PEM: Orthopedic injuries and NAT- Dr. Warnick

1. 4 types of child abuse: physical, sexual, emotional, neglect
2. Consider developmental milestones: start to roll at 4 months, crawl at 9 months, taking steps at 12 months
3. TEN4FACES: bruises on torso, ears, neck, angle of jaw, cheeks, eyelids, subconj hemorrhage, frenulum tear; bruises on 4 months or younger; patterned bruising
4. Workup: trauma labs, skeletal survey (under age of 2), CT Head
   • UA > 50 RBC –> CT abd
   • ALT 3x upper limit –> CT abd
   • if low hgb –> look at context
5. Bucket handle fracture/corner fracture = concern for abuse
6. Posterior rib fractures
7. Spiral fracture vs toddler’s fracture
8. Social work, Law Enforcement, CPS report, Transfer to pediatric center

Hand injuries- Dr. Shaw

1. Perfusion: pulses, cap refill, most distal part of hand
2. Sensation: ulnar, median, radial, palmar/volar vs dorsal
3. Motor: “rock, paper, scissors, ok”; FDS vs FDP
4. Phalanx dislocation: frequently have ligamentous disruption, reduction with traction, splint with alumafoam to MCP
5. Nail avulsion: inspect for underlying laceration, repair as needed, suture/dermabond nail back in place
6. Fingertip avulsion injury: finger tourniquets
7. Subungal hematoma: assox with tuft fracture, trephination, abx if open fracture
8. Boxer’s fracture/metacarpal fracture with fight bite: closed reduction with 20-20-40 rule, hematoma block, ulnar/radial gutter splint
9. Scaphoid fracture: assess snuffbox, prone to malunion, thumb spica, follow up outpatient
10. Lunate dislocation: require emergent hand eval
11. Paronychia: I&D, abx if inflammation or abscess
12. Herpetic whitlow: topical acyclovir
13. Sporotrichosis: itraconazole 4-6 months
14. Felon: I&D lateral margin, bactrim
15. Flexor tenosynovitis: kanavel signs- sausage digit, pain with percussion of flexor sheath, held in passive flexion, pain with passive extension; hand consult, IV abx, OR
16. Water bath for ultrasound

Lightning Lectures: Swollen Joint- Dr. Scott

1. Septic arthritis: knee, hip, older- staph aureus, younger- gonorrhea
2. Gout: negatively birefringent, needle-shaped monosodium urate crystals, consider precipitants, tx: NSAIDs, colchicine, 90%. have positive uric acid
3. Pseudogout: positively birefringent
4. Post-strep
5. Traumatic
6. Avascular necrosis

Arthrotomy- Dr. Angel

1. Joint exploration, assess for extravasation of joint fluid (straw-colored)
2. X-ray to assess for open fracture, foreign body in joint, intra-articular air
3. Saline loading/methylene blue test vs CT scan
4. Also assess joints with range of motion
5. Tx: tdap, abx, ortho for washout in OR

Core US Topics- Dr. DiMeo, Dr. Nix

1. Abdominal Aortic US
2. Case: 72 yom h/o HTN, HLD, smoking presenting with left flank/lower back pain after lifting
3. Curvilinear probe
4. Orientation: find spine, aorta, and IVC
5. Obtain views in proximal, mid, and distal aorta in both short and long axis
6. Proximal aorta: celiac trunk with seagull sign
7. Mid aorta: left renal vein and SMA anterior to aorta
8. Distal aorta: bifurcation into iliac vessels
9. Pitfalls: intestinal gas, BMI
10. AAA: HTN, HLD, CAD, connective tissue disease; smoking (ever), age, sex (males)
11. 90% infrarenal
12. < 3 cm
13. > 5.5 cm = immediate call to vascular
14. Bladder US
15. Assess bladder volume, post-void residual, foley placement, renal failure
16. Landmark to pubic symphysis
17. Bladder volume- height x transverse depth x width x 0.7

