Orthopedics_Procedural Sedation Flashcards
Complications of Ketamine
Central apnea<div>Airway malposition</div><div>Laryngospasm</div><div>Hypersalivation</div>
“What determine good reduction in Colle’s fracture”
“Radial inclination = 22 degrees<div>Radial length = 11 mm</div><div>Volar tilt = 11 degrees</div><div><img></img><br></br></div>”
What determines unstable elbow dislocation
The terrible Triade<div>Dislocation</div><div>Radial head #</div><div>Coronoid #</div>
Drugs for procedural sedation
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<strong>C</strong><strong>ontraindications to ketamine</strong>
<ul><li>Age</li><li>Increased risk of respiratory complications</li><li>Animal studies suggest NMDA antagonists are associated with apoptosis and neuro-degeneration in developing brains</li><li>History of schizophrenia/psychotic disorder</li></ul>
What is the main x-ray finding of a scapholunate dissociation?
The Terry Thomas Sign and the Madonna Sign as all 2 of these famous entertainers have a gap between their two front teeth.<div>A gap between the scaphoid and lunate on the AP xray of the wrist of >3mm is a scapholunate dissociation until proven otherwise.<br></br></div>
What are the main x-ray finding for a perilunate dislocation and lunate dislocation on x-rays of the wrist?
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What are consequences of missing a <br></br>perilunate dislocation?
Chronic wrist pain<div>median n. palsy</div><div>pressure necrosis</div><div>Compartment syndrome</div><div>Long term wrist dysfunction</div>
“ORIF indications in Colle’s #”
<ol> <li>Significant comminution</li> <li>Intra-articular involvement with > 2 mm step-off despite reduction</li> <li>High grade open #</li> <li>Failure to achieve adequate reduction esp in youg with dominant hand</li> </ol>
How much is the degree that metacarpal bones can tolerate as of rotation?
5th through 2nd=40, 30, 20,10 degrees respectively
“Specific recommendations about Boxer’s #”
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DDx of pain in snuff box post trauma
Scaphoid #<div>distal radius/styloid #</div><div>Lunate #</div><div>Scapholunate dissociation</div><div>1st CMC sprain</div>
“What is this #<div><img></img><br></br></div>”
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<p>Adequate Colles Reduction</p>
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<p>Perilunate dislocation</p>
“<img></img><div><img></img><br></br></div>”
Quick Sensory and motor exam of hand
<b>Motor</b>:<div>Radial (thumbs up)</div><div>Median (OK sign)</div><div>Ulnar (fingers abduction)</div><div><br></br></div><div><b>Sensory</b>:</div><div>Radial (dorsal 1st webspace)</div><div>Median (palmar 3rd digit)</div><div>Ulnar (5th digit)</div>
<p>Galeazzi Fracture/Dislocation</p>
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What nerve inj occurs with Monteggia #
Post interosseous nerve (radial n) causing wrist drop
Complications of Monteggia #
Open #<div>Compt synd</div><div>PIN inj</div><div>Collateral lig inj</div>
GRUM
Galeazzi<div>Radial #/ Ulnar dislocation</div><div>Ulnar #/ Radial dislocation</div><div>Monteggia</div>
Nightstick # considerations
Domestic violence<div>If unstable ==> ORIF/ Indications:</div><div>>50% displacement</div><div>> 10 deg angulation</div><div>Proximal 1/3 involvement</div>
Supracondyler #
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Shoulder dislocation reduction techniques
Traction-countertraction<div>External rotation</div><div>FARES (FAst, REliable and Safe)</div><div>Spaso</div><div>Cunningham</div>
Complications of shoulder dislocation
Hill-Sacks#<div>Bankart #</div><div>Axillary n injury</div>
<p>6 Unstable C-spine #’s</p>
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<p>Normal C-spine Soft tissue swelling</p>
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<p>3 Column System</p>
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Facts about clavicular #
Middle 1/3 is most common<div>Lateral 1/3 often injures CC lig</div><div>Med 1/3 ass with intra-thoracic inj</div>
How to assess pt for analgesia?
