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Emergency Med rotation > Ortho part 1 > Flashcards

Ortho part 1 Flashcards

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1
Q

Pathophys of bursitis

A

Inflammation of the bursa causes synovial cells to multiply and thereby increases collagen formation and fluid production
A more permeable capillary membrane allows entrance of high protein fluid
The bursal lining may be replaced by granulation tissue followed by fibrous tissue

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2
Q

Acute phase of bursitis

A

Local inflammation occurs and the synovial fluid is thickened
Movement becomes painful as a result

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3
Q

Chronic phase of bursitis

A

Leads to continual pain and can cause weakening of overlying ligaments and tendons and, ultimately, rupture of the tendons

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4
Q

Etiology of bursitis

A 
Autoimmune disorders
Crystal deposition
Infectious diseases
Traumatic events
Hemorrhagic disorders
Secondary to overuse
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5
Q

Hx of bursitis

A 
Localized tenderness
Decreased ROM or pain with movement
Erythema or edema
Hx of repetitive movement
Hx of inflammatory dz
Hx of trauma
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6
Q

PE of bursitis

A

Tenderness at the site of the inflamed bursa
If superficial, localized tenderness, warmth, edema, and erythema of the skin
Reduced active ROM with preserved passive ROM
With chronic bursitis, affected limb may show disuse atrophy and weakness
Tendons may also be weakened and tender

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7
Q

What should be part of the differential for bursitis?

A 
Tendinitis 
Muscle injury
Septic arthritis- ROM will not be decreased, and fever will be present
Ligamentous injury
Fracture
OA
Cellulitis
Gout and Pseudogout\
RA
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8
Q

Common areas affected by bursitis

A 
Subacromial
Olecrenon
Trochanteric
Prepatellar
Infrapatellar
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9
Q

Labs for bursitis

A

With septic bursitis, leukocyte count and ESR may be mildly to moderately elevated
Draw BCx if concerned about deep infection
Order ESR, ANA, RF, and anti-CCP where autoimmune dz is suspected

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10
Q

Procedure workup for bursitis

A

Joint aspiration and analysis to r/o infection or rheumatic causes
May also be therapeutic
Fluid should be analyzed for monosodium urate crystals, cell count with diff, Gram stain, and culture

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11
Q

Cell counts of nonseptic vs septic bursitis

A

Nonseptic: <2,000, with predominance of mononuclear cells
Septic: >70,000, with a predominance of PMNs

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12
Q

What are the most infected bursae?

A

Olecranon
Prepatellar
Infrapatellar

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13
Q

Imaging in bursitis

A

Plain radiography does not help with dx of bursitis but may be useful for identifying triggering pathology

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14
Q

Tx of bursitis

A 
Conservative tx usually:
Rest
Cold and heat txs
Elevation
NSAIDs
Bursal aspiration
Intrabursal steroid injections
When septic suspected, give abx
-Oxacillin or first-gen cephalosporin
-PCN allergy: cipro and rifampin
Surgery for chronic or recurrent
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15
Q

When to treat bursitis surgically

A

Failure of needle aspiration to drain the bursa adequately
Bursa site inaccessible to repeated needle aspirations
Abscess, necrosis, or sinus formation
Need for exploration to assess the extent of infection of adjacent structures
Recurrent or refractory disease after conservative tx

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16
Q

What areas does tendinitis most commonly affect?

A

Rotator cuff
Insertion of the wrist extensors and flexors at the elbow
Patellar and popliteal tendons and iliotibial band at the knee
Insertion of the posterior tibial tendon in the leg
Achilles tendon at the heel

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17
Q

Etiology of tendinitis

A 
Usually unknown
RFs:
-Middle aged or older
-Repetitive microtrauma
-Strain
-Excessive or unaccustomed exercise
-FQs
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18
Q

Workup for tendinitis

A

Radiographs if hx of trauma is present, but will be negative with tendinopathy
U/s is good to detect tendinitis
That with u/s is reserved for those whose dx is unclear or who fail conservative management

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19
Q

Nonpharmacologic tx of tendinitis

A

Rest or decrease activity level: restrict activities that cause pain
Ice for first 24-48 hrs
Splint or immobilize; sling for rotator cuff
Strengthening and stretching exercises once pain has subsided

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20
Q

Pharmacologic and surgical tx of tendinitis

A

NSAIDs
Consider corticosteroid injection for conservative tx failure
NEVER use injections for Achilles tendinitis
Avoid repetitive injections
Also consider surgery for conservative tx failure

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21
Q

Pathophys of cauda equina syndrome

A

A LMN lesion

May result from any lesion that compresses cauda equina nerve roots

22
Q

Etiology of cauda equina syndrome

A 
Lumbar stenosis
Spinal trauma
Herniated nucleus pulposus
Neoplasm
Spinal infection/abscess
Idiopathic
Spina bifida and subsequent tethered cord syndrome
23
Q

Presentation of cauda equina syndrome

A

Gradual and unilateral presentation
Both ankle and knee jerks affect
Severe radicular pain
Numbness localized to saddle area
No sensory dissociation
Asymmetric areflexic paraplegia that is more marked
Atrophy
Urinary retention late in course of disease
Diminished reflexes and muscle strength in lower extremities
Radicular leg pain
Poor anal sphincter tone
Sensation decreased to pinprick and light touch in a dermatomal pattern

