Upper and Lower Extremity Nerve Palsies

Pediatric Ortho

• Always consider non-accidental trauma in children
• Occult fractures are more common in peds
• If in doubt, splint and follow-up with ortho
• Presence of fat pads can indicate underlying fracture
  • Posterior is always pathologic.
  • A thin anterior fat pad is normal, but a “sail sign” is pathologic
• Management of common fractures
  • Monteggia fracture – urgent ortho consult for ORIF
  • Seymour fracture – physeal fracture of distal phalanx with associated nailbed injury. High risk for soft tissue entrapment. Requires Hand consult for likely ORIF
  • Tufts fracture w/ nailbed injury – antibiotics not required. Follow-up in 7-10 days with Hand
  • Common avulsion fractures (e.g. ASIS, lesser troch, iliac crest apophysis avulsion) should be NWB on affected extremity and f/u with ortho.
  • Torus fracture – splint with short arm cock-up splint
  • Greenstick fracture – unstable, requires splinting
  • Bowing deformity – treat it like a fracture and splint it
  • Mid and proximal humerus fracture – sling and swathe OR coaptation splint, sling, ortho f/u

Drug Rashes

• Common drug-induced rashes
  • Exanthematous drug eruption (EDE) – maculopapular
  • Urticaria w/o anaphylaxis
  • Vancomycin flushing syndrome (“Red man”)
• Uncommon and severe drug-induced rashes
  • Fixed drug eruptions
  • angioedema
  • acute generalized exanthematous pustulosis
  • DRESS
  • SJS and TEN
• DRESS can occur up to 8 weeks from drug exposure
• EDE (T-cell related) vs Urticaria (histamine) – draw an image on patient’s skin. If it appears red and/or raised after 10 min, it is urticaria
• Antihistamines: First gen (sedating): diphenhydramine, hydroxyzine; Second gen (less sedating): cetirizine, loratadine
• Topical corticosteroids – medium to high potency preferred for short course

ABEM

• ABEM exists to verify the abilities of physicians and to promote quality, trust, and responsibility.
• They aim to make our board certification more valuable by advocating for our value in hospitals
• See ABEM website for details about board certification and the exam
• Study for your exam!

Small Group: Nail bed Infections

• Flexor tenosynovitis
  • Hand emergency. Pt will often require OR washout with Hand surgery.
• Paronychia
  • Manage with warm compress and/or I&D
• Subungual hematoma
  • Ensure there is no underlying fracture
  • Trephination is generally reserved for symptomatic treatment within the first 24hrs

HIPAA: common scenarios and what is appropriate

• Family member: provider may disclose “directory info” (patient location and general health status) if caller identifies the patient by name.
  • The provider must first provide the patient with opportunity to agree or object
• Personal physician
  • Disclosures of PHI from one provider to another for treatment purposes are permissible without the patient’s authorization. Disclosing provider must use professional judgement to determine whether the requested PHI relates to the patient’s treatment by the requesting physician
• Press
  • Location and general health status can be disclosed if requestor identifies the patient by name, unless the patient has objected to such disclosures
  • Can’t just ask about the status of a GSW
• Test results
  • Provider must use their judgement to infer from the situation that a patient does or does not object
• Law Enforcement
  • Limited situations – PHI about a patient who is suspected to be a crime victim and the patient cannot agree to disclosure; the provider may disclose the PHI if (1) she/he determines that disclosures is in the patient’s best interest and the law enforcement officials represent that the PHI needed to determine whether another person violated the law. (2) The PHI is not intended to be used against the patient. (3) An immediate law enforcement activity depends on disclosure.