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36 Cards in this Set
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R TA:Leg slightly flexed, the shortened adducted and internally rotated plus loss of sensation after posterior leg and foot loss of dorsi flexion and planter flexion. loss of deep tendon reflexes at the ankle. |
Presentation is of posterior hip dislocation with associated sciatic nerve injury. It is about 90% of all of this locations and often occur due to Dashboard injuries Around 10% of the posterior hip dislocation that associated with sciatic nerve injury, which may present with the loss of sensation of the posterior leg and foot loss of dorsiflexion and difficulty with plantarflexion loss of deep tendon reflexes at the ankle Reduction under sedation should be done in six hours to decrease the risk of AVN.pa INJURY TO THE FEMORAL NERVE, is typically associated with indeed hip, dislocation and presents as loss of sensation over the Thai weakness of the quadriceps muscle and lots of deep tendon reflexes. Anthony. should |
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Patellar tendon, rupture, patella, fracture, or quadriceps tendon rupture Occurs in patients who are unable to actively extend the knee after an injury |
The patellar tendon connects the patella to the tibia. While uncommon, patellar tendon rupture typically occurs in younger athletes. If ruptured, patient's will often have a high-riding patella (ie, patella alta) In contrast, the quadriceps tendon connects the quadriceps muscle to the patella and when ruptured, results in a low-riding patella (ie, patella baja) on plain film. Patellar fractures are rare and typically occur with direct impact injuries (ie, high-energy dashboard injuries) or extensor mechanism injury. Patients will often have a palpable patellar defect with significant hemarthrosis, and are unable to perform a straight leg raise. The ACL (e) is the most commonly injured knee ligament and typically occurs due to noncontact |
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Tibial plateau fractures are fractures of the proximal aspect of the tibia. They have a bimodal distribution -typically occurring due to high-energy mechanisms in the young and low-energy mechanisms in the elderly. Patients will refuse to bear weight on the affected leg. Quadriceps tendon rupture is more commonly seen in older patients with chronic illnesses or repeated steroid injections. Similar to patellar tendon rupture, disruption of the quadriceps tendon causes inability to extend the knee. |
The ACL is the most commonly injured knee ligament and typically occurs due to noncontact athletic injuries. Patients often describe a "popping" sensation at the time of injury with subsequent knee swelling. Physical exam maneuvers may aid in diagnosis- including the Lachman test and anterior drawer test. |
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Hx of fall Left foot pain after falling off a ladder Swelling and ecchymosis of the middle of his left foot |
Lisfranc injury is a disruption of the tarsal-meta-tarsal (TM'T) joint with or without an associated fracture. This is a "can't miss" diagnosis given that the Lisfranc ligament is a major stabilizer of the TM'T joint, and injury or disruption to this ligament can cause mid-foot instability. Physical exam will typically demonstrate ecchymosis of the midfoot with swelling and pain at the TMT joint. Patients typically cannot bear weight, as in the case above. When a Lisfranc injury is suspected or confirmed, be sure to conduct a thorough neurovascular exam because the dorsal pedis artery crosses at the base of the first and second metatarsals, making it susceptible to potential injury. |
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A Jones fracture refers to a fracture of the base of the fifth meta-tarsal. A pseudo-Jones is a fracture of the base of the fifth metatarsal involving the lateral tuberosity. |
The navicular bone is the most commonly fracture midfoot bone and is important to diagnosis due to high risks of AVN. Stress fractures typically occur secondary to repetitive low-intensity trauma where the rate of bone damage exceeds the rate of bone repair. This patient's injury is acute. |
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Maisonneuve fracture. A Maisonneuve fracture is a proximal spiral fracture of the fibula that is associated with a fracture of the medial malleolus or rupture of the deep deltoid ligament. |
The typical mechanism of injury is ankle eversion. Many patients will only complain of ankle pain; therefore, it is critical to examine the entire leg as this will reveal tenderness over the proximal fibula. If tenderness over the proximal fibula is present, dedicated tibia-fibula radiographs should be obtained to make the diagnosis as below. Management in the ED involves analgesia and orthopedic consultation to plan for surgical repair. |
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In septic arthritis, the fluid is typically cloudy or opaque in color and has a thin/watery viscosity. |
Synovial WBC more than 50,000/ mm' with synovial PMN 90% or more is most consistent with a diagnosis of septic arthritis. |
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Septic arthritis is a bacterial infection of the join space and its synovial fluid. It is an acute emergency and typically caused by either the hematogenous spread of bacteria to the joint capsule or by direct inoculation from recent arthrocentesis or joint surgery. Management includes analgesia, antibiotics, and investigation for primary source of infection if hematogenous spread is suspected. Orthopedics consultation is helpful to determine need for operative debridement or hardware removal if applicable. |
In this case, the patient's history of IV drug abuse makes hematogenous spread more likely. Over 80% of cases are monoarticular and the most common joint affected is the knee. Patients classically present as above-with a painful, erythematous, warm joint and endorse pain with both passive and active range of motion.