<b><i>History</i></b>:<div>Previous pain medications (type/dose/freq/last one/SE)</div><div>Allergies</div><div>Hx of opioids use</div><div><br></br></div><div><b><i>Exam</i></b>: HR, BP, diaphoresis</div><div><br></br></div><div><b><i>Types of analgesia:</i></b></div><div>Non-pharmacological (splinting, ice, sling, compression)</div><div>Pharmacological (regional anesth, nerve block, hematoma block, NSAIDs, Opioids, procedural sedation)</div>
Foot neurovascular exam
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Foot N/V exam
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<p>What does plantar bruising make you concerned for?</p>
<p>Lisfranc injury, mechanism is injury to deep penetrating arterial branch of dorsalis pedis, which runs by Lisfranc ligament.</p>
Lesfranc #
“<p>Pathognomonic injury is a fracture at the medial base of the 2nd MT with widening of the Lisfranc joint (isolated movement of 1st MT medially)<img></img></p> <p>More obvious injuries will show malalignemnt of each metatarsal with its respective tarsal bone (homolateral, diveregent):</p> <ul> <li>1st MT = medial cuneiform,</li> <li>2nd MT – middle,</li> <li>3rd MT = lateral,</li> <li>4/5th MT - cuboid</li> </ul>”
What are the ankle sprain mimics?
<ol> <li>Avulsions of: lateral malleolus, 5th MT, navicular, or talus.</li> <li>Peroneal or Achille’s tendon rupture.</li> </ol>
“What is Bohler’s angle”
“<img></img>”
Lateral malleolar classes
“<p><img></img><br></br></p> <p>Type A can be treated with immbolization assuming no other malleolar injury.</p> <p>Type B may injure the syndesmotic ligament.</p> <p>Type C it is assumed that syndesmosis is injured and needs a screw fixation</p>”
<p>What determines if an ankle injury is unstable?</p>
<p>To simplify, involvement of multiple malleoli, whether ligamentous or bony</p>
<p>Maisonneuve Fracture</p>
“<ul> <li><em>Triad of fibular fracture, syndesmotic and medial malleolar injury</em></li> <li>Usually requires surgical fixation</li> <li>Splint and call Ortho</li> <li>Any suggestion of medial injury, even with normal x-rays should be treated the same</li> <li><img></img></li> <li> <p>Think of this like a Galeazzi of the leg.</p> </li><li><p><span>Isolated syndesmotic injury can be suspected on exam or xray, distal compression of tib/fib is suggestive, on xray should have at least 1 mm of tib/fib overlap on mortise view. If this is lacking and especially if there is lateral talar shift, consider syndesmotic injury.</span></p></li> </ul>”
AB for compound #
Cefazolin for all open #<div>Add Gentimicin for anything more than Grade 1</div><div>Add penicillin for gross contamination with soil</div>
What is the gold syandard for diagnosis of compt syndrome
Compt pressure measurement
Mx of Tibial Plateau #
<b>Non-Operative:</b><div> No or minimal displaced #</div><div> Lat plateau # with stable knee on exam</div><div><br></br></div><div><b>Operative:</b></div><div> Open #</div><div> Severe comminution</div><div> Bicondyler</div><div> All med #</div><div> Unstable knee</div><div> > 3 mm articular step off</div>
“<p>What about this x-ray?</p><p><img></img><br></br></p>”
<p><strong>Lipohemarthrosis </strong>best seen in a cross table lateral, see fat/blood level, indicates occult intra-articular fracture, with otherwise normal x-ray this is an indication for CT scan.</p>
Tests of knee ligaments stability
Ant drawer/pivot shift<div>Post drawer/look for sagging</div><div>Varus/valgus stress test</div>
<p>What physical exam finding is important in suspected patellar fractures?</p>
<p>Ability to extend the knee actively (ie. SLR).</p>
How do you reduce patellar dislocation?
