1
Q
What 5 are true ortho emergencies
A
- Hip dislocation
- Ankle dislocation with tenting
- Open fx (OR in <6 hours)
- Compartment syndrome
- High pressure injection injuries
2
Q
Fx complications
A
- Hemorrhage
- Vascular injury
- Nerve injury
- Compartment syndrome
- Fat embolism
3
Q
Overall ortho pearls
A
- Don’t correct a deformity without an XR first (and neuro exam)
- Caveat is pulseless, cold, vascular compromised area
- Eval and document: deformity, color of skin, TTP, ROM, NV status
- Eval NV before and after attempts to reduce a fx
- Any soft tissue wound proximal to fx is treated like open fx until proven otherwise
- Use the word amputation not “cut off finger”
- Fingers: thumb, index, long, ring, small
4
Q
Salter-Harris
A
I: straight across II: above, in metaphysis, no joint, MC III: lower, epiphysis, is in joint IV: through: both metaphysis and epiphysis V: Crush: no more physis
5
Q
what XR view is needed on shoulder and elbow injuries
A
true lateral
6
Q
Things to not miss on XR
A
- Massonneuve
- talar shift
- syndesmosis widening
7
Q
Three types of nerve injury
A
- Neuropraxia: Loss of function dt ischemia, no damage, will recover 90% of the time
- Axonotmesis: Axons are damaged, will recover but often incomplete. Better prognosis if injury is distal
- Neurotmesis: Entire nerve transected, requires repair (can be done 3-6 months after injury!)
8
Q
When is it appropriate to do an EMG after a nerve injury?
A
Not until min 6 weeks to allow adequate healing time
** neurons heal proximal to distal, about 1 mm per day
9
Q
How to assess vascular status
A
- Pulses ☺
- Color, temp, cap refill
- If asymmetric pulses or unsure, get a Doppler study!
- If absent, call sx and consider duplex study. Arterial blood flow must be reestablished within 4 hours to avoid irreversible damage
- Doppler: uses sound
- Duplex: sound and US together, colored
10
Q
Fracture language, things to note (5)
A
- Closed vs. open
- Displaced %
- Distracted/shortened
- Angulated (degrees from where bone should be), need two views
- Articular involvement?
11
Q
6 Ps of compartment syndrome
A
- Pain out of proportion
- Pallor
- Paresthesias
- Poikilothermia (cold)
- Pain with passive motion distally (ex. Toes)
- Pulselessness
12
Q
Compartment syndrome
- where MC
- PE
- What pressure = fasciotomy
- tx
A
- MC: anterior leg
- PE: firm, swollen, tense extremity
- > 30 mmHG = fasciotomy needed
- Ortho consult and admission
13
Q
Open fx management
A
- Early broad spectrum abx (1st gen cephalosporin, maybe aminoglycoside, maybe pcn)
- Hemostasis
- Debride wound but no aggressive irrigation
- Occlusive, sterile saline soaked dressing
- Splint
- Tetanus
- OR
14
Q
Quick UE neuro check
A
Rock Paper Scissors OK
- Rock: median nerve
- Paper: radial nerve
- Scissors: ulnar nerve
- OK: anterior interosseus nerve
- *Axillary: lift arm
- Musculocutaneous : flex bicep
15
Q
High pressure injection injuries
A
- True ortho emergency: ortho or plastics
- Injected material spreads along fascial planes, extent can look less than it is
- Risk of compartment syndrome
- Tx: Tetanus, analgesia, broad spectrum abx, splint, elevate
- Consult: hand surgeon, urgent operative debridement is tx of choice
- Digital blocks are CI
16
Q
Fight bite
A
- Depth usu worse than appears
- Assess full ROM
- Infection major issue
- If tendon involvement – consult hand surgeon
- No tendon involvement: irrigate, closure, oral abx
17
Q
Scaphoid fx
A
- High risk AVN
- Anatomic snuffbox
- Negative XR do not rule out
- Thumb spica splint and ortho f/u
- Will need MRI
Triquentrum is second MC fx carpal bone
18
Q
Flexor Tendon Injuries
A
- Rupture tx: splint (block extension) and ortho referral
- Flexor tenosynovitis: admit, IV abx, ortho consult
- Kanaval’s signs:
19
Q
What are Kanaval’s signs (4)
A
- Sausage digit: uniform swelling along entire finger
- Held in passive flexion
- Pain with passive extension
- Pain to percussion/palpation of flexor tendon sheath
20
Q
FOOSH
- Tx
- Two types
A
- Reduce, splint, refer to ortho
- Good NV check and documentation
- Colles (dinner fork): dorsal angulation MC
- Smith: volar angulation
21
Q
Galeazzi and Monteggia
A
- Don’t trust a single bone forearm fracture!
