Orthopedics Flashcards
(38 cards)
1
Q
trauma
A
- Trauma Centers: Level 1-4
- Level 1 = all specialties/modalities avail 24hrs
- Trauma Team
- Trauma surgeons, residents/PA, ED/ICU nurses, nurse recorder, blood bank, xray, social services
- ED attending/res/PA (responsible for airway and ultrasound)
- The “Golden Hour”
- How does the PA student fit? Anticipate
- Undress, log-roll, IV access, foley, doppler/API’s, CPR, to CT
- Lac repair, help ortho (reductions, etc), ophtho, ENT, etc
- OR, care in-house
- Field Criteria “Trauma Activation”
- On arrival to ED:
- Primary Survey
- ABCDE + GCS + C-Spine
- AMPLE Hx (if awake)
- Allergies, Meds, PMH/PSH, Last PO, Events/Environment
- Ultrasound
- FAST or E-FAST (includes lungs)
- Secondary Survey
- Full systems exam, head to toe
- More complete Hx
- Primary Survey
2
Q
gunshot wounds
A
- Wound ballistics: Tissue damage related to
- Range, velocity, caliber, type, fragmentation, deformity
- Bullet hits, bounces around or goes thru
- ED deals w/ minor distal extremity GSW’s
- Think anatomy, trajectory, possible injury
- Avoid describing wounds as “entry” or “exit”
- Close range – look for gunpowder, burns around the site
- Look for clothing in wound, save clothes
- Check entire body
3
Q
GSW managment
A
- Stabilize the patient if unstable - undress
- Determine where, how many, other injury
- Neurovascular integrity is the priority in extremities
- Check: pulses, pallor, temp (cold?), cap refill
- Sensory exam
- Penetrate the joint?
- Air in joint = penetration
- X-ray all – joint above/below
- If fx, treat as open fx
- Local wound care, debridement
- Surgery, ortho consult
- Consider Abx
- Splint, close follow-up
- Tetanus
4
Q
Major ortho trauma
A
- Femur fracture
- High energy
- Risk for compartment syndrome
- Steinmann pin with traction device
- Pelvis fracture
- Internal injury common
- Surg admit, ortho consult
- Hip fracture
- Can’t weight bear
- Describe location
- Risk for AVN
- Occult fx? CT or MRI*
- Ortho admits for pin or replacement
5
Q
knife/stab wounds
A
- We deal with extremities/stable pt only
- Good history; police report made?
- Count, measure, explore deeper structures
- Function, neurovascular exam
- Imbedded objects are removed in the OR – don’t pull them out
- Do not extend wounds if possible
- Repair or leave open for delayed primary closure in 3-5 days
- X-ray all – fx, foreign body
- Consult surgery, ortho
- Consider Abx, close follow-up
6
Q
Delayed primary closure
A
- High risk, contaminated or neglected wounds – don’t suture
- Hands, feet, over joints; immunocomp pt; crush, bite, puncture
- Predict high infection risk
- Copious irrigation, wound debriedment
- Leave open, no suture, dry dressing
- Follow-up in 3-5 days – suture the wound then if no infection
- Pt Ed/document: Discussed, return signs infection, increased scar risk
7
Q
Arterial bleeding - extremity
A
- Universal precautions, ABC’s
- Check for foreign body, elevate
- Direct pressure first
- One finger, gauze, pressure just proximal for 10min
- Blood pressure cuff as tourniquet (mark time – 15min max)
- Pressure dressingà
- Tightly rolled/folded gauze
- Layer progressively larger on top, firm wrap
8
Q
Traumatic arterial injury: ABI
A
- Ankle-Brachial Index (ABI)
- Comparison of ipsilateral upper and lower extremity systolic pressure
- Pt supine, BP cuff, doppler
- Doppler brachial SBP, then highest of dorsalis pedis and posterior tibial
- ABI = Ankle SBP/Brachial SBP
- Arterial Pressure Index (API)
- Compare injured extremity to the other
- API = Injured SBP/Uninjured SBP
- >0.9 normal; if less than 0.9 = concern for traumatic arterial injury
- Duplex ultrasound, arteriogram if <0.9
- In non-traumatic Peripheral Artery Disease (PAD), ABI of 1.0-1.4 are normal, 0.9-0.99 are “borderline” for PAD, 0.8-.89 are “mild” and 0.5-0.79 are considered “moderate” indicators of the degree of PAD. Non-traumatic ABI of <0.5 is concerning for significant arterial occlusion and <0.4 indicates severe arterial disease.
9
Q
Approach to ortho injuries
A
- History
- Mechanism and when occurred
- Associated sx’s/risk – fall, high energy, helmet, protective gear
- Sx’s other than pain? Numb? Weak? LOC? Weight bear? Hear noise?
- Pain right away or delayed?
