4- Lower Extremity Flashcards
What is the typical MOI for pelvic fractures?
High energy
(can be low energy/ fall in elderly)
50% of pelvic fractures are a/w internal injuries with high risk of what?
Vascular hemorrhage (pelvic viscera)
Pt presents with pain, B+B incontinence, numbness, weakness and bleeding. Pt is hemodynamically unstable. What are you concerned for and what should be included on PE?
Pelvic fx
Include rectal and vaginal exam
What imaging should you perform for pelvic fx and what is gold standard?
CT scan = gold standard
Xray- AP pelvis, Judet views, inlet + outlet views for pelvic ring
Bedside US if blunt trauma
What is the most common pattern for pelvic fx?
Posterior wall fx +/- femoral head dislocation
What type of pelvic injury is more common in skeletally immature athletes?
Avulsion fx
(not a trauma pt)
Pelvic ring typically is unstable with how many fractures? And with the exception of what population?
2 fractures
Exception: pediatric population
What included in the tx for pelvic fx if hemodynamically unstable?
Pelvic wrapping w/ sheet or pelvic binder
(stabilize fx, minimize bleeding)
What is the tx for pelvic fx?
Conservative- avulsion or stable fx
Surgical- ORIF/ external fixation
Survival of femoral head w/ hip dislocation requires reduction within how long after injury?
6-8 hrs
What is the typical MOI for hip dislocation?
High energy trauma (MVA)
What is the most common type of hip dislocation?
Posterior dislocation
What is the difference between simple vs complex hip dislocation?
Simple- dislocation only
Complex- dislocation a/w fx
Pt presents with leg adducted and internall rotated. They are in pain, unable to bear weight on leg, and their leg appears shorter. What are you concerned for?
Posterior hip dislocation
What should be the focus of the NV function check for hip dislocation?
Sciatic nerve distribution
What imaging is ordered to confirm hip dislocation and r/o fx?
Pre-reduction AP/ lateral
When should you order a CT scan for hip dislocation?
If suspicious for fx not evident on xray/ to eval pelvis and femur
What is the tx for hip dislocation?
Emergent reduction w/i 6 hrs
Proximal femoral fxs are a/w with what in elderly populations?
Increased risk of death and major mobidity
Femoral neck fractures are what type of fracture and are a risk for ___ requiring emergent fixation if stable?
Intracapsular
Retrograde blood
Pt presents holding leg in external rotation/ abduction with pain to groin that radiates to the inner thigh. You note difficulty with flexion and internal rotation and leg appears shorter. What are you concerned for?
Proximal femoral fx
What imaging should you order for proximal femoral fx?
- AP/ lateral xray and full femur, include knee joint
- CT to eval displacement
- MRI if high suspicion + neg xrays
What complications are a/w proximal femoral fx? (4)
AVN
Infection
DVT/ PE
Nonunion
What is the tx for proximal femoral fx?
Surgery if medically stable +/- prophylaxis for DVT
What MOI is typically a/w femoral shaft fx?
Severe trauma
(young men highest risk population)
Pt presents with obvious deformity of leg, inability to bear weight, and loss of ROM due to pain. What are you concerned for?
Femoral shaft fx
What imaging should be ordered for femoral shaft fx?
AP and lateral
What is the tx for femoral shaft fx?
Urgent ortho consult (blood loss can be life threatening)
Surgery (except medically unstable and some peds fxs)
What complications are a/w femoral shaft fx? (3)
Malunion, delayed union, nonunion
Infection
Pain a/w hardware
What lower leg injury is a surgical emergency w/ high incidence of NV injury?
Knee dislocation
What are the most common MOIs a/w knee dislocation?
Dashboard injuries (posterior dislocation)
Hyperextension (anterior dislocation)
What associated injuries are common with a knee dislocation?
Peroneal > tibial nerve
Fractures
Why is a vascular exam critical for knee dislocation?
Risk for amputation significantly increases > 8 hrs
If pulses absent, must reduce and confirm reperfusion
What imaging is ordered for knee dislocation?
Pre and post reduction AP/ lateral xray
+/- CT/ MRI (post reduction)
What is included in the management for a knee dislocation? (3)
Emergent reduction w/ assessment of limb perfusion
Eval for spontaneous reduction
Splint in 20 deg flexion
What is the most common direction of patellar dislocation?
Lateral
What is the typical MOI for patellar dislocation?
Twisting on flexed knee
Pt presents with hx of knee “giving way” w/ severe pain. Knee is fixed in 20-30 deg flexion, deformity, swlling, and hemarthrosis. What are you concerned for?
Patellar dislocation
Is imaging prior to reduction necessary for patellar dislocation?
NO
What is included in the initial management for a patellar dislocation?
Immediate reduction if does not spontaneously reduce
What is included as part of the post-reduction eval for patellar dislocation?
Repeat PE, eval for fx/ soft tissue injury
AP/ lateral/ sunrise xrays
What is included in post-reduction management for patellar dislocation?
RICE, NSAIDs, knee immobilizer/ crutches
Referral
When is surgery indicated for patellar dislocation?
Repeat dislocation
What is the typical MOI for patellar fx?
Direct force in knee flexion
Pt presents with knee effusion, hemarthrosis, and inability to extend knee. What are you concerned for?
Patellar fx
What imaging should be ordered for a patellar fx?
AP/ lateral/ sunrise xrays
What is included in the management for patellar fx?