Risk factors for nongonococcal septic arthritis are history of IV drug use (as this patient), prosthetic joint, diabetes, immunocom-promised states, the elderly, and those with indwelling catheters. |
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Reactive arthritis is a rare seronegative human leukocyte antigen B27 (HLA-B27) associated spondyloarthropathy secondary to a precipitating infection. |
It occurs most commonly in males under the age of 40 and typically affects large joints. It is classically characterized by a triad of urethritis, conjunctivitis (or uveitis), and arthritis (can't see, can't pee, cant climb a tree"'). |
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Pseudogout is a metabolic arthropathy caused by deposition of calcium pyrophosphate dihydrate crystals in the connec five tissue. Patients typically present with pain, erythema, and warmth of the affected joint (similar to gout). Diagnosis is confirmed by arthro-centesis showing positively birefringent rhomboid crystals, and treatment may include NSAIDs, colchicine, or glucocorticoids. Gout is another acute monoarticular arthropathy that presents similarly to pseudogout as mentioned above. It is distinguished by negatively birefringent needle-shaped monosodium urate crystals on arthrocentesis. Treatment is similar to pseudogout and may include NSAIDs, colchicine, or glucocorticoids. |
Rheumatoid arthritis is a progressive systemic inflammatory poly-arthritis. It more commonly affects women, and patients typically present with symmetric severe joint pain. While NSAIDs may be helpful in improving pain in acute flares, they do NOT prevent joint destruction. Importantly, many patients are on diseases modifying antirheumatic drugs (DMARDs) or biologics. While these medications do prevent disease pro-pression, they also cause immunosuppression and increase susceptibility to underlying infection. |
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Acute carpal tunnel syndrome?? X-ray : spilled tea, cup radiograph of the rest |
The patient has a lunate dislocation as shown on the hieral radiograph of the wrist with volarly displaced lunate in the "spilled teacup" appearance. Lunate dislocations are usually caused by a hyperextension injury or a FOOSH. The median nerve runs through the carpal tunnel between the flexor carpi radialis and the palmaris longus. It provides sensation to the palmar aspect of the radial three and one-half fingers as wellas the dorsal aspect of the tips of the index and middle fingers and the radial half of the ring finger. The median nerve may be compressed in the carpal tunnel by the lunate, and the patient may display signs of acute carpal tunnel syndrome. |
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Acute carpal tunnel syndrome |
Perilunate dislocations are the most common wrist dislocations and can also be associated with carpal tunnel syndrome. However, they have a different radiographic appearance.
