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Emergency Medicine Clerkship > Orthopedic Emergencies > Flashcards

Orthopedic Emergencies Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

What 4 factors tend to predict injuries?

A

Complaint
Age
Mechanism
Energy delivered

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2
Q

If there is a high suspicion for fracture but a negative x-ray, what should be done?

A

Treat as a fracture with rest and immobilization via sling, splint, or crutches

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3
Q

List types of fractures.

A 
Transverse
Oblique
Spiral
Comminuted
Segmental
Avulsed
Impacted
Torus
Greenstick
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4
Q

What is a comminuted fracture?

A

Multiple pieces

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5
Q

What is an avulsion?

A

Results from a ligament pulling off a segment

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6
Q

What is an impaction?

A

Fractured but pushed into itself

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7
Q

What is a torus fracture?

A

Compression&raquo_space;buckling of the cortex

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8
Q

What is a Greenstick fracture?

A

Cortical disruption on 1 side only

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9
Q

What is the Salter Harris classification?

A

For pediatrics
Involvement of cartilaginous epiphyseal plate or “physis”
Can lead to growth deformity

I - growth plate does not show up on x-ray; diagnosed if swelling of soft tissue is most prominent directly across the growth plate, treated as a fracture
II - involves metaphysis + growth plate
III - involves epiphysis + growth plate
IV - involves both
V - growth plate is completely impacted
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10
Q

Define open fracture.

A

Fracture in which there is an open wound or break in the skin near the site of the broken bone
All lacerations near a fracture site are open until proven otherwise

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11
Q

Other fracture descriptors?

A 
Open or closed
Exact anatomic location
Direction of fracture line
Simple/comminuted
Displacement/alignment
Involvement of articular surface (%)
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12
Q

Management of open fractures?

A 
Remove gross debris
Reduce if neurovascular compromise
Dress
Give prophylactic ABX (Ancef = cefazolin)
Time limit - 6 hours for long bones
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13
Q

6 P’s of compartment syndrome

A 
Pain - usually the first sign
Paresthesias
Pulselessness
Pallor
Poikilothermia
Paresis
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14
Q

Risk factors for septic joint

A 
Young and old
IVDU
Alcohol abuse
DM
Skin infection
HIV and other immunocompromise
Arthritis
S/p joint injection or replacement
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15
Q

Dx septic joint?

A

Requires aspiration
Synovial lactate >10 mmol/L (LR infinity :P)
Synovial WBC 50,000, but cutoff not definite

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16
Q

Common bugs in septic joint?

A

Staph

Nesseria

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17
Q

Rx septic joint

A

IV ABX

Irrigation/drainage of joint

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18
Q

Who should get plain imaging in low back pain?

A

Direct trauma and midline spine tenderness

At risk for pathologic fracture (>50, cancer, osteoporosis, IVDU, fever)

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19
Q

Who should get an MRI in low back pain?

A

Objective weakness not related to pain
Loss of bladder function
Suspect epidural abscess (fever?)

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20
Q

90% of spinal cord injuries result from ___.

A

Blunt trauma

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21
Q

Most common spinal cord injuries?

A

C-spine (#1)

Thoracolumbar, thoracic, lumbosacral

22
Q

M:F ratio of spinal cord injuries?

A

4:1

23
Q

NEXUS criteria for spinal imaging in patients with blunt trauma?

A
  1. No tenderness at the posterior midline
  2. No focal neurologic deficit
  3. Normal level of alertness
  4. No intoxication
  5. No distracting injury as determined by the clinician (gestalt)
24
Q

Canadian C-spine rule?

A
  1. Are there any high-risk factors mandating radiography?
    -Age 65+
    -Extremity paresthesias
    -Dangerous mechanism (fall from 3+ feet, 5 stairs, axial load injury, high speed MVC, rollover, ejection, bike collision, motorized recreational vehicle)
    If yes, radiography
    If no, proceed with #2
  2. Are low risk factors?
    -Simple rear-end MVC
    -Sitting position in ED
    -Ambulatory at any time
    -Delayed onset of neck pain
    -Absence of midline C-spine tenderness
    If yes, proceed with #3
    If no, radiography
  3. Able to actively rotate neck 45 degrees L and R)?
    -If yes, no radiography
    If no, radiogrpahy
25
Q

What are the Ottawa ankle rules?

A

An ankle X-Ray series is only required if there is any pain in the malleolar zone and…

Bone tenderness at the posterior edge or tip of the lateral malleolus (A)
OR
Bone tenderness at the posterior edge or tip of the medial malleolus (B)
OR
An inability to bear weight both immediately and in the emergency department for four steps

26
Q

What are the Ottawa foot rules?

A

A foot X-Ray series is only required if there is any pain the midfoot zone and…

Bone tenderness at the base of the fifth metatarsal (C)
OR
Bone tenderness at the navicular (D)
OR
And inability to bear weight both immediately and in the emergency department for four steps

27
Q

Caveats to Ottawa ankle and foot rules?

A

Clinical judgment should prevail if patient is intoxicated or uncooperative, has other distracting painful injuries, has diminished sensation in their legs, or has gross swelling which prevents palpation of the malleolar bone tenderness

Be cautious in patients under 18

Bearing weight counts even if the patient limps

28
Q

Ottawa knee rules?

