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ER 2 > Ortho > Flashcards

Ortho Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

What 5 are true ortho emergencies

A
  • Hip dislocation
  • Ankle dislocation with tenting
  • Open fx (OR in <6 hours)
  • Compartment syndrome
  • High pressure injection injuries
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2
Q

Fx complications

A
  • Hemorrhage
  • Vascular injury
  • Nerve injury
  • Compartment syndrome
  • Fat embolism
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3
Q

Overall ortho pearls

A
  • Don’t correct a deformity without an XR first (and neuro exam)
  • Caveat is pulseless, cold, vascular compromised area
  • Eval and document: deformity, color of skin, TTP, ROM, NV status
  • Eval NV before and after attempts to reduce a fx
  • Any soft tissue wound proximal to fx is treated like open fx until proven otherwise
  • Use the word amputation not “cut off finger”
  • Fingers: thumb, index, long, ring, small
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4
Q

Salter-Harris

A 
I: straight across
II: above, in metaphysis, no joint, MC
III: lower, epiphysis, is in joint
IV: through: both metaphysis and epiphysis
V: Crush: no more physis
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5
Q

what XR view is needed on shoulder and elbow injuries

A

true lateral

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6
Q

Things to not miss on XR

A
  • Massonneuve
  • talar shift
  • syndesmosis widening
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7
Q

Three types of nerve injury

A
  • Neuropraxia: Loss of function dt ischemia, no damage, will recover 90% of the time
  • Axonotmesis: Axons are damaged, will recover but often incomplete. Better prognosis if injury is distal
  • Neurotmesis: Entire nerve transected, requires repair (can be done 3-6 months after injury!)
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8
Q

When is it appropriate to do an EMG after a nerve injury?

A

Not until min 6 weeks to allow adequate healing time

** neurons heal proximal to distal, about 1 mm per day

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9
Q

How to assess vascular status

A
  • Pulses ☺
  • Color, temp, cap refill
  • If asymmetric pulses or unsure, get a Doppler study!
  • If absent, call sx and consider duplex study. Arterial blood flow must be reestablished within 4 hours to avoid irreversible damage
  • Doppler: uses sound
  • Duplex: sound and US together, colored
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10
Q

Fracture language, things to note (5)

A
  • Closed vs. open
  • Displaced %
  • Distracted/shortened
  • Angulated (degrees from where bone should be), need two views
  • Articular involvement?
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11
Q

6 Ps of compartment syndrome

A
  • Pain out of proportion
  • Pallor
  • Paresthesias
  • Poikilothermia (cold)
  • Pain with passive motion distally (ex. Toes)
  • Pulselessness
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12
Q

Compartment syndrome

  • where MC
  • PE
  • What pressure = fasciotomy
  • tx
A
  • MC: anterior leg
  • PE: firm, swollen, tense extremity
  • > 30 mmHG = fasciotomy needed
  • Ortho consult and admission
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13
Q

Open fx management

A
  • Early broad spectrum abx (1st gen cephalosporin, maybe aminoglycoside, maybe pcn)
  • Hemostasis
  • Debride wound but no aggressive irrigation
  • Occlusive, sterile saline soaked dressing
  • Splint
  • Tetanus
  • OR
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14
Q

Quick UE neuro check

A

Rock Paper Scissors OK

  • Rock: median nerve
  • Paper: radial nerve
  • Scissors: ulnar nerve
  • OK: anterior interosseus nerve
  • *Axillary: lift arm
    • Musculocutaneous : flex bicep
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15
Q

High pressure injection injuries

A
    • True ortho emergency: ortho or plastics
  • Injected material spreads along fascial planes, extent can look less than it is
  • Risk of compartment syndrome
  • Tx: Tetanus, analgesia, broad spectrum abx, splint, elevate
  • Consult: hand surgeon, urgent operative debridement is tx of choice
  • Digital blocks are CI
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16
Q

Fight bite

A
  • Depth usu worse than appears
  • Assess full ROM
  • Infection major issue
  • If tendon involvement – consult hand surgeon
  • No tendon involvement: irrigate, closure, oral abx
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17
Q

Scaphoid fx

A
  • High risk AVN
  • Anatomic snuffbox
  • Negative XR do not rule out
  • Thumb spica splint and ortho f/u
  • Will need MRI
    Triquentrum is second MC fx carpal bone
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18
Q

