6NU518 Minor Injuries

FOOSH injury defined as mechanism of injury that occurs due to fall of any individuals and injured area can be wrist, hand and any other places of the body. One common injury observed is colle’s fracture. , In few cases, swelling and bruising observed and weak hand grips, loss of wrist motion observed in patients (Lee et al. 2017). Increase in pain generally observed. .If pain persist for longer period then ligament tear might occur which decrease the motion of hands. In severity of the injury, surgery can be needed to cure the patient.

For older patient like her, the fracture is a common phenomenon due to soft bone as compared to others.  In the above case study, an patient who fell on icy path outside of house two days ago, putting her hand down to break the fall (i.e. FOOSH). The possible injury that was observed is wrist injury. The wrist injury is one of the leading injuries in the category of fall on outstretched hand injury that mostly damages the scaphoid bone of the wrist. The principal reason behind this fracture is that with ages bone becomes soft and fractured with sudden fall.  Therefore, this paper will illustrate the pathophysiology, diagnosis and further research and management in discussion.

Discussion:

Pathophysiology of injury:

In the above case study, Two days ago she fell on an ice path outside of the house, in order to prevent the fall patient put her down and subsequently injury observed, which is named as fall on out stretched hand injury (FOOSH). After the injury, there was an immediate pain in the left wrist below the thumb due to outstretch of hand.  Deformity after acute trauma is the signature of fracture .From the evaluation of patient, tender swelling at the wrist observed. Redness in the portion of left wrist below the thumb and decrease in active movement of scaphoid bone in the wristwas observed after examination (Koxet al. 2015).

Moreover, after sensory assessment of the thumb, minor injury observed in median nerve due to increased pressure during fall and subsequently localized swelling and inflammation (Payne et al 2017). Eventually, in further assessment loss of sensation in thumbs and wrist also observed due to decreases in space at carpel tunnel and obstacles in blood flow in the thumb (Mustafa and Negm 2017).

Differential diagnosis:

Scaphoid bone injury includes fracture of the distal radius, fracture due to massive strain, scapholunate dissociation and arthritis (Bergh et al. 2014). All the different kinds of injuries differentiated by the location of tenderness, redness of specific place and sensation of a particular nerve ( Ecker 2017).

There are diverse-imaging options for evaluating older patients with suspected injury in scaphoid bone. The differential diagnosis of suspected injury generally performed in diagnosis centre Plain radiography imaging.

• Plain radiography imaging:

For evaluating specific injury in the patient anterioposterior, lateral and oblique radiographic imaging is required. For imaging technique, four dimensions need to confirm any severity of the case. If there is any fracture observed then specific imaging positions are used for an accurate result.  A great deal of variability found concerning sensitivity towards radiographic imaging, initially approximately 85% of sensitivity observed in injury (Grant, Robinson and Stevenson 2017).

For accurate results, Other imagining techniques are required. Since, during injury, due to falling carpal bone arched in order to prevent the fall, carpal bone imaging is important to determine the fall (Dreyer et al 2015). However, the inner wall imaging is difficult to obtain by the regular imaging technique.  Front view of scaphoid bone is also obtained for the accurate result of suspected injury and subsequent fracture. Front view of scaphoid bone imaging and stress imaging need to perform or detecting abnormalities in bone.

Investigation and further findings:

Wrist damage in fall on outstretched hand injury does not always show symptoms of fractures, and sometimes even medical expertise miss out the signs of scaphoid fracture as the fracture line is not still visible. For further investigation of the suspected injury. Swelling sometimes is not enough to confirm deformity. Further assessment needed for monitoring the blood supply of wrist and hands. For establishing the scaphoid fracture, other diagnoses need to perform such as Magnetic resonance imaging and CT scan and assessment of nerve impulses.

• Magnetic resonance imaging:

Magnetic resonance imaging mainly detects any soft tissues and bone tumour in patients. It is not an efficient method for detecting primary damaging.

For initial evaluation of a patient with suspected fall on outstretched hand injury, MRI shows negative result mainly as compared to plain radiographic imaging. Magnetic resonance imaging generally used for cases that are more sensitive where plain imaging cannot detect certain disability (Lefever, Winter and Troyer 2017). However, MRI needed for providing more specific treatment procedure for suspected injury, where there is a probability of severe fracture.

• CT scan:

Sometimes, X-ray can only detect the damage but not efficient enough to detect breakage. This phenomenon is specifically observed in injuries such as wrist fracture and pelvis bone fracture. Therefore, CT scan easily detects the rupture.CT scan generates transverse images of the damaged wrist. It is one of the efficient performing equipment to detect disease that cannot be detected by the usual x-ray imaging technique (Oguzet al.2017). For confirming fracture, three-dimension imaging needed.

• Vascular examination of the wrist:

It helps to check the vascular status of the hand specifically pulses of radius and ulna (Mustafa and Negm, 2017)

• Assesment of muscles:

In order to understand the degree of severity of the injury assessment of different tissues performed by medical expertise( Ali 2014). Different kinds of factors need to consider to understand the wrist injury. Medical knowledge take account of wrist flexion, grips strength, key and pinch grip and forearm supination for providing proper treatment (Norkinetal. 2016)

• Assessment of sensation in hand:

Damages of the nerve are quite common in injuries and subsequent fracture of the wrist or any other portion of hand (Magee 2014). In such wounds, three significant nerve damages observed such as radial nerve, median nerve and ulnar nerve. Since the median nerve is the only nerve that enters in the thumb from the wrist, median nerve sensation assessment is one of the crucial steps. Radiographic images also give the estimation of nerve damages due to extreme pressure in carpal tunnel and obstacles of blood (Grinsell and Keating 2014).

