P-2 Ortho 1 > 2 Ortho Emergencies > Flashcards

2 Ortho Emergencies Flashcards

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1
Q

Indications for surgery

A
  • Open fx or arthrotomy
  • Containment/clearance of infection
  • Neurovascular compromise
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2
Q

Open fracture classification is called?

A

Gustilo classificaiton

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3
Q

Gustilo classification

A

Type I:

  • wound <1cm
  • clean
  • simple fx pattern

Type II:

  • wound >1cm (II is 2)
  • soft tissue damage not extensive
  • no flaps/avulsions
  • simple fx pattern

Type III:

  • high energy (extensive soft tissue damage)
  • complicated fx pattern
  • crush inj
  • vascular inj
  • sever contamination (farm)
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4
Q

Abx for open fractures?

A

Gustilo I and II - 1st gen cephalosporin (could use clinda/vanc)

Gustilo III - add aminoglycoside (mycins)

Farm inj - add PCN

Irrigate and tetanus prophylaxis

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5
Q

How to test for an arthrotomy?

A

(arthrotomy - hole in joint)

Saline load test (95% sensitive)

Elbow can hold 40 ml
Knee can hold 155ml to knee

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6
Q

Initial management of an arthrotomy?

A
  • Through neuro exam
  • Remove gross contamination
    Irrigate w min 1L
  • dress wound
  • immobilize in position of comfort

immediate orthopedic surg consult

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7
Q

All infections need?

A 
Plain radiographs
Inflammatory indicies
- WBC
- CRP
- ESR
Blood culture
Site culture
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8
Q

When sto start abx on a ortho type infection?

A

After you consult ortho, they may want a sample first

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9
Q

Tenosynovitis is caused by?

A

Cats

Tenosynovitis is inflammation of a tendon and its sheath (see the image below). Most acute cases of flexor tenosynovitis (FT)—which involves disruption of normal flexor tendon function in the hand—result from infection. However, FT also can develop secondary to acute or chronic inflammation from a noninfectious cause, such as diabetes, overuse, or arthritis.

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10
Q

Ddx for tenosynovitis?

A

Herpetic witlow
Septic arthritis
Crystal-induced arthritides
Hand infections (paronychia, felon, cellulitis)

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11
Q

S/S of tenosynovitis?

A

Kanavel signs

  • symmetrical swelling of digitis
  • TTP on tendon sheath
  • semiflexed posture
  • pain w passive extension

S/S

  • pain on extension
  • uniform swelling
  • slight flexion
  • TTP on tendon sheath
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12
Q

Extensor tendons dont have?

A

Sheaths

- tenosynovitis is an infection of tendon and sheath so it isnt in extensor tendons

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13
Q

Tenosynovitis management?

A

Ortho consult
Admission/IV abx
Rest/elevation (splint)
I/D

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14
Q

What is osteomyelitis?

A

Infection in the bone

Peds: hematogenous spread
- metaphysis of long bones

Adults:

  • open fx,
  • surgical fixation,
  • immunocompromised
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15
Q

MC osteomyelitis infection?

A

Almost 50% are <5 yrs old

Peds: staph A, strep
Adults: staph A, pseudomonas

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16
Q

Osteomyelitis bacteria if cause is:

  • nail in shoe
  • animal bite
A

Nail: pseudomonas
Animal: pasturella multocida

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17
Q

S/S of osteomyelitis?

A

Neonates
- the usual

Knee pain -> R/o hip pathology

Older kids/adults

  • fever
  • pain/swelling at site
  • drainage/delayed healing at bone surg site
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18
Q

Workup for osteomyelitis?

A

CBC, ESR, CRP,
Blood culture
X-ray
Aspiration/biopsy

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19
Q

Radiology findings w osteomyelitis?

A

early radiographs will be neg or show only:

  • soft tissue swelling
  • periosteal elevation
  • focal lucency around implant

X rays 10 days later show periosteal elevation

CT - early cortical erosions
MRI - bone marrow changes

Bone scan detects early

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20
Q

Most important diagnostic step for osteomyelitis?

