13 CEN: Musculoskeletal and Wound Emergencies

Question 1

6 Ps of Neurovascular Assessment?

Answer 1

6 Ps: Pain, Paresthesia, Pallor, Pressure, Paralysis, Pulselessness

Question 2

How to assess radial, median, and ulner nerves?

Answer 2

Radial - motor - extend wrist or thumb (hitchhike or thumbs up), sensation to thumb.
Median - motor - oppose thumb to fingers, sensation of index finger.
Unar - motor - abduct (fan) fingers, sensation to 4th and 5th fingers.

Question 3

Tetanus toxoid (active immunity).
How often is vaccination? What does tetanus cause?

Answer 3

Tetanus toxoid (active immunity) - revaccinate q 10 years for minimal contamination; revaccinate a 5 years for grossly contaminated, add 250 units of IM immunoglobulin (TIG) if no or unsure of initial vaccination with gross contamination (migrant farm worker).

Tetanus - trismus, or lock jaw.

Question 4

Explain Crutch walking to patient.

Answer 4

• fit with wearing shoe on unaffected side,
  arm pieces 2 inches below axilla,
  elbow at 30-degree angle,
  keep crutches 6 inches to side for stable gait,

stairs - uninjured (good leg) first ascending (going up), injured (bad leg) first descending (going down).

Question 5

Abrasion vs Avulsion

Answer 5

Abrasions “friction burn” - consider pain control prior to cleansing with soap and water, apply non-adherent dressing.

Avulsion - peeling of skin from underlying tissue; degloving injury is avulsion where skin is pulled away from the scalp, hands, digits, foot, and toes; apply non-adherent dressing.

Question 6

Vegetative Foreign body. What is dx tool and tx?

Answer 6

Retained object in wound, caused by dirt, debris, gravel (tattooing), glass, wood, metal etc.
vegetative requires MRI.
TX: remove vegetative material (thorn) ASAP, do not soak or it swells, tetanus, antibiotics.

Question 7

Where should lidocaine w/ epi not be given? Why?

Answer 7

on ears, nose, fingers, toes, and penis (hose) - decreased circulation to distal areas increases risk of infection.

Question 8

How long are staples left in scalp laceration?

Answer 8

remove in 10-14 days.

Question 9

How long before adhesive taple falls off? What should be avoided?

Answer 9

Leave adhesive tape strips until they fall off on their own (7-10 days) - avoid petroleum ointments or weakens glue

Question 10

Suture removal time- Face

Answer 10

Face is 3-5 days;

Question 11

Suture removal time- Scalp/Trunks

Answer 11

Scalp/Trunks 7-10 days;

Question 12

Suture removal time- Arm/leg

Answer 12

Arm/Leg is 10-14 days

Question 13

Suture removal time- Over joint

Answer 13

Over Joint is 14 days.

Question 14

What causes poor outcomes with Traumatic amputation? Tx?

Answer 14

Poor outcomes with crush injuries due to contamination, comorbidities, age, poor nutrition.

TX: ABCs, bleeding control (pressure or tourniquet to stump), immobilization, antibiotics, tetanus

Question 15

What should be done to prep amputated part?

Answer 15

a. Prepare early for transfer to applicable facility for replantation.
b. Lightly brush off gross material, rinse gently with sterile saline (avoid iodine).
c. Wrap amputated part in saline moistened gauze; do not soak in saline or part swells.
d. Place amputated part in sealable plastic bag, label with patient info.
e. Place bag on separate bag of ice; avoid direct contact between amputated part and ice.

Question 16

What is Compartment syndrome? Common areas?

Answer 16

1.Excessive pressure develops within a body cavity enclosed by fascia; as pressure increases, circulation decreases, and edema increases; leading to ischemia and necrosis.
2. Most common in lower leg and forearm; irreversible damage after 4-6 hours of ischemia.


Question 17

Causes of compartment syndrome?
S/S? DX? TX?

