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Ortho Flashcards

1
Q

What 5 are true ortho emergencies

A
  • Hip dislocation
  • Ankle dislocation with tenting
  • Open fx (OR in <6 hours)
  • Compartment syndrome
  • High pressure injection injuries
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2
Q

Fx complications

A
  • Hemorrhage
  • Vascular injury
  • Nerve injury
  • Compartment syndrome
  • Fat embolism
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3
Q

Overall ortho pearls

A
  • Don’t correct a deformity without an XR first (and neuro exam)
  • Caveat is pulseless, cold, vascular compromised area
  • Eval and document: deformity, color of skin, TTP, ROM, NV status
  • Eval NV before and after attempts to reduce a fx
  • Any soft tissue wound proximal to fx is treated like open fx until proven otherwise
  • Use the word amputation not “cut off finger”
  • Fingers: thumb, index, long, ring, small
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4
Q

Salter-Harris

A 
I: straight across
II: above, in metaphysis, no joint, MC
III: lower, epiphysis, is in joint
IV: through: both metaphysis and epiphysis
V: Crush: no more physis
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5
Q

what XR view is needed on shoulder and elbow injuries

A

true lateral

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6
Q

Things to not miss on XR

A
  • Massonneuve
  • talar shift
  • syndesmosis widening
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7
Q

Three types of nerve injury

A
  • Neuropraxia: Loss of function dt ischemia, no damage, will recover 90% of the time
  • Axonotmesis: Axons are damaged, will recover but often incomplete. Better prognosis if injury is distal
  • Neurotmesis: Entire nerve transected, requires repair (can be done 3-6 months after injury!)
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8
Q

When is it appropriate to do an EMG after a nerve injury?

A

Not until min 6 weeks to allow adequate healing time

** neurons heal proximal to distal, about 1 mm per day

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9
Q

How to assess vascular status

A
  • Pulses ☺
  • Color, temp, cap refill
  • If asymmetric pulses or unsure, get a Doppler study!
  • If absent, call sx and consider duplex study. Arterial blood flow must be reestablished within 4 hours to avoid irreversible damage
  • Doppler: uses sound
  • Duplex: sound and US together, colored
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10
Q

Fracture language, things to note (5)

A
  • Closed vs. open
  • Displaced %
  • Distracted/shortened
  • Angulated (degrees from where bone should be), need two views
  • Articular involvement?
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11
Q

6 Ps of compartment syndrome

A
  • Pain out of proportion
  • Pallor
  • Paresthesias
  • Poikilothermia (cold)
  • Pain with passive motion distally (ex. Toes)
  • Pulselessness
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12
Q

Compartment syndrome

  • where MC
  • PE
  • What pressure = fasciotomy
  • tx
A
  • MC: anterior leg
  • PE: firm, swollen, tense extremity
  • > 30 mmHG = fasciotomy needed
  • Ortho consult and admission
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13
Q

Open fx management

A
  • Early broad spectrum abx (1st gen cephalosporin, maybe aminoglycoside, maybe pcn)
  • Hemostasis
  • Debride wound but no aggressive irrigation
  • Occlusive, sterile saline soaked dressing
  • Splint
  • Tetanus
  • OR
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14
Q

Quick UE neuro check

A

Rock Paper Scissors OK

  • Rock: median nerve
  • Paper: radial nerve
  • Scissors: ulnar nerve
  • OK: anterior interosseus nerve
  • *Axillary: lift arm
    • Musculocutaneous : flex bicep
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15
Q

High pressure injection injuries

A
    • True ortho emergency: ortho or plastics
  • Injected material spreads along fascial planes, extent can look less than it is
  • Risk of compartment syndrome
  • Tx: Tetanus, analgesia, broad spectrum abx, splint, elevate
  • Consult: hand surgeon, urgent operative debridement is tx of choice
  • Digital blocks are CI
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16
Q

Fight bite

A
  • Depth usu worse than appears
  • Assess full ROM
  • Infection major issue
  • If tendon involvement – consult hand surgeon
  • No tendon involvement: irrigate, closure, oral abx
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17
Q

