EM- ortho emergencies

Question 1

most common location of clavicle fracture?

Answer 1

middle 1/3 (80% of the time)

Question 2

what fracture accounts for 90-95% of birth fractures?

Answer 2

clavicle

Question 3

which bone in the body is the last one to fuse?

Answer 3

clavicle (finally finishes at 22-25)

Question 4

ED treatment of clavicle fracture?

Answer 4

sling and swath immobilization for 2 weeks (almost all are treated non-operatively, especially in kids)

Question 5

when would you consider operative tx for clavicle fracture? (3)

Answer 5

open fracture, skin tenting, NV injury

Question 6

what is the most common type of shoulder dislocation?

Answer 6

anterior (about 90%)

Question 7

which type of anterior shoulder dislocation is most common?

Answer 7

subcoracoid- humeral head ends here

Question 8

how do you check NV status with ant shoulder dislocation?

Answer 8

• check radial pulse for axillary artery
• sensation over lateral deltoid for axillary nerve (most common injury)
• test wrist extension for radial nerve

Question 9

how do you NOT reduce an ant shoulder dislocation?

Answer 9

DONT put pressure in the armpit (could injure the brachial nerve)

Question 10

what is a common complication of closed ant shoulder dislocation reduction? why is this important?

Answer 10

humeral neck fracture- can lead to AVN (why its important to get post-reduction films)

Question 11

if a patient has this along with their ant shoulder dislocation, then you notify ortho upon consult

Answer 11

bankart lesion- disruption of anteroinferior portion of labrum or inferior part of bony glenoid

Question 12

ED Tx of anterior shoulder dislocation?

Answer 12

Reduction: get pre & post reduction films

Sling & swath for 2 weeks

Question 13

besides procedural sedation & analgesia, what can you add before reducing an ant shoulder dislocation?

Answer 13

intraarticular lidocaine

Question 14

most common reduction maneuver for ant shoulder dislocation?

Answer 14

traction counter- traction: gentle adduction with gentle lateral rotation

Question 15

what is the most important thing to check NV status of post ant shoulder dislocation reduction?

Answer 15

axillary nerve

Question 16

what are some causes of a post shoulder dislocation?

Answer 16

seizures, electric shock, trauma (MVC)

Question 17

what is the indication on an XRAY of a post shoulder dislocation?

Answer 17

light bulb sign- due to internal rotation of humeral head

Question 18

ED tx of post shoulder dislocation

Answer 18

closed reduction

2 weeks of sling and swath

Question 19

what is a sign of a nondisplaced supracondylar elbow fracture on an XRAY?

Answer 19

presence of a posterior fat pad sign (joint effusion of fluid, blood or pus)

Question 20

what is the classification system for supracondylar elbow fractures?

Answer 20

Gartland
type 1: hairline crack transverse through humerus
Type 2: displaced anterior wall
type 3: complete displacement (both ant and post wall)

Question 21

what is the most common peds elbow fracture?

Answer 21

supracondylar fracture

Question 22

ED tx of lateral condyle fracture?

Answer 22

long arm cast for 4-6 weeks

if greater than 2mm displacement then operative & consult ortho

Question 23

which type of lateral condyle fracture is more unstable?

Answer 23

type 2 because fracture is into trochlear groove

Question 24

why is lateral condyle fracture more dangerous?

Answer 24

higher risk of nonunion, malunion, and AVN

Question 25

what is the adult equivalent of a supracondylar fracture?

Answer 25

radial head fracture

Question 26

most common orthopedic injury?

Answer 26

distal radius fracture

Question 27

most commonly missed fracture?

Answer 27

scaphoid

Question 28

distal radial fracture: distal radius is _________ angulated to the proximal radius

Answer 28

dorsally

Question 29

monteggia vs galeazzi fracture

Answer 29

monteggia: proximal 1/3 ulnar fracture with associated radial head dislocation galeazzi: distal 1/3 radius shaft fracture + DRUJ injury (distal radial-ulnar joint)

Question 30

TX of distal radial fractures?

Answer 30

usually ortho right away: ORIF of radius + reduction and stabilization of DRUJ injury

Question 31

what is important to push on every time you check for a wrist injury?

Answer 31

push on scaphoid

Question 32

ED tx of scaphoid?

Answer 32

thumb spica splint and call ortho (displacement over 1mm = ORIF)

Question 33

what ABX do you give to prevent infection in a fight bite?

Answer 33

augmentin

Question 34

ED tx of metacarpal fractures?

Answer 34

splint it and let ortho decide if angulation is appropriate

Question 35

what is acceptable angulation for the fingers?

Answer 35

index & long finger- 10 to 20 ring finger- 30 little finger- 40

Question 36

what is the most common injury to the skeletal system?

Answer 36

phalanx fractures

Question 37

what is important to check during exam for phalanx fractures?

Answer 37

tendon function- injury is often near tendon insertion site

Question 38

ED tx for phalanx fractures?

Answer 38

early mobilization: buddy loops and outpatient follow-up | ORIF/CRPP for unstable irreducible fractures

Question 39

Tuft's fracture: where is the fracture located? how to tx?

Answer 39

distal phalanx | assess nail bed (maybe repair) and almost always non-op

Question 40

ED tx of phalanx dislocations?

