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Emergency Medicine - BT > Ch 22-23. Orthopedics > Flashcards

Ch 22-23. Orthopedics Flashcards

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1
Q

DDx of mono-articular pain (5), and poly-articular pain (6)


A

Mono-articular=1. Septic arthritis, 2. Gout, 3. Pseudogout, 4. Trauma, 5. OA

Poly-articular pain (6)

1. OA
2. Septic arthritis and gout can be poly-articular as well

3. Gonococcal arthritis

4. Reactive arthritis (from C+G or campylobacter)
*Triad of reactive arthritis: conjunctivitis, urethritis, arthritis (cant see pee climb a tree)

5. Viral arthritis

6. Lyme disease

7. Drug-induced arthritis

8. Rheumatic fever

9. Rheumatic arthritis, ank spond, psoriatic arthritis, seronegative arthritis (IBD)

10. Lupus
11. Enthesitis (inflammation of tendons and ligaments onto bones)

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2
Q

Rule of 11’s for distal radius (3)


A
  1. Radial inclination is 22 degrees, minimum 15 degrees

  2. Radial length 11mm, minimum 5mm

  3. Palmar tilt is 11 degrees, minimum 15 degrees dorsal and 15 palmar, but aim for neutral
    
4. Maximum 2mm articular step

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3
Q

Treatment of Smith fracture (1)


A
  1. ?Long arm cast with dorsal angulation

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4
Q

Treatment of humeral neck fracture (1)


A
  1. The humerus hates the surgeon


2. Backslab or sling. FU ortho

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5
Q

What is damaged in distal third humeral fractures? (1)


A
  1. Radial nerve (goes from posterior to anterior, wrapping around the distal third of the humerus laterally)

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6
Q

Treatment of undisplaced radial head fracture (1)


A
  1. Simple sling or posterior slab, then early ROM, with ortho FU.
    
Expect 2-3 months for full recovery

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7
Q

Xray will miss what % of scaphoid fractures? (1)

Treatment of clinical scaphoid and Xray scaphoid (2)


A
  1. Xray misses ~20%
    Treatment of scaphoid fracture:
    
1. Clinical scaphoid – volar slab or commercial scaphoid splint
    
2. Xray scaphoid – short arm thumb spica
*Scaphoid waist and proximal 1/3 scaphoid fractures need to be referred. High risk of non-union

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8
Q

Treatment of tibial spine (avulsion) fractures (2)


A
  1. Make sure they have full extension (may need intra-articular block)
    
2. Brace locked in full extension. Crutch support. FU ortho.

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9
Q

Weber classification of ankle fractures (3), and treatment (3). 


A
  1. Weber A – Below syndesmosis

  2. Weber B – at level of syndesmosis. Aircast boot. WB as tolerated and FU ortho.
Any medial pain, swelling, or displacement require surgery.
    
3. Weber C – above syndesmosis. 
*An isolated distal fibular fracture above the mortise is not a Weber C

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10
Q

Calcaneal fractures: associated fractures (2)

A

*High morbidity. 20% of people are incapacitated at 3 years

1. 10% are bilateral

2. 10% have compression # L spine

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11
Q

Angle to be used to detect calcaneal fractures (1)
treatment of undisplaced fractures (1)
treatment of displaced fractures (1)


A
  1. Calcaneal fracture – use Bohler’s angle
 (normal 20-40, <20 suggests compression fracture)
  2. Undisplaced calcaneal fracture – non-weight bearing below knee cast 6 weeks

  3. Displaced fracture – needs a CT and orthopedics consult.

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12
Q

Treatment of Lisfranc injury (1)


A
  1. Non-weight bearing. Consult ortho.

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13
Q

Treatment of Buckle fracture (1)


A
  1. Short arm cast 3 weeks. No FU Xrays needed. 4 weeks to return to full activities

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14
Q

Treatment of Greenstick fracture (1)


A
  1. Reduce with sedation. You need to complete the fracture (hear a crack)

  2. Well molded cast (3 point)

  3. Careful Xray FU qweekly – peds ortho FU
    
* These can angulate over time

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15
Q

What is Monteggia fracture and Galeazzi fractures (2) 


A
  1. Monteggia fracture - isolated fracture of ulnar shaft with dislocation of radial head

  2. Galeazzi fractures - isolated fracture of the distal radius shaft with dislocation of the distal radio-ulnar joint
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16
Q

Shoulder reduction techniques (4)


A
  1. Traction counter-traction (strap method)

  2. External rotation

  3. Hippocratic (foot in axilla)

  4. Stimson (prone with weight on arm)
  5. Scapular manipulation
  6. Cunningham
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17
Q

How long to immobilize after a first-time and recurrent shoulder reduction (2)


A
  1. After a first-time: 2 weeks, then gentle ROM


2. Recurrent: days

18
Q

Location of the leg in a humeral neck fracture, and posterior dislocation (2)


A
  1. Femoral neck fracture – shortened and externally rotated


2. Posterior dislocation – SHY. Shortened, internally rotated, adducted


19
Q

Complications of hip dislocation (2)


A
  1. Sciatic nerve injury


2. Avascular necrosis of the femoral head


20
Q

Treatment of hip dislocation (1)


A
  1. Early partial weight bearing with crutches. Outpatient ortho FU

21
Q

Treatment of knee dislocation (2)


A
  1. Reduce (gently)
  2. Neurovascular assessment and CT-angio

    * Splint in extension (brace is OK) – consult ortho

22
Q

What is the Gustilo Classification system for open fractures (4)


A

I. Wound <1cm – Ancef 2g IV

II. Wound >1cm, - Ancef 2g IV

III. Wound >10cm, severe mechanism/crush/loss of soft tissue coverage - Ancef + Gent

IIIC. Wound >10cm, severe mechanism/contamination/soft tissue loss/vascular injury Ancef + Gent + Penicillin (concern for anaerobes/clostridia)


23
Q

Tetanus guidelines – clean, dirty, >10 years and tetanus prone, no primary vaccinations, (3)


A
  1. Clean wound – update q10years

  2. Dirty wound – update q5years

  3. Over 10 years and tetanus prone wound (>6hours, crush, devitalized tissue) – immunoglobulin and tetanus vaccine

  4. No primary vaccinations – tetanus immunoglobulin and immunize

24
Q

Treatment of Boxer’s fracture (2)


A
  1. Hematoma block. Reduce by pushing proximal phalynx down against metatarsal head.

