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Ortho Emergencies
Orthopedics
| Question | Answer |
|---|---|
| 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
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