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265 Cards in this Set
- Front
- Back
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Hip Pain causes
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Hip fracture
Hip dislocation Osteoarthritis Osteonecrosis Iliotibial band tendonitis Intraarticular pathology Trochanteric bursitis Pediatric Causes Inguinal hernia |
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intra-articular patholgy Hip
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labral tears
ossified loose bodies synovitis- pigmented villonodular septic arthritis |
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septic arthritis
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pain in anterior aspect of hip joint
Pseudoparalysis Fever Possible trauma history Hip positioning: external rotation, abduction, and mild flexion –Why? Patient is usually less than 4 years of age with no underlying illness. *ultrasound used diagnostically - very sensitive |
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people with septic arthritis hold the hip
ext rotation adduction, and mild flexion , why ? |
inflamitory fluids take up space in the joint , so this is the postion of comfort / unloading
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if you can't get fluid out of joint ?
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use sterile water to draw out cells to make a Dx
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if glucose level in synovial fluid is about 40 mg/dl less than serum level ?
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bacteria are here feeding!
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WBC greater than 50 K cell/ml w/ 90% being PMN
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septic arthritis
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not an easy Dx to make , but your charge to do so , so as to not destroy the child's hip
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septic arthritis
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*****Age group bacterial causes of septic arthritis
BOARDS !!!!! 1. group one --- low birth weight neonates |
S. Aureus , then B. Strep
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3 mo. to 3 years
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H. influenza (type B )
followed by staph and strep (declined drastically due to H. flu vacinne. ) |
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third age group
older than 3 years |
S. aureus (50%) , and strptococci (25%)
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Legg - Calve -Perthes (LCP)
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4:1 males to femlaes
aseptic AVN of femoral head could be related to clotting factors and viscosity |
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LCP , presentation
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**femoral head collapse during fragmentation phase
limited internal rotation and abduction age : about 4 to 8 may be ****limping a long time before they come to office |
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knee pain , look where ?
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joint above and below
hip and ankle |
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referred pain from the hip
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suprapetellar region
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***greatest contact surface area of femoral head on acetabulum , when ?
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during abduction and limited internal rotation
also pos. trendelenburg test ****in lieu of infection , this is going to inc. the patients' pain ! |
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flex abduct and internal rotation
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illicits pain in DJD , hip ****
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referred pain from the hip **
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**Suprapatellar region: femoral nerve
Medial thigh: obturator nerve Buttock: Sciatic nerve |
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what imaging study does one need for femoral arthritis ?
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plain film is good enough !!
esp a weight bearing film |
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Tx for Osteoarthriti
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Conservative therapy based on the preservation of activity (motion) and the control of pain.
**Surgical Treatment often includes total hip replacement. |
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I fractured my hip , how do i present ?
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groin pain
possibly a deformed limb shortened and externally rotated leg |
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to be a total hip arhtroplasty ?
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have to replace fmeoral head and acetabulum
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femoral head fracture , what test to order ?
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MRI is the gold standard
bone scan --- not specific at all (good shotgun approach however) |
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fixation of intertroch fractures
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be awre of osteoporosis pateints and this not being the best Tx
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Subtroch fracture , surgical tx ?
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screws through neck ? no
you need a cephalo-medularic rod |
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tx difference for intertroch fracture and subtroch fracture
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see previous card, and slide 67 on hip - intro
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hip dislocation , forces involved
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abduction and external rotation forces
not common |
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posterior hip location
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occurs when longitudinal force is applied in line with the femur and acting on an adducted hip
9:1 ratio of posterior to anterior |
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Tx for a hip dislocation
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emergent reduction
ideally , complete paralysis should be obtained prior to attempt at reduction |
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types of joint infections
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septic arthritis - joint
osteomyelitis - bone cellulitis - soft tissue blood supply , not as rich |
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systemic conditions associated with ortho infections
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Congenital:
Sickle cell Hemophillia Chronic granlomatous disease Leukocyte adhesion deficiency Diabetes mellitus Acquired: HIV Pharmacological suppression Radiation therapy Smoking Malnutrition |
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virulence of staph A. *********
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50% have plasmid mediated resistance to antibiotics
Excretion of protein A that inactives immunoglobulin G Production of capsular polysaccharide that inhibits phagocytosis Produces biofilm to seclude the organism |
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septic joint imaging
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MRI !!!
