ED, ortho, psych and randos Flashcards
Indications for a back slab
- Non-displaced #
- Minor injuries e.g. buckle or minor physeal #
- Swelling anticipated to be a problem - elbow or tibial #
- Crush injuries
- Open #
Clinical signs of scaphoid #
- Pain on dorsiflexion of wrist
- Tenderness over anatomical snuff box
- Pain on gripping
* Can have normal XR for first few days
Complications of scaphoid #
- Avascular necrosis (proximal portion)
2. Non-reunion
Distal humerus # can cause injury to… x nerve
Clinical signs would include…
- Radial nerve
- Wrist drop (supplies extensor muscle of forearm - extension of wrist and fingers + triceps to extend elbow) and loss of sensation over dorsal surface of thumb to middle of 2nd digit
Abnormal fat pads in supracondylar # of humerus…
- Visible posterior fat pad
- Usually tucked into olecranon fossa –> unable to visualise on XR
- Haemarthrosis/effusion assoc. w/ # lifts the posterior fat pad - Sail sign: an upward lifting of the anterior fat pad due to anterior haematoma
Hangman’s fracture
MOI: hyperextension of neck
- Bilateral fracture of C2 pedicle
- Horizontal tearing of disc C2-C3
- Anterior subluxation of C2 on C3
Salter-Harris Physeal Injury (growth plate #)
Type 1: separation through physis, usually through areas of hypertrophic and degenerating cartilage cell columns
Type 2: # through portion of physis extending into metaphysis
Type 3: # through portion of physis extending into epiphysis and into the joint
Type 4: # through epiphysis, physis and metaphysis
Type 5: crush injury to physis
Which Salter-Harris # is most likely to disrupt growth?
Type 4 and 5 are at high risk of growth disturbance
Jefferson’s #
Compression fracture of bony ring of C1
UNSTABLE #
MOI: axial blow to vertex of the head (e.g. diving injury)
Wedge fractures of C-spine
MOI: flexion injury to anterior column –> anterior compression #
- Most common at C4/5/6
- DDx: r/o burst # –> suspicious if >50% anterior vertebral body height loss
Perthe’s disease
Temporary interruption of the blood supply to the proximal femoral epiphysis -> osteonecrosis and femoral head deformity
Assoc with thrombophilia, FVL, protein C/S deficiency, lupus anticoagulant etc
MC boys than girls 4-8 years
Bilateral 10%
Supracondylar fractures
- Age group: 3-15yrs
- MOI: FOOSH with hyperextension at elbow
- Concerning signs: severe swelling, ischaemia of hand, absent radial pulse, skin puckering or anterior bruising, open injury, nerve injury
- -> Ulnar and radial nerve (7%) injuries are uncommon
- XR: posterior fat pad, sail sign, anterior humeral line passes through anterior 1/3 of capitellum or misses it completely
Supracondylar # classification and management
Gartland classification:
- Non-displaced #: immobilisation with above elbow back slab, 90 deg elbow flexion w/ sling for 3/52
- Displaced with intact posterior cortex: ortho referral, can trial gentle reduction in ED. If displacement in coronal plane, requires ortho review as it can cause malunion –> cubitus varus (cosmetically unacceptable)
- Displaced with no cortical contact: ortho referral - open reduction and percutaneous pin fixation
Volkmann’s ischaemic contracture
Highest risk with Gartland Type 3 Supracondylar #
- Also increased risk if full arm cast is used instead of backslab with hyperflexion of elbow
Monteggia’s fracture-dislocation
- Proximal ulna # causing radial head dislocation at proximal radioulnar joint
- Age group: 4-10yrs
- MOI: FOOSH with hyperpronation or hyperextension of forearm
- Clinical pres: diffuse swelling, pain to move elbow in any plane
- Other complications: radial nerve injury (most common), posterior interosseous nerve injury, delayed Dx = biggest concern
- XR: radiocapitellar line does not intersect centre of capitellum = radial head dislocation, ulnar # (can be subtle with plastic deformation)
- Mx: urgent ortho review
CRITOE
Ossfication centres of elbow:
- Capitellum (1yr)
- Radial head (3yr)
- Internal/medial epicondyle (5yr)
- Trochlea (7yr)
- Olecranon (9yr)
- External/lateral epicondyle (11yr)
Formulas for airway adjuncts
- ETT size uncuffed = (age/4) + 4 if >1yr
- 3.5-4mm uncuffed or 3.0mm cuffed for neonate - 1yr - ETT size cuffed = (age/4) + 3
- ETT measurement at lip = (age/2) + 12 OR ETT size x3
- ETT measurement at nose = (age/2) + 15
Psychiatric disorder with the highest mortality rate?
Anorexia nervosa
- 50% due to malnutrition
- 50% due to suicide
- 10-20% mortality within 20yrs
Life-threatening weight loss for eating disorders
- Total body weight <75% expected (for height)
- Acute weight loss of 15-20% in 3 months
Management of anorexia nervosa
- Inpatient feeding
- Refeeding to 90% ideal body weight or until medically stable
- Careful monitoring of electrolytes, cardiovascular and metabolic profile - Psychotherapy
- Family-based therapy (FBT) - good RCT evidence
- No RCT evidence to support medication use. Anti-depressants for co-morbid depression, but not helpful when pt at very low wt –> wait till recovery
- CBT for anxiety once wt recovery has occurred
Cardiac changes in anorexia
- Prolonged QT - especially with re-feeding syndrome
- Low amplitude QRS waves and T waves
- Bradycardia
- Arrhythmias
Which co-morbid psychiatric disorder is most predictive of a poor outcome in anorexia?
Obsessive compulsive disorder
Which eating disorder benefits from early SSRI use?
Bulimia nervosa
- Use with CBT in a group or for the individual
ADHD
- Inattention, hyperactivity, impulsivity
- -> Subtypes: inattentive, hyperactive or combined
- Symptoms before 7 years of age
- Sx in 2 or more settings i.e. school and home
- Disruptive/causes dysfunction
Syndromes associated with ADHD
Velocardiofacial syndrome
Fragile X syndrome
Tuberous sclerosis
Other risk factors for ADHD
- Genetic: heritability 80%, D4 and D5 receptor gene variants
- Syndromes
- Poor mother-child relationship, extreme adversity
- Prematurity, LBW
- Antenatal: maternal ETOH and smoking(?)
- Environmental toxins: lead
ADHD Management
- Psychostimulants: Tx alone is as good as/better than combination treatment for CORE ADHD SX
- Other meds/psychotherapy depends on co-morbidity
- Co-morbid anxiety: meds + behavioural/CBT
- Co-morbid ODD/CD: parent management training
- Tourette’s: does not preclude stimulants (use lower doses)
Common side effects of stimulants
- Decreased appetite
- Abdominal pain
- Headaches
- Mood changes/irritability/anxiety
- Pulse and BP change
- “Rebound” effects - post-therapy anger, irritability, lethargy
Uncommon, but clinically important SEs of stimulants
- Growth suppression
- Tics, stereotyped behaviour
- Drug dependence if misused - BUT, does not increase risk of substance abuse overall
Which psychiatric conditions increase the risk of antisocial personality disorder
ADHD and conduct disorder
Glucose concentration in dextrose solutions
% = mass percentage
–> 5% means 50g/L
–> 50% dextrose means 500g/L
Dextrose provides 3.4kcal/g –> a 5% dextrose solution provides 0.17kcal/mL (50 x 3.4/1000)
