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Arcadia ED Orthopedics

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Department of Emergency Medicine

on 16 February 2016

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Transcript of Arcadia ED Orthopedics

Back Pain
amputation
compartment
osteomyelitis
abscess
nec fasc
arthrocentesis
can't walk
ED Musculoskeletal
Jenna Fredette, MD
Department of Emergency Mecidicine
Christiana Care Health System
Approximately 2/3 adults are affected by low back pain
Second most common complaint in ambulatory medicine
Third most expensive disorder in terms of health care dollars spent surpassed only by cancer and heart disease
Occurs at least once in 85% of adults younger than 50 years
15-20% of Americans have at least one episode of back pain per year
Of these patients, only 20% can be given a precise pathoanatomic diagnosis
massive midline compression of the caudal sac (tumor/disc material)
Bilateral sciatica, bowel or bladder dysfunction present in 90% of patients
Urinary retention is initially observed and followed by overflow incontinence
Perineal or perianal anesthesia is present in 60-80% of patients
Sharp
well localized
can have paresthesia
+straight leg raise
Dull
Poorly localized
No paresthesias
Management
AAA
Appy
Ectopic, Ovarian Cysts, PID
UTI
Perirectal Abscess
Renal Calculi
Epidural Abscess
Structural Low Back
Labs
only performed if dx is unclear
UA
CBC/ESR if infection is considered
Radiology
XR (expensive with significant radiation)
XR at significant age ranges (young and old) or if there is trauma or concern for malignancy
CT/MRI - rarely performed in the ER and only for suspected neurosurgical emergency like cauda equina
Medications
CONSERVATIVE TREATMENT usually improves in 4-6 weeks
SHORT Bedrest (longterm no longer recommended)
NSAIDS, NSAIDS, NSAIDS
Muscle Relaxants
Narcotics for short term (2-3 days)
Steriods (controverstial, no good studies)
Back Exercises, physcial therapy
Broad Differential
Low Back Differential
Herniated Disc
Impingement VS Irritation
Cauda Equina
Spinal Stenosis
Presentation
History
c/o pain in the lumbosacral area
is it worse with movement, sitting, standing?
gradual onset or sudden onset?
precipitating event like lifting?
fever, weight loss, bowel or bladder problems
medications --> steriod usage = compression fractures, coumadin = hematomas
numbness and tingling down back of legs
Exam
STRIAGHT LEG RAISE is the single best test for determining radiculopathy from DISC HERNIATION
CAUDA EQUINA = rectal exam
At L4: Pain along the front of the leg; weak extension of the leg at the knee; sensory loss about the knee; loss of knee-jerk reflex
At L5: Pain along the side of the leg; weak dorsiflexion of the foot; sensory loss in the web of the big toe
At S1: Pain along the back of the leg; weak plantar flexion of the foot; sensory loss along the back of the calf and the lateral aspect of the foot; loss of ankle jerk
L5 and S1: These nerve roots are involved in approximately 95% of all disc herniations
Can't Walk, Can't Go Home
Muscular, Structural, CNS, deconditioning, infection, toxic substance, volitional
Ultrasound can be helpful in diagnosis
Mostly gram positive organisms (skin flora)
Need fluctulance for drainage (some aren't ready)
+/- Antibiotics (but cover for MRSA)
+/- packing
syndrome
Crush Injuries
Tight splints, casts, dressings
IV Fluid infusion into a muscle
Hematomas
Excessive muscle use (exercise, seizures...)
Burns
Envenomation
DVT
When fasciotomy was performed within 12 hours of onset normal limb function was regained in 68% of patients
When fasciotomy was delayed 12 hours or longer, only 8% of patients had normal function
pain out of proportion to the injury
ain, aresthesia, allor, ulselessness, oikilothermia
Clinical
Stryker Pressure Measurement
Presentation
deep and aching
worsened by passive stretching
5 P's
P
P
P
P
P
Causes
Diagnosis
Outcomes
gout
Differential
Presentation
spontaneous onset of pain, edema, and inflammation in a joint
Most common joints = great toe, ankle, wrist, and knee
1 or 2 joints are usually involved
Joints are red, hot, and exquisitely tender
Causes
Crystal formation in the joint
Gout = monosodium urate monohydrate crystals
Pseudogout = calcium pyrophosphate crystals
Although gout is associated with hyperuricemia, the level of uric acid does not precipitate gout
Acute changes in the level of uric acid cause gout
Diagnosis
Clinically
demonstration of urate crystals in aspirated synovial fluid
Arthritis (Rheumatoid, Septic)
Bursitis
Cellulitis
Treatment
treating the acute attack
providing prophylaxis to prevent acute flares
lowering excess stores of urate
NSAIDs and colchicine (now rarely used) are the mainstays of treatment
Steriod injection or orally/IV steroids
Fluid Analysis
Causes
Acute or chronic inflammation of the bone
Infection locally or from hematogenous spread
More common in diabetics, sickle cell disease, AIDS, IVDA, ETOH, immunosuppresed
Presentation
non-specific
non healing ulcers
malaise
localized erythema
Diagnosis
CBC and local culture often unhelpful
ED w/u includes XR though misses many
MRI very specific and usually done as inpatient
CT not useful or recommended
Ultrasound may be on the horizon
Treatment
IV abx; patients can be very sick or very stable depending on chronicity
surgical debridement
long term outpatient management
Reimplantation
depends on functionality of body part
depends on mechanism (guillotine vs crush injuries)
depends on level of nerve and artery damage
Management
Control bleeding (BP cuff, finger tourniquet)
Rinse off dirt and debris; Do not scrub
Wrap part in a dry, sterile gauze or clean cloth and place in plastic bag
Place the plastic bag on ice
Don't place the amputated part directly on ice as it will causes further tissue damage
Progressive, rapidly spreading, inflammatory infection located in the deep fascia, with secondary necrosis of the subcutaneous tissues
What is it?
How do I find it?
Very hard! Maintain high index of suspicion
It rapidly progress and requires prompt recognition and aggressive treatment
Pain out of proportion to exam
How do I treat it?
Aggressive surgical debridement of all necrotic tissue and administration of antibiotics are necessary
Nerve Root
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