synovial thickening in fat bone edema |
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common bug
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Pseudomonas most frequent in IV drug abusers
Fungal infections most common in pts on long term parenteral nutrition Salmonella in pts with hemoglobinopathy (Sickle cell) |
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Brodie Abscess
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subacute osteomyelitis
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puncture wound to the foot
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Pseudomonas osteomyelitis of the foot is highly coorelated with puncture wounds of the foot
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involucrum
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Bone formed below periosteum and surrounds sequestrum
**A sequestrum is a piece of dead bone that has become separated during the process of necrosis from normal/sound bone. |
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*****osteomyelitis Tx
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IV antibiotics
Surgery Topical irrigations (open and closed systems) Hyperbaric oxygen therapy Stablilzation with external fixators Increased nutritional states Eliminate risk factors (smoking, Diabetes) Wound vac |
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Dx for septic arthritis
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Pain with passive joint motion, effusion, warmth, erythema, systemic symptoms
Septic arthritis synovial fluid cell count >80000 with 75% PMNs = septic joint G. stains + for organisms in 1/3 of aspirates for infection Wbc>12,000 : 40-60% PMN : ESR>55 |
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Peds osteomyelitis
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50% of cases are children under 5
25% of cases are children under 1 |
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**spread of infection in children
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Metaphyseal vessels traverse physis
Septic arthritis occurs in 33% of children with metaphyseal infections (Knee-Hip) |
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*****Clinical Findings in Pediatric Hematogenous Osteomyelitis
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Pain (inconsolable crying)
Refusal to bear weight or move affected area Fever Lethargy Previous trauma(30-50%) |
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******Management of Pediatric Osteomyelitis and Septic Arthritis
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Identify organism (aspiration and blood cultures)
Begin IV antibiotics (based on S. aureus) Surgical evacuation of abscess or septic joints Any child with a fever and limb pain for 3 days should be evaluated for osteomyelitis |
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DDx for septic joint
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Inflammatory arthritis
JRA Post streptococcal arthritis Viral synovitis Rheumatic fever Transient synovitis |
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Necrotising Fascitis***
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Group A Streptococcus / Streptococcus pyogenes
Recent emergence of MRSA as pathogen Bacteria release exotoxins which activates T-cells and formation of cytokinens Aggressive debridement and removal of infected tissue necessary (amputations) |
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disease transmitted by human bite *****
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Syphilis
Hepatitis B and C Herpes Simplex Tuberculosis Teatnus HIV |
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pathogens in human bites
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Aerobes:
Eikenella corrudens Corynebacterium Staphlococcus species Anaerobes Bacteriodes Peptostreptococcus |
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hospitalization after a bite
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Patient with significant co-morbidities
Failure to improve after initial OP management Non-compliance Infected Hand wounds Systemic involvement (fever, chills, sepsis) |
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**brown recluse bite
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Causes Necrotising Arachnoidism
Inflammation, eschar, tissue necrosis, sloughing\ Syringomyelin D2 responsible for erythrocyte lysis |
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worse in the morning , gradually gets better
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it's juvenile RA ****
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new terms***
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Pre-axial –side of great toe or thumb
Post-axial side of small toe or finger |
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foot deformities that are benign
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Simple Polydactyly
Simple Syndactyly Metatarsus varus (adductus) Calcaneovalgus Congenital curled toe |
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infant foot defromities that are pathologic
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Complex Polydactyly
Complete &/or complex Syndactyly Clubfoot Vertical talus Macrodactly Cleft foot |
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simple syndactyly
complex complete |
skin only
bone only enite length of digit |
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Metatarus Varus (Adductus)
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Medial border of foot curves inward (adductus)
***odten confused with club foot !!! |
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Calcaneovalgus
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Benign
Flexible foot position corrects with gentle manipulation Tx Gentle stretching DDx vertical talus fibular hemimelia |
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clubfoot deformity
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sign: are ?
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cause of syndactyly
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failure of programmed cell death
usually occurs btw 3rd and 4th toes |
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grading for syndactyly
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Complete - webbing the entire length of digit
Incomplete - webbing partial length of digit Simple - soft tissue union Complex - boney union |
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when do we often see packaging defects ?
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with first preggers
large baby ***remember always check the hips !!!! |
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Metatarus varus
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Mild > moderate
Medial border of foot curves inward (adductus) flexible Severe Medial border of foot curves inward Stiff May see shallow medial skin crease Beback shoes used |
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Calcaneovalgus
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another packaging defect...so ...CHECK HIPS !!!
