FALLS IN THE ELDERLY

History A 78-year-old woman is brought in to the emergency department following a fall at home.She is complaining of severe pain affecting her left leg and groin, and has been unable to get up since the fall. On further questioning, the patient has been treated with steroids for polymyalgia rheumatica for the last 12 months and had sustained an injury of the right hip 5 years ago. Her only other medication is ramipril for essential hypertension. She lives independently in a three-bedroom, two-storey house and was widowed 4 years ago. She has a supportive son who normally visits her once a week. Examination The patient is now comfortable having been given intravenous morphine sulphate. Her left leg appears shorter than her right one and is externally rotated. She is unable to actively lift her leg, and any attempt to passively move it results in pain. Her pedal foot pulses and sensation are intact. Questions • What investigation is depicted in figure, and what does it show? • What other relevant history would you wish to elicit? • What would be the further management in this patient? • Why is the social history particularly important in this patient? ANSWER This woman has sustained a (intracapsular) sub-capital neck of femur fracture. The X-ray also demonstrates a hip prosthesis on the right side, after a previous similar injury .Fractured neck of the femur is a relatively common injury following a fall in the elderly population. The rate of hip fracture doubles every decade from the age of 50 years. There is a female preponderance of three to one. This woman is at particularly high risk because of her long-term steroid use. It is now a British National Formulary (BNF) recommendation that patients on long-term steroids should have concomitant treatment for the prevention of osteoporosis. There are two different types of fractured neck of femur, intracapsular and extracapsular.Displaced fractures that are intracapsular disrupt the intra-osseous blood supply; the remaining blood supply comes from the retinacular vessels and from the artery of the ligamentum teres. This is usually not adequate to provide enough nutrition to allow fracture healing, leading to avascular necrosis of the femoral head. In this situation the fracture is not amenable to fixation; instead the head and proximal femoral neck are removed and replaced by a hemi-arthroplasty. Fractures that are extracapsular do not compromise the blood supply to the femoral head, so can be treated by fixation, i.e. a dynamic hip screw. Irrespective of the fracture type, the initial management remains the same. It involves providing adequate analgesia, usually in the form of intravenous morphine. Intravenous fluid resuscitation is essential as these patients may well have been incapacitated for some time and will have sustained blood loss secondary to the fracture. Since these patients are likely to require an operation, they need a complete work-up for theatre. This will include blood tests (renal function, full blood count and group and save) and electrocardiogram and a chest X-ray if clinically indicated. As part of the initial assessment it is important to take a comprehensive history, concentrating on of the mechanism of injury. It is incorrect to assume that all falls are mechanical; it is not uncommon to find the cause of the fall is actually due to a urinary or chest infection or even a silent myocardial infarction. The patient’s social history is also very important. The input of physiotherapists and occupational therapists is essential to ensure an adequate social care package is in place for discharge. KEY POINTS • Femoral neck fractures are classified as either intracapsular or extracapsular. • Methods of surgical treatment depend on which type of fracture has been sustained

