emed II exam 1 ortho

Print this FlashCard
Question Answer open 5th metacarpal fracture that is displaced anteriorly Displaced anterior boxers fracture Left hip is shortened and externally rotated indicative of fracture Fractures involving the growth plate of long bones in pediatric patients are described by Salter-Harris classification***** (type I and V might not be seen on XRAY) salter harris classification what are the 5 main long term complications of fractures (1) malunion (2) nonunion (3) AVN (4) arthritis (5) osteomyelitis flexes the thumb against resistance median nerve spreading the fingers against resistance ulnar nerve maintaining extension of the wrist and fingers against resistance radial nerve Pain along the tendon may mean partial tear complete rupture of the extensor tendon occurs at the distal phalanx. o PE- DIP joint is flexed at 40 degreeso TX- splint the PIP joint in extension mallet finger injury at the dorsal surface of the PIP joint that disrupts the extensor hood apparatuso Lateral bands of the extensors mechanism become flexors of the PIP joint and hyperextensors of the DIP jointo TX- splint the PIP joint in extension boutonniere deformity is dip or pip joint more common and what direction are the dislocations normally DIP less common. Dislocations are usually dorsal how do you treat dip/pip dislocations Reduction using a digital block. Then splinted in extension. If it is the 1st digit(thumb) place in the thumb spica. Irreducible joints require surgical intervention. – M/C involve the tuft (tip of the finger) usually associated w/ subungal hematoma and nail bed laceration. Splinto Subungual hema—bruising under nail, put needle through that distal phalynx fracture how would you treat a proximal/middle phalanx fracture if non-displaced buddy tape displaced or midshaft splint and f/u with hand surgeon M/C involve the fourth and fifth MC neck (boxers fx)- Angulation 20 degrees of the 4th or 40 degrees of the 5th needs to be reduced-Thumb fracture should be placed in thumb spica and usually involves the baseTreatment is an ulnar gutter splint metacarpal fractures mc fractured carpal bone scaphoid MOST IMPORTANT fall on outstretched wrist pain on radial inflexion snuffbox tenderness what do you do – put in a short arm thumb spica splint MOI: FOOSHExam: snuffbox tenderness, pain w/ radial dev and flexion ED mgmt: short arm thumb spica splint scaphoid MOI: avulsion fx, twisting of the hand against resistance or hyperextension from direct trauma Exam: tenderness over the dorsum of the wrist, distal to the ulnar styloid ED mgmt: short arm sugar tong spling triquetrium MOI: FOOSHExam: tenderness at shallow indentation of mid dorsum of the wrist ED mgmt: short arm thumb spica splint lunate MOI: direct blow to thumb, force to wrist while flexed and radially deviated Exam: painful thumb movement and pinch strength possible, snuffbox tenderness ED mgmt: short arm thumb spica splint trapezium MOI: fall directed on hypothenar eminence Exam: tender pisiform, prominent at the base of the hypothenar eminence ED mgmt: short arm volar split in 30 degrees of flexion and ulnar deviation pisiform MOI: interrupted swing of a golf club, bat or racquet Exam: tenderness at the hook of the hamate, just distal and radial to the pisiform ED mgmt: short arm volar splint w/ 4th and 5th MCP joints in flexion hamate MOI: forceful flexion of the hand w/ radial impact Exam: tenderness over the capitate just proximal to the third mcp ED mgmt: short arm volar splint capitate MOI: axial load onto the index metacarpal Exam: tenderness over the radial aspect o the base of the index metacarpal ED mgmt: short arm thumb spica splint trapezoid dorsal angulation of the plan of the distal radius, distal radius fragment displaced proximally and dorsally, radial displacement of the carpus, ulnar styloid fx colles fracture (fork deformity) volar angulation of the plane of the distal radius, distal radius fragment displaced proximally & volarly, radial displacement of the carpus , fx line extends obliquely from the dorsal surface to the volar surface 1-2 cm proximal to the articular surface smith fracture volar and proximal displacement of a larger fragment of radial articular surface, volar displacement of the carpus, radial styloid may be fractured barton fracture – Patient c/o a “pop” and has