ortho Flashcards Preview

Emergency Medicine > ortho > Flashcards

Flashcards in ortho Deck (134):
1

level 1 trauma center needs

all specialties/modalities avail 24hrs
MRI, Fluoroscopy, CT scan, etc avail for 24 hrs

2

The “Golden Hour”

Time we have to make a difference
ii. 1 hour – if you’re going to crump, you will crump

3

How does the PA student fit? Anticipate

Undress, log-roll (if on backboard), IV access, foley, doppler/API’s (looking for pulses, compartment syndrome), CPR, to CT

Lac repair, help ortho (reductions, etc), ophtho, ENT, etc

OR, care in-house

4

primary survey

ABCDE hx (if awake)

GCS and a C spine and a ULS

pt is phonating =has an airway

5

AMPLE survey

allergies
meds
PMH/PSH
last PO
events environment

6

Secondary Survey

1. Full systems exam, head to toe
2. More complete Hx

7

how to management pt with . GSW

Stabilize the patient if unstable - undress

Determine where, how many, other injury

Neurovascular integrity is the priority in extremities

Penetrate the joint?

8

checking neurovascular integrity should look like what

Check: pulses, pallor, temp (cold?), cap refill
2. Sensory exam

9

how to evaluate weather or not a shot has penetrated the joint

Air in joint = penetration

10

how should you report a fx with a GSW

"i have a GSW with an open fracture to the left tibia"

11

how to treat fxs

• X-ray all – joint above/below
• If fx, treat as open fx
• Local wound care, debridement
• Surgery, ortho consult
• Consider Abx
• Splint, close follow-up
• Tetanus

12

big concern with femur fracture

Risk for compartment syndrome

all of huge critical arteries that supply the leg will be pulled and the legg will probably need a steinman pin might be needed to correct

13

what should we be thinking about with pelvis fx

Internal injury common (strap them with stabilization device)

Surg admit, ortho consult


worry about the bladder, reproductive organs, rectum

14

big tell tale sign of hip fx

can't bare weight

15

risk for hip fx

Describe location
1. Classic – old woman who
fell down

Risk for AVN


Occult fx? CT(first test) or MRI*(definitive)
Ortho admits for pin or
replacement

16

talking to pts about knife and stab wound

We deal with extremities/stable pt only
think immediately about assault and police reports

Good history; police report made?

tell me what happened and show me what position you were in

17

how to approach stab wounds

Count, measure, explore deeper structures
i. Function, neurovascular exam

Imbedded objects are removed in the OR – don’t pull them out (may have lacerated one of the arteries but if you leave it in it stops the bleeding)

18

why would you do delayed primary closure

High risk, contaminated or neglected wounds – don’t suture

1. Hands, feet, over joints; immunocomp pt; crush, bite, puncture

2. Predict high infection risk

19

when to have pt return for high risk wounds

Copious irrigation, wound debriedment
iii. Leave open, no suture, dry dressing
iv. Follow-up in 3-5 days – suture the wound then if no infection
v. Pt Ed/document: Discussed, return signs infection, increased scar risk

20

arterial bleed 1st approach

Universal precautions, ABC’s

Check for foreign body, elevate

21

managing arterial bleed in the wilderness

1st small tightly folded nugget with pinpoint accuracy

2 incremental larger or less folded piece of gauze

22

TXA used for

Tranexamic acid
clott promoter arterial bleed

23

Traumatic ABI looks like

Comparison of ipsilateral upper and lower extremity systolic pressure

24

how to take ABI


Pt supine, BP cuff, doppler

Doppler brachial SBP, then highest of dorsalis pedis and posterior tibial

25

ABI

ABI = Ankle SBP/Brachial SBP

26

Arterial Pressure Index (API)

Compare injured extremity to the other one (for example – compare L foot to R foot)

API = Injured SBP/Uninjured SBP

27

Approach to Ortho Injuries


Mechanism and when occurred

Associated sx’s/risk – fall, high energy, helmet, protective gear

Sx’s other than pain? Numb? Weak? LOC? Weight bear? Hear noise?

Pain right away or delayed?

Blood loss estimate; arterial?

Dominant hand? DON;T MISS

Hx same/other injury in past?

Occupation? Work related?

Assault? DV? Police report?

PMH, Meds, Allergies

Tetanus?

Social situation

28

PE for ortho needs

anatomy, neurovascular exam are key

Master exam for each area

29

medication and imaging that needs consideration for ortho injuries

Pain control. Abx? Oral? IV?

