Orthopedics Flashcards
1
Q
trauma
A
- Trauma Centers: Level 1-4
- Level 1 = all specialties/modalities avail 24hrs
- Trauma Team
- Trauma surgeons, residents/PA, ED/ICU nurses, nurse recorder, blood bank, xray, social services
- ED attending/res/PA (responsible for airway and ultrasound)
- The “Golden Hour”
- How does the PA student fit? Anticipate
- Undress, log-roll, IV access, foley, doppler/API’s, CPR, to CT
- Lac repair, help ortho (reductions, etc), ophtho, ENT, etc
- OR, care in-house
- Field Criteria “Trauma Activation”
- On arrival to ED:
- Primary Survey
- ABCDE + GCS + C-Spine
- AMPLE Hx (if awake)
- Allergies, Meds, PMH/PSH, Last PO, Events/Environment
- Ultrasound
- FAST or E-FAST (includes lungs)
- Secondary Survey
- Full systems exam, head to toe
- More complete Hx
- Primary Survey
2
Q
gunshot wounds
A
- Wound ballistics: Tissue damage related to
- Range, velocity, caliber, type, fragmentation, deformity
- Bullet hits, bounces around or goes thru
- ED deals w/ minor distal extremity GSW’s
- Think anatomy, trajectory, possible injury
- Avoid describing wounds as “entry” or “exit”
- Close range – look for gunpowder, burns around the site
- Look for clothing in wound, save clothes
- Check entire body
3
Q
GSW managment
A
- Stabilize the patient if unstable - undress
- Determine where, how many, other injury
- Neurovascular integrity is the priority in extremities
- Check: pulses, pallor, temp (cold?), cap refill
- Sensory exam
- Penetrate the joint?
- Air in joint = penetration
- X-ray all – joint above/below
- If fx, treat as open fx
- Local wound care, debridement
- Surgery, ortho consult
- Consider Abx
- Splint, close follow-up
- Tetanus
4
Q
Major ortho trauma
A
- Femur fracture
- High energy
- Risk for compartment syndrome
- Steinmann pin with traction device
- Pelvis fracture
- Internal injury common
- Surg admit, ortho consult
- Hip fracture
- Can’t weight bear
- Describe location
- Risk for AVN
- Occult fx? CT or MRI*
- Ortho admits for pin or replacement
5
Q
knife/stab wounds
A
- We deal with extremities/stable pt only
- Good history; police report made?
- Count, measure, explore deeper structures
- Function, neurovascular exam
- Imbedded objects are removed in the OR – don’t pull them out
- Do not extend wounds if possible
- Repair or leave open for delayed primary closure in 3-5 days
- X-ray all – fx, foreign body
- Consult surgery, ortho
- Consider Abx, close follow-up
6
Q
Delayed primary closure
A
- High risk, contaminated or neglected wounds – don’t suture
- Hands, feet, over joints; immunocomp pt; crush, bite, puncture
- Predict high infection risk
- Copious irrigation, wound debriedment
- Leave open, no suture, dry dressing
- Follow-up in 3-5 days – suture the wound then if no infection
- Pt Ed/document: Discussed, return signs infection, increased scar risk
7
Q
Arterial bleeding - extremity
A
- Universal precautions, ABC’s
- Check for foreign body, elevate
- Direct pressure first
- One finger, gauze, pressure just proximal for 10min
- Blood pressure cuff as tourniquet (mark time – 15min max)
- Pressure dressingà
- Tightly rolled/folded gauze
- Layer progressively larger on top, firm wrap
8
Q
Traumatic arterial injury: ABI
A
- Ankle-Brachial Index (ABI)
- Comparison of ipsilateral upper and lower extremity systolic pressure
- Pt supine, BP cuff, doppler
- Doppler brachial SBP, then highest of dorsalis pedis and posterior tibial
- ABI = Ankle SBP/Brachial SBP
- Arterial Pressure Index (API)
- Compare injured extremity to the other
- API = Injured SBP/Uninjured SBP
- >0.9 normal; if less than 0.9 = concern for traumatic arterial injury
- Duplex ultrasound, arteriogram if <0.9
- In non-traumatic Peripheral Artery Disease (PAD), ABI of 1.0-1.4 are normal, 0.9-0.99 are “borderline” for PAD, 0.8-.89 are “mild” and 0.5-0.79 are considered “moderate” indicators of the degree of PAD. Non-traumatic ABI of <0.5 is concerning for significant arterial occlusion and <0.4 indicates severe arterial disease.