Orthopedic Surgery • Joint Preservation + 2 more

RIGHT SHOULDER INJURY

History A 23-year-old woman is brought to the emergency department having fallen over while on a dry ski slope. She is holding her right arm and is very reluctant to move her shoulder. She has previously had an appendicectomy and is known to have had mild attacks of asthma. She takes salbutamol and beclometasone regularly, and she is allergic to penicillin. She lives with her parents and works in the computer industry. Examination Her shoulder shows an obvious deformity and looks ‘squared off’, the arm is held in slight abduction and is externally rotated. Both active and passive movement of the shoulder cause pain. The radial pulse and capillary refill are normal. Questions • What is the diagnosis? • What are the other essential examination findings that have not been commented on? • How should this injury be managed? ANSWER This patient has sustained an anterior dislocation of her right shoulder. Shoulder dislocations are the commonest joint dislocation, accounting for nearly half of all dislocations. The glenohumeral joint is a multi-axial ‘ball and socket’ joint and can, therefore, dislocate in any direction. However, in the majority of cases (90–98 per cent) the dislocation is anterior. Posterior dislocation is much less common and is typically secondary to either an epileptic fit or electric shock. In order to confirm the diagnosis, radiographic assessment should be performed. The commonly used views are the anterior-posterior view in combination with either an axillary or scapular view. The important point is to examine the joint with two different views. The axillary view has the advantage of showing the glenoid cavity, which may pick up any associated fracture. An assessment of both the distal vascular and neurological function must be made in any patient with a severe limb injury. The close relationship of the shoulder joint to the brachial plexus makes a nerve injury more likely. At particular risk are the radial and axillary nerves. The incidence of axillary nerve neuropraxias following anterior shoulder dislocation is quoted at up to 10 per cent. The axillary nerve supplies sensation to the lateral aspect of the upper arm, the ‘regimental badge area’.The majority of anterior shoulder dislocations can be replaced by closed reduction. The key to successful reduction is to ensure adequate analgesia. This will relax the shoulder musculature that is typically in spasm resisting any joint movement. After successful reduction, the patient should be able to touch the contralateral shoulder tip. The shoulder should be supported in a sling, with radiological confirmation of the reduction. KEY POINTS • A full neurological examination must be performed prior to reduction of any dislocated joint. • The X-ray should be carefully examined for associated fractures. • Adequate analgesia is crucial during reduction of the dislocation.

Orthopedic Surgery • Joint Preservation + 1 more

LEFT HIP PAIN

History A 67-year-old woman comes to see you in the orthopaedic outpatient clinic complaining of left groin pain. The pain has been present for the last 12 months and has become progressively worse. It initially responded to ibuprofen and paracetamol, but now the pain is keeping her awake at night. Over a similar time period there has been a reduction in mobility and she now uses a stick when going outside. There has been no history of injury and there are no neurological symptoms. She underwent a mastectomy for breast cancer 15 years ago. She takes tamoxifen and omeprazole. Examination She is overweight with a body mass index (BMI) of 31. She walks with an antalgic gait and has a positive Trendelenberg test. There is no gross deformity of the lower limbs and the real leg lengths are equal. There is a restriction of all her left hip movements, especially internal and external rotation. Her back and knee examinations are unremarkable. Her pedal pulses are palpable and the sensation in the leg is normal. ANSWER This woman has primary osteoarthritis of her left hip. There is a reduction in joint space and periarticular sclerosis seen in the left hip joint.Primary osteoarthritis is by far the most common cause of joint degeneration. Less common is secondary osteoarthritis where there are a variety of different causative factors including developmental (congenital) dislocation of the hip, slipped upper femoral epiphysis, osteonecrosis and trauma. Patients typically present with pain felt in the groin that may radiate to the knee, usually occurring after periods of activity. As the condition progresses, the pain is more constant and may cause sleep disturbance. Other symptoms may include stiffness, and limping. The Trendelenberg test examines the strength and function of the hip abductor muscles. The examiner should perform the test by getting the patient to first stand on the ‘good’ leg and flex the other leg at the knee. This is repeated for the ‘bad’ leg. With normal function, the pelvis is held stable by the gluteus medius acting as an abductor in the supporting leg. A positive result is seen when the patient has a weak or a mechanically disadvantaged gluteus medius. This results in the pelvis ‘sagging’ down on the contralateral side. In this case when the patient stood on her left leg, the weakened gluteus medius on this side resulted in the right side of the pelvis dropping downwards. A Trendelenberg gait demonstrates the same weak abductor mechanism. Normally when walking, the hip abductors are required to lift the pelvis and leg on the opposite side during the swing phase. If the abductors are not working, then the pelvis will tip downwards towards the lifted foot. Other frequent examination findings with osteoarthritis of the hip ! • The affected leg is held adducted and in external rotation • A positive Thomas’ test: demonstrates a fixed flexion deformity • Restriction of movements of the hip joint • Normal knee and back examination • The Trendelenberg test is used to determine the strength and function of the hip abductor muscles. KEY POINT This woman’s progressive symptoms and pain at night would suggest that she would benefit from a hip replacement.

