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Path 3 Flashcards

1
Q

Most Common Joints in ER?

A

1) Ankle
2) Wrist
3) Knee
4) Hip
5) Shoulder
6) Elbow

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2
Q

How many ankle injuries a year?

A

5 million in US

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3
Q

Most common type of ankle injury?

A

lateral sprain due to inversion, while walking or running

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4
Q

How to treat an ankle sprain?

A 
PRICE
Protection
Rest
Ice
Compression
Elevation
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5
Q

Ankle Fracture Etiology

A

5,600/year in US

  • equally common in men & women
    • young men
    • late middle-aged women
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6
Q

Where is ankle fractured?

A

vast majority-malleolar fractures

majority-unimalleolar

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7
Q

Complications of Ankle Fractures?

A
  • joint space disruption
  • dislocation
  • soft tissue/skin necrosis
  • nerve injury
  • arterial disruption
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8
Q

Loss of arterial blood supply is???

A

a surgical emergency

“dislocation pressuring skin needs reduction as soon as possible to avoid necrosis of overlying skin”

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9
Q

Wrist Injuries: How many?

Most common type?

A
  1. 25 million

- fracture of radius (or ulna or carpal bones) due to fall on outstretched hand

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10
Q

Do wrist injuries or ankle injuries cause fractures more?

A

Wrist

1.5 million/year

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11
Q

Most common type of wrist fracture?

A

Colles fracture, at the distal radial metaphysis, with proximal and dorsal displacement, creating “dinner fork” deformity

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12
Q

How many knee injuries a year?

A

1 million ER visits

100,000 ACL

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13
Q

Hemarthroses

A

blood in the joint

-ligamentous injuries of the knee

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14
Q

Epidemiology of Hip Fractures

A
  • Common-310,000 in 2003, decrease each year
  • Primarily in elderly (female 77, male 72)
  • 2X more in women
  • 1/3 more common in whites
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15
Q

Pathophysiology of Hip Fractures

A
  • Weakening of bone with aging 90% of hip fractures in the elderly associated with a simple fall from standing positions
  • Fall because femoral neck breaks
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16
Q

Symptoms of Hip Fractures

A

sudden onset of hip pain, before or after fall, and inability to bear weight

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17
Q

Signs of Hip Fractures

A

leg shortened and externally rotated if fracture displaced

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18
Q

Hip Fracture Risk

A

deep venous thrombosis in the leg

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19
Q

Low Back Pain

A

15 million visits
85% are idiopathic
non-idiopathic: intervertebral disc herniated, spinal mets, spinal infection, epidural abscess, hemorrhage, spinal fracture & ankylosing spondylitis

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20
Q

Lumbar Intervertebral DIsc Herniation

A
  • middle-aged adult 30-50y/o
  • typically with recurring episodes of low back pain
  • 95% have sciatica
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21
Q

Sciatica

A

-Syndrome of pain +/- sensorimotor symptoms in the distribution of a sciatic nerve
-Pain in the lower back, buttock & leg, typically sharp and commonly in a single dermatome
+/- leg weakness
+/- numbness or tingling (typically unilateral)

90% due to herniation of lower lumbarsacral intervertebral disc

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22
Q

Straight Leg Raise Test

A

-for lower lumbar intervertebral disc herniation
-raise b/w 30-70 deg above level
Positive=pain in the dist. of sciatic nerve
Sen: about 90% Spec: about 25%
-if opposite leg causes pain
sen:25% spec:90%

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23
Q

Cauda Equina Syndrome

A

-compression causing combo of:
low back pain, sciatica, leg weakness, bladder dysfunctioin, saddle hypo-or anesthesia, fecal incontinence, sexual dysfunction

Bladder dysfunction

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24
Q

Cauda Equina Syndrome: Signs

A

-bladder distention
-decreased anal tone
-absent ankle, knee, or bulbocavernosus reflexes
-saddle anesthesia
-bilateral sciatica
>500mL urinary retention

