FINAL EM LE trauma Flashcards
Basics of fracture care
Always check NV Reduce to anatomical Surgery prn Cast vs Splint Immobilization (4-6 wks) Radiographs always
Components of fracture assessment:
Hx of injury
PE: Visual (deformity, color change, tissue trauma), tactile (temp, pulse, sensation, strength)
Radiographs: Xrays, MRI, CT
Findings: Pain Deformity, active bleeding, swelling Ecchymosis/fx blisters “Position of protection” with guarding Inability to use
What should you do about a fx blister
Leave it alone.. let it do it’s thing (pop/not)
*these can delay surgery sometimes
Foot structures (distal to proximal)
Forefoot: Distal phalanx Interphalange Joint (IP) Proximal phalanx Metatarsophalangeal joint Metatarsals Tarsometatarsal joint
Midfoot:
Cuneiforms, cuboid, navicular
Talonavicular joint, calcaneocuboid joint
Hindfoot
Talus
Subtalar joint
Calcaneus
What is the most common way to sprain an ankle and why
Invert ankle (sprain posterior/anterior talofibular ligament?)
*this is bc the medial malleolus doesn’t extendas far down as the lateral
What is a fifth metatarsal fx? MOI? Muscle involved?
Either Stress, Jones or Tuberosity/avulsion fx
Vertical and/or medial-lateral force when foot is inverted with heel raise; wide insertion of PERONEUS BREVIS muscle
How do you differentiate Stress from Jones from avulsion fx of 5th metatarsal
Jones = fx to base of 5th MT, specifically the METAPHYSIAL DIAPHYSEAL JUNCTION, extends to 4-5th MT intermetatarsal area
*avascular zone/watershed area bw articulation
*often confused with fx of 5th MT tuberosity
What is a Lisfranc injury
Fracture/dislocation of 1st-2nd TMT (tarsometatarsal) joint aka the keystone of the transverse arch of the 5 metatarsals; may involve other TMT joints
1st and 2nd metatarsal articulation, commonly missed
How can you get a lisfranc fx/dislocation (of 1st-2nd TMT joint)
High energy or low energy
High: MVA, fall from height
Low: stepping off curb, step into hole
Why is a lisfranc fx/dislocation so significant
Bc the 2nd metatarsal is responsible for STABILITY
5 metatarsals with 2nd acting as keystone
s/sx and dx of Lisfranc fx/dislocations
s/sx:
Midfoot pain when bearing weight
Point tenderness over Lisfranc joint
Swelling/deformity in midfoot
Plantar flexion and rotation of forefoot painful
Dx
20% mis-diagnosed or overlooked; sprain vs dislocation vs fx; obvious vs subtle findings, acute vs chronic presentation
Xray findings of Lisfranc injury
AP: Medial margin 2nd metatarsal and middle cunieform alignment
Lateral: Dorsal margin 1st/2nd metatarsal and cuneiform alignment
Oblique: base of 4th metatarsal and cuboid alignment
When is surgery indicated for lisfranc injury
More than 2 mm
Tx for Lisfranc injury (dislocation or fx of 1st-2nd TMT joint)
Goal: stable anatomic foot
EARLY RECOGNITITION important!!
Conservative: cast immobilization, orthotics
Surgical: acute injury with displacement (2mm), or neurovascular compromise/compartment syndrome
1 yr recovery time
Calcaneus fx: tx
Conservative: cast immobilization 6 wk, NWB, transition to padded shoewear, orthotics
Surgery
Achilles tendon: anatomy, acute/chronic injury
Common insertion of gastrocnemius/soleus
Function: plantarflexes ankle/foot
Acute: tendinitis, rupture (think of referees running backward)
Chronic: tendinosis, insertional enthesitis (haggling deformity, bone grows away from tendon)
What is insertional enthesitis
Haggling deformity where bone grows away from achilles tendon
Achilles tendon: H&P, findings
Hx: precipitating events (often misdiagnosed as ankle sprain), are they on CIPRO?
