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Flashcards in Ortho/Vascular/Peds Deck (46):
1

Indications for ortho studies

Injury
Pt is unsure whether injury occurred
Abscesses
Osteomyelitis
Bony tumors
MSK pathologies, think sprains, tears, etc
Pt assurance
Parental assurance

2

How to choose imaging modality for ortho?

Usually start with plain films for injuries and FBs
CT/MRI/NM after plain films usually if re: injury
Abnormal labs?
Length of sx
Mechanism of injury
-Always report this when you order the test
Pt limitations with regard to radiographic principle of 2 views/obliques, etc

3

How to order ortho imaging

If injury: MOI, PE findings (deformity, TTP, test results if any)
If chronic or no injury: labs if applicable, PE findings (same as above)
Order what hurts. However, radiology principles dictate if long bones are ordered they must include both proximal and distal joints. Keep in mind so you don't overorder

4

General bony pathology

Will have the same general appearance among the pathology regardless of which bone is involved
Osteomyelitis
Bony tumors
RA
OA
Osteopenia/osteoporosis

5

What is the test of choice for sprains/strains/tears?

MRI, without contrast

6

Types of Salter-Harris fractures

Type I: straight
Type II: Above
Type III: Below
Type IV: Through
Type V: Crush

7

Colles fx

Distal radius

8

Greenstick fx

Rare, long bones with angulated longitudinal force, incomplete fx

9

Buckle/torus fx

Primary wrist fx
Incomplete fx

10

Stress fx

10 day rule for feet

11

Shoulder

Includes the clavicle, scapula, and proximal humerus
Complete shoulder is neutral/external/internal rotation and Y view of scapula
Also can do an axillary view (must be at a 90 degree angle) but the Y view is easier on the pt usually and standard in the shoulder series

12

Elbow

Complete is 4 views:
AP
Lateral
Internal rotation
External rotation
If obvious deformity, 2 views (AP/lateral) will suffice

13

Occult fractures

Commonly a concern with the elbow
Nothing seen overtly on radiographic imaging including CT sometimes. MRI/NM will usually show them
Pos fat pad signs (anterior/posterior), sail sign (anterior)
Adults: radial head fx
Children: supracondylar fx
Children don't lie or fake guarding their extremities, err on side of caution and splint with ortho f/u

14

Pelvic girdle

If ordering a unilateral hip, also order an AP pelvis
Hip fxs and dislocations are pretty straightforward
Pelvis fxs need CT of the pelvis for best detail, regardless of age

15

Pathologies possible in the pelvic girdle
How can they be imaged?

AVN
Slipped capital femoral epiphysis
Legg-Calve-Perthes dz
All can be diagnosed usually with plain films but MRI will give definitive dx
Hip clicks/dysplasia in infants, u/s is test of choice for dx IF sonographers are capable

16

Knees

Fxs are rare
Dislocations are more rare
Knee complete is 4 views: AP, lateral, int/ext obliques
Older people (60 and older) with injury, neg plain films, still with pain days later, do CT will find tibial plateau fxs
Most knee plain films will be negative, high incidence of strain/sprain/tear, good PE, if no improvement after 7-10 days of RICE, MRI warranted

17

Ankles

When examining pts with ankle injuries, always check the fibular head for point tenderness
Many twisting injuries can result in fibular head fractures
If TTP on fibular head order a knee series as well
Ankle complete is 3 views:
AP
Lateral
Internal oblique
Ankle joint should be flexed to see if ankle mortise is intact

18

Feet

Standard exam is 3 views:
AP
Lateral
Oblique
Neg X-ray at time of injury with continued sx 7-10 later pt should be re-imaged with plain film
Foot fxs can show on later films, always caution your pts to return to clinic for re-eval or see PCP if no improvement in sx
Jones fxs must be NWB

19

Specialty ortho

C arm for surgery and reductions (in ER if the doctor wants)
-Reactive when it's on
Nuclear medicine: bone scans for fx age, bony mets, tumors
MRI: gold standard for eval of sprains/tears
-Not routinely ordered in ER, either in office or by ortho specifically

20

Words of wisdom in ortho

Dislocations must be reduced ASAP, regardless of fracture type
If you have access to ortho, call
When in doubt, splint and refer, treat it like a fracture
Always have help when reducing fractures/dislocations

21

What is considered part of the peripheral vascular system?