Scaphoid fx

A
  • High risk AVN
  • Anatomic snuffbox
  • Negative XR do not rule out
  • Thumb spica splint and ortho f/u
  • Will need MRI
    Triquentrum is second MC fx carpal bone
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18
Q

Flexor Tendon Injuries

A
  • Rupture tx: splint (block extension) and ortho referral
  • Flexor tenosynovitis: admit, IV abx, ortho consult
  • Kanaval’s signs:
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19
Q

What are Kanaval’s signs (4)

A
  • Sausage digit: uniform swelling along entire finger
  • Held in passive flexion
  • Pain with passive extension
  • Pain to percussion/palpation of flexor tendon sheath
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20
Q

FOOSH

  • Tx
  • Two types
A
  • Reduce, splint, refer to ortho
  • Good NV check and documentation
  • Colles (dinner fork): dorsal angulation MC
  • Smith: volar angulation
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21
Q

Galeazzi and Monteggia

A
  • Don’t trust a single bone forearm fracture!
  • Check for dislocation of the distal or proximal radioulnar joints
  • Distal: DRUJ
  • Proximal: PRUJ
  • Galeazzi (MC): radius shaft fx with DRUJ dislocation
  • Monteggia: ulna fx with proximal radial head dislocation
22
Q

Supracondylar fx

A
  • Usually kids 5-10 FOOSH with hyperextension of elbow
  • Poor tx → serious morbidity
  • Assess interosseous nerve via OK sign
  • Check radiocapitellar alignment
  • Lateral xray is required – look for fat pad signs!!!
  • Posterior fat pad
  • Anterior fat pad is “sail sign”
  • DO NOT reduce, ortho consult
23
Q

Shoulder Dislocation

- Overview

A
  • Arm adducted and elbow flexed, should step off
  • Scapular Y view (and AP)
  • Reduce within 24 hours
  • Assess axillary nerve
  • Associated with Bankart lesion and Hill-Sachs deformity
  • If first dislocation, increased risk of soft tissue injury
24
Q

Shoulder Dislocation

- Anterior vs. Posteior

A
  • Anterior: MC, arm adducted and elbow flexed, step off

- Posterior: usu dt electrocution or seizure (<10% of dislocations)

