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Ortho Emergencies

Orthopedics

QuestionAnswer
MESS Score > ____ needs trauma center >7
Hemodynamically Unstable Fx imaging/look for: AP lateral xray: Inspect inner/ outer main ring cortices; 2 small rings; SI joint spaces (equal); symphysis pubis should align, < 5mm joint space; acetabulum
Hemodynamically Unstable Fx: if fx identified or suspected: CT (+/- MRI)
True Orthopedic Emergencies Pelvis, Femoral neck; Extremity Arterial Injury; Compartment Syndrome; Mangled Extremity and Traumatic Amputations; Threatened Soft Tissues / Open Fx; Hip Dislocation ; Septic Joint / Osteomyelitis
Open fx Type I <1 cm, clean; minimal mx contusion; simple transverse/oblique fx
Open fx Type II Lac >1 cm; extensive tissue damage; min crushing
Open fx Type IIIA extensive ST damage w/mx, skin, neurovasc
Open fx Type IIIB ext ST damage with periosteal stripping & bone exposure
Open fx Type IIIC High energy features with art damage
Septic joint/osteo: orgs: bone Bone: GAS, S. aureus
Septic joint/osteo: orgs: joint H. flu, GAS, E. coli, NG
Septic joint/osteo: sx Fever, joint or bone pain, leukocytosis
Septic joint/osteo: Dx tests Bone scans localize osteomyelitis; Joint aspiration to identify organism
MS trauma complications Most common: Nerve compression, compartment syndrome, DVT, fx comps; Other = Rhabdomyolysis; Reflex Sympathetic Dystrophy; Myositis Ossificans
Fx complications Delayed union; nonunion; infxn; N/V injury
MS Imaging Plain films (at least 2 views); consider joints above/below injury; CT (bony); MRI (ST); nuc med (tumors); EMG/NCS
Trauma x-ray series Lateral C-Spine; PA Chest; AP Pelvis
____ are prone to avascular necrosis Femoral neck fractures and hip dislocations
Injuries assoc w/arterial damage: Knee dislocations, displaced tibial plateau fx, floating joint, GSW or knife wounds, mangled extremity
Compartment syndrome: compartment pressure of ____ warrants decompression with fasciotomy > 30 mm Hg
Time from amputation to replantation Warm ischemia: 6 hrs; Cold ischemia: 12 hrs; up to 30 hrs for digits
Septic joint/ Osteomyelitis Rx: Parenteral Abx, I&D
MS injuries: plain films At least 2 views; Check entire film; Consider joint above & below injury
Nuclear med studies to: define tumors, etc
Dislocations shoulder 95% ant; hip 90% posterior
Avulsion of the antero-inferior glenoid labrum = Bankart lesion
Compression fx of posterior humeral head = Hill-Sachs lesion
Shoulder dislocation: xray & reduction maneuvers (3): Rowe (opposite ear over head), Stimson (prone), Hippocratic (traction)
Shoulder xrays AP Grashey (30 deg), scap Y, axillary
Posterior fat pad is always: pathologic
Hand lac: close within: 8 hrs
Kanavel sx (fusiform swelling, tendon TTP, passive extension pain) = septic tenosynovitis (staph, strep); I&D, Abx; tetanus/rabies prn
High pressure injection injury: paint vs grease Paint: tissue necrosis; Grease causes fibrosis
Hip dislocation tx Allis maneuver
Femur fx tx usually ORIF; femoral fx = closed reduction & Nail; femoral neck fx: Garden III & IV need prosthetic
Bucket-handle or corner fracture on xray = Metaphyseal Corner fx; less common, more specific for abuse than diaphyseal fx; represent planar fx through primary spongiosa
Vertebral fx & child abuse spinous process avulsions > vertebral fractures; most are Asx; consequent neuro or kyphosis rare
Epiphyseal Separation True physeal injuries unusual in the abused child; result of violent traction or rotation; MRI or arthrogram may be needed for dx
planar fx through primary spongiosa = Metaphyseal Corner fx
Fracture: Region of bone: diaphysis, metaphysis, epiphysis
Direction of fracture: transverse, oblique, spiral
Fracture: Condition of bone: comminuted, incomplete
Fracture: Condition of soft tissue: closed, open, open joint
Fracture: Deformities of fracture: displaced, angulated
Fracture: Peds: greenstick, torus, Salter-Harris
Salter-Harris Growth Plate injury classification: I (S): Straight. Affects growth plate only
Salter-Harris: II (A): Above. Through growth plate and metaphysis
Salter-Harris: III (L): Lower. Through growth plate and epiphysis
Salter-Harris: IV (T): Through. Through growth plate, metaphysis, and epiphysis
Salter-Harris: V (R): Ram. Crush/compression fx
