Anterior Shoulder Dislocation

Anterior Shoulder Dislocation

• Often occurs due to a fall on an outstretched hand (FOOSH) or a direct blow
• Causes severe shoulder pain, with the arm typically abducted and externally rotated
• Axillary nerve involvement may be present, leading to sensory loss and deltoid weakness
• Diagnosis involves X-rays (AP, scapular Y, axillary views) to identify anteriorly displaced humeral head
• A neurovascular exam is needed to check distal pulses and axillary nerve sensation
• MRI is used if a rotator cuff tear or other soft-tissue injury is suspected
• Immediate reduction is crucial to prevent complications like muscle spasm or vascular compromise
• Analgesia/sedation is administered via procedural sedation or regional block
• Post-reduction X-rays confirm alignment and exclude fractures
• Immobilization in a sling for 2-3 weeks, followed by gentle range-of-motion exercises, is typical
• Complications to watch for include recurrent dislocations, axillary nerve injury, and Hill-Sachs lesion

Scaphoid Fracture

• Presents as wrist pain after FOOSH with tenderness in the anatomic snuffbox
• Pain may worsen with wrist extension or radial deviation
• Initial X-rays can be normal, potentially leading to missed fractures
• Plain X-rays for diagnosis include PA, lateral, and scaphoid (oblique) views
• MRI or repeat X-rays are recommended in 1-2 weeks if suspicion remains high despite negative initial X-rays
• The snuffbox compression test (axial loading of the thumb) often elicits pain
• Immobilization is achieved with a thumb spica cast or splint for scaphoid fractures or high suspicion
• Follow-up imaging (repeat X-ray or MRI) is necessary if initial films are negative
• Surgery (