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EM Rotation 2018 > Ortho/Rheum > Flashcards

Ortho/Rheum Flashcards

1
Q

If a patient is diagnosed with Septic arthritis and the culture reveals Gram NEGATIVE cocci, what is the best choice of antibiotic? The patient does not have any allergies.

A

Ceftriaxone (Rocephin): 3rd gen Cephalosporin + Arthrotomy

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2
Q

If a patient is diagnosed with Septic arthritis and the culture reveals Gram NEGATIVE Rods, what is the best choice of antibiotic?

A

Ceftriaxone (Rocephin): 3rd gen Cephalosporin
+ Anti-Pseudomonal aminoglycoside (ex. Gentamycin)

+ Arthrotomy

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3
Q

If your leading diagnosis is septic arthritis and the culture reveals no organism but you are highly suspicious of a bacterial infection, what is the best choice of antibiotic?

A

Nafcillin + Arthrotomy

OR

Vancomycin + Ceftriaxone (Rocephin) (+/- Anti-pseudomonal)

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4
Q

If a patient is diagnosed with Septic arthritis and the culture reveals Gram NEGATIVE cocci, what is the best choice of antibiotic? MRSA is highly suspected.

A

Vancomycin + Arthrotomy

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5
Q

If a patient is diagnosed with Septic arthritis and the culture reveals Gram NEGATIVE cocci, what is the best choice of antibiotic? The patient is allergic to PCN.

A

Ciprofloxacin (Cipro) + Arthrotomy

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6
Q

If a patient is diagnosed with Septic arthritis and the culture reveals Gram POSITIVE cocci, and MRSA is suspected. What is the best choice of antibiotic? The patient is allergic to PCN.

A

Vancomycin*** + Arthrotomy

OR

Clindamycin

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7
Q

If a patient is diagnosed with Septic arthritis and the culture reveals Gram POSITIVE cocci, and MRSA is not suspected. What is the best choice of antibiotic? The patient is not allergic to PCN.

A

Nafcillin + Arthrotomy

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8
Q

How is septic arthritis diagnosed?

A

Arthrocentesis: WBC > 50K: primarily PMN + gram stain + culture + crystals

Cell count >2K = inflammatory range

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9
Q

A patient with a Hx of Sickle Cell disease is diagnosed with Osteomyelitis. What organism is most likely to be the offending organism?

A

Salmonella

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10
Q

Which of the following is NOT a risk factor to Osteomyelitis?

A. DM 
B. HTN
C. HIV 
D. URI 
E. Juvenile Rheumatoid Arthritis* 
F. Sickle cell disease
A

B. HTN

DM 
Immunocompromised
URIs in children
Preexisting joint disease 
Sickle cell disease
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11
Q

A 2 month infant is diagnosed with Acute Osteomyelitis. What is the best tx for this patient?

A

Nafcillin

OR

Oxacillin + 3rd gen Cephalosporin

Group B Strep Gram Negative

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12
Q

A 5 month infant is diagnosed with Acute Osteomyelitis. What is the best tx for this patient? The culture revealed MSSA. The patient does not have any allergies.

A

Nafcillin

OR

Oxacillin

OR Cefazolin (Ancef)

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13
Q

A 5 month infant is diagnosed with Acute Osteomyelitis. What is the best tx for this patient? The culture revealed MSSA. The patient is allergic to PCN.

A

Clindamycin

OR

Vancomycin

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14
Q

A 5 month infant is diagnosed with Acute Osteomyelitis. What is the best tx for this patient? The culture revealed MRSA. The patient is allergic to PCN.

A

Vancomycin

OR

Linezolid

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15
Q

An 8 y/o patient with a Hx of Sickle cell disease is diagnosed with Acute Osteomyelitis. What is the best tx for this patient?

A

3rd generation Cephalosporin

OR

Fluoroquinolone: Cipro or Levofloxacin

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16
Q

An 17 y/o patient is seen because he stepped on a dirty nail. He is diagnosed with Acute Osteomyelitis. What is the best tx for this patient?

