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EM > Ortho > Flashcards

Ortho Flashcards

1
Q

Carpal Bones

A

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2
Q

Ankle Xray Views & Metrics

A
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3
Q

Nomenclature of hip #’s

A
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4
Q

Distal phalanx #

A
  • repair nailbed injury if present
  • hairpin splint not involving PIP
  • plastics within 2 weeks
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5
Q

Middle/Proximal Phalanx #

A
  • correct any rotational deformity
  • buddy tape (dynamic splint) if stable (transverse, non-displaced)
  • radial or ulnar gutter splint if unstable
  • plastics within 1 week
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6
Q

Bennett’s #

A
  • intraarticular base of thumb MC # with dislocation/subluxation of CMC
  • reduce, thumb spica
  • plastics within 2-3 days
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7
Q

Rolando’s #

A
  • comminuted # of base of thumb MC
  • worse prognosis than Bennett’s
  • thumb spica
  • plastics within 2-3 days
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8
Q

DIP Dislocation

A
  • reduce
  • dorsal splint in full extension
    • or buddy tape if stable post-reduction
  • plastics within 1 week
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9
Q

PIP Dislocation

A
  • reduce
  • dorsal splint in 30 deg flexion at PIP
    • or buddy tape if stable post-reduction
  • plastics within 1 week (2-3 d if unstable)
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10
Q

Extensor zones of the hand

A

see Evernote “Hand Injuries”

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11
Q

Management of extensor tendon injuries of the hand

A
  • Zone I, II open injuries: repair 5-0 sutures, splint in extension.
  • Zone III injuries: modified Elson’s test to check for central slip damage. If open & have Boutonniere deformity, call plastics on call. If closed, place PIP in extension and f/u plastics (may leave DIP free).
  • Zone IV injuries: primary repair with 5-0 sutures, splint MCP in 15 deg flexion.
  • Zone V, VI injuries: primary repair with 4-0 sutures if clean laceration, splint.
  • Zone VII, VIII injuries: splint, refer to plastics.
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12
Q

Management of Flexor Tendon Injuries of the Hand

A
  • Splint in position of function
  • Plastics within 1 week
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13
Q

Fingertip Amputation Zones

A

See Hand Injuries on Evernote

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14
Q

Describing Angulation in a #

A
  • for midshaft #’s, angulation is direction of apex
  • for distal fractures (e.g. Colles), angulation is direction of distal fragment
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15
Q

MCP Dislocation

A
  • do not hyperextend during reduction
    • reduce with wrist flexed to relax flexor tendon
    • pressure and traction on base of prox phalanx
  • splint in flexion
  • volar dislocations usually need operative reduction
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16
Q

Scapholunate Ligament Injury

A
  • FOOSH on thenar eminence
  • clicking with wrist movement
  • tender on dorsum of wrist just distal to Lister’s tubercle
  • pain with ballottement of the scaphoid
  • scaphoid shift/Watson shift test
    • wrist in ulnar deviation, thumb on scapohid prominence volarly –> move wrist into ulnar deviation
    • test positive if scaphoid ‘clunks’ dorsally/gives or patient’s pain reproduced
  • XRay
    • 3 mm widening on PA view
    • clenched fist view may help
    • scaphoid shortening with dense ring (cortical ring sign)
  • dorsal intercalated segment instability of lateral view (zig-zag pattern instead of 3 C’s)
  • Tx: radial gutter splint
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17
Q

Triquetrolunate Ligament Injury

A
  • ulnar equivalent to scapholunate injury
  • FOOSH on hypothenar eminence
  • volar intercalated segment instability on lateral xray
  • ulnar gutter splint
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18
Q

Perilunate Dislocation

A
  • FOOSH with great force
  • posterior dislocation of carpal bones, lunate remains in place
  • call ortho/plastics
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19
Q