<p>Flex the hip, gently extend the knee while providing medial pressure to lateral patellar border.</p>
“What is the abnormality?<div><img></img><br></br></div>”
<p>Patella alta or high riding knee cap,</p>
<p>very common finding in recurrent patellar dislocation</p>
Techniques of reduction of post hip dislocation
<p>Allis = supine, knee/hip flexion, upward traction with assistant holding pelvis down, int/ext rotation may help clear the rim.</p>
<p>Rochester (“Captain Morgan”) = Using uninjured side/knee as leverage point, Rocket Launcher</p>
Complications of post hip dislocation
AVN of femoral head<div>Sciatic n inj</div>
<p>Can you list some classic injures?</p>
<ul> <li>Metaphyseal chip #</li> <li>Clavicle #</li> <li>Spiral #</li> <li>Any long bone # in non-ambulatory child</li> <li>Posterior rib #</li> <li>Circular bruises (bite or cigarette burn)</li> <li>Immersion burn injuries</li> <li>Linear bruises (slap injuries)</li> <li>Complex skull #</li> <li>Multiple injuries at different stages</li> <li>Any injury not fitting mechanism</li> </ul>
<p>Salter Harris Classes</p>
“<ul> <li>S-straight</li> <li>A-above</li> <li>L- BeLow</li> <li>T-Through</li> <li>ER- Erasure of growth plate (crush)</li> </ul><div><img></img><br></br></div>”
<p>Elbow Xrays, Ossification centres</p>
“<b>CRITOE</b><div><img></img><br></br></div>”
<p>What radiographic lines are important in pediatric elbow interpretation?</p>
“<p>Radiocapitellar and anterior humeral lines</p><p><img></img><br></br></p>”
<p>What injuries the radiocapitellar and ant humeral lines to the help to identify?</p>
Elbow dislocation<div>Radiocapitellar dislocation (Monteggia #)</div><div>Supracondylar #</div>
“Describe the important lines:<div><img></img><br></br></div>”
<ul> <li><strong>Anterior humeral line</strong> should intersect middle third of capitellum = abnormal here</li> <li><strong>Radiocapitellar line</strong>, should intersect the middle of the capitellum = normal here</li> <li>Also <strong>posterior fat pad</strong> and break seen in cortex posteriorly, this is a Type 2 Supracondylar</li> </ul>
“What is shown here?<div><img></img><br></br></div>”
<ul> <li><strong>Sail sign</strong> is an anterior fat pad that is pushed anterior so it looks triangular.</li> <li>Signifies joint effusion and increased risk of occult fracture.</li> </ul>
Complications of supracondylar #
Compt syndrome<div>Nerve inj</div><div>Arterial inj</div>
DDx of Atraumatic hip pain
Septic arthritis<div>SCFE</div><div>Osteomylitis</div><div>Transient synovitis</div><div>Bursitis</div><div>IT band syndrome</div><div>Referred pain from knee j.</div>
“Describe this X-ray<div><img></img><br></br></div>”
<p>Klein’s line = line from superior cortex of femoral neck should intersect at least 1/3 of femoral head</p>
<p>Widened physis is the early finding, this xray is obviously quite advanced.</p>
“Describe this X-ray<div><img></img><br></br></div>”
<p>Toddler’s fracture = distal spiral tibia fracture from low energy mechanism</p>
<p>What if it was not related to an accident?</p>
<p>Highly suspicious for non-accidental trauma (abuse)</p>
<p>Consider extra views to exclude abuse</p>
<p>Universal Answers for Injuries</p>
<ul> <li>Analgesia</li> <li>NV assessment (pre and post reduction)</li> <li>Irrigate wounds</li> <li>Td status</li> <li>Antibiotics</li> <li>Reduce/Splint</li> <li>Refer to specialist</li> </ul>
<p>Universal answers for Trauma</p>
<ul> <li>Get Surgeon/Trauma team to bedside</li> <li>C-spine precautions</li> <li>Fluid bolus</li> <li>Massive transfusion protocol</li> <li>CT liberally, but not if unstable</li> <li>Wedge Pregnant patients</li> <li>Get them off the backboard fast</li> <li>Don’t move on if ABCs are still an issue</li> </ul>
Drugs for Procedural Sedation
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Which fat pad is more significant for supracondylar #
Posterior fat pad
“<h2><span><strong><em>APPROACH TO THE CHILD WITH A LIMP</em></strong></span></h2>”
<ol><li>Rule out septic arthritis</li><li>Look for fractures, which can bevery subtle, and ask about trauma</li><li>Look for clues of systemic illnessessuch as a rash, fever, bruising</li><li>Consider age-specific diagnoses as appropriate</li></ol>
The<b>Kocher criteria</b>for predictingseptic arthritis
<ol><li>Non-weight-bearing on affect side</li><li>ESR > 40 mm/hr</li><li>Fever</li><li>WBC >12,000</li></ol>
“Criteria for acceptible reduction of Colle’s #”
<p><3mm loss of radial height<br></br><5 degree change in radial inclination<br></br><10 degree loss of volar tilt<br></br>DRUJ reduction<br></br><1-2mm of articular displacement</p>
