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Emergency Med Exam 4 > Acute MSK injuries > Flashcards

Acute MSK injuries Flashcards

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1
Q

RHABDOMYOLYSIS etiology

A
  • Injury to skeletal muscle & the release of intracellular contents
    – myoglobin, creatine kinase, aspartate aminotransferase, & K +
  • Disruption of the Na+ K + ATPase pump & calcium transport
    – Leading to ↑ intracellular Ca2+ & muscle cell necrosis.
    – Ca2+activates phospholipase A2 & various vasoactive molecules &
    proteases leading to free oxygen radicals
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2
Q

RHABDOMYOLYSIS: most common causes in adults

A

– Trauma/crush injury
– Alcohol abuse or illicit drug use
– Some medications (statins)
– Neuroleptic malignant syndrome
– Immobility → ischemic injury

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3
Q

RHABDOMYOLYSIS: most common causes in children

A

– viral myositis
– trauma
– exercise
– drug overdose (cocaine)

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4
Q

RHABDOMYOLYSIS diagnosis

A
  • Gold standard for definitive diagnosis = ↑ serum creatine kinase (CK)
    – concentrations at least 5x upper limit of normal = Rhabdomyolysis
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5
Q

RHABDOMYOLYSIS: management

A

1st → Treat the cause
* Early & aggressive IV fluid (isotonic saline)
– Initial rate o= 400-1,000 mL/hour
* Titrate based on volume status & urine output
– Goal = urine output of 1-3 mL/kg/hour
* Maintain fluids >10 L/day
* Manage potassium (K+)
– Check q 4h if CK levels >60,000 units/L
– If K+ is >6 mEq/L or ↑ monitor EKG
* Renal replacement therapy (Dialysis)
– Indicatation acute renal injury, inability to correct volume overload,
acidosis or hyperkalemia

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6
Q

RHABDOMYOLYSIS: late complications

A

– Acute kidney injury
* Most serious complication of
rhabdomyolysis
* ~13-50% of cases

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7
Q

Etiology of osteomyelitis

A
  • acute osteomyelitis
    – usually single organism
  • chronic osteomyelitis
    – usually polymicrobial
    Most common pathogens (> 50%)
  • Staphylococcus aureus
    – Methicillin resistant S. aureus (MRSA)
  • ~1/3 of cases
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7
Q

Pathogenesis of osteomyelitis

A
  • Hematogenous seeding of bone
    – Common in children
  • Contiguous spread from adjacent
    soft tissues & joints
  • Direct inoculation of
    microorganisms into bone
    – Wound contamination during
    surgery or trauma
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8
Q

Osteomyelitis clinical presentation: acute

A
  • Typically presents within 2
    weeks of initial infection
  • Children > adults
  • Fever, lethargy, irritability
  • Cardinal signs of inflammation
  • Delayed wound healing
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9
Q

Osteomyelitis clinical presentation: chronic

A
  • Presents months to years after initial infection
  • Adults > children
  • chronic pain
  • persistent wound drainage
  • low-grade fever
  • delayed wound healing
  • bone instability
  • soft tissue damage
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10
Q

OSTEOMYELITIS acute diagnosis

A
  • Acute (develops over several days)
    – Systemic symptoms (fever)
    – Acute pain at affected site
    – Warmth, erythema, swelling, &
    delayed wound healing
    – Clinical Dx
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11
Q

OSTEOMYELITIS chronic diagnosis

A

– chronic pain
– persistent sinus tract or
wound drainage
– low-grade fever
– delayed wound healing
– bone instability
– soft tissue damage
– presence of risk factors
* Probe-to-bone screening test (Good for ER)
– Insert sterile blunt probe into ulcer
(+) contacts bone (Sen. 87%, Spec. 83%)
* Definitive diagnosis
* Bone biopsy → histopathology consistent
with bone necrosis

