Orthopedics

Question 1

trauma

Answer 1

• 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

Question 2

gunshot wounds

Answer 2

• 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

Question 3

GSW managment

Answer 3

• 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

Question 4

Major ortho trauma

Answer 4

• 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

Question 5

knife/stab wounds

Answer 5

• 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

Question 6

Delayed primary closure

Answer 6

• 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

Question 7

Arterial bleeding - extremity

Answer 7

• 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

Question 8

Traumatic arterial injury: ABI

Answer 8

• 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.

Question 9

Approach to ortho injuries

Answer 9

• 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!

Question 10

neurovascular exam

Answer 10

• 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)

Question 11

Consulting the orthopedic surgeon

Answer 11

• 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

Question 12

orthopedic emergencies

Answer 12

• 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

Question 13

contusions

Answer 13

• 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

Question 14

Ligamentous injury

Answer 14

• 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

Question 15

sprains

Answer 15

• 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

Question 16

Tendon rupture

Answer 16

• Biceps
  
  • Popeye sign (sling)
• Patellar
  
  • Can’t extend lower leg
  • Knee immobilizer
• Quadriceps
  
  • Defect, hip flexion
  • Knee immobilizer
• Achilles
  
  • Hear “pop”, local defect
  • Thompson’s test
  • Posterior splint, equinus
• Xray all, Ortho/Pods consult all
• Immobilize, outpt f/u

Question 17

description of fractures

Answer 17

• Open or closed?
  
  • Open = compound
• Location
  
  • Which bone(s)?
  • Where in the bone?
  • “Head” proximal
  • Proximal, middle, distal shaft, neck
  • Intra-articular?
• Number of fragments
  
  • Simple (2)
  • Comminuted (>2)
• Direction of fx line
  
  • Transverse, oblique spiral, longitudinal
• Alignment
  
  • Displaced, distracted
  • Angulated
  • Shortened, impacted, depressed
  • Rotated
• Special fractures
  
  • Torus, greenstick, compression
  • Name of fracture type

Question 18

special fractures: forearm/UE

Answer 18

• The Elbow
  
  • Post fat pad, sail sign
  • Anterior Humeral Line
  • Radiocapetellar Line
• Radial Head Fx
  
  • Subtle, common, FOOSH
• Nightstick
  
  • Defensive, midshaft ulna
• Monteggia
  
  • Fx ulna w/ radial head dislocation
• Galeazzi
  
  • Fx distal 1/3 radius with ulna dislocation

Question 19

special fractures: wrist

Answer 19

• Intra-articular?
• Check carpal bone arches
• spaces and alignment
• Scaphoid
  
  • AVN risk if at “waist”
  • Check snuff box
• Colles/Smith’s
  
  • Colles dorsal, Smith’s volar
  • FOOSH; need reduction?
• Lunate dislocation
  
  • Teacup (lunate) is tipped over
• Perilunate dislocation
  
  • Teacup is empty, carpals dislocated

Question 20

special fractures: hand

Answer 20

• Boxer’s Fx
  
  • 4-5th at neck (fight bite?)
  • Note finger rotation
  • Reduce >30deg angulation
• Gamekeeper’s, Bennett’s, Rolando fx’s
• Finger disloc? Xray, reduce
• Tuft or proximal distal phalanx?
• Volar Plate
  
  • Hyperextened finger
• Extensor avulsion
  
  • Jammed, Mallet finger

Question 21

special fractures: knee

Answer 21

• Patella
  
  • Direct blow
  • Sunrise view
  • Check patellar tendon
• Tibial Plateau
  
  • MVA, Auto vs Ped
  • Jumpers
  • Can be subtle
  • Can’t weight bear
  • Get CT

Question 22

special fractures: ankle

Answer 22

• Mortise
  
  • Wide? Disrupted?
  • Ligamentous injury
• Maisoneuve
  
  • Mortise plus proximal fibula fx
  • Palpate proximal leg in all ankle injuries
• Bimaleolar
  
  • Unstable
• Trimaleolar
  
  • Unstable
  • Check that lateral!