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clubfoot deformity
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arhtrogryposis---- stiffening of joints
pathologic ***Ponsetti technique used to tx |
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clubfoot signs
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Posterior crease
Medial crease Empty heel pad Adductus of forefoot Varus of hind foot Supination mid & forefoot |
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what is the goal of any foot surgery?
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flexible plantar grade foot
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vertical talus
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aka rockerbottom foot
aka rigid hindfoot disease *can't plantarflex can palpate head of talus on plantar surface ******* associated with NM disease |
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macrodactyly
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Gigantism of bones, muscles,nerves,vasculature
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cleft foot
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Tx goal is comfortable shoe wear
same for macrodactyly central failure of formation |
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acquired foot deformity
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Pes planus --flexible, rigid
Cavus---cavovarus these are flat foot problems flexible form , not that bad !!! |
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hindfoot valgus , typically found in ?
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congenital flat foot diseases
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sever flattened longitudinal arch defined by ?
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Navicular subluxation
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flat foot , stnading on toes.....
quick test to see if patient has flexible flat feet |
associated with ligamentous laxity
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ddx for Pes Planus ( flat feet )
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Ligamentous laxity
tight tendoachilles overcorrected clubfoot fibular longitudinal deficiency |
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rigid pes planus
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tarsal coalitions (define )
duck walk -- have a little bit of a waddle , can become painful *******can't stand on toes .... why ? listen again ...... BO486 |
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foot coalitions
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60% bilateral , and multiple ...
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accessory navicular
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little prominance medially on x- ray , aka an ossicle
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Cavus / Cavovarus
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high arch --- bad !!!! neuro .....
hereitary ... Sharko --Murray tooth ... Increased height of longitudinal arch Hindfoot varus Claw Toes Deformities may be flexible or fixed Charcot-Maire Tooth Disease other underlying conditions : Spinocerebellar Degenerations Myelodysplasia Polio Spastic Monoplegia or Dyplegia Polyneuritis Myopathy |
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workup for Cavovarus
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Detailed history
Prenatal Perinatal Developmental history Family Medical History ***Onset of deformity (congenital, gradual,rapid) Functional Status |
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Cavovaru assessment
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Examine Gait
Muscle Strength Testing ***Reflexes Upper and Lower Extremities Muscle Tone & testing for strength Clonus Babinski Sign ***Superficial Abdominal Reflex, tells you |
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Coleman block test
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for varus feet testing
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developmental hip dysplasia
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impossible before 12th week of gestation
85% association with genu recurvatum *tight swaddling |
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**********slipped capital femoral epiphysis
aka : SCFE |
ortho emergency
***** 10 yrs to 14 yrs !!! presents as pudgy and overweight hypergonadal --endocrinopathies also a culprit causing inc. zone of hypertrophy - esp. hyperthyroidism ******Feet externally rotated frog lateral shows how head is slipping off ddx : LCP -- in a different age group |
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SCFE untreated
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leads to progressive slippage and early arthritis
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Perthes (vs. SCFE )
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age group is different 3- 9
whereas for SCIFE it is 10-14 painful hip when bilateral, need to consider hypothyroidism **caused by an idiopathic AVN to the femoral head |
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hinge abduction
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can be a problem associated with Perthes (LCP)
flattened head and acetabulum |
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who benefits most from surgery due to Perthes disease ?
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children ages 6-9
BEST --- occurs in children younger than 6 ---- more room for remodeling |
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Osgood Schlatter's
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inflammed tendon at tibial tuberosity
11-14 boys most commonly |
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Osteochondritis Dessicans
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AVN of medial femoral condyle
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a patient comes in your office with bowed legs, what should you keep in mind ?
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Always keep in mind dwarfisms and metabolic disorders
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Tibia Vara
aka Blouts disease |
Unlike typical physiological genu varum, this only gets worse and leads to early degenerative arthritis
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Q angle *****
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Q angle is the angle formed by a line drawn from the ASIS to central patella and a second line drawn from central patella to tibial tubercle;
- an increased Q angle is a risk factor for patellar subluxation; |
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stress fractures , more common risk in female atheltes , why ?
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poor nutrition and eating disorders
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anorexia nervosa vs. bulemia nerv.
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anorexia -- is intesne fear of weight gain
whereas bulemia nerv. is over eating , with a sense of loss of control .. |
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female athlete traid
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amennorhea, eating disorders, osteoporosis
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why do I care about amenorrhea ?