Imaging: Xray 1st. Need CT?

Repair, reduction, splint?

ED splints; no cylindrical casting

Ortho consult, rec’s, f/u

30

pt education should include

• Splint care
• Importance of f/u
• Red Flags to return
• Recovery period
• Document!

31

neurovascular test should include

Know anatomy of injury area

Check at injury area and distal

Neuro: sensory, motor, DTR’s
1. 2-point discrimination fingertips

2. <6mm normal

32

vascular check should include

: pulses, cap refill, temp, color, Allen’s test

33

no pulse or weak pulse?

GO GET THE DOPPLER

34

Neuropraxia

nerve contusion
a. Temporary – recover

35

No sensation

nerve cut/damaged
a. Which nerve, reproduce, compare

36

Cold extremity, pallor of the hand/foot means

) = Vascular emergency (Surg/Ortho

37

example of consulting hx

Lauri's example of talking to a specialist

Begin with Dx; then age, gender, PMH
1. If fx: open or closed?
iii. Mechanism, other injury
iv. Dominant hand. Occupation.

\Good PE prior to call: describe it
1. Know motor, neuro, vascular status

and what have you done
1. Imaging, ultrasound
2. Reduction?
3. Antibiotics, Tetanus


"i have a 35 yo male with an OPEN tip fib s/p MVA x1 hour BIBA xray show comminuted fx of the __ the pt is otherwise stable and placed in a splint, they are in bed 14"

38

scaphoid fx is at risk of AVM

at the waist

39

ortho should be consulted for

• All fractures to arrange f/u
• Joint infection/issues (may have cellulitis around the joint)
• Ligament/Tendon injury/rupture
• Hand/finger cellulitis
• Minor crush/soft tissue injury
• Major dislocations
• Ortho Admits:
• Fractures/injuries requiring surgery now

40

true emergencies

• Open fractures
• Compartment syndrome
• Septic joint (in the joint)
• Un-reducible dislocation
• Amputations
• Crush/mangled
• Pressure, air-gun injury**special (devastating, very high risk)
• Neurovascular compromise

41

mechanism of contusions

1. Crush is high risk
2. Spontaneous is high risk
3. Coumadin?

42

exam of contusions

need MOA

ii. Neurovascular exam
iii. Is this cellulitis/nec fasc?
1. Search for wound/gas

43

cellulitis

red
tender
warm

44

complications you are worried about in contusions

iv. Check for ligament/tendon rupture

v. Check joint above/below

vi. Check compartments; soft?

45

mnmgt from contusions

Xray for fx, gas, foreign body


Ice, elevation, return precautions

46

how to write about ligamentous injury


• Know ligamentous anatomy of injured area
• Know the “special moves” for each joint
• Stress joints to uncover laxity
• Sprains:

joint is stable to...
mcmurrys
lachmans
anterior drawer **

47

1st degree sprint

mod pain, minimal swelling, no laxity

48

2nd degree sprain

pain, swelling, loss function but no laxity

49

3rd degree sprint

complete ligamentous disruptions
• Significant pain/swelling/function loss
• Joint laxity present

50

collecting information on sprain should look like

i. Mechanism, when occurred, other injury, weight bear?

ii. Neurovascular exam
iii. Stable or unstable joint
iv. Look for wound, lesions
v. Infection? Septic joint?

51

sprain management

Xray – Ottawa Rules

vii. ACE/Brace/RICE if minor
viii. Joint disruption or unstable?
1. Splint like fracture
2. Ortho consult, f/u

52

Popeye sign (sling)

biceps tendon rupture

53

Can’t extend lower leg
Knee immobilizer
think

patellar rupture

54

Defect, hip flexion
Knee immobilizer

quadriceps rupture

55

mangement achilles

Hear “pop”, local defect
Thompson’s test
Posterior splint, equinus

56

patellar rupture test

can you kick me while sitting down

"the patient has full extension of the patella"

57

mnmgt of patellar fx

Xray all, Ortho/Pods consult all
Immobilize, outpt f/u

58

describe fx

open or closed

location
number of fragments

direction of fx line

alignment

special fxs

59

describing lcoation (5)

Which bone(s)?
Where in the bone?
“Head” proximal
Proximal, middle, distal shaft, neck
Intra-articular?