A

A knee X-Ray series is only required for knee injury patients with any of these findings:

Age 55 or older
OR
Isolated tenderness of the patella
No bone tenderness of knee other than patella
OR
Tenderness of the head of the fibula
OR
Cannot flex to 90 degrees
OR
Unable to bear weight both immediately and in the emergency room department for 4 steps

Use only for injuries <7 days

29
Q

What is a supracondylar fracture?

A

Pediatric elbow fracture

30
Q

Risk for compromise of which artery and nerve in a supracondylar fracture?

A

Brachial artery

Median nerve

31
Q

What is a nursemaid’s elbow and what is a classic cause?

A

Annular ligament of the radius is stuck in articulation

Classically a pull, though about half are a fall on an outstretched arm

32
Q

How does the patient with a nursemaid’s elbow present?

A

Arm held adducted, semiflexed, prone, mild distress, increased pain with slight supination

33
Q

Rx nursemaid’s elbow?

A

Hyperpronation reduction (unless you think there’s a fracture) -> place thumb on radial head, grasp the distal radius, pronate at the wrist further than the position the child is already in, feel a click, better in 5-10 minutes

34
Q

General principles of splinting?

A
  • Immobilize the joint above and below the area of the fracture
  • Non-circumferential aka posterior mold (permits swelling)
  • Under-padding then plaster then ACE
  • Repeat neurovascular exam after
  • Non-emergent cases can be splinted and referred for further evaluation within 1 week
35
Q

General principles of managing suspected scaphoid injury?

A

Check snuff box for tenderness, axial loading of the thumb
Special views on XR when suspicious
High risk fracture because there is only one blood vessel (radial artery) supplying this bone and is susceptible to avascular necrosis
Thumb spica immobilization

36
Q

How can you identify an occult fracture?

A

Repeat X-ray later shows callus formation

37
Q

Identify an ulnar collateral ligament injury. What causes it?

A

Hyperextension

Palpate and radial stress MCP joint (compare laxity to other side, as women can have more laxity in general)

38
Q

Indications for thumb spica

A 
Scaphoid injury
Lunate injury
1st MC fracture
Ulnar collateral ligament injury
Positioning for de Quervain tenosynovitis
39
Q

How is a thumb spica applied?

A

Distal to IP joint of thumb
Proximal along distal 2/3 of radial forearm
Wrist and hand neutral position, extend wrist 20 degrees, abduct thumb as if holding wine glass

40
Q

What is the mallet finger?

A

DIP joint injury

Tendon can rupture itself, or it can rupture and pull off bone

41
Q

Rx mallet finger?

A

Prolonged (6-8 weeks) splinting with finger in extension to approximate avulsed end of extensor tendon

42
Q

When MCP joints need to be immobilized, what is the correct position?

A

Clam digger (position of function) - used to avoid decreased ROM

43
Q

Indications for sugar tong immobilization?

A

Distal ulnar fracture

Distal radius fracture

44
Q

Indications for posterior mold of foot/ankle?

A 
Severe ankle sprain
Tibia
Fibula
Tarsal
Metatarsal
45
Q

Indications for posterior mold of elbow?

A

Fracture or soft tissue injury of the elbow or proximal radius or ulna

46
Q

What should you be looking for in C-spine plain films (3 view - lateral, AP, open mouth)

A

Count - need to see C7 and C8
Any subluxation? (C2 and C3 may appear pseudosubluxation
Look at 3 lines (anterior vertebral body, posterior vertebral body, spinal laminar, +/- spinous processes)
Fracture
Soft tissue swelling
6 mm in front of C2 and 22 mm in front of C6 -> rough estimate of normal amount of soft tissue

47
Q

What are the anterior and posterior fat pad signs?

A

Normally, there are fat pads in the elbow.

Anterior fat pad - normally elliptical; if triangle or sail shaped, indicates likely fracture

Posterior fat pad - not normally seen; if seen, indicates likely fracture

48
Q

Provocative knee tests?

A
  1. Varus (LCL) and valgus (MCL) stress tests - collateral ligaments
  2. Posterior and anterior drawer tests - cruciate ligaments
  3. Lachman’s test - cruciate ligament
  4. McMurray’s test - meniscus
  5. Patellar grind test - patellofemoral problems
49
Q

Provocative shoulder tests?

A
  1. Painful arc of motion (abduction all the way over the head + forward flexion over the head)
  2. Empty beer can test - supraspinatus
  3. Resisted strength test (external rotators -> teres minor and infraspinatus)
  4. Subscapularis lift off test
  5. Neer’s impingement test
  6. Hawkin’s impingement test
  7. Sulcus sign test
  8. Anterior apprehension sign
  9. Yergason’s test - biceps tendon impingement
  10. Speed’s test - biceps tendon impingement
50
Q

Provocative hip and spine tests?

A
  1. Seated slump test - nerve root tension
  2. Straight leg raise
  3. Faber’s test - hip or SI joint pathology
  4. Ober’s test - iliotibial band tightness

Emergency Medicine Clerkship (18 decks)

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