Orthopedic Emergencies Flashcards
orthopedic emergencies are acute injuries to __
bone, joint, or related soft tissue structures
orthopedic emergencies can result to ___
loss of life or loss of limb
factors for msk tissue damage
- inherent blood supply
- response to ischemia
- susceptibility to infection
- regenerative and reconstructive potential
- patient characteristics
care prior to hospitalization
- splint where they lie
- immobilize joints above and below
- gentle in-line traction to re-align extremities
- tamponade bleeding
- avoid tourniquets, unless life is in danger
steps in caring for a multiple injured patient
- abcde
- resuscitation
- secondary survey (xrays)
- definitive care
injury and energy dissipated
- fall from curb 100
- skiing 300-500
- high velocity gsw 2,000
- automobile collision 100,000
t/f gustilo classification can be used on any bone
false, only on long bones (humerus, forearm, femur, tibia)
signs of long bone fracture
- visible bone
- proximity to fracture
- bleeding that is not proportionate to size
- fat globules in blood
infection in the bone can lead to ___
osteomyelitis
gustilo I
< 1 cm
1st gen cephalosporin + tetanus prophylaxis
“inside out”
gustilo II
> 1 cm but <10 cm
1st gen cephalosporin + tetanus
comminution more likely
gustilo IIIA
> 10 cm
- minimal periosteal stripping but with adequate coverage
- 1st gen cehpa + aminoglycoside
- high energy, gsw, natural disasters
gustilo IIIB
- periosteal stripping that may need flap coverage
gustilo IIIC
- vascular injury requiring repair
- add high dose penicillin for farm injuries
t/f the amount of soft tissue injury will dictate what happens to a fracture
true
infection rates per gustilo type
I = 0-2% II = 2-7% III = 10-25%
gold standard for treatment of open fractures
immediate debridement of open fracture
steps of debridement of open fractures
- expose adequately without causing more damage
- remove foreign bodies/contaminants
- 4cs: color, consistency (resilient and not easily friable), contractility (twitching), capacity to bleed
t/f you can leave bleeding arteries open
false
(open fractures) if proper debridement is not done, there will be ___
increased bacterial load –> delay in closure
(open fractures) if wound is clean and proper antibiotics are given, fracture can be closed at __
10 hour mark
t/f you can close a gustilo type 2 or 3 that is grossly contaminated
false, don’t close. pack it, make sure there’s a moist environment, wrap and elastic bandage and immobilize, and refer
repeat debridement in open fractures are done every __
24-72 hours
in open fractures, specimens are taken from ___
the soft tissue envelope around injury
t/f you can get samples before debridement
false!! get samples when wound looks clean
parts of mangled extremity severity scale
- skeletal soft tissue injury
- limb ischemia
- shock
- age
mess scoring
> 7 = might amputate
for any section with limb ischemia, the score is doubled for ischemia time of >6 hours
common sequelae of open fractures
- infection/sepsis
- delayed union/non-union
- joint stiffness
- chronic post traumatic osteomyelitis
- prolonged disability
more common dislocations
shoulder: anterior
hip: posterior
patellar (vs knee)
elbow (axial load)
ankle: inversion
emergent problems in dislocation
- know what xrays
- pain and loss of motion
- acute neurovascular compromise
- soft tissue necrosis
- acute ischemia to sensitive bone structures
- long term complications (arthritis, osteonecrosis)
treatment for acute dislocations
- early reduction
- check neurovascular status before and after reduction
- check with xrays to confirm
indications for open reduction
- anatomic reduction not achieved by closed reduction
- unstable joint after reduction
- neurologic or vascular injury
- presence of limb ischemia
mechanisms of neurovascular injuries
- fractures or dislocations
- sharp trauma
- acute thrombi
- iatrogenic (after manipulation of limb)
presentation of anterior dislocation
- internally rotated
- adducted
- with shortening
presentation of posterior hip dislocation
- externally rotated
- abducted
injuries and corresponding affected vessels
read!!
clinical presentation of neurovascular injuries
- increase/decrease in sensation
- numbness
- cyanosis
- weak/absent pulses
- neuropraxia
- open injuries: transection of nerves (neurotmesis)
nerve and test for shoulder dislocation
axillary nerve
test sensation around deltoid area
nerve and test for humeral shaft fracture
radial nerve
sensory: 1st dorsal rib space
motor: wrist drop inability to extend thumb
nerve and test for medial epicondyle of elbow
ulnar nerve
test ulnar side of small finger
nerve and test for humeral supercondylar fracture
radial/median nerve
test: a-ok sign and isolating tip of index muddle finger
nerve in hip dislocation and knee dislocation
hip: sciatic nerve
knee: peroneal nerve
what is acute compartment syndrome
- results from elevation of interstitial pressure
- leading to microvascular compromise and dec local tissue perfusion
sites at risk for compartment syndrome
- compartments bound by non-compliant fascia or bone
- fractures and dislocations
- vascular injury
- burns
- limb compression
pathophysiology of acute compartment syndrome
- insult/injury
- increased pressure
- decreased capillary blood flow = ischemia
- local tissue necrosis due to lack of oxygen
t/f acute compartment syndrome is a clinical diagnosis
true
4ps of actue compartment syndrome
- pain out of proportion to that expected from inciting injury (most sensitive sign!!)
- pulselessness
- paresthesia/hypoesthesia
- pallor
intracompartmental pressure measurement is diagnostic if it’s ___
within 10-30 mmhg of diastolic pressure
treatment for compartment syndrome
- fasciotomy
- make multiple incisions to allow complete decompression of all compartments
- leads to decrease in pressure and restore perfusion
- repeat debridement 48-72 hours
kanavel’s signs of the hand
- palpable tenderness along tendon sheath
- pain on passive extension of the digit
- symmetric digital swelling
- digit fixed in a semi-flexed position
conus medullaris ends at __
l1 or l2 and after is the cauda equina
clinical presentation of cauda equina syndrome
- severe low back pain
- uni/bilateral sciatica
- radiating pain beyond the knee
- saddle anesthesia around anus (s3-5)
- motor weakness and reflexes on LE
- bladder or rectal dysfunction
table for clinical presentation of ces
read
causes of ces
- sacral root injury: neurological deficit
- compression: disc, tumor, epidural hematoma
- should be rules out in acute radiculopathy
acute vs insidious onset ces
acute: sudden, motor weakness, saddle anesthesia, urinary retention
insidious: recurrent, motor weakness, no saddle anes, gradual symptoms
imaging of choice for ces
mri
treatment for ces
- immediate surgical decompression
- wide laminectomy followed by discectomy
- for better motor recovery, poorer bladder and bowel recovery
