Orthopedics- The ED side (Ross)- exam 2 Flashcards
What is a good ortho history?
OLD CARRTS
- If chronic complaint–> then a focused hx & don’t forget to ask if there isnumbness/weakness !!!
- How/when did it happen, the mechanism what is the complaint
- Did they hear a snap/crackle or pop?
- Right or left handed
- Previous injury
- ARE THEY UTD w/ TETANUS
- Ask when their last meal was (if acute)
Neurovascular Intact
Vital Sign of Musculoskeletal
- not just a word
- base it on pulses and the color of extremities
- base it on peripheral nerve function–sensory and motor
85 yo has left arm pain for 3 days. Staff has found that pt is unable to use arm when he presents to ED.
Check radial pulse–> its ok, you test sensory and motor function and notice wrist drop and sensory loss. What is wrong?
Radial nerve damage and fx of humeral shaft = causes wrist drop!!
surgical neck fracture= axillary nerve damage
An acute ortho injury: what questions should you ask the Pt about their MOI?
- Listen to mechanism that the patient describes
- OPEN Ended Questions
- Are they able to move affected area?
- After ABC’s Immediately assess neurovascular status
- **document before and after any manipulation
Signs and symptoms of Bone Fracture
- Deformity
- Tenderness (TTP)
- Splinting
- Swelling
- Bruising
- Crepitus
- False motion (they lift a body part and it goes the wrong way)
- Exposed fragments
- Pain
- Locked joint (usually a fracture of the knee or elbow that inhibits movement of the joint)
- *Document all of these on the chart!! A joint above and below!!!!!
say the Pt presents with an elbow injury. What do you HAVE to document?
- document below and above that joint
- ie document how their shoulder joint and wrist joint functions
Red Flags
for HX and PE:
Blood on clothing–>
open fracture
Pain out of proportion–>
compartment syndrome
Elderly Pt with hip pain (neg film)–>
Occult hip fracture (may need Ct, MRI or bone scan)
**if elderly Pt has pain with ambulation–> its a hip fracture until proven otherwise
Jumping from a height
–>
Calcaneous FX with vertebral body compression
Eldery, hx of malignancy, mechanism doesn’t fit–>
Pathologic fracture
Grossly deformed extremity in field, now normal–>
Dislocation reduced in the field query vascular injury
13 yo boy running at gym has severe pain and stops.
Pathologic fx from lesion: osteocondroma
bones heal by _____ ______
callus formation & Remodeling of deposits of new bone along the fracture line
Fractures: clinical relevance
Some folks you don’t see initial fracture repeat films in 10 days
stage 1-6 fractures
- impact
- Induction
- Inflammation
- Soft callus
- Ossification
- Remodeling
3 stages of bone healing: Inflammatory, ossification and remodeling
Pearls ED ortho:
- please examine first then order X-ray
- may find unexpected findings such as jewelry or clothing causing tourniquet
- may find incorrect side documented
- **may find other injuries
How to describe a Fracture (steps)
Closed vs Open Location of injury Orientation of fracture line Displacement Angulation Shortening -Dislocation or subluxation
ex: closed fracture of the —- that is ———with ——displacement, with no angulation or shortening
_____ fracture is typically pediatric
greenstick
Physical Exam: In addition to the basics of ABC– what other steps should be taken?
- Inspect deformity
- Edema
- Discoloration
- Assess passive and active ROM
- Palpation to detect deformity or tenderness
- Check for pulse and neuro eval
What is included for neuro and vascular for the arm exam?
radial /ulnar and cap refill
What is included for neuro and vascular for the leg exam?
popliteal, post tip, doraslis pedis
Vascular and neuro exam:
- how many hours until their limb is dead?
- what sign is problematic?
- 6 Hours until limb is DEAD
- check pulse distal to fracture
- *Skin tenting: problematic, needs to be addressed urgently.
What are the peripheral nerves (branches) of the upper extremity?
musculocutaneus, axillary, radial, median and ulnar
What are the peripheral nerves (branches) of the lower extremity?
genitofemoral, lat. cutaneous, obturator, femoral, and sciatic
Orthopedic conditions commonly found with the radial nerve.
- Wrist and finger extension
- Wrist drop
- Injury to shaft of humerus
- Compression of nerve results in first drop
- Saturday night or crutch palsy
What muscles are involved with the flexion of the digits?
Flexor digitorum profundus
Flexor digitorum superficialis
Describe the role of the flexor digitorum profundus
- 2 motor nerve branches
- Distal end of phalanges
- Ulnar nerve innervates the 4th and 5th
- Median nerve innervates the 2nd and 3rd
Describe the flexor digitorum superficialis.
Innervated by median nerve
Ulnar nerve
- Provides motor innervation to: flexor digitorum profundus of 4th & 5th digit as well as flexor carpi ulnaris, adductor pollicis, all interosseous, lumbricals 3 and 4.