Radial head fx (Mason) Class I: undisplaced
Radial head fx (Mason) Class II: displaced
Radial head fx (Mason) Class III: comminuted
Radial head fx (Mason) Class IV: dislocated
Fracture Description Anatomic location; Region; Direction of fracture; Condition of bone
Fracture Healing: inflammation stage Hematoma forms at fracture site; Osteoclasts remove necrotic bone; Hematopoietic cells in clot secrete growth factors
Fracture Healing: Repair stage Soft callus stage: fibrous tissue unites fragments; Hard callus stage: callus converts to bone
Fat Embolism Syndrome results from: Embolic marrow fat damaging pulmonary capillary beds leading to ARDS
Fat Embolism Syndrome: Pt presents with: hypoxemia, dyspnea, altered mental status, tachycardia, and petechia
Rhabdomyolysis etiology Blunt trauma, seizures, burns, strenuous exercise, electric shock, drugs (Lipitor), viruses
Rhabdomyolysis: Clinical sequelae Hypovolemia, Hyperkalemia, Metabolic acidosis, Acute renal failure, DIC
Nerve Compression Syndromes Carpal tunnel syn; Ulna n. palsy; peroneal n. palsy; sciatic n. neuropraxia
Reflex Sympathetic Dystrophy: S/S Intense burning pain, edema, stiffness, skin discoloration and atrophy
Myositis Ossificans: Cause Focal trauma to mx; calcification of hematoma in 3 months, ossification in 5 months
MESS Score > ____ needs trauma center >7
True Orthopedic Emergencies Pelvis, Femoral neck; Extremity Arterial Injury; Compartment Syndrome; Mangled Extremity and Traumatic Amputations; Threatened Soft Tissues / Open Fx; Hip Dislocation ; Septic Joint / Osteomyelitis
MS trauma complications Most common: Nerve compression, compartment syndrome, DVT, fx comps; Other = Rhabdomyolysis; Reflex Sympathetic Dystrophy; Myositis Ossificans
Fx complications - Injuries assoc w/arterial damage: Knee dislocations, displaced tibial plateau fx, floating joint, GSW or knife wounds, mangled extremity
Compartment syndrome: compartment pressure of ____ warrants decompression with fasciotomy > 30 mm Hg
Dislocations: common types/sites shoulder 95% ant; hip 90% posterior
Kanavel sx (fusiform swelling, tendon TTP, passive extension pain) = septic tenosynovitis (staph, strep); I&D, Abx; tetanus/rabies prn
High pressure injection injury: paint vs grease Paint: tissue necrosis; Grease causes fibrosis
Vertebral fx & child abuse spinous process avulsions > vertebral fractures; most are Asx; consequent neuro or kyphosis rare
Epiphyseal Separation True physeal injuries unusual in the abused child; result of violent traction or rotation; MRI or arthrogram may be needed for dx
planar fx through primary spongiosa = Metaphyseal Corner fx
comorbid illness that predisposes to adhesive capsulitis diabetes
Pain after tx of fracture w/ cast Compartment syndrome
Sprain: Stretched or torn ligament
Sprain: 1st degree partial tear
Sprain: 2nd degree partial/instability
Sprain: 3rd degree complete tear
Strain: Musculo-tendinous unit injury; first, second, third degree; Pulled muscle
Contusion: Bruise; Hematoma ; Abrasions, lacerations
Tendonitis = Overuse, mechanical irritation of tendon
Teenage female with long bone pain w/o trauma or injury; XR w/ lytic mass, multi-laminated periosteal reaction Ewing sarcoma; periosteal “onion skin” reaction
AVN etiologies Corticosteroids, EtOH, trauma
Rhabdomyolysis = Breakdown of mx fibers with release of cellular contents into circulation
Rhabdomyolysis S/S Muscle pain, dark urine
Neurapraxia etiology Blunt injuries may produce nerve contusion
Neurapraxia: assoc with: fracture; recovers in 6-12 weeks
Axonotmesis: Crush injury; also seen in traction injuries; recovers at 1mm/day or 1 inch/month
Neurotmesis: Sharp trauma results in a severed nerve; primary surgical repair indicated
Reflex Sympathetic Dystrophy = Chronic Regional Pain Syndrome
Reflex Sympathetic Dystrophy = Persistent pain & hyperesthesia after an injury
Myositis Ossificans = Heterotrophic bone formation
Myositis Ossificans: must R/O: R/O osteosarcoma
(Fx comp) Delayed union: Slow callus formation
(Fx comp) Nonunion: No clinical or radiographic signs of progression to bony union after 3 months
(Fx comp) Infection: esp. with: open fractures
Osteomyelitis orgs: S. aureus, Beta strep
(Fx comp) N/V injury Evaluate circulation & sensation distal to injury site.
