Orthopedics_Procedural Sedation Flashcards
(76 cards)
Complications of Ketamine
Central apnea<div>Airway malposition</div><div>Laryngospasm</div><div>Hypersalivation</div>
“What determine good reduction in Colle’s fracture”
“Radial inclination = 22 degrees<div>Radial length = 11 mm</div><div>Volar tilt = 11 degrees</div><div><img></img><br></br></div>”
What determines unstable elbow dislocation
The terrible Triade<div>Dislocation</div><div>Radial head #</div><div>Coronoid #</div>
Drugs for procedural sedation
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<strong>C</strong><strong>ontraindications to ketamine</strong>
<ul><li>Age</li><li>Increased risk of respiratory complications</li><li>Animal studies suggest NMDA antagonists are associated with apoptosis and neuro-degeneration in developing brains</li><li>History of schizophrenia/psychotic disorder</li></ul>
What is the main x-ray finding of a scapholunate dissociation?
The Terry Thomas Sign and the Madonna Sign as all 2 of these famous entertainers have a gap between their two front teeth.<div>A gap between the scaphoid and lunate on the AP xray of the wrist of >3mm is a scapholunate dissociation until proven otherwise.<br></br></div>
What are the main x-ray finding for a perilunate dislocation and lunate dislocation on x-rays of the wrist?
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What are consequences of missing a <br></br>perilunate dislocation?
Chronic wrist pain<div>median n. palsy</div><div>pressure necrosis</div><div>Compartment syndrome</div><div>Long term wrist dysfunction</div>
“ORIF indications in Colle’s #”
<ol> <li>Significant comminution</li> <li>Intra-articular involvement with > 2 mm step-off despite reduction</li> <li>High grade open #</li> <li>Failure to achieve adequate reduction esp in youg with dominant hand</li> </ol>
How much is the degree that metacarpal bones can tolerate as of rotation?
5th through 2nd=40, 30, 20,10 degrees respectively
“Specific recommendations about Boxer’s #”
“<img></img>”
DDx of pain in snuff box post trauma
Scaphoid #<div>distal radius/styloid #</div><div>Lunate #</div><div>Scapholunate dissociation</div><div>1st CMC sprain</div>
“What is this #<div><img></img><br></br></div>”
“<img></img>”
<p>Adequate Colles Reduction</p>
“<img></img>”
<p>Perilunate dislocation</p>
“<img></img><div><img></img><br></br></div>”
Quick Sensory and motor exam of hand
<b>Motor</b>:<div>Radial (thumbs up)</div><div>Median (OK sign)</div><div>Ulnar (fingers abduction)</div><div><br></br></div><div><b>Sensory</b>:</div><div>Radial (dorsal 1st webspace)</div><div>Median (palmar 3rd digit)</div><div>Ulnar (5th digit)</div>
<p>Galeazzi Fracture/Dislocation</p>
“<img></img>”
What nerve inj occurs with Monteggia #
Post interosseous nerve (radial n) causing wrist drop
Complications of Monteggia #
Open #<div>Compt synd</div><div>PIN inj</div><div>Collateral lig inj</div>
GRUM
Galeazzi<div>Radial #/ Ulnar dislocation</div><div>Ulnar #/ Radial dislocation</div><div>Monteggia</div>
Nightstick # considerations
Domestic violence<div>If unstable ==> ORIF/ Indications:</div><div>>50% displacement</div><div>> 10 deg angulation</div><div>Proximal 1/3 involvement</div>
Supracondyler #
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Shoulder dislocation reduction techniques
Traction-countertraction<div>External rotation</div><div>FARES (FAst, REliable and Safe)</div><div>Spaso</div><div>Cunningham</div>
Complications of shoulder dislocation
Hill-Sacks#<div>Bankart #</div><div>Axillary n injury</div>
6 Unstable C-spine #’s
Normal C-spine Soft tissue swelling
3 Column System
What does plantar bruising make you concerned for?
Lisfranc injury, mechanism is injury to deep penetrating arterial branch of dorsalis pedis, which runs by Lisfranc ligament.
Pathognomonic injury is a fracture at the medial base of the 2nd MT with widening of the Lisfranc joint (isolated movement of 1st MT medially)
More obvious injuries will show malalignemnt of each metatarsal with its respective tarsal bone (homolateral, diveregent):
- 1st MT = medial cuneiform,
- 2nd MT – middle,
- 3rd MT = lateral,
- 4/5th MT - cuboid
- Avulsions of: lateral malleolus, 5th MT, navicular, or talus.
- Peroneal or Achille’s tendon rupture.
Type A can be treated with immbolization assuming no other malleolar injury.
Type B may injure the syndesmotic ligament.
Type C it is assumed that syndesmosis is injured and needs a screw fixation
"What determines if an ankle injury is unstable?
To simplify, involvement of multiple malleoli, whether ligamentous or bony
Maisonneuve Fracture
- Triad of fibular fracture, syndesmotic and medial malleolar injury
- Usually requires surgical fixation
- Splint and call Ortho
- Any suggestion of medial injury, even with normal x-rays should be treated the same
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Think of this like a Galeazzi of the leg.
Isolated syndesmotic injury can be suspected on exam or xray, distal compression of tib/fib is suggestive, on xray should have at least 1 mm of tib/fib overlap on mortise view. If this is lacking and especially if there is lateral talar shift, consider syndesmotic injury.
What about this x-ray?
