ortho Flashcards
level 1 trauma center needs
all specialties/modalities avail 24hrs
MRI, Fluoroscopy, CT scan, etc avail for 24 hrs
The “Golden Hour”
Time we have to make a difference
ii. 1 hour – if you’re going to crump, you will crump
How does the PA student fit? Anticipate
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
primary survey
ABCDE hx (if awake)
GCS and a C spine and a ULS
pt is phonating =has an airway
AMPLE survey
allergies meds PMH/PSH last PO events environment
Secondary Survey
- Full systems exam, head to toe
2. More complete Hx
how to management pt with . GSW
Stabilize the patient if unstable - undress
Determine where, how many, other injury
Neurovascular integrity is the priority in extremities
Penetrate the joint?
checking neurovascular integrity should look like what
Check: pulses, pallor, temp (cold?), cap refill
2. Sensory exam
how to evaluate weather or not a shot has penetrated the joint
Air in joint = penetration
how should you report a fx with a GSW
“i have a GSW with an open fracture to the left tibia”
how to treat fxs
- 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
big concern with femur fracture
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
what should we be thinking about with pelvis fx
Internal injury common (strap them with stabilization device)
Surg admit, ortho consult
worry about the bladder, reproductive organs, rectum
big tell tale sign of hip fx
can’t bare weight
risk for hip fx
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
talking to pts about knife and stab wound
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
how to approach stab wounds
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)
why would you do delayed primary closure
High risk, contaminated or neglected wounds – don’t suture
- Hands, feet, over joints; immunocomp pt; crush, bite, puncture
- Predict high infection risk
when to have pt return for high risk wounds
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
arterial bleed 1st approach
Universal precautions, ABC’s
Check for foreign body, elevate
managing arterial bleed in the wilderness
1st small tightly folded nugget with pinpoint accuracy
2 incremental larger or less folded piece of gauze
TXA used for
Tranexamic acid
clott promoter arterial bleed
Traumatic ABI looks like
Comparison of ipsilateral upper and lower extremity systolic pressure
how to take ABI
Pt supine, BP cuff, doppler
Doppler brachial SBP, then highest of dorsalis pedis and posterior tibial
ABI
ABI = Ankle SBP/Brachial SBP
Arterial Pressure Index (API)
Compare injured extremity to the other one (for example – compare L foot to R foot)
API = Injured SBP/Uninjured SBP
Approach to Ortho Injuries
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
PE for ortho needs
anatomy, neurovascular exam are key
Master exam for each area
medication and imaging that needs consideration for ortho injuries
Pain control. Abx? Oral? IV?
Imaging: Xray 1st. Need CT?
Repair, reduction, splint?
ED splints; no cylindrical casting
Ortho consult, rec’s, f/u
pt education should include
- Splint care
- Importance of f/u
- Red Flags to return
- Recovery period
- Document!
neurovascular test should include
Know anatomy of injury area
Check at injury area and distal
Neuro: sensory, motor, DTR’s
1. 2-point discrimination fingertips
2. <6mm normal
vascular check should include
: pulses, cap refill, temp, color, Allen’s test
no pulse or weak pulse?
GO GET THE DOPPLER
Neuropraxia
nerve contusion
a. Temporary – recover
No sensation
nerve cut/damaged
a. Which nerve, reproduce, compare
Cold extremity, pallor of the hand/foot means
) = Vascular emergency (Surg/Ortho
example of consulting hx
Lauri’s example of talking to a specialist
Begin with Dx; then age, gender, PMH
- 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
- Imaging, ultrasound
- Reduction?
- 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”
scaphoid fx is at risk of AVM
at the waist
ortho should be consulted for
- 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
true emergencies
- 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
mechanism of contusions
- Crush is high risk
- Spontaneous is high risk
- Coumadin?
exam of contusions
need MOA
ii. Neurovascular exam
iii. Is this cellulitis/nec fasc?