anterior shoulder pain. Patient has tenderness, swelling, and crepitus over the biciptal grove. When the elbow is flexed you will see a mid arm “ball”. Strength may be maintained by surrounding muscles proximal biceps tender rupture reveals swelling, ecchymosis, tenderness and inability to palpate tendon in the antecubital fossa. Is weak with elbow flexion and supination distal biceps tendon rupture with the patient seated and the elbow flexed and forearm resting on the patients lap, the examiner squeezes the belly of the biceps causing there forearm to supinate biceps squeeze test (distal) – Presenting with pain, swelling and tenderness proximal to the olecranon (a sulcus with a proximal mass may be palpable)o Forearm extension is weako A modified thompsons test can be performed (will cause extension of forearm unless complete tear) triceps tendon rupture how do you dx and tx tendon ruptures – Diagnosis: usually clinically made. May obtain xray to r/o avulsion fx- Treatment includes sling, ice, NSAIDs, and referral to orthopedic specialist OUTPATIENT M/C is a posterolateral dislocationPE- pt holds their arm in 45 degrees of flexion; significant swelling on the elbow, must do neuro eval, dx w/ XR lateral view elbow dislocations how do you treat elbow dislocations reduction with procedural sedation and recognition of neurovascular complications, associated fractures, and post reduction instability. Obtain post reduction films. Long arm splint in less than 90 degrees of flexion. Orthopedics follow up. Dx w/ XR, sometimes not visual may only have a posterior or anterior (sail sign) fat pad, ER- immobilization w splint and ortho f/u, Non displaced radial head fractures only need a sling- Immediate consult with displaced, open, or neovascular compromise elbow fractures pain, swelling, and tenderness over the lateral elbow; inability to fully extend elbow, pain with supination(ant and post fat pads radial head fracture swelling, tenderness and LROM at the elbow supra/intercondylar fractures present with pain, swelling and crepitus over the posterior elbow olecranon fracture p/w swelling, tenderness and deformity of the forearm (monteggia and galeazzi)—Dx- x-ray- ED care-o Nondisplaced- fractures long arm splint, referral to orthoDisplaced- consult(closed reduction for kid; ORIF for adults) forearm fractures – fracture of proximal third of the ulna with a radial head dislocation, pain and swelling at t he elbow think hit by a bat moteggia fracture a fracture of the distal radius with an associated distal radioulnar joint disloctation, pain and swelling at the wrist galeazzi fracture p/w pain, swelling and tenderness over the clavicle – Dx- xray- definitive is CT – Tx- RICE(sling) ortho consult for open fx, neurovascular compromise, or skin tenting clavicle fracture how do you dx AC joint injuries x ray what types of AC joint injuries do you treat w/ include sling, rest, ice and analgesics. Tell them what types of AC joint injuries do you treat w/to start early ROM exercises usually 7-14 days after injury I and II what types of AC joint injuries do you treat w/ sling or operation type III what types of AC joint injuries do you treat w/ surgery only IV-VI p/w arm held in abd and slight ext rotation w/ shoulder appearing squared off MOI: indirect blow w/ arm in abd, extension and external rotation assoc w/: ax nerve palsy, fx of greatery tub or humeral neck, disruption of glenoid rim (bankart lesion) anterior glenohumeral dislocation disruption of glenoid rim assoc w/ anterior glenohumeral dislocation (bankart lesion) p/w arm adducted and internally rotated, ant shoulder =flat and post aspect=full, coracoid prcess is prominent, pt will not allow ext rotation or abd bc severe pain assoc w/ fx of post glenoid rim, fx humeral head or shaft, fx lesser tuberosity posterior glenohumeral dislocaiton fracture of the humeral head can be assoc w/ posterior glenohumeral dislocation hill sachs deformity what is the diagnostic imaging view to confirm shoulder dislocation Xray- AP and a scapular “y” view to confirm dislocation. how do you treat glenohumeral dislocations in the er reduction (traction, leverage and scapular manipulation) may req sedation. You may try an intraarticular injection of lidocaine. After reducing, sling and repeat the xray. Othro f/u humerus fx- pain, swelling, tenderness, ecchymosis, and