TRAUMA EMERGENCIES Flashcards
(135 cards)
1
Q
How are sprains classified?
A
- grade 1: mild stretch, micro tears, mild swelling/tenderness, no instability, ambulatory. Early mobilization, few days elastic wrap.
- grade 2: incomplete tear, pain, swelling, tender, ecchymosis, joint instability. painful ambulation. Ace w/ aircast for a few weeks + ambulation.
- grade 3: complete tear, swelling, tender, ecchymosis, instability, loss of most of motor function. Unable to bear weight. 10 day cast, then splint…
2
Q
A pediatric patient gets a soft tissue injury from volleyball practice. Her mom wants you to explain the healing process, how long each step takes and what to do for each….
A
- Inflammatory phase 72 hrs, protect, relative rest, decrease swelling (ice immediately 20-30 min or 10 on 10 off 3-4 times daily., most effective w/ compression.
- Reparative(fibroblast) 3wks, protect, FAROM, strength, endurance, power
- Maturation/remodel 2 yrs, card fitness, ROM, flexibility, proprioception, skills.
3
Q
Stephanie hurt her ankle in gymnastics. She walks in to the clinic with her mom and you conduct a physical exam. Her ankle is swollen, but you don’t feel any tenderness around the back of the medial/lateral malleoli. Her mom thinks she should get an X-ray. What guidelines can you use to guide your decision?
A
Probably doesn’t need an X-ray.
Ottawa ankle rules:
- Ankle:-pain in malleolar zone + bone tenderness at posterior tip of L/M malleolus. OR can’t bear weight after injury and 4 steps in ED.
- Foot: Pain in midfoot zone + bone tenderness at base of 5th metatarsal or navicular bone. OR unable to bear weight post injury and 4 steps in ED.
4
Q
William plays JV football. He injures his knee in a dog pile. He comes to your clinic complaining of pain. His father brings him in on a wheel chair and you note tenderness over the patella on examination. His father is in a rush, and would like to get going. Should you get an x-ray?
A
Ottawa knee rules
> 55, unable to bear weight post injury and 4 steps in ED, patellar tenderness or tibial tuberosity, can’t flex >90.
5
Q
Define: avulsion fracture:
A
injury to the bone in a location where a tendon or ligament attaches to the bone. When an avulsion fracture occurs, the tendon or ligament pulls off a piece of the bone.
6
Q
Define :closed fracture
A
-broken bone does not break the skin.
7
Q
Define: comminuted fracture
A
-fracture in which the bone is splintered, crushed, or broken into pieces.
8
Q
Define: displaced fracture
A
- the abnormal position of the distal fracture fragment in relation to the proximal bone. Types of fracture displacement include - angulation, rotation, change of bone length, and loss of alignment.
9
Q
Define: epiphyseal fracture
A
-A Salter–Harris fracture is a fracture that involves the epiphyseal plate or growth plate of a bone. It is a common injury found in children,
10
Q
Define: greenstick fracture
A
-fracture of the bone, occurring typically in children, in which one side of the bone is broken and the other only bent.
11
Q
Define: impacted fracture
A
-fracture caused when bone fragments are driven into each other.
12
Q
Define: intra-articular fracture
A
fractures that involve a joint space
13
Q
Define: occult fracture
A
fracture that does not appear in x-rays, although the bone shows new bone formation within three or four weeks of fracture
14
Q
Define: open fracture
A
the ends of the broken bone tear the skin.
15
Q
Define: pathologic fracture
A
-fracture caused by disease that led to weakness of the bone structure. This process is most commonly due to osteoporosis, but may also be due to other pathologies such as: cancer, infection, inherited bone disorders, or a bone cyst.
16
Q
Define: stress fracture
A
- fracture of a bone caused by repeated (rather than sudden) mechanical stress.
17
Q
Define: torus fracture
A
-(also known as buckle fractures) are incomplete fractures of the shaft of a long bone that is characterised by bulging of the cortex.
18
Q
Define: bone alignment
A
-in line w/ normal anatomy as opposed to angulation.
19
Q
Define: bone apposition
A
- The relationship of fracture fragments to one another.
20
Q
Define: delayed union
A
- fracture takes longer than normal to heal, nonunion is when it doesn’t heal.
21
Q
Imaging of choice for tendon, ligament and muscle
A
Tendon, ligament and muscles: MRI and US.
22
Q
Imaging of choice for bone
A
Bones: X-ray, CT, MRI.
23
Q
Jon is an 8 year old boy who comes in with an elbow fracture. What are key elements of your PE?
A
Name of the injured bone
Location of the injury (eg, dorsal or volar; metaphysis, diaphysis, or epiphysis)
Orientation of the fracture (eg, transverse, oblique, spiral)
Condition of the overlying tissues (eg, open or closed fracture).
Other important descriptors include fracture angulation, displacement, and comminution.
24
Q
What fractures require special care/ referral to orthopedist?
A
- intra-articular fractures
- blood vessel or nerve involvement.
- open fractures
- severe fractures, nonunion, displacement…if a cast won’t realign it….
- Fractures that can cause stunted growth : Salter Harris
- Fractures that can result in avascular necrosis:
25
Which fractures are associated with avascular necrosis?
- 5th metatarsal
- scaphoid
- femoral head
- Talus (neck of)
26
Name the different kinds of Salter-Harris Fractures and the prognosis of each:
S: straight across- prognosis good: closed manipulation and plaster cast
A: above- prognosis good: closed manipulation and plaster cast
L: lower- prognosis good if blood supply intact. CT, open reduction, internal fixation.
T: two/through- prognosis poor, needs reduction and fixation via surgery. CT, open reduction and internal fixation.
R: ram closed. poor prognosis: usually found in retrospect, but MRI can catch it.
*Long term follow up with all of these.
27
When do growth plates usually close in females? Males?
*Growth plates close for females: 13-15, males: 15-17.
28
The nurse hands you a chart and says the patient is a 5-8 year old girl who was roller skating and had a FOOSH injury. She has swelling of her elbow and pain w/ supination and pronation. What is a very common injury you suspect? What sign might you see on x-ray? How will you treat this?
