISS”
ALTERNATIVELY…
Pediatric
Bag-Valve
Mask can be
used.
CASE
22 ♂, mall security officer
Chasing after thief, L hand through glass door
Seen in the ER, glass removed and sutured
Several months of persistent hand pain, swelling,
and now purulent discharge from hand
LHD
Returns to your office
Management?
SOFT TISSUE FOREIGN BODIES
Infections most common complications.
Wound evaluation critical.
80-90% can be seen on plain radiographs
Organic matter cannot be seen; CT scanning may
be used.
i.e. metal, bone, teeth, pencil, some plastics, glass,
gravel, sand, aluminum
i.e. wood, thorns, cactus spines, some fish bones, most
plastics, etc.
U/S – 90% sensitivity
Operator, size dependant (>4-5mm)
MANAGEMENT
Not all FBs need to be removed.
Removal Indications:
Infection/Toxicity
Functional problems
Potential for persistent pain
Radiopaque skin markers for localization.
If unable to locate FB, refer to surgery, consider
prophylactic antibiotics.
ADDITIONAL REFERENCES
Berson, F. G., Basic Ophthalmology. Library of Congress, 1993.
McRae, R., Esser, M. Practical Fracture Treatment. Churchill
Livingstone Elsevier, 2008.
Sayal, A. CASTED Manual.
Schwartz, D. Emergency Radiology Case Studies. McGraw-Hill, 2008.
Tintanalli, J.E., Kelen, G., J. Stapczinski. Emergency Medicine.
McGraw Hill Publishing, 2004.
Questions/Comments