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Emergency Medicine Module 3 > Orthopedics > Flashcards

Flashcards in Orthopedics Deck (38):
1

trauma

  • 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

2

gunshot wounds

  • 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

GSW managment

  • 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

Major ortho trauma

  • 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

knife/stab wounds

  • 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

Delayed primary closure

  • 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

Arterial bleeding - extremity

  • 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

Traumatic arterial injury: ABI

  • 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

Approach to ortho injuries

  • 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

neurovascular exam

  • 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)

11

Consulting the orthopedic surgeon

  • 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

orthopedic emergencies

  • 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

contusions

  • 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

Ligamentous injury

  • 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

sprains

  • 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

Tendon rupture

  • 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

description of fractures

  • 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

special fractures: forearm/UE

  • 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

special fractures: wrist

  • 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

special fractures: hand

  • 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

special fractures: knee

  • 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

special fractures: ankle

  • 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

special fractures: foot

  • 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

special bony conditions

  • 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