- Check for dislocation of the distal or proximal radioulnar joints
- Distal: DRUJ
- Proximal: PRUJ
- Galeazzi (MC): radius shaft fx with DRUJ dislocation
- Monteggia: ulna fx with proximal radial head dislocation
22
Q
Supracondylar fx
A
- Usually kids 5-10 FOOSH with hyperextension of elbow
- Poor tx → serious morbidity
- Assess interosseous nerve via OK sign
- Check radiocapitellar alignment
- Lateral xray is required – look for fat pad signs!!!
- Posterior fat pad
- Anterior fat pad is “sail sign”
- DO NOT reduce, ortho consult
23
Q
Shoulder Dislocation
- Overview
A
- Arm adducted and elbow flexed, should step off
- Scapular Y view (and AP)
- Reduce within 24 hours
- Assess axillary nerve
- Associated with Bankart lesion and Hill-Sachs deformity
- If first dislocation, increased risk of soft tissue injury
24
Q
Shoulder Dislocation
- Anterior vs. Posteior
A
- Anterior: MC, arm adducted and elbow flexed, step off
- Posterior: usu dt electrocution or seizure (<10% of dislocations)
25
Shoulder dislocation
| - Tx
- Analgesia +/- light sedation
- Anterior: reduce via gentle traction of humerus w/ external rotation of shoulder/forearm. Can use countertraction
- Posterior: reduce with traction and countertraction
- Might have to fatigue the muscles to get it to reduce
- Immobilize in sling, internal rotation
Ortho f/u in 1-2 days, will need PT
26
Humerus Fx
- Look horrible but very forgiving
- Proximal or shaft
- Radial nerve (runs along humerus)
- AP and lateral XR
- Bc of large ROM of shoulder, can compensate for small rotational or angular deformities
- Immobilize in sling, ortho referral
27
Hip Fx
- Not always due to trauma, can be little old lady with osteoporosis
- Elderly pt with inability to bear weight on a hip is fx until proven otherwise
- A fracture-dislocation of the femoral head in a young person requires great force, check for other abdominal injuries
- Recognize femoral neck fx vs. intertrochanteric fx
28
Hip dislocation
- Sig force required
- Eval for nerve injuries (sciatic and femoral)
- Need pre and post op xrays, AP pelvis
- True emergency
29
Hip dislocation
| - tx
- Reduction w/in 6-12 hrs of injury
- Sedation
- ORTHO consult
30
Hip Dislocation
| - Posterior
- MC, 90%
- Often dashboard injury
- Displaced superior and lateral
- Exam: Hip flexed, adducted, internally rotated
31
Hip Dislocation
| - Anterior
- 10%
- More common in pts with a hip prosthesis
- Displaced inferior and medial
- Exam: externally rotated, abducted, slight flexion
32
Pelvic Fx
- High mortality rate, risk of hemorrhage, shock
- Low E trauma usually results in stable fx which requires conservative tx, WBAT
- High E trauma usually results in unstable fx which require operative tx
- AP XR of pelvis confirms, might need CT
33
Pelvic Fx
| - 4 types
- 1 Fx with intact ring
- Fx of pelvic ring
- Fx of acetabulum (less concerning)
- Sacrococcygeal fx (less concerning)
34
Pelvic Fx
| - types of injury
- Anterior posterior compression (APC)
• Disrupts symphysis, “open book” injury
- Lateral compression (LC)
• Breaks rami, look at SI joint
- Vertical shear (VS)
• BAD. Always unstable, hemorrhage
35
Pelvic Fx
| - Exam (3)
- GU: blood at urethral meatus, high-riding prostate, gross hematuria, scrotal hematoma
- Neuro: L5, S1, rectal exam: tone and temperature sensation and prostate position
