CR - Orthopedic Emergencies Flashcards
What is the mechanism whereby infectious tenosynovitis occurs in the flexor tendon of a finger?
Penetrating trauma
Particularly a trauma wound, along the polar aspect of the finger or in the palm of the hand.
Infection is most commonly caused by skin flora such as staph aureus and streptococci. In sexually active patients, consider disseminated gonorrhea especially if presenting with polyarthralgia and pustular skin lesions
Clinical presentation: a young athlete complains of lower leg pain with no history of trauma. The lower leg is firm and tender lateral to the tibia but is of equal girth when measured against the opposite leg.
What diagnosis must be excluded?
Acute compartment syndrome
Remember the 6 Ps, all don’t have to be present
- Pain out of proportion (only finding early)
- Pallor
- Poikilothermia
- Pulselessness
- Parasthesia
- Paralysis
Clinical evaluation has low sensitivity and negative predictive value so acquiring consultation for repeat exams and potential pressure measurements are highly recommended
Which nerve injury is most commonly associated with anterior glenohumeral dislocations?
Axillary nerve (C5-C6)
42% incidence of axillary nerve damage and is more frequent when age >50. Test lateral shoulder sensation. Deltoid muscle weakness may also be noted but is difficulty to assess in acute injury.
Fractures of the clavicle are most likely to occur in which region of the bone?
Middle third (69-80%)
No difference in functional or cosmetic outcome between utilizing the figure 8 brace or regular sling.
A fracture at the base of the second metatarsal is pathognomonic for what type of injury?
Lisfranc’s fracture
This is a fracture of the base of the second metatarsal with separation of the first and second metatarsals. Separation of the first and second metatarsal greater than 1mm on x-ray is pathologic. Mechanism is often an axial load as the plantar foot is flexed. Consider obtaining a CT scan if there is high clinical suspicion despite negative XRs. Can be an unstable fracture; >2 mm widening requires emergent orthopedic consultation.
What is the most immediate concern in patients with fractures of the tibia and fibula?
The development of compartment syndrome
The anterior compartment of the lower leg is the most common site for compartment syndrome
Calcaneous fractures may be associated with what other fracture or injury?
Lumbar spine fracture (10%)
Bilateral calcaneal fracture (10%)
Other lower extremity injuries
Calcaneous injuries are most commonly caused by axial load by a fall from a height.
Damage to which nerve is frequently associated with acetabular fractures?
Sciatic
What is the most common dislocation of the patella?
Lateral
Usually from a twisting mechanism on an extended knee.
Accounts for 3% of all knee injuries
Recurrent dislocations can occur and may require surgical intervention
What is the most common type of hip dislocation?
Posterior dislocation
90% of hip dislocations.
Typically occur when a posterior force is applied to a flexed knee, such as striking the knee against a dashboard during a motor vehicle accident.
Reduction is performed with procedural sedation and in-line traction with the knee and hip flexed at 90 degrees while a colleague stabilizes the pelvis at the ASIS
What are the expected physical findings of hip dislocations?
Posterior - leg is shortened, adducted and internally rotated
Anterior - the leg is shortened, abducted and externally rotated
What is the most serious complication of hip dislocations
Avascular necrosis of the femoral head
The chance of this problem occurring is in direct proportion to delays in reduction.
They also are associated with sciatic nerve injury in 10% of cases
A patient with a history of knee injury states that he heard a “popping” sound at the time of injury. On examination, you find hemarthrosis of the joint. There is positive anterior drawer test.
What structure is most likely injured?
Anterior cruciate ligament (ACL)
There is often an associated injury to the lateral > medial meniscus
Where are the tendinous insertions of the muscles comprising the rotator cuff?
Subscapularis - lesser tubercle of the humerus
Supraspinatus, infraspinatus and teres minor all insert on the greater tubercle.
All four originate from the scapula.