1. Search for wound/gas
cellulitis
red
tender
warm
complications you are worried about in contusions
iv. Check for ligament/tendon rupture
v. Check joint above/below
vi. Check compartments; soft?
mnmgt from contusions
Xray for fx, gas, foreign body
Ice, elevation, return precautions
how to write about ligamentous injury
- 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 **
1st degree sprint
mod pain, minimal swelling, no laxity
2nd degree sprain
pain, swelling, loss function but no laxity
3rd degree sprint
complete ligamentous disruptions
• Significant pain/swelling/function loss
• Joint laxity present
collecting information on sprain should look like
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?
sprain management
Xray – Ottawa Rules
vii. ACE/Brace/RICE if minor
viii. Joint disruption or unstable?
1. Splint like fracture
2. Ortho consult, f/u
Popeye sign (sling)
biceps tendon rupture
Can’t extend lower leg
Knee immobilizer
think
patellar rupture
Defect, hip flexion
Knee immobilizer
quadriceps rupture
mangement achilles
Hear “pop”, local defect
Thompson’s test
Posterior splint, equinus
patellar rupture test
can you kick me while sitting down
“the patient has full extension of the patella”
mnmgt of patellar fx
Xray all, Ortho/Pods consult all
Immobilize, outpt f/u
describe fx
open or closed
location
number of fragments
direction of fx line
alignment
special fxs
describing lcoation (5)
Which bone(s)? Where in the bone? “Head” proximal Proximal, middle, distal shaft, neck Intra-articular?
number of fragments think
simple (2)
comminuted (>2)
direction of fx line
Transverse, oblique spiral, longitudinal
alignment thnk
Displaced, distracted
Angulated
Shortened, impacted, depressed
Rotated
elbow look for
Post fat pad, sail sign
Anterior Humeral Line
Radiocapetellar Line
radial head
Subtle, common, FOOSH
Nightstick
Defensive, midshaft ulna
Fx ulna w/ radial head dislocation
Monteggia
Galeazzi
Fx distal 1/3 radius with ulna dislocation
special features of the wrist to consider with intra-articular
Check carpal bone arches
spaces and alignment
scaphoid fx at risk at
AVN risk if at “waist”
Check snuff box
Colles vs Smith’s
Colles dorsal, Smith’s volar
FOOSH; need reduction?
Teacup is tipped over
lunate
teacup is empty
perilunate
carpals dislocated
Boxer’s Fx
what is it and when do you reduce
4-5th at neck (fight bite?)
Note finger rotation
Reduce >30deg angulation
review right now
Gamekeeper’s, Bennett’s, Rolando fx’s
Hyperextened finger
volar plate
Jammed
suspect
extensor avulsion
mallet finger
patellar consideration
Direct blow
Sunrise view
Check patellar tendon
who get’s tibila plateau fxs
MVA, Auto vs Ped Jumpers Can be subtle Can’t weight bear Get CT
Mortise fx
Wide? Disrupted?
Ligamentous injury
Maisoneuve
Mortise plus proximal fibula fx
Palpate proximal leg in all ankle injuries
bimal
vs trimal
Unstable both
check lateral for tri mal
mngmt of talus fx
CT
Not common
High risk AVN
CT all
SIGN w/ calcaneus fx
Mechanism, Mondor’s sign
CT all
Lisfranc fx/dislocation
what are they and how are they manged
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
4 special bony conditions
open fxs
non-union or malunion
osteomyelitis
AVN
open fxs worry about
All get xrays first, then ortho consult
Non-union/malunion worry about
Deformity, pain after fx
chronic pain prone to stressors
Often non-compliance
who get’s osteomyelitis
what are we worried about
DM, chronic infections
Ask: Is this nec fasc?
AVN risk
talus
navicular/scaphoid
head of the numerous
consideration in shoulder dislocation
Anterior or posterior?
Hill-Sachs–repetitive frequent dislocation
how to describe dislocations
always describe the distal portion
70% of hip dislocation posterioer
in all joint dislocations consider
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
considerations with effusions
mono articular vs. poly – ballottment (does the patella bounce)– hot/red? (eep think spetic)
big concerns for spetic joint
Atraumatic, +/- fever, red/hot, won’t move it
pathogens common with septic joint
S. aureus most common, N. gonorrhea 20%
GC big one for mono articular
Hemarthrosis is usually mono or poly?
usually in the setting of….
mono
Post trauma
findings in gout
usually mono, or poly
Uric acid crystals (bi-refringent)
Pseudogout - CPPD
Reiter’s Syndrome
asking about penile of vaginal discharge
mono/poly
Arthritis, conjunctivitis, urethritis
Inflammatory – usually mono or poly?