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Skeletal demineralization predisposing athlete to stress fractures
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tx for menstral irregularities ********
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If less than 3 years since menarche
Decrease exercise Increased rest |
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etiology o amenorrhea
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Amenorrhea-absence of menarche by age 16 (secondary sex characteristics present)
Etiology unknown possibly hypothalamic origin—decreased ovarian hormone production |
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preggers excercising
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HR should not exceed 140 bpm
and temp should not go over 38 C |
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little league shoulder
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--stress reaction to proximal humeral epiphysis (microfracture and widening)
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what kind of young athletes are prone to labral tears ?
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kids that play sports all year round --- micro instability ...
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little league elbow
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excessive acceleration and deceleration
Medial epicondylar apophysitis Lateral joint compression-associated OCD of capitellum Ulno-humeral chondromalacia |
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pediatric wrist in sports
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gymnanst and weight lifters
Dorsal impaction of radiocarpal joint (due to excessive dorsiflexion under load) Can cause Madelung’s deformity (shortened and deformed distal radius) |
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Kohler's disease
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AVN of navicular bone
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Frieberg's disease
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second metatarsal head ...
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with tendon overuse injuries...
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avoid immobilization !!!!!
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heat related illnesses
cramps exhaustion stroke |
fever less than 102
b. fever over 102 --loss of water and electrolytes c. high fever over 104 |
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Staph a. virulence
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plasmid
protein A that inact. IgG a capsule that inhibits phago. produces biofilm |
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ortho infections
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labs : CBC, ESR , CRP
conventional film will show soft-tissue swelling |
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bone scan technique
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Flow phase: demonstrates blood flow
Equilibrium phase: distribution of isotope in extracellular space Delayed phase: osteoblastic activity Positive in osteomyelitis, tumors, DJD, post surgical, trauma |
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triple phase bone scanning *****
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Cellulitis shows increased activity in flow and equilibrium phase, but decreased activity in delayed phase
Osteomyelitis shows increases in all phases ****DJD: increase in delayed, but not in flow or equilibrium phase |
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most sensitive radiological modality in terms on infection
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Indium 111
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most specific radio mod. in terms of infection
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MRI
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acute hematogenous osteomyelitis most common in ?
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children , due to blood supply of bone
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Brodies abcess
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Localized subacute osteomyelitis
Metaphyseal/epiphyseal involvment Lytic lesion with rim of sclerotic bone Often confused with a neoplasm |
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chronic osteomyelitis
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infected dead bone , within a compromised soft tissue envelope
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common sites for osteomyeliti
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calcaneous !! very porous , so bacteria can get in and hide .. common in kids ..that walk funny
also : Ilium Spine Distal Femur Distal Tibia Ishium Pubis |
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puncture wound of the foot , what bug ?
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Pseudomonas osteomyelitis of the foot is highly coorelated with puncture wounds of the foot
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sequestrum
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a piece of dead bone that has become separated from normal bone ..
leads to an increase in intramedullary pressure from inflammatory exudates Periostreum becomes stripped from osteum leads to vascular thrombosis |
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involcrum and sequestrum
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forms in response to untreated infections
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dx for septic arthritis in adults
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Pain with passive joint motion, effusion, warmth, erythema, systemic symptoms
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Mm for infectious arthritis involving Staph a.
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Collagen receptors have been found on Staph aureus !!!! and allow it to bind to collagen
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pediatric osteomyelitis
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50% of cases are children under 5
25% of cases are children under 1 Males to females 2:1 No racial differences 70% are in long bones |
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spread of infection in kids
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Metaphysis is perfused by end arteries that enter large venous sinusoids.
