Day 11 - Ms1 Common Adult Ortho Flashcards
Anterior v. Posterior shoulder dislocation
Arm position; ANTERIOR - External rotation, slight abduction (blow to abducted, externally rotated, extended arm - e.g., hitting humerus), PE - prominent acromion (if pt is thin), loss of shoulder roundness, neurovascular compromise (axillary artery/nerve at risk - test for sensation over shoulder before and after reduction); POSTERIOR (less common) - Internal rotation, adduction, unable to externally rotate (blow to anterior shoulder, seizures, electrocutions), PE - Posterior prominence, Anterior shoulder is flat, Unusual to have neurovascular compromise
Tx acute anterior shoulder dislocation
Pain control (consider narcotics); May give lidocaine into glenoid cavity; Conscious sedation may make it easier to reduce shoulder back into place; Variable reduction techniques (e.g., Stimson technique - pt prone, 10-15 lbs traction on pt wrist splint & allowed to hang over bed for 30 min, pressure applied medially over scapula tip; Traction-Countertraction technique - wrap bedsheet around pts axilla, apply outward pulling force to disloated arm while other person pulls sheet in opposite direction); Sling; Ortho f/u within 1 wk; If repeated dislocations, may be candidate for surgical repair
Nerve injury: Claw hand
Ulnar nerve injury
Nerve injury: Ape hand
Median nerve injury
Nerve injury: Wrist drop
Radial nerve injury
Nerve injury: Scapular winging
Long thoracic nerve injury
Nerve injury: unable to wipe bottom
(deficit w/ adduction, internal rotation, & extension) Thoracodoral nerve injury (latissimus dorsi)
Nerve injury: loss of forearm pronation
Median nerve injury
Nerve injury: inability to ab/adduct fingers
Ulnar nerve injury (interosseous muscles)
Nerve injury: loss of arm abduction
Axillary nerve injury
Nerve injury: weak lateral rotation of arm
Suprascapular or Axillary nerve injury
Nerve injury: loss of arm & forearm flexion
Musculocutaneous nerve injury
Nerve injury: loss of forearm extension
Radial nerve injury
Nerve injury: trouble initiating arm abduction
Suprascapular nerve injury (supraspinatus muscle - initiates arm abduction, first 10 degrees)
Nerve injury: unable to abduct arm beyond 10 degrees
Axillary nerve injury (deltoid)
Nerve injury: unable to raise arm horizontally?
Long thoracic nerve injury (serratus anterior - also involved w/ winged scapula); Spinal accessory (trapezius needed to go above horizontal)
Nerve most at risk: Fracture to shaft of humerus
Radial nerve
Nerve most at risk: Injury to surgical neck of humerus
Axillary nerve
Nerve most at risk: Injury to supracondyle of humerus
Median nerve
Nerve most at risk: Injury to medial epicondyle of humerus
Ulnar nerve
Nerve most at risk: Anterior shoulder dislocation
Axillary nerve
Nerve most at risk: Injury to carpal tunnel
Median nerve
Pt comes to ER complaining of wrist pain after fall - findings suggesting scaphoid fracture?
Anytime tenderness in anatomical “snuffbox”, traumatic wrist pain
Tx scaphoid fracture
Short arm thumb spica cast (middle fracture longer, proximal fracture least vascularization = highest risk AVN); If displaced, open reduction also
Mgt femur fracture
Maintain hemodynamic stability (IV fluids, packed RBCs); In past, if CLOSED femur shaft fracture, closed reduction & traction… Now, open reduction & internal fixation to limit bleeding; If OPEN fracture, copious irrigation w/ at least 3 L of normal saline, cover wound w/ sterile dressing, apply gentle pressure to control bleeding, ppx antibx for gram + coverage, OR w/i 6 hrs for debridement, pulsative lavage, irrigation, & delayed primary closure after open reduction & internal fixation; Pain control w/ narcotics; Definitive care ASAP/OR ready; Tetanus ppx
Types of fractures prompt search for ruptured thoracic aorta
(High velocity); 1st and 2nd rib fractures, scapular fractures, sternal fractures
General requirements for tx open fracture in ER
(1) Address hemorrhage w/ wound pressure (2) X-ray (3) Antibx (cephalosporins, if extensive soft tissue damage &/or high contamination, add aminoglycoside; if farm? injury, add penicillin) (4) Apply saline soaked sterile dressing to wound (5) Provisional fracture reduction & splint application (6) Operative intervention w/i 8 hrs; If surgical delay anticipated, remove obvious foreign bodies & irrigate gently; Avoid probing and pressure irrigation, which may force debris deeper into wound; Do not remove any bone fragments; Tetanus ppx
Tx ankle sprain
In first 24 hrs, RICE = Rest, Ice, Compression of swelling, Elevation; NSAIDs; ROM exercises; Rehab starts in first 24-48 hrs, Continue crutches or cane until able to walk with normal gate; Lace up ankle support with metal bars inside (superior to semi-rigid support which is superior to ACE wrap alone); Immobilization (rigid boot), NOT if grade 1-2 sprain then delay return to work/sports; Only if grade 3 sprain = complete tear & joint instability, loss of fxn or motion, unable to bear wt; Warn pts of increased risk of DVT (swelling/color changes/pain or tenderness in calf - return to ER)
Knee injury: Most commonly injured ligament
Medial collateral ligament (MCL)
Knee injury: Positive Lachman test
Type of anterior drawer test (leg at 20 degrees instead of 45 degrees) = ACL tear
Knee injury: Positive McMurry’s test aids in dx
(applying pressure to meniscus causes pain); Meniscus tear
Knee injury: Common dashboard injury in MVA
PCL tear
Characteristics feat of compartment syndrome
Earliest sign is pain in excess of what’s expected, occurring even w/ passive motion; 6P’s (apin, pallor, poikilothermia, pulselessness, paresthesia, paralysis); Measure cmpartment pressures >= 30 mmHg;
Most common compartments &/or fractures leading to compartment syndrome
Most common compartments: Volar compartment of forearm & Anterior compartment of lower leg; Most commonly due to fractures, like supracondylar fractures both bone forearm or proximal tibial fractures