- Injured in supra-condylar fractures (proximal)
Ulnar nerve: PE
- Examine in open hand position
- Ask to close hand with ulnar n. injury
- PROXIMAL injury takes out flexor digitorum profundus m.
- 2nd & 3rd digits will flex to close
- 4th & 5th stay extended at MCP
- Weakened lumbricals no abduction of fingers
- DISTAL n ijury (at wrist)
Compression of ____ nerve results in wrist drop
radial
-Saturday night or crutch palsy: time +/- steroids
The ulnar nerve is injured in ____ _____ fractures
medial. epicondyle
- when Pt asked to flex fingers, they are weakened on 4,5
slide 27-60
dd
Danger of a septic joint:
-PE is not specific
***Gunmetal gray lesions on the palm=
Disseminated Gonorrhea
–Tx: Ceftriaxone
***Gunmetal gray lesions on the palm=
Disseminated Gonorrhea
–Tx: Ceftriaxone and aythromycin
Septic joint: MC sites
- typically knee, wrist and ankles
- S. aureus and streptococci MC organisms
ABx early!– tx gram + cocci with vanco IV or beta lactase cefazolin
Tools for dx of septic joint
- joint aspirate with LACTATE levels–> when high lactate, this is a septic joint
- use IV steroids
Gonococcal arthritis is the MC cause of _____ _____ in young sexually active young adults
septic arthritis
Gonococcal arthritis: Sx
- large joints: Knee wrist and ankle, tenosynovitis +/- skin lesions typically on fingers
- disseminated gonococcemia: one or more joint
- fevers and joint pain 1-4 days
- NOT AS destructive as septic arthritis, can do daily aspiration and antibiotics IV then switch to po
Bursitis=
=inflammation of thin walled sac lined with synovial tissue bursa, OVERUSE injury also traumatic
- prepatellar, olecrenon, suprapatellar, subdeltoid, trochanteric
- Not much pain at rest, can have pain with motion
- rest, nsaid, steroid injections
- Bursal aspiration can be diagnostic and therapeutic: careful as it can be infectious such as cellulitis
- –If you think a cellulitis with a bursitis: Infectious are skin flora S. aureus
- -14 day outpatient is ok unless septic, pus, surrounding cellulitis
Gout= altered _____ _____
purine metabolism
Gout Labs and Sx
- increased body pool of urate with hyperuricemia
- uric acid (monosodium rate MSU) =gout=negative biofringence=needle shape
- calcium pyrophosphate=pseudogout=rhomboid
- middle age men
- serum uric acid levels not useful for acute attacks as can be high or low ( inflammatory cytokines are uricosuric) but at some point are elevated and can be used to follow therapy
How to confirm dx of gout?
aspirate the joint and send to lab to look for crystals
mcc : initial attack in in great toe (podagra)
Typically gout has occurred ____
before,
- pain is constant at rest
- WBC count can be elevated
Algorithm for Gout: (not using joint fluid)
- male 2 points
- previous attack 2 points
- onset within one day .5 points
- Joint redness 1 point
- first metatarsal 2.5 points
- htn or cardiovascular dz 1.5
- serum urate greater than 5.88 3.5 points
low risk <4
intermediate 4-8
high risk >8
Gout tx 1st line
- NSAID 5-7 days
- 1st Line: indomethacin, naproxen
- 2nd prednisone PO or IV
-or colchicine- 0.6mg tid, potent anti-inflammatory agent can help prevent and abort attacks
Osteomyelitis: bone infection generally caused by ____
staph aureus
- usually due to acute open fx
- can be due to hematogenous spread of bacteria or contiguous
- -think DM Pts with foot ulcers
Osteomyelitis in sickle cell. Pt is caused by which organism
salmonella
Osteomyelitis: dx/tx
- CBC, CRP are initial labs
- get several blood cultures
- Xray
- MRI or bone scan is easiest way to dx
- BONE BX is GOLD STANDARD
tx: IV ABX, consult with ID, acute 6-8 weeks, chronic= 4-24 months
Upper body:
shoulder–> ____ nerve
arm–> ____ nerve
Forearm–> ___ nerve
axillary nerve, C5 (shoulder abduction)
arm= musculocutaneous nerve, C6 (biceps cant flex elbow)
Forearm= radial nerve, C7 (wrist and finger extension)
Wrist–> median nerve (C6-C8)
Hand: Ulnar T1 , median nerve= flexion of fingers
Digits: Palmar digital
PE: Ulnar nerve
- examine in open hand position
- Ask them to close hand with Ulnar n. injury
- Proximal injury takes out flexor digitorum profundus muscle
- –the 2nd and 3rd digits will flex to close
- –4th and 5th stay extended at mcp
- -weakened lumbricals no abduction of fingers
-Distal n injury (at wrist) the 4,5th digits have some flexion as FDP is ok but hyperextended due to force of extensors and paralyzed 3 4th lumbricals, ulnar claw hand
“claw hand” slide 28-60
ulnar nerve damage
