Blessington lecture

Question 1

what is the most common joint in the body to dislocate?

Answer 1

proximal interphalangeal joint

Question 2

does a shoulder typically dislocate anteriorly or posteriorly?

Answer 2

anteriorly

Question 3

what is the re-dislocation rate in young people and athletes?

Answer 3

90 percent

Question 4

scapular rotational maneuver would be a good option for shoulder reduction in which population?

Answer 4

elderly patients and those without huge amounts of muscle mass

Question 5

which reduction technique for shoulder dislocations requires the patient to hold a weight to slowly bring the shoulder back to place? what may you want to do for this technique?

Answer 5

stimson’s technique

sedate but not overly sedate (airway issue because they’re on their stomach)

Question 6

which technique for shoulder reduction requires two people? who is it commonly employed for?

Answer 6

traction countertraction

common for muscular patients/dislocated for long periods

Question 7

why may the external rotation technique for shoulder reduction be difficult?

Answer 7

requires a lot of cooperation from patient

Question 8

what should you do immediately following shoulder reduction?

Answer 8

1) immobilize shoulder in sling
2) post reduction films
3) evaluate neurovascular function

Question 9

what should you tell your patient to do in terms of recovery following shoulder dislocation?

Answer 9

avoid abduction and external rotation (hair brushing)

immobilize for 2-4 weeks, PT therapy is advised

Question 10

what are the three phases of wound healing?

Answer 10

1) inflammatory phase (2-5 days)
2) proliferative phase (2 days-3 weeks)
3) remodeling phase (3 weeks-2 years)

Question 11

scar tissue is only ___ percent as strong as original skin tissue

Answer 11

80 percent

Question 12

order the following in terms of when they occur: epithelialization, granulation, contraction

Answer 12

1) granulation: fibroblasts lay bed of collagen
2) contraction: wound edges pull together to reduce defect
3) epithelialization

Question 13

which type of wound closure allows for the best cosmetic results? which wounds are typically closed by this method?

Answer 13

primary intention

best on wounds that are ‘clean’ and uncomplicated

Question 14

what is the type of wound closure that allows a wound to heal on its own through granulation and re-epithelialization? when is this appropriate?

Answer 14

secondary intension

for abscesses, fight bites, dirty wounds, or if a wound is >12 hours old

Question 15

if you decide to leave a patient’s wound open for 1-3 days and then surgically close it, what is this called? why do we do it?

Answer 15

tertiary intension

• done to allow tissue edema to reduce (ortho injuries)
• wounds with likely chance of infection (abdominal incision post rupture appendix)

Question 16

how can you remove grease from an injury?

Answer 16

bacitracin/polysporin ointment

Question 17

what should you do if a patient presents with a “ragged” appearing injury with poorly-approximated wound edges?

Answer 17

trim with iris scissors and scalpel to minimize necrotic tissue and decrease likelihood of infection

Question 18

how long should your patient leave the initial dressing on following surgical closure of a laceration?

Answer 18

24-48 hours, return to re-apply second dressing

Question 19

with what types of lacerations do we want to refer out?

Answer 19

eyelids (plastics or opthalmology)

ear if full thickness (ENT)

Question 20

what is the DOC for animal bites?

Answer 20

augmentin

Question 21

what type of fracture are subungual hematomas often associated with?

Answer 21

distal phalanx tuft FX

Question 22

how do we treat subungual hematomas?

Answer 22

trephination with cautery stick

Question 23

before you cauterize someones subungual hematoma, what should you clean with?

Answer 23

not alcohol! it will light on fire

use betadine

Question 24

what are the desired effects of conscious sedation?

Answer 24

relaxation, cooperation, protective airway reflexes, purposeful responses to verbal or tactile commands

Question 25

is decreased respirations normal in conscious sedation?

Answer 25

NOooO

Question 26

what is the sedative agent of choice in the pediatric population

Answer 26

ketamine (dissociative agent)

Question 27

which sedative agent has the shortest action of onset and the shortest recovery time? what class is it?

Answer 27

propofol

hypnotic

Question 28

how can we reverse the effet of benzodiazepines when giving them for conscious sedation? in what instance would we use this?

Answer 28

flumazenil (romazicon) – benzos can produce respiratory depression

Question 29

how can we reverse the effects of narcotics when used for conscious sedation? what may this drug induce?

Answer 29

naloxone

reduces respiratory depression but may potentiate aggression

Question 30

most common etiology of abscesses and paronychia?

Answer 30

staph aureus

Question 31

how should you definitively treat an abscess? when do you follow up?

Answer 31

anesthetize, incise, drain, pack, dress

re-check in 24-48 hours

Question 32

what do you typically anesthetize with? what can you do to reduce the pain?

Answer 32

lidocaine with epinephrine

add bicarb to decrease burning sensation by 10 percent

Question 33

what signs do you look for to ensure that your patient’s wound has been properly anesthetized and is ready to be incised?

Answer 33

blanching, fullness, pointing

Question 34

in rare cases, a paronychia can be accompanied by fever and painful glands where?

Answer 34

axilla

Question 35

ABX therapy of choice for paronychia?

Answer 35

cephalexin or dicloxacin

bactrim/doxy/clinda if MRSA suspected

Question 36

how should we treat an abscess that cannot be drained?

Answer 36

ABX therapy and re-check in 24-48 hours

warm soaks 3-4x/day

Question 37

your preceptor wants to use topical ABX to treat his patient’s paronychia, what should you tell him?

Answer 37

that ain’t gon’ do it

Question 38

do we need to anesthetize a patient when draining their paronychia in their fingers?

Answer 38

nope

Question 39

when is a digital nerve block required?

Answer 39

paronychia or ingrown toenail that requires wedge-resection

Question 40

reduction method for nursemaid’s elbow?

Answer 40

put thumb on radial head, first supinate and flex forearm, followed by pronation and flexion of forearm

Question 41

should you get x-rays in a child with suspected nursemaid’s elbow?

Answer 41

if mechanism and PE are not absolutely consistent

always get x-rays afterwards

Question 42

when should a child’s pain and range of motion return following reduction of NME?

Answer 42

10-15 minutes

Question 43

with which type of dislocation is an associated fracture the rule, rather than the exception?

Answer 43

ankle

Question 44

what is the principal concern when dealing with an ankle dislocation?

Answer 44

neurovascular compromise of the talus, lower extremity tissue necrosis

Question 45

most common type of ankle dislocation?

Answer 45

posterior dislocation (joint moves into plantar flexion and is inverted)

Question 46

post reduction, what should we do in terms of management of our ankle dislocations?

Answer 46

immediate orthopedic or podiatric surgical consult; will likely get internal or external fixation