Flexor Tendon Injuries

A
  • Rupture tx: splint (block extension) and ortho referral
  • Flexor tenosynovitis: admit, IV abx, ortho consult
  • Kanaval’s signs:
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19
Q

What are Kanaval’s signs (4)

A
  • Sausage digit: uniform swelling along entire finger
  • Held in passive flexion
  • Pain with passive extension
  • Pain to percussion/palpation of flexor tendon sheath
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20
Q

FOOSH

  • Tx
  • Two types
A
  • Reduce, splint, refer to ortho
  • Good NV check and documentation
  • Colles (dinner fork): dorsal angulation MC
  • Smith: volar angulation
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21
Q

Galeazzi and Monteggia

A
  • Don’t trust a single bone forearm fracture!
  • Check for dislocation of the distal or proximal radioulnar joints
  • Distal: DRUJ
  • Proximal: PRUJ
  • Galeazzi (MC): radius shaft fx with DRUJ dislocation
  • Monteggia: ulna fx with proximal radial head dislocation
22
Q

Supracondylar fx

A
  • Usually kids 5-10 FOOSH with hyperextension of elbow
  • Poor tx → serious morbidity
  • Assess interosseous nerve via OK sign
  • Check radiocapitellar alignment
  • Lateral xray is required – look for fat pad signs!!!
  • Posterior fat pad
  • Anterior fat pad is “sail sign”
  • DO NOT reduce, ortho consult
23
Q

Shoulder Dislocation

- Overview

A
  • Arm adducted and elbow flexed, should step off
  • Scapular Y view (and AP)
  • Reduce within 24 hours
  • Assess axillary nerve
  • Associated with Bankart lesion and Hill-Sachs deformity
  • If first dislocation, increased risk of soft tissue injury
24
Q

Shoulder Dislocation

- Anterior vs. Posteior

A
  • Anterior: MC, arm adducted and elbow flexed, step off

- Posterior: usu dt electrocution or seizure (<10% of dislocations)

25
Q

Shoulder dislocation

- Tx

A
  • Analgesia +/- light sedation
  • Anterior: reduce via gentle traction of humerus w/ external rotation of shoulder/forearm. Can use countertraction
  • Posterior: reduce with traction and countertraction
  • Might have to fatigue the muscles to get it to reduce
  • Immobilize in sling, internal rotation
    Ortho f/u in 1-2 days, will need PT
26
Q

Humerus Fx

A
  • Look horrible but very forgiving
  • Proximal or shaft
  • Radial nerve (runs along humerus)
  • AP and lateral XR
  • Bc of large ROM of shoulder, can compensate for small rotational or angular deformities
  • Immobilize in sling, ortho referral
27
Q

Hip Fx

A
  • Not always due to trauma, can be little old lady with osteoporosis
  • Elderly pt with inability to bear weight on a hip is fx until proven otherwise
  • A fracture-dislocation of the femoral head in a young person requires great force, check for other abdominal injuries
  • Recognize femoral neck fx vs. intertrochanteric fx
28
Q

Hip dislocation

A
  • Sig force required
  • Eval for nerve injuries (sciatic and femoral)
  • Need pre and post op xrays, AP pelvis
  • True emergency
29
Q

Hip dislocation

- tx

A
  • Reduction w/in 6-12 hrs of injury
  • Sedation
  • ORTHO consult
30
Q

Hip Dislocation

- Posterior

A
  • MC, 90%
  • Often dashboard injury
  • Displaced superior and lateral
  • Exam: Hip flexed, adducted, internally rotated
31
Q

Hip Dislocation

- Anterior

A
  • 10%
  • More common in pts with a hip prosthesis
  • Displaced inferior and medial
  • Exam: externally rotated, abducted, slight flexion
32
Q

Pelvic Fx

A
  • High mortality rate, risk of hemorrhage, shock
  • Low E trauma usually results in stable fx which requires conservative tx, WBAT
  • High E trauma usually results in unstable fx which require operative tx
  • AP XR of pelvis confirms, might need CT
33
Q

Pelvic Fx

- 4 types

A
  • 1 Fx with intact ring
  • Fx of pelvic ring
  • Fx of acetabulum (less concerning)
  • Sacrococcygeal fx (less concerning)
34
Q