60

number of fragments think

simple (2)

comminuted (>2)

61

direction of fx line

Transverse, oblique spiral, longitudinal

62

alignment thnk

Displaced, distracted
Angulated
Shortened, impacted, depressed
Rotated

63

elbow look for

Post fat pad, sail sign
Anterior Humeral Line
Radiocapetellar Line

64

radial head

Subtle, common, FOOSH

65

Nightstick

Defensive, midshaft ulna

66

Fx ulna w/ radial head dislocation

Monteggia

67

Galeazzi

Fx distal 1/3 radius with ulna dislocation

68

special features of the wrist to consider with intra-articular

Check carpal bone arches
spaces and alignment

69

scaphoid fx at risk at

AVN risk if at “waist”
Check snuff box

70

Colles vs Smith’s

Colles dorsal, Smith’s volar
FOOSH; need reduction?

71

Teacup is tipped over

lunate

72

teacup is empty

perilunate

carpals dislocated

73

Boxer’s Fx

what is it and when do you reduce

4-5th at neck (fight bite?)
Note finger rotation
Reduce >30deg angulation

74

review right now

Gamekeeper’s, Bennett’s, Rolando fx’s

75

Hyperextened finger

volar plate

76

Jammed
suspect

extensor avulsion

mallet finger

77

patellar consideration

Direct blow
Sunrise view
Check patellar tendon

78

who get's tibila plateau fxs

MVA, Auto vs Ped
Jumpers
Can be subtle
Can’t weight bear
Get CT

79

Mortise fx

Wide? Disrupted?
Ligamentous injury

80

Maisoneuve

Mortise plus proximal fibula fx

Palpate proximal leg in all ankle injuries

81

bimal
vs trimal

Unstable both

check lateral for tri mal

82

mngmt of talus fx

CT

Not common
High risk AVN
CT all

83

SIGN w/ calcaneus fx

Mechanism, Mondor’s sign
CT all

84

Lisfranc fx/dislocation

what are they and how are they manged

Mechanism
Check the 1st, 2nd, 3rd MT joints
CT all

THIS NEEDS TO BE ON THE DDX OF THE FOOT

goes to the operating room TONight

85

4 special bony conditions

open fxs
non-union or malunion
osteomyelitis
AVN

86

open fxs worry about

All get xrays first, then ortho consult

87

Non-union/malunion worry about

Deformity, pain after fx

chronic pain prone to stressors
Often non-compliance

88

who get's osteomyelitis

what are we worried about

DM, chronic infections

Ask: Is this nec fasc?

89

AVN risk

talus
navicular/scaphoid
head of the numerous

90

consideration in shoulder dislocation

Anterior or posterior?

Hill-Sachs--repetitive frequent dislocation

91

how to describe dislocations

always describe the distal portion

70% of hip dislocation posterioer

92

in all joint dislocations consider

Open or closed?
Neurovascular exam paramount
Xray all: fracture dislocation?
We try reduction first if no fx
Ultrasound guided nerve blocks
Intra-articular injection
Procedural sedation
Xray post reduction
Ortho consult, immobilize

93

considerations with effusions

mono articular vs. poly – ballottment (does the patella bounce)– hot/red? (eep think spetic)

94

big concerns for spetic joint

Atraumatic, +/- fever, red/hot, won’t move it

95

pathogens common with septic joint

S. aureus most common, N. gonorrhea 20%

GC big one for mono articular

96

Hemarthrosis is usually mono or poly?

usually in the setting of....

mono
Post trauma

97

findings in gout

usually mono, or poly
Uric acid crystals (bi-refringent)
Pseudogout - CPPD

98

Reiter’s Syndrome

asking about penile of vaginal discharge

mono/poly
Arthritis, conjunctivitis, urethritis

99

Inflammatory – usually mono or poly?

Inflammatory – poly

100

labs for swollen joints

Get xrays, CBC (ESR, CRP)

101

Arthrocentesis

Consent pt, check contras
Cellulitis, coumadin, prosthetic jt


Strict sterile procedure

102

arthrocentesis is done for

Diagnostic and therapeutic
Suspect septic joint
Hemarthrosis post trauma
Gout diagnosis

103

how do you do a arthrocentesis

Big joint, big needle
Ultrasound guidance
Take out as much as possible: can inject bupivicaine after tap
Send fluid for cell count, culture

104

when to suspect infection after arthrocentesis

what are the complications

>50,000 WBC’s: infection***

Complications: iatrogenic infection, bleeding, local trauma

105

Five “P’s”:

Five “P’s”: pain, pallor, paralysis, pulselessness, paresthesias


106

do you need all 5 of the p's for compartment syndrome ?