Orthopedic Surgery • Joint Preservation + 1 more

PAINFUL LIMB IN SICKLE CELL DISEASE

History A 15-year-old boy with known sickle cell disease, presents to the emergency department with pain in his right leg. The pain has been worsening over the last 4 days and he is now barely able to walk. He has an associated fever and lethargy. There is no reported history of trauma and he is taking prophylactic penicillin. Examination His temperature is 37.8°C and pulse rate 114/min. His oxygen saturations are 91 per cent on room air. He looks unwell and is in severe pain. There is no obvious abnormality of his right leg. He has significant tenderness over his right thigh. He has normal knee and hip movements. The neurovascular examination of his limb is unremarkable. Questions • What is the cause of his pain? • How should this patient be managed acutely? • What is the differential diagnosis in a patient with sickle cell disease? ANSWER Sickle cell anaemia is an autosomal recessive genetic disease that results from the substitution of valine for glutamic acid at position 6 of the beta-globin gene, leading to production of a defective form of haemoglobin, hemoglobin S (HbS). Deoxygenation of HbS leads to distortion of the red blood cell into the classic sickle shape. The sickle cells are much less deformable than normal red cells and can obstruct the microcirculation. This results in tissue hypoxia, which causes further sickling. Patients with a sickle cell crisis should be treated with high-flow oxygen, opioid analgesia and fluid resuscitation. If the precipitating factor is thought to be infective then intravenous antibiotics should be started. Causes of sickle cell crises ! • Dehydration • Bleeding • Infection • Hypoxia • Cold exposure • Drug and alcohol use • Pregnancy and stress Limb and back pain are common presentations for sickle cell sufferers. Osteomyelitis should be considered as a differential diagnosis, although bone infarction secondary to a sickle crisis is 50 times more common. The two conditions have a similar presentation with common features: • pain • fever • tenderness • inflammation • raised inflammatory markers (CRP, ESR and WCC). Radiographs are of limited use in the acute phase of osteomyelitis, as bone destruction and periosteal reaction do not become evident until at least 10 days. A more sensitive investigation is a technetium bone scan which is reported to detect signs of osteomyelitis after 3 days. Magnetic resonance imaging is also useful in helping to identify abscesses, sequestra and sinus tracts. A fine-needle bone aspirate provides a definitive diagnosis and can isolate the causative organism. The most common organism is Staphylococcus aureus. In sickle cell sufferers this remains the likely organism, but Salmonella and Enterobacter are also commonly cultured. KEY POINTS • Radiographical evidence of osteomyelitis may not be present during the first 10 days. • A sickle cell crisis should be initially treated with analgesia, oxygen and fluids

General Surgery • Microbiology + 4 more

FOOTBALLER’S KNEE

History A 34-year-old builder presents to the emergency department having injured his left knee earlier that afternoon while playing football. He describes being tackled and feeling his knee twist inwards. Immediately after the injury his knee began to swell and he was unable to continue playing. He now has only limited movement of his knee and is unable to walk. He is otherwise fit and healthy and does not take any regular medication. He has a wife and two children and smokes 20 cigarettes a day. His average alcohol intake is 34 units a week. Examination The left knee is held in approximately 30° of flexion. It is swollen and there is an obvious effusion. Palpation elicits localized tenderness along the medial tibiofemoral joint line. It is not possible to fully extend the knee either passively or actively. The ligamentous stability of the knee appears normal. Neurovascular examination of the limb is normal. Questions • What is the likely injury? • What are the other causes of a haemarthrosis? • How should this patient be managed? ANSWER This man has sustained a meniscal injury. Most knee injuries result in swelling which develops over hours rather than minutes. The history of immediate knee swelling suggests that there is a haemarthrosis. (This can be easily confirmed by aspirating a few millilitres of fluid from the joint using an aseptic no-touch technique). Causes of a haemarthrosis! • Anterior cruciate tear: in 75 per cent of cases • Meniscal tear • Fracture • Spontaneous haemarthrosis: haemophilia It is not uncommon to sustain a simultaneous cruciate and meniscal injury. In practice it is often difficult to assess the ligamentous stability in the acutely injured knee and make a definitive diagnosis on clinical examination alone. However, in this case the findings of a ‘locked’ knee, and the fact there was thought to be no ligamentous deficiency, suggest an isolated meniscal injury. The classical cause of an acutely ‘locked’ knee is a ‘buckethandle meniscal tear’. This refers to a longitudinal full-thickness tear of the meniscus. The flap which is created can flip into the joint on the other side of the femoral condyle,blocking full extension of the knee. The blood supply of the meniscus is located at its periphery, the ‘red zone’. The inner ‘white’ portion is avascular. The importance of this relates to the location of any meniscal tear; if confined to the red zone then there is the potential for repair and subsequent healing. In this scenario the patient should be taken to theatre for an arthroscopy. As well as allowing the knee to be ‘unlocked’, it will provide a definitive diagnosis, with the potential to repair the meniscal tear. KEY POINTS • A history of immediate knee swelling suggests a haemarthrosis. • A locked knee can be caused by a bucket-handle meniscal tear.