Elbow: supracondylar fracture
Sail sign/fat pad sign on x-ray of ant/post fat pads.
TX: if nondisplaced, long arm cast. If displaced, closed reduction, external fixation and cast.
29
A 3 year old is brought to your clinic. He is holding his arm close to his body and extended. What do you suspect?
-Radial head subluxation: occurs when a portion of the annular ligament slips into the radiohumeral joint and becomes trapped.
Kiddo holds elbow close to body w/ elbow extended.
Reduce w/ hyperpronation or supination w/ flexion.
30
Evan is an overweight adolescent who appears to been b/t 10-18 years of age. His mom brings him to clinic because he has started limping and complaining of pain in his hip, groin and knee. You watch him walk and he walks with one leg turned outward. What do you suspect? What might you find on x-ray? How will you treat this?
-Hip: Slipped Capital Femoral Epiphysis:
overweight males, 10-18 yoa. Pain in hip, groin, thigh or knee worsened by activity. Limps w/ affected leg turned outward.
X-ray shows ice cream slipping off cone/ posterior displacement of femoral head.
TX: surgery and PT. If severe: closed fixation.
31
Barbara is a college volleyball player. She shows up to the ED 20 minutes after her game started with a swollen right knee. She says she landed from a block and heard/felt a "pop". She couldn't keep playing b/c of the pain and her knee kept giving out. What is this? How is it treated?
-Knee: ACL tear. Impact/abrupt stops and turns.
Knee swelling w/in 24 hours, “pop”, knee is unstable/gives out.
MRI. Surgical repair and PT.
32
Wally is a toddler who appears less than 5 yoa. His mom says he was running in a field that was pretty uneven. His foot planted and he kept moving forward and he tumbled. When he got up he was crying and has been limping since. You note swelling, warmth and increased pain with dorsiflexion. What do you suspect? How might you treat it?
-Leg: Toddler’s fracture.
33
Jimmy comes in to your clinic complaining of low back pain. It's lasted less than 4 weeks and so you decide a history and physical exam are all he needs. What would be some risk factors that would cause you to consider imaging like x-ray, CT or MRI?
- new onset and Hx of CA
- CA sx: weight loss, night sweats, pain worse at night/ laying down
- pain that lasts more than 4 weeks
- age> 50 yoa
- Hx of osteoporosis
- Hx of corticosteroid use
- neuro deficits
*concerned about CA and things like compression fractures.
34
Sam is a 38 year old UPS worker. He is complaining of low back pain that radiates below his knees and numbness/weakness in his legs. What do you suspect? What nerves should you test? What are tests you can use to support your diagnosis?
- Sciatica: pain that radiates below knees, numbness and weakness in legs.
- Test L5 (dorsiflextion of ankle and great toe + sensation of web of great toe) and S1 (achilles reflex, sensation over post and lat. foot, plantarflexion) nerve roots.
- Try also cross, seated and straight leg tests.
35
Benjamin is a 62 year old that comes to the ED complaining of bladder dysfunction, numbness in his saddle area and pain and weakness in his lower extremities. What do you suspect?
Cauda equina
36
Barbara is a 55 year old woman who walks into your office using a walker. You note that she leans forward while pushing her walker. She complains of low back pain that is worse with standing and walking and better when she leans forward or at rest. She also has pain and numbness that radiates to her feet. What do you suspect?
Spinal stenosis
37
Oliver is a 74 year old man who has a history of smoking and is complaining of pain in his lumbar region. What does his age and smoking history increase his risk for that could cause this type of pain?
-AAA: lumbar pain. USPSTF says screen men ages 65 to 75 who have ever smoked
38
How often are bulging discs seen in asymptomatic patients?
over 50% asymptomatic patients have bulging discs, so this is not a reliable way to diagnose back pain.
39
What is the prognosis for most acute back pain? Back pain d/t sciatica?
prognosis excellent, 90% recover in 2 weeks, <75% if sciatica
Recurrence is common
40
How should you treat acute low back pain?
No bed rest: return to activity asap. NSAID/Tylenol/Muscle relaxant. Manipulation may help, injections are not recommended (unless failed therapy and radicular sx). PT, braces, etc. not recommended.
41
What sort of back pain diagnoses are considered an emergency?
cauda equina, spinal cord compression, progressive neuro deficits.
42
Evan is a 34 year old who just got into a car wreck. He appears well, but is complaining of a progressive, deep aching pain in his right thigh. You note extreme pain with passive ROM of his right leg. What might this be?
- Compartment syndrome, oftend d/t long bone fracture or trauma.
- 5 p’s of arterial insufficiency inaccurate. Need to measure compartment pressure and get fasciotomy if compartment syndrome.
43
What is the general protocol for acid/akali burns of the eye?
- irrigation then get to ophthalmologist for ABX, Cycloplegics and Steroids. Alkali penetrate more and are worse than acid.
44
Amy was using a sander and feels like something shot into her eye. You do an exam…..if it's just an abrasion, how long will it take to heal? If there is a foreign body what sorts of tools can you use to remove it? Is there anything else you should do? What if she wears contacts?
- Abrasions heal in 24-72 hours regardless of therapy.
- FB can be removed w/ irrigation, swab or needle.
- after FB removed give abx ointment (not drops..they sting and don’t lubricate as well): erythromycin ointment
- if they use contacts then give abx that cover pseudomonas like tobramycin or cipro.
* no patching unless the FB is large and even so needs to be
45
Tim comes to clinic complaining of eye pain and decreased visual acuity. On PE you notice a tear drop shaped pupil and afferent pupillary defect. He may have been playing with his new BB gun he got for Christmas. What do you suspect and how should you manage this?
penetrating/perforating trauma AKA open globe trauma.
-SX: decreased VA, Afferent pupillary defect, tear drop pupil, extrusion of vitreous, tenting of cornea.
Don’t apply pressure or put drugs onto eye. Cover eye, bed rest, antiemetic, sedation, IV ABX of Vanc and Ceftriaxone, send to opth for CT and TX.
