It can result in irreversible ischaemia in less than 2 hours. Proptosis, chemosis, ophthalmoplegia and loss of visual acuity is a sight-threatening emergency and requires immediate treatment. Traumatic optic neuropathy is an acute injury of the optic nerve with disruption of visual function. The nerve can be directly or indirectly injured. Indirect optic neuropathy is when the injury to the nerve results from the nonpenetrating effects of trauma, including haemorrhage, oedema and concussion.
The patient has decreased visual acuity and possibly decreased pupillary reflexes. The pathognomonic feature of this injury is painful restriction of eye movement Figure 15 with nausea and occasional vomiting. Importantly there is no subconjunctival haematoma. Note the severe restriction in upward gaze of eye on right. It involves a fracture of the orbital floor with ischaemic impingement of the ocular contents in this localised area.
These fractures are typically visualised on CT scan as an undisplaced linear fracture Figure CT findings in a right sided white eye blowout fracture with entrapment of orbital tissue arrow. These injuries must be treated within 48 hours otherwise permanent restriction of ocular motility may occur. Diplopia, nausea, vomiting with no subconjunctival haematoma in a young patient requires immediate referral. Maxillofacial injuries are unfortunately becoming a more common presentation to general practice. The ATLS guidelines should be adhered to in the initial management of these injuries.
This should be followed by a thorough and comprehensive assessment of vision and facial skeleton mobility, with careful documentation. Practitioners should be aware of retrobulbar haemorrhage, traumatic optic neuropathy and white eye blowout fracture. Missing these injuries can have devastating consequences for the patient and medicolegal ramifications for the practitioner.
If these types of injuries are suspected, immediate transfer to hospital is mandatory. Although uncommon, any patient with a panfacial fracture should also be transferred to hospital immediately. Pain and discomfort dictate that mandibular and midface fractures should be referred within 24 hours. All other nonlife or nonsight threatening injuries can be referred within 7 days.
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If you don't have anything you can download the MS Word Viewer free of charge. Hands, fingers, thumbs Assessment and management of common hand injuries in general practice. Feeding in the first year of life Emerging benefits of introducing complementary solids from 4 months. Fitness to drive GP perspectives of assessing older and functionally impaired patients. Patients and tests A study into patient understanding of blood tests ordered by their doctor. The Kirketon Road Centre Improving access to primary care for marginalised populations. Requests for permission to reprint articles must be sent to permissions racgp.
The views expressed by the authors of articles in Australian Family Physician are their own and not necessarily those of the publisher or the editorial staff, and must not be quoted as such. Every care is taken to reproduce articles accurately, but the publisher accepts no responsibility for errors, omissions or inaccuracies contained therein or for the consequences of any action taken by any person as a result of anything contained in this publication.
Maxillofacial trauma Volume 41, No. Article Download article Download Citations. Anthony Lynham Joel Tuckett Patrick Warnke Background Maxillofacial injuries are a common presentation to general practice and hospital emergency departments in Australia; surprisingly they can be easily overlooked at initial assessment.
Discussion The full extent of functional disturbances might not be detectable in the first instance. Figure 2. A sublingual haematoma arrow can be an indicator of a mandibular fracture. Figure 3. Multiple titanium miniplates in situ postopen reduction and internal fixation surgery. Figure 5. Figure 7. Axial CT of a comminuted zygomatic complex fracture. Figure 8. A zygomatic complex fracture treated with titanium miniplates and screws. Coronal CT of a left orbital floor fracture arrow. Depressed anterior table frontal sinus fracture. Obvious cosmetic deformity associated with frontal sinus fracture.
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MP3 Most web browsers will play the MP3 audio within the browser. No competing interests:. I declare the following competing interests:. Yes No. Confirm E-mail:. Add Another Author. Competing Interests:. A hazardous life Our role in injury prevention. Letters to the editor. Sprains and strains. Maxillofacial trauma. Meniscal tear Presentation, diagnosis and management. Shoulder injuries Management in general practice. Cervical spine Assessment following trauma. Hepatitis B serology. Initial assessment of the injured shoulder. The Ottawa knee rules A useful clinical decision tool.
Dementia and driving An approach for general practice. MRI in an unconscious polytrauma patient is not straightforward, and in many patients may not be practical for many days. Spinal injury: assessment and initial management NG Historically there has been controversy about how to manage simple neck sprain injury i. A Cochrane review in reviewed the evidence for conservative management of neck sprain injury so-called whiplash.
They found that there was insufficient evidence to support or refute the effectiveness of active versus passive treatments to relieve the symptoms of neck sprain injury. There were, however, a number of trials in this review which reported that cervical spine collars resulted in worse outcome than early mobilisation. Although there are no randomised trials evaluating the use of analgesia in the management of neck sprain injury, it would be sensible to recommend analgesia to permit early mobilisation.
Patients who have a spinal cord injury should immediately be discussed with the nearest Neurosurgeon or Spinal Surgeon on call by the trauma team leader or senior doctor in charge of the patients care. There is considerable uncertainty surrounding the prognosis from neck sprain injuries.
Cervical Spine Injury - RCEMLearning
It is clear that the vast majority of patients have a good prognosis, however certain risk factors predicting worse prognosis have been reported 20 :. Insurance and compensation claims have been found to be associated with a worse prognosis. In countries without a litigation culture the prognosis of neck sprain injury is considerably better that in countries with a more litigious system.