Question 23

special fractures: foot

Answer 23

• Talus
  
  • Not common
  • High risk AVN
  • CT all
• Calcaneus
  
  • Mechanism, Mondor’s sign
  • CT all
• Lisfranc fx/dislocation
  
  • Mechanism
  • Check the 1st, 2nd, 3rd MT joints
  • CT all

Question 24

special bony conditions

Answer 24

• All get xrays first, then ortho consult
• Open fx’s
  
  • Ortho emergency
  • High risk infection, osteo
• Non-union/malunion
  
  • Deformity, pain after fx
  • Often non-compliance
• Osteomyelitis
  
  • DM, chronic infections
  • Ask: Is this nec fasc?
• Avascular necrosis
  
  • Usual suspect sites

Question 25

joint dislocations

Answer 25

• Fingers, wrist, elbow
• Shoulder
  
  • Anterior or posterior?
  • Hill-Sachs?
• Ankle, knee, hip
• In all:
  
  • Open or closed?
  • Neurovascular exam paramount
  • Xray all: fracture dislocation?
  • We try reduction first if no fx
  • Ultrasound guided nerve blocks
  • Intra-articular injection
  • Procedural sedation
  • Xray post reduction
  • Ortho consult, immobilize

Question 26

Joint reduction

Answer 26

• Each joint has special considerations
• Reduction should not be delayed
• All involve traction/counter-traction/motion
• Xray before and after reduction
• Large joints: admit for neurovascular checks

Question 27

swollen joints

Answer 27

• Effusions – mono vs. poly – ballottment – hot/red?
  
  • Septic – mono – the biggie – cannot miss!
    
    • Atraumatic, +/- fever, red/hot, won’t move it
    • S. aureus most common, N. gonorrhea 20%
      
      • Fever, chills, arthralgias. GC: hemorrhagic pustules
• Hemarthrosis - mono
  
  • Post trauma
• Gout – usually mono, or poly
  
  • Uric acid crystals (bi-refringent)
  • Pseudogout - CPPD
• Reiter’s Syndrome – mono/poly
  
  • Arthritis, conjunctivitis, urethritis
• Inflammatory – poly
• Get xrays, CBC (ESR, CRP)

Question 28

arthrocentesis

Answer 28

• Consent pt, check contras
  
  • Cellulitis, coumadin, prosthetic jt
• Strict sterile procedure
• Diagnostic and therapeutic
  
  • Suspect septic joint
  • Hemarthrosis post trauma
  • Gout diagnosis
• Big joint, big needle
• Ultrasound guidance
• Take out as much as possible: can inject bupivicaine after tap
• Send fluid for cell count, culture
  
  • >50,000 WBC’s: infection***
  • Complications: iatrogenic infection, bleeding, local trauma

Question 29

compartment syndrome

Answer 29

• Elevated pressures in confined compartment
  
  • Edema, bleeding = reduced blood flow
  • Muscle/nerve necrosis ensues
  • First few hours to 48hrs
  • Femur/tibia, humerus/elbow/hand fx/injury
  • Severe pain w/ cast? Remove it
• Symptoms
  
  • Severe/pain out of porportion, w/ passive stretch: early hallmarks
  • Five “P’s”: pain, pallor, paralysis, pulselessness, paresthesias
  • Don’t need all for dx. All = late
• Stryker pressures
• Fasciotomy
• Anticipation, high vigilance

Question 30

Puncture wounds

Answer 30

• Common, management controversial
• 6-10% get infected: DM, immunocomp, PVD high risk
• Xray all for FB, fx; low pressure irrigate, tetanus shot
• <6hrs old, clean wound, healthy pt:
  
  • No abx, return precautions, do well
• >6hrs, high risk pt/wound, plantar surface/hand:
  
  • Consider abx (Cipro, Keflex), strict return precautions
• Foot: where, when, with what, shoe?
  
  • Consider vascular/neuro/lig/tendon injury
  • Tennis shoe: psuedomonas - Cipro
• Hand: High risk
  
  • Consider vasc/neuro/lig/tendon injury
• Complications: discuss/document
  
  • Cellulitis, abscess, osteomyelitis (pseudomonas)

Question 31

hands are special

Answer 31

• Small problem, big trouble
• Anatomy/function/neurovascular
• Inspect lacs in bloodless field
  
  • Move finger/hand to expose deep structures – see them move
  • Joint violation?
• Fight bite
• “No man’s land”
• Tendon lacs
  
  • Flexor repaired in OR – ortho
  • Some extensor – ED can repair
• Flexor tenosynovitis, cellulitis

Question 32

human bites

Answer 32

• “Only a camel bite is worse”
• 190 different microbes in human saliva
• “Fight Bite”
  
  • Closed fist vs. mouth
  • Must ask/document in every pt w/ hand wound
  • High risk infection, septic joint, tendon sheath infection, osteomyelitis
  • Xray all. Open fx? FB?
  • Eikenella corrodans, polymicrobial
  • Copious irrigation
  • DO NOT SUTURE human bites! DPC
  • Admit, IV abx fight bite. Others: Augmentin
  • Tetanus, consider Hep B vaccine
  • Don’t miss DV!!