R2 Pathway: Low Back Pain- Dr. Lyons and Dr. Mattingly

1. Consider red flag symptoms- trauma, age > 50, fever, immunocompromised, IVDU, recent surgery, epidural injection, urinary retention, abnormal reflexes, saddle anesthesia
2. Fracture: CT scan, spine consult
3. Malignacy: CBC, ESR, CRP, CT
4. Cauda equina: emergent MRI, PVR, 10 mg decadron, spine consult
5. Epidural abscess: CBC, ESR, CRP, Cultures, CT vs MRI; Vanc, flagyl, rocephin, spine consult
6. Transverse myelitis: MRI, LP (high protein), neuro consult, steroids +/- PLEX
7. Radicular back pain: no risk factors = no diagnostic imaging required
8. Nonspecific back pain: 85%, no labs required, can consider CBC, ESR, CRP, HCG
   • Imaging: CT better than XR, but does not assess spinal cord well, if concerned for spinal cord pathology > MRI; < 6 weeks of pain + no red flags = no immediate imaging
   • Treatment: heat/ice, remain active, light stretching
   • MMPC: NSAIDs, acetaminophen, lido patch, muscle relaxants
   • Trigger point injections

Open fractures– Dr. Gosser

1. Gustilo-Anderson classification: type 1-3
2. Management: if vascular compromise > attempt reduction, irrigate wound, immobilize in splint, abx, tdap, ortho consult
3. Antibiotics: cefazolin, add gentamycin for complex, add fluoroquinolones for fresh water, add doxy for salt water wounds
4. Complications: surgical site infection, osteomyelitis, surgical amputation, neurovascular injury, compartment syndrome

Splinting- Dr. Rizzo

1. Proximal humerus: cuff and collar
2. Supracondylar: posterior long arm
3. Distal radius and ulnar: sugar tong
4. Distal tibia: posterior short leg w or w/o stirrups
5. 5th metacarpal: ulnar gutter

Room 9 Follow up- Dr. Roberts

1. Aortic dissection
2. Symptoms: chest pain, abdo pain, syncope, stroke-like symptoms, paraplegia
3. Widened mediastinum on CXR in 40% of patients
4. Tx: BP control- short-acting beta blockers > long-acting, such as esmolol or labetalol; vasodilators such as nicardipine, clevidipine, nitroglycerine, nitroprusside
5. Ruptured aortic aneurysm
6. Symptoms: hypotensions, abdominal pain, pulsatile mass
7. Unstable > bedside ultrasound vs stable > CT w/ contrast
8. Tx: SBP 80-90, esmolol if HTN
9. Bowel perforation
10. Tx: fluids, NPO, abx, ppi, surgery consult, pain control
11. Decompensated cirrhosis
12. SBP tx: third gen cephalosporin, fluoroquinolone, carbapenem

Eponymous Fractures- Dr. Eisenstat

1. LeFort 1: horizontal maxillary, teeth from face
2. Lefort 2: pyramidal fracture, maxilla, orbital wall, nasal bone
3. LeFort 3: craniofacial disjunction, assox with CSF leak, temporalis muscle disruption
4. Chance: involves all 3 columns, assox with seat belt injury
5. Clay Shoveler: lower C spine process (usually C7), stable
6. Jefferson: C1 burst fx from axial loading (diving)
7. Bennett vs Rolando: 2 vs 3 fx fragments of 1st metacarpal > thumb spica
8. Bankart: glenohumeral avulsion with ant shoulder dislocation
9. Hill Sachs: humeral head depression fx
10. Monteggia: proximal ulna, dislocation of radial head; peds FOOSH
11. Galeazzi: distal radius fx with radio/ulnar dislocation
12. Boxer: distal metacarpal fx, no rotation accepted
13. Chauffer: radial styloid, direct blow to back of wrist
14. Colles: FOOSH, elderly women, distal radius, indication for DEXA scan
15. Smith: fall on flexed wrist
16. Game-keeper/Skier thumb: rupture of ulnar collateral ligament, caused by forced abduction, thumb spica > possible OR
17. Jones: base of 5th metatarsal, NWB 6-8 wks
18. Lisfranc: separation between tarsal bones, ligamentous injury in midfoot joint
19. Maisonneuve injury: tib/fib syndesmosis, proximal fib fracture
20. Pilon: comminuted distal tib
21. Segond: avulsion fracture assox with ACL tear
22. Weber classification of lateral malleolus fracture: A below, B @, C above syndesmosis
23. Salter harris classification of physeal fractures