The Washington Manual Internship Survival Guide (27 page)

▪  Protect yourself. Wash your hands frequently around patients with suspected viral conjunctivitis and avoid touching your eyes.

•  Allergic:

▪  Eliminate inciting agent.

▪  Cool compresses and artificial tears.

▪  Olopatadine or nedocromil antihistamine drops bid.

•  Bacterial:

▪  Topical trimethoprim/polymyxin B or bacitracin ointment qid for 5 to 7 days.

▪  For
H. flu
: Amoxicillin/clavulanate (20 to 40 mg/kg/d in three divided doses).

▪  For GC: Ceftriaxone 1 g IM and empiric treatment for
Chlamydia
with azithromycin 1 g PO × 1. Treat sexual partners.

ORTHOPEDIC SURGERY

Prior to Calling the Consult

•
  Examination: A thorough examination of the patient should be made prior to calling an orthopedic consult. This should include neurovascular exam (pulses, sensation, motor function) of the involved extremity. All wounds should also be examined.

•
  Radiography: Prior to calling a consult, obtain and evaluate X-rays of the affected joint/bone. Usually two views, an AP and a lateral
view, of the affected area are sufficient. Special cases are listed below:

•  
Shoulder/proximal humerus
: AP, true AP, axillary, scapular lateral (or Y) views. An axillary view is especially important. This can be hard for the radiology techs to perform when the patient has a painful shoulder, but this view is essential to determine that the shoulder is not dislocated.

•  
Hip fractures
(femoral neck/intertrochanteric fractures): AP hip, cross-table lateral (not a frog leg lateral), AP ortho pelvis.

•  Pelvis/acetabular fractures: AP ortho pelvis, Judet (oblique) views, inlet/outlet views.

•  
Ankle
: AP, lateral, mortise views.

•  
Foot
: AP, lateral, medial oblique views; and a Harris heel (axial) view if a calcaneus fracture is suspected.

•  Consultation with the orthopedic service is preferred, prior to obtaining a CT, MRI, or bone scan. Plain X-rays should always be obtained prior to ordering more advanced imaging.

•
  For fractures, acute dislocations, suspected compartment syndrome, joint sepsis, cauda equina syndrome, or diabetic infections; make patients NPO and discontinue all anticoagulants.

•
  If not already done, order basic pre-op labs: CBC, BMP, PT/INR, PTT, and type and screen. If infection is suspected, include an ESR and CRP. If the patient is febrile, order blood cultures.

•
  Certain orthopedic issues are better managed in an outpatient setting. Examples include chronic pain in the spine or extremity, chronic rotator cuff tears, ankle sprains, patients requesting joint injections. For these types of problems, consider having the patient follow-up with an orthopedist once they are discharged from the hospital, rather than calling an inpatient orthopedic consult.

•
  Rule out medical or general surgical causes of orthopedic symptoms, such as cholecystitis causing right shoulder pain, myocardial ischemia causing left shoulder pain, and inguinal hernia causing hip pain.

•
  If an orthopedist has operated on the patient within the past several months, even for an unrelated problem, consider a courtesy call to alert the orthopedist that the patient has been admitted. Any unexpected hospital admissions may affect the patient’s post-op rehab course.

Fractures

•
  
Open fractures and fractures with associated neurovascular compromise
are emergencies: Order X-rays and basic pre-op labs, make patient NPO, discontinue any anticoagulants, and
call a consult immediately!
Any open wound in the same limb segment as a fracture means that the fracture is open unless proven otherwise by the orthopedic resident.

•
  History: Mechanism of injury and pre-injury level of activity (e.g., does the patient walk, do they use a walker, are they wheelchair bound, what kind of work do they do?).

•
  Physical exam: Complete distal neurologic and vascular exam. Examine joints proximal and distal to the injury. Carefully examine all extremities to rule out other injuries. Take down splints/dressings to perform exams, unless the fracture has been reduced by another physician or outside hospital prior to your exam. Err on the side of taking down the dressing, as open fractures have been missed by referring EDs.

•
  Describing fractures: Attempt to delineate the following prior to calling consultation:

•  Fracture pattern (transverse, oblique, spiral).

•  Displacement: How far are the fragments away from each other? Which direction, anterior, posterior, medial, lateral?

•  Angulation: By how many degrees do the fragments relate to each other?

•  Shortening: How much do the fragments overlap?

•  Comminution: Is it a “clean” break or are there multiple small fragments about the fracture site?

•  Open versus closed: Any break in the skin in the vicinity of a fracture must be considered an open fracture until proven otherwise with a careful examination of the wound.

•
  Initial management:

•  Closed fractures are treated on an individual basis based on particular bone involvement and amount of displacement.

•  
Open fractures require emergent operative debridement and fixation.

•  Keep patients NPO until they are evaluated by the ortho team.

•  Open fractures require a tetanus booster and antibiotics, usually cefazolin with or without gentamicin depending on the size and contamination of the wound. If there is fecal or barnyard contamination of the wound, consider anaerobic coverage (metronidazole or clindamycin) as well.

Septic Joint

•
  
This is an emergency: call an orthopedic consult immediately
after complete examination, X-rays and labs obtained. Make the patient NPO and discontinue any anticoagulants.

•
  Pertinent history: Warmth, painful range of motion, tenderness, fever, inability to ambulate/use extremity.

•
  Pertinent exam: Neurovascular exam (pulses, sensation, motor), effusion/fluctuance, erythema, warmth. Considerable pain with passive range of motion.