“<span>What are the potential complications Compt syndrome?</span>”
-Acidosis<br></br>-Hyperkalemia<br></br>-Myoglobinuria/ rhabdomyolysis<br></br>-Acute renal failure<br></br>-Shock<br></br>-Delayed fracture healing
“<span>Describe the motor and sensory exam of the upper extremity to screen for neurovascular compromise</span>”
<ul> <li><strong>Radial</strong>: sensory at 1st webspace, motor with thumbs up, wrist and elbow extension</li> <li><strong>Median</strong>: sensory at 2nd digit, motor with thumb/finger opposition (ok sign)</li> <li><strong>Ulnar</strong>: sensory at 5th digit, motor with finger abduction, wrist flexion</li> </ul>
“Describe this x-ray<div><img></img><br></br></div>”
<ul> <li><strong>Lateral view:</strong><br></br> <ul> <li>distal humerus fracture line</li> <li>less than 1/3 of the capitellum is anterior to the anterior humeral line (both indicate supracondylar humerus fracture)</li> <li>raised posterior and anterior fat pads (indicates joint effusion)</li> </ul> </li> <li><strong>AP view:</strong> <ul> <li>fracture line</li> <li>no apparent intra-articular involvement, rotation, angulation or displacement</li> </ul> </li> <li><strong>Both views:</strong> <ul> <li>surrounding soft tissue swelling (elbow injury - non-specific but are a result of the # in this case)</li> </ul> </li> </ul>
“Describe this X-Ray<div><img></img><br></br></div>”
<ol> <li>There is significant soft tissue swelling, which indicates that the elbow has been dislocated.</li> <li>The medial epicondyle is seen entrapped within the joint.</li> <li>There is only minor joint effusion (medial epicondyle is an extra-articular structure; avulsion will not produce joint effusion). The small amount of joint effusion is probably the result of the prior dislocation.</li> </ol>
“<span>List 3 classic deformity patterns of traumatic hip/femur injuries and the corresponding diagnosis on imaging?</span>”
<ul><li>Shortened, externally rotated - Hip fracture</li><li>Shortened, internal rotated - Posterior hip dislocation</li><li>Midshaft femur angulation and swelling - Femoral shaft fracture</li><li>Extended, externally rotated, abducted - Anterior hip dislocation</li></ul>
“<span>If this patient has an arthroplastic posterior hip dislocation instead of a hip fracture, describe 2 different techniques for closed reduction?</span>”
<b>Allis technique</b><br></br>Hip extension, in line traction, assistant provided posterior traction to pelvis, internal/external rotation as required.<br></br><b><br></br>Lefkowitz or “Captain Morgan”</b><br></br>hip extension/traction using knee as a fulcrum, use assistant/strap to immobilize pelvis, internal/external rotation as required<br></br><b><br></br>Whistler maneuver</b><br></br>Arm placed under affected leg at knee joint, hold unaffected knee, uses as fulcrum similar to Lefkowitz.<br></br><br></br>Howard, Stimson, Lateral traction, Bigelow, Rocket launcher, Piggyback, and many more could be listed if they describe them accurately.
“<span>List 3 sedative agents you could use for performing these procedures? List pros and cons of each?</span>”
”-<b>Propofol</b><br></br><i>Advantage:</i> Rapid onset and short duration, anti-emetic effects<br></br><i>Disadvantage:</i> Hypotension, respiratory depression, no analgesia<br></br><br></br><b>-Ketamine</b><br></br><i>Advantage</i>: Potent analgesic effect, minimal effect on BP, preserves airway reflexes<br></br><i>Disadvantage</i>:Vomiting, increased airway secretions, laryngospasm, emergence reaction<br></br><br></br>-<b>Midazolam</b><br></br><i>Advantage</i>: Amnestic, reversible, can be given nasally<br></br><i>Disadvantage</i>: Respiratory depression, long duration, hypotension”
Concentration of lidocain
1% = 10 mg/ml
What #s are prone to AVN
Femoral head<br></br>Scaphoid<br></br>Capitate<br></br>Talus
<b>Pain management in children in acute surgical causes</b>
<div>· Intranasal medications: fentanyl (1-2ug/kg), midazolam (0.2-0.3mg/kg; anxiolysis often is helpful), ketamine (1mg/kg); max volume 0.5-1mL/nare</div>
<div>· Nebulized fentanyl (3mcg/kg/dose via standard nebulizer)</div>
<div>· Inhaled nitrous oxide</div>
<div>· Make liberal use of EMLA/Ametop prior to procedures/IV insertion if time permits</div>
<div>· Use LET (lidocaine-epinephrine-tetracaine) gel for open or mucosal wounds - apply as soon as possible and cover with occlusive dressing</div>
<div>· Consider a hematoma block or ultrasound guided peripheral nerve block</div>
<div>· NSAIDs/acetaminophen are always reasonable</div>
<div>· Oral opioids or IV opioids are also acceptable and should be used with appropriate care in patients with moderate to severe pain</div>
