Treatment of Acute Musculoskeletal Injury Flashcards
Five most common causes of malpractice claim?
- Med errors
- Dx failures
- Negligent supervision
- Delayed tx
- Failure to obtain consent
General Initial Eval 4
- Neurovasculr status. Nerve distributions: Sensory and Motor.
- Any breaks of the skin that may represent open injury
- Check joint above and below point of injury
- Press on bony prominences of the remainder of the uninjured body to evaluate for unrealized injury
Open Fracture Considerations?
Any overying injury of a fractured bone should be considered a possible open fracture. But not all are. Break in skin in which the bone directly communicates with the outside
Open Fracture Evaluation
- Environement in which open fracture occurred
- Size of open injury and gross contamination of the wound bed
- Associated structures that may be injured
General evaluation – Open Fractures • Open Fractures are graded on a scale of severity from 1 through 3 by the Gustillo & Anderson Classification: Descibe types 1-3c?
- Type 1: opening is less than 1 cm in length
- Type 2: skin opening is between 1cm and 10 cm in length
- Type 3a: skin lac > 10cm
3b: skin lac > 10cm with soft tissue loss and unclose able skin edges
3c: skin lac > 10 cm with vascular injury
- The most important treatment in open fracture care is what?
- Compared to what?
- Type 1 and some type 2 injuries can be safely delayed for upwards of how long without increasing risk of what?
- open fracture care is initiation of antibiotics.
- The time to surgical debridement of these injuries has not been shown to be as important a factor in preventing infection as early initiation of antibiotics
- 12 hours, osteomyelitis
General Evaluation – open fracture
- Check and make sure pt is up to date on their what? -Get how what if its been what amount of time?
- Antibiotic choice is determinate on open fracture severity -Type 1 injury = ? -Type 2 and 3 injury = ?
- All barn yard related injuries should also receive what?
- tetanusprophylaxis. -If they are over 10 yrs out then they should get tetanus antibody as well as the antigen (in opposite areas of the body)
- -1st generation cephalosporin ( ancef ) 1 g Q 6 hrs -Cephalosporin as above, add in Gentamycin IV for gram neg coverage
- Penicillin G 2million units Q 6 hrs for tetanus prone injury
General evaluation – Compartment syndrome
- Compartment syndrome def?
- The building pressure results in what?
- The possible cause of compartment syndrome is what?
- a condition where pressure builds up within a fascia enclosed compartment of the body.
- compression of the many capillaries which service the muscles of thatcompartment.
- multi-factorial including bleeding, edema, and infiltration
General evaluation – Compartment syndrome
- Although compartment syndrome can occur in any region of the body with compartments (most) by far the most common areas for compartment syndrome is the what? 2
- followed by? 2
- lower leg (4 compartments) and forearm region (4 compartments)
- followed by the hand and foot regions
General evaluation – Compartment syndrome
- Compartment syndrome is a clinical diagnosis. The most sensitive test to check for compartment syndrome is what?
- The most sensitive clinical sign for compartment syndrome is what?
- pain with passive range of motion of the muscles within the compartment
- pain out of proportion to the injury
General Evaluation – Compartment syndrome What are the 5 ps and why are they not necessarily good for dx?
- Although the 5 P’s are a favorite pimp question to evaluate perfusion, they are not sensitive for diagnosis of compartment syndrome, by the time they are clinically present the damage from compartment syndrome has already been done
- Pain, Pulse, Pallor, Paralysis, Paresthesia
General evaluation – Compartment syndrome What is a better way then the 5 Ps to dx compartment syndrome?
Whats the value we want to look for?
How will it feel?
- Intracompartmental pressure measurements can be performed with a hand held monometer.
- If the measured value is within 30mmHg of the patients diastolic pressure than compartment pressures are too high to allow for capillary perfusion
Like an apple in late.
If it feel like a banana its getting there
Why do we splint?
The reason we splint things is to allow for sufficient swelling to be able to occur. early casting does not allow for soft tissue expansion which can elevate compartment pressures.
General evaluation - splinting -Which splint?
- Proximal Humerus fx – ?
- Shoulder dislocation – ?
- Humerus/elbow –?
- Forearm – ?
- Wrist – ?
- Scaphoid –?
- Metacarpals – ?
- Hip dislocation – ?
- Femur neck - ?
- Femur shaft – ?
- Distal femur/knee/prox tibia – ?
- Tibial shaft – ?
- Ankle – ?
- Foot – ?
- Coaptation splint
- sling/shoulder immobilizer
- Long arm posterior splint
- sugartong splint
- sugartong splint
- thumb spica splint
- ulnar or radial sided gutter splint
- Knee immobilizer
- +/- skin (bucks) traction
- traction (skeletal)
- Knee immobilizer
- Long leg posterior splint
- Short leg post splint +/- stir-ups
- Short leg splint
Orthopedic Xray
- Every xray tells a story. Always start at where and work where?
- Don’t fall into the trap of what?
- edges of the xray and work your way in.
- looking at the fracture right away – remember the most commonly missed fracture is the second fracture
How would you describe this?
AP and Lateral views of a skeletally mature patient with a comminuted intraarticular fracture of the distal radius with associated ulnar styloid
fracture.
The fracture is 100% dorsally translated and approx 3 cm of shortening
with bayonet apposition.
Loss of radial height, radial inclination, and volar tilt
How would you read this?
4
- AP and lateral views of a skeletally
mature leg
- No free air to indicate an open injury
- Long oblique fracture of the tibial
shaft with approx 1 cm of shortening.
The fracture has approximately a 15
degree apex lateral angulation with
30% posterior translation
- There is an associated long oblique
fracture of the fibula just above the
level of the tibial plafond without
translation, as well as a minimally
displaced transverse medial
malleolus fracture. The talus is
centered in the mortise
Boxers fracture is generally where on the hand?
5th metacarpel neck
- Bennet’s fracture is where?
- Rolandos fracture?
- carpel/metacarpel- abductor pollucis broken on medial side
- Comminuted
What is wrong with this xray?
How can you tell? 2
Symptoms? 2
- Lunate dislocation
2.
- Spacing in the AP view
- tipped teacup sign
3.
- Falls into palmar space compressining median nerve = numbess
- Painful
What are these two fractures?
Whats the difference?
Colles facture
then
Smith fracture
Distal FRAGMENT displaced volarly = Smith
dorsally = Colles
What is a Galeazzi Fracture?
The Galeazzi fracture is a fracture of the radius with dislocation of the distal radioulnar joint.
What is a Monteggia fracture?
The Monteggia fracture is a fracture of the proximal third of the ulna with dislocation of the head of the radius.
What kind of fractures are these?
- Radial Head/neck
- Olecranon
What is this?
Distal humerus fracture
What kind of fracture is this?
Associated with?
Holstein-lewis fracture- Fractures/humerus shaft
radial nerve injury
Describe the Garden classifications for femur head fractures
What do we worry about with these?
Who do we see this in?
Tx?
Blood supply to the area
>65 + hip replacement
fix in surgery
What is a subtrochanteric fracture?
Compare this to the femur head fracture
Not as dangerous because the blood supply is not comprimised
Describe types 1 through 6 of tibial plateu fractures?
What kind of fractue is this?
What does this usually come from?
Tibial plafond/pilon
falls
What are these?
Whrere?
LISFRANC fractures
tarsal metatarsal joint
Describe where a stress fracture, a jones fx and where a pseudojones fracture are at?
