EM- ortho emergencies Flashcards
most common location of clavicle fracture?
middle 1/3 (80% of the time)
what fracture accounts for 90-95% of birth fractures?
clavicle
which bone in the body is the last one to fuse?
clavicle (finally finishes at 22-25)
ED treatment of clavicle fracture?
sling and swath immobilization for 2 weeks (almost all are treated non-operatively, especially in kids)
when would you consider operative tx for clavicle fracture? (3)
open fracture, skin tenting, NV injury
what is the most common type of shoulder dislocation?
anterior (about 90%)
which type of anterior shoulder dislocation is most common?
subcoracoid- humeral head ends here
how do you check NV status with ant shoulder dislocation?
- check radial pulse for axillary artery
- sensation over lateral deltoid for axillary nerve (most common injury)
- test wrist extension for radial nerve
how do you NOT reduce an ant shoulder dislocation?
DONT put pressure in the armpit (could injure the brachial nerve)
what is a common complication of closed ant shoulder dislocation reduction? why is this important?
humeral neck fracture- can lead to AVN (why its important to get post-reduction films)
if a patient has this along with their ant shoulder dislocation, then you notify ortho upon consult
bankart lesion- disruption of anteroinferior portion of labrum or inferior part of bony glenoid
ED Tx of anterior shoulder dislocation?
Reduction: get pre & post reduction films
Sling & swath for 2 weeks
besides procedural sedation & analgesia, what can you add before reducing an ant shoulder dislocation?
intraarticular lidocaine
most common reduction maneuver for ant shoulder dislocation?
traction counter- traction: gentle adduction with gentle lateral rotation
what is the most important thing to check NV status of post ant shoulder dislocation reduction?
axillary nerve
what are some causes of a post shoulder dislocation?
seizures, electric shock, trauma (MVC)
what is the indication on an XRAY of a post shoulder dislocation?
light bulb sign- due to internal rotation of humeral head
ED tx of post shoulder dislocation
closed reduction
2 weeks of sling and swath
what is a sign of a nondisplaced supracondylar elbow fracture on an XRAY?
presence of a posterior fat pad sign (joint effusion of fluid, blood or pus)
what is the classification system for supracondylar elbow fractures?
Gartland
type 1: hairline crack transverse through humerus
Type 2: displaced anterior wall
type 3: complete displacement (both ant and post wall)
what is the most common peds elbow fracture?
supracondylar fracture
ED tx of lateral condyle fracture?
long arm cast for 4-6 weeks
if greater than 2mm displacement then operative & consult ortho
which type of lateral condyle fracture is more unstable?
type 2 because fracture is into trochlear groove
why is lateral condyle fracture more dangerous?
higher risk of nonunion, malunion, and AVN
what is the adult equivalent of a supracondylar fracture?
radial head fracture
most common orthopedic injury?
distal radius fracture
most commonly missed fracture?
scaphoid
distal radial fracture: distal radius is _________ angulated to the proximal radius
dorsally
monteggia vs galeazzi fracture
monteggia: proximal 1/3 ulnar fracture with associated radial head dislocation
galeazzi: distal 1/3 radius shaft fracture + DRUJ injury (distal radial-ulnar joint)
TX of distal radial fractures?
usually ortho right away: ORIF of radius + reduction and stabilization of DRUJ injury
what is important to push on every time you check for a wrist injury?
push on scaphoid
ED tx of scaphoid?
thumb spica splint and call ortho (displacement over 1mm = ORIF)
what ABX do you give to prevent infection in a fight bite?
augmentin
ED tx of metacarpal fractures?
splint it and let ortho decide if angulation is appropriate
what is acceptable angulation for the fingers?
index & long finger- 10 to 20
ring finger- 30
little finger- 40
what is the most common injury to the skeletal system?
phalanx fractures
what is important to check during exam for phalanx fractures?
tendon function- injury is often near tendon insertion site
ED tx for phalanx fractures?
early mobilization: buddy loops and outpatient follow-up
ORIF/CRPP for unstable irreducible fractures
Tuft’s fracture: where is the fracture located? how to tx?
distal phalanx
assess nail bed (maybe repair) and almost always non-op
ED tx of phalanx dislocations?
reduce finger (usually only takes a slight pull) *do a digital block beforehand and then splint for 6-8 weeks
ED tx of hip fractures
image hip & make sure nothing else will kill them…pain meds and call ortho
what is the prognosis of elderly after having a hip fracture?
one yr mortality post fracture is 25-30%
which type of hip dislocation is most common?
posterior
ED tx of hip dislocation?