Lunate Dislocation

A
  • posterior dislocation of carpal bones with lunate facing anteriorly
  • XRay
    • piece of pie sign (lunate triangular on PA)
    • spilled teacup sign (lunate displaced and angled palmar)
    • if fracture associated, then add trans- to the name (e.g. transscaphoid lunate disclocation)
  • call ortho/plastics
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20
Q

Scaphoid Fracture

A
  • tender in snuffbox with ulnar deviation
  • pain with resisted pronation/supination
  • pain with axial load to thumb
  • 10% initial xrays -ve
  • may get dedicated scaphoid view
  • thumb spica with mild wrist dorsiflexion and radial deviation (to compress # fragments)
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21
Q

Triquetrum Fracture

A
  • often a dorsal avulsion # on lateral view
  • sugartong splint
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22
Q

Lunate Fracture

A
  • tender in dorsum wrist groove on flexion
  • AVN possible (blood supply enters distally)
  • xrays may be negatve
  • thumb spica
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23
Q

Hamate Fracture

A
  • interrupted bat/golf club swing
  • carpal tunnel view
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24
Q

Colles’ Fracture

A
  • reduction: > 20 deg angulation, intra-articular involvement, > 1 cm shortening, comminution
  • criteria for adequate reduction
    • At least 11 mm radial height
    • At least 22 deg radial inclination
    • At least 11 deg volar angulation
    • practically, neutral is OK for age < 50 and 10 deg dorsal tilt is OK for age > 50
      • Acceptable angulation in kids
      • < 5 yrs = 30 deg
      • 5-10 yrs = 20 deg
      • 10-12 yrs = 10-15 deg
      • +-2 mm ulnar variance
    • < 3 mm impaction
  • ulnar styloid often also fractured
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25
Q

Smith’s Fracture

A
  • volar angulation of distal radius
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26
Q

Radial Styloid Fracture

A
  • often with dislocation of the lunate
  • major carpal ligaments insert at styloid so carpal instability
  • short arm splint
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27
Q

Ulnar Styloid Fracture

A
  • ulnar gutter splint
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28
Q

DRUJ Injuries

A
  • ulnar deviation on lateral
  • splint in supination for dorsal and pronation for volar dislocations
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29
Q

Compartment Syndrome

(Diagnosis, treatment)

A
  • traditional, tissue pressure > 30-50 mm Hg
  • better, delta pressure (diastolic - tissue pressure) > 30 mm Hg
  • pain refractory to opioids, pain to passive stretch, firmness/fullness in compartment
  • normal pulses/cap refill as tissue pressure less than arterial pressure
  • Stryker kit
    • pressures highest near injured area, obtain within 5 cm of # site
    • 2 readings each compartment
  • place limb at level of heart
  • reverse anticoag/replace factors for hemophiliacs
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30
Q

Biceps Tendon Ruptures

A
  • proximal
    • usually older, chronic tendonitis
    • pain in anterior shoulder
    • shoulder xray r/o avulsion #
    • sling –> # clinic
  • distal
    • usually younger, eccentric load
    • pain in AC fossa
    • Hook sign
    • sling –> # clinic more urgently
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31
Q

Elbow Dislocation

A
  • 90% are posterolateral
  • assess (pre- and post-reduction):
    • brachial artery (just medial to distal biceps tendon)
    • ulnar, radial, median nerves
  • Check for full ROM post-reduction, fragments often trapped
    • call ortho if unstable on ROM or reduced ROM or NV compromise post-reduction
  • splint in long-arm posterior splint in slightly less than 90 deg flexion and forearm in mild pronation
  • NV f/u exam next-day
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32
Q

Supracondylar #

A
  • common in 5-10 years of age
    • common to injure anterior interosseous nerve
      • motor only branch of median
      • test OK sign
  • extension-type (95%, posterior displacement)
    • FOOSH in extension
    • posterior fat pad or large anterior fat pad (sail sign), disruption of anterior humeral line
    • long-arm posterior splint 90 deg, neutral rotation
    • if only sign is fat pad then ortho f/u in 2-7 days
    • if any angulation/break through cortex then fasting + ortho in ED
  • flexion-type (5%, anterior displacement)
    • rare, direct force, often open
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33
Q