Carotid arteries
Jugular veins
Upper extremities
Lower extremities

22

Imaging that is possible on the carotid arteries

U/S (fast, cheap and easy)- good screening tool
Images the common carotid, internal carotid, external carotid, vertebral arteries
Internal carotid/external carotid named for what they feed not where they lie
CTA of neck
MRA of neck
Angiogram

23

Carotid duplex/doppler

CCA/ICA/ECA/vertebrals in black and white, with color, with doppler waveforms and measurements

24

Indications for carotid duplex/doppler

Any neuro complaint, e.g. dizziness, visual changes, weakness
Usually done post CVA/TIA
Bruit on exam
Screening exam now for pts >65 yo with RFs

25

Jugular/subclavian veins

included with an upper extremity venous doppler (ultrasound)
Can order separately if needed
Can use bedside u/s to localize EJ for IV access in difficult pts

26

Upper/lower extremity imaging options

Arterial doppler
ABIs
Venous doppler
CTA/MRA/Angiography

27

Upper/lower extremity arterial indications

Decreased or absent pulses
Skin changes: color, temp
Pain in the setting worrisome for vascular dz (think DM, smoking)

28

How to order upper/lower extremity arterial

RUE
LUE
BUE
RLE
LLE
BLE
arterial doppler (duplex)

29

What you get with upper/lower extremity arterial imaging

Subclavian to as much radial/ulnar arteries as is able to be visualized, includes axillary and brachial
Common femoral vein/great saphenous vein/popliteal vein/post tibs
Black and white images, color images, doppler with waveforms and measurements

30

Types of extremity arterial waveforms

Triphasic flow is nl
Biphasic flow is indicative of early changes/disease
Monophasic flow is diseased/pre-occlusive
No flow = occlusive
Can have collaterals

31

ABI

Screening test, easy, can do in your office if you have a doppler
The ankle-brachial pressure index (ABPI) or ABI is the ratio of the BP of the ankle to the BP in the upper arm. Compared to the arm, lower BP in the leg is an indication of diseased arteries d/t PVD

32

Upper/lower extremity venous

Very overused test
Fast, cheap, and easy, most bang for your buck
Rules out something potential deadly
Pt reassurance
Images deep venous system from hip to knee and then as far as is possible to image, usually mid-calf region
Common femoral vein/great saphenous vein/superficial femoral vein, pop, post tibials
Never order venous and arterial together just because you are unsure

33

What you get with upper extremity venous

Internal jugular
Subclavian
Axillary
Brachial (s)
Cephalic
Basilic
Radial/ulnar as far as you can see usually mid forearm

34

Lower extremity venous- what you get

Central femoral vein
Great saphenous vein
Superficial femoral vein
Popliteal vein
Posterior tibial

35

Pediatric pearls

Good hx from parent/guardian
Good PE
Learn how to build rapport with the pt AND the parents
Both can tell when you're not confident
Defer to radiologist whenever possible
When in doubt err on side of caution and proceed as needed

36

Pediatric considerations

Head injury/LOC
Neurologic sx
Spine injuries/scoliosis
CXR
Abd X-ray: common and uncommon pathology
Appendicitis
Pyloric stenosis
Hip dysplasia
Ortho
Osteogenesis imperfecta
Radiation exposure

37

Head injury with or without LOC

Assess pt, neuro exam
Good hx from parents
PE concerns
Benign exam findings with no LOC: monitor for concussive sx
Benign exam findings with LOC: monitor vs skull X-ray vs CT scan
Pos exam findings with or without LOC: scan the pt

38

Neuro sx in the pediatric pt

Chronic headaches
Syncope
New onset seizure
Abnl neuro exam
CT scan without contrast

39

Spine injuries/scoliosis

Start with plain films and proceed based on those results
If <18 but adult sized teenager may do CT scans instead
Scoliosis series: radiologist will give you the degree of lateral curvature

40

CXR in peds: when to get it

Cough, fever, ill-appearing
Low O2 sat
Unable to correct wheezing/coarse breath sounds with meds
Hx of pneumonia
Abnl labs: elevated WBC
Ingestion of FB

41

Abdominal X-ray in peds: when to get it

Vague abdominal complaint no worry for appy
Constipation
Exam findings with no worry for appy
Ingestion of FB
Worrisome for:
Volvulus
Intussusception
SBO
Free air
NEC
Duodenal atresia
These conditions usually require a barium study either under fluoro or CT scan

42

Appendicitis

Good hx from parents
PE findings worrisome for appy
May order u/s first- know the LIMITATIONS
Best imaging choice when u/s is not a viable option: CT abd/pelvis with IV/PO contrast
If an obese teenager may do without any contrast same as adult

43

Pyloric stenosis

Start with u/s, usually an excellent way to diagnose
If u/s is neg, pt still with sx, proceed to upper GI

44

Hip dysplasia

U/s if PE is concerning
Must be done by a confident sonographer
Read by a confident radiologist

45

Orthopedics

For small children and infants, it's really difficult to interpret images
Treat as a fracture, splint and ortho this DOES NOT AID IN DX
Radiograph the unaffected side for comparison when a dx is needed
Your decision will be based on parents mostly, some want to know for sure if there is a fx
Elbow fxs (supracondylar
fx) are emergent and must be found

46

Radiation exposure

Osteogenesis imperfecta pts get imaged a lot d/t multiple fxs, try to order the least amount of exams to limit their lifetime exposure
CT head to children is a lot of radiation, be prudent when ordering this, esp if PE if benign and the pt is well-appearing, parent reassurance is important, you must learn to reassure without ordering
Sick infants will be imaged a lot, always limit your orders as best you can to decrease their lifetime exposure
Use u/s when possible