46
Suzy comes in to your clinic w/ her mom because she cut her eyelid after running into a street sign. Under what circumstances should you refer her to opthalmology?
-refer if: open globe injury, full thickness lack of eyelid, orbital fat prolapse, involvement of lid margin, drainage system, poor alignment.
47
Dan is a pitcher for his baseball team. He just got hit in the face by a line drive. He comes to your clinic with a grossly red anterior chamber. What is this and what should you do?
hyphema
-blunt trauma or blood dyscrasia = pain and layering of red blood cells in the anterior chamber. Be suspicious of other eye trauma. Refer to opth. for CT. Eye shield and analgesia for the ride.
48
Snorkel Sean free dove with swim goggles on this afternoon and was startled when he looked in the rear-view mirror of his car he was surprised to see well-demarcated areas of extravasated blood just beneath the sclera in his eyes. What is this and how long will it take to heal?
subconjunctival hemorrhage
pupil reacts, no foreign body sensation or photophobia, no corneal opacity, no hypopyon.
-can happen w/ valsalva, coughing, sneezing, vomiting.
-Dx’d in absence of VA decrease, discharge, photophobia, FB sensation.
-Will resorb in 1-2 weeks.
49
Name 3 common symptoms of TBI
LOC
confusion
amnesia
50
A 25 year old male cyclist who just flipped over his handlebars without a helmet is brought to the ED. The nurse asks you if she should arrange for imaging….You recall the CANDADIAN CT HEAD RULES:
```
If GCS 30 min,
MVA vs Ped,
ejection, fall > 3ft,
anticoag use,
sz,
focal neuro def.
```
=> CT=> neuro consult.
51
Ben just ran into a door and cut his scalp. It's bleeding profusely. How will you control the bleeding? How will you close the wound. What kind of abx?
scalp lacerations:
- lots of blood= direct pressure 15 mn, can use lido/epi, rapid closure.
- Don’t cut hair (introduces FB),
- if not closing just to stop bleed then use staples, can use hair if > 1cm and straight lac<10cm. Most don’t need ABX, leave open to air.
52
Nathan was playing baseball and was hit in the forehead by a ball. He has a giant bump on his forehead. What is this? Are you concerned? How long will it take to go away?
- scalp hematoma
- can indicate skull fracture or intracranial trauma so be wary
- most resolve in 2-3 days.
53
True/False: scalp wounds should be probed to detect the degree of injury.
False
54
What are 5 signs of skull fracture?
- crepitus
- battle sign
- raccoon eyes
- CSF leak from ears or nose
- hemotympanum
55
Tom is a patient just brought into the ED after being ejected from his jeep. He has bilateral black eyes and clear fluid leaking from his ears. What do yo suspect and how will you manage this?
Skull fracture
Non-con CT and admit. If linear and no underlying damage on CT = 4-6 hrs observation and discharge. Depressed open brain to infection = cefazolin/piperacillin and admit.
56
Jamie was in a bar fight. He was hit in the side of his head with the leg of a stool. His friends say he was knocked out, stood back up complaining of a headache, threw up and started behaving strangely. What do you suspect? What will your diagnostics show? What treatment does this need?
. epidural hematoma
- bleeding b/t dura and skull d/t trauma, usually adolescents/young adults. Arterial/venous injury to middle meningeal artery d/t trauma of temporoparietal area or sphenoid= blood in cerebral convexity in middle cranial fossa.
SX: alt. MS, HA, vomitting, drowsy, hemiparesis. Classic = head trauma, LOC, lucid period and then deterioration.
DX:CT shows lens/football shaped pattern that does not cross sutures.
TX: surgical hematoma evacuation.
57
Morgan is a 52 year old who was in a head-on collision. He was found unconscious and has been brought to the ED. You get a CT and see a crescent-shaped lucency. What do you suspect? How is this treated?
subdural hematoma
-bleeding in space b/t dura and subarachnoid membrane. Usually d/t tearing of the bridging veins that drain from the surface of the brain to the dural sinuses.
Head trauma from MVA, trauma, assault often middle-aged men, older adults on antithrombotics.
SX usually coma from onset of injury.
DX: Ct shows crescent shape, may cross sutures.
TX: surgical hematoma evacuation.
58
Max drove over an IED while on a routine patrol. It exploded and flipped his MRAP on its side. He lost consciousness, but came to and was evacuated by another MRAP in his convoy. He appears fine, just shaken up. 3 days later he gets severe headaches, feels cloudy in his head and very tired. His buddies say he hasn't been himself. What do you suspect? How can this be diagnosed? Treatment?
cerebral contusion
direct impact, rapid acceleration/deceleration, penetrating injury, and blast waves. MVA 65 yoa.
Cerebral contusion is the most frequently encountered lesion and often seen in the basal frontal and temporal areas (attention, emotional and memory problems). Can lead to SDH or EDH. Contusion is primary injury, can be followed by sequella.
SX : headache; confusion; sleepiness; dizziness; loss of consciousness; nausea and vomiting; alt. MS. Can cause edema and inc. ICP. Swelling starts in 2-3 days and is worse +/-6 days post injury.
DX: Contusions are visible on CT.
TX is to control hemorrhage, may need surgery.
59
Amy ran into her teammate while playing basketball. They hit heads hard. Amy was knocked out and had some amnesia and confusion afterwards. Her mom has brought her to your clinic. What next? Can she go to practice tomorrow? What if she gets hit in the head again?
concussion
-mild TBI, common, usually good prognosis, but can have acute and chronic complications. Often d/t blunt force or accel/decel head injury.
SX: LOC, confusion, amnesia.
DX: neuro and mental status eval.
- Gradual return to activity until asymptomatic.
- Repeated TBI can lead to cerebral edema that's life-threatening or chronic neuropsychological impairment.
60
What are common symptoms of post concussion syndrome?
Post concussion syndrome = headaches, dizziness, fatigue, irritability, anxiety, insomnia, loss of concentration and memory, and noise sensitivity.
61
What are signs/symptoms that make you worry about a supposed mild concussion?