SITS mnemonic: supraspinatus, infraspinatus, teres minor, subscapularis
Clinical presentation: a patient complains of a painful shoulder after a fall. There is no fracture. On examination, there is weak and painful abduction with tenderness over the greater tuberosity.
What structure is injured?
The rotator cuff is injured.
Partial tears are more common than complete.
Supraspinatus is the most commonly involved muscle.
The supraspinatus is essential for the first 15 degrees of abduction.
The posterior fat pad sign seen on the lateral radiographic view of the elbow of an adult is presumptive evidence of which injury? What is commonly injured in a pediatric patient with this finding?
An occult fracture.
Radial head fracture in adults.
Supracondylar fracture in peds.
What are the signs of flexor tenosynovitis?
Kanavel’s four signs of flexor tenosynovitis:
- finger held in slight flexion
- symmetric swelling of the finger
- tenderness along flexor tendon sheath
- pain with passive extension of the finger
Fracture of the lateral tibial plateau may be associated with injury to the ___?
Lateral meniscus tears
Anterior cruciate ligament (ACL) and medial meniscus tears can occur with more severe tibial plateau fractures (Schatzker IV or worse)
Have a high suspicion for compartment syndrome.
Why is it important to obtain an early orthopedic referral for infants with developmental dysplasia of the hip?
In order to avoid later instability, chronic dislocations and the need for surgery. Treatment should consist of orthopedic consultation for splinting or casting in flexion / abduction (Pavlik harness)
How does on assess for a possible scaphoid fracture?
Palpate the anatomic snuffbox, apply axial load through the first metacarpal (scaphoid compression test) and obtain wrist, carpal bone, or dedicated scaphoid x-ray
Note: tenderness here can be suggestive of an occult fracture not detected on radiographs on the index visit (can be >25%)
What is a Toddler’s fracture?
A Toddler’s fracture is a non displaced spiral fracture of the distal tibia, and is usually accidental.
Note: mid-shaft fractures in children who are non-ambulatory generally occur as a result of non-accidental traumaWH
When is angiography with embolization indicated in the treatment of severe hemorrhage secondary to a pelvic fracture?
Trans-arterial embolization (TAE) is used to manage hemorrhage when fluid and blood product resuscitation has failed to stabilize the patient. Indications for TAE include:
> 4 units of blood are required on initial resuscitation
Contrast extravasation on CT
Persistent hemodynamic instability with a negative evaluation for other sources of hemorrhage or a pelvic hematoma on CT
Large (or expanding) retroperitoneal hemorrhage
Highly consider in patients older than 60 with major pelvic fractures.
Name the tests used to assess the stability of the anterior cruciate ligament of the knee
ACL tests
Anterior drawer sign - knee flex at 90. Proximal tibia is pulled anteriorly, check for anterior translation.
Lachman test - knee flexed at 30 degrees. Stabilize femur with one hand and pull the proximal tibia anteriorly with the other hand, checking for anterior translation of the tibia.
Pivot shift - knee starts in extension. One hand holds the lower leg, putting the tibia in internal rotation. Other hand puts the knee in valves stress. The clinician flexes the knee. This causes a clunk from reduction of the subluxed tibia
Name the tests used to assess the stability of the posterior cruciate ligament of the knee
PCL tests
Posterior drawer sign - hip is flexed at 45 degrees. Knee is flexed at 90 degrees. Clinician sits on patient’s foot of affected leg. Apply posterior force on patient’s tibial tuberosity. This is the most accurate test at assessing the PCL.
Posterior sag test – same starting pin as posterior drawer test. If PCL is intact, the medial tibial plateau lies in 1cm anterior to the femoral condyle when viewed from the side
Which upper extremity amputations have the best prognosis for reimplantation?
Amputations at the level of the middle phalanx, wrist and distal forearm have the best chance of a functionally successful re-implantation.
How should the amputated part(s) of the hand be preserved?
The amputated part(s) should b handled as aseptically as possible. Gently irrigate large debris from the wound, then wrap the part(s) in sterile saline soaked gauze, place in a plastic bag and place sealed bag in iced water in an insulated container. Never freeze the amputated part or place it directly on ice.