A

Bone biopsy or aspiration of suspected site

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21
Q

Tx for osteomyelitis?

A

IV abx x 4-6 weeks

Surgical excision and bony reconstruction for abx failure

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22
Q

Osteomyelitis classificaiton?

A

The modified eichenholtz classificaiton of charcot neuropathy

Stage 0-III

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23
Q

The modified eichenholtz classificaiton of charcot neuropathy

Stage 0

A

Findings:
- Normal radiographs, swelling, erythema, instability

Tx:

  • serial radiographs
  • protected wt bearing
  • PT ed
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24
Q

The modified eichenholtz classificaiton of charcot neuropathy

Stage I

A

Stage I: Fragmentation or dissolution

Findings:

  • swelling, warmth, erythema
  • fx/dislocations
  • osteopenia
  • periarticular framents

Tx:

  • total casting or pneumatic brace
  • serial radiographs until s/s resolove
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25
The modified eichenholtz classificaiton of charcot neuropathy Stage II
Stage II coalescence Findings: - reduced Warmth, swelling - resorption of small bone fragments - early fusion and sclerosis Tx: - total casting/ pneumatic brace - charcot restraint orthotic walker/clam shell ankle foot orthosis
26
The modified eichenholtz classificaiton of charcot neuropathy Stage III
Stage III: reconstruction Findings: - consolidation of deformity w - joint arthrosis - subcondral sclerosis - dissipation of inflammation - stable on exam Tx: - plantigrade foot: custom inlay shoes - nonplantigrade foot/ulceration - debried, exostomy correction, of fusion - osteomyelitis: debride w staged reconstruction/amputation
27
Osteomyelitis mainstay of tx?
IV abx are mainstay of initial treatment
28
How does one get septic arthritis?
Direct inoculation of bacteria into a joint - (i.e. joint surgery) Hematogenous event - from adjacent infection (Chlamydia)
29
MCC of septic arthritis by age?
Kids: hematogenous spread Adults: - immunocompromsised/immunosuppressed - joint damaging conditon (RA, SLE) Can also see seeding of joint from metaphyseal osteomyelitis
30
What will you find with septic arthritis?
Cartilage damage 2/2: - proteolytic enzymes from bacteria - inflammatory response Detected w/in 48-72 hrs
31
Red flags for septic arthritis?
- New limp in child (vague hx) - Recent inj/surgery (arthroplasty) - PHM for RA, SLE, CA - constitutional sx
32
Septic arthritis ddx?
Transient synovitis Cristal-induced arthritides Osteomyelitis Fx (tibia plateau or physeal)
33
Septic arthritis clinical exam?
``` Joint TTP Effusion Erythema Inability to move Non-wt bearing ```
34
Diagnostic tests for septic arthritis?
X-ray (all suspected infection) Inflammatory indicies (WBC, CRP, ESR) Blood culture x 3 Arthrocentesis
35
Its not septic arthritis if:
If CRP <2.0 and able to bear wt <1% probability of septic arthritis
36
Septic arthritis lab findings?
``` WBCs are elevated (70% of cases) ESR > 50mm/hr CRP >2.0 >50,000 WBC/ml >90% PMNs ```
37
Septic arthritis management?
Neurovascualr exam Dress wounds Immobilize in position of comfort IMMEDIATE ORTHO CONSULT - NO ABX prior to ortho consult - NPO prior to ortho consult
38
Crystal arthropathies are?
Gout - uric acid (monosodium urate crystals) pseudo gout - CPP crystals (calcium pyrophosphage)
39
Gout presentation
Starts at night Wt of a sheet is unbearable Erythema looks like septic joint
40
Podagra?
MTP joint of great toe gout infection | - 50% of initial episodes of gout
41
Tophi?
Soft-tissue masses from urate crystals deposition
42
Gout diagnosis?
Joint aspiration - get gram stain (r/o septic arthritis) Findings will be - neg birefringent urate crystals Check 24hr uric acid excretion - 90% underexcrete uric acid