Sluggish circulation and decreased phagocytosis allow bacterial inoculation Infection spreads through volkmans canals to periosteum |
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Pain (inconsolable crying)
Refusal to bear weight or move affected area Fever Lethargy Previous trauma(30-50%) |
Clinical Findings in Pediatric Hematogenous Osteomyelitis
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fever and limb pain for 3 days
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should be evaluated for osteomyelitis
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transient synovitis of the hip
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3-8
irritable hip |
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ddx for septic arthritis
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Inflammatory arthritis
JRA Post streptococcal arthritis Viral synovitis Rheumatic fever Transient synovitis |
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TB
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affects every organ system
50% with osseous involvement have pulmonary involvement |
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charcot neuroarthropathy
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chronic arthralgias
syphilis |
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types of necrotising fascitis
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Type I—polymicrobial
TypeII—monomicrobial (Strep. pyogenes) Type III—gas gangrene (clostridial) |
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Diskitis
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Hematogenous infection of disk and vertebral body
Staph aureus—most common organism Presents with severe pain and limited motion Narrowing of disk space Needle biopsy may help Rest, antibiotics, braces unless abscess |
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pathogens in human bites
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Aerobes:
Eikenella corrudens Corynebacterium Staphlococcus species Anaerobes Bacteriodes Peptostreptococcus |
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management of human bites ****
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DOC - Augmentin (oral) (875 mg bid)
Doxycycline if allergic to penicillin (100mg bid) IV Rocephin if admitted to hospital (1gm qd) |
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Syringomyelin D2 responsible for erythrocyte lysis
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brown recluse
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limb length defromity consequences
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pelvic obliquity causing inc. center-edge angle of hip
on PE *** beware of hemi hypertrophy and Wilm's tumors! |
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what causes functional LLD
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flexion contractures of hip or knee
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standard of tx for LLD
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2-6 cm -- get a shoe lift , epiphysiodesis --destroys growth plate on the long side
6-10 - lengthening 20 --- prosthetic fitting |
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patellofemoral syndrome , common in ?
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adolescent girls
localized to anterior knee pos. patellar grind test |
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patellofemoral syndrome tx
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excercises with the knee near full extension
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Osgood schlatter's
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painful elevation of the tibial apophysis
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pain at the tibial tubercle
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dx of osgood schaltters
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Tx for Osgood Sch.
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work on hamstring stretching
some patients develop a loose ossicle common in 11-14 year old boys |
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patellar subluxation
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hurts anteriorly
pos. apprehension sign |
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osteochondritis dessicans presentation
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appears often in the 2nd decade
AVN |
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discoid lateral meniscus
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snapping in the lateral aspect of knee
occasional blocking of knee extension |
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bowed legs under age two
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not abnormal
age two is the diving line between normal and abnormal |
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Blount's disease
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Tibia Vara
Unlike typical physiological genu varum, this only gets worse and leads to early degenerative arthritis medial growth plate shuts down , lateral keeps going |
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Ricket's
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metaphyseal flaring
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snapping hip
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IT band
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age group for osteochondritis dessicnas ?
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10-19 (second decade)
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acquired leg length differences
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growth arrest
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harris growth arrest
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causes a LLD
nutritional def. can lead to this |
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salter harris I
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can lead to a knock knee , valgus
palpate the growth plate |
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trauma
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ligamentous injury
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AM pain
Decrease motion Swelling Any age |
Rheumatoid arthritis
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cause of a limp originating from the knee
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discoid meniscus
other : Osgood Schlatter Disease – adolescence Patellar instability – adolescence Loose joint bodies Osteochondritis Dessicans – adolescence Septic joint – any age |
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what will you see on x-ray following a chronic osteomyelitis ?
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brodie's abcess
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avascular necrosis of navicular
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Kohler disease
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apophysitis (not only in the tibia ) but of tendo-achilles (gastroc distal insertion ... pulls on distal tibia apopysis ... pain , not uncommon , called ?
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sever disease
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benign flexible flat foot vs. a tarsal coalition *******
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stand up on toe, if hind foot valgus corrects and goes into varus , it's just a soft tissue problem vs. a coalition
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foreign bodies
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don't try to remove these in your office, need to visulaize with flouroscopy !!!! unless sticking out of skin
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large calves, tight heel cords, altered gait ... loss of ability to walk by age 12
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Duchenne Muscular Dystrophy
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ddx for limping in toddlers
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Reactive synovitis hit on..... due to viral inflamation of synovium
also ... DDH Cerebral Palsy Trauma Infection ****Reactive synovitis Spinal Dysraphyism Contracture Discitis Tumor Leg length discrepancy Clubfoot deformity Foreign body Tight Shoes JRA Septic joint C1- C2 instability |
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ddx for 4-10 years old
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DDH
Cerebral Palsy Trauma/fracture Reactive Synovitis Foreign body Spinal Dysraphism Septic joint Fibrous dysplasia Discoid meniscus Kohler disease Spinal dysraphism *****Legg-Calv-Perthes Leg length discrepancy Infection Tumor Tight shoes Spondylolysis Spondylolisthesis Osteomyelitis Sever disease Residual clubfoot deformity Contracture C1 –C2 instability |
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ddx for limping in preteen/adolescent
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DDH
Cerebral Palsy Trauma/fracture Reactive synovitis Tumor - Spinal Dysraphism Spondylothesis Iliotibial band disorder *****Osgood-schlatter disease Patellar instability Spinal dysphrasim ****Slipped Capital Femoral Epiphysis (SCFE) Leg length discrepancy Psychogenic Septic joint Foreign body Tarsal Coalition Spondylolysis Osteochondritis dessicans Contracture JRA ***C1-C2 instability |
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fibrous dysplasia ddx for ?