Orthopedic Surgery • General Surgery + 1 more

A LIMPING CHILD

History A 13-year-old boy presents to his general practitioner with an 8-week history of an ache in the left thigh. Over the last few days this has got worse and now he is complaining of groin pain and has developed a pronounced limp. He is unsure, but his worsening symptoms may have coincided with a fall while playing football. He is feeling well and reports no back or neurological symptoms. His past medical history is unremarkable and he takes no regular medication. Examination His pulse and blood pressure are within the normal range and he is afebrile. He is overweight and has a body mass index of 33. His abdominal examination is normal and there are no detectable abnormalities of the back or left knee. His left leg is held in slight external rotation. There is a restriction in abduction and internal rotation. When the hip is flexed the leg is forced into external rotation. There is no distal neurovascular deficit. Questions • What is the diagnosis? • What further plain X-rays should be requested? • What are the other causes of a ‘limping child’? ANSWER This boy has a (acute-on-chronic) slipped capital femoral epiphysis. This refers to a weakening or fracture of the proximal femoral epiphyseal growth plate.Continued shear stresses on the hip cause the epiphysis to move posteriorly and medially. This condition has a peak presentation in adolescent boys. There are a number of risk factors including obesity,hypothyroidism and renal failure. There are three different types described: • acute slip: normally secondary to significant trauma • chronic slip: the commonest (60 per cent) presentation with symptoms 3 weeks • acute-on-chronic: duration of symptoms >3weeks with sudden deterioration. This scenario is also an excellent example of the orthopaedic mantra of examining the ‘joint above and below’ the suspected origin of the pathology. Up to half of the patients with a chronic slipped capital femoral epiphysis present with thigh or knee pain. In this case one of the important clues in the examination is the finding of obligatory external rotation when the hip is flexed. The anterior-posterior X-ray demonstrates Trethowan’s sign. When a line (Klein line) is drawn along the superior surface of the neck, it should pass through part of the femoral head. If the line remains superior to the femoral head then this is termed Trethowan’s sign. A frog-lateral view of the hip is normally requested to further aid diagnosis, although caution should be applied in acute presentations as this can worsen the slip. It is also worth noting that when a patient is diagnosed with a slipped capital femoral epiphysis,an X-ray of the opposite hip should be performed as a bilateral presentation occurs in one-third of patients. At any age, a limp in a child should always be taken seriously. General points to note are: if the child is febrile or unwell then the diagnosis of a septic arthritis or osteomyelitis should be considered. In the well child, trauma and neoplasia can occur in all age groups. The limping infant should make the clinician think of a developmental hip dysplasia, whereas in the 4–10-year age range, one should think of Perthes’ disease. KEY POINTS • The joints above and below the presumed source of the pain should always be examined.