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Terry, Thomas, or David Letterman sign |
Scapholunate dislocation is sometimes defined on radiograph by the "Terry Thomas" or "David Letterman" sign, where there is a gap (›3 mm) in the space between the scaphoid and lunate (similar to a gap in the front teeth of these two people). 👍🏼Scaphoid fractures do not cause compression of the median nerve. |
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The extra demonstrates AVN of the femoral head IN WITH COLLAPSE OF THE FEMORAL HEAD. |
AVN is a known complication of sickle cell disease. AVN is the result of cellular death of bone components due interruption of the blood supply. The anemia and vaso-occlusive crisis of sickle cell disease contribute to the interruption of the blood supply. The bone structures collapse, resulting in bone destruction, pain, and loss of foint function. Other risk factors for AVN include trauma (including femoral neck fracture) disrupting blood supply via the round ligament, hip dislocation (risk increases proportionally to duration), collagen vascular disease, Cushing's disease or chronic systemic steroid use, alcohol abuse, among other causes including idiopathic. Osteosarcoma (b), hypertension (c), prostate cancer (d), and gout (e) have not been causally related to AVN of the hip. |
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A spiral fracture of the distal tibia is known by the eponym toddler structures. It is a fracture commonly seen in ambulatory children aged 123 years. The mechanism of injury usually involves a trivial fall or a twisting mechanism on a planted foot
spiral fractures are seen in non-ambulatory. Children are highly suspicious for non-accidental trauma, child abuse |
Greenstick fractures are seen in children because the bones are soft and can bend resulting in incomplete fractures. X-rays demonstrate a "bow" fracture in which the bone becomes curved in its longitudinal axis. The outer cortex of the bone remains intact. The radiograph pictured demonstrates a fracture and is not within normal limits. |
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Salter Harris classification |
The Salter Harris classification is used to describe fractures involving the epiphyseal plate (physis) or growth plate. A Salter Harris I fracture is a fracture through the growth plate or physis. Diagnosis of this fracture is made clinically as the radiographs are negative. A Salter Harris II fracture involves the metaphysis and physis. A Salter Harris III fracture involves the physis and epiphysis Salter Harris IV fracture involves the physis, metaphysic, and epiphy-sis. A Salter Harris V fracture is a crush injury to physis. |
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The patient presents with nursemaid's elbow, or radial head subluxation due to immaturity of the annular ligament. This injury is most commonly seen in toddlers as the annular ligament strengthens over time. |
If there are no signs of joint effusion, the examiner can flex and supinate the forearm with slight pressure held on the radial head in an attempt to reduce the subluxation. The radial head should be palpated and during the maneuver, a click noted by the examiner has been shown to have a positive predictive value of over 90%. The child should begin to use the arm within minutes of the reduction, and immobilization is not needed for a first-time occurrence. |
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An uncomplicated, painful subungual hematoma that does not involve disruption of nail edge should be drained via trephi-nation. Trephination is performed using electrocautery or by twisting an 18 G needle through the nail. Once the trephination is performed, the blood that had collected under the nail will drain, alleviating pain and pressure. Multiple trephinations are sometimes needed. Some experts suggest that painless hematomas may be left alone and do not require drainage Trephination and drainage is normally performed to alleviate pain and discomfort for the patient. |
If the nail edges are disrupted or the hematoma involves greater than 50% of the nail bed, the entire nail should be removed to evaluate for nail bed laceration. Nail bed lacerations require repair with suturing since optimal initial management of the damaged nail bed decreases the likelihood of chronic painful nail plate deformity. Scalpel insertion under the nail edge is the appropriate method to drain a paronychia. A pressure dressing would cause increased pain and is not indicated. Buddy taping the finger is not indicated. |
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'The patient presents with a subungual hematoma, (after slamming her finger in the car door, two hours prior to arrival, there’s no deformity and ship used to have full range of motion of an ungal Fingers )a collection of blood underneath the nail that usually results from trauma. |
The diagnosis is made by visual examination of the nail. If there is concern of injury to the underlying bone, X-ray imaging should be performed to rule out associated fracture. While a cold compress and digital nerve block would assist with pain, it is more important to rule out underlying fracture. If a distal phalanx tuft fracture is detected on X-ray, then splinting would be indicated . |
