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Emergency Medicine > ortho > Flashcards

ortho Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

level 1 trauma center needs

A

all specialties/modalities avail 24hrs

MRI, Fluoroscopy, CT scan, etc avail for 24 hrs

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2
Q

The “Golden Hour”

A

Time we have to make a difference

ii. 1 hour – if you’re going to crump, you will crump

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3
Q

How does the PA student fit? Anticipate

A

Undress, log-roll (if on backboard), IV access, foley, doppler/API’s (looking for pulses, compartment syndrome), CPR, to CT

Lac repair, help ortho (reductions, etc), ophtho, ENT, etc

OR, care in-house

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4
Q

primary survey

A

ABCDE hx (if awake)

GCS and a C spine and a ULS

pt is phonating =has an airway

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5
Q

AMPLE survey

A 
allergies 
meds
PMH/PSH
last PO
events environment
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6
Q

Secondary Survey

A
  1. Full systems exam, head to toe

2. More complete Hx

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7
Q

how to management pt with . GSW

A

Stabilize the patient if unstable - undress

Determine where, how many, other injury

Neurovascular integrity is the priority in extremities

Penetrate the joint?

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8
Q

checking neurovascular integrity should look like what

A

Check: pulses, pallor, temp (cold?), cap refill

2. Sensory exam

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9
Q

how to evaluate weather or not a shot has penetrated the joint

A

Air in joint = penetration

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10
Q

how should you report a fx with a GSW

A

“i have a GSW with an open fracture to the left tibia”

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11
Q

how to treat fxs

A
  • X-ray all – joint above/below
  • If fx, treat as open fx
  • Local wound care, debridement
  • Surgery, ortho consult
  • Consider Abx
  • Splint, close follow-up
  • Tetanus
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12
Q

big concern with femur fracture

A

Risk for compartment syndrome

all of huge critical arteries that supply the leg will be pulled and the legg will probably need a steinman pin might be needed to correct

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13
Q

what should we be thinking about with pelvis fx

A

Internal injury common (strap them with stabilization device)

Surg admit, ortho consult

worry about the bladder, reproductive organs, rectum

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14
Q

big tell tale sign of hip fx

A

can’t bare weight

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15
Q

risk for hip fx

A

Describe location
1. Classic – old woman who
fell down

Risk for AVN

Occult fx? CT(first test) or MRI*(definitive)
Ortho admits for pin or
replacement

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16
Q

talking to pts about knife and stab wound

A

We deal with extremities/stable pt only
think immediately about assault and police reports

Good history; police report made?

tell me what happened and show me what position you were in

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17
Q

how to approach stab wounds

A

Count, measure, explore deeper structures
i. Function, neurovascular exam

Imbedded objects are removed in the OR – don’t pull them out (may have lacerated one of the arteries but if you leave it in it stops the bleeding)

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18
Q

why would you do delayed primary closure

A

High risk, contaminated or neglected wounds – don’t suture

  1. Hands, feet, over joints; immunocomp pt; crush, bite, puncture
  2. Predict high infection risk
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19
Q

when to have pt return for high risk wounds

A

Copious irrigation, wound debriedment

iii. Leave open, no suture, dry dressing
iv. Follow-up in 3-5 days – suture the wound then if no infection
v. Pt Ed/document: Discussed, return signs infection, increased scar risk

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20
Q

arterial bleed 1st approach

A

Universal precautions, ABC’s

Check for foreign body, elevate

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21
Q

managing arterial bleed in the wilderness

A

1st small tightly folded nugget with pinpoint accuracy

2 incremental larger or less folded piece of gauze

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22
Q

TXA used for

A

Tranexamic acid

clott promoter arterial bleed

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23
Q

Traumatic ABI looks like

A

Comparison of ipsilateral upper and lower extremity systolic pressure

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24
Q

how to take ABI

A

Pt supine, BP cuff, doppler

Doppler brachial SBP, then highest of dorsalis pedis and posterior tibial

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25
Q

ABI

A

ABI = Ankle SBP/Brachial SBP

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26
Q

Arterial Pressure Index (API)

A

Compare injured extremity to the other one (for example – compare L foot to R foot)

API = Injured SBP/Uninjured SBP

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27
Q

Approach to Ortho Injuries

A

Mechanism and when occurred

Associated sx’s/risk – fall, high energy, helmet, protective gear

Sx’s other than pain? Numb? Weak? LOC? Weight bear? Hear noise?