Prolonged unconsciousness,
persistent mental status alterations,
abnormalities on neurologic examination
->require urgent neuroimaging and neurosurgical consultation.
62
Suzan has been snorting cocaine. She's now complaining of the worst headache of her life. What could this be? How will you work it up?
traumatic subarachnoid hemorrhage
-bleeding disorder/cocaine/malformation/etc.
SX: severe sudden onset HA.
DX: CT. If nothing on CT do LP. Often shows blood in/around ventricles and sulci.
TX: neurosurg.
63
A patient has just been brought in with a knife through their neck. You are consulting with a surgeon on the phone. They tell you not to remove the knife until you are in the OR. The surgeon asks what zone the blade is in....what are the zones and the vital structures in each?
3 above jaw to base of skull: carotid and vertebral arteries, pharynx and spinal cord
2 b/t jaw and cricoid: vertebral arteries, jugular veins, esophagus, tracheal, larynx and spinal cord.
1 clavicles to the cricoid cartilage: vertebral and proximal carotid arteries, major thoracic vessels, superior mediastinum, lungs, esophagus, trachea, thoracic duct and spinal cord, CN 7-12.
Zone 1 worst. Airway, Air embolism, bleeding issues.
64
Amanda is a 12 year old who was riding a snowmobile when she got clotheslined by a wire fence. What will you suspect if you hear stridor? Bruising and progressive airway obstruction? How will you manage this?
- laryngeal fracture
- ruptured carotid
- C-spine fracture possible so stabilize, look out for impaired cerebral blood flow: ABCs, CT, surgery.
65
Theo just took a bat to the face in a fight. He has a Lefort 1 fracture: what are your findings?
-Lefort 1: horizontal through base of nasal septum: swelling upper lip, ecchymosis of cheeks, instability when tug upper teeth.
66
Juan just took a bat to the face in a fight. He has a Lefort 2 fracture: what are your findings?
-Lefort 2: pyramid up through nasal bridge and own around sides of mouth: edema of central face, bilat black eyes, conjunctival hemorrhage, epistaxis, diplopia, cracked pot sound, enopthalmos, anesthesia of face, instability.
67
Austin just took a bat to the face in a fight. He has a Lefort 3 fracture: what are your findings?
-Lefort 3: through nasal bridge, across orbits and through zygoma: see Lefort II.
68
A patient comes in to the ED with broken face bones. You are concerned about nerve involvement so you check CN 7 and CN 5. What branch of CN 5 is V1? V2? V3? What are some exams you can do to check for orbital fracture? Maxillary fracture?
- V1 (infraorbital) V2 (maxillary), V3 (mandibular) of CN 5, CN 7 warrant eval.
- Unequal pupillary light reflex.,
- dysphonia, edema of oropharynx, step-off/laceration in palate, malocclusion.
- Get CT. Send to maxillofacial surgery.
69
Tong was in a MVA and smashed his face on the dash. You note proptosis, limited EOMs, and he has been complaining of dizziness, nausea and has a heart rate of 45. What do you suspect? How will you treat this?
orbital fracture
- young adult male vs MVA, assault, sports.
- Assess VA, EOMS, and eye.
- SX: orbital hematoma/proptosis, globe rupture (contents or tear shaped pupil), enopthalmos, limited EOMS, decreased VA, asymmetric pupillary reflex.
* vasovagal reflex from occulocardiac reflex: N/V, dizziness, bradycardia.
- ABX: augmentin, corticosteroids to reduce swelling, CT and refer to opth .
70
John just got punched in the nose and it's now crooked. He shows up to the ED 2 days later. What should you look for that could be an emergency? Is it too late to reduce his nose? Does he need a CT? Does he need an x-ray? How will you treat this?
NASAL FRACTURE
-be wary of septal hematoma (dark purple or bluish mass against the septum) - needs urgent otolaryngologist referral for drainage, abx, repair.
-deviation of nasal septum need to be reduced w/ in 7 days.
- findings that suggest cerebrospinal fluid leaks, LeFort fractures, or naso-orbito-ethmoid fractures warrant CT
- pain/swelling only over bridge, nares patent bilat, nose is straight, no septal hematoma: no x-ray
TX: ice, head elevation, immediate reduction if w/in 6 hours of injury, otherwise wait 3 days for swelling to go down to reduce. Older than 10 days then refer.
71
Zan is a mail man who just knocked his front tooth out after he fell while running from a german shepherd. You find him while riding your bike to work and he asks for help. What should you do with the tooth? What should you tell him for management?
- If normal MS and self protected airway then carry teeth in patient’s mouth, otherwise put in cup of NS, milk, saliva. Put teeth back in place asap.
- hold crown, gently rinse in tap water, put back in socket, keep in place w/ finger/bite on gauze.
- eval: when? MOI? tooth pain/sensitivity? malocclusion? Primary/secondary teeth?
- send to dentist: out of place, fracture of tooth or jaw. *don’t replace primary teeth.
72
Cindy comes into your clinic with a facial laceration she got from running into a glass door. She has significant bleeding and is complaining of numbness over her right cheek. The lac extends from her eyebrow and down through the ala of her nose. How should you manage this? Will it need ABX? Cartilage is exposed over her nose - should you suture this? When will you remove sutures?
When to refer:
- deep wounds with damage to underlying nerves, arteries, or other important structures
- complex wounds that require extensive revision or grafting to achieve reasonable cosmetic results;
- wounds that require precise cosmetic alignment (eg, lacerations through the columella, nasal ala, lip...)
If a non referral then:
-primary closure preferred. leave eyebrows intact, clip don’t shave facial hair. most don’t need irrigation if small and most don’t need abx. Put bacitracin on, cover for a day, then leave uncovered. 5.0-6-0 non absorbable, avoid suturing into cartilage. Remove sutures in 3-5 days.
73
What are three types of vertebral fractures and their treatment?
- flexion: compression of ant. or both ant/post vertebra. TX: brace 6-12 wks or surgery (laminectomy) to decompress and stabilize.
- extension: vertebrae are pulled apart: MVA w/ seat belt. TX: brace or surgery.