24
Q

Workup of cauda equina syndrome: labs

A

CBC, BG, CMP, BUN and creatinine- to r/o anemia, infection, and renal dysfunction
ESR- may point to inflammatory pathology
Syphilis

25
Q

Workup of cauda equina syndrome: imaging

A

Plain radiography may be performed in cases of traumatic injury or in search of destructive changes, disk-space narrowing, or spondylolysis
CXR to r/o pulmonary source
MRI with gadolinium contrast is the diagnostic test of choice

26
Q

Cauda equina syndrome: other tests and procedures

A 
Needle EMG
Nerve conduction studies
SSEPs to r/o MS
Duplex u/s
LP to r/o inflammatory disease of the meninges or spinal cord
27
Q

Tx of cauda equina syndrome

A

Treat underlying cause

Admit to the appropriate service with frequent neuro checks

28
Q

Etiology of costochondritis

A

Repetitive minor trauma is most likely cause

Uncommon- bacterial and viral infections

29
Q

Hx of costochondritis

A

Onset is often insidious
Chest wall pain with hx of repeated minor trauma or unaccustomed activity
Pain descriptions:
-Exacerbated by trunk movement, deep inspiration, and/or exertion
-Lessens with decreased movement, quiet breathing, or change of position
-Sharp, nagging, aching, or pressurelike
-Usually quite localized but may extend or radiate extensively
-May be severe
-May wax and wane

30
Q

PE of costochondritis

A

Pain with palpation of affected costochondral joints

PE should include assessment of the lateral ribs and the cervical and thoracic spine

31
Q

Workup for costochondritis

A

EKG

CXR

32
Q

Tx of costochondritis

A

Reassure pt that the condition is benign

Use adequate pain control with NSAIDs

33
Q

Etiology of shoulder dislocation

A 
95% from major traumatic event
5% from atraumatic causes
Atraumatic causes include:
-Ligamentous lax shoulder
-Congenital causes
-Neuromuscular causes
34
Q

Hx of shoulder dislocation

A

Feeling of shoulder popping out
Determine position of shoulder at the time of injury
Anterior- arm abducted and externally rotated
Ask about previous dislocations
Numbness of arm

35
Q

PE of shoulder dislocation

A

Poor ROM
Lot of pain
Anterior- abduction and external rotation of arm
In thin pts- prominent humeral head can be felt anteriorly, and the void can be seen posteriorly in the shoulder
Posterior- arm kept in internal rotation and adduction
Thin pts- prominent head can be seen and palpated posteriorly

36
Q

Workup for shoulder dislocation

A

XR with 2 views- AP and axillary lateral view or scapular Y view
If >45 yo, get MRI if rotator cuff testing is positive

37
Q

Tx of shoulder dislocation

A

Appropriate reduction of shoulder
PT
Limited course of narcotics (3-4 days) for moderate to severe pain
Tramadol or tylenol #3 or #4 for mild to moderate pain

38
Q

PE of humerus fracture

A

Pain with palpation or movement of shoulder or elbow
Ecchymosis and edema
Can have radial nerve injury- manifested by wrist drop, fingers are in flexion at MCP joints and thumb is adducted
Proximal:
-Painful shoulder and very restricted ROM
-Obvious deformity with glenohumeral dislocation
-Nerve damage is rare
Diaphyseal:
-Painful deformed arm that may be associated with a radial nerve palsy
-Crepitus
-Shortening of the arm can be indicative of displacement
Complaint of pain while throwing, lifting, or pushing off on affected arm should raise suspicion of stress fracture

39
Q

Workup of humerus fracture

A

Distal and diaphyseal: AP, lateral of the humerus, transthoracic, and axillary views of the shoulder
Proximal: AP of scapula and glenohumeral joint, axillary view, lateral Y view of the scapula

40
Q

Tx of humerus fracture

A

Proximal: Sling and swathe
Refer anatomical neck fractures to ortho
Diaphyseal: coaptation splint

41
Q

Pathophys of forearm fracture

A

Fall onto an outstretched hand or direct blow

42
Q

Etiology of forearm fracture

A

Sports
Trauma, particularly from automobile collisions
Blows with blunt object
Child abuse

43
Q

PE of forearm fracture

A

Localized pain, tenderness, and swelling at fracture site
Evaluate 2 point discrimination
OK sign tests median nerve
Extending fingers or wrist against resistance tests radial nerve
Separating fingers against resistance tests ulnar nerve

44
Q

Workup of forearm fracture

A

AP and lateral views of wrist, forearm, and elbow

45
Q

Nightstick fracture

A

Isolated midshaft ulnar fracture
Ortho referral
Long-arm splint with 90 degrees of elbow flexion and the hand in a neutral position

46
Q

Monteggia fracutre

A

Fracture of the ulna with dislocation of the radial head

Long-arm splint

47
Q

Galeazzi fracture

A

Fracture of the distal one third of the radius with dislocatin of the distal radioulnar joint
Long-arm splint
Admission for ORIF

48
Q

Concomitant radius and ulna fractures

A

Potential complication of compartment syndrome

Admission for urgent ORIF

49
Q

Essex-Lopresti fracture

A

Fracture of radial head and distal radioulnar joint, with partial or complete disruption of the radioulnar interosseous membrane

50
Q

Torus (greenstick fracture)

A

Long-arm cast for 4-6 week when angulation is <10%

All require ortho referral

Emergency Med rotation (12 decks)

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