crepitus about the shoulder. ROM is severely limited. Patients will not move arm and hold arm close proximal humerus humerus fx-pain, swelling, localized tenderness, limited mobility, and possible shortening of the arm humeral shaft fracture how do you treat humerus fx in the ED sling immoblization for nondisplaced fx, ice, analgesics and ortho referral. Humeral shafts get long arm or sugar tong splints and ortho referral. Any displaced or communted fractures get an immediate ortho consult Pts usually present shortened and externally rotated–usually complain of pain in the groin or knee, dx w/ XR or poss CT Tx: reduced (sedation) w/ in 6 HOURS to prevent AVN, order post reduction films hip fracture how soon should you reduce a hip fx to prevent AVN 6 hours What are the 5 Ottowa rules that determine if an XR is needed for a knee fracture (if ANY of the following are present) 1) Age >= 55 years 2) Pain at the head of fibula3) Isolated patella tenderness4)Inability to flex knee 90 degrees5) Inability to walk 4 weightbearing steps isolated fx rare, result of high E trauma ( dashboard to flexed knee MC)- sup aspect or impaction fracture in ant dislocation- inf aspect in posterior dislocation – CM: limb shortened/ ext rotated (ant), shortened and flexed, int rotated (post) femoral head fracture common in older pts w/ osteoporosis, rarely seen in younger, low impact falls or torsion in elderly, high-energy trauma or stress fx in young – ranges from pain w/ weightbearing to inability to ambulate; limb may be shortened and externally rotated femoral neck fracture uncommon fx, older patients or adolescents, from direct trauma (oldr), avulsion due to contraction of gluteus medius (younger), sxs= ambulatory, pain w/ paipation or abduction (can tx w/ crutches) grater trochanteric fracture uncommonfx, adol (85%) > adults, avulsion due to forceful contraction of iliopsoas (adolescents); avusion of pathologic bone (older adults), usually ambulatory; pain w/ flexion or rotation (can treat w/ crutches) lesser trochanteric fracture common in older patients w/ osteoporosis, rare in younger, MOI=falls or high energy trauma, CM= severe pain, swelling, limb shortened and externally rotated needs surgery intertrochanteric fracture similar to intertrochanteric fx, MOI=falls or high energy trauma, may also be pathologic, CM= severe pain; ecchymosis; limb shorted, abducted and externally rotated needs surgery subtrochanteric fracture What views should you get on XR for hip and proximal femur fractures – evaluate the hips including AP and lateral views. Get an AP pelvis an evaluate for rami fractures (will also show you other hip). You may need a femur and knee 100% sensitive test for hip fracture, You order this when a patient can not bear weight to r/o occult fracture. CT scan may be used also but not as sensitive MRI What is the tx in the ED for femoral head/ neck fracture? immediate ortho consult, admission to ortho serviceORIF vs. total hip arthroplasty What is the tx in the ED for greater/lesser trochanteric fracture? anagesics, protected/weight bearing as toleratedOrtho f/u 1-2d or admit if unable to tolerate ambulation What is the tx in the ED for inter/subtrochanteric fracture? orhto consult, admit to ortho service MOI=direct blow (fall, motor vehicle crash, forceful contraction of quad muscle)- nondisplaced, intact ext mechanism: immobilize, RICE- displaced >3mm/ disrupt ext mech: above + ORIF – comminuted: surgical debridement, suture quad/patellar tendon patellar fracture MOI= fall w/ axial load/blow to distal femur TX= – incomplete or nondisplaced fx any age/stable fx in elderly, long leg splint, ortho referral – displaced fx/ joint incongruity: splinting and ORIF femoral condyles MOI= force directed against flexed proximal tibia in an ant/post direction (motor vehicle, sports injury)TX= – incomplete or nondisplaced: immobilization in full extension, ortho referral 2-7 days – completely displace: early ortho referral, ORIF tibial spines and tuberosity MOI= sudden force to flexed knee with quad contracted TX= – incomplete or small avulsion: immobilization – complete avulsion: ORIF tibial tubercle fracture valgus/ varus forces comb w/ axial load, drives femoral condyle into the tibia (fall, leg hit by car bumper) TX= – nondisplaced/ unilat: knee immobili w/ nonweightbearing/ referral in 2-7 d- depression of articular surface: early ortho consult/ orif tibial plateau fracture Results in pain and deformity of the knee. Tearing of the medial knee joint occurs.