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child 4-10 positive, not so in toddlers
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Munchenhausen by proxy
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withholding care deliberately to cause a medical condition
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fatalities resulting from abuse or neglect
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50-60 % of child deaths resulting from abuse or neglect are not reported
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risk factors for infant maltreatment
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maternal smoking,
presence of more than 2 siblings, low infant birth weight, unmarried mother. children living in households with unrelated adults were approximately 50 times more likely to die of inflicted injuries than were children residing with 2 biological parents |
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abuse of children with disabilities
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The US Department of Health and Human Services has indicated that the rate of physical abuse is 2.1 times higher among children with disabilities than children without disabilities
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skin injury in abused kids
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Approximately 60% of abused children had injuries on the head, face, or neck.
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ddx for cutaneous 'lesions'
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Accidents,
Idiopathic Thrombocytopenic Purpura, Vitamin K deficiency, Henoch-Schönlein Purpura, Hemophilia, von Willebrand Disease. *****size, is a key differential here |
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shaken baby syndrome effects
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immediate - vomiting
concussion long term --- blindness , learning disabilities |
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long bone injury
musculoskeletal patterns suggestive of non-accidental injury |
**metaphyseal lesions in young children
multiple fractures in various stages of healing posterior rib fractures |
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buckel fractures in PEDS
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distal radius , grabbed by wrist , squeezed
**also think about corner fractures |
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common ddx errors associated with child abuse
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Osteogenesis Imperfecta
b. Henoch-Schönlein Purpura, c. Preterm Birth d. Copper Deficiency e. Rickets f. Osteomyelitis g. Fractures Secondary to Demineralization From Paralysis h. Rare conditions |
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Musculoskeletal injury patterns suggestive of abuse are :
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metaphyseal lesions in young children,
multiple fractures in various stages of healing, ******posterior rib fractures, long-bone fractures in children less than 2 years old long bone fracture & other injury *****Bucket handle & corner fractures |
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copper deficiency
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can cause pathological fractures
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Mm of ankle injury
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inversion and plantar flexion
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Weber , ankle sprain classifications
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A - transverse at the joint , inversion injury*****
B - oblique , and above the joint C -- oblique - high sprain **both B and C are eversion sprains |
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Maisonneuve Fx.
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eversion inj.
Typically involves medial malleolus fx. & disruption of tib/fib syndesmosis ***just like Weber C , except instead of distal fibula , it is proximal ***this is often missed on x-ray |
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Maisonneuve Fx.
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Includes ALL of the Following:
1) tear of deltoid (medial ligament) 2) rupture of syndesmotic ligament 3) high fracture of fibula |
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why are steroids contraindicated for tendon injection ?
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Steroid disrupts the collagen bonds, weakens it , caused it to rupture ******** done in middle aged patient , some of these patients have a hx of chronic disease..
Low does cortisone can weakne fibers and pre-dispose to rupture |
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achilles tendon rupture associations..
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increased-pronation
Pes cavus Tight calf muscles |
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thompson test
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for achilles rupture
squeeze the cal and foot will nrmally plantar flex |
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Freiberg infarction
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AVN of lesser metatarsal heads
2nd metatarsal head |
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Units of blood lost in trauma situations
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radius and tib/fib : 1-2 units
humerus and femur fx 2-4 units of blood pelvic fx 3-5 units |
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joint dislocations
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require splinting in the position in which they are found
**if distal pulses are absent, one attempt at reduction should be initiated |
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secondary survey
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detailed history
SAMPLE Hx prehospital observations like blood loss , damage to vehicle , neurosensroy exam , time of injury |
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PE in emergency med , goals
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primary -- life threastening
secondary -- limb- threatening re-eval --- avoid missed injuries |
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mechanics of pelvic injuries
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posterior ligament damage
opens pelvic ring tears pelvic venous plexus and.. internal iliac arterial system |
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signs of major pelvic hemorrhage
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Flank, scrotal, or perianal swelling/bruising
Open fracture wounds High-riding prostate Blood at the urethral meatus |
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management of life threatening pelvic injuries
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basiclly --- stop the hemorrhage, then stabilize
sheet method -- bedsheet from hospital --- wrasp across ASIS -- closes volume of pelvis down ... Hemorrhage control and rapid fluid resuscitation Pelvic stabilization External fixation ***Pneumatic anti-shock garment-MAST “Sheet” method Definitive operative care Angiography with embolization |
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crush syndrome
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rhabdomyolysis -- a lot of toxic materials released from muscle breakdown itself , can lead to acute renal failure****
**usually someone that has been pinned ******positive for hemoglobin by dipstick , but when they look at it in the lab under microscope, it is negative for blood so, injured muscle releases bad stuff |
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management of crush syndrome
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maintains a high tubular vol and urine flow - IV fluid resuscitation , Lasix , mannnitol
**alkalinization of urine with sodium bicarb reduces intratubular precip. of myoglobin |
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muscle necrosis secondary to ischemia begins after ?