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A 26-year-old, restrained driver is brought in by EMS after a low-to moderate speed MVC where he was at a stop sign and struck from behind He was immobilized on a long spine board and a cervical collar was placed He is hemodynamically stable and his primary survey is intact. He complain of pain in his left arm and the back of his neck. On secondary survey, ther are no neurologic deficits noted. The CT C-spine was negative for fractur or dislocation. The patient continues to complain of pain upon palpation o the cervical spine. What is the next step in the management of this patient? a. Remove the cervical collar and clinically clear his cervical spine b. Instruct the patient to wear the hard cervical collar until his pain resolves c. Place him in a soft cervical collar and discharge with outpatient follow-up d. Admit him for emergent magnetic resonance imaging (MRI) of the cervical spine E . Consult Neurosurgery |
The answer is c. Although CT-cervical spine imaging is negative, he patient continues to have midline tenderness on examination and therefore should be discharged in a soft c-collar. These patients should follow-up within 2 weeks and may require a routine MRI to evaluate for ligamentous injury. Occult ligamentous injuries can be missed on CT and plain radiographs, so patients with persistent midline tenderness require immobilization. The National Emergency X-Radiography Utilization Study (NEXUS) Criteria is a clinical decision rule to help determine which patients require imaging. Patients do not require C-spine imaging if all of the NEXUS criteria are met. |
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NEXUS Criteria |
Absence of posterior midline cervical tenderness Normal level of conscious No evidence of intoxication No abnormal neurologic findings No painful or distracting injuries |
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A 32-year-old dental hygienist presents to the ED with a painful lesion at the distal aspect of her right index finger. She reports a low grade fever and malaise over the last week and subsequently developed pain and irning of the digit. In the past few days, she has noted erythema, edema,and the development of small grouped vesicles on an erythematous base .Which of the following is the most appropriate next ep in management? |
The patient has herpetic whitlow, a viral infection of the distal finger. This condition can be treated with oral antiviral agents such as acyclovir. It is caused by the herpes simplex virus type I or Il This condition typically occurs in health care providers with exposure to oral secretions, parents of children with primary oral infections, and in patients with coexistent herpes infections. There is generally a prodrome period of fever and malaise. Subsequently, there is localized burning, itching, andpain that precede the development of the classic clear herpetic vesicles. Typically, only one finger is involved. The diagnosis is usually made clini-cally, but, if doubt remains or if the presentation is atypical, it can be confirmed with a Tzanck smear or viral culture. When managing this condition, it is important to note that surgical drainage is contraindicated as this can result in secondary infection and delayed healing. It would be appropriate to splint the digit for comfort but you do not want to buddy tape it to the neighboring digit because the tape wound be painful and cause additional damage to the skin underlying the vesicles. This practice would also increase the likelihood of spread to the adjacent digit. It would be inappropriate to leave the vesicles uncovered. A dry dressing should be placed over the vesicles to prevent transmission. Antibiotics are not indicated unless there is evidence of bacterial superinfection. |
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Monteggla fracture is a fracture of the proximal one-third of the ulnar shaft combined with a radial head dislocation. This injury commonly occurs from either a direct blow to the posterior aspect of the ulna or a FOOSH with the forearm in forced pronation. This fracture is associated with an injury to the radial nerve. It is always important to look for an associated fracture or dislocation when one is noted in a forearm bone. This diagnosis requires an orthopedic consult as the majority require surgical repair to provide stability to the elbow. |
The Galeazzi fracture is a fracture of the distal radial shaft associated with a distal radioulnar dislocation at the DRUJ. This fracture is often confused with Monteggia fracture. |
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A nightstick fracture is an isolated fracture of the shaft of the ulna. This injury can occur after a direct blow to the ulna and usually occurs when an individual raises his or her forearm up to protect their face from a blow. |
A Colles' fracture is a transverse fracture of the metaphysis of the distal radius with dorsal displacement of the distal frag-ment. 'The median nerve is at risk for injury in a Colles' fracture. A Smith fracture is a transverse fracture of the distal radial metaphysis with volar displacement of the distal fragment. The median nerve is at risk for injury in the Smith fracture. |
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The earliest signs of compartment syndrome are pain out of proportion to exam and pain on passive flexion of the muscle in the affected area. Compartment syndrome is defined as increased pressure within a closed space, ultimately companis ing circulation and therefore function of tissues within the space. The end result is necrosis and damage to tissues. Up to 10% of tibial plateau fracture develop compartment syndrome. Compartment syndrome can occur in the setting of fractures (typically of long bones), vascular injury, crush injuries, circumferential burns, or iatrogenic etiologies (eg, surgical com-plications, IV infiltration). |
Compartment syndrome is a surgical emergency and requires orthopedic or surgical consult for fasciotomy. Pallor, pulselessness, paralysis, and paresthesia are all incorrect as they are late findings of compartment syndrome The presence of a pulse does not rule out compartment syndrome. |