- Blood loss estimate; arterial?
- Dominant hand?
- Hx same/other injury in past?
- Occupation? Work related?
- Assault? DV? Police report?
- PMH, Meds, Allergies
- Tetanus?
- Social situation
- PE: anatomy, neurovascular exam are key
- Master exam for each area
- Pain control. Abx? Oral? IV?
- Imaging: Xray 1st. Need CT?
- Repair, reduction, splint?
- ED splints; no cylindrical casting
- Ortho consult, rec’s, f/u
- Pt Education
- Splint care
- Importance of f/u
- Red Flags to return
- Recovery period
- Document!
10
Q
neurovascular exam
A
- Know anatomy of injury area
- Check at injury area and distal
- Neuro: sensory, motor, DTR’s
- 2-point discrimination fingertips
- <6mm normal
- Vascular: pulses, cap refill, temp, color, Allen’s test
- No/weak pulse: get doppler
- Deficits
- Neuropraxia: nerve contusion
- Temporary – recovers
- No sensation: nerve cut/damaged
- Which nerve, reproduce, compare
- Cold extremity, pallor (hand/foot) = Vascular emergency (Surg/Ortho)
- Neuropraxia: nerve contusion
11
Q
Consulting the orthopedic surgeon
A
- Have a diagnosis before you call
- Begin with Dx; then age, gender, PMH
- If fx: open or closed?
- Mechanism, other injury
- Dominant hand. Occupation.
- Know Red Flags for area/injury
- Mention if they have them or they don’t
- Good PE prior to call: describe it
- Know motor, neuro, vascular status
- What have you done in ED?
- Imaging, ultrasound
- Reduction?
- Antibiotics, Tetanus
12
Q
orthopedic emergencies
A
- True emergencies
- Open fractures
- Compartment syndrome
- Septic joint
- Un-reducible dislocation
- Amputations
- Crush/mangled
- Pressure, air-gun injury
- Neurovascular compromise
- Consult ortho for
- All fractures to arrange f/u
- Joint infection/issues
- Ligament/Tendon injury/rupture
- Hand/finger cellulitis
- Minor crush/soft tissue injury
- Major dislocations
- Ortho Admits:
- Fractures/injuries requiring surgery now
13
Q
contusions
A
- Mechanism
- Crush is high risk
- Spontaneous is high risk
- Coumadin?
- Neurovascular exam
- Is this cellulitis/nec fasc?
- Search for wound/gas
- Check for ligament/tendon rupture
- Check joint above/below
- Check compartments; soft?
- Xray for fx, gas, foreign body
- Ice, elevation, return precautions
14
Q
Ligamentous injury
A
- Know ligamentous anatomy of injured area
- Know the “special moves” for each joint
- Stress joints to uncover laxity
- Sprains:
- 1st degree: mod pain, minimal swelling, no laxity
- 2nd degree: pain, swelling, loss function but no laxity
- 3rd degree: complete ligamentous disruptions
- Significant pain/swelling/function loss
- Joint laxity present
15
Q
sprains
A
- Mechanism, when occurred, other injury, weight bear?
- Neurovascular exam
- Stable or unstable joint
- Examine, stress ligaments
- Look for wound, lesions
- Infection? Septic joint?
- Xray – Ottawa Rules
- ACE/Brace/RICE if minor
- Joint disruption or unstable?
- Splint like fracture
- Ortho consult, f/u
16
Q
Tendon rupture
A
- Biceps
- Popeye sign (sling)
- Patellar
- Can’t extend lower leg
- Knee immobilizer
- Quadriceps
- Defect, hip flexion
- Knee immobilizer
- Achilles
- Hear “pop”, local defect
- Thompson’s test
- Posterior splint, equinus
- Xray all, Ortho/Pods consult all
- Immobilize, outpt f/u
17
Q
description of fractures
A
- Open or closed?
- Open = compound
- Location
- Which bone(s)?
- Where in the bone?
- “Head” proximal
- Proximal, middle, distal shaft, neck
- Intra-articular?
- Number of fragments
- Simple (2)
- Comminuted (>2)
- Direction of fx line
- Transverse, oblique spiral, longitudinal
- Alignment
- Displaced, distracted
- Angulated
- Shortened, impacted, depressed
- Rotated
- Special fractures
- Torus, greenstick, compression
- Name of fracture type
18
Q
special fractures: forearm/UE
A
- The Elbow
- Post fat pad, sail sign
- Anterior Humeral Line
- Radiocapetellar Line
- Radial Head Fx
- Subtle, common, FOOSH
- Nightstick
- Defensive, midshaft ulna
- Monteggia
- Fx ulna w/ radial head dislocation
- Galeazzi
- Fx distal 1/3 radius with ulna dislocation
19
Q
special fractures: wrist
A
- Intra-articular?