Orthopedic Surgery • General Medicine

VOMITING AND ABDOMINAL DISTENSION

History You are called to the ward at 3 a.m., to see a 20-year-old man with persistent vomiting. He had an emergency laparotomy 3 days previously. The doctor on call earlier had prescribed anti-emetics for the patient, without carrying out a full assessment. The patient is extremely distressed and the nurse in charge is concerned about his sudden deterioration. You retrieve the operation note and find the patient had undergone a ‘normal’ laparotomy for trauma. The small and large bowel were both examined carefully and no injury was found. He had made a good recovery and had been moved onto free fluids earlier in the day. There was no nasogastric tube left after the operation, and the urinary catheter had been removed. Examination The patient is rolling around in the bed having just vomited. His blood pressure is 120/75mmHg and pulse rate 110/min. He has a midline incision covered with a dry dressing. The abdomen is distended and tympanic. On palpation, he is tender around the incision only. There are no bowel sounds on auscultation. Questions • What is shown on the abdominal X-ray? • What are the most common causes? • What is the most likely cause in this patient? • How would you manage the patient? ANSWER When assessing a postoperative patient on the ward it is important to read the operation note as well as making a physical assessment. Unexpected findings or difficulties during the procedure should be documented, and this may aid your clinical decision making. This patient has a postoperative paralytic ileus. An ileus is a normal physiological event after abdominal surgery. It usually resolves spontaneously within 2–3 days of the procedure. Paralytic ileus is defined as ileus of the intestine persisting for more than 3 days after surgery. His bowels had not returned to normal function by day 3 and he had started free fluids that morning. This resulted in vomiting and abdominal discomfort. A nasogastric tube should be placed to decompress the bowel, and a urinary catheter inserted to monitor his urine output. Non-steroidal anti-inflammatory drugs (NSAIDs) can be used for pain relief, rather than opiates, as these will not affect bowel motility. The most common cause of an ileus is an intra-abdominal operation. Other factors can prolong an ileus and should be looked for and corrected if possible. This patient has hypokalaemia which should be corrected. Causes Of Ileus: • Sepsis: intra-abdominal inflammation and peritonitis • Drugs: opioids, antacids • Metabolic: hypokalaemia, hyponatraemia, hypomagnesia, anaemia • Myocardial infarction • Pneumonia • Head injury and neurosurgical procedures • Retroperitoneal haematomas For patients with protracted ileus, mechanical obstruction should be excluded by a smallbowel follow through or a computerized tomography scan. Before further investigation, underlying sepsis or electrolyte abnormalities should be corrected. Medications that produce ileus (e.g. opiates) should also be stopped. KEY POINTS • Postoperative ileus should resolve after 2–3 days. • Electrolyte abnormalities are a common cause of paralytic ileus during the postoperative period.

General Surgery • Surgical Gastroenterology

STRIDOR

History An 18-month-old baby girl is bought to the emergency department by her parents, as they are concerned about her noisy breathing. She has had a mild cough for the last 24 h and her temperature is elevated. She is up to date with her vaccinations and has had no developmental problems. There is no other relevant history. Examination Her oxygen saturation is 94 per cent on air. The baby is restless and has a hoarse cry.There is an audible stridor at rest. The baby has a low-grade fever with a mildly increased respiratory rate. There is no evidence of cyanosis. Auscultation of the chest is difficult but there is an audible inspiratory noise. Questions • What is the differential diagnosis? • How do you define stridor? • What are the causes of stridor? ANSWER In this case the two most likely diagnoses are croup (acute laryngo-tracheo-bronchitis) or acute epiglottitis. Laryngo-tracheo-bronchitis presents in childhood and is usually preceded by an upper respiratory tract infection. The child develops malaise, a high temperature and stridor. The stridor is the result of subglottic oedema which soon spreads to the trachea and bronchi. It is usually caused by a viral infection (parainfluenza). Mild cases of croup often respond to oral steroids. Severe cases may require ventilatory support as well as nebulized adrenaline and inhaled or intravenous steroids. Acute epiglottitis is an absolute emergency and is usually caused by Haemophilus influenzae. There is significant swelling and any attempt to examine the throat may result in airway obstruction. It is rare in children these days because they receive the Haemophilus influenzae type B (HiB) vaccination aspart of their routine immunization programme. In adults it tends to cause a supraglottitis. It has a rapid progression and can lead to total airway obstruction. The patient must be sat upright and an airway secured with an endotracheal tube, by an anaesthetic specialist. Stridor is defined as a high-pitched noise caused by turbulent airflow in the larynx or trachea as the result of narrowing of the airway. Aetiology of stridor ! • Neonate: • laryngomalacia/tracheomalacia • vocal cord lesion/palsy, e.g. neurological, birth/surgical trauma • laryngotracheal stenosis, e.g. congenital • airway haemangioma Child: • vocal cord palsy secondary to thyroid or chest surgery • acute epiglottitis/supraglottitis • laryngeal carcinoma • laryngotracheal stenosis, e.g. secondary to endotracheal intubation or heat inhalation • inhalation of a foreign body • trauma to the anterior neck • airway compression by thyroid disease • Stridor is an ominous sign and needs to be taken seriously. Adult: • croup • acute epiglottitis • airway haemangioma • foreign body • trauma • airway compression, e.g. thyroid disease KEY POINTS • Treatment is urgent and the patient should be managed in a suitable area, e.g. theatre, resuscitation bay. • Call for ear, nose and throat and anaesthetic help early