Intercondylar #

A
  • assume any supracondylar # in adult is intercondylar
  • supracondylar + T or Y component separating condyles from each other and going intraarticular
  • splint in long arm posterior splint at 90 deg in neutral position
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34
Q

Epicondyle #

A
  • mostly medial, an apophyseal avulsion fracture
  • pain, tenderness, swelling
  • medial from repeat valgus stress such as throwing
  • posterior splint in pronation
35
Q

Condyle #

A
  • mostly lateral
  • a fracture through the condyle
  • usually much larger/unstable than radiograph because mostly cartilaginous
36
Q

Ossification Centres of Elbow

A
  • all usually ossify by 12 years
  • Capitellum
  • Radial head
  • Internal (medial) epicondyle
  • Trochlear
  • Olecranon
  • External (lateral) epicondyle
37
Q

Monteggia/Galeazzi #

A
  • Fracture
  • Ulna/radius
  • Monteggia/galeazzi
  • Elbow (radius)/wrist (ulna) dislocated
  • may reduce, but often need operative management
38
Q

Calcaneus #

A
  • Boehler angle: line from highest part of anterior process of calcaneus and highest point of posterior articular surface of calcaneus + line between highest point of posterior articular surface of calcaneus and the most superior part of calcaneal tuberosity
  • normal 25-40 deg
  • < 25 deg suspect #
  • posterior splint, NWB
39
Q

Lisfranc Injury

A
  • plantar flexion + axial load
  • pain with torsion/dorsi/plantar flexion
  • weight-bearing AP, lateral, 30 deg oblique
    • 1 mm displacement base 1st/2nd MT
40
Q

Base of 5th MT #

A
  • Review Evernote “Foot Injuries”
41
Q

Hip #

A
  • Review Evernote
42
Q

Ottawa Knee Rules

A
  • age >= 2
  • Xray if
    • age >55
    • tender at
      • fibular head
      • patella
    • cannot flex > 90 deg
    • cannot WB 4 steps immediately + in ED
43
Q

Additional Knee Xray Views

A
  • sunrise view
    • patellar #/subluxation
  • tunnel view
    • intercondylar region/tibial spine #
  • oblique view
    • (internal for lateral, external for medial plateau #)
44
Q

Treatment for Locked Knee

A
  • usually meniscal tear
  • sedation
    • supine with knee 90 deg flexed hanging over edge
    • longitudinal traction, internal + external rotation
    • ortho if not successful
45
Q

Knee Dislocation

A
  • 50% self-reduce
    • ++ injured & unstable multiple directions
  • reduce, splint in 20 deg flexion
  • if no vascular + ortho in house & NV intact, delay reduction for transfer
  • CT angio post-reduction
46
Q

Patellar Dislocation

A
  • flex hip, hyperextend knee, posteromedial pressure on lateral border of patella
  • 1st time dislocation: tensor, knee immobilizer, no flexion allowed, urgent ortho
  • recurrent: less strict need for immobilization (ligaments already lax), semi-elective ortho
47
Q

Tibial Shaft #, criteria for adequate reduction

A
  • criteria for adequate reduction:
    • <10 deg varus or valgus
    • <10 deg anterior/posterior angulation - can accept more in the plane of joint motion
    • <1 cm shortening
    • min 50% apposition
  • long leg splint, elevate
  • ortho in ED
48
Q

Pilon/Tibial Plafond #

A
  • “mortal pestle” #
  • axial load grinds tibia into talus
  • look for L1 # & compartment syndrome
49
Q

Gastrocnemius Tear

A
  • sudden pop, swelling in calf
  • RICE
  • may splint in equinus
50
Q

Ankle Syndesmosis Injury

A
  • see Evernote
51
Q

Grading Ankle Sprains

A
  • Grade I: no tear, minimal functional loss, pain and ecchymosis
  • Grade II: partial tear, some loss of function
  • Grade III: complete tear, ++ swelling, bruising, usually NWB
  • Any medial maleolar swelling/tenderness needs to be NWB and have close ortho f/u
  • lateral mal # with medial mal swelling/tenderness needs posterior slab with medial molding
52
Q

