Day 11 - Ms1 Common Adult Ortho

Question 1

Anterior v. Posterior shoulder dislocation

Answer 1

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

Question 2

Tx acute anterior shoulder dislocation

Answer 2

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

Question 3

Nerve injury: Claw hand

Answer 3

Ulnar nerve injury

Question 4

Nerve injury: Ape hand

Answer 4

Median nerve injury

Question 5

Nerve injury: Wrist drop

Answer 5

Radial nerve injury

Question 6

Nerve injury: Scapular winging

Answer 6

Long thoracic nerve injury

Question 7

Nerve injury: unable to wipe bottom

Answer 7

(deficit w/ adduction, internal rotation, & extension) Thoracodoral nerve injury (latissimus dorsi)

Question 8

Nerve injury: loss of forearm pronation

Answer 8

Median nerve injury

Question 9

Nerve injury: inability to ab/adduct fingers

Answer 9

Ulnar nerve injury (interosseous muscles)

Question 10

Nerve injury: loss of arm abduction

Answer 10

Axillary nerve injury

Question 11

Nerve injury: weak lateral rotation of arm

Answer 11

Suprascapular or Axillary nerve injury

Question 12

Nerve injury: loss of arm & forearm flexion

Answer 12

Musculocutaneous nerve injury

Question 13

Nerve injury: loss of forearm extension

Answer 13

Radial nerve injury

Question 14

Nerve injury: trouble initiating arm abduction

Answer 14

Suprascapular nerve injury (supraspinatus muscle - initiates arm abduction, first 10 degrees)

Question 15

Nerve injury: unable to abduct arm beyond 10 degrees

Answer 15

Axillary nerve injury (deltoid)

Question 16

Nerve injury: unable to raise arm horizontally?

Answer 16

Long thoracic nerve injury (serratus anterior - also involved w/ winged scapula); Spinal accessory (trapezius needed to go above horizontal)

Question 17

Nerve most at risk: Fracture to shaft of humerus

Answer 17

Radial nerve

Question 18

Nerve most at risk: Injury to surgical neck of humerus

Answer 18

Axillary nerve

Question 19

Nerve most at risk: Injury to supracondyle of humerus

Answer 19

Median nerve

Question 20

Nerve most at risk: Injury to medial epicondyle of humerus

Answer 20

Ulnar nerve

Question 21

Nerve most at risk: Anterior shoulder dislocation

Answer 21

Axillary nerve

Question 22

Nerve most at risk: Injury to carpal tunnel

Answer 22

Median nerve

Question 23

Pt comes to ER complaining of wrist pain after fall - findings suggesting scaphoid fracture?

Answer 23

Anytime tenderness in anatomical “snuffbox”, traumatic wrist pain

Question 24

Tx scaphoid fracture

Answer 24

Short arm thumb spica cast (middle fracture longer, proximal fracture least vascularization = highest risk AVN); If displaced, open reduction also

Question 25

Mgt femur fracture

Answer 25

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

Question 26

Types of fractures prompt search for ruptured thoracic aorta

Answer 26

(High velocity); 1st and 2nd rib fractures, scapular fractures, sternal fractures

Question 27

General requirements for tx open fracture in ER

Answer 27

(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

Question 28

Tx ankle sprain

Answer 28

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)

Question 29

Knee injury: Most commonly injured ligament

Answer 29

Medial collateral ligament (MCL)

Question 30

Knee injury: Positive Lachman test

Answer 30

Type of anterior drawer test (leg at 20 degrees instead of 45 degrees) = ACL tear

Question 31

Knee injury: Positive McMurry’s test aids in dx

Answer 31

(applying pressure to meniscus causes pain); Meniscus tear

Question 32

Knee injury: Common dashboard injury in MVA

Answer 32

PCL tear

Question 33

Characteristics feat of compartment syndrome

Answer 33

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;

Question 34

Most common compartments &/or fractures leading to compartment syndrome

Answer 34

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