Pain right away or delayed?

Blood loss estimate; arterial?

Dominant hand? DON;T MISS

Hx same/other injury in past?

Occupation? Work related?

Assault? DV? Police report?

PMH, Meds, Allergies

Tetanus?

Social situation

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28
Q

PE for ortho needs

A

anatomy, neurovascular exam are key

Master exam for each area

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29
Q

medication and imaging that needs consideration for ortho injuries

A

Pain control. Abx? Oral? IV?

Imaging: Xray 1st. Need CT?

Repair, reduction, splint?

ED splints; no cylindrical casting

Ortho consult, rec’s, f/u

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30
Q

pt education should include

A
  • Splint care
  • Importance of f/u
  • Red Flags to return
  • Recovery period
  • Document!
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31
Q

neurovascular test should include

A

Know anatomy of injury area

Check at injury area and distal

Neuro: sensory, motor, DTR’s
1. 2-point discrimination fingertips

2. <6mm normal
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32
Q

vascular check should include

A

: pulses, cap refill, temp, color, Allen’s test

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33
Q

no pulse or weak pulse?

A

GO GET THE DOPPLER

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34
Q

Neuropraxia

A

nerve contusion

a. Temporary – recover

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35
Q

No sensation

A

nerve cut/damaged

a. Which nerve, reproduce, compare

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36
Q

Cold extremity, pallor of the hand/foot means

A

) = Vascular emergency (Surg/Ortho

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37
Q

example of consulting hx

Lauri’s example of talking to a specialist

A

Begin with Dx; then age, gender, PMH

  1. If fx: open or closed?
    iii. Mechanism, other injury
    iv. Dominant hand. Occupation.

\Good PE prior to call: describe it
1. Know motor, neuro, vascular status

and what have you done

  1. Imaging, ultrasound
  2. Reduction?
  3. Antibiotics, Tetanus

“i have a 35 yo male with an OPEN tip fib s/p MVA x1 hour BIBA xray show comminuted fx of the __ the pt is otherwise stable and placed in a splint, they are in bed 14”

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38
Q

scaphoid fx is at risk of AVM

A

at the waist

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39
Q

ortho should be consulted for

A
  • All fractures to arrange f/u
  • Joint infection/issues (may have cellulitis around the joint)
  • Ligament/Tendon injury/rupture
  • Hand/finger cellulitis
  • Minor crush/soft tissue injury
  • Major dislocations
  • Ortho Admits:
  • Fractures/injuries requiring surgery now
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40
Q

true emergencies

A
  • Open fractures
  • Compartment syndrome
  • Septic joint (in the joint)
  • Un-reducible dislocation
  • Amputations
  • Crush/mangled
  • Pressure, air-gun injury**special (devastating, very high risk)
  • Neurovascular compromise
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41
Q

mechanism of contusions

A
  1. Crush is high risk
  2. Spontaneous is high risk
  3. Coumadin?
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42
Q

exam of contusions

A

need MOA

ii. Neurovascular exam
iii. Is this cellulitis/nec fasc?
1. Search for wound/gas

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43
Q

cellulitis

A

red
tender
warm

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44
Q

complications you are worried about in contusions

A

iv. Check for ligament/tendon rupture
v. Check joint above/below
vi. Check compartments; soft?

