Orthopedic Emergencies Flashcards
What 4 factors tend to predict injuries?
Complaint
Age
Mechanism
Energy delivered
If there is a high suspicion for fracture but a negative x-ray, what should be done?
Treat as a fracture with rest and immobilization via sling, splint, or crutches
List types of fractures.
Transverse Oblique Spiral Comminuted Segmental Avulsed Impacted Torus Greenstick
What is a comminuted fracture?
Multiple pieces
What is an avulsion?
Results from a ligament pulling off a segment
What is an impaction?
Fractured but pushed into itself
What is a torus fracture?
Compression»_space;buckling of the cortex
What is a Greenstick fracture?
Cortical disruption on 1 side only
What is the Salter Harris classification?
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
Define open fracture.
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
Other fracture descriptors?
Open or closed Exact anatomic location Direction of fracture line Simple/comminuted Displacement/alignment Involvement of articular surface (%)
Management of open fractures?
Remove gross debris Reduce if neurovascular compromise Dress Give prophylactic ABX (Ancef = cefazolin) Time limit - 6 hours for long bones
6 P’s of compartment syndrome
Pain - usually the first sign Paresthesias Pulselessness Pallor Poikilothermia Paresis
Risk factors for septic joint
Young and old IVDU Alcohol abuse DM Skin infection HIV and other immunocompromise Arthritis S/p joint injection or replacement
Dx septic joint?
Requires aspiration
Synovial lactate >10 mmol/L (LR infinity :P)
Synovial WBC 50,000, but cutoff not definite
Common bugs in septic joint?
Staph
Nesseria
Rx septic joint
IV ABX
Irrigation/drainage of joint
Who should get plain imaging in low back pain?
Direct trauma and midline spine tenderness
At risk for pathologic fracture (>50, cancer, osteoporosis, IVDU, fever)
Who should get an MRI in low back pain?
Objective weakness not related to pain
Loss of bladder function
Suspect epidural abscess (fever?)
90% of spinal cord injuries result from ___.
Blunt trauma
Most common spinal cord injuries?
C-spine (#1)
Thoracolumbar, thoracic, lumbosacral
M:F ratio of spinal cord injuries?
4:1
NEXUS criteria for spinal imaging in patients with blunt trauma?
- No tenderness at the posterior midline
- No focal neurologic deficit
- Normal level of alertness
- No intoxication
- No distracting injury as determined by the clinician (gestalt)
Canadian C-spine rule?
- 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 - 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 - Able to actively rotate neck 45 degrees L and R)?
-If yes, no radiography
If no, radiogrpahy
What are the Ottawa ankle rules?
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
What are the Ottawa foot rules?
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
Caveats to Ottawa ankle and foot rules?
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
Ottawa knee rules?
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
What is a supracondylar fracture?
Pediatric elbow fracture
Risk for compromise of which artery and nerve in a supracondylar fracture?
Brachial artery
Median nerve
What is a nursemaid’s elbow and what is a classic cause?
Annular ligament of the radius is stuck in articulation
Classically a pull, though about half are a fall on an outstretched arm
How does the patient with a nursemaid’s elbow present?
Arm held adducted, semiflexed, prone, mild distress, increased pain with slight supination
Rx nursemaid’s elbow?
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
General principles of splinting?
- 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
General principles of managing suspected scaphoid injury?
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
How can you identify an occult fracture?
Repeat X-ray later shows callus formation
Identify an ulnar collateral ligament injury. What causes it?
Hyperextension
Palpate and radial stress MCP joint (compare laxity to other side, as women can have more laxity in general)
Indications for thumb spica
Scaphoid injury Lunate injury 1st MC fracture Ulnar collateral ligament injury Positioning for de Quervain tenosynovitis
How is a thumb spica applied?
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
What is the mallet finger?
DIP joint injury
Tendon can rupture itself, or it can rupture and pull off bone
Rx mallet finger?
Prolonged (6-8 weeks) splinting with finger in extension to approximate avulsed end of extensor tendon
When MCP joints need to be immobilized, what is the correct position?
Clam digger (position of function) - used to avoid decreased ROM
Indications for sugar tong immobilization?
Distal ulnar fracture
Distal radius fracture
Indications for posterior mold of foot/ankle?
Severe ankle sprain Tibia Fibula Tarsal Metatarsal
Indications for posterior mold of elbow?
Fracture or soft tissue injury of the elbow or proximal radius or ulna
What should you be looking for in C-spine plain films (3 view - lateral, AP, open mouth)
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
What are the anterior and posterior fat pad signs?
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
Provocative knee tests?
- Varus (LCL) and valgus (MCL) stress tests - collateral ligaments
- Posterior and anterior drawer tests - cruciate ligaments
- Lachman’s test - cruciate ligament
- McMurray’s test - meniscus
- Patellar grind test - patellofemoral problems
Provocative shoulder tests?
- Painful arc of motion (abduction all the way over the head + forward flexion over the head)
- Empty beer can test - supraspinatus
- Resisted strength test (external rotators -> teres minor and infraspinatus)
- Subscapularis lift off test
- Neer’s impingement test
- Hawkin’s impingement test
- Sulcus sign test
- Anterior apprehension sign
- Yergason’s test - biceps tendon impingement
- Speed’s test - biceps tendon impingement
Provocative hip and spine tests?
- Seated slump test - nerve root tension
- Straight leg raise
- Faber’s test - hip or SI joint pathology
- Ober’s test - iliotibial band tightness