- worry about popliteal artery and peroneal nerve injuryDX: XR (sunrise view) Tx: flex hip, hyperextend knee, immobilize & f/u patella dislocation how do you treat an open patellar fracture irrigation and antistaphococcal abx in the ed , debridement and irrigation in the OR what is the XR view you use to dx a patellar dislocation sunrise view why dont you give lidocaine or block in a patellar dislocation don’t give them lidocaine or a block bc it goes into the capsule behind the patella and it wouldn’t work Pain and swelling PATIENT WILL NOT BE ABLE TO EXTEND THE KNEE AGAINST RESISTANCE; depending on the tendon involved you will feel a palpable defectDX: pe, XR, MRI OUTPTTX: knee immobil, ice, elev, crutches, NSAID, ortho referral quads/ patellar tendon rupture Pt hears a “POP, has signif swelling (hemarthrosis) over next couple of hours. The Lachman test is the MOST sensitive test (pt playing sport)- Dx- PE and MRI OUTPATIENT!!!- TX- knee immobilization, ice, elevation, crutches, NSAIDs, ortho referral ACL tear what is the test for ACL tear and when do you do it – Do Lachman right after injury bc you get so much swelling that if you wait too long you wont be able to perform the test : “hit my knee on the dash board” Posterior draw test (in a car accident pts) – Dx- PE and MRI OUTPATIENT!!!- TX- knee immobilization, ice, elevation, crutches, NSAIDs, ortho referral PCL tear Sports injury/twist injury; test with valgus and varus stress(laxity)- Dx- PE and MRI OUTPATIENT!!!- TX- knee immobilization, ice, elevation, crutches, NSAIDs, and physical therapy, ortho referral MCL/LCL tear Painful knee locking, popping, clicking or snapping sensation; mcmurray test (may not be sensitive) – Dx- PE and MRI OUTPATIENT!!! TX- knee immobilization, ice, elevation, crutches, NSAIDs, ortho referral meniscal injury What are the ottowa rules for XR for the foot 1) Tenderness at base of 5th metatarsal 2) Tenderness at navicular bone3) Inability to bear weight both immediately and at the ER What are the ottowa rules for XR for the ankle 1) Tenderness posterior edge or tip of lat. Mal.2) Tenderness posterior edge or tip of med. Mal. 3) Inability to bear weight both immediately and at the ER fx of ankle disrupts interosseous membrane and you have fibular head fracture maisonneuve fracture results from inversion or eversion injuries; m/c is the ATFL (anterior talofibular); painful and swollen- Dx- eval joints above and below (Maisonneuve fx), XRTx- RICE, NSAIDS; ankle brace and ortho follow up +/- crutches ankle sprains Hyperdorsiflexion or sudden planter flexion. Full ruptures have severe pain and are unable to walk on their toes, run or climb stairs; may feel a gap from rupture- Dx- thompsons testTx- RICE, NSAIDS; posterior splint and ortho follow up +crutches achilles tendon rupture what is the most common ankle dislocation posterior dislocation – Usually occurs with a backward force on the plantarflexed foot. Usually results in the rupture of the tibiofibular ligaments or a lateral malleolus fx. – reduce immediately if vasc compromise, splint and post red xr- ortho consult immediately ankle dislocation how do you reduce an ankle fracture grasp the heel and foot and apply downward traction (analgesia or sedation) apply splint obtain post reduction (1) unimalleolar fracture (2) lateral and medial malleoli are broken, this is called a bimalleolar fx (3) posterior malleolus is also fractured, this is called a trimalleolar DX: XR TX: posterior splint, non wb (crutches), RICE, orhto consult ankle fractures what is the treatment for bi/tri malleolar ankle fractures posterior splint; non weight bearing(crutches); RICE and ortho consult; bi/trimalleolar fx require ortho consult for ORIF what is the treatment for open ankle fractures Open fx splinting, tetanus, first generation cephalosprin and immediate ortho consult fracture along the 4th metatarsal, if doesn’t heal well send them to surgery- Cant walk on jones fracture, get placed in posterior boot or splint and are non weight bearing jones fracture 5th metatarsal diaphysis is fractured (cast and non-weight bearing); avulsion fracture of the 5th metatarsal (walking