Pediatrics • Pediatric Emergency Medicine + 2 more

THUNDERCLAP HEADACHE

History A 56-year-old woman is brought to the emergency department by her partner. She had initially complained of a severe headache before collapsing unconscious on the floor at home. She has no significant past medical history but smokes 30 cigarettes a day. She has now regained consciousness and is complaining of neck stiffness. Her initial assessment is carried out using the system shown below. Examination Eye opening Best motor response Best verbal response 1 None
1 None
1 None 2 To pain
2 Extension to pain
2 Incomprehensible sounds 3 To speech
3 Flexion to pain
3 Inappropriate words 4 Spontaneous
4 Withdraws from pain
4 Confused 5 Localizes to pain
5 Orientated
6 Obeys commands Score 13/15 Questions • What system has been used to assess the patient? • What is the likely diagnosis? • What are the possible underlying causes? ANSWER The Glasgow Coma Score (GCS) is composed of three parameters: verbal commands, eye opening and motor responses. The patient is assessed on their ‘best’ response. The scores are summed to give an overall value from 3 (being the worst) to 15 (being the best). In this case the GCS is 13. While the score is useful in absolute terms, such as defining coma (GCS 8), the main value of the GCS is being able to monitor the ongoing neurological status of a patient by repeated assessment every 15 min. A fall in the score of 2 or more should prompt an urgent review of the patient, as this indicates a potentially significant deterioration in their condition. The most likely diagnosis in this case is of a subarachnoid haemorrhage. The classical symptoms are of a severe ‘thunderclap’ headache affecting the back of the head that reaches maximal intensity within a few seconds. Causes of bleeding into the subarachnoid space ! • 85 per cent: saccular aneurysms in the cerebral vasculature – ‘berry’ aneurysms • 15 per cent: non-aneursymal subarachnoid haemorrhage: • arterial dissection • arteriovenous malformation • tumour • cocaine abuse • trauma • septic aneurysm The initial management involves stabilizing the patient and arranging the following: • blood tests: full blood count, renal function, coagulation screen and group and save • computerized tomography (CT) of the brain: to look for evidence of subarachnoid blood and hydrocephalus • lumbar puncture: if the CT scan does not show any pathology, then cerebral spinal fluid should be sent for spectrophotometric analysis to look for the presence of oxyhaemoglobin and bilirubin. Differential diagnoses include transient ischaemic attacks, migraine or epilepsy. Patients confirmed to have a subarachnoid haemorrhage should be referred to a neurosurgical unit for further assessment (cerebral angiography) and treatment (embolization). KEY POINTS • The Glasgow Coma Score ranges from 3 to 15. • A fall of 2 points or more should prompt an immediate reassessment

Neuro Surgery • General Medicine

Lead Pellets in Belly

This 8-year old kid took the expression 'bite the bullet' personally. After doctors found out that he had high levels of lead in his blood for the last two years, and after the kid had been complaining about severe stomachache, the doctors discovered lead formations in the X-ray. Turns out, he was from a hunting family who used to gather food using lead pellets. The kid had ingested 57 pellets during a game with his siblings. All of them were found when the doctors removed his appendix.

General Surgery • Surgical Gastroenterology