General Orthopedics Flashcards
What is a sprain?
An acute injury usually involving a ligament.
What are the grades of a sprain?
Gr I: mild pain, swelling. Little to no tear in the ligament.
Gr II: moderate pain + swelling, minimal instability, minimal to moderate tearing, decreased range of motion.
Gr III: severe pain + swelling, substantial instability + decreased range of motion, complete tear.
What is a strain?
An injury involving the musculotendinous unit that involves a muscle, tendon, or attachments to bone.
What are the grades of a strain?
Gr I: localized pain, minimal swelling, tenderness to palpation.
Gr II: localized pain, moderate swelling, tenderness to palpation + impaired motor function.
Gr III: a palpable defect of the muscle, severe pain, poor motor function.
What is the diaphysis?
The shaft of the bone, made of cortical bone, contains bone marrow.
What is the metaphysis?
The area between the epiphysis and diaphysis. Contains the growth plate and ossifies with growth.
What is the epiphysis?
The end of the bone, filled with red bone marrow.
Which Salter fracture type has the worst prognosis?
Type V. Involves the R of SALTR, cRush of growth plate
What does SALTR stand for?
Slipped, straight across
Above
Lower
Through (two)
Ruined or rammed
What is a Green Stick fracture?
A break on one side of the bone that does not damage the periosteum on the other side. Often seen in children.
What is a transverse fracture?
A fracture that is at a right angle, caused by shearing forces.
What is a spiral fracture?
A fracture due to torsion and twisting.
What is an oblique fracture?
A fracture also due to twisting/torsional forces, where fragments can displace easily.
What is a comminuted fracture?
A fracture that breaks into more than two fragments at the site of injury.
What is an impacted fracture?
A fracture where the bone fractures into multiple pieces that are driven into each other.
What is a segmental fracture?
A fracture where a fragment of free bone is present between the main fragments.
What is an avulsion fracture?
A tension failure from the pull of a ligament or muscle, occurring when a small chunk of bone attached to a tendon or ligament gets pulled away from the bone.
What are common areas of blood loss in fractures?
Hip/femur, spine, pelvis (greatest loss).
What complications can arise from fractures?
Nerve damage & vascular compromise
soft tissue damage
swelling (compartment)
fat embolism
infection
non or malunion
Where are Fractures most often missed?
Navicular, hip (subcapital), C7/T1 area, odontoid.
How are Fractures Identified?
site, extent, Configuration, relation of fragments(displaced or non), relation to enviorment (open or closed)
How are open vs closed fractures graded?
graded 1-3 based off tissue damage
what are some ways we can initially treat fxs?
splinting or casting
Stabilize or reduction
Internal or external fixation
What are the goals of splinting/casting?
decrease pain, decrease bleeding, prevent further soft tissue injury
Reduction?
do the bones need to be surgically rearranged
Stabilization?
naturally stabilize the fx via fixation or splint/cast
When do we use external fixation?
open wounds
complex/unstable fx
significant swelling
goals of internal fixation
maintain stability of fx: very important to do early pt mobility post op
What other injuries may occur with a fracture?
neurologic
vasucular
compartment syndrome
amputation
Neurologic injury with fracture?
stretch/contusion of nerves
transection
vascular injury with a fracture?
stretch/compress of vessels
Common places for neurologic injuries
shoulder disclocation=axillary nerve
humerus fracture=radial nerve
hip dislocation=sciatic nerve
spine trauma=SCI
Common places for vascular injuries
supracondylar humerus fracture=brachial artery
knee dislocation=popliteal artery
Criteria for Amputation
- 6 hours= time frame in which soft tissue death will occur due to a vascular injury=amputation
- location
- sharp vs. avulsion
amputation happens more commonly in the LE
Compartment syndrome
- Elevated pressure
- Bleeding, tight cast
- Obstruction of venous outflow
- Muscle and nerve necrosis
- common in Lower leg, forearm
what are the symptoms of compartment syndrome?
The 5 P’s
- Pain (local, with stretch of muscles)
- Paresthesias
- Paralysis
- Decreased pulse
- Pallor
How is compartment syndrome treated?
- Fasciotomy
- Delayed wound closure Infection
osteomyelitis
- Infection within the bone
- Staphylococcus aureus
- Compound fx, surgery, puncture wound that penetrates bone
- Bone biopsy.
tetanus
Tetanus bacteria from wounds. damages nervous system.
Gangrene Dry
- Dry:
- loss of vascular supply=local tissue death.
- Not painful.
- Can lead to auto amputation Wet
Wet:
- bacterial infection, severe burn, untreated wound.
- Cessation of blood flow. Serious medical event.
What is DVT?
Bolus of coagulated blood in the circulatory system.
When is DVT commonly seen?