- rotation: transverse process fracture (usually stable) or fracture-dislocation (unstable = cord compression). TX: for transv. process fracture: +/- brace and rest. dislocation: surgery for reduction and fixation.
74
Betty is an 85 year old with osteoporosis and back pain. You do an x-ray that shows compression fracture. What sx would indicate cord involvement?
If cord involved: numbness, tingling, bowel/bladder dysfunction.
75
Eliot is a 55 year old UPS worker. He has been complaining of pain over his lateral deltoid, pain with overhead activities and weakness in his arm. What do you suspect? What are three tests that will help with this diagnosis? How will you manage this?
acute rotator cuff injury
- 3 tests:
- painful arc (Pain with active abduction beyond 90 degrees) suggests rotator cuff tendinopathy.
- Drop arm test (failure to smoothly control shoulder adduction)
- Weakness in external rotation (primarily infraspinatus).
other helpful tests:
- empty beer test: supraspinatus.
- Hawkin’s test: shoulder impingement.
* pain suggests tendinopathy, weakness suggests tear.
- TX : activity modification, analgesics, and physical therapy. 6 wks pt, steroid inj….surg consult.
76
What shoulder exam tests for impingement? Supraspinatus involvement? Infraspinatus involvement? Cuff tendinopathy?
- Hawkin’s
- empty beer can
- external rotation
- painful arc
77
How are spinal cord injuries classified? What percentage involve the c-spine and what would this result in? How will you manage these?
- young males vs. mva, fall, violence.
- Classified based on cord level and deficit.
- Half involve C-spine = quadriplegia.
-ABC’s, immobilize until imaging (x-ray/ct) excludes unstable spine. If injury, then send to neurosurg. Steroids of unknown benefit and risky. only use w/ non-penetrating injury.
78
A patient comes in from a MVA and complains of pain in the back of their neck and HA in their occipital region. What might this be? How might the symptoms progress? Should you get imaging? How long will this take to resolve?
Whiplash
SX: -pain in back of neck worse with movement, peaks 24-48 hours post injury, HA in occiput, shoulder muscle spasm, irritability, fatigue, diff. concentration, numb/tingle in arms.
DX: Nexus criteria for imaging: neuro def, midline tender, altered LOC, intoxication, distracting injury.
TX: Immobilize, ABC’s rule out unstable spine. C3/4/5 injury can cause resp. paralysis.
-heals w/ time, may splint w/ soft collar, analgesia, relaxants, ice. 4-6 wks
79
What are the Nexus criteria?
```
distracting injury
altered LOC,
midline tender,
focal neuro def,
intoxication
```
80
Jamie fell while roller blading. She comes to clinic with a swollen and bruised right elbow. She says that her fingers feel numb and refuses to extend her elbow. What do you suspect? What bone is involved? What might you see on x-ray? When should you refer? How is this treated?
- elbow fracture
- tip of elbow(ulna/olecranon) fracture form fall/blow
- fracture, fat pad sign, also note that in kids elbow has 6 ossification centers.
- if open or displaced then need surgical reduction and fixation.
- Ice, analgesia, cast/splint and sling
81
Mike was rock climbing and fell with his left arm outstretched. His elbow appears deformed when he shows up in clinic. What should you assess in his arm first? How will you decide whether to refer? How will you treat this if you don’t refer?
Elbow dislocation: (joint = ulnohumoral, radiohumoral, radioulnar= hinge and ball/socket).
- assess neuro/vascular compromise first.
- If no broke bones then reduce and sling, if broke bones then refer.
- x-ray. If simple (no broken bones) then reduce and sling.
82
Weston is a rancher in eastern Oregon. He was working on some baling equipment and his left arm was amputated from the mid forearm down. His brother put a tourniquet on to stop the bleeding. He’s en route to your clinic and his brother has called and wants to know what to do with the rest of Weston’s arm. They are 4 hours away by car. What can you tell him? What is the prognosis?
Clean and place part in moist wrap and plastic bag, then on ice = good for 18 hours. warm ischemia of amp. limb = 6 hrs.
- Expect 50% motor/sensory in salvage.
- Need to manage bleeding, shock, infection. Surgery for salvage, sometimes prosthesis better.
83
What types of radial and ulnar fractures should you refer?
displaced, angulated salter 3-5 = emergent ortho consult.
84
What is the basic treatment for radial and ulnar fractures?
immobilize w/ short arm cast/splint and sling. Best practice is to have follow up w/ orthopedist.
85
What is the most fractured bone in the arm?
Radius.
86
What is the basic treatment of all fractures?
put back in place and stabilize for healing.
87
David fell on an outstretched hand while skateboarding and has pain in his right wrist. X-ray shows fracture and posterior displacement of the distal radius. What is the name of this fracture? What should you do before putting a cast on?
- Colles fracture
- reduce the fracture, then splint. Allow 2-3 days for swelling to go down, then cast. May need to recast as swelling decreases. Follow up x-rays advised. 6 weeks.
88
Name the 8 carpal bones
Bottom row from radial to ulnar: Scaphoid, Lunate, Triquetrum, Pisiform.
Top: Trapezium, Trapezoid, Capitate, Hamate.
89
General approach to carpal bone fractures....
- ice, analgesia, immobilization (colles splint).
- If no sign on x-ray and suspect, then wait 7 days and re-x-ray.
- May also be nerve damage (radial, ulnar, median), ligament damage, dislocation, bone bruise, sprain of traingular fibro-cartilage complex (TFCC) (b/t rad/unla and carpals on ulnar side).
90
What is the most common carpal bone fracture?
-scaphoid most common. Watch out for nonunion/avascular necrosis w/ fractures at the proximal pole since blood supply runs distal to proximal. Thumb spica: takes a long time.
91
Where do most clavicle fractures occur?
middle third, often d/t mva, fall on shoulder.
92
Tony fell from a tree and broke his clavicle. What are some potential complications of this? When should you refer? How is this treated?
Check for neuro/vasc comp. and lungs.
- If open, tenting, neuro/vasc comp, glenoid fracture also, or displacement then urgent referral;
- otherwise analgesics, sling, and elbow ROM xc.
