2
Q
Ankle Xray Views & Metrics
A
3
Q
Nomenclature of hip #’s
A
4
Q
Distal phalanx #
A
- repair nailbed injury if present
- hairpin splint not involving PIP
- plastics within 2 weeks
5
Q
Middle/Proximal Phalanx #
A
- correct any rotational deformity
- buddy tape (dynamic splint) if stable (transverse, non-displaced)
- radial or ulnar gutter splint if unstable
- plastics within 1 week
6
Q
Bennett’s #
A
- intraarticular base of thumb MC # with dislocation/subluxation of CMC
- reduce, thumb spica
- plastics within 2-3 days
7
Q
Rolando’s #
A
- comminuted # of base of thumb MC
- worse prognosis than Bennett’s
- thumb spica
- plastics within 2-3 days
8
Q
DIP Dislocation
A
- reduce
- dorsal splint in full extension
- or buddy tape if stable post-reduction
- plastics within 1 week
9
Q
PIP Dislocation
A
- reduce
- dorsal splint in 30 deg flexion at PIP
- or buddy tape if stable post-reduction
- plastics within 1 week (2-3 d if unstable)
10
Q
Extensor zones of the hand
A
see Evernote “Hand Injuries”
11
Q
Management of extensor tendon injuries of the hand
A
- Zone I, II open injuries: repair 5-0 sutures, splint in extension.
- Zone III injuries: modified Elson’s test to check for central slip damage. If open & have Boutonniere deformity, call plastics on call. If closed, place PIP in extension and f/u plastics (may leave DIP free).
- Zone IV injuries: primary repair with 5-0 sutures, splint MCP in 15 deg flexion.
- Zone V, VI injuries: primary repair with 4-0 sutures if clean laceration, splint.
- Zone VII, VIII injuries: splint, refer to plastics.
12
Q
Management of Flexor Tendon Injuries of the Hand
A
- Splint in position of function
- Plastics within 1 week
13
Q
Fingertip Amputation Zones
A
See Hand Injuries on Evernote
14
Q
Describing Angulation in a #
A
- for midshaft #’s, angulation is direction of apex
- for distal fractures (e.g. Colles), angulation is direction of distal fragment
15
Q
MCP Dislocation
A
- do not hyperextend during reduction
- reduce with wrist flexed to relax flexor tendon
- pressure and traction on base of prox phalanx
- splint in flexion
- volar dislocations usually need operative reduction
16
Q
Scapholunate Ligament Injury
A
- FOOSH on thenar eminence
- clicking with wrist movement
- tender on dorsum of wrist just distal to Lister’s tubercle
- pain with ballottement of the scaphoid
- scaphoid shift/Watson shift test
- wrist in ulnar deviation, thumb on scapohid prominence volarly –> move wrist into ulnar deviation
- test positive if scaphoid ‘clunks’ dorsally/gives or patient’s pain reproduced
- XRay
- 3 mm widening on PA view
- clenched fist view may help
- scaphoid shortening with dense ring (cortical ring sign)
- dorsal intercalated segment instability of lateral view (zig-zag pattern instead of 3 C’s)
- Tx: radial gutter splint
17
Q
Triquetrolunate Ligament Injury
A
- ulnar equivalent to scapholunate injury
- FOOSH on hypothenar eminence
- volar intercalated segment instability on lateral xray
- ulnar gutter splint
18
Q
Perilunate Dislocation
A
- FOOSH with great force
- posterior dislocation of carpal bones, lunate remains in place
- call ortho/plastics
19
Q
Lunate Dislocation
A
- posterior dislocation of carpal bones with lunate facing anteriorly
- XRay
- piece of pie sign (lunate triangular on PA)
- spilled teacup sign (lunate displaced and angled palmar)
- if fracture associated, then add trans- to the name (e.g. transscaphoid lunate disclocation)
- call ortho/plastics
20
Q
Scaphoid Fracture
A
- tender in snuffbox with ulnar deviation
- pain with resisted pronation/supination
- pain with axial load to thumb
- 10% initial xrays -ve
- may get dedicated scaphoid view
- thumb spica with mild wrist dorsiflexion and radial deviation (to compress # fragments)
21
Q
Triquetrum Fracture
A
- often a dorsal avulsion # on lateral view
- sugartong splint
22
Q
Lunate Fracture
A
- tender in dorsum wrist groove on flexion
- AVN possible (blood supply enters distally)
- xrays may be negatve
- thumb spica
23
Q
Hamate Fracture
A
- interrupted bat/golf club swing
- carpal tunnel view
24
Q
Colles’ Fracture
A
- reduction: > 20 deg angulation, intra-articular involvement, > 1 cm shortening, comminution