43
Radiographs for gout?
Normal for acute gout Chronic gout shows - subchondral bony erosions - peripheral articular spurs
44
Untreated gout leads to?
Tohpi Chronic gouty arthritis Chronic hyperuricemia leads to - neuropathy - renal stones
45
Acute gout tx?
Indomethicin 50mg q 8 hrs Colchicine Oral glucocorticoids (watch for DM) Can do steroid into joint (ill advised)
46
Chronic gout tx?
Underexcretors - Probenecid (raises urine excretion of uric acid) Overproducers - allopurinol (decreased production) Small dose of colchicine daily Indomethacin at first sign of s/s
47
What causes pseudogout?
Calcium pyrophosphate dihydrate crystals reside in cartilage and are shed into joint -> calcium pyrophosphage deposition disease (CPPD)
48
Pseudogout is MC’ly found?
In the knee - big word, big joints In elderly MCC of acute arthritis of single joint
49
Lab findings for pseudogout?
Weakly positive birefringent rhomboid-shaped calcium pyrophosphate crystals
50
Crystal arthropathies summary: - joint - pain - lab findings - physical
Joint - gout: MTP (podagra) - pseudo: knee Pain - gout: severe - pseudo: mild Lab findings - gout: Urate crystals - pseudo: Ca++ phosphate Physical - gout: tophi - pseudo: chondrocalcinosis
51
Cauda equina exam?
2 point discrimination of sacral roots - pressure and light touch will be preserved Get: - Post residual void - Bulbocavernosus reflux
52
Cauda equina, when to get an MRI?
Progressive neurologica findings Hx of malignancy w new onset pain Infection risk - IV drug use - steroids - aids - UTI Everybody else gets an x ray
53
Signs of vascular injury with knee dislocations?
Hard signs - pulslessness - pallor - paresthesia - pain - paralysis - rapid hematoma - massive bleeding - Palpable/audible brut Soft signs - bleeding in transit - Proximity-related inj - neurologic finding from nerve adjacent to named artery - hematoma over named artery
54
ABI
ABI = SBP affected extremety / SBP upper extremity Over 0.90 is bad
55
Knee dislocation management?
``` Reduce Neurovascualr exam Serial exams/ABIs Angiogram Ortho consult w hard signs Leg immobilization at 30-45 degrees of flexion ```
56
Compartments of the leg?
``` Anterior Lateral Posterior - superficial - deep ```
57
Anterior compartment contains?
Extensor muscles - tibialis anterior - extensor digitorum longus - extensor hallucis longus - fibularis (peroneus) tertius ``` Anterior tibial artery and veins Deep fibular (peroneal) nerve ```
58
Lateral compartment contains?
``` Fibularis (peroneus) longus muscle Fibularis (peroneus) bervis muscle Superficial fibular (peroneal) nerve ```
59
Deep posterior compartment contains?
``` Deep flexor muscles - flexor digitorum longus - tibialis posterior - flexor hallucus longus - popliteus Posterior tibial artery and veins Tibial nerve Fibular (peroneal) artery and veins ```
60
Superfical posterior compartment contains?
Superficial flexor muscles - soleus - gastrocnemius - plantaris (tendon)
61
Definition of compartment syndrome?
Vascular perfusion of muscle and other tissues w/in a compartment decreases to a level that is inadequate to sustain the viability of the tissues - acute - chronic
62
Chronic compartment syndrome basics?
New/major change in activity Improves w rest NOT AN EMERGENCY
63
You suspect compartment syndrome, you should not?
Dont elevate the leg | - reduces vascular flow to tissue
64
DVT prognosis?
Most patients who die of PE do so w/in 30 min of acute event | - like a pizza, 30 min or its free
65
Thrombosis triad?
Stasis Hypercoagulability Epithelial injury All associated w poly trauma
66
DVT symptoms?
Commonly asymptomatic ``` Homans sign Dypsnea Hemoptysis Tachycardia Pleural rub Tachypnea ```
67
Gold standard for DVT?
Venography But everyone use duplex US
P-2 Ortho 1
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