Answer 17

3. Causes: fractures; external compression from circumferential burns, casts, splints, ace bandages, edema, soft tissue, or vascular injury (crush injury, bleeding, hemarthrosis, recent surgery).
4. S/S: early sign - severe pain disproportionate to the injury, unrelieved by narcotics; pulselessness is late sign (permanent damage).
5. DX: measure compartment pressure with compartmental pressure monitoring device - normal: < 10 mm Hg, 20 (high)-30 close observation.
6. TX: elevate to level of heart (neutral position), remove any external compression, surgical decompression - fasciotomy at > 30 mm Hg.

Question 18

Clavicle fracture- assess what? Tx?

Answer 18

Assess for axillary nerve as well as damage to subclavian or axial artery, may have associated pneumothorax/hemothorax or great vessel injury.

TX: Ice, sling & swath, Figure of 8.

Question 19

Humerus fracture- assess what? Tx?

Answer 19

Humerus - assess for brachial nerve injury.

• TX: Sling & swath for proximal, sugar tong splint if mid-shaft humeral fracture, surgery for distal humerus fracture.

Question 20

FOOSH- assess what? Tx?

Answer 20

FOOSH - fall on outstretched hand, Colles silver fork deformity - distal radius), Monteggia’s (dislocation of radius, fracture of ulna), or Smith fracture (arms full).
Assess for median nerve damage.

TX: Splinted with elbow flexed 90 degrees, sling to support arm.

Question 21

Scaphoid- assess what? Tx?

Answer 21

Scaphoid

• S/S: Pain in anatomic snuff box. TX: Splint with thumb abduction (thumb spica splint).

Question 22

Boxer’s “Amateur Boxer” fracture- assess what? Tx?

Answer 22

(4 or 5m metacarpal fracture)

• S/S: depression of knuckles. TX: Apply a posterior ulnar splint.

Question 23

Pelvic fracture- assess how? Risks?
Tx?

Answer 23

Stable (fall - one point broken) versus unstable (MVC - multiple points broken).

Assess: gentle inward compression and down over symphysis pubis if no obvious injury, only once so you do not dislodge clot.

Risk: hypovolemic shock, associated urethral damage and bladder rupture.

TX: apply pelvic binder over greater trochanter ASAP for pelvic ring fractures, massive transfusion protocol (10 units of PRBCs plus plasma and platelets), permissive hypotension, prepare for embolization (REBOA) or surgery,

post-op risk: DVT/PE/Fat emboli.

Question 24

Femur fracture- S/s? Tx?

Answer 24

Femoral head fracture seen in falls especially in elderly with osteoporosis; femoral shaft fractures seen in high-energy forces.

S/S: shortened leg, external rotation, swollen thigh.
TX: apply a traction splint for mid-shaft fractures to align and reduce blood loss and pain; ORIF for femoral head fracture; highest risk of fat emboli (12-48 hours after injury).

Question 25

Hip fracture- anterior vs posterior?
Time to reduce?

Answer 25

Fall or front seat MVC dashboard injury -
Posterior - adducted, internal rotation;
Anterior - abducted, external rotation.
Reduce emergently within 6 hours to prevent femoral head necrosis.

Question 26

Patella/Knee injury may damage what arteries?
Tx?

Answer 26

Blow or fall on knee, may damage peroneal and popliteal artery.
Extend leg to reduce, compression, place in a knee immobilizer.

Question 27

Gouty Arthritis etiology?
S/s? DC teaching?

Answer 27

Etiology: Acute arthritis with uric acid crystals in synovial fluids, mostly male.

S/S: Intolerable pain in toes, increased at night. TX: Colchicine, Allopurinol, steroids, NSAIDs.

DC teaching: avoid high purine diet (heart, herring, mussels, salmon, sardines, anchovies, veal, bacon, organ meats). Caution with aspirin, alcohol, and thiazide diuretics. Increased risk of kidney (uric acid) stones.