1) . attempt reduction in ED under conscious sedation
2) . post-reduction CT to rule out femoral head fractures
3) . protected weight bearing following reduction for 6 weeks
when do you not need post reduction films after hip dislocation?
when the pt has had a total hip replacement and acetabulum is made of titanium
distal Tib/Fib fracture classification
Weber- level of fibular fracture relative to syndesmosis
A= below syndesmosis
B = level of syndesmosis
C = above level of syndesmosis
ED tx for distal tib/fib fracture
if isolated nondisplaced malleoli fracture- conservative tx with short leg walking cast vs boot
displacement of isolated fracture, open, or bimalleolar fracture- ORIF
what is the maisonneuve fracture?
spiral proximal fibular fracture & distal medial malleolar fracture (and/or deltoid ligament rupture) which COMPROMISES SYNDESMOSIS
tx of maisonneuve fracture?
it is unstable so surgical fixation is required
if you have a distal ankle fracture, what is also important to examine?
fibular head!
ED tx of tibial plateau fractures?
knee immobilizer
ED tx of high ankle sprain
sprain w/o diastasis or ankle instability = non weight bearing CAM boot or cast for 2-3 weeks
if syndesmosis is unstable = SURGERY
ED tx of subtalar dislocation?
closed reduction FIRST (sedation and post reduction films)
*open reduction if failed attempt at closed reduction
tibiofemoral dislocations: fracture of what in 60% of cases?
tibia +/- femur
what is the dimple sign?
buttonholing of medial femoral condyle through medial capsule during a tibiofemoral dislocation
dislocated knees always get what test?
vascular studies (ABI AND arteriogram) to evaluate popliteal artery injury; consult vascular if found
ED tx of knee dislocation?
1) . get vascular studies
2) . reduce knee and reexamine NV
3) . splint in 20-30 degrees of flexion (takes pressure off NV)
4) . post reduction films
what is the leading cause of death in pelvic ring fracture?
hemorrhage
if patient is hemodynamically unstable and has a pelvic fracture then what do you give them?
probably will need blood
ED tx of pelvic fracture
place binder on them (goes over trochanter), give blood if needed and call ortho
fat embolism is common in patients with what type of injury?
pelvis or long bone fractures (breaking bones causes marrow to be released into the bloodstream)
fat embolism is more common in bilateral _______ fractures
femur
treatment of fat embolism
prevention! by early fracture stabilization
two major clinical signs of compartment syndrome?
pain out of proportion and pain on passive motion
what striker pressure indicates compartment syndrome?
> 30
tx for compartment surgery
call ortho bc emergent fasciotomy
___% of low back pain resolves within one year of onset
90%
red flags that are signs of severe back issue (2)
1) . saddle anesthesia or acute bowel/bladder incontinence (indicates cauda equina)
2) . constant severe pain that is worse lying down (infection or CA)
ED Tx for cauda equina syndrome
call neurosurgery bc urgent surgical decompression within 48 hours
ED tx for spinal epidural abscess
bracing and IV ABX (surgical decompression with neurosurgery)
ED tx for open fractures
resuscitate, direct pressure, clean it up and place sterile saline dressing, splint, check NV status, START EMPIRIC ABX and call ortho
why is it important to treat gonococcal arthritis FAST?
can destroy the joint in hours (immune system is causing the damage)
gold standard for diagnosing septic joint?
joint fluid aspiration and culture
septic joint: joint fluid aspiration results?
WBC > 50,000
cloudy or purulent fluid
ED tx of septic joint
broad spectrum parenteral ABX after culture; once results back, then narrow down ABX
also irrigate and drain infected joint
how does compartment syndrome happen?
there is an increased pressure in the closed fascial space which leads to decreased tissue perfusion and severe tissue damage
where does compartment syndrome frequently happen?
anywhere skeletal muscle is surrounded by fascia
*leg, forearm, hand, foot, thigh, butt
septic joint presentation
monoarticular, red, hot, tender and decreased ROM (knee most common)
anterior shoulder dislocation MOA
abduction, external rotation and extension
what movements are hard to do for a patient with an anterior shoulder dislocation?
adduction and internal rotation
hip dislocation MOA
young people- high energy injuries
older people- low energy injury
presentation of leg in hip dislocation
slight flexion, adduction and internal rotation