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six hours
note that nerves are also very sensitive to anoxic injuries |
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traumatic amputation
transport of the amputated part : |
1. wash in ISOTONIC solution
2. wrap in sterile soaked gauze and put in plastic bag 3. transport with the patient in a cooling chest with crushed ice |
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compartment syndrome
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where muscle is contained within a closed fascial space
--pressure causes ischemia and necrosis ---end stage is called Volkmann's ischemic contracture |
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6 P's of compartment syndrome
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first one is pain out of proportion to the injury
pallor , paresthesia , pulselessness , paralysis , and palpable tenderness ----all are late findings |
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measuring intracompartmental pressure
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immediate fasciotomy indicated if greater than 30 mmHg
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side effects of narcotics
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hypotension and a little bit of somnalence
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tetanus toxoid vacinne --- boards !!!!!
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can give to preggers as well as polio ****
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increased risk of tetanus in wounds
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if wound is more than 6 hours old
more than 1 cm in depth ****** high velocity injury |
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goal of initial assessment and management
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ID injuries that pose a threat to life and limb
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things to recognize...
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essential to recognize pelvic fractures, arterial injuries, compartment syndrome, open fractures, crush injuries, and fracture-dislocations in a timely manner
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emphasis on trauma care
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Emphasis should be placed on airway maintenance, control of external bleeding and shock, and the immobilization of the patient
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treating pregnant patients
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all over the boards!!!!!
The body sees a growing baby as a parasite! there are two patients that you are treating !! when mom gets into trouble, body shunts blood to center of the body |
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GCS scale level that requires an airway ?
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8
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AVPU method
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rapid neuro exam
A - alert ? V - responds to vocal stim P - responds to pain U - unresponsive to all stim |
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Resuscitation
circulation |
****Hypovolemic shock should not be treated by vasopressors, steroids, sodium bicarbonate, or by continued crystalloid/blood infusion
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what might indicate blunt cardiac trauma ?
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Dysrhythmias, including unexplained tachycardia, atrial fibrillation, PVCs, and ST changes
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standard of care for imaging in trauma
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lateral C - spine
Chest X-ray Pelvic X-ray |
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imaging in Preggers
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should not be avoided!!!!
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space behind the right kidney under the liver ?
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Morrison's pouch , where fluid accumulates !!!
aka -- hepato-renal abcess |
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PUNTT syndrome
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purposely or Unintentionally Not Treating Trauma
Purposely-- guy thinks he knows better Unintentionally --- family doc moonlighting, doesn't know better |
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oral boards station
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make sure you say that you want to keep EMS here !!!! they can provide pertinent information !!!!
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information to obtain about MVA's
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Seat belt usage
Steering wheel deformity Direction of impact Damage to the exterior of the vehicle Damage to the interior of the vehicle Ejection from the vehicle Fatalities at the scene |
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information to obtain about motorcycle crashes
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Helmet usage
Loss of consciousness Ejection Approximate speed |
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penetrating trauma , concerns :
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Region of the body injured
Organs in the proximity to the path of the penetrating object Velocity of the missile |
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septal hematoma *******
if you don't drain it , what happens ? |
necrosis of cart. of nose, causes saddle nose defromity !!!
***can get sued for that !!!!! |
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distant heart sounds and narrow pulse pressure may indicate ?
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cardiac tamponade
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JVD indicates ?
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cardiac tamponade or tension pneumo
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cardiac tamponade
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fluid around the heart that constricts/restricts heart from beating
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key to Dx for cardiac tamponade
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breathe sounds are equal !!!!!
tension pneumo breath sounds diminished on one side |
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tx for cardiac tamponade
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pericardial centesis
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tension pneumo tx
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needle @ second intercostal space , then chest tube
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before placing a urinary catheter, what should be done ?