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Anterior elbow dislocations, although uncommon, have a much higher incidence of vascular injury than posterior dislocations. It is important to evaluate for an associated brachial artery injury. Olecranon fractures are associated with injury to the ulnar nerve not the median nerve. Individuals may experience paresthesias and numbness in the ulnar nerve distribution or weakness of the interossei muscles. Posterior elbow dislocations are associated with injuries to the ulnar and median nerves. They are not associated with brachial artery injuries (b). |
Supracondylar fractures common in young individuals, are associated with injuries to the brachial artery and median nerve as the distal humeral fragment is displaced posteriorly, thus displacing the sharp fracture frag ments anteriorly. Supracondylar fractures are not associated with injury to the radial nerve. Humeral shaft fractures most commonly occur from a direct blow to the mid-upper arm. The fracture usually involves the middle third of the humeral shaft. The most common associated injury is damage do the radial nerve that causes wrist drop and loss of sensation in the is dorsal web space. Humeral shaft fractures are not associated with injury is the axillary nerve. |
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The CT image presented earlier demonstrates a burst fracture of L2. These fractures are commonly seen when a direct axial load is transmitted through the spine, in this case landing on the feet from a 15-foot fall. Burst fractures are unstable and require a thorough neurological examination and prompt neurosurgical consultation, as bone fragments and the disc may be retropulsed into the spinal cord. This type of injury is often seen in conjunction with calcaneal fractures. All patients with calcaneal fractures require dedicated imaging of their spine. It is critical to distinguish burst fractures from simple compression fractures. |
While compression fractures only involve the anterior aspect of the vertebral body, burst fractures also have compression of the posterior vertebral body. Solitary transverse process fractures are stable and most often related to blunt trauma. |
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Spinous process fractures historically known as clay-shoveler fractures, occur most often from deceleration injuries and direct trauma and are noted to be stable. |
Simple wedge fractures occur with longitudinal forces below the C2 level and can be differentiated from compression burst fractures by the absence of a vertical fracture of the vertebral body and less than 40% loss of height. Subluxation injuries in the lumbar spine can be due to seatbelt injury and can be associated with fractures of the vertebral bodies. These injuries can be quite devastating as they result in complete transection of the spinal cord. |
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Calcaneal fractures are usually caused by an axial load such as a fall from a height with the patient landing on his or her feet. The examination reveals swelling, tenderness, and ecchymosis of the hindfoot and the inability to bear weight on the fracture. Ten percent of calcaneal fractures are associated with compression fractures of the lumbar spine. Therefore, it is important to examine the patient's entire spine. |
The calcaneus is the most commonly fractured tarsal bone .The talus is the second most commonly injured tarsal bone. Calcaneal fractures are usually caused by compression injuries, not rotational injuries. Ten percent of calcaneal fractures are bilateral. Treatment varies depending on the extent of injury. In general, nondisplaced or minor extraarticular fractures only require supportive care with immobilization in a posterior splint and follow-up with an orthopedic surgeon. The management of intraarticular or displaced calcaneal fractures remains controversial regarding nonoperative versus immediate surgical reduction. |
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A 33-year-old carpenter was building a new house and using a high-pressure paint gun when he inadvertently injected his left index finger. On arrival to the ED, he complains of intense hand pain. On examination, you note a 2-mm wound over the second proximal phalanx. He has full range of motion and brisk capillary refill. Radiographs of the finger show soft tissue swelling, a small amount of subcutaneous air, but no fracture. The patient sustained a high-pressure injection injury of his finger. This is a surgical emergency. These injuries may involve extensive tissue loss and are associated with high infection rates. Most of these injuries involve grease, paint, or other industrial toxins. Paint generates a large, early inflammatory response, resulting in a high percentage of amputations., and there is no indication for advanced imaging. |
Within several hours after the digit has been injected, the extremity becomes painful and swollen. Initially, there may be anesthesia and even vascular insufficiency of the extremity. In the late stages, marked breakdown of the skin occurs, resulting in ulcers and draining sinuses. If the material injected into the extremity is radiopaque, it is possible to determine its degree of spread. Management involves splinting and elevating the extremity, administration of antibiotics, tetanus prophylaxis as indicated, analgesia, and immediate hand surgery consultation. The patient requires admission, emergent orthopedic evaluation |
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The best way to preserve an amputated part is to rinse it with normal saline to remove gross contamination, wrap it in sterile gauze moistened with saline or lactated ringers, and place it in a sterile, watertight container. Then store this container in ice water.