Tendonitis: Shoulder: site/mx Supraspinatus
Tendonitis: Elbow AKA Medial/lateral epicondylitis
Tendonitis: Wrist AKA DeQuervain
Tendonitis: Hand AKA Trigger finger
Tendonitis: Hip: site ITB
Tendonitis: Knee: site ITB, Patella, Quadriceps
Tendonitis: Ankle: sites Peroneal tendon, Posterior tibial tendon, Achilles
Tendonitis: Foot AKA Plantar Fasciitis
Plantar Fasciitis pain worst 1st few steps in AM; tx = restrict prolonged standing; arch supports
Tumors: prevalence in ortho Benign bone tumors common; malignant tumors rare
Metastases to bone are common in: Pts > 40 yo
Benign tumors: Osteoblastoma, Osteoid osteoma
Malignant tumors: Ewing sarcoma, Osteosarcoma, Chondrosarcoma
Ratio benign soft tissue tumors to malignancy 100:1
Benign soft tissue tumors Ganglia, giant cell tumor, lipoma, hemangioma, angiomyoma
Malignant soft tissue tumors Fibrosarcoma, liposarcoma, rhabdomyosarcoma
acute monoarticular sxs, consider: trauma, infxn, crystalline dz (gout/ pseudogout)
Fat Embolism Syndrome: most common with: femoral shaft fracture
Fat Embolism Syndrome occurs when? Within several days of fracture
Peroneal nerve palsy: with hip, fibular head, or ankle fracture/dislocation
Spinous Process fx: MOI: sudden forceful ligamentous traction on spinous process, or a direct blow to the process
50% of pts with solid tumors have: mets to spine
Tumor: Highest prevalence: BrCa, lung, prostate, colon, thyroid, kidney ca (hematogenous spread)
Tumor: Sx: Night pain, n. root compression
10% of spinal bone tumors are: primary
Spinal bone tumors: in children, 20% are: malignant
Spinal bone tumors: Primary malignant: Osteosarcoma, Ewing Sarcoma, Chondrosarcoma
Spine Films/ Frontal: Vert body (owl head) for: Missing eye (destrn); pedicle
Spine Films/ Frontal: Vert body: Crack in owls eye: in = Chance fx (seat belt fx)
Spine Films/ Frontal: Vert body: Inc space btw owls eyes: in = Burst fx
Chance fx: MOI MVA: lap belt immobilizes pelvis & thorax is forcefully flexed forward
Chance fx: Seen on AP = crack thru eyes (pedicles), or open beak (crack through spinous process)
Burst fx: Unstable = Collapse of vert body
Burst fx: MOI: fall from a ht, landing on feet or buttocks
Burst fx: Fragments: may extend into spinal canal causing neuro S/S
Wedge fx: Stable = Collapse of ant vert body w/ an intact posterior wall
Wedge fx: Stable: result of: hyperflexion injury and / or osteoporosis
____ are prone to avascular necrosis Femoral neck fractures and hip dislocations
Greenstick fx = Incomplete fx
Greenstick fx: MOA thick periosteum in children prevents displacement; dorsal cortex intact
Septic Tenosynovitis: Etiology: Staph, Strep, MRSA
Septic Tenosynovitis: Rx: IV Abx, I&D if progressing; consider tetanus & rabies prophylaxis
Temporal bone fx: complications hearing loss, facial paralysis, CSF leak, vertigo, TM perforation, nystagmus
Rhabdomyolysis: Labs Myoglobinuria; CK elevated 5-10x normal (37-200)
Rhabdomyolysis: Rx Fluids; Correct imbalances; tx underlying cause
Fat Embolism Syndrome: Rx: Maintain perfusion with O2, inotropics, maintain hematocrit, correct metabolic acidosis; mechanical ventilation may be required.
Reflex Sympathetic Dystrophy: Rx Early referral to a pain specialist; neuroleptic pain meds (Neurontin, Lyrica); Regional sympathetic nerve blocks; PT
Locations of sarcomas Ewing: diaphysis of long bones, flat bones, ribs. Osteosarcoma: metaphysis of long bones. (ED / OM)
Created by: Abarnard