A

Ciprofloxacin OR Levofloxacin

Ceftazidime OR Cefepime

*Pseudomonas = puncture wound

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17
Q

A patient presents with lower back pain radiating to the anterior thigh to the lower leg. Which dermatome is likely affected and what is the correct management of this patient?

A

L4

Sensory loss to the medial ankle
Weakness to ankle dorsiflexion
Loss of knee jerk and weak knee extension

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18
Q

A patient’s X-ray reveals a Jones fx. What do you explain to the patient this is? What is the correct tx?

A

It is a transverse fx through the diaphysis of the 5th metatarsal.

Non-weight bearing for 6-8 wks followed by repeat x-rays as it is often complicated by nonunion/malunion Frequently requires ORIF (Open Reduction Internal Fixation)/pinning

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19
Q

A patient’s X ray reveals a Pseudo Jones fx. What do you explain to the patient this is? What is the correct management of this patient?

A

It is a TRANSVERSE avulsion fx at the base (tuberosity) of the 5th metatarsal

*much more common and less serious than a true Jones fx

Walking cast for 2-3 wks; ORIF if displaced

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20
Q

A patient’s X ray reveals a Pseudo Jones fx. What was the mechanism of injury of this patient?

A

Due to plantar flexion with inversion

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21
Q

Which part of the body is most commonly affected with Stress/March fxs?

A

3rd metatarsal

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22
Q

What is commonly injured with dashboard injuries?

A

Posterior cruciate ligament

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23
Q

A patient presents in the ED following a MVA. You notice bruising the anteromedial aspect of the proximal tibia.There is also notable effusion in the area. What test on PE is indicated? If this test is +, what is the tx for this injury?

A

Pivot shift test & Posterior drawer test

Operative tx*

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24
Q

A patient is seen for knee pain. On PE, there is notable swelling. The patient reports buckling and “popping.” Hemarthrosis is also present. The patient states she cannot actively extend her knee. What tests on PE are indicated? If this test is +, what is the tx for this injury?

A

Test for ACL laxity: Lachman’s test–is most sensitive (can also perform the pivot shift test)

Tx is controversial: therapy vs. surgical; depends on the activity level of the patient

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25
Q

A patient is seen for knee pain. On PE, there is notable swelling. The patient reports buckling and “popping.” Hemarthrosis is also present. The patient states she cannot actively extend her knee. What injury commonly occurs with an ACL tear/sprain?

A

Second fx: avulsion of the lateral tibial condyle with varus stress to the knee)

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26
Q

A positive McMurray’s sign is indicative of what?

A

A meniscal tear

A pop or a click while the tibia is externally or internally rotated*

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27
Q

Explain what each of the following are used for:

A. McMurry's sign
B. Lachman's test 
C. Pivot shift test
D. Anterior drawer test
E. Posterior drawer test
F. Apley test
G. Thomson test
H. Ober test
A 
A. + sign = Meniscal tear
B. ACL 
C. PCL* & ACL
D. ACL (not as specific) 
E. PCL
F. Meniscal tear
G. Achilles tendon rupture
H. ITB syndrome
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28
Q

What is a Maisonneuve fx?

A

Spiral fx of the proximal fibula

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29
Q

What is the etiology of a Maisonneuve fx?

A

rupture of the distal talofibular syndesmosis & interosseous membrane as a result of a distal medial malleolar fx AND/OR deltoid ligament rupture

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30
Q

What is the most common mechanism of injury to cause a patellar fx?

A

direct blow (fall on a flexed knee) +/- forceful quadriceps contraction

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31
Q

What is the best view to diagnose a patellar fx?

A

Sunrise view

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32
Q

What is the tx for a patellar fx?

A

If displaced: surgery

If not displaced: knee immobilizer, leg case for 6 wks

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33
Q

If a patient has a “patella baja” what does this mean?

A

The patient has a quadriceps tendon rupture; there will be a palpable defect ABOVE the knee

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34
Q

If a patient has a “patella alta” what does this mean?

A

The patient has a patellar tendon rupture; there will be a palpable defect BELOW the knee

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35
Q

What is the management for a patient with a quadriceps/patellar tendon rupture?