- criteria for adequate reduction
- At least 11 mm radial height
- At least 22 deg radial inclination
- At least 11 deg volar angulation
- practically, neutral is OK for age < 50 and 10 deg dorsal tilt is OK for age > 50
- Acceptable angulation in kids
- < 5 yrs = 30 deg
- 5-10 yrs = 20 deg
- 10-12 yrs = 10-15 deg
- +-2 mm ulnar variance
- < 3 mm impaction
- ulnar styloid often also fractured
25
Smith's Fracture
* volar angulation of distal radius
26
Radial Styloid Fracture
* often with dislocation of the lunate
* major carpal ligaments insert at styloid so carpal instability
* short arm splint
27
Ulnar Styloid Fracture
* ulnar gutter splint
28
DRUJ Injuries
* ulnar deviation on lateral
* splint in supination for dorsal and pronation for volar dislocations
29
Compartment Syndrome
| (Diagnosis, treatment)
* traditional, tissue pressure \> 30-50 mm Hg
* better, delta pressure (diastolic - tissue pressure) \> 30 mm Hg
* pain refractory to opioids, pain to passive stretch, firmness/fullness in compartment
* normal pulses/cap refill as tissue pressure less than arterial pressure
* Stryker kit
* pressures highest near injured area, obtain within 5 cm of # site
* 2 readings each compartment
* place limb at level of heart
* reverse anticoag/replace factors for hemophiliacs
30
Biceps Tendon Ruptures
* **proximal**
* usually older, chronic tendonitis
* pain in anterior shoulder
* shoulder xray r/o avulsion #
* sling --\> # clinic
* **distal**
* usually younger, eccentric load
* pain in AC fossa
* Hook sign
* sling --\> # clinic more urgently
31
Elbow Dislocation
* 90% are posterolateral
* assess (pre- and post-reduction):
* brachial artery (just medial to distal biceps tendon)
* ulnar, radial, median nerves
* Check for full ROM post-reduction, fragments often trapped
* call ortho if unstable on ROM or reduced ROM or NV compromise post-reduction
* splint in long-arm posterior splint in slightly less than 90 deg flexion and forearm in mild pronation
* NV f/u exam next-day
32
Supracondylar #
* common in 5-10 years of age
* common to injure anterior interosseous nerve
* motor only branch of median
* test OK sign
* extension-type (95%, posterior displacement)
* FOOSH in extension
* posterior fat pad or large anterior fat pad (sail sign), disruption of anterior humeral line
* long-arm posterior splint 90 deg, neutral rotation
* if only sign is fat pad then ortho f/u in 2-7 days
* if any angulation/break through cortex then fasting + ortho in ED
* flexion-type (5%, anterior displacement)
* rare, direct force, often open
33
Intercondylar #
* assume any supracondylar # in adult is intercondylar
* supracondylar + T or Y component separating condyles from each other and going intraarticular
* splint in long arm posterior splint at 90 deg in neutral position
34
Epicondyle #
* mostly medial, an apophyseal avulsion fracture
* pain, tenderness, swelling
* medial from repeat valgus stress such as throwing
* posterior splint in pronation
35
Condyle #
* mostly lateral
* a fracture through the condyle
* usually much larger/unstable than radiograph because mostly cartilaginous
36
Ossification Centres of Elbow
* all usually ossify by 12 years
* **C**apitellum
* **R**adial head
* **I**nternal (medial) epicondyle
* **T**rochlear
* **O**lecranon
* **E**xternal (lateral) epicondyle
37
Monteggia/Galeazzi #
* **F**racture
* **U**lna/radius
* **M**onteggia/galeazzi
* **E**lbow (radius)/wrist (ulna) dislocated
* may reduce, but often need operative management
38
Calcaneus #
* Boehler angle: line from highest part of anterior process of calcaneus and highest point of posterior articular surface of calcaneus + line between highest point of posterior articular surface of calcaneus and the most superior part of calcaneal tuberosity
* normal 25-40 deg
* \< 25 deg suspect #
* posterior splint, NWB
39
Lisfranc Injury
* plantar flexion + axial load
* pain with torsion/dorsi/plantar flexion
* weight-bearing AP, lateral, 30 deg oblique
* 1 mm displacement base 1st/2nd MT
40
Base of 5th MT #
* Review Evernote "Foot Injuries"
41
Hip #
* Review Evernote
42
Ottawa Knee Rules
* age \>= 2
* Xray if
* age \>55
* tender at
* fibular head