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45
Q

mnmgt from contusions

A

Xray for fx, gas, foreign body

Ice, elevation, return precautions

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46
Q

how to write about ligamentous injury

A
  • Know ligamentous anatomy of injured area
  • Know the “special moves” for each joint
  • Stress joints to uncover laxity
  • Sprains:

joint is stable to…
mcmurrys
lachmans
anterior drawer **

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47
Q

1st degree sprint

A

mod pain, minimal swelling, no laxity

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48
Q

2nd degree sprain

A

pain, swelling, loss function but no laxity

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49
Q

3rd degree sprint

A

complete ligamentous disruptions
• Significant pain/swelling/function loss
• Joint laxity present

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50
Q

collecting information on sprain should look like

A

i. Mechanism, when occurred, other injury, weight bear?

ii. Neurovascular exam
iii. Stable or unstable joint
iv. Look for wound, lesions
v. Infection? Septic joint?

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51
Q

sprain management

A

Xray – Ottawa Rules

vii. ACE/Brace/RICE if minor
viii. Joint disruption or unstable?
1. Splint like fracture
2. Ortho consult, f/u

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52
Q

Popeye sign (sling)

A

biceps tendon rupture

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53
Q

Can’t extend lower leg
Knee immobilizer
think

A

patellar rupture

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54
Q

Defect, hip flexion

Knee immobilizer

A

quadriceps rupture

55
Q

mangement achilles

A

Hear “pop”, local defect
Thompson’s test
Posterior splint, equinus

56
Q

patellar rupture test

A

can you kick me while sitting down

“the patient has full extension of the patella”

57
Q

mnmgt of patellar fx

A

Xray all, Ortho/Pods consult all

Immobilize, outpt f/u

58
Q

describe fx

A

open or closed

location
number of fragments

direction of fx line

alignment

special fxs

59
Q

describing lcoation (5)

A 
Which bone(s)?
Where in the bone?
“Head” proximal
Proximal, middle, distal shaft, neck
Intra-articular?
60
Q

number of fragments think

A

simple (2)

comminuted (>2)

61
Q

direction of fx line

A

Transverse, oblique spiral, longitudinal

62
Q

alignment thnk

A

Displaced, distracted
Angulated
Shortened, impacted, depressed
Rotated

63
Q

elbow look for

A

Post fat pad, sail sign
Anterior Humeral Line
Radiocapetellar Line

64
Q

radial head

A

Subtle, common, FOOSH

65
Q

Nightstick

A

Defensive, midshaft ulna

66
Q

Fx ulna w/ radial head dislocation

A

Monteggia

67
Q

Galeazzi

A

Fx distal 1/3 radius with ulna dislocation

68
Q

special features of the wrist to consider with intra-articular

A

Check carpal bone arches

spaces and alignment

69
Q

scaphoid fx at risk at

A

AVN risk if at “waist”

Check snuff box

70
Q

Colles vs Smith’s

A

Colles dorsal, Smith’s volar

FOOSH; need reduction?

71
Q

Teacup is tipped over

A

lunate

72
Q

teacup is empty

A

perilunate

carpals dislocated

73
Q

Boxer’s Fx

what is it and when do you reduce

A

4-5th at neck (fight bite?)
Note finger rotation
Reduce >30deg angulation

74
Q

review right now

A

Gamekeeper’s, Bennett’s, Rolando fx’s

75
Q

Hyperextened finger

A

volar plate

76
Q

Jammed

suspect

A

extensor avulsion

mallet finger

77
Q

patellar consideration

A

Direct blow
Sunrise view
Check patellar tendon

78
Q

who get’s tibila plateau fxs

A 
MVA, Auto vs Ped
Jumpers
Can be subtle
Can’t weight bear
Get CT
79
Q

Mortise fx

A

Wide? Disrupted?