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a rectal exam
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purpose of casting and splinting
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to reduce pain!!
by providing stability and to maintain adequate alignment so healing may occur |
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indication for splint
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temporary!
when more swelling is anticipated ****need to control the joint above and below |
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complications :
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can get compartment syndrome !! if too tight
pressure points can be created |
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purpose of padding under the cast ?
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besides the obvious of some comfort , also ... provides some room for swelling to occur!!!!!
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achilles rupture
most common site of rupture |
4-6 cm proximal to insertion
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surg tx for achilles rupture
non-surgical |
end to end , fascial graft
cast in equinas |
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medial gastroc tear
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mimics DVT !!! a lot of bruising
*pain is more proximal |
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complications with calcaneal inj.
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severe , swelling and bleeding
can't close skin post surgery, have to leave it open ..... great blood supply --- PLATE 516 |
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to test sub-tala joint
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evert and invert
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posterior tibial tendon insuff.
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acquired flatfoot
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what happens to the position of the foot , when it becomes flat
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pronation
**weakness when standing on toes tendon degenerates ****too many toes sign |
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tarsal tunnel syndrome ...
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could be caused from heel strikes during running
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patient comes in with recent history of ankle trauma , reports an inversion injury , and you suspect Osteochodritis Diss. , what imaging studying will you order to confirm this ?
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MRI
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Osteo.Cho. Des Tx
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NWB , RICE
***younger patients do better |
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Talar neck fractures , what is the classification system ?
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Hawkins
Hawk's have Talons tx : hawkin's I --- does not require surgery hawkin's II -- usually requires surgery |
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snowboarders fracture
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lateral process of talus
**created by forced dorsiflexion and ext. rotation of the foot |
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athletes that are on their toes a lot
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posterior impingement syndrome
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plantar fasciitis
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repetitive stress during weight bearing and or push off
***morning pain |
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sharp point tenderness worse with walking
diffuse swelling |
march fracture
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jones fracture healing
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high incidence of non-union
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lisfranc injury
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fracture --dislocation of tarsal/metatarsal joint
complex, often missed ... ****x-ray may show minimal displacement , but sever ligament damage may exist need a CT to see |
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lisfranc injury Mm
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Result from dorsally applied force (i.e. crush, drop tool box on dorsum of foot, etc
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fleck sign
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Avulsion of the Lisfranc ligament off of the ***2nd metatarsal base
Fleck - Frank CT gold standard for this |
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tx for Lisfranc
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if greater than or equal to a 2 mm gap, will require reduction of 2nd metatarsal
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morton's neuroma
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Fibrous enlargement of a plantar interdigital nerve with entrapment between metatarsal heads (usually 3rd and 4th )
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upper motor neuron symptoms
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Spastic paralysis
Increased tone Limited atrophy No fasciculations Hyperreflexia / bladder Babinski sign |
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lower moto neuron symptoms ...
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Flaccid paralysis
Decreased tone Significant atrophy Possible **fasciculations Hyporeflexia / bladder No Babinski sign |
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signs of both upper and lower problems
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think spinal cord, cervical spondylosis
diffuculty walking , hyper-active bowel |
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plastic vs. metal orthosis ....
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edema --- needs to be able to expand ?
plastic orthotic can be molded , and is better able to distribute forces |
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when is quad not needed to hold yourself up ?
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when the force line from an orthotic goes from the the ankle, and through the knee .... joint just "rolls" forward
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if force line is behind the knee ?
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need good quad strength
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Virchow's traid
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1. venous stasis
2. hypercoaguability 3. Endothelial wall injury of the vein can lead to pulmonary embolism, if there is not enough activity in the patient |
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when evaluating wrist and hand , finger extensors, wrist extensors , forearm supinators all originate from ?
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lateral condyle of humerus
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all wrist and finger flexors , extrinsic hand muscles , FPL , pronator teres originate from
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medial epicondyle
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ulnar, humeral motion
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on a hinge joint, just up/down , to get rotation , need radius into play ...
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woman who is on the phone a lot comes in and complains and numbness and tingling in 4th and 5th digit , how can you educate her about the mechanics ?
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the OL ( olecranon ) is looser in extension , tighter in flexion , so , when flexed .. can compress on ulnar nerve
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lister's tubercle ...
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above snuff box and radial styloid
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Boutonniere
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buckaniere and POP
PIP flexed , DIP extended Swan neck is the opposite !! |