A

knee immobilizer; non or partial weight bearing; RICE

SURGICAL REPAIR WITHIN 7-10 DAYS

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36
Q

Which of the following is not a risk factor for a quadriceps/patellar tendon rupture?

A. DM 
B. >40 
C. Male 
D. Female 
E. Obesity 
F. Gout
G. Renal disease 
H. Smoking
A

D. Female

H. Smoking

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37
Q

What is the mechanism of injury of a patellar dislocation?

A

Valgus stress after twisting injury OR direct blow

*MC in females

38
Q

What is the management of a patellar dislocation?

A

Closed reduction: push anteriomedially on the patella while gently extending the leg; take post reduction films and knee immobilizer (full extension); quad strengthening

39
Q

What is a complication to knee (tibial-femoral) dislocations?

A

Popliteal artery rupture*** (1/3 of pts)
Peroneal or tibial nerve injury

SEVERE LIMB THREATENING EMERGENCY

40
Q

What diagnostic study is performed to rule out a popliteal artery rupture?

A

Arteriography

41
Q

What is the management for a knee (tibial-femoral) dislocations?

A

IMMEDIATE Orthopedic consult

Prompt reduction via longitudinal traction

42
Q

How will a knee (tibial-femoral) dislocation clinically present?

A

With gross deformity; it may reduce itself

43
Q

What is the mechanism of injury for a femoral condyle fracture?

A

Axial loading (fall from a height); direct blow to the femur

44
Q

What is a complication of a femoral condyle fracture?

A

peroneal nerve injuries (check 1st web space)

popliteal artery injury

45
Q

What is the management for a femoral condyle fracture?

A

IMMEDIATE Orthopedic consult

ORIF; usually heals poorly*

46
Q

If a patient has dislocated their anterior glenohumeral joint, what was their mechanism of injury?

A

a direct blow to an ABducted, extended, externally rotated arm

47
Q

How is an anterior glenohumeral joint dislocation diagnosed?

A

X-ray: Axillary and Y view

-Humeral head inferior and anterior to the glenoid fossa

48
Q

What is a Hill Sachs lesion?

A

Groove on the humeral head

Compression fx on the humeral head from impact against the glenoid

49
Q

What is a Bankart lesion?

A

Glenoid inferior rim fx

50
Q

If a patient has an anterior glenoid dislocation, what must you ALWAYS rule out?

A

Axillary nerve injury

-the patient will feel a pinprick sensation over their deltoid

51
Q

What is the management of an anterior glenohumeral dislocation?

A

Reduction

52
Q

A patient’s x-ray reveals a posterior glenohumeral dislocation, what was the mechanism of injury?

A

Forced adduction with internal rotation

53
Q

A patient is seen with an erythematous, stiff, and painful first MTP joint. The patient has a history of gout and has not been taking his medication as directed. He has a history of DM and HTN. He is currently on hydrochlorothiazide for his HTN; and Metformin for his DM. The patient tells you he took an aspirin for the pain but it “just made it worse.” What do you tell this patient in regards to his medications?

A 
AVOID ASPIRIN! 
-diuretics (loop and thiazides) 
-ACEI
-ARB
-Ethambutol
-Pyrazinaminde 
ALL increase uric acid levels
54
Q

A patient is seen with an erythematous, stiff, and painful first MTP joint. The patient has a history of gout and has not been taking his medication as directed. He has a history of DM and HTN.

He is currently on hydrochlorothiazide for his HTN; and Metformin for his DM. The patient tells you he took an aspirin for the pain but it “just made it worse.” What medication change would you suggest in regards to his HTN?

A

Losartan (ARB) decreases uric acid levels

55
Q

A patient is seen with an erythematous, stiff, and painful first MTP joint. The patient has a history of gout and has not been taking his medication as directed. He has a history of DM and HTN.

He is currently on hydrochlorothiazide for his HTN; and Metformin for his DM. The patient tells you he took an aspirin for the pain but it “just made it worse.” What medication would you prescribe to his while in the ED?

A

NSAIDS DOC* (Indomethacin or Naprosyn)

Colchicine 2nd line

56
Q

A patient is seen with an erythematous, stiff, and painful first MTP joint. The patient has a history of gout and has not been taking his medication as directed. He has a history of DM and HTN.