Weber Classification Distal Fibula #’s

A
  • NWB with aircast unless avulsion #
53
Q

Sternoclavicular Joint Dislocation

A
  • CT imaging of choice
  • US + aspiration if infectious/effusion (common in IVDU)
  • anterior dislocation
    • sling, ice, no need to reduce (won’t hold anyway)
  • posterior dislocation
    • ortho, open reduction
    • closed reduction if mediastinal compromise
54
Q

Clavicle #

A
  • xray may miss #’s at extreme ends of bone
    • 45 degree cephalad tilt view +- CT
  • distal
    • displaced often operated on
    • sling + early ortho f/u
  • middle third/distal #’s
    • usually non-op unless athlete/cosmetic
    • rule of 2’s for op mgmt
      • 2 cm short
      • 2 cm displaced
      • 2 pieces
    • sling, early ROM (in 3-5 days)
  • proximal third clavicle #’s
    • rare, check with ortho
55
Q

Scapular #

A
  • dedicated views
  • look for associated rib #’s/lung injury
  • sling, ice
56
Q

Anterior Shoulder Dislocation

A
  • slight abduction + external rotation
  • check deltoid sensation (axillary)
  • reduction
    • 10-20 mL 1% lidocaine subacromial
  • Modified Hippocratic
    • traction-countertraction
  • Snowbird
    • belt looped over flexed elbow
    • use foot to pull down on belt
  • Stimson
    • prone, weights
  • Scapular Manipulation
    • Stimson + rotate scapula (distal tip goes medial)
  • Kocher’s
    • elbow 90 deg, slow external rotation
    • may bring elbow anteriorly
  • Milch
    • external rotation, arm straight
    • arm abduction to 180 degrees
    • push on humeral head upwards with R thumb
  • Cunningham
    • sitting massage, shrug shoulders back
57
Q

Posterior Shoulder Dislocation

A
  • <1%
  • usually held in internal rotation + adduction
  • unable to external rotate + abduct
  • reduce with longitudinal traction
58
Q

Inferior Shoulder Dislocation (Luxatio erecta)

A
  • hyperabduction force (levers neck of humerus against acromion)
  • humerus fully abducted, elbow flexed, hand on or behind head
  • traction upward + outward in line with humerus
59
Q

Proximal Humerus #

A
  • Neer classification of shoulder #’s
    • a “part” is a fragment displaced > 1cm or angulated > 45 deg
    • i.e. even if many fragments, if none angulated/displaced then it is a “one-part” #
  • one part #
    • sling + swathe, ice, early ROM
  • more than one part # or #-dislocation
    • ortho in ED
60
Q

Humeral Shaft #

A
  • proximal
    • accept up to 45 deg angulation, 1 cm displacement
    • minimal displacement
    • shoulder immobilizer, close f/u
    • displacement/comminution
    • d/w ortho
  • middle third #’s
    • most common
    • usually non-op
    • radial nerve
    • not comminuted
      • sugar-tong, close follow-up
    • comminuted
      • call ortho
  • distal humerus #
    • ED consultation re: NV structures
61
Q

Jersey Finger

A
  • FDP rupture from grabbing jersey
    • splint in slight flexion
    • hand clinic
62
Q

Compression #’s

A
  • Discuss all spine #’s with a surgeon
  • if <40% loss of height, generally stable
  • if >= 50% loss of height, or angle between damaged vertebra and spinal column is >25-30 deg usually unstable
  • can often misdiagnose Chance (transverse) + burst #’s as compression #’s
  • consider CT in all compression #’s found on plain films
  • if truly stable, non-pathologic –> heat, massage, rest, f/u
63
Q