•
  Workup: Plain radiographs, CBC, BMP, ESR, CRP, and blood cultures (if febrile). The diagnosis is confirmed with joint aspiration. Aspiration may be done by the primary physician or an orthopedic consultant.
Do not aspirate a joint through cellulitis
if at all possible. Synovial fluid should be sent for stat Gram stain, cell count, crystals, and cultures (aerobic and anaerobic).
Antibiotics should not be administered until a joint aspirate is obtained
.

•
  Diagnosis:

•  Septic arthritis is diagnosed with a synovial fluid leukocyte count generally >50,000/mm
³
, a positive Gram stain, or a positive culture result.

•  An inflammatory/autoimmune arthropathy typically has a synovial fluid leukocyte count of 10,000 to 50,000/mm
³
with positive crystals (for gout or CPPD disease) and negative Gram stain and culture results.

•
  Treatment:

•  
Operative drainage
:
Neisseria
spp. are exceptions to this rule, as they are highly responsive to antibiotic therapy; operative debridement is not necessary. A privately taken history may be of great importance in these cases.

•  Appropriate intravenous antibiotics as determined by cultures. The course of antibiotics is typically 6 weeks. Consider an infectious diseases consult and long-term venous access (e.g., PICC line or tunneled central venous catheter) if intravenous antibiotics are needed.

•
  Clinical pearls:
S. aureus
is the most common organism in septic arthritis.
N. gonorrhoeae
is also prevalent in sexually active adolescents and adults, whereas
Salmonella
is more common in patients with sickle cell disease.

Compartment Syndrome

•
  
Compartment syndrome is an emergency, call a consult immediately
after complete examination and X-rays. Make the patient NPO and discontinue any anticoagulants.

•
  Definition: Compartment syndromes are caused by elevated hydrostatic pressure within a fixed osteofascial space, leading to
tissue ischemia as compartment pressure exceeds capillary pressure (i.e., the pressure in the compartment prevents blood flow out of and into the affected area). Elevated hydrostatic pressure commonly occurs from bleeding or swelling from within the compartment or from persistently elevated externally applied pressure.

•
  When to consider this: The most specific signs and symptoms of compartment syndrome are pain out of proportion to injury, pain with passive stretch of the muscles in the involved compartment, and hard tense compartments. Paresthesias, pallor, pulselessness, and paralysis may or may not be present (all are more indicative of arterial insufficiency). All external circumferential dressings should be removed before examining a patient for compartment syndrome.

•
  History: A typical history may include the following:

•  Trauma (fracture or muscle contusion)

•  Ischemia (vascular injury, extended compression)

•  Venous obstruction

•  Massive inflammation from snake or insect bites

•  Bleeding into the compartment (consider in anticoagulated patients)

•  Infiltration of fluid into a compartment (paint gun injuries, IV infiltration)

•  Tight circumferential dressings

•
  Physical exam: Directly palpate the concerning area to determine “tightness” of compartments. Compare with the contralateral side. Passively range the muscles that traverse the compartment (i.e., in the forearm, passively flex and extend the fingers). Check for pulses, sensation, and motor function. Continue to monitor the patient with serial exams.

•
  When clinical signs are equivocal, or when the patient is obtunded or not cooperative with the exam, compartment pressures may be measured by an orthopedic consultant. Compartment pressures >30 mm Hg (or a diastolic blood pressure to compartment pressure difference <30 mm Hg in hypotensive patients) are diagnostic of compartment syndrome.

•
  Treatment: Make patient NPO immediately upon suspicion of diagnosis. Obtain plain X-rays and any indicated pre-op labs. If compartment syndrome is confirmed, the orthopedics team will proceed with
emergent fasciotomy
.

•
  Clinical pearls: Remember that rhabdomyolysis can occur with compartment syndrome from muscle necrosis. Administer IV fluids, follow urine output, creatinine, and CPK.

Acute Cauda Equina Syndrome

•
  
This is an emergency, call a consult immediately
after examination and X-rays. Again, make the patient NPO and discontinue any anticoagulants.

•
  Definition: Cauda equina syndrome is caused by a lesion in the spinal canal located in the lumbar spine, between the conus medullaris and the lumbosacral nerve roots, resulting in urinary retention, bowel incontinence, saddle anesthesia, severe lower extremity neurologic deficit, and anal sphincter laxity.

•
  History: Suspect in a patient with low back pain and the previously mentioned signs and symptoms.

•
  Physical exam: A complete lower extremity neurologic exam should be performed including lower extremity strength, sensation, and reflexes. A rectal exam must be performed to assess both rectal tone and perianal sensation. Remember that the cauda equina functions as the peripheral nervous system. Therefore, in a complete cauda equina injury, all peripheral nerves to the bowel, bladder, perianal area, and lower extremities will be lost, resulting in absent bulbocavernosus, anal wink, and lower extremity reflexes. Nerve root tension signs such as pain on straight leg raise are likely to be present as well. On occasion, pain may radiate down the leg that is not being flexed (crossover pain) in addition to radiating down the leg being flexed.

•
  Workup: Stat AP and lateral views of the lumbar spine and a stat MRI of the lumbar spine. If the patient has had a prior discectomy, obtain MRI with gadolinium contrast. If the patient has had previous spinal surgery with instrumentation, obtain a CT myelogram.

•
  Treatment: Keep patient NPO, obtain necessary preoperative blood work, and discontinue anticoagulants. If cauda equine syndrome is confirmed, the orthopedic spine team will proceed with emergent operative decompression.

Diabetic Foot Ulcer/Infections

•
  Pertinent information: The acuity of these infections is dictated by the patient’s systemic symptoms. If the patient is febrile and/or hemodynamically unstable, call a consult immediately.

•
  Definition: Diabetic ulcerations occur after patients lose the protective sensation in their feet. Patients may present with an advanced infection due to lack of pain.