93
Adam was tackled playing football and fell onto his arm while it was tucked carrying the ball (adducted). On PE you noted tenderness over the AC joint and mild deformity. What do you suspect? What test on PE can you do that might convince you of this diagnosis? What two ligaments may be involved? How is this treated? What are the classifications of the injury?
acromioclavicular joint separation : trauma to superior/lateral shoulder while arm adduction. TTP over A/C, deformity,
- pain w/ passive cross body adduction to compress joint. Need neurovasc exam of extremity and c-spine screen, x-ray.
- coracoclavicular and acromioclavicular
- Rest, ice, sling.
- types: 1: partial tear of ac ligaments, 2 complete tear ac and come coracoclavicular (CC), 3 complete ac and cc, ...and worse, 3 + gets ortho and surg.
94
Steve comes to the ED after sticking his finger in a Vitamix blender to dislodge some fruit. On PE you see exposed bone. How should you manage this?
if open wound then treat like open fracture give ABX and refer to hand surgeon w/in 6 hours.
95
Dave busted his finger from a basketball being jammed into his finger. You x-ray and find a fracture of the 3rd phalanx. What should you do if the fracture is unstable? If stable what should you do? What is the maximum time for splinting and why?
phalanx dislocations and fractures
- If unstable then refer w/in 3 days.
- If closed and stable then splint, manage pain, elevate and reeval in 7 days.
- Don’t splint > 3 weeks or will get stiff. Non displaced start ROM in 7-10d, displaced 3w, and continued splint till bone heals (6 weeks).
96
-What is the objective of splints for the hands and wrist? What position should you splint the wrist in? MCPJ? PIPJ? DIPJ?
- Splints permit swelling, and prevent neurovasc. comp, splint should counter deforming forces, cover proximal and distal joints and be in safe position:
- wrist: 15 deg extension,
- MCPJ: 65 deg flexion,
- PIPJ: full extension,
- DIPJ full extension.
97
Sherri was jaywalking and got hit by a speeding car. On PE you notice her legs are resting in an odd position, tenderness over her flank and perineal area and rectal bleeding. What do you suspect? How can you stabilize this? Imaging?
pelvic fractures
MVA, ped vs MVA. Types: ring disruption, sacral, acetabular, avulsion.
SX: abnormal position of LE’s, flank/scrotal/perineal tenderness or tenderness, LE weakness/loss of sensation, hematuria or rectal/vaginal bleeding. Be careful when checking pelvic instability.
-FAST exam, Get CT, immobilize w/ binder (not too tight), send to surgery if hemodynamically unstable.
98
What is the most common type of shoulder dislocation and how does it look on PE? Where is pain referred?
- most common is anterior dislocation (arm abducted and ext. rotated), pt resists all movement, prominent acromion.
- Need to check neurovasc.: distal pulses, axillary nerve (motor of deltoid and teres minor).
- sensation of rotator cuff and skin over lateral delt.).
99
After getting x-rays of a shoulder dislocation you decide it's time to reduce the shoulder.....What are some techniques? This might be painful: how will you manage the pain? When should you consider getting ortho involved?
- No reduction technique is superior.
* Scapular manipulation,
* ext. rotation technique,
* traction-counter traction.
- Can give IV meds, intra articular lido (just as good as anesthesia) etc. Look for “clunk”
- consider ortho consult w/ old folks and w/ injuries that are old (vasc comp. common).
100
Margaret is an 88 year old female who tripped on her cat and fell. What sorts of PE findings would suggest hip fracture? What is an intracapsular fracture? Extracapsular fracture? Since Margaret is older than 75 what are some other things you need to do for her management if she has a hip fracture? Will she need surgery if its a hip fracture?
- increase morbidity in elderly.
- SX: groin pain, external rotation or shortening of leg.
- Classified by location and type: intracapsular (neck/head- worse prognosis) extracapsular (intertrochanteric, subtrochanteric).
- Give analgesia and consult ortho. Get type and crossmatch if >75, HgB
101
Tonya was broadsided in a car wreck. X-rays show a fracture of the humerus. What classification system is used for humerus fractures? When should you refer? When can you treat and what should you do? What if it is mid shaft?
humerus fractures
-proximal: d/t falls. swelling, bruising, check neuro vasc., classify based on Neer system:1 (not displaced) up to Neer 4, which has 3 + frags displaced).
- 2+ frags or involves anatomic neck need referral to ortho surg.
- If Neer 1 (most) then: collar/cuff sling, ice, pain meds. and pendulum xc in 1-2 weeks, follow up radiographs till healed.
- mid shaft: rare. Sugar tong splint to upper arm, sling if transverse, colar/cuff sling for spiral/oblique.
102
Edna was in a head on vehicle collision. she attempted to walk away from the wreck, but was unable to walk on her leg. In the ED, the doctor notices that one leg looks shorter than the other. What might this be? How is it treated?
femur fractures
longest and strongest bone. MVA. classified based on location (distal, middle, proximal), type of break and open/closed. pain, deformity, not able to bear weight, shortening. check for neurovasc problems. x-rays/ct.
-Most need surgery. 4-6 m to heal.
103
Tom was dancing at the roller skating rink and landed harder than he expected when dropping into side splits. His knee is very tender and swollen and he can't fully extend his lower leg when you test the extensor mechanism of this leg. What do you suspect? How is it treated?
patella fractures
-Patella: blunt force or contracting quad (landing on feet from fall). Swollen knee, patella pain, may not be able to extend knee. Assess extensor mechanism by asking to to straight leg raise/ bend knee then extend. x-ray.
-ortho referral. immobilize in extension. 4-6 w.
104
How is a distal femur fracture treated?
nonsurgical: casting and traction (old school) new school = surg.
105
James jumped out of his truck while driving down the highway....his girlfriend was playing with his phone and discovered text messages from another girl. He's brought to the ED with a grossly deformed knee (tibia and femur are displaced). What are your biggest concerns about this injury?
