Emergencies, osteoporosis, thoracic outlet Flashcards
MC in leg and forearm
7Ps:
Pain (out of proportion)
Pallor
Paresthesias
Paresis
Poikilothermia
Pressure
pulselessness
compartment syndrome
Intercompartmental pressure > vascular perfusion pressure → ischemia of muscles, nerves, and vessels
Trauma
compartment syndrome
> 30 mmHg = absolute value
Perfusion pressure by subtracting compartment pressure from diastolic pressure
Pain out of proportion esp w/ passive stretching
compartment syndrome
compartment syndrome tx
Remove all restrictive dressings, splints, and casts
Refer for emergent fasciotomy
Acute onset of pain, swelling, and warmth in affected joint (knee = MC, hip in younger children)
Chills and fever
SC or SI joints = IVDA
RF: pre-existing joint disease
septic arthritis
Nongonococcal acute bacterial arthritis – hematogenous spread + direct inoculation (bacteremia, damaged joints, prosthetic joints, DM2, age, immune status, ulcers)
MCC = staph aureus
E. coli or pseudomonas in IVDA
septic arthritis
PE: look for any breaks in the skin, skin/tooth abscesses, all joints palpated/inspected
Hallmark = joint tenderness, effusion, erythema w/ marked limitation of passive motion
Joint held in flexion
Hips flexed + abducted
Labs: WBC, ESR, CRP
US = joint effusion
Aspiration → crystal analysis, gram stain, cell count, cultures w/ sensitivities
Blood cultures
Gonococcus = throat, cervical, urethral cultures
XR: AP/lat, usually normal but may show soft tissue swelling w/ widening of joint space
MRI to rule out osteomyelitis
septic arthritis
How do you treat septic arthritis
IV antibiotics after synovial fluid + blood cultures are obtained
→ IV ceftriaxone + vancomycin
Emergent surgical decompression + lavage of septic joint
Hospitalization
Prosthetic = may need removal and/or chronic suppression
50% spontaneously reduce before ED arrival → must reduce immediately if obvious deformity, especially if there are absent pulses
knee dislocation
High energy trauma (MVA, fall from height), or athletic injury
→ ¾ ligaments affected
Vascular + nerve injury common
– common peroneal nerve
Anterior MCC
Posterior → popliteal artery tear
Lateral → peroneal nerve
knee dislocation
Instability on exam
If pulses are absent = immediate surgery
XR: look for avulsion fx, asymmetric/irregular joint space
MRI
knee dislocation
How do you tx knee dislocation
Vascular consult, delayed ligament repair
Deformity, pain, loss of independence, premature bone death
Commonly seek medical care for: back pain, fracture, loss of height, spinal deformity
osteoporosis
What are RFs of osteoporosis?
White women > 50 years
Hip fracture
Age
Sex hormone deficiency
Alcohol
Smoking
Long term PPI use
High dose steroid use
Women + cola
Hypogonadal men
Anti-androgen therapy for prostate cancer
Multiple myeloma
Hyperthyroid + hyperparathyroid
Prolonged immobilization
Low bone strength from loss of bone density with inadequate bone mass/quality → deterioration
MC = vertebral fractures, hip, pelvis, wrist
osteoporosis
Blood tests for dx to screen for secondary causes – CBC, CMP, PTH, serum 25-V D, thyroid, hypogonadism celiac
Med adherence/efficacy: CTX (bone resorption), P1NP (bone formation)
osteoporosis
You should have a BMD to screen for osteoporsosis in
All women >/= 65 years and men >/= 70 years
Postmenopausal <65, transition, men 50-69
Adults with fragility fracture
Adults with conditions or medications ass w/ bone loss
Anyone considered for medication for osteoporosis
Anyone being treated for osteoporosis
Anyone not being treated but with bone loss would lead to treatment
best test for osteoporosis
DEXA: quick, painless, accurate to measure bone mass in density compared to peers (Z) and young (T)
T >/= -1 is normal
</= - 2.5 = osteoporosis
What predicts your 10 year risk of hip or other fracture
FRAX
Follow-up scan based on DXA:
-1 to -1.5 = 5 years
- 1.5 to -2 = 3-5 years
<-2 = 1-2 years
High dose prednisone = q1-2 years
You should do DEXA screening in patients — or with risk
> 65
Treatment for osteoporosis is reccomended in
women who have a T score <-2.5 who have already had a fracture or who have a high risk for fracture
non-pharm osteoporosis treatment
maximize bone formation during youth w/ proper diet + exercise = avoid tobacco/alcohol, minimize steroids
Older patients → maintain body weight, minimize caffeine treat visual impairments, prevention w/ exercise
pharm osteoporosis prevention
~ Vitamins → Vitamin D 600-800, calcium 1000-1200 (reserve for those with calcium-deficient diets)
~ Sex hormones → prevent, but do not treat, low dose transdermal estrogen, testosterone/estradiol (men)
What are other osteoporosis treatments?
Bisphosphonates (–dronate) inhibits resorption, lots of SEs
SERMs (-xifene) increase bone in postmenopausal women only (NO in DVT/PE hx)
Denosumab - impaired renal function
Calcitonin - last resort
Anabolic agents (-paratide) - high fracture risk
Mixed agent (romosozumab) - for high fracture risk
Upper extremity pain, numbness, weakness, swelling with gradual onset (or sudden)
– pain radiating from point of compression to base of neck, axilla, shoulder girdle, arm, forearm, and hand
Paresthesias common over volar aspect of 4th and 5th fingers - ulnar neuropathy
Symptoms provoked with 60 seconds by having patients elevate arms
Pallor, cold sensitivity, gangrene
Swelling and/or discoloration prompted with abduction of the arm
females > males
thoracic outlet syndrome
Compressive neuropathy as it passes over first rib/scalene muscle from muscle abnormalities, cervical rib, abnormal posture/pendulous breasts or in athletes (fibromuscular bands, abnormal pectoralis minor, repetitive shoulder use, extreme arm positions, weightlifting, rowing, swimming, pitching)
thoracic outlet syndrome
XR, C-spine, CXR
Angiography
+ Adson sign = loss of radial pulse w/ head rotated to affected side
thoracic outlet syndrome
thoracic outlet syndrome tx
PT and activity modifications w/ shoulder girdle strengthening, proper posture, relaxation techniques
Neurological decompression and vascular reconstruction
Unilateral tingling in arm not typically isolated to single dermatome with resolution in 1-2 minutes
common in contact sports
stinger’s
“Dead arm syndrome” or brachial plexopathy (transient neuropraxia) caused by
Traction injury (downward displacement of arm and bending of neck away from side)
Compression injury occurs by lateral head turning toward affected side
Direct blow
stinger’s
PE: full cervical ROM with no tenderness, unilateral transient weakness in C5, C6 muscles (deltoid, biceps
Spurling test
XR: unremarkable, but rule out
MRI when symptoms are bilateral
EMG if symptoms persist >3 weeks
stinger’s
stinger’s tx
Non-operative = return to play with complete resolution of symptoms, normal strength + ROM
CIs to return to play: recurring symptoms, if cervical XRs have not come back
Try neck collars