Lipohemarthrosis best seen in a cross table lateral, see fat/blood level, indicates occult intra-articular fracture, with otherwise normal x-ray this is an indication for CT scan.
What physical exam finding is important in suspected patellar fractures?
Ability to extend the knee actively (ie. SLR).
Flex the hip, gently extend the knee while providing medial pressure to lateral patellar border.
Patella alta or high riding knee cap,
very common finding in recurrent patellar dislocation
Allis = supine, knee/hip flexion, upward traction with assistant holding pelvis down, int/ext rotation may help clear the rim.
Rochester (“Captain Morgan”) = Using uninjured side/knee as leverage point, Rocket Launcher
Can you list some classic injures?
- Metaphyseal chip #
- Clavicle #
- Spiral #
- Any long bone # in non-ambulatory child
- Posterior rib #
- Circular bruises (bite or cigarette burn)
- Immersion burn injuries
- Linear bruises (slap injuries)
- Complex skull #
- Multiple injuries at different stages
- Any injury not fitting mechanism
Salter Harris Classes
- S-straight
- A-above
- L- BeLow
- T-Through
- ER- Erasure of growth plate (crush)
Elbow Xrays, Ossification centres
What radiographic lines are important in pediatric elbow interpretation?
Radiocapitellar and anterior humeral lines
What injuries the radiocapitellar and ant humeral lines to the help to identify?
- Anterior humeral line should intersect middle third of capitellum = abnormal here
- Radiocapitellar line, should intersect the middle of the capitellum = normal here
- Also posterior fat pad and break seen in cortex posteriorly, this is a Type 2 Supracondylar
- Sail sign is an anterior fat pad that is pushed anterior so it looks triangular.
- Signifies joint effusion and increased risk of occult fracture.
Klein’s line = line from superior cortex of femoral neck should intersect at least 1/3 of femoral head
Widened physis is the early finding, this xray is obviously quite advanced.
Toddler’s fracture = distal spiral tibia fracture from low energy mechanism
What if it was not related to an accident?
Highly suspicious for non-accidental trauma (abuse)
Consider extra views to exclude abuse
Universal Answers for Injuries
- Analgesia
- NV assessment (pre and post reduction)
- Irrigate wounds
- Td status
- Antibiotics
- Reduce/Splint
- Refer to specialist
Universal answers for Trauma
- Get Surgeon/Trauma team to bedside
- C-spine precautions
- Fluid bolus
- Massive transfusion protocol
- CT liberally, but not if unstable
- Wedge Pregnant patients
- Get them off the backboard fast
- Don’t move on if ABCs are still an issue
APPROACH TO THE CHILD WITH A LIMP
"- Rule out septic arthritis
- Look for fractures, which can be very subtle, and ask about trauma
- Look for clues of systemic illnesses such as a rash, fever, bruising
- Consider age-specific diagnoses as appropriate
- Non-weight-bearing on affect side
- ESR > 40 mm/hr
- Fever
- WBC >12,000
<3mm loss of radial height
<5 degree change in radial inclination
<10 degree loss of volar tilt
DRUJ reduction
<1-2mm of articular displacement
-Hyperkalemia
-Myoglobinuria/ rhabdomyolysis
-Acute renal failure
-Shock
-Delayed fracture healing
- Radial: sensory at 1st webspace, motor with thumbs up, wrist and elbow extension
- Median: sensory at 2nd digit, motor with thumb/finger opposition (ok sign)
- Ulnar: sensory at 5th digit, motor with finger abduction, wrist flexion
- Lateral view:
- distal humerus fracture line
- less than 1/3 of the capitellum is anterior to the anterior humeral line (both indicate supracondylar humerus fracture)
- raised posterior and anterior fat pads (indicates joint effusion)
- AP view:
- fracture line
- no apparent intra-articular involvement, rotation, angulation or displacement
- Both views:
- surrounding soft tissue swelling (elbow injury - non-specific but are a result of the # in this case)
- There is significant soft tissue swelling, which indicates that the elbow has been dislocated.
- The medial epicondyle is seen entrapped within the joint.
- There is only minor joint effusion (medial epicondyle is an extra-articular structure; avulsion will not produce joint effusion). The small amount of joint effusion is probably the result of the prior dislocation.
- Shortened, externally rotated - Hip fracture
- Shortened, internal rotated - Posterior hip dislocation
- Midshaft femur angulation and swelling - Femoral shaft fracture
- Extended, externally rotated, abducted - Anterior hip dislocation
Hip extension, in line traction, assistant provided posterior traction to pelvis, internal/external rotation as required.
Lefkowitz or “Captain Morgan”
hip extension/traction using knee as a fulcrum, use assistant/strap to immobilize pelvis, internal/external rotation as required
Whistler maneuver
Arm placed under affected leg at knee joint, hold unaffected knee, uses as fulcrum similar to Lefkowitz.
Howard, Stimson, Lateral traction, Bigelow, Rocket launcher, Piggyback, and many more could be listed if they describe them accurately.
Advantage: Rapid onset and short duration, anti-emetic effects
Disadvantage: Hypotension, respiratory depression, no analgesia
-Ketamine
Advantage: Potent analgesic effect, minimal effect on BP, preserves airway reflexes
Disadvantage:Vomiting, increased airway secretions, laryngospasm, emergence reaction
-Midazolam
Advantage: Amnestic, reversible, can be given nasally
Disadvantage: Respiratory depression, long duration, hypotension"
Scaphoid
Capitate
Talus