-dislocation: Tibiofemoral. Potentially limb threatening. Neuro vasc comp. needs to be eval’d (popliteal artery). Reduce immediately (posteriolateral not reduceable), check neurovasc, send to ortho.
106
Miranda was playing soccer and twisted her knee. Her kneecap is on the side of her knee now and she's holding her knee partially flexed. You also note swelling and tenderness over the medial edge of the patella. How should you fix this?
- dislocation: patellar: lateral dislocation most common. knee held at 20-30 deg flexion and patella is displaced laterally, may be swollen, TTP over medial edge of patella.
- Give analgesia, reduce by placing supine, hips flexed, then slowly extend knee w/ gentle medial pressure to lateral aspect. Then get x-rays. RICE and splint w/ brace.
107
T/F: Females are more likely than males to get ligamentous knee injuries.
T
108
How are ligamentous injuries of the knee classified?
Same as ankle sprains, 1-3 scale.
109
Sandra was playing volleyball, jumped up to make a block and when she landed she felt/hears an "pop". Her knee gave out and started swelling immediately. She's now complaining of loss of ROM and instability. What do you suspect? How is this managed?
-acl: rarely isolated injury. classified on 1-3 sprain scale. Most are near complete or complete. change in direction/sudden stop/landing from jump. F>M. “pop”, knee gives out, pain and swelling
110
Kelly was playing soccer and was slide tackled. The other player hit the outside of her right knee. She felt a lot of pain and is now complaining of instability. What test on PE can you do, what is the best treatment?
- collateral ligament: soccer, football: lateral impact, change in direction. graded by 1-3 sprain scale. MCL more than LCL.
- Pain at sides of knee, swelling over site, instability/feeling like knee will give away.
- Valgus/varus test for laxity (compare sides).
- TX: PT.
111
Brandon was skiing and ran into a tree root. He is brought to your clinic and you immediately note the deformed appearance of his tibia. Can you take care of this yourself? How should you splint a proximal fracture? Mid shaft?
tibial fractures
-closed tib shaft = most common long bone fractures. mva, skiing, cycling, falls, contact sports, repetitive.
- Proximal: look for injury to ligaments/menisci, most need to see ortho in 48 hrs., : splint in extension, analgesia, non weight bearing (crutches), cast.
- shaft: refer to ortho: posterior leg splint, analgesia, compression, crutches. cast.
112
Angie twisted her knee playing lacrosse 2 days ago. She immediately felt discomfort and a catching sensation whenever she walked. Yesterday she noticed her knee was swollen. What do you think this is? Where might you noted tenderness on PE? What sort of treatment is appropriate for this?
-meniscal injuries of the knee
.twisting knee while foot planted.
- SX: Variable pain w/ ambulation, swelling over 24 hours or more, may feel tearing/popping/catching sensation. Need MRI to confirm, but not necessary.
- PE: joint line tender? able to squat? extend knee fully? effusion? thessaly test (one foot balance and rotate).
- TX: Refer if persistent effusion, disabling/impaired ROM. Otherwise RICE, straight leg raises/ PT.
113
Ben rolled his ankle while trail racing. He inverted his ankle while stepping down a hill. If he broke his ankle, where is the fracture most likely to be? What constitutes a stable fracture? How should you splint this?
ankle joint fractures and dislocations
- common, most are malleolar, and most are unimalleolar.
- Inversion: lateral distraction and medial compression.
- Eversion medial distraction, lateral compression.
- Distraction fractures sooner than compression.
- Stable= isolated to lat/med/post malleolus, non displaced, no ligaments involved.
- TX: X-ray, splint ankle at 90 degrees in short leg posterior splint., ice, elevate, analgesics,
* Open/neurovasc/unstable refer. Dislocation needs immediate reduction.
114
Taylor got big air while snowboarding....too big. He can't walk and his left ankle is bruised and swollen. What is an uncommon, but possible injury he may have?
calcaneal and talar fractures
-calcaneal: uncommon, jump/fall from height. Severe pain, impossible to weight bare, swelling, deformity, tenderness over insertion of ATFL. Look for other injury. X-rays. If open/neurovasc or dislocated (reduce), intra articular: refer. RICE, analgesia, 6-8 w no weight bearing.
-talus: collision, fall. Most often breaks at mid portion or along outside (snowboarders). Classified based on degree of displacement. Pain, can’t walk, swelling, bruising, tender.
RICE, analgesia, 6-8 w cast no weight bearing. Usually surgery if displaced.
115
Michelle dropped a bowling ball on her foot. She can walk, but it hurts. On PE you note point tenderness over her 3rd metatarsal. If this is a fracture, how will you manage it? How will you know when it is healed?
tarsometatarsal and metatarsal fractures
- phalangeal fractures of the foot, point tender.
- TX: reduce if needed, buddy tape toes, if bone in forefoot may need short leg cast/ brace/ rigid flat bottom shoe.
- RICE and no weight-bearing 2-3 days and RTC, then rigid shoe, weight-bearing as tolerated, may use walker boot. follow up xr in 1 week, then 2-3 wks.
- Considered healed when callus is visible on x-ray and point tenderness is resolved...6w.
- Usually surgery not required.
*Refer if gross displacement/neurovasc. compromise.
116
What are signs of a tension pneumothorax? Treatment?
tachypnea, chest pain, hypoxia, unilateral diminished breath sounds, unilateral hyperresonance.
-dart then chest tube.
117
Bruce just got rammed in the chest by an angry rhino. He now has chest pain, anxiety, hypotension, shock, tachycardia, and SOB. What could be happening? It rhymes with hemothorax...TX?
Hemothorax
| Chest tube
118
Bubba just got shot in the chest. How will you treat this?
Occlusive dressing and chest tube
119
A man comes into the ED with chest pain, dyspnea, tachypnea, inc. JVP, hypotension, pulsus paradoxus and enlarged cardiac silhouette on x-ray. What is this?