Inflammatory – poly
labs for swollen joints
Get xrays, CBC (ESR, CRP)
Arthrocentesis
Consent pt, check contras
Cellulitis, coumadin, prosthetic jt
Strict sterile procedure
arthrocentesis is done for
Diagnostic and therapeutic
Suspect septic joint
Hemarthrosis post trauma
Gout diagnosis
how do you do a arthrocentesis
Big joint, big needle
Ultrasound guidance
Take out as much as possible: can inject bupivicaine after tap
Send fluid for cell count, culture
when to suspect infection after arthrocentesis
what are the complications
> 50,000 WBC’s: infection***
Complications: iatrogenic infection, bleeding, local trauma
Five “P’s”:
Five “P’s”: pain, pallor, paralysis, pulselessness, paresthesias
do you need all 5 of the p’s for compartment syndrome ?
Don’t need all for dx. All = late
first sign of compartment
Severe/pain out of porportion, w/ passive stretch: early hallmarks
common findings with compartment syndrome
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
Stryker pressures
???
Fasciotomy
Anticipation, high vigilance
who is at risk of puncture wounds
6-10% get infected: DM, immunocomp, PVD high risk
management of puncture
Xray all for FB, fx; low pressure irrigate, tetanus shot
irrigate softly with gravity
(don’t push shit back in)
what is the time consideration with
<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
tennis shoe puncture wound?
psuedamonas !
cipro
Consider vascular/neuro/lig/tendon injury
Hand puncture wounds consider
Consider vasc/neuro/lig/tendon injury
complications with hands
Cellulitis, abscess, osteomyelitis (pseudomonas)
“No man’s land”
flexor tendon injury
mangement of flexor tendons
Flexor repaired in OR – ortho
Some extensor – ED can repair
sausage finger held in flexion
Flexor tenosynovitis, cellulitis
why do we worry about a fight bite?
weird bite
Eikenella corrodans, polymicrobial
mngmt of human bite
Admit, IV abx fight bite. Others: Augmentin
Tetanus, consider Hep B vaccine
Don’t miss DV!!
DO NOT SUTURE human bites!
high risk pathogen of cat bites
Pasturella Multoceda, Staph, Strep, Moraxella
Bartonella: Cat scratch fever
tx of animal bits
Clean like puncture
Do not suture!
Augmentin, close f/u
management of dog bites
Medium risk infection Polymicrobial Copious irrigation, debridement No suture if hand, feet; face/scalp ok Abx if hand, foot, big. Close f/u
rabies concerns
Medium risk infection Polymicrobial Copious irrigation, debridement No suture if hand, feet; face/scalp ok Abx if hand, foot, big. Close f/u
splints for
Splint all fractures,
tendon injuries,
Grade 2,3 sprains, infections,
lacs over joint area,
post-reduction/tap
back pain-how many need imagining
1:100 need imaging today
vast majority are muscle spasms or muscle strain
history for low back pain
OPQRST, mechanism, Hx same, plus…
Fever, weakness, numbness/sensory changes, bowel/bladder incontinence or retention, weight loss, IVDU…abdominal/female GU/prostate
when would you get an MRI for back pain
Plain film rare (older, fx, mets), CT: bone or if suspect fx
MRI: cord: if fever, IVDU, true new weakness or true sensory deficit
everyday mngmt of bakc pain
NSAID’s, APAP, muscle relaxant, self-care, expectations, work note
PE for back pain must include
Abdominal exam – rectal only if weakness/sensory change
Back: rash/lesions, bony tenderness, ROM, SLR
Neuro: Strength, sensory exam, DTR’s, gait
managment of low back pain
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 AbscessMRI)
concerning low back pain
radicular sx’s, positive SLR, loss of DTR’s
May need outpt MRI - unless precipitous progression (TM, cord)
Limp in Kids ddx
Acute Septic Arthritis Transient (Toxic) Synovitis Slipped Capital Femoral Epiphysis Legg-Calve-Perthes Rheumatic fever: 2-6wks after Grp A Strep Juvenile Rheumatoid Arthritis
Acute Septic Arthritis
Often younger; hip, knee, elbow
Fever, +/- toxic appearing