* patella
* cannot flex \> 90 deg
* cannot WB 4 steps immediately + in ED
43
Additional Knee Xray Views
* sunrise view
* patellar #/subluxation
* tunnel view
* intercondylar region/tibial spine #
* oblique view
* (internal for lateral, external for medial plateau #)
44
Treatment for Locked Knee
* usually meniscal tear
* sedation
* supine with knee 90 deg flexed hanging over edge
* longitudinal traction, internal + external rotation
* ortho if not successful
45
Knee Dislocation
* 50% self-reduce
* ++ injured & unstable multiple directions
* reduce, splint in 20 deg flexion
* if no vascular + ortho in house & NV intact, delay reduction for transfer
* CT angio post-reduction
46
Patellar Dislocation
* flex hip, hyperextend knee, posteromedial pressure on lateral border of patella
* 1st time dislocation: tensor, knee immobilizer, no flexion allowed, urgent ortho
* recurrent: less strict need for immobilization (ligaments already lax), semi-elective ortho
47
Tibial Shaft #, criteria for adequate reduction
* criteria for adequate reduction:
* \<10 deg varus or valgus
* \<10 deg anterior/posterior angulation - can accept more in the plane of joint motion
* \<1 cm shortening
* min 50% apposition
* long leg splint, elevate
* ortho in ED
48
Pilon/Tibial Plafond #
* "mortal pestle" #
* axial load grinds tibia into talus
* look for L1 # & compartment syndrome
49
Gastrocnemius Tear
* sudden pop, swelling in calf
* RICE
* may splint in equinus
50
Ankle Syndesmosis Injury
* see Evernote
51
Grading Ankle Sprains
* Grade I: no tear, minimal functional loss, pain and ecchymosis
* Grade II: partial tear, some loss of function
* Grade III: complete tear, ++ swelling, bruising, usually NWB
* Any medial maleolar swelling/tenderness needs to be NWB and have close ortho f/u
* lateral mal # with medial mal swelling/tenderness needs posterior slab with medial molding
52
Weber Classification Distal Fibula #'s
* NWB with aircast unless avulsion #
53
Sternoclavicular Joint Dislocation
* CT imaging of choice
* US + aspiration if infectious/effusion (common in IVDU)
* anterior dislocation
* sling, ice, no need to reduce (won't hold anyway)
* posterior dislocation
* ortho, open reduction
* closed reduction if mediastinal compromise
54
Clavicle #
* xray may miss #'s at extreme ends of bone
* 45 degree cephalad tilt view +- CT
* **distal**
* displaced often operated on
* sling + early ortho f/u
* **middle third/distal #'s**
* usually non-op unless athlete/cosmetic
* rule of 2's for op mgmt
* 2 cm short
* 2 cm displaced
* 2 pieces
* sling, early ROM (in 3-5 days)
* **proximal third clavicle #'s**
* rare, check with ortho
55
Scapular #
* dedicated views
* look for associated rib #'s/lung injury
* sling, ice
56
Anterior Shoulder Dislocation
* slight abduction + external rotation
* check deltoid sensation (axillary)
* **reduction**
* 10-20 mL 1% lidocaine subacromial
* **Modified Hippocratic**
* traction-countertraction
* **Snowbird**
* belt looped over flexed elbow
* use foot to pull down on belt
* **Stimson**
* prone, weights
* **Scapular Manipulation**
* Stimson + rotate scapula (distal tip goes medial)
* **Kocher's**
* elbow 90 deg, slow external rotation
* may bring elbow anteriorly
* **Milch**
* external rotation, arm straight
* arm abduction to 180 degrees
* push on humeral head upwards with R thumb
* **Cunningham**
* sitting massage, shrug shoulders back
57
Posterior Shoulder Dislocation
* \<1%
* usually held in internal rotation + adduction
* unable to external rotate + abduct
* reduce with longitudinal traction
58
Inferior Shoulder Dislocation (Luxatio erecta)
* hyperabduction force (levers neck of humerus against acromion)
* humerus fully abducted, elbow flexed, hand on or behind head
* traction upward + outward in line with humerus
59
Proximal Humerus #
* Neer classification of shoulder #'s
* a "part" is a fragment displaced \> 1cm or angulated \> 45 deg
* i.e. even if many fragments, if none angulated/displaced then it is a "one-part" #
* one part #
* sling + swathe, ice, early ROM
* more than one part # or #-dislocation
* ortho in ED
60
Humeral Shaft #
* **proximal**
* accept up to 45 deg angulation, 1 cm displacement