Coccyx #

A
  • pain meds, doughnut pillow
64
Q

Prevertebral soft tissue spaces in cervical trauma

A
  • 6 mm at C3
  • 22 mm at C6
65
Q

C-Spine Trauma Approach

A
  • NEXUS
  • CCSR
  • Xray
  • CT if inadequate
  • If CT -ve but suspcious and MRI not available, may DC in firm foam collar and f/u in 3-5 days. If pain resolved, may DC collar
66
Q

Neurogenic Shock vs. Spinal Shock

A

Neurogenic Shock

  • loss of peripheral sympathetic innervation
  • if T1-T4 then unopposed vagal to heart, bradycardia

Spinal Shock

  • temporary loss of spinal reflex activity below injury that may recover
67
Q

Thoracolumbar Spine Trauma

Xray vs. CT

A
  • EAST recommends CT over xray (Level 1) although no studies in mildly injured patients
68
Q

How Long to Immobilize a Shoulder Dislocation For?

A
  • “8 minus decade of life”
  • means if 75 years old then simple sling + ROM immediately
  • max 3 weeks
  • longer for first-time dislocators
69
Q

Radial Head #

A
  • undisplaced, radial neck
    • sling, f/u 1 week
  • undisplaced, intra-articular
    • posterior slab, f/u 1 week
  • displaced
    • call ortho to discuss
70
Q

Coronoid Process #

A
  • displaced, large fragment
    • call ortho to discuss
  • undisplaced
    • posterior slab, 1 week
71
Q

Olecranon #

A
  • check triceps with arm horizontal (gravity eliminated)
  • displaced
    • call ortho to discuss
  • undisplaced
    • posterior slab, 1 week
72
Q

Ulnar Collateral Ligament Injury

A
  • 25% have Stener’s lesion (interposition of adductur pollicis between ends of ligament tear resulting in poor healing + chronic thumb pain)
  • Grade 1/2
    • thumb spica
    • plastics 1-2 weeks
  • Grade 3
    • plastics within 2-3 days (operate within 1 week)
73
Q

Toe Fracture

A
  • Indications for referral (Great Toe)
    • Fracture with dislocation
    • Displaced intraarticular fractures
    • Unstable, displaced fractures (ie, fractures initially reduced that immediately displace once traction is released unstable displaced fractures
  • Indications for referral (lesser toes)
    • Displaced intraarticular fractures
    • Irreducible fractures
    • Open fractures of non-distal phalanges
    • Fractures that do not maintain acceptable position with buddy taping
74
Q

Toddler’s #

A
  • 9 mo to 5 yrs
  • twisting of foot –> oblique tibial #
  • often minor mechanism, subtle tenderness
  • additional oblique views increase sensitivity
  • above knee splint –> ortho 1 wk
75
Q

Tillaux #

A
  • girls age 11-13, boys age 12-15
  • distal tibial growth plate closes from medial to lateral
  • external rotation results in SH III # of the distal tibia
  • ortho in ED
76
Q

Patella #

A
  • if has active knee extension: knee immobilizer, ortho 1 wk
  • if no active knee extension: ortho in ED
77
Q

Segond #

A
  • vertically oriented avulsion # from lateral tibial plateau at the attachment of the lateral capsular ligament
    • 75% association with ACL tear
    • tensor, crutches, WBAT
    • early ROM as tolerated
    • early sports med f/u
78
Q

Tibial Plateu #

A
  • suspected/undisplaced
    • long-leg splint, NWB, urgent ortho
  • displaced
    • ortho in ED
79
Q

How to examine extensor tendons of fingers

A
  • Test extension PIP/DIP with MCP in extension to remove lumbricals
  • Modified Elson’s Test for zone III injuries
80
Q

How to test SLR in knee exam

A
  • test SLR seated to remove IT band
81
Q

Mandible Dislocation

A

See Evernote “Dental”

82
Q

How to Apply a Thomas Splint

A

See Evernote “Procedures”

83
Q

Snowboarder’s #

A

See evernote “Leg + Ankle Injuries”

EM (27 decks)

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