This Week’s EMCQs – Week 7

QUESTION 1

A 23-year-old athlete has a fall while playing sport and landed on his right shoulder. He presents to Emergency with severe pain and restricted movement of his right shoulder.

His right shoulder X-ray is included:

Xray shoulder

Which one of the following is the most likely injury?

A: Partial rupture of acromioclavicular ligament only.

B: Complete rupture of coracoclavicular ligament only.

C: Complete rupture of acromioclavicular ligament only.

D: Complete rupture of acromioclavicular and coracoclavicular ligaments

A: Partial rupture of acromioclavicular ligament only.

B: Complete rupture of coracoclavicular ligament only.

C: Complete rupture of acromioclavicular ligament only.

D: Complete rupture of acromioclavicular and coracoclavicular ligaments (Correct answer)

Commentary

This is grade 3 (severe) AC joint injury demonstrating complete rupture of acromioclavicular and coracoclavicular ligaments.

Grade 1 (mild)…

An athlete with a grade 1 injury of the AC joint will experience tenderness and discomfort palpation and movement of the joint.  Grade 1 sprains involve only partial damage to the joint capsule and the AC ligament.  Return to play – up to 3 weeks.

Grade 2 (moderate)…

A grade 2 injury will involve complete rupture of the acromioclavicular ligament and partial tear of the coracoclavicular ligament.  This tearing allows the clavicle to move upward, and as a result the bump on the shoulder is more pronounced.  Pain is more severe and movement of the shoulder is restricted.   Return to play – minimum 4-6 weeks.

Grade 3 (severe)…

A grade 3 injury involves the complete rupture of the acromioclavicular and coracoclavicular ligaments.  The bump visible in a grade 2 tear is even more pronounced in a grade 3 injury due to complete dislocation of the acromioclavicular joint.  Return to play – dependent on management eg. surgery.

QUESTION 2

A 65-year-old patient presented to Emergency with severe respiratory distress. Multiple attempts at direct laryngoscopy have failed and a needle cricothyroidotomy was performed.

Which one of the following is TRUE regarding jet insufflation for the above patient?

A: 20 G IV cannula can be used

B: Inspiratory/Expiratory ratio 1:4

C: Oxygenation may be maintained for 2 hours

D: Inspiratory/Expiratory ratio 4:1

A: 20 G IV cannula can be used

B: Inspiratory/Expiratory ratio 1:4 (Correct answer)

C: Oxygenation may be maintained for 2 hours

D: Inspiratory/Expiratory ratio 4:1

Commentary

Ventilation can be achieved by occluding the side hole for 1 sec and release for 4 secs to allow expiration. 14 G cannula is the recommended size. Oxygenation can be maintained for up to 45min whilst definitive airway control is planned.

Reference: The Emergency Medicine Manual, Dunn R et al, 5th edition. Page 38