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Povidone-iodine is a strong antiseptic solution that is used commonly in the hospital setting, particularly in the operating room to re-ate a sterile field. However, it is thought to be injurious to fibroblasts and may limit wound healing. The amputated part should not be placed directly on ice or in ice waterbecause this may also damage the tissue. Reimplantation of the thumb should be performed by a plastic surgeon in the operating room. The risk of tissue death increases the longer the severed part is not properly stored. |
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Dexamethasone and other systemic steroids are used in the treatment of gout in patients who cannot tolerate NSAIDs NSAIDs are contraindicated in patients with comorbidities, such as peptic ulcer disease, GI bleeding, renal insufficiency, hepatic dysfunction, or are on warfarin. Indomethacin,naproxen ,and ketorolac are all NSAIDs and would be contraindicated in this patient with renal insufficiency. |
Colchicine can be used in patients with renal insufficiency but is less commonly prescribed due to a narrow therapeutic window and risk of toxicity. Colchicine should be started within 36 hours of the onset of symptoms and is associated with side effects including vomiting and diarrhea. Intraarticular steroids such as triamcinolone acetonide, can be used for the treatment of gout. Topical steroid ointment is not shown to be of benefit in the treatment of patients with gout. |
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The glenohumeral joint is the most commonly dislocated joint in the body, mainly because of the lack of bony stability and its wide range of motion. Anterior shoulder dislocations account for 95% to 97% of cases and are most commonly seen in younger, athletic male patients and geriatric female patients. The mechanism of injury is usually an indirect force that involves an abduction plus extension plus external rotation. Directly, it may occur due to a posterior blow that forces the humeral head out of the glenoid rim anteriorly. Radiographs obtained must include an axillary view to determine positioning of the humeral head. Patients usually present in severe pain, holding the affected arm with the contralateral hand in slight abduc-tion. The lateral acromial process is prominent giving the shoulder a full or squared-off appearance. Patients typically cannot internally rotate their shoulder. |
Axillary nerve injuries can occur in up to 54% of anterior dis-locations; however, these are neuropraxic in nature and tend to resolve on their own. Following the C5/C6 dermatome distribution, patients have a loss of sensation over the lateral aspect of the deltoid with decreased muscle contraction with abduction. After proper muscle relaxation with conscious sedation or intraarticular injection, closed reduction may be attempted using a variety of methods after deduction. It is imperative to repeat a neurovascular examination, and obtain a confirmatory radiograph. |
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Acromioclavicular joint sprains occur primarily in men and account for 25% of all dislocations. However, the mechanism of injury primarily involves a fall or direct blow to the adducted arm causing a downward and medial thrust to the scapula. |
Posterior dislocations are rare owing to the scapular angle on the thoracic ribs. They are seen, how ever, in convulsive seizures where the large internal rotator muscles one: power the weaker external rotators and cause the dislocation. |
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Median nerve injuries mainly involve weakness in the first three finger flexors. |
Ulnar nerve injuries mainly involve weakness in the interossei muscles of tie hand and paresthesia along the fifth digit. |
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Achilles tendon rupture: The Individual gives a history of a sudden excruciating pain and having heard orfelt a pop or snap. This entity is most common in sedentary, middle. aged men, or in episodic athletes (ie, "weekend warriors'). Other risk fae-tors include fluoroquinolone antibiotic use (now a Black Box Warning), steroid injections, and chronic inflammatory conditions. The diagnosis can be made with the Thompson test. The patient is placed in the prone position. With normal function, squeezing the calf produces plantar flex-ion of the foot. With a complete tear of the Achilles tendon, plantar flex-ion will not occur. If doubt remains, MRI or ultrasound can be used to confirm the diagnosis. Treatment includes splinting the affected leg and discharging the patient with crutches. Orthopedic follow-up is required for repair. |
Homans sign is traditionally used to help diagnose a deep vein thrombosis (DVT). It is considered positive when passive dorsiflexion of the ankle elicits sharp pain in the calf. However, this sign is neither sensitive nor specific for DVT. The Lachman test is used to detect an injury of the ACL. The McMurray test is used to detect an injury to the meniscus of the knee. A ballotable patella signifies a significant knee effusion. |
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