- trauma
- hip/pelvic fracture
- spinal cord injury
- s/p joint arthroplasty
- CHF
- Obesity
- Post op or post fx immobilization
- Use of oral contraceptives Signs and sx’s
Signs and Symptoms of DVT
- Dull ache or severe pain in calf
- Tenderness, warmth and swelling with palpation
- Changes in skin temperature or color (only seen in 25-50% of cases can be recognized by clinical signs)
tool for clinically predicting DVT
wells clinical prediction rule
0 is low probability
1-2 is intermediate (call the surgeon)
>3 is high risk for DVT (emergency)
who is at greater risk for DVT
- Post-operative or post-fracture immobilization (total joint replacement)
- Prolonged bed rest
- Sedentary lifestyle, extended episode of sitting
- Prolonged standing (>6 hours)
- Trauma to venous vessels
- Limb paralysis
- Active malignancy (within last 6 months)
- Hx of DVT or PE
- Obesity
- Advanced age
- CHF
- Use of oral contraceptives
- Pregnancy
How can we reduce the risk of DVT?
take blood thinners
elevate legs when in supine or sitting
avoid long periods of sitting
iniate ambulation ASAP
active pumping (ankle pumps) throughout the day when in supine
compression socks or pants
pneumatic compression devices
Management Guidelines of DVT
- Administration of anticoagulant medication
- Bed rest, elevation of involved extremity, graded compression stockings
- Bed rest: 2 days→one week +
- Ambulation may begin when anticoagulant therapy reaches therapeutic levels.
Contraindications and precautions for DVT
- Contraindications: P or AROM or heat, compression pump, ambulation is contraindicated until enough medication is in the system
- Precautions: Avoid contact sports and high fall risks activities Plan of Care Interventions
Plan of Care and interventions of DVT
- Plan of Care:
- Relieve pain during acute inflammatory phase Bed rest, meds, elevation
- Relieve pain during acute inflammatory phase Graded ambulation w/ pressure garments
- Prevent reoccurrence
- Interventions:
- Bed rest,meds, elevation
- Graded ambulation w/ pressure garments
- Cont. of meds and imaging
What is Pulmonary Embolism( PE)?
Possible consequence of DVT- embolus travels proximally and affects pulmonary circulation
Signs of PE
- Sudden onset of dyspnea
- Rapid & shallow breathing (tachypnea)
- Chest pain- lateral aspect of the chest
- tachycardia
- Hypoxia
- Blood in sputum
- Swelling in LE’s
- Fever
how is PE diagnosed
- Ultrasound, Venogram
- CT scan
- Blood Gas
How is PE prevented
anticoagulation medicine
early mobility
compression therapy
ankle pumps
elevation
Most Common places for pressure ulcers?
- Sacrum
- Hip
- Cast
- heel
Fat Embolism causes
- Major/multiple traumas (femur)
- Bone marrow fat tissue passes into bloodstream.
- Lodges in vessel and blocks it.
- Inadequate perfusion
fat embolism signs
- dyspnea
- tachycardia
- confusion, agitation
- Early fracture stabilization is key preventive measure Late complications
Malunion
fracture that heals in less-than-optimal position
Nonunion/delayed
break in the bone that has failed to heal after 9-12 months
common sites of nonunion/delayed union
- femoral neck
- navicular
- tibia
- ulna
- odontoid
what is avascular necrosis
death of bone + bone marrow components as a result of blood loss supply or infection.
common sites of avascular necrosis
- Femoral head (chandler disease)
- Scaphoid
- Talus
- Proximal humerus
- Tibial Plateau
what is post traumatic arthritis
intra articular fxs
Complex Regional pain syndrome ( CRPS)
formerly known as RSD
Dx: pain disproportionate to event & no other dx that explains signs + sxs
commonly caused by surgery
Type 1 CRPS
-noxious event, soft tissue injury, immobilization, tight cast, surgery (absence of nn lesion).
- Edema and vascular abnormalities
Type 2 CRPS
-Develops after a nerve injury. Edema, skin blood flow abnormality.
CRPS NOS
sx’s consistent with CRPS but a specific injury/lesion no determined.
Phases of CRPS
- Dynamic~ affected limb evolves from acute warm phase
- Limb is sensitive, swollen, increased temp
- Progresses to chronic cold phase
- Resolution of inflammatory appearance, decreased temp, pain, disability persists.
- Acute phase→prominent peripheral characteristics
- Chronic phase→central changes (central sensitization) CRPS (common impairments)
CRPS impairments
- Pain/hyperesthesia disproportionate to inciting event
- Decreased ROM, motor dysfunction
- Sudomotor/Edema: edema and/or sweating changes and/or sweating asymmetry
- Vasomotor instability: temp asymmetry and/or skin color changes
- Trophic changes: increased/decreased hair and nail growth or skin changes (thin or shiny) Complex regional pain syndrome (reflex sympathetic dystrophy)
- Pain out of proportion to the original injury
stage 1 of CRPS
- pain
- swelling
- discoloration
- abnormal temperature
stage 2 of CRPS
- (3-4) months post injury
- stiffness
- tight skin
stage 3 of CRPS
- (8-9) months post injury
- Muscle atrophy
- Contractures
- Chronic pain
treatment of CRPS
- Early recognition and Rx.
- Pain relief, edema control
- injections, medicines, modalities prn
- Mobilization
- Sensory re-education, mirror therapy
- Treatment within 1 year=80% have significant improvement!