Question 28

Bursitis

Answer 28

1. Excessive fluid in or infection of the bursa. Etiology: overuse, repetitive movements, inflammatory disease, infection, trauma. S/S: pain, redness, warmth, swelling, decreased ROM. TX: NSAIDS, analgesia, bursal aspiration. D/C teaching: RICE, decrease movement of extremity.

Question 29

Joint effusion

Answer 29

1. Collection of fluid in joint space; knee is most common from trauma or overuse. S/S: pain, redness, warmth, swelling, stiffness, decreased ROM. TX: NSAIDS, RICE, arthrocentesis. DC teaching:
   RICE, decrease movement of extremity.

Question 30

Osteomyelitis

Answer 30

Infection of the bone and surrounding tissue; may lead to sepsis.
Etiology: open fractures, infection in area of fracture, puncture wounds (hand from fight bite or wound on bottom of foot).
S/S: pain, malaise, fever, redness, swelling, warmth.
DX: blood cultures. TX: analgesia, IV antibiotics, specialty consults.

Question 31

What is Rhabdomyolysis? Causes?

Answer 31

Breakdown of skeletal muscle, resulting in release of myoglobin, CK, and potassium.

Etiology: prolonged immobilization, stimulant drug use, statins (Lipitor), heatstroke, and crush injuries.



Question 32

Rhabdomyolysis s/s? Tx?

Answer 32

S/S: malaise, fever, myalgia (muscle soreness), dark brown urine (tea colored), increased K*, myoglobin, and CK.

TX: ABCs, Large volumes of IV fluids (6-12 liters in 24 hours) to produce urine output > 100 ml/hour, 1-2 amps of sodium bicarbonate in NS (urine alkalization pH > 6.5), loop diuretics, mannitol, hemodialysis.

Treatment effective if increased clear urine. Complication: Acute tubular necrosis (renal failure).

Question 33

Achilles’ tendon rupture. Cause? What meds pt older pts at risk?
Dx? Tx?

Answer 33

A tear in the Achilles tendon from a sudden, unexpected dorsiflexion; sprinter or basketball ballplayer who hears “pop” when pushing off.
Higher risk if on fluoroquinolones (Cipro, Levaquin), especially for older patients.

DX by MRI,
TX: Surgery.

Question 34

High Pressure Injection Injuries (grease gun, paint gun, hydraulics) cause what? Tx?

Answer 34

• Cause massive underlying tissue trauma, carries high risk for complications such as compartment syndrome and infection;

hydraulics, paint and grease can travel down through hand, leading to major damage.
TX: Requires immediate surgical intervention.

Question 35

Injection/Penetrating injuries.
What is important to remember about wound appearance and impaled object?
Tx?

Answer 35

Penetrating injuries related to guns & industrial incidents; appearance of wound may not reflect actual tissue damage; DO NOT REMOVE impaled objects.

TX: ABCs, bleeding control, stabilize any object, preserve any forensic evidence, projectile path can be unpredictable, most chest and abdominal require surgical intervention.

Question 36

Examples of primary blast injuries?

Answer 36

Primary injuries are those that result from the over-pressurization or under- force impacting the body.

-blast lung
-tympanic membrane rupture
-ABD hemorrhage & perforation
-Globe (eye) rupture
-Mild TBI

Question 37

Examples of secondary blast injuries?

Answer 37

Secondary injuries result from projectiles propelled by explosion

-primary fragmemts rom expoding weapon
-eye penetration (can be occult)
-closed and open brain injury
-secondary fragments: projectiles from the environment (debris, vehicular metal)

Question 38

Examples of Quaternary blast injuries?

Answer 38

Quaternary injuries are all other injuries resulting from the blast. Heat or combustion fumes)

-external or internal burns
-crush injuries
-asthma, COPD, breathing issues from dust, smoke, toxic fumes
-angina
-hyperglycemia, HTN

Question 39

Examples of tertiary blast injuries?

Answer 39

tertiary injuries result from displacement of the victim by the blast wind and structural collapse

-blunt/penetrating trauma
-fractures
-traumatic amputations
-closed and open brain injury