Fluid analysis of knee joint aspirate reveals the presence of positive birefringent crystal.
What is the diagnosis?
Pseudogout
Uric acid crystals found in gout are negatively birefringent.
Note: serum uric acid levels are not useful for diagnosis because up to 30% of patients have normal uric acid
What is suggested when there is:
- inability to flex the DIP joint of a finger and
- signs of traumatic tenosynovitis, such a s swelling gnat tenderness in the flexor tendon sheath
Rupture of the flexor digitorum profundus tendon
Clinical presentation: a worker was cleaning a high-pressure device filled with pain when he injected his left first digit. A small wound is noted at the injection site.
What is the definitive treatment for this patient?
Early surgical decompression and debridement.
High-pressure injection injuries are surgical emergencies, and hand surgery should be consulted immediately. Immobilize and elevate the hand, provide tetanus prophylaxis, broad spectrum antibiotics, and provide analgesia.
What is the initial treatment when a scaphoid fracture is suspected?
Thumb spica splint and referral to an orthopedist
Injury can be seen on plan radiographs in 10-14 days
What is the most common nerve injured in humeral shaft fractures?
Radial nerve
Will be unable to extend wrist and fingers at the MCP joints
Could see numbness on the dorsum of the radial side of the hand
What is the name of a C1 vertebrae burst fracture after axial loading (e.g. diving into shallow pool)?
Is this stable or unstable?
Jefferson fracture
Unstable
What is the mechanism of injury that causes a hangman’s fracture?
Describe the fracture pattern.
Stable or unstable?
Hyperextension of the neck.
Bilateral C2 pars interarticularis fracture and posterior longitudinal ligament rupture with resulting subluxation of C2 on C3
Unstable
What are the two major orthopedic complications of sickle cell disease?
Avascular necrosis
Osteomyelitis
What is a mallet finger?
Complete laceration, rupture of, or avulsion fracture of the insertion site of the extensor tendon over the DIP/distal phalanx that leads to the inability to extend the DIP in a finger
What is the ED treatment for a patient with mallet finger?
Splint the DIP joint in full extension leaving the PIP free using a stack splint or dorsally applied foam-laminated aluminum splint
Follow up with hand specialist within 1 week for possible surgical management
For non-operative management, splint should remain for 8-10 weeks without any flexion of the DIP permitted during healing period
Define a flail chest
When 3 or more consecutive ribs are broken in at least 2 places
What characteristics of a clavicle fracture require emergent or urgent orthopedic consultation for operative management?
- Open fracture or skin tenting
- Neuromuscular compromise
- Posteriorly displaced proximal 1/3 fractures (must also evaluate fro great vessel and airway injury)
- 100% displaced fractures
- Greater than 2cm of shortening
- Comminuted
- Unstable distal fracture fragments
- Floating shoulder
What antibiotic prophylaxis regimen should be prescribed to a patient with a dog bite to the hand with a true penicillin allergy?
A patient unable to take amoxicillin/clavulanic acid should be prescribed a 2 antibiotic regimen:
- activity against pasteurella multimode such as cefuroxime (preferred), TMP/SMX (preferred), doxycycline, or ciprofloxacin
- plus activity against anaerobes such as clindamycin (preferred) or metronidazole
Additionally, ensure no underlying fracture, foreign body, tendon disruption, or neuromuscular injury. Thoroughly irrigate and update tetanus. Consider rabies prophylaxis if regionally indicated.
A patient presents with a painful, swollen, erythematous, and warm native knee joint with significant pain on passive ROM testing. What lab findings on arthrocentesis are suggestive of a septic joint?
- Cloudy fluid appearance
- positive gram stain
- > 50,000 WBC
- > 90% PMNs
Immunocompromised patients and non-native joints may not have typical septic arthritis lab findings. Consider gonococcus in young patients, especially if polyarticular.
Crystal presence does not rule out septic arthritis.