25
Shoulder dislocation | - Tx
- Analgesia +/- light sedation - Anterior: reduce via gentle traction of humerus w/ external rotation of shoulder/forearm. Can use countertraction - Posterior: reduce with traction and countertraction - Might have to fatigue the muscles to get it to reduce - Immobilize in sling, internal rotation Ortho f/u in 1-2 days, will need PT
26
Humerus Fx
- Look horrible but very forgiving - Proximal or shaft - Radial nerve (runs along humerus) - AP and lateral XR - Bc of large ROM of shoulder, can compensate for small rotational or angular deformities - Immobilize in sling, ortho referral
27
Hip Fx
- Not always due to trauma, can be little old lady with osteoporosis - Elderly pt with inability to bear weight on a hip is fx until proven otherwise - A fracture-dislocation of the femoral head in a young person requires great force, check for other abdominal injuries - Recognize femoral neck fx vs. intertrochanteric fx
28
Hip dislocation
- Sig force required - Eval for nerve injuries (sciatic and femoral) - Need pre and post op xrays, AP pelvis - True emergency
29
Hip dislocation | - tx
- Reduction w/in 6-12 hrs of injury - Sedation - ORTHO consult
30
Hip Dislocation | - Posterior
- MC, 90% - Often dashboard injury - Displaced superior and lateral - Exam: Hip flexed, adducted, internally rotated
31
Hip Dislocation | - Anterior
- 10% - More common in pts with a hip prosthesis - Displaced inferior and medial - Exam: externally rotated, abducted, slight flexion
32
Pelvic Fx
- High mortality rate, risk of hemorrhage, shock - Low E trauma usually results in stable fx which requires conservative tx, WBAT - High E trauma usually results in unstable fx which require operative tx - AP XR of pelvis confirms, might need CT
33
Pelvic Fx | - 4 types
- 1 Fx with intact ring - Fx of pelvic ring - Fx of acetabulum (less concerning) - Sacrococcygeal fx (less concerning)
34
Pelvic Fx | - types of injury
- Anterior posterior compression (APC) • Disrupts symphysis, “open book” injury - Lateral compression (LC) • Breaks rami, look at SI joint - Vertical shear (VS) • BAD. Always unstable, hemorrhage
35
Pelvic Fx | - Exam (3)
- GU: blood at urethral meatus, high-riding prostate, gross hematuria, scrotal hematoma - Neuro: L5, S1, rectal exam: tone and temperature sensation and prostate position - Skin: ecchymosis of anterior abd wall, flank, sacral and gluteal region (lack of ecchymosis does not r/o hemorrhage)
36
Pelvic Fx | - Imaging
- 5 view of pelvis: AP, pelvic inlet and outlet, R and L oblique - If you see one fx, look for more, displacement can only occur if ring is disrupted in 2+ locations - CT scan - +/- urethrography
37
Pelvic Fx | - Pearls
- Posterior pelvic fx: NV injuries and hemorrhage - Anterior pelvic fx: urogenital injuries - NO catheter - FAST exam is less sensitive if there is a pelvic fracture
38
Pelvic Fx | - Tx
Stabilize, close the book | If fx is stable, WBAT with walker
39
Ankle Dislocation
- True ortho emergency! - Displacement of talus (foot) from the tibia - Usually associated with other fx - Check if the skin is tenting and NV status quickly! - Reduction as soon as possible, consult neuro - Splint it, get post-reduction xrays - Do not discharge without emergent ortho consult
40
Maisonneuve
- Consider with all ankle injuries - Proximal fibula fx with ankle injury - Check the “clear spaces” in the ankle for disruption of the ankle mortise - Tx: splint, NWB, ortho referral, will need surgery
41
Lisfranc injury
- Tarsometatarsal joint is the Lisfranc joint - Injury requires large force: dislocation +/- fracture - PE: mid-foot pain and swelling - On XR: look for widening of spaces, don’t’ miss!! - TX: splint, NWB, ortho referral
42
General Splinting
- No case in ER or acute setting, let swelling subside first - Never cast a swollen limb!! - Immobilization = relief, remind pt - Immobilize joint above and joint below injury - Remove excess water from material - Protect patient from sharp edges - Eval neuro before and after splint, document
43
Splinting material
- 3” good for UE in most adults - 4” good for LE - don’t apply with too much tension, be gentle - Use soft roll - Fiberglass MC vs. plaster
44
Intrinsic plus position
- true neutral position of hand and wrist – not Barbie hands
45
Sugar Tong splint
- Distal radius fx and forearm fx - Can double for an unstable wrist/elbow (pic on right above) - Watch the styloid and ulnar nerve - Don’t be stingy with soft roll - Hand and wrist in intrinsic plus position!
46
Volar Splint | - wrist and hand
- Wrist sprains, simple buckle fx in kids, carpal tunnel, extensor tendon injuries - Mind the thumb - Ensure min 2 inches distal to the antecubital fossa – don’t splint up into the elbow bend - Immobilize in slight wrist extension (neutral wrist position)
47
Thumb Spica Splint
- For thumb fx - Collateral ligament injuries, gamekeepers thumb, scaphoid fx - Soft roll around thumb, watch for fiberglass edges!
48
Ulnar Gutter Splint
- Boxers fx, 4th metacarpal fx, 4th and 5th phalanx fx | - Immobilize in 80-90 flexion, PIP at <20 flexion
49
Dorsal Splint
- Used to block extension: flexor tendon injuries | - Can also use on 2nd and 3rd metacarpal fractures
50
Posterior short leg splint
- LOTS of soft roll. Pad: lateral and medial malleolus and calcaneus - Add stirrup for unstable fx or if unsure - Immobilize ankle in neutral position - Stop 3-4” distal to knee (4 fingers) - Don’t leave toes hanging!

ER 2 (10 decks)

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