Don’t need all for dx. All = late

107

first sign of compartment

Severe/pain out of porportion, w/ passive stretch: early hallmarks

108

common findings with compartment syndrome

Edema, bleeding = reduced blood flow
Muscle/nerve necrosis ensues
First few hours to 48hrs
Femur/tibia, humerus/elbow/hand fx/injury
Severe pain w/ cast? Remove it

109

Stryker pressures

???

Fasciotomy
Anticipation, high vigilance

110

who is at risk of puncture wounds

6-10% get infected: DM, immunocomp, PVD high risk

111

management of puncture

Xray all for FB, fx; low pressure irrigate, tetanus shot

irrigate softly with gravity

(don't push shit back in)

112

what is the time consideration with

<6hrs old, clean wound, healthy pt:
No abx, return precautions, do well

>6hrs, high risk pt/wound, plantar surface/hand:
Consider abx (Cipro, Keflex), strict return precautions

113

tennis shoe puncture wound?

psuedamonas !

cipro

Consider vascular/neuro/lig/tendon injury

114

Hand puncture wounds consider

Consider vasc/neuro/lig/tendon injury

115

complications with hands

Cellulitis, abscess, osteomyelitis (pseudomonas)

116

“No man’s land”

flexor tendon injury

117

mangement of flexor tendons

Flexor repaired in OR – ortho
Some extensor – ED can repair

118

sausage finger held in flexion

Flexor tenosynovitis, cellulitis

119

why do we worry about a fight bite?

weird bite

Eikenella corrodans, polymicrobial

120

mngmt of human bite

Admit, IV abx fight bite. Others: Augmentin

Tetanus, consider Hep B vaccine

Don’t miss DV!!

DO NOT SUTURE human bites!

121

high risk pathogen of cat bites

Pasturella Multoceda, Staph, Strep, Moraxella

Bartonella: Cat scratch fever

122

tx of animal bits

Clean like puncture
Do not suture!
Augmentin, close f/u

123

management of dog bites

Medium risk infection
Polymicrobial
Copious irrigation, debridement
No suture if hand, feet; face/scalp ok
Abx if hand, foot, big. Close f/u

124

rabies concerns

Medium risk infection
Polymicrobial
Copious irrigation, debridement
No suture if hand, feet; face/scalp ok
Abx if hand, foot, big. Close f/u

125

splints for

Splint all fractures,
tendon injuries,
Grade 2,3 sprains, infections,
lacs over joint area,

post-reduction/tap

126

back pain-how many need imagining

1:100 need imaging today


vast majority are muscle spasms or muscle strain

127

history for low back pain

OPQRST, mechanism, Hx same, plus...

Fever, weakness, numbness/sensory changes, bowel/bladder incontinence or retention, weight loss, IVDU...abdominal/female GU/prostate

128

when would you get an MRI for back pain

Plain film rare (older, fx, mets), CT: bone or if suspect fx

MRI: cord: if fever, IVDU, true new weakness or true sensory deficit

129

everyday mngmt of bakc pain

NSAID’s, APAP, muscle relaxant, self-care, expectations, work note

130

PE for back pain must include

Abdominal exam – rectal only if weakness/sensory change
Back: rash/lesions, bony tenderness, ROM, SLR
Neuro: Strength, sensory exam, DTR’s, gait

131

managment of low back pain

Trauma/fall/assault/direct blow (plain or CT – depends on severity)
*Fever (MRI)
*Motor weakness (cord compression, Transverse Myelitis (TM) MRI)
*Numb, sensory deficit: check saddle distribution (Cauda Equina: MRI)
*Bowel/bladder incontinence/retention (Cauda Equina - MRI)
*Bony or central tenderness (Fx, met, TM – plain vs CT first)
*Weight loss (Cancer – CT for mets)
*Elderly and no trauma (Think Aorta – CT)
*IVDU (Fever, back pain? Think Spinal Epidural AbscessMRI)

132

concerning low back pain

radicular sx’s, positive SLR, loss of DTR’s
May need outpt MRI - unless precipitous progression (TM, cord)

133

Limp in Kids ddx

Acute Septic Arthritis
Transient (Toxic) Synovitis
Slipped Capital Femoral Epiphysis
Legg-Calve-Perthes
Rheumatic fever: 2-6wks after Grp A Strep
Juvenile Rheumatoid Arthritis

134

Acute Septic Arthritis

Often younger; hip, knee, elbow
Fever, +/- toxic appearing