9
Q
Approach to ortho injuries
A
- History
- Mechanism and when occurred
- Associated sx’s/risk – fall, high energy, helmet, protective gear
- Sx’s other than pain? Numb? Weak? LOC? Weight bear? Hear noise?
- Pain right away or delayed?
- Blood loss estimate; arterial?
- Dominant hand?
- Hx same/other injury in past?
- Occupation? Work related?
- Assault? DV? Police report?
- PMH, Meds, Allergies
- Tetanus?
- Social situation
- PE: anatomy, neurovascular exam are key
- Master exam for each area
- Pain control. Abx? Oral? IV?
- Imaging: Xray 1st. Need CT?
- Repair, reduction, splint?
- ED splints; no cylindrical casting
- Ortho consult, rec’s, f/u
- Pt Education
- Splint care
- Importance of f/u
- Red Flags to return
- Recovery period
- Document!
10
Q
neurovascular exam
A
- Know anatomy of injury area
- Check at injury area and distal
- Neuro: sensory, motor, DTR’s
- 2-point discrimination fingertips
- <6mm normal
- Vascular: pulses, cap refill, temp, color, Allen’s test
- No/weak pulse: get doppler
- Deficits
- Neuropraxia: nerve contusion
- Temporary – recovers
- No sensation: nerve cut/damaged
- Which nerve, reproduce, compare
- Cold extremity, pallor (hand/foot) = Vascular emergency (Surg/Ortho)
- Neuropraxia: nerve contusion
11
Q
Consulting the orthopedic surgeon
A
- Have a diagnosis before you call
- Begin with Dx; then age, gender, PMH
- If fx: open or closed?
- Mechanism, other injury
- Dominant hand. Occupation.
- Know Red Flags for area/injury
- Mention if they have them or they don’t
- Good PE prior to call: describe it
- Know motor, neuro, vascular status
- What have you done in ED?
- Imaging, ultrasound
- Reduction?
- Antibiotics, Tetanus
12
Q
orthopedic emergencies
A
- True emergencies
- Open fractures
- Compartment syndrome
- Septic joint
- Un-reducible dislocation
- Amputations
- Crush/mangled
- Pressure, air-gun injury
- Neurovascular compromise
- Consult ortho for
- All fractures to arrange f/u
- Joint infection/issues
- Ligament/Tendon injury/rupture
- Hand/finger cellulitis
- Minor crush/soft tissue injury
- Major dislocations
- Ortho Admits:
- Fractures/injuries requiring surgery now
13
Q
contusions
A
- Mechanism
- Crush is high risk
- Spontaneous is high risk
- Coumadin?
- Neurovascular exam
- Is this cellulitis/nec fasc?
- Search for wound/gas
- Check for ligament/tendon rupture
- Check joint above/below
- Check compartments; soft?
- Xray for fx, gas, foreign body
- Ice, elevation, return precautions
14
Q
Ligamentous injury
A
- Know ligamentous anatomy of injured area
- Know the “special moves” for each joint
- Stress joints to uncover laxity
- Sprains:
- 1st degree: mod pain, minimal swelling, no laxity
- 2nd degree: pain, swelling, loss function but no laxity
- 3rd degree: complete ligamentous disruptions
- Significant pain/swelling/function loss
- Joint laxity present
15
Q
sprains
A
- Mechanism, when occurred, other injury, weight bear?
- Neurovascular exam
- Stable or unstable joint
- Examine, stress ligaments
- Look for wound, lesions
- Infection? Septic joint?
- Xray – Ottawa Rules
- ACE/Brace/RICE if minor
- Joint disruption or unstable?
- Splint like fracture
- Ortho consult, f/u