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Context Cervical spine injuries are rare but potentially devastating. Cervical spine immobilisation is not a benign procedure2: Collars significantly raise intracranial pressure: an effect that is potentially significant in the presence of head injury Long boards and collars cause pain and tissue ischaemia which can lead to pressure sores Supine immobilisation causes considerable deterioration in respiratory function A large number of patients present to Emergency Departments ED with their necks immobilised; as significant cervical spine injury is rare and there are potentially adverse consequences of cervical spine immobilisation, reliable methods are needed to clinically exclude cervical spine injury wherever possible clearing their necks.
Learning Bite Cervical spine immobilisation is not a benign intervention. Results from judicial hanging rather than suicidal which causes asphyxiation or from striking chin on steering wheel in a collision. Figure 3: Hangmans fracture Rotation Rarely occurs in isolation Primary injury occurs to the posterior ligament complexes, and is often unstable May result in facet joint dislocation see Figure 4 Figure 4: Facet joint dislocation see slippage of C4 on C5 : Compression This mechanism is common in thoracic and lumbar spine injuries and results in wedge fractures The Jefferson Fracture of C1 see Figures 5 and 6 is a specific cervical spine fracture caused by an axial loading mechanism eg.
The characteristic features are: The atlas is compressed between the occipital condyle and C2 The laminae and pedicles are fractured and transverse ligament holding peg in position can be torn.
The skull and C1 may slide forward on C2. Younger children below 10 yrs are also more likely than older children to: Injure the upper cervical spine C1-C4 compared with lower c-spine Dislocate the cervical spine Injure the spinal cord itself The cervical spine takes on its adult form from about the age of 8 years. Figure 7: Pseudosubluxation note the apparent forward slippage of C2 on C3 Learning Bite The cervical spine in children is anatomically different to that in adults and this results in different patterns of injury.
Clinical Assessment. Conscious cooperative patients This is the most commonly encountered group of patients who present to the ED or pre-hospital practitioner. Therefore, a focussed history and examination can be used to clinically clear their necks various clinical decision rules have been developed to be used in these patients: Nexus Low Risk Criteria Canadian Cervical Spine Rules 2. The decision rule resulting from this study asks 3 questions see Box : Is there any high-risk factor present which mandates radiography?
Is there any low-risk factor present that allows safe assessment of the range of neck motion? Is the patient able to actively rotate their neck 45 to the left and right? Clinical assessment and risk stratification in children Childrens cervical spines are different to those of adults see above , with injury to the upper cervical spine and purely ligamentous injury being more common. Clinical exclusion of cervical spine injury in children: Viccellio and colleagues9 performed a subgroup analysis of the NEXUS study, specifically evaluating children with neck injury.
Investigation Strategies. In children under 5, the PEG view is considered unnecessary This view can be difficult to interpret due to overlying bones. MRI is indicated if there is any neurology referable from the cervical spine, or if there is severe pain, despite a normal CT scan as some unstable ligamentous injuries may only be seen on MRI CT vs. MRI scanning In unconscious patients there is some concern about the possibility of ligamentous instability which may be missed by CT, and so some authors consider that patients should have MRI to clear the spine in these patients.
Adults 1. Children 1. All rights reserved. Page 12 of 23 1. Prognosis and Followup Strategies. Safety Pearls and Pitfalls. The elderly are at high risk of cervical spine injury from relatively minor mechanisms of injury e. Missed cervical spine fractures tend to occur in patients with distracting injuries, reduced level of consciousness or under the influence of alcohol or drugs. There are many case reports of paralysis resulting from putting patients with Ankylosing Spondylitis into a collar. Key Learning Points. Milby A. Neurosurgical Focus 25 5 :E10 Benger J. Why do we put cervical collars on conscious trauma patients?
And Garner J. E, Clancy M. Clearing the cervical spine of paediatric trauma patients. R, Mower W.
Bibliographic Data: Hodder Arnold, Distributor: Oxford University Press, Inc. Reviewer's Expert Opinion:. Description: This is the second edition of a comprehensive textbook describing the physiology, pathology and management of head injury in the adult and pediatric patient. The first edition appeared in the mid s. Purpose: Provided is a conceptual framework with a review of mechanisms for brain damage along with an integrated imaging and management strategy.
Audience: Trainees in neurosurgery, critical care, and traumatology are an appropriate audience for this work. Editors and authors represent thought leaders on three continents: Western Europe, Australasia, and North America. Features: Traumatic brain injury is described in three large sections beginning with the epidemiology and molecular mechanisms of injury followed by contemporary measurement techniques and treatment. The third section, the largest group of chapters, is devoted to treatment modalities and outcome. Appendixes include recent thinking on antibiotic therapy for infectious complications, seizure management, and characteristics of cardiovascular drugs used to augment cerebral perfusion.
Chapters are clearly written with texture of type and tables effectively used to highlight key concepts. An extensive reference list is also provided featuring primary work with citations dating to within two to three years of publication. Notably, recent guidelines of the Brain Trauma Foundation are cited extensively.
Line drawings, tables, and photographs of pathology sections reproduce with excellent quality. Unfortunately, the quality of a large number of CT scan reproductions is inconsistent. A brief table of contents groups the 23 chapters by content and lists authorship while a subject index of approximately 10 pages concludes.
Related Head Injury 2Ed: Pathophysiology & Management (Hodder Arnold Publication)
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