* minimal displacement
* shoulder immobilizer, close f/u
* displacement/comminution
* d/w ortho
* **middle third #'s**
* most common
* usually non-op
* radial nerve
* not comminuted
* sugar-tong, close follow-up
* comminuted
* call ortho
* **distal humerus #**
* ED consultation re: NV structures
61
Jersey Finger
* FDP rupture from grabbing jersey
* splint in slight flexion
* hand clinic
62
Compression #'s
* Discuss all spine #'s with a surgeon
* if \<40% loss of height, generally stable
* if \>= 50% loss of height, or angle between damaged vertebra and spinal column is \>25-30 deg usually unstable
* can often misdiagnose Chance (transverse) + burst #'s as compression #'s
* consider CT in all compression #'s found on plain films
* if truly stable, non-pathologic --\> heat, massage, rest, f/u
63
Coccyx #
* pain meds, doughnut pillow
64
Prevertebral soft tissue spaces in cervical trauma
* 6 mm at C3
* 22 mm at C6
65
C-Spine Trauma Approach
* NEXUS
* CCSR
* Xray
* CT if inadequate
* If CT -ve but suspcious and MRI not available, may DC in firm foam collar and f/u in 3-5 days. If pain resolved, may DC collar
66
Neurogenic Shock vs. Spinal Shock
**Neurogenic Shock**
* loss of peripheral sympathetic innervation
* if T1-T4 then unopposed vagal to heart, bradycardia
**Spinal Shock**
* temporary loss of spinal reflex activity below injury that may recover
67
Thoracolumbar Spine Trauma
Xray vs. CT
* EAST recommends CT over xray (Level 1) although no studies in mildly injured patients
68
How Long to Immobilize a Shoulder Dislocation For?
* "8 minus decade of life"
* means if 75 years old then simple sling + ROM immediately
* max 3 weeks
* longer for first-time dislocators
69
Radial Head #
* **undisplaced, radial neck**
* sling, f/u 1 week
* **undisplaced, intra-articular**
* posterior slab, f/u 1 week
* **displaced**
* call ortho to discuss
70
Coronoid Process #
* displaced, large fragment
* call ortho to discuss
* undisplaced
* posterior slab, 1 week
71
Olecranon #
* check triceps with arm horizontal (gravity eliminated)
* displaced
* call ortho to discuss
* undisplaced
* posterior slab, 1 week
72
Ulnar Collateral Ligament Injury
* 25% have Stener's lesion (interposition of adductur pollicis between ends of ligament tear resulting in poor healing + chronic thumb pain)
* **Grade 1/2**
* thumb spica
* plastics 1-2 weeks
* **Grade 3**
* plastics within 2-3 days (operate within 1 week)
73
Toe Fracture
* Indications for referral (Great Toe)
* Fracture with dislocation
* Displaced intraarticular fractures
* Unstable, displaced fractures (ie, fractures initially reduced that immediately displace once traction is released unstable displaced fractures
* Indications for referral (lesser toes)
* Displaced intraarticular fractures
* Irreducible fractures
* Open fractures of non-distal phalanges
* Fractures that do not maintain acceptable position with buddy taping
74
Toddler's #
* 9 mo to 5 yrs
* twisting of foot --\> oblique tibial #
* often minor mechanism, subtle tenderness
* additional oblique views increase sensitivity
* above knee splint --\> ortho 1 wk
75
Tillaux #
* girls age 11-13, boys age 12-15
* distal tibial growth plate closes from medial to lateral
* external rotation results in SH III # of the distal tibia
* ortho in ED
76
Patella #
* if has active knee extension: knee immobilizer, ortho 1 wk
* if no active knee extension: ortho in ED
77
Segond #
* vertically oriented avulsion # from lateral tibial plateau at the attachment of the lateral capsular ligament
* 75% association with ACL tear
* tensor, crutches, WBAT
* early ROM as tolerated
* early sports med f/u
78
Tibial Plateu #
* suspected/undisplaced
* long-leg splint, NWB, urgent ortho
* displaced
* ortho in ED
79
How to examine extensor tendons of fingers
* Test extension PIP/DIP with MCP in extension to remove lumbricals
* Modified Elson's Test for zone III injuries
80
How to test SLR in knee exam
* test SLR seated to remove IT band
81
Mandible Dislocation
See Evernote "Dental"
82
How to Apply a Thomas Splint
See Evernote "Procedures"
83
Snowboarder's #
See evernote "Leg + Ankle Injuries"
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