Ligamentous injury

80
Q

Maisoneuve

A

Mortise plus proximal fibula fx

Palpate proximal leg in all ankle injuries

81
Q

bimal

vs trimal

A

Unstable both

check lateral for tri mal

82
Q

mngmt of talus fx

A

CT

Not common
High risk AVN
CT all

83
Q

SIGN w/ calcaneus fx

A

Mechanism, Mondor’s sign

CT all

84
Q

Lisfranc fx/dislocation

what are they and how are they manged

A

Mechanism
Check the 1st, 2nd, 3rd MT joints
CT all

THIS NEEDS TO BE ON THE DDX OF THE FOOT

goes to the operating room TONight

85
Q

4 special bony conditions

A

open fxs
non-union or malunion
osteomyelitis
AVN

86
Q

open fxs worry about

A

All get xrays first, then ortho consult

87
Q

Non-union/malunion worry about

A

Deformity, pain after fx

chronic pain prone to stressors
Often non-compliance

88
Q

who get’s osteomyelitis

what are we worried about

A

DM, chronic infections

Ask: Is this nec fasc?

89
Q

AVN risk

A

talus
navicular/scaphoid
head of the numerous

90
Q

consideration in shoulder dislocation

A

Anterior or posterior?

Hill-Sachs–repetitive frequent dislocation

91
Q

how to describe dislocations

A

always describe the distal portion

70% of hip dislocation posterioer

92
Q

in all joint dislocations consider

A 
Open or closed?
Neurovascular exam paramount
Xray all: fracture dislocation?
We try reduction first if no fx
Ultrasound guided nerve blocks
Intra-articular injection
Procedural sedation
Xray post reduction
Ortho consult, immobilize
93
Q

considerations with effusions

A

mono articular vs. poly – ballottment (does the patella bounce)– hot/red? (eep think spetic)

94
Q

big concerns for spetic joint

A

Atraumatic, +/- fever, red/hot, won’t move it

95
Q

pathogens common with septic joint

A

S. aureus most common, N. gonorrhea 20%

GC big one for mono articular

96
Q

Hemarthrosis is usually mono or poly?

usually in the setting of….

A

mono

Post trauma

97
Q

findings in gout

A

usually mono, or poly
Uric acid crystals (bi-refringent)
Pseudogout - CPPD

98
Q

Reiter’s Syndrome

A

asking about penile of vaginal discharge

mono/poly
Arthritis, conjunctivitis, urethritis

99
Q

Inflammatory – usually mono or poly?

A

Inflammatory – poly

100
Q

labs for swollen joints

A

Get xrays, CBC (ESR, CRP)

101
Q

Arthrocentesis

A

Consent pt, check contras
Cellulitis, coumadin, prosthetic jt

Strict sterile procedure

102
Q

arthrocentesis is done for

A

Diagnostic and therapeutic
Suspect septic joint
Hemarthrosis post trauma
Gout diagnosis

103
Q

how do you do a arthrocentesis

A

Big joint, big needle
Ultrasound guidance
Take out as much as possible: can inject bupivicaine after tap
Send fluid for cell count, culture

104
Q

when to suspect infection after arthrocentesis

what are the complications

A

> 50,000 WBC’s: infection***

Complications: iatrogenic infection, bleeding, local trauma

105
Q

Five “P’s”:

A

Five “P’s”: pain, pallor, paralysis, pulselessness, paresthesias

106
Q

do you need all 5 of the p’s for compartment syndrome ?

A

Don’t need all for dx. All = late

107
Q

first sign of compartment

A

Severe/pain out of porportion, w/ passive stretch: early hallmarks

108
Q

common findings with compartment syndrome

A 
Edema, bleeding = reduced blood flow
Muscle/nerve necrosis ensues
First few hours to 48hrs
Femur/tibia, humerus/elbow/hand fx/injury
Severe pain w/ cast? Remove it
109
Q

Stryker pressures

A

???

Fasciotomy
Anticipation, high vigilance

110
Q

who is at risk of puncture wounds

A

6-10% get infected: DM, immunocomp, PVD high risk

111
Q

management of puncture

A

Xray all for FB, fx; low pressure irrigate, tetanus shot

irrigate softly with gravity

(don’t push shit back in)

112
Q

what is the time consideration with

A

<6hrs old, clean wound, healthy pt:
No abx, return precautions, do well

>6hrs, high risk pt/wound, plantar surface/hand:
Consider abx (Cipro, Keflex), strict return precautions
113
Q

tennis shoe puncture wound?