He is currently on hydrochlorothiazide for his HTN; and Metformin for his DM. The patient tells you he took an aspirin for the pain but it “just made it worse.”

He then tells you he is on dialysis and has not gone in all week. He regularly goes 3x a week. What medication would you prescribe to his while in the ED?

A

NSAIDS DOC* (Indomethacin or Naprosyn)
Colchicine 2nd line
*Since severe renal failure: ADD STEROIDS

57
Q

What are the MsOA of each of the following medications used to treat Gout:

A. Allopurinol
B.

A

A. reduces uric acid production by inhibiting xanthine oxidase and increases uric acid excretion

58
Q

Which Gout medication can potentiate SJS and gastric irritation if not taken with meals?

A

Allopurinol : careful with renal pts*

59
Q

What medication should a Gout patient with renal disease be prescribed? What is its MOA?

A

Febuxostat : xanthine oxidase inhibitor that is safer in pts with renal dz

60
Q

What vitamin should Gout patients be taking along with their regular medications?

A

Vitamin C

61
Q

Which drugs promote renal uric acid secretion?

A

Uricosuric drugs: Probenecid & Sulfinpyrazone

62
Q

A patient is seen with an erythematous, stiff, and painful first MTP joint. The patient has a history of gout and has not been taking his medication as directed. He has a history of DM and HTN.

He is currently on hydrochlorothiazide for his HTN; and Metformin for his DM. The patient tells you he took an aspirin for the pain but it “just made it worse.”

He then tells you he is on dialysis and has not gone in all week. He regularly goes 3x a week. What would you expect to see on this patients X ray?

A

“Mouse/Rat bite/punched out” lesions

63
Q

A patient is seen with an erythematous, stiff, and painful first MTP joint. The patient has a history of gout and has not been taking his medication as directed. He has a history of DM and HTN.

He is currently on hydrochlorothiazide for his HTN; and Metformin for his DM. The patient tells you he took an aspirin for the pain but it “just made it worse.”

He then tells you he is on dialysis and has not gone in all week. He regularly goes 3x a week. What would you see on this patients arthrocentesis?

A

Negitively bifringement needle shaped urate crystals

64
Q

A patient fell on an outstretched hand with his wrist extended. One PE, you note tenderness in his anatomical snuffbox. Would the patient have pain along the ulnar or radial side of the wrist if there was a scaphoid fx?

A

Pain along the radial side of the wrist

65
Q

A patient fell on an outstretched hand with his wrist extended. One PE, you note tenderness in his anatomical snuffbox and pain along the radial side of the wrist. How would you manage this patient?

A

Thumb spica

If displaced –> ORIF

66
Q

When attempting to diagnose a suspected scaphoid fx using a radiograph, what should you keep in mind if nothing is found?

A

The fx may take up to 2 weeks to present itself.

If + for anatomical snuffbox tenderness, tx as a fx! Complication of Avascular necrosis!

67
Q

A patient is diagnosed with a Colles fx–the radiograph revealed a “dinner fork deformity.” What is a possible complication to this fx?

A

EPL: Extensor Pollicus Longus tendon rupture

60% of patients also have an ulnar styloid fx

68
Q

A patient is diagnosed with a Colles fx–the radiograph revealed a “dinner fork deformity.” What is the management for this fx?

A

Sugar tong splint/cast

  • if stable (<20 angulation) = closed reduction
  • if unstable (>20 angulation) = ORIF
69
Q

A patient is diagnosed with a Colles fx–the radiograph revealed a “dinner fork deformity.” The patient is wondering what all this means–how do you respond?

A

Colles fx = distal radius fx with DORSAL/POSTERIOR angulation

70
Q

What does a “spilled tea cup” and “piece of pie” sign refer to?

A

Lunate dislocation : does not articulate with the capitate or the radius

EMERGENT CONSULT: ORIF

71
Q

What is Keibbock’s disease?

A

Avascular necrosis of the lunate bone

72
Q

What is the management for a Boxer’s fx?

