Ortho ED Flashcards
What are the high risk factors that mandate and x-ray
> 65age, paresthesias in extremities, MVA >62mph, fall from height (>3 feet or 5 stairs), axial load to head/neck, ekection from vehicle or rollover
what are you looking for to decide no x-ray
No x-ray: pt can sit up in ED, is ambulatory at any time, delayed onset of neck pain, no midline c-spine tenderness, or simple rear-end collision, can rotate neck 45 degrees to both sides
What are the guidelines for C-spine injury
1) no midline C-spine tenderness
2) no focal neurologic deficit
3) normal level of alertness
4) no evidence of intoxication
5) no painful distracting injury
6 year old girl brought in to ED by parents for pain in the neck and holding head in rotated position. She cannot or will not “un bend” her neck. She says it hurts to try.
Never had this before. No trauma. No numbness, tingling in arms or fingers. Otherwise healthy, no medical problems
Atlantoaxial Rotary Subluxation Get CT to establish diagnosis Soft collar, rest Refer to neurosurgery within 72 hours Usually reduce themselves Tx= rest with a soft collar
Ottawa Foot, Ankle & Knee guidlines?
to reduce the use of x-rays in the ed
Tenderness to palpation
Unable to bear weight at scene or in ED
Ottawa Rules for knees
Not as sensitive or specific Tenderness to palpation over patella Cannot flex past 90 Tenderness over head of fibula Age >55 Inability bear weight at scene or in ED
Caveat: Things to Beware of
Data NOT validated in kids
Have higher index suspicion in kids and get the x-rays, especially <16yrs
ALWAYS palpate knee in every ankle injury
ALWAYS
(Dont miss the Masoneuvre)
what is septic arthritis
what is most sensitive finding?
Pain, erythema, edema in joint
Often atraumatic
May or may not be febrile
what is most sensitive finding? pain
50% of the time there is bacteriemia
Bacteria like cartilage like cavier and eat it up……
Septic Arthritis risk factors?
Monoarticular? Polyarticular?
Risks: age extremes, immune compromise, IVDU, RA, DM, had jt surgery in the past, prosthesis, HIV can get weird bugs and fungul infections. Adults: staph or strep, Kids: same
Teens: gonococcus
Elderly, immune compromise: E. coli Gonnoccocal inf arthritis., lime dz
Polyarticular?–less common
Septic Arthritis complex?
labs?
Complex to rule in or out
Crp, sed rate, cbc with diff
When suspicious: got to tap it!
Osteomylitis risk factor…
DM
Acute osteomylitis?
50% are kids, pain is most sensitive finding.
Dont call the ortho residents they dont know bugs
call infectious patho guys?
44 year old man plays basketball in evening. Down from jump, went down, can’t bear weight right leg. Pain in ankle, posterior aspect. Sounded like a gunshot went off.
Differential?
achilles tendon rupture…do the thompson test..lay pt down prone bend knee squeeze calf and foot plater flexes. Do both sides…
47yof was riding bike, got hit by car. Right leg pain, mostly in calf and tibial area. Exam: edema, erythema, PAIN getting worse
Compartment Syndrome
Compartment Syndrome 5P’s
5 P’s: Pain Pallor, Paresthesias, Pulselessness, Paralysis
Compartment Syndrome from what?
Trauma, crush injury
Pressure builds in
compartment
Compartment Pressure
the area gets sqeezed and the build up of pressure stops the flow to the area for oxygen= this kills the tissue in the area.Classification of Open Fractures
Grade 1: low energy mechanism, little soft tissue damage (<1cm), little contamination
Grade 2 open: moderate energy, more than 1cm tissue damage, moderate contamination
Grade 3: large soft tissue damage, contaminated, high energy mechanism, polytrauma
Open Fractures; what do you want to prevent?
Prevention of gangrene and limb salvage are issues
Open Fractures;tx the soft tissues
Stop Bleeding Realign (prevents soft tissue damage) Splint (comfort) Examination ONCE then sterile dressing (infection!!) Antibiotics ASAP
Antibiotics and coverage
timeline
(the solution is dolution)
Left alone >90% infection rates
1-4 hours after: 50% infection
<1hour 30% risk infection
Grade 1: cephalosporin
Grades 2-3 add aminoglycoside
High risk: add penicillin
Peter 11 year old with sudden onset left thigh and knee pain and limping. Brought in by mother because he continued limping. Was playing basketball with friends in street before noticing pain.
Exam: big kid, seems reasonably comfortable. Exam: gait antalgic, limping. Thigh and knee nontender to palpation. Limited internal rotation right hip compared to left.
What do you do?
Do a log roll test on bothlegs.
SCFE= slipped capital femoral epiphysis
emergency!!!!!! wake someone up!!
Open Fractures; what do you want to prevent?
Prevention of gangrene and limb salvage are issues
Open Fractures;tx the soft tissues
Stop Bleeding Realign (prevents soft tissue damage) Splint (comfort) Examination ONCE then sterile dressing (infection!!) Antibiotics ASAP
Antibiotics and coverage
timeline
(the solution is dolution)
Left alone >90% infection rates
1-4 hours after: 50% infection
<1hour 30% risk infection
Grade 1: cephalosporin
Grades 2-3 add aminoglycoside
High risk: add penicillin