Electromyogram needs to perform if carpal tunnel syndrome is suspected. The thin electrode is inserted in the muscles and the electrical activity is recorded for muscle when it contracts, or in resting phase (Silva etal .2017) The studies of nerve conduction sometimes performed if the motion of nerve decreases in a specific area of the carpal tunnel.  Physical examination of nerve sensation is performed by tapping the place of injury for receiving sensation. Shaking thermometers are used generally for measuring the nerve velocity in hands and wrist.

Working diagnosis:

Working diagnosis is an accurate procedure to confirm suspected physiological issues. In the above scenario, wrist injury observed in the patient due to sudden fall followed by immediate swelling in the wrist. The pain increased when she tried to pick up something or movement of the wrist. The working diagnosis of such injury involves plain radiographic imaging, Magnetic resonance imaging, specific ultrasonography of bone, bone scintigraphy, arthrography of the wrist and arthroscopy of a wrist. Every radiographic evaluation together requires confirming the suspected injury. Magnetic resonance imaging and CT scan generally used for alleged fracture whereas Bone scintigraphy and Ultrasonography performed only when necessary.  After an x-ray, imaging every diagnosis method should be used by considering the necessity of the test, the stress of patients and physiological status to tolerate radiological exposure. 

• Ultrasonography:

Routine equipment of ultrasonography for detecting any injuries is not a reliable source for confirming suspected damage of scaphoid injury. For achieving error-free result of the evaluation, High spatial resolution ultrasonography is equipment that is more reliable (Oguz 2017).

• Bone scintigraphy:

Abone scanning is a nuclear medicine imaging technique of the bone, which helps to diagnose different kinds of bone condition and deformity. That also includes the location of bone inflammation, specific infection in bone and fracture (Iammarino 2018). However, MRI is an efficient imaging technique as compared to scintigraphy for achieving the error-free result of the suspected injury.

• Arthrography of the wrist:

This is an effective procedure for diagnosis ligament injury and triangular fibro-cartilage injury of the wrist. Contrast medium is generally injected in the radiocarpal articular cavity. The leak of contrast medium is leaked in the distal radioulnar joint, and then only triangular fibrocartilage injury is detected (Suojärvietal. 2017). However, this is especially useful for younger patients, not aged patients as perforation due to abrasion which is an age-related problem.

• Arthroscopy of the wrist:

Arthroscopy of wrist provides the advantage of direct observation of synovial membrane, an articular cartilage surface, triangular fibrocartilage complex and ligament for obtaining the error-free result. However, this method requires specialized equipment for direct observation which costly, and it is the stressful procedure for the patient. Recently accumulated pieces of evidence suggested that arthroscopy used for primary indication of injury in triangular fibrocartilage complex and other ligament damages in carpal bones (Liverneauxetal. 2017).  This technique performed by partial resection of Triangular fibrocartilage complex under arthroscopy.

Management of the injury and referral plan:

The wrist injury is one of the leading injuries in the category of fall on outstretched hand injury that mostly damages the scaphoid bone of the wrist.  A significant number of evidence accumulated in literature where the damage of wrist gives rise fracture in the older individual as compared to a younger individual. The principal reason behind this fracture is that with ages bone becomes soft and fractured with sudden fall.  Therefore, immediate management of the injury required for preventing further damages.  Brief management of such injuries are following:

• It should be recommended to rest the injured wrist for at least 48 hours.
• Ice should be applied for 20 to 30minutes to reduce the pain, inflammation and immediate swelling in the injured area and the cycle repeats for every three to two hours. However, it should be recommended not to use ice directly to the skin rather ice bag should be used. In the absence of ice bag, frozen vegetable wrapped in a container can be used to reduce the redness and immediate pain.
• It should be advised to lay the wrist on the soft pillow without any movement and seek medical help immediately to prevent further damage. Bone fracture needed immediate assistance of medical experts.
• If there is no specific deformity observed in the wrist and no fracture detected, then it should be recommended to consume acetaminophen such as Tylenol or ibuprofen or other analgesic drugs for reduction of pain (Karacaetal. 2016). However, there are no drug allergies detected in-patient of the case study but consuming analgesic drugs can give rise to other complications. Non-steroidal drugs generally recommended drinking for daily purpose.
• Severe cases need the assistance of surgeon and grafting of bone. Bone grafting generally requires plates, screw and wires (Caloiaetal. 2016). However, the many dangerous consequences involved in bone grafting. Risk factors include severe pain in the place of damage. Many nerves can be damaged during surgery which will give rise to permanent loss of sensation in hand. Grafting mainly faces obstacles such as rejection and inflammation.

Conclusion:

Thus, it can be concluded that FOOSH injury is one of leading cause of injury in adults. The prime reason behind such cause is softness of the bone and sometimes the misbalance. The main diagnosis methods is plain radiographic images. However, to confirm further injury require the assistance of the MRI, CT scan and other process along with assessments of nerve and sensory movements along. Management of the wrist injury require proper expertise to understand the severity of the injury and specific set of skills to manage the immediate injury. By walking carefully and proper medication and exercise this injury can be healed.

References:

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