Cardiac tamponade
120
The nurse says that the patient in bay 5 has a flail chest. What is this? Is it an emergency? How is it treated? Should you splint? Give narcotics?
flail chest
-break of 3+ ribs in 2+ areas leaves a segment that moves independent of rest of thorax. Medical emergency. Often associated w/ pulmonary contusion that can interfere with blood oxygenation. Also look for pneumo. TX: analgesia to facilitate breathing, but avoid narcotics as they suppress respirations. PPV. Imaging, ABC’s. No splint.
121
Andrew rammed his chest into a steering wheel during a head on collision. He was fine 24 hours ago, but you decided to monitor him and now he's complaining of shortness of breath. You hear crackles on PE and note streaking and diffuse lucencies on CXR. What is this?
. pulmonary contusion
MVA, blunt trauma. Vent/perf mismatch and decrease in lung compliance. Develops over 24 hours: edema and blood in alveolar spaces = loss of structure and function. Inflammation from blood can lead to ARDS, atelectasis and pneumonia. Often seen w/ rib fracture/ flail chest. May hear crackles. CXR shows streaking and diffuse lucency around area of damage, but often lags behind actual injury. CT works too. TX: supportive.
122
Alan is a circus performer. He takes cannon balls to the belly...this time the ball hit his upper left chest. He has pain over his mid/anterior chest, tachycardia and a new BBB on EKG. What is this?
myocardial contusion
Blunt chest trauma: pain and tenderness over mid anterior chest, sternal fracture, sx of cardiac disease. Get EKG: tachycardia, new BBB, dysrhythmia. Refer to cards.
123
What are 6 causes of esophageal perforation?
```
iatrogenic d/t endoscopy,
vomiting (Boerhaave’s syndrome),
pill esophagitis,
Barrett’s esophagitis,
AIDs,
ulcers
```
124
Esteban has been retching for 4 days and is now complaining of excruciating retrosternal chest and upper abdominal pain, odynophagia, dyspnea, tachypnea, cyanosis, fever, and appears to be in shock....what is this and how is it treated?
esophageal perforation
May see sub-Q emphysema, pain can radiate to left shoulder too. CXR, CT. ABX, surgical repair.
125
A man is in a MVA and his aorta is ruptured. Will this be obvious on PE? How is it diagnosed and treated?
Hard to find unless you look. CT angiogram. CXR shows widened mediastinum, tracheal deviation. Surgical repair, high mortality.
126
What are three bad things that a broken rib can lead to ?
can cause pneumothorax, splenic rupture or pneumonia.
127
What rib fractures cause a high index of suspicion for other underlying injury?
ribs 1-3 (takes lot of force).
128
How are rib fractures treated?
TX: pain relief to prevent atelectasis and subsequent pneumonia, incentive spirometry, avoid rib binders.
129
When should you consult a hand surgeon regarding finger tip amputations/lacerations?
- infected wounds;
- fingertip injuries with associated tendon injuries;
- displaced finger fractures (other than tuft fractures);
- complicated digit dislocations (eg, open dislocation);
- large soft tissue injuries (>1 cm) in children with absent, destroyed, or heavily contaminated tissues requiring nail bed or skin grafting;
- large proximal germinal matrix avulsion or laceration; or amputations with significant bone exposure
130
You decide to reattach an amputated fingertip. What sort of suture will you use and what will you do with the piece being reattached?
:full: allow injury to degranulate, and suture the cleaned and defatted piece back on w/ 5.0 chromatic.
-if tissue not available and under 2 yoa, dress wound and allow to granulate. If > 2 yoa send to surgery for grafting.
131
Carl just avulsed his nail while trying to climb a tree. On PE you see that he has lacerated the nail bed. How will you manage this? How long does it take for nails to regrow?
pain relief, remove nail or displace as needed, 5.0/6.0 or glue to close bed, then drill hole through nail for drainage and put back in place under eponychium to prevent adhesions w/ glue or use sterile material in its place. Takes 3-12 months to regrow. 1cm/3months.
132
Andy smashed his thumb with a hammer. He has a very painful and blackened nail. When should you treat this? How?
subungual hematoma
-trephination only effective before blood has clotted/t need treatment. Ensure there is no tendon disruption (mallet finger: extensor tendon disruption) and x-ray if you suspect fracture. Avoid trephination if underlying fracture b/c this technically causes open fracture. Trephination: cautery device or 18 g for hole, aspirate w/ insulin syringe/29g. No abx needed.
133
Dwayne got a splinter a week ago while mending fences. Now the tip of his finger is red, swollen and painful. In clinic he says he thinks he should just let it resolve on its own. Is this a good idea? Why? How should you treat this initially? Later if it persists?
felon
-Penetrating trauma (splinter or cut) leads to abscess of distal pulp of fingertip. Pulp divided into compartments that run from periosteum to skin. Pain and swelling can cause necrosis and osteomyelitis is a risk. Swelling doesn’t go past DIP. Early: elevate, abx, warm water soaks. Late: I&D, packing and ABX.
134
Edna gets her nails done regularly. Today she shows up to the clinic with a painful and swollen nail fold. What is this? What organism causes it usually? If there is an abscess what do you do? If no abscess? If this is chronic what might be causing it?
paronychia and eponychia
-infection of nail fold. Swelling, erythema, pain at base of fingernail. Acute= usually d/t trauma and then infection often from staph or strep. If no abscess, then try warm water soaks. If abscess, I&D then Diclox or cephalexin. If chronic, consider candida and try antifungal/steroid.
135
Frank has cold sores. He also has a bad habit of biting hangnails. He presents to clinic with small clear vesicles on his index finger that are very painful. What do you suspect? What else might you find on PE? What test can you perform to confirm? When will this resolve? Can you treat it? Is it contagious? Should you I&D this?
herpetic whitlow
-Autoinoculation of type 1 or 2 herpes simplex virus into broken skin. Can be from contact w/ infected oral secretions. Abrupt onset edema, erythema, tenderness. Pain out of proportion w/ physical findings. May see fever, lymphadenitis of epitrochlear/axillary nodes. Small, clear vesicles may be present and coalesce and appear abscess like. Tzanck test, viral culture, pcr.
Self-limited and resolves in 2-3w. If caught in first 48 hours then acyclovir. Can be contagious and needs to be dressed. Do not I&D