Splint in full extension + NWB
Activity restriction + PT
Ortho referral
When is surgical vs nonsugical management indicated after ortho referral for patellar fx?
Surgery if displaced or complex fx
What is the typical MOI for tibial plateau fx?
High energy
What concomitant injuries are often a/w tibial plateau fx?
Meniscus, ligament injury
Pt presents with localized knee pain/ swelling, knee effusion, restricted ROM and pain w/ WB. What are you concerned for?
Tibial plateau fx
What imaging is ordered for tibial plateau fx?
AP/ lateral/ intercondylar notch xrays
+/- CT, MRI
What is included in the management for a tibial plateau fx?
Splint in full extension
NWB for up to 6 weeks
Ortho consult (brace, casting, ORIF)
What is the typical MOI for ankle injuries?
Inversion or eversion
What is a bimalleolar vs trimalleolar fx?
(BOTH unstable vs non-displaced are stable)
Bimalleolar- medial and lateral
Trimalleolar- medial, lateral, and posterior
What population is a/w Tilleaux/ triplace fxs and what imaging is used for evaluation?
Adolescents
CT scan
What rules are used to determine necessary imaging for ankle injury?
Ottawa ankle rules
What imaging is ordered for an ankle fx? (3)
2 view- AP/ lateral
Ankle series- AP/ lateral and mortise
CT for ankle mortise/ fx alignment
(ankle mortise = slight internal rotation)
What is included in the management for ankle fx aside from RICE, NWB, and analgesics?
Splinting, brace, CAM boot
Ortho consult
What type of fx can occur w/ abrupt increase in activity or chronic overload?
MT stress fx
What is the most commonly fractured MT in adults and what is the associated risk?
5th MT
Risk of AVN
What type of MT fx is a metaphyseal-diaphyseal junction fx and is a/w with risk of non-union?
Jones
What type of MT fx involves the proximal tubercle and is NOT commonly a/w non-union?
Pseudo-Jones/ avulsion
(can be confused w/ apophysis in peds pts)
What xrays should be ordered for MT fx?
AP/ lateral/ oblique
What are the conservative tx options for MT fx?
Rigid shoe or CAM boot
When is casting/ surgery indicated for a MT fx?
Jones fx, delayed union, unstable fx
What is a Lisfranc injury?
Fx/ dislocation of 1st and 2nd MT = mid foot pain
(“keystone” of the foot)
What imaging is indicated for a Lisfranc (1st/ 2nd MT) fx?
AP WB BL feet, lateral xray, CT scan
What is the tx for Lisfranc (1st/ 2nd MT) fx?
Early recognition/ stabilization
Casting vs surgery if > 2mm
Calcaneal fx is typically a/w a fall from a high height. What imaging should be ordered and what view is the most helpful?
3 views- lateral most helpful
What is the tx for calcaneal fx?
Casting w/ NWB
Surgery if displacement
Where is acute compartment syndrome most common?
Lower leg, anterior compartment
What injuries are at high risk for acute compartment syndrome?
High-energy trauma or crush injuries
What medical interventions can contribute to acute compartment syndrome?
Tight bandages, splints, early casting
What is the first/ most important sign of acute compartment syndrome?
Pain OOP to injury
Worse w/ passive stretching
What are the 6 P’s of acute compartment syndrome?
PAIN
Paresthesia (nerve hypoxia)
Pallor
Pulselessness (late)
Poikilothermia (late)
Paralysis (8-24 hrs)
When are intra-compartmental pressure measurements helpful if suspicion for acute compartment syndrome?
If dx unclear
(higher the measurement, quicker the tissue damage occurs)
What intra-compartmental pressure is concerning and warrants fasciotomy?
> 30 mmHg
What is included in the management for acute compartment syndrome if diagnosed w/i 8 hrs?
Fasciotomy +/- fracture fixation (wounds remain open + skin grafts)
What is included in the management for acute compartment syndrome if diagnosed late (> 8 hrs)?
Amputation more likely +/- fracture fixation (wounds remain open + skin grafts)
What complications are a/w acute compartment syndrome? (4)
Infection
Amputation
Volkmann’s ischemic contracture- forearm
Rhabdo
(Irreversible) cartilage destruction a/w septic arthritis starts in how long?
Destruction in 8 hrs
Becomes irreversible in 48 hrs
What is the most commonly associated location for septic arthritis?
Knee (adults)
Knee and hip (peds)
What is the pathophysiology of septic arthritis?
Hematogenous spread > direct inoculation
Staph aureus most common, MRSA > Strep
N. gonorrhoeae if sexually active adolescent
Pt presents with acute monoarthritis w/ associated erythema, edema, and warmth. You note limited ROM/ NWB due to pain. What are you concerned for?
Septic arthritis
What population w/ septic arthritis typically presents w/ fever, constitutional sxs, joint pain, and NWB?
Children and adolescents
What population w/ septic arthritis typically presents with irritability and poor feeding, limited ROM, and fever?
Neonate
What position will a peds pt typically presents if septic arthritis?
Limited passive ROM
FABER position (hip involved)
What risks are a/w septic arthritis in peds? (3)
Femoral venipuncture, JRA, STI
What is the gold standard for dx of septic arthritis?
Prompt arthrocentesis - watery, cloudy, WBC > 50,000, leukocytes > 90%
In addition to arthrocentesis (gold standard), what other dx studies should be ordered for septic arthritis? (4)
CRP
AP/ lateral xrays- increased joint space, effusion
US- effusion and guide aspiration
MRI- peds require sedation