- Skin: ecchymosis of anterior abd wall, flank, sacral and gluteal region (lack of ecchymosis does not r/o hemorrhage)
36
Pelvic Fx
| - Imaging
- 5 view of pelvis: AP, pelvic inlet and outlet, R and L oblique
- If you see one fx, look for more, displacement can only occur if ring is disrupted in 2+ locations
- CT scan
- +/- urethrography
37
Pelvic Fx
| - Pearls
- Posterior pelvic fx: NV injuries and hemorrhage
- Anterior pelvic fx: urogenital injuries
- NO catheter
- FAST exam is less sensitive if there is a pelvic fracture
38
Pelvic Fx
| - Tx
Stabilize, close the book
| If fx is stable, WBAT with walker
39
Ankle Dislocation
- True ortho emergency!
- Displacement of talus (foot) from the tibia
- Usually associated with other fx
- Check if the skin is tenting and NV status quickly!
- Reduction as soon as possible, consult neuro
- Splint it, get post-reduction xrays
- Do not discharge without emergent ortho consult
40
Maisonneuve
- Consider with all ankle injuries
- Proximal fibula fx with ankle injury
- Check the “clear spaces” in the ankle for disruption of the ankle mortise
- Tx: splint, NWB, ortho referral, will need surgery
41
Lisfranc injury
- Tarsometatarsal joint is the Lisfranc joint
- Injury requires large force: dislocation +/- fracture
- PE: mid-foot pain and swelling
- On XR: look for widening of spaces, don’t’ miss!!
- TX: splint, NWB, ortho referral
42
General Splinting
- No case in ER or acute setting, let swelling subside first
- Never cast a swollen limb!!
- Immobilization = relief, remind pt
- Immobilize joint above and joint below injury
- Remove excess water from material
- Protect patient from sharp edges
- Eval neuro before and after splint, document
43
Splinting material
- 3” good for UE in most adults
- 4” good for LE
- don’t apply with too much tension, be gentle
- Use soft roll
- Fiberglass MC vs. plaster
44
Intrinsic plus position
- true neutral position of hand and wrist – not Barbie hands
45
Sugar Tong splint
- Distal radius fx and forearm fx
- Can double for an unstable wrist/elbow (pic on right above)
- Watch the styloid and ulnar nerve
- Don’t be stingy with soft roll
- Hand and wrist in intrinsic plus position!
46
Volar Splint
| - wrist and hand
- Wrist sprains, simple buckle fx in kids, carpal tunnel, extensor tendon injuries
- Mind the thumb
- Ensure min 2 inches distal to the antecubital fossa – don’t splint up into the elbow bend
- Immobilize in slight wrist extension (neutral wrist position)
47
Thumb Spica Splint
- For thumb fx
- Collateral ligament injuries, gamekeepers thumb, scaphoid fx
- Soft roll around thumb, watch for fiberglass edges!
48
Ulnar Gutter Splint
- Boxers fx, 4th metacarpal fx, 4th and 5th phalanx fx
| - Immobilize in 80-90 flexion, PIP at <20 flexion
49
Dorsal Splint
- Used to block extension: flexor tendon injuries
| - Can also use on 2nd and 3rd metacarpal fractures
50
Posterior short leg splint
- LOTS of soft roll. Pad: lateral and medial malleolus and calcaneus
- Add stirrup for unstable fx or if unsure
- Immobilize ankle in neutral position
- Stop 3-4” distal to knee (4 fingers)
- Don’t leave toes hanging!
ER 2
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Decks in class (10)
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