Question 33

animal bites

Answer 33

• Cat bites
  
  • High risk infection
  • Pasturella Multoceda, Staph, Strep, Moraxella
  • Bartonella: Cat scratch fever
  • Clean like puncture
  • Do not suture!
  • Augmentin, close f/u
• Dog bites
  
  • Medium risk infection
  • Polymicrobial
  • Copious irrigation, debridement
  • No suture if hand, feet; face/scalp ok
  • Abx if hand, foot, big. Close f/u
• Rabies
  
  • Rare in US dogs – consider if bitten abroad, sick animal
  • Bats, raccoons, skunks

Question 34

splinting/immobilization

Answer 34

• Splint all fractures, tendon injuries, Grade 2,3 sprains, infections, lacs over joint area, post-reduction/tap
• Unstable? Joint above/below
• ACE, sling, immobilizer
• Determine weight bearing status - discuss
• Crutches/training
• Home care

Question 35

low back pain in the ED

Answer 35

• Vast majority are muscle strain/spasm
  
  • NSAID’s, APAP, muscle relaxant, self-care, expectations, work note
  • No opiate Rx
  • 1:100 need imaging today
    
    • Plain film rare (older, fx, mets), CT: bone or if suspect fx
    • MRI: cord: if fever, IVDU, true new weakness or true sensory deficit
• History must include: OPQRST, mechanism, Hx same, plus…
  
  • Fever, weakness, numbness/sensory changes, bowel/bladder incontinence or retention, weight loss, IVDU…abdominal/female GU/prostate
• PE must include:
  
  • Abdominal exam – rectal only if weakness/sensory change
  • Back: rash/lesions, bony tenderness, ROM, SLR
  • Neuro: Strength, sensory exam, DTR’s, gait
• Chart documents all of above, every time

Question 36

Low back pain red flags

Answer 36

• Red Flag/DDx in Hx/PE – document presence/absence
  
  • *Trauma/fall/assault/direct blow (plain or CT – depends on severity)
  • *Fever (MRI)
  • *Motor weakness (cord compression, Transverse Myelitis (TM) MRI)
  • *Numb, sensory deficit: check saddle distribution (Cauda Equina: MRI)
  • *Bowel/bladder incontinence/retention (Cauda Equina - MRI)
  • *Bony or central tenderness (Fx, met, TM – plain vs CT first)
  • *Weight loss (Cancer – CT for mets)
  • *Elderly and no trauma (Think Aorta – CT)
  • *IVDU (Fever, back pain? Think Spinal Epidural AbscessàMRI)
• Concerning: radicular sx’s, positive SLR, loss of DTR’s
  
  • May need outpt MRI - unless precipitous progression (TM, cord)

Question 37

pediatrics: fractures

Answer 37

• Mechanism, other injury
• Non-accidental?
• Motor/neuro/vascular exam
• Salter Harris Classification
• Elbow/wrist ossification
• Same immobilization/RICE
• Refer to Pediatric Orthopedics

Question 38

Limp in kids

Answer 38

• Hip, groin, thigh, knee pain
• Xray all, Ortho consult all
• Differential Diagnosis
  
  • Acute Septic Arthritis
    
    • Often younger; hip, knee, elbow
    • Fever, +/- toxic appearing
  • Transient (Toxic) Synovitis
    
    • Most common cause hip pain <10yo
    • +/- fever; non-toxic, passive movement ok
  • Slipped Capital Femoral Epiphysis
    
    • Salter I; obese boys 11-16yo
    • Externally rotated leg, antalgic gait
  • Legg-Calve-Perthes
    
    • AVN femoral head
    • No systemic sx’s; MRI
  • Rheumatic fever: 2-6wks after Grp A Strep
    
    • Migratory, poly, rare in US
  • Juvenile Rheumatoid Arthritis