- Check carpal bone arches
- spaces and alignment
- Scaphoid
- AVN risk if at “waist”
- Check snuff box
- Colles/Smith’s
- Colles dorsal, Smith’s volar
- FOOSH; need reduction?
- Lunate dislocation
- Teacup (lunate) is tipped over
- Perilunate dislocation
- Teacup is empty, carpals dislocated
20
Q
special fractures: hand
A
- Boxer’s Fx
- 4-5th at neck (fight bite?)
- Note finger rotation
- Reduce >30deg angulation
- Gamekeeper’s, Bennett’s, Rolando fx’s
- Finger disloc? Xray, reduce
- Tuft or proximal distal phalanx?
- Volar Plate
- Hyperextened finger
- Extensor avulsion
- Jammed, Mallet finger
21
Q
special fractures: knee
A
- Patella
- Direct blow
- Sunrise view
- Check patellar tendon
- Tibial Plateau
- MVA, Auto vs Ped
- Jumpers
- Can be subtle
- Can’t weight bear
- Get CT
22
Q
special fractures: ankle
A
- Mortise
- Wide? Disrupted?
- Ligamentous injury
- Maisoneuve
- Mortise plus proximal fibula fx
- Palpate proximal leg in all ankle injuries
- Bimaleolar
- Unstable
- Trimaleolar
- Unstable
- Check that lateral!
23
Q
special fractures: foot
A
- Talus
- Not common
- High risk AVN
- CT all
- Calcaneus
- Mechanism, Mondor’s sign
- CT all
- Lisfranc fx/dislocation
- Mechanism
- Check the 1st, 2nd, 3rd MT joints
- CT all
24
Q
special bony conditions
A
- All get xrays first, then ortho consult
- Open fx’s
- Ortho emergency
- High risk infection, osteo
- Non-union/malunion
- Deformity, pain after fx
- Often non-compliance
- Osteomyelitis
- DM, chronic infections
- Ask: Is this nec fasc?
- Avascular necrosis
- Usual suspect sites
25
joint dislocations
* Fingers, wrist, elbow
* Shoulder
* Anterior or posterior?
* Hill-Sachs?
* Ankle, knee, hip
* In all:
* Open or closed?
* Neurovascular exam paramount
* Xray all: fracture dislocation?
* We try reduction first if no fx
* Ultrasound guided nerve blocks
* Intra-articular injection
* Procedural sedation
* Xray post reduction
* Ortho consult, immobilize
26
Joint reduction
* Each joint has special considerations
* Reduction should not be delayed
* All involve traction/counter-traction/motion
* Xray before and after reduction
* Large joints: admit for neurovascular checks
27
swollen joints
* Effusions – mono vs. poly – ballottment – hot/red?
* Septic – mono – the biggie – cannot miss!
* Atraumatic, +/- fever, red/hot, won’t move it
* S. aureus most common, N. gonorrhea 20%
* Fever, chills, arthralgias. GC: hemorrhagic pustules
* Hemarthrosis - mono
* Post trauma
* Gout – usually mono, or poly
* Uric acid crystals (bi-refringent)
* Pseudogout - CPPD
* Reiter’s Syndrome – mono/poly
* Arthritis, conjunctivitis, urethritis
* Inflammatory – poly
* Get xrays, CBC (ESR, CRP)
28
arthrocentesis
* Consent pt, check contras
* Cellulitis, coumadin, prosthetic jt
* Strict sterile procedure
* Diagnostic and therapeutic
* Suspect septic joint
* Hemarthrosis post trauma
* Gout diagnosis
* Big joint, big needle
* Ultrasound guidance
* Take out as much as possible: can inject bupivicaine after tap
* Send fluid for cell count, culture
* \>50,000 WBC’s: infection\*\*\*
* Complications: iatrogenic infection, bleeding, local trauma
29
compartment syndrome
* Elevated pressures in confined compartment
* Edema, bleeding = reduced blood flow
* Muscle/nerve necrosis ensues
* First few hours to 48hrs
* Femur/tibia, humerus/elbow/hand fx/injury
* Severe pain w/ cast? Remove it
* Symptoms
* Severe/pain out of porportion, w/ passive stretch: early hallmarks
* Five “P’s”: pain, pallor, paralysis, pulselessness, paresthesias
* Don’t need all for dx. All = late
* Stryker pressures
* Fasciotomy
* Anticipation, high vigilance
30
Puncture wounds
* Common, management controversial
* 6-10% get infected: DM, immunocomp, PVD high risk
* Xray all for FB, fx; low pressure irrigate, tetanus shot
* \<6hrs old, clean wound, healthy pt:
* No abx, return precautions, do well
* \>6hrs, high risk pt/wound, plantar surface/hand:
* Consider abx (Cipro, Keflex), strict return precautions
* Foot: where, when, with what, shoe?