NEUROSURGICAL EMERGENCY

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25
Spinal Epidural Abscess
Rare - risk: spinal surgery, recent trauma, immunosuppression, distal infection, IV drug use, diabetes mellitus & alcoholism - 20% no predisposing factor Back Pain, Fever
26
Drug-Seeking in ER
10% of patients | -opioid
27
Necrotizing Fasciitis
-rare acute progressive destructive infection of muscle fascia and overlying subcutaneous fat "flesh-eating bacteria" 1) Infection typically spreads along muscle fascia due to poor blood supply (muscle spared) 2) Overlying tissue can seem unaffected 3) Area of erythema (w/o sharp margins), swelling, warmth, shiny, exquisitely tender 4) Pain out of proportion 5) Type 1 polymicrobial (aerobes + anaerobes) Type 2 group A strep (or MRSA)
28
Risk Factors for Necrotizing Fasciitis
``` diabetes vascular disease immunosuppression trauma surger ```
29
Microscopic Pathology
coagulative necrosis w/acute inflammation (neutrophils & fibrin exudation) starting at the edge, +/- aggregates of bacteria (but not where neutrophils are) +/- nuclear dust (from neutrophil breakdown) +/- hemorrhage
30
Necrotizing Fasciitis Over 3-7 days
Skin: red to purple to purple with patches of blue-grey - 3-5 days: skin breaks down with bullae - frank cutaneous gangrene, involved area is anesthetic due to thrombosis of small blood vessels and destruction of superficial nerves - anesthesia precedes skin necrosis
31
Top 2 sites for Necrotizing Fasciitis?
1st: legs 2nd: perineum
32
Necrotizing Fasciitis Type I
subcutaneous gas often present
33
Advanced Necrotizing Fasciitis
``` fever of 38.9 to 40.5 tachycardia hypotension malaise myalgias anorexia diarrhea ```
34
Diagnosing Necrotizing Fasciitis
history and physical
35
Treatment of Necrotizing Fasciitis
surgical debribement of necrotic tissue broad spectrum abx hemodynamic support
36
Prognosis of Necrotizing Fasciitis
bad (40% mortality)
37
Compartment Syndrome
- muscle groups divided into compartments formed by strong unyeilding fascial membranes - increased pressure within a compartment compromises the circulation within that space - acute, often following trauma - chronic, athletes, insidious pain
38
Pathophysiology of Compartment Syndrome
- arteriovenous/arteriointerstital pressure gradient theory: a prerequisite for compartment syndrome is a fascial enclosure that prevents adequate expansion of tissue volume to compensate for an increase in fluid - inadequate venous drainage results in tissue edema and a rise in interstitial pressure - as compartment pressure rises, venous outflow is reduced and venous pressure rises, decreasing the arteriovenous pressure gradient - arterioles collapse when tissue pressure exceeds end-arteriolar pressure, then arteriolar pressure is insufficient to overcome compartment pressure and blood is shunted away from compartmental tissues
39
When Does Acute Compartment Syndrome Occur?
- soon after sig. trauma (long bone fractures-leg/forearm) - Nontraumatic: bleeding, thrombosis, vascular disease, nephrotic syndrome, extravasation of IV fluids, injectionof recreational drugs, prolonged limb compression
40
Acute Compartment Syndrome Symptoms
1) pain out of proportion to injury 2) persistent deep ache or burning 3) paresthesias (onset within 1/2-2 hours)
41
Acute Compartment Syndrome Signs
1) Pain w/passive stretch of muscles in affected compartment (early) 2) Tense comp. with a firm "wood-like" feeling 3) Diminished sensation 4) Muscle weakness (2-4hrs)
42
Normal Compartment Pressure
0 to 8mmHg
43
Pain with Compartment Pressure of?
20 to 30mmHg
44
Clostridial Myonecrosis
"gas gangrene" -life-threatening necrotizing muscle infection from contiguous are of trauma or hematogenous muscle seeding from GI tract
45
2 Forms of Clostridial Myonecrosis
1) Traumatic - C. perfringens | 2) Spontaneous - C. septicum
46
C. perfrigens virulence
1) alpha toxin - hemolytic | 2) theta toxin - cholesterol dependent
47
Pathophysiology of Clostridial Myonecrosis
Trauma introduces bacteria/spores into deep tissue | -anaerobic if trauma impairs blood supply (low ox-red potential and acidic pH)
48
How long from trauma to necrosis
24-36 hours
49
Are neutrophils present in muscle necrosis?
no
50
Clostridial Myonecrosis Micrograph
- large box-car shaped gram + rods | - gram variable
51
Alpha Toxin
potent rapid irreversible decline in muscle blood flow and ischemic necrosis due to formation of occlusive introvascular masses of activated platelets, leukocytes, fibrin -lack of perfusion increase anaerobic environment and contribute to growth (activation of platelet fibrinogen receptor glycoprotein IIb/IIIa)
52
Skin over Clostridial Myonecrosis
-pale then bronze, purple/red -tense and tender Bullae form gas bubbles
53
Clostridial Myonecrosis
tachycardia fever shock multiorgan failure
54
Histopathology of Clostridial Myonecrosis
absence of inflammatory cells
55
Treatment of Clostridial Myonecrosis
aggressive and thouough surgical debridement with clindamycin and penicillin
56
Prognosis of Clostridial Myonecrosis
20% mortality - shock at presentation | spon: 67-100% mortality (malignancy/immunocompromised)
57
Rhabdomyolysis
condition of muscle necrosis and release of intracellular muscle constituents into circulation
58
Symptoms of Rhabdomyolysis
1) muscle pain, weakness, dark urine 2) muscle pain - proximal muscles (thighs shoulders), lower back, calves 3) stiffness/cramping 4) 1/2 have no muscular symptoms 5) malaise, fever, tachycardia, nausea, vomiting, abdominal pain * **vairy, some asymptomatic
59
Signs of Rhabdomyolysis
- reddish brown urine - muscle swelling with rehydration - muscle tenderness - muscle weakness - no signs
60
3 causes of rhabdomyolysis
1) Trauma - crush 2) Exertion 3) Miscellaneous - toxins, meds, infection
61
Hallmark of rhabdomyolysis
elevation in serum muscle enzymes | creatine kinase
62
myoglobinuria
present in 50-75% rhabdomyolysis + blood dipstick, no cells in urine myoglobin clogs renal tubules (acute renal failure)

Musculoskeletal (19 decks)

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