A

psuedamonas !

cipro

Consider vascular/neuro/lig/tendon injury

114
Q

Hand puncture wounds consider

A

Consider vasc/neuro/lig/tendon injury

115
Q

complications with hands

A

Cellulitis, abscess, osteomyelitis (pseudomonas)

116
Q

“No man’s land”

A

flexor tendon injury

117
Q

mangement of flexor tendons

A

Flexor repaired in OR – ortho

Some extensor – ED can repair

118
Q

sausage finger held in flexion

A

Flexor tenosynovitis, cellulitis

119
Q

why do we worry about a fight bite?

weird bite

A

Eikenella corrodans, polymicrobial

120
Q

mngmt of human bite

A

Admit, IV abx fight bite. Others: Augmentin

Tetanus, consider Hep B vaccine

Don’t miss DV!!

DO NOT SUTURE human bites!

121
Q

high risk pathogen of cat bites

A

Pasturella Multoceda, Staph, Strep, Moraxella

Bartonella: Cat scratch fever

122
Q

tx of animal bits

A

Clean like puncture
Do not suture!
Augmentin, close f/u

123
Q

management of dog bites

A 
Medium risk infection
Polymicrobial
Copious irrigation, debridement
No suture if hand, feet; face/scalp ok
Abx if hand, foot, big. Close f/u
124
Q

rabies concerns

A 
Medium risk infection
Polymicrobial
Copious irrigation, debridement
No suture if hand, feet; face/scalp ok
Abx if hand, foot, big. Close f/u
125
Q

splints for

A

Splint all fractures,
tendon injuries,
Grade 2,3 sprains, infections,
lacs over joint area,

post-reduction/tap

126
Q

back pain-how many need imagining

A

1:100 need imaging today

vast majority are muscle spasms or muscle strain

127
Q

history for low back pain

A

OPQRST, mechanism, Hx same, plus…

Fever, weakness, numbness/sensory changes, bowel/bladder incontinence or retention, weight loss, IVDU…abdominal/female GU/prostate

128
Q

when would you get an MRI for back pain

A

Plain film rare (older, fx, mets), CT: bone or if suspect fx

MRI: cord: if fever, IVDU, true new weakness or true sensory deficit

129
Q

everyday mngmt of bakc pain

A

NSAID’s, APAP, muscle relaxant, self-care, expectations, work note

130
Q

PE for back pain must include

A

Abdominal exam – rectal only if weakness/sensory change
Back: rash/lesions, bony tenderness, ROM, SLR
Neuro: Strength, sensory exam, DTR’s, gait

131
Q

managment of low back pain

A

Trauma/fall/assault/direct blow (plain or CT – depends on severity)

  • Fever (MRI)
  • Motor weakness (cord compression, Transverse Myelitis (TM) MRI)
  • Numb, sensory deficit: check saddle distribution (Cauda Equina: MRI)
  • Bowel/bladder incontinence/retention (Cauda Equina - MRI)
  • Bony or central tenderness (Fx, met, TM – plain vs CT first)
  • Weight loss (Cancer – CT for mets)
  • Elderly and no trauma (Think Aorta – CT)
  • IVDU (Fever, back pain? Think Spinal Epidural AbscessMRI)
132
Q

concerning low back pain

A

radicular sx’s, positive SLR, loss of DTR’s

May need outpt MRI - unless precipitous progression (TM, cord)

133
Q

Limp in Kids ddx

A 
Acute Septic Arthritis
Transient (Toxic) Synovitis
Slipped Capital Femoral Epiphysis
Legg-Calve-Perthes
Rheumatic fever: 2-6wks after Grp A Strep
Juvenile Rheumatoid Arthritis
134
Q

Acute Septic Arthritis

A

Often younger; hip, knee, elbow

Fever, +/- toxic appearing

Emergency Medicine (28 decks)

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