boot, less serious pseudo jones fracture (avulsion) Foot fracture –ED imaging: plain films/ CT ED care: posterior splintortho/pod referral: intraarticular–immediate, extra-24 hours calcaneal Foot fracture –ED imaging: CTED care: posterior splintortho/pod referral: 24-48 hrs talus Foot fracture –ED imaging: CTED care: posterior splintortho/pod referral: ED ortho consult lisfranc Foot fracture –ED imaging: plain films/ CT ED care: posterior splintortho/pod referral: 24-48 hrs navicular Foot fracture –ED imaging: plain films/ CT ED care: posterior splintortho/pod referral: 24-48 hrs cuboid Foot fracture –ED imaging: plain films/ CT if athleteED care: posterior splintortho/pod referral: 24-48 hrs jones Foot fracture –ED imaging: plain filmsED care: posterior splintortho/pod referral: w/in one week metatarsal Foot fracture –ED imaging: clinical ED care: posterior splintortho/pod referral: w/in one week stress Foot fracture –ED imaging: plain filmsED care: BUDDY TAPEortho/pod referral: w/in one week phalange Foot fracture –ED imaging: open fracture ED care: pain control ortho/pod referral: ED ortho consult open Elevated pressures within a confined muscle compartment can lead to functional and circulatory impairment of that limb. M/C are legs(lower) and forearm compartment syndrome severe/difficult pain to control (out proportion) and w passive stretch; Muscle weakness(paralysis); swollen/ tender(pressure); pulselessness(late); Pallor(late) ;Paresthsia(late), Sxs usually start w/in 48 hrs of injury compartment syndrome what is normal compartment pressure, how do you dx compartment syndrome – measure compartment pressures (vascular sx consult) normal compartment pressures at <10 mmhg what is the tx for compartment syndrome TX- surgical fasciotomy needs to occur within 6 hours of onset when is it indicated to get a nexus C spine CT (most radiation from a CT) o Midline c-spine tendernesso Evidence of intoxicationo Abnormal level of alertnesso Focal neurological deficito Painful distraction injury –fracture/something very painful –stay in collar until that is cleared rare, surgical emergency–, something compresses on the spinal nerve roots. You may need fast treatment to prevent lasting damage leading to incontinence and possibly permanent paralysis of the legs cauda equine syndrome infxn in a boneby traveling through the blood or spreading from nearby tissue, can also begin in the bone itself if an injury exposed- Dx- xray, MRI***, CBC, CRP(elev), ESR(elev), cultures—admit pts for MRI- Tx- high dose BS abx (vanc/zosyn) admit osteomyelitis where does osteomyelitis affect children the most long bones of the legs and upper arm where does osteomyelitis affect adults the most vertebrae where does osteomyelitis affect diabetic the most feet infection of one or more joints by microorganisms, microbs are identifiable in an affected joint fluid. Common in immunocompromisedcan be caused by bacteria, viruses and fungi MCC bacteria (S. aureus, H. flu) septic arthritis what is the mcc septic arthritis in iv drug abusers or elderly E. coli, pseudomonas what is the mcc septic arthritis in young children/ people w/ sickle cell salmonella how do you DDX with cellulitis and septic arthritis— – pt wont be able to bend knee in septic arthritis bc the infection is in the joint capsule whereas cellulitis they can bc it’s a superficial skin infection what is the dx/ tx of septic arthritis tap the joint (needle aspiration); admit for IV antibiotics, arthroscopy/open drainage (vanco/cipro or vanco/imipenem) Synovial fluid shows: Clarity: transparentColor: clearWBC/uL: <200PMNs: <25Culture: negativeCrystals: noneAssociated condition: normal synovial fluid Synovial fluid shows: Clarity: transplarentColor: yellowWBC/uL: <200 to 2000PMNs: <25Culture: negativeCrystals: noneAssociated condition: OA, trauma, rheumatic fever non-inflammatory synovial fluid Synovial fluid shows: Clarity: cloudyColor: yellowWBC/uL: 200-50,000PMNs: >50%Culture: negativeCrystals: multiple or noneAssociated condition: gout, pseudogout, RA, lyme, SLE inflammatory synovial fluid Synovial fluid shows: Clarity: cloudyColor: yellowWBC/uL: >50,000PMNs: >50%Culture: positive >50%Crystals: noneAssociated condition: septic arthritis septic synovial fluid

Leave a Reply

Your email address will not be published. Required fields are marked *