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12
Q

OSTEOMYELITIS treatment

A
  • Follows operative debridement
    – Removal of necrotic tissue
  • Based on pathogen(s) from bone culture
  • Typically, ABX are started based on
    organism suspicion
    – Changed based on culture results
  • Empirical Antibiotic Choices
    – Vancomycin + 3rd or 4th generation
    cephalosporin
    e.g. ceftriaxone,
    ceftazidime, or cefepime
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13
Q

OSTEOMYELITIS complications

A
  • Acute osteomyelitis may progress to chronic
    illness & bone necrosis
    – 5-33% of cases are refractory to ABX
    – Possible death & disability
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14
Q

INFECTIOUS (SEPTIC) ARTHRITIS etiology

A
  • S. aureus = most frequent causative agent
    in adults & children
    – may cause mono- or polyarticular arthritis
  • Hematogenous (seeding) spread
    most common route of infection
  • Direct inoculation
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15
Q

INFECTIOUS (SEPTIC) ARTHRITIS

A
  • Acute onset
  • Unilateral joint pain
  • Swelling
  • Warmth
  • ↓ROM
  • Loss of function
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16
Q

INFECTIOUS (SEPTIC) ARTHRITIS diagnosis

A

Acute onset, hot, red, tender, swollen joint with restricted movement
– Medical emergency & prompt diagnosis is imperative
– Consult ortho if suspected
* Synovial Fluid Analysis
– Purulent, WBC count,
Glucose, Gram Stain, Culture,
Crystals
* Blood Tests
– Blood cultures (+) ~50% of cases
– CBC with diff
– ESR & CRP (Typically elevated)

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17
Q

INFECTIOUS (SEPTIC) ARTHRITIS management

A

Management – Joint drainage
* Septic arthritis is essentially a closed abscess…we drain abscesses.
– Needle aspiration (necessary for joint fluid analysis)
– Arthroscopic drainage
– Arthrotomy (open surgical drainage)
* Adequate drainage not achieved by needle aspiration or arthroscopy

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18
Q

NFECTIOUS (SEPTIC) ARTHRITIS mangement: antibiotics

A

– Vancomycin (Vancocin®)
* Gram stain = Gram (+) cocci
– Ceftriaxone (Rocephin®) → If
* Gram stain = Gram (-) bacilli
– Azithromycin (Zithromax ®) or
doxycycline (Vibramycin®)
* cover for Chlamydia

19
Q

Most common cause of infectious arthritis in young adults

A

Gonococcal Arthritis
(Disseminated Gonococcal Infection)

20
Q

Risk factors for Gonococcal Arthritis

A

– Exposure (usually sexual)
– Recent menstruation
– Pregnancy or the immediate
post-partum state
– Congenital or acquired
complement deficiencies
– Systemic lupus erythematosus

21
Q

Gonococcal Arthritis presentation

A

Septic arthritis
– Fever, chills, & generalized malaise (acute phase of infection)
– Monoarticular or asymmetric polyarticular
– Knee (Most frequent)
– wrist
– ankle
– Elbow (Least frequent)
* Arthritis dermatitis syndrome

22
Q

Gonococcal Arthritis diagnosis

A
  • Suspect in pts with risk factors
    for STI & mono-/polyarticular
    asymmetric arthritis
  • Systemic illness, often with
    arthralgias, tenosynovitis, &
    maculopapular or pustular skin
    lesions
  • Synovial fluid analysis required
  • Consider cultures from other sites
23
Q

Gonococcal Arthritis management

A
  • In-patient
    – Parenteral ceftriaxone
    (Rocephin®)
    – Oral azithromycin (if chlamydia)
    (Zithromax®)
  • Transition to oral meds & discharge after 24-48 hours
  • Expedited partner therapy partner therapy (without examining partner)
24
Q

T/F ALL OPEN Fx GET AN ORTHOPAEDIC
CONSULT

A

T

25
Q

Subluxation & Dislocation

A

Nonconcentricity of the joint
articular surface, in any degree

26
Q

Emergent factors for Subluxation & Dislocation

A

– Neurologic compromise
– Vascular compromise
– Time of subluxation/dislocation
– Avascular necrosis (Hip)

27
Q

Inspection of fracture/dislocatiosn

A

– Gross deformity along the
bone shaft is pathognomonic
for fracture
– Deformity at the joint, loss of
range of motion, severe pain
at rest suggest
dislocation/fracture at the
joint

28
Q

Palpation of fracture/dislocations

A

– May demonstrate bony step-off
and/or point tenderness
– Start away from the pain & move
toward it
* Helps rule out referred pain

29
Q

Why is it important to not base treatment of fracture/dislocations solely upon the radiology report?