Pelvic Fx

- types of injury

A
  • Anterior posterior compression (APC)
    • Disrupts symphysis, “open book” injury
  • Lateral compression (LC)
    • Breaks rami, look at SI joint
  • Vertical shear (VS)
    • BAD. Always unstable, hemorrhage
35
Q

Pelvic Fx

- Exam (3)

A
  • GU: blood at urethral meatus, high-riding prostate, gross hematuria, scrotal hematoma
  • Neuro: L5, S1, rectal exam: tone and temperature sensation and prostate position
  • Skin: ecchymosis of anterior abd wall, flank, sacral and gluteal region (lack of ecchymosis does not r/o hemorrhage)
36
Q

Pelvic Fx

- Imaging

A
  • 5 view of pelvis: AP, pelvic inlet and outlet, R and L oblique
  • If you see one fx, look for more, displacement can only occur if ring is disrupted in 2+ locations
  • CT scan
  • +/- urethrography
37
Q

Pelvic Fx

- Pearls

A
  • Posterior pelvic fx: NV injuries and hemorrhage
  • Anterior pelvic fx: urogenital injuries
  • NO catheter
  • FAST exam is less sensitive if there is a pelvic fracture
38
Q

Pelvic Fx

- Tx

A

Stabilize, close the book

If fx is stable, WBAT with walker

39
Q

Ankle Dislocation

A
  • True ortho emergency!
  • Displacement of talus (foot) from the tibia
  • Usually associated with other fx
  • Check if the skin is tenting and NV status quickly!
  • Reduction as soon as possible, consult neuro
  • Splint it, get post-reduction xrays
  • Do not discharge without emergent ortho consult
40
Q

Maisonneuve

A
  • Consider with all ankle injuries
  • Proximal fibula fx with ankle injury
  • Check the “clear spaces” in the ankle for disruption of the ankle mortise
  • Tx: splint, NWB, ortho referral, will need surgery
41
Q

Lisfranc injury

A
  • Tarsometatarsal joint is the Lisfranc joint
  • Injury requires large force: dislocation +/- fracture
  • PE: mid-foot pain and swelling
  • On XR: look for widening of spaces, don’t’ miss!!
  • TX: splint, NWB, ortho referral
42
Q

General Splinting

A
  • No case in ER or acute setting, let swelling subside first
  • Never cast a swollen limb!!
  • Immobilization = relief, remind pt
  • Immobilize joint above and joint below injury
  • Remove excess water from material
  • Protect patient from sharp edges
  • Eval neuro before and after splint, document
43
Q

Splinting material

A
  • 3” good for UE in most adults
  • 4” good for LE
  • don’t apply with too much tension, be gentle
  • Use soft roll
  • Fiberglass MC vs. plaster
44
Q

Intrinsic plus position

A
  • true neutral position of hand and wrist – not Barbie hands
45
Q

Sugar Tong splint

A
  • Distal radius fx and forearm fx
  • Can double for an unstable wrist/elbow (pic on right above)
  • Watch the styloid and ulnar nerve
  • Don’t be stingy with soft roll
  • Hand and wrist in intrinsic plus position!
46
Q

Volar Splint

- wrist and hand

A
  • Wrist sprains, simple buckle fx in kids, carpal tunnel, extensor tendon injuries
  • Mind the thumb
  • Ensure min 2 inches distal to the antecubital fossa – don’t splint up into the elbow bend
  • Immobilize in slight wrist extension (neutral wrist position)
47
Q

Thumb Spica Splint

A
  • For thumb fx
  • Collateral ligament injuries, gamekeepers thumb, scaphoid fx
  • Soft roll around thumb, watch for fiberglass edges!
48
Q

Ulnar Gutter Splint

A
  • Boxers fx, 4th metacarpal fx, 4th and 5th phalanx fx

- Immobilize in 80-90 flexion, PIP at <20 flexion

49
Q

Dorsal Splint

A
  • Used to block extension: flexor tendon injuries

- Can also use on 2nd and 3rd metacarpal fractures

50
Q

Posterior short leg splint

A
  • LOTS of soft roll. Pad: lateral and medial malleolus and calcaneus
  • Add stirrup for unstable fx or if unsure
  • Immobilize ankle in neutral position
  • Stop 3-4” distal to knee (4 fingers)
  • Don’t leave toes hanging!

ER 2 (10 decks)

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