  2. Ulnar gutter splint 3 weeks.
25
Q

Treatment of base of fifth avulsion fracture (1) and Jones fracture (1)


A
  1. Avulsion – from inversion. Rx. Below knee walking cast or stiff shoe.

  2. Jone’s/Dancer’s fracture – from repetitive dancing/running.
    Rx. Non-weight bearing cast 6-8weeks. Ortho FU.
26
Q

Salter-Harris pediatric fracture classification? (5)

A
  1. Straight through the physis (growth plate)

  2. Above the physis

  3. Below the physis into epiphysis
    
4. Through the metaphysis, physis, and epiphysis

  4. Crushed
27
Q

Treatment of a mallet finger (1)


A
  1. Splint in full extension 6-10 weeks. NO flexion permitted.
28
Q

Diagnosis of hand compartment syndrome (5)


A
  1. Pain (deep pain, poorly localized)

  2. Parastesia

  3. Pain with passive stretching
    
4. Pressure (tense swelling)
  4. Poikilothermia (don’t wait for that one)

29
Q

Treatment of high pressure injection injury (3)


A
  1. Neurovascular assessment and Xray

  2. Tetanus

  3. IV antibiotics

  4. Urgent referral for surgical debridement

30
Q

Bones of the wrist (8)


A
  1. Scaphoid

  2. Lunate

  3. Triquetrum

  4. Pisiform

  5. Trapezium

  6. Trapezoid

  7. Capitate

  8. Hamate
31
Q

How do you test for a triangular fibrocartilage complex (TFCC) injury (1)?


A
  1. Ulnocarpal stress test 


* They get pain and clicking with ulnar deviation, like turning a handle or key 


32
Q

How do you test for a distal radio-ulnar joint (DRUJ) injury (1)?


A
  1. Piano key sign

33
Q

Borders of the anatomical snuff box (3)


A
  1. EPL (ulnar)

  2. EPB (radially)

  3. Radial tuberosity (proximal)

34
Q

Radiographic feature of scapholunate dissociation (1) and how to accentuate this (1)?


A
  1. Scapholunate space >3mm

  2. Accentuated by hand grip view

    Can also have dorsal intercalated segment instability

35
Q

Xray finding of peri-lunate dislocation? (1)


A
  1. Spilled teacup sign

36
Q

Why does a scaphoid fracture get AVN? (1)


A
  1. The blood supply goes distal to proximal, and the scaphoid is 80% articular surface

37
Q

Steps to interpreting an elbow Xray (3)


A
  1. Anterior humeral line should intersect the posterior 2/3 of the capitellum

  2. Radiocapitellar line – line from radius should intersect middle of the capitellum

  3. Posterior and anterior fat pads: posterior is always bad. Anterior sail sign is bad

38
Q

Treatment of biceps tendon rupture (proximal or distal - same) (2)


A
  1. Xray for avulsion fracture (US if you are not sure clinically that it is a 100% rupture)

  2. Consult ortho for surgical repair 

    Active males should be repaired (they lose 50% or supination, 30% flexion strength)

39
Q

Ankle sprain mimics/DDx (4)

A
  1. Achilles tendon rupture
  2. Snowboarder’s fracture (lateral process of talus)
  3. Posterior talus fracture
  4. Talar dome fracture
  5. Anterior calcaneus fracture
  6. Maissoneuve syndesmosis injury
    * Beware eversion injury, injury in a snowboard/skiboot/skate
    * *If in doubt: posterior slab, non-weight-bearing until follow-up
40
Q

What are findings in joint arthrocentesis for septic arthritis? (3)

A
  1. Bacteria seen on gram stain (Sens 50%, Culture sens 80%)
  2. WBC <25,000 (LR 0.3), WBC >25,000 LR 3, WBC >50,000 LR 8
  3. PMNs >90% LR 3, <90% LR 0.3
    *1.5% of patients with crystals will have concomitant septic arthritis
    **CBC, ESR, CRP are all crap. LR ~1.5
    Rx. Ceftiraxone 2g + Vanco 1g IV, consult ortho for washout
41
Q

Workup and treatment of acute mono-arthritis in a sexually active 25yo M (3)

A
  1. Xrays, Joint aspiration, cell count, gram stain and culture
  2. Urethral, rectal, pharyngeal swabs for G+C
  3. Rx Ceftriaxone 2g IV q24h until Sx improve, and Azithro/Doxy.
  4. Contact public health if concerned
42
Q

Treatment of acute gout (3)

A
  1. NSAIDs
  2. Consider oral prednisone (minimum 10days with taper)
  3. Colchicine 1.2mg PO, then 0.6mg one hour later, then 0.6mg BID until flare done.
**Best started within 12 hours of a flare
  4. **Do not stop allopurinol or diuretics as they fluctuate uric acid levels and may worsen gout

Emergency Medicine - BT (16 decks)

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