* Consider vascular/neuro/lig/tendon injury
* Tennis shoe: psuedomonas - Cipro
* Hand: High risk
* Consider vasc/neuro/lig/tendon injury
* Complications: discuss/document
* Cellulitis, abscess, osteomyelitis (pseudomonas)
31
hands are special
* Small problem, big trouble
* Anatomy/function/neurovascular
* Inspect lacs in bloodless field
* Move finger/hand to expose deep structures – see them move
* Joint violation?
* Fight bite
* “No man’s land”
* Tendon lacs
* Flexor repaired in OR – ortho
* Some extensor – ED can repair
* Flexor tenosynovitis, cellulitis
32
human bites
* “Only a camel bite is worse”
* 190 different microbes in human saliva
* “Fight Bite”
* Closed fist vs. mouth
* Must ask/document in every pt w/ hand wound
* High risk infection, septic joint, tendon sheath infection, osteomyelitis
* Xray all. Open fx? FB?
* Eikenella corrodans, polymicrobial
* Copious irrigation
* DO NOT SUTURE human bites! DPC
* Admit, IV abx fight bite. Others: Augmentin
* Tetanus, consider Hep B vaccine
* Don’t miss DV!!
33
animal bites
* Cat bites
* High risk infection
* Pasturella Multoceda, Staph, Strep, Moraxella
* Bartonella: Cat scratch fever
* Clean like puncture
* Do not suture!
* Augmentin, close f/u
* Dog bites
* Medium risk infection
* Polymicrobial
* Copious irrigation, debridement
* No suture if hand, feet; face/scalp ok
* Abx if hand, foot, big. Close f/u
* Rabies
* Rare in US dogs – consider if bitten abroad, sick animal
* Bats, raccoons, skunks
34
splinting/immobilization
* Splint all fractures, tendon injuries, Grade 2,3 sprains, infections, lacs over joint area, post-reduction/tap
* Unstable? Joint above/below
* ACE, sling, immobilizer
* Determine weight bearing status - discuss
* Crutches/training
* Home care
35
low back pain in the ED
* Vast majority are muscle strain/spasm
* NSAID’s, APAP, muscle relaxant, self-care, expectations, work note
* No opiate Rx
* 1:100 need imaging today
* Plain film rare (older, fx, mets), CT: bone or if suspect fx
* MRI: cord: if fever, IVDU, true new weakness or true sensory deficit
* History must include: OPQRST, mechanism, Hx same, plus...
* Fever, weakness, numbness/sensory changes, bowel/bladder incontinence or retention, weight loss, IVDU...abdominal/female GU/prostate
* PE must include:
* Abdominal exam – rectal only if weakness/sensory change
* Back: rash/lesions, bony tenderness, ROM, SLR
* Neuro: Strength, sensory exam, DTR’s, gait
* Chart documents all of above, every time
36
Low back pain red flags
* Red Flag/DDx in Hx/PE – document presence/absence
* \*Trauma/fall/assault/direct blow (plain or CT – depends on severity)
* \*Fever (MRI)
* \*Motor weakness (cord compression, Transverse Myelitis (TM) MRI)
* \*Numb, sensory deficit: check saddle distribution (Cauda Equina: MRI)
* \*Bowel/bladder incontinence/retention (Cauda Equina - MRI)
* \*Bony or central tenderness (Fx, met, TM – plain vs CT first)
* \*Weight loss (Cancer – CT for mets)
* \*Elderly and no trauma (Think Aorta – CT)
* \*IVDU (Fever, back pain? Think Spinal Epidural AbscessàMRI)
* Concerning: radicular sx’s, positive SLR, loss of DTR’s
* May need outpt MRI - unless precipitous progression (TM, cord)
37
pediatrics: fractures
* Mechanism, other injury
* Non-accidental?
* Motor/neuro/vascular exam
* Salter Harris Classification
* Elbow/wrist ossification
* Same immobilization/RICE
* Refer to Pediatric Orthopedics
38
Limp in kids
* Hip, groin, thigh, knee pain
* Xray all, Ortho consult all
* Differential Diagnosis
* Acute Septic Arthritis
* Often younger; hip, knee, elbow
* Fever, +/- toxic appearing
* Transient (Toxic) Synovitis
* Most common cause hip pain \<10yo
* +/- fever; non-toxic, passive movement ok
* Slipped Capital Femoral Epiphysis
* Salter I; obese boys 11-16yo
* Externally rotated leg, antalgic gait
* Legg-Calve-Perthes
* AVN femoral head
* No systemic sx’s; MRI
* Rheumatic fever: 2-6wks after Grp A Strep
* Migratory, poly, rare in US
* Juvenile Rheumatoid Arthritis