Answer 40

``` reduce finger (usually only takes a slight pull) *do a digital block beforehand and then splint for 6-8 weeks ```

Question 41

ED tx of hip fractures

Answer 41

image hip & make sure nothing else will kill them...pain meds and call ortho

Question 42

what is the prognosis of elderly after having a hip fracture?

Answer 42

one yr mortality post fracture is 25-30%

Question 43

which type of hip dislocation is most common?

Answer 43

posterior

Question 44

ED tx of hip dislocation?

Answer 44

1) . attempt reduction in ED under conscious sedation 2) . post-reduction CT to rule out femoral head fractures 3) . protected weight bearing following reduction for 6 weeks

Question 45

when do you not need post reduction films after hip dislocation?

Answer 45

when the pt has had a total hip replacement and acetabulum is made of titanium

Question 46

distal Tib/Fib fracture classification

Answer 46

Weber- level of fibular fracture relative to syndesmosis A= below syndesmosis B = level of syndesmosis C = above level of syndesmosis

Question 47

ED tx for distal tib/fib fracture

Answer 47

if isolated nondisplaced malleoli fracture- conservative tx with short leg walking cast vs boot displacement of isolated fracture, open, or bimalleolar fracture- ORIF

Question 48

what is the maisonneuve fracture?

Answer 48

spiral proximal fibular fracture & distal medial malleolar fracture (and/or deltoid ligament rupture) which COMPROMISES SYNDESMOSIS

Question 49

tx of maisonneuve fracture?

Answer 49

it is unstable so surgical fixation is required

Question 50

if you have a distal ankle fracture, what is also important to examine?

Answer 50

fibular head!

Question 51

ED tx of tibial plateau fractures?

Answer 51

knee immobilizer

Question 52

ED tx of high ankle sprain

Answer 52

sprain w/o diastasis or ankle instability = non weight bearing CAM boot or cast for 2-3 weeks if syndesmosis is unstable = SURGERY

Question 53

ED tx of subtalar dislocation?

Answer 53

closed reduction FIRST (sedation and post reduction films) | *open reduction if failed attempt at closed reduction

Question 54

tibiofemoral dislocations: fracture of what in 60% of cases?

Answer 54

tibia +/- femur

Question 55

what is the dimple sign?

Answer 55

buttonholing of medial femoral condyle through medial capsule during a tibiofemoral dislocation

Question 56

dislocated knees always get what test?

Answer 56

vascular studies (ABI AND arteriogram) to evaluate popliteal artery injury; consult vascular if found

Question 57

ED tx of knee dislocation?

Answer 57

1) . get vascular studies 2) . reduce knee and reexamine NV 3) . splint in 20-30 degrees of flexion (takes pressure off NV) 4) . post reduction films

Question 58

what is the leading cause of death in pelvic ring fracture?

Answer 58

hemorrhage

Question 59

if patient is hemodynamically unstable and has a pelvic fracture then what do you give them?

Answer 59

probably will need blood

Question 60

ED tx of pelvic fracture

Answer 60

place binder on them (goes over trochanter), give blood if needed and call ortho

Question 61

fat embolism is common in patients with what type of injury?

Answer 61

pelvis or long bone fractures (breaking bones causes marrow to be released into the bloodstream)

Question 62

fat embolism is more common in bilateral _______ fractures

Answer 62

femur

Question 63

treatment of fat embolism

Answer 63

prevention! by early fracture stabilization

Question 64

two major clinical signs of compartment syndrome?

Answer 64

pain out of proportion and pain on passive motion

Question 65

what striker pressure indicates compartment syndrome?

Answer 65

>30

Question 66

tx for compartment surgery

Answer 66

call ortho bc emergent fasciotomy

Question 67

___% of low back pain resolves within one year of onset

Answer 67

90%

Question 68

red flags that are signs of severe back issue (2)

Answer 68

1) . saddle anesthesia or acute bowel/bladder incontinence (indicates cauda equina) 2) . constant severe pain that is worse lying down (infection or CA)

Question 69

ED Tx for cauda equina syndrome

Answer 69

call neurosurgery bc urgent surgical decompression within 48 hours

Question 70

ED tx for spinal epidural abscess

Answer 70

bracing and IV ABX (surgical decompression with neurosurgery)

Question 71

ED tx for open fractures

Answer 71

resuscitate, direct pressure, clean it up and place sterile saline dressing, splint, check NV status, START EMPIRIC ABX and call ortho

Question 72

why is it important to treat gonococcal arthritis FAST?

Answer 72

can destroy the joint in hours (immune system is causing the damage)

Question 73

gold standard for diagnosing septic joint?

Answer 73

joint fluid aspiration and culture

Question 74

septic joint: joint fluid aspiration results?

Answer 74

WBC > 50,000 | cloudy or purulent fluid

Question 75

ED tx of septic joint

Answer 75

broad spectrum parenteral ABX after culture; once results back, then narrow down ABX also irrigate and drain infected joint

Question 76

how does compartment syndrome happen?

Answer 76

there is an increased pressure in the closed fascial space which leads to decreased tissue perfusion and severe tissue damage

Question 77

where does compartment syndrome frequently happen?

Answer 77

anywhere skeletal muscle is surrounded by fascia | *leg, forearm, hand, foot, thigh, butt

Question 78

septic joint presentation

Answer 78

monoarticular, red, hot, tender and decreased ROM (knee most common)

Question 79

anterior shoulder dislocation MOA

Answer 79

abduction, external rotation and extension

Question 80

what movements are hard to do for a patient with an anterior shoulder dislocation?

Answer 80

adduction and internal rotation

Question 81

hip dislocation MOA

Answer 81

young people- high energy injuries | older people- low energy injury

Question 82

presentation of leg in hip dislocation

Answer 82

slight flexion, adduction and internal rotation