A

Ulnar gutter splint in at least 60 degree flexion

73
Q

A patient presents with lower back pain radiating to the lateral thigh to the leg, hip and groin. Patient is also complaining of paresthesias. Which dermatome is likely affected?

A

L5

  • Sensory loss to the dorsum of the foot, esp between 1st and 2nd toes.
  • Weakness in Big toe extension/dosiflexion
  • Walking on heels harder than walking on toes.
  • (+/-) Normal reflexes
74
Q

A 65 y/o patient presents with back pain and paresthesias in his legs bilaterally. Patient says its worse with extension, such as prolonged standing or walking; and received with flexion, such as sitting, walking up a hill. What is this patients most likely diagnosis?

A

Spinal stenosis (pseudoclaudication)

-Lumbar flexion increases the spinal canal

75
Q

A patient presents with lower back pain radiating to the posterior leg, calf and gluteus. Which dermatome is likely affected?

A

S1

Sensory weakness in plantar surface of the foot
Weak plantar flexion
Walking on heels better than walking on toes
Loss of Ankle jerk*

76
Q

A 65 y/o patient presents with back pain and paresthesias in his legs bilaterally. Patient says its worse with extension, such as prolonged standing or walking; and received with flexion, such as sitting, walking up a hill. What management is best for this patient?

A

Lumbar epidural injection of corticosteroids*

Decompression, laminectomy

77
Q

What is the most common form of back pain in children and adolescents?

A

Spondylolysis : pars interarticularis defect

MC L5/S1

78
Q

An adolescent (10-15) is most commonly going to have what type of lower back pain?

A

Spondylolisthesis: slipping forward of vertebrae on another

79
Q

A patient is seen with back pain. Pt states she was out dancing with her boyfriend and thinks she “tore something.” She does not have any neurological deficits and her pain does not extend beyond the knee. She seems to be having back spasms, loss of lordotic curve and decreased range of motion. What is the most likely diagnosis and how do you manage this patient?

A

Lumbosacral sprain/strain: acute strain on the paraspinal muscles

-BREIF bed red and NSAIDS; muscle relaxers

80
Q

If a pt has ruptured their ACL, what was their MOI?

A

Non-contact pivoting injury (deceleration, hyperextension, internal rotation)

81
Q

What is O’Donoghue’s (Unhappy) triad?

A

Injury to:

  1. ACL
  2. MCL
  3. Medial meniscus
82
Q

What is the most commonly fx bone in children, adolescents, and newborns?

How do you tx it?

A

Clavicle

  • Mid 1/3 = arm sling 4-6 wks in adults; figure 8 in children
  • Proximal 1/3 = ortho consult
83
Q

A patient with a humeral shaft fx has “wrist drop.” What is the cause?

A

Radial nerve injury

84
Q

What is the tx for a Humeral shaft fx?

A

Sugar tong

Ortho follow up in 24-48 hrs

85
Q

A patient with adhesive capsulitis would have problems with which ROM:

A. Internal rotation
B. External rotation
C. Adduction
D. Abduction

A

B. External rotation

***Rehab is the mainstay of tx

86
Q

A patient with a hx of trauma from a MVA presents with a shortened, internally rotated and adducted leg with hip and knee slightly flexed. What is the most likely diagnosis?

A

Hip dislocation

87
Q

An elderly patient presents with hip pain and a hx of minor trauma. The patient’s leg is abducted, shortened, externally rotated. What is the most likely diagnosis?

A

Hip Fx!

ORIF

88
Q

What is the gold standard for diagnosing Osteomyelitis?

A

Bone aspiration

89
Q

If a patient’s ESR is normal, and their are exhibiting signs of Osteomyelitis–what is this indicative of?

A

Another inf–Osteomyelitis is unlikely if ESR is normal

90
Q

A patient is having pain along the radial aspect of the wrist radiating to the forearm especially with thumb extension or gripping. There is a + Finkelstein test on PE. What is your management of this patient?

A

Thumb spica splint for 3 weeks

deQuervain Tenosynovitis: stenosing of the APL & EPB

EM Rotation 2018 (7 decks)

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