A
  1. (-) report does not exclude
    significant injury
  2. Radiology often describe
    fracture & dislocation different
    from orthopaedics
30
Q

Benefits of Reducing fracture deformities?

A
  • ↓ pain
  • Relieves tension on nerves
    and/or vessels
  • ↓ possibility of closed fx
    becoming open
  • Restore circulation to a
    pulseless distal extremity
31
Q

Manage open fractures

A
  • Irrigation
    – Typically done in the OR
  • Debridement
    – Typically done in the OR
  • Antibiotics
    – In the ED
  • Tetanus prophylaxis
32
Q

When ortho consult is needed for fracture/dislocations in the ER

A
  • Compartment syndrome
  • Irreducible dislocation
  • Circulatory compromise
  • Open fracture
33
Q

Pros and cons to fiberglass fabric with polyurethan resin

A
  • Pros: Lightweight,
    resistant to moisture
    damage,
  • Cons: generates heat
34
Q

Off-the-shelf prefabricated splints: pros and cons

A
  • Pros: Quick, easy
  • Cons: A few sizes fit most usually
    means most fit none
35
Q

Ulnar Gutter Splint indications

A

– 4th metacarpal fracture
– 5th metacarpal fracture

36
Q

Volar Splint indications

A

– Wrist sprain/strain
– Carpal Tunnel
– Lacerations
– Night Splint

37
Q

Thumb Spica Splint indications

A

– Scaphoid fracture
– Thumb dislocation
– Thumb fracture

38
Q

Sugar Tong Splint indications

A

– Nondisplaced or minimally displaced fractures of the distal wrist,
such as
* Colles & Smith fx or greenstick, buckle, & physeal fractures
(kids)
* carpal bone fractures other than scaphoid or trapezium

39
Q

Sugar Tong Splint indications

A

– Forearm fractures
* (Colle’s, Smith)
– Humeral fractures
– Double Sugar Tong Splint may be
used in combination with each other

40
Q

Posterior Long-Arm Splint indications

A

– Supracondylar fracture
– Elbow sprain/strain

41
Q

Posterior Short-Leg Splint indications

A

– Tibia/Fibula fracture
– Ankle fracture
– Metatarsal fracture

42
Q

Posterior Long-Leg Splint indications

A

– Knee ligament injuries
– Knee joint dislocation
– Tibia & fibula fractures
– Femoral shaft fracture

43
Q

Medial-Lateral Long-Leg Splint indications

A

– Knee ligament injuries
– Tibia & Fibula fractures

44
Q

Crutches sizing

A

– 1 hand width below the axilla
– Elbows mildly flexed (~15°)
– Bearing weight on the hands, NOT
the axilla

45
Q

Canes and walkers

A
  • Canes
    – Held in the hand opposite
    the injury
    – Advanced along with the
    injured lower limb
  • Walkers
    – Lifted or slid a short distance
    ahead followed by the
    advancing patient
46
Q

Proper wheelchair fit

A
  • Seat width = widest area across
    the hips or thighs + 2”
  • Seat depth = posterior buttocks
    to the popliteal fossa + 1-2”
  • Leg length = 90° knee bend,
    measure from top of knee to
    bottom of heel
  • Seat height = 90° knee bend,
    measure from bottom of the
    heel to the seat + 2”
  • Arm height = 90° elbow bend, measure
    from the seat to the elbow + 1”
  • Back height = Dependent on level of
    function

Emergency Med Exam 4 (5 decks)

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