PE: POINT tenderness and/or palpable defect, positive THOMPSONS test
Radiographs: plain xray, MRI
*even with soft tissue like Achilles tendon, start with an xray to r/o bone damage
Tx of Achilles tendon rupture/injury
Immobilization (equinus position), surgical repair, PT
*equinus positon: natural position assumed by leg/foot when bend leg and lift it
Important question to ask with fibula fracture/ leg/ankle fracture
Is fibula out to length
*often from primary care perspective, fibula fx will be treated the same regardless.. we are imaging, and splinting and sending to ortho freq
Tx and things to be aware of with fibula fx
Is fibula out to length? Immobilization 4-6wk Post traumatic stress Syndesmotic screw removal at 12 wk post op Gradual return to activity
Tx: fiberglass cast, boot/splint, weightbearing (NWB, partial, WBAT)
Types of Tibia fx
Mid shaft, plateau,
Tx of Tibia Plateau fx
Immobilization: SL immobilizer, ROM hinged brace
NWB (crutches vs wheelchair)
Analgesics
Further dx studies (CT scan), Referral
Tx Femur Fx
Admit to hospital
Traction
Lab work (CBC, TxS (type and ?), Coag studies – anticoag prefer coumadin)
Surgical Consult
Postop: anticoag, physiotherapy mobilization
*can los 2 L of blood in thigh
Acetabular Fx: MOI and tx
High energy:
1) trauma: may be life threatening
2) Look for other injuries: head, abdomen, urological, spine
Tx: Observation (team approach), surgery
Low Energy
1) insuffieciency Fx
F>M
Tx: Protected wt bearing, analgesics
Etiology, findings,tx of LE stress fx?
May occur in pubic rami or femoral neck
- insidious onset of pain in groin region, F>M
- xrays initially negative, may need MRI to delineate; look for cortical disruption on xray
Tx: rest, protected WB, Analgesics, surgery
Pubic Rami fx tx? What to look for on xray?
Weightbearing as tolerated with walker
Pain mgmt: narcotics, analgesics
Look for step offs on xray
What are the types of hip fx?
Subcapital/femoral neck (transcervical?)
Intertrochanteric
Sub trochanteric
Femoral shaft
Hip fx: s/sx and tx
s/sx: pain, inability to weight bear, shortened leg typically held in external rotation
Tx: non surgical: NWB, bed rest (traction), surgical
What is traction/what is it used for? Counterweight?
Aligns fx fragments, relieves muscle spasm, relieves pain
Reduces pressure on ends of bones by relaxing muscles
Ex: used in hip fx and femoral
Skin: 5-10 lb counterweight
Skeletal 25-40 lb counterweight
Arteries in femoral neck
Subsynovial intracapsular arterial ring Ascending cervical arters Ascending branch LFC (lat femoral circumflex) Lateral femoral circumflex artery Descending branch LFC
*risk avascular necrosis
Xray findings femoral neck/subcapital fx and what are risks a/w this fx
Shortened femoral neck
*risk avascular necrosis
What is something unique about subcapital/femoral neck fx surgery
Can walk on the same day of surgery
Intertronchanteric hip fx surgery option
Dynamic hip screw
Gamma short inter medullary rod
Presentation, tx compartment syndrome
Volkmans?
Caused by crush injury of forearm vs tight bandage or cast
5 p: pain, pallor, Parethesia, Pulselessness, Paralysis
*pain with passive extension, stocking glove anesthesia, Rock hard forearm
ABSOLUTE EMERGENCY
Tx: surgical decompression via fasciotomy
*ntoe: under 20 is normal pressure, foot drop is peroneal nerve
Saltar Harris classification: I-IV
*note: proximal to distal: Metaphysis – physis - epiphysis
I: horizontal fx through physis (growth plate)
*II: Fx through physis extending proximally into metaphysis
*III: Fx through distal epiphysis extending proximally into physis
IV: fx through all (epiphysis, physis, metaphysis)
V: crush injury of physis
Salter Harris II is most freq on boards
Trick for remembering Saltar Harris
I: Same II: Above III: Lower IV: through everything R: crush
What is a greenstick fx
Bending of bone, kids
How should you describe a fx
Verbally paint a picture of xray when describing it
Open vs closed
Include bone, # fragments, position of fragments
Intra vs Extra articular
What is volkman’s syndrome/contracture
a/w compartment syndrome: Volkmann’s contracture, also known as Volkmann’s ischaemic contracture, is a permanent flexion contracture of the hand at the wrist, resulting in a claw-like deformity of the hand and fingers. It is more common in children. Passive extension of fingers is restricted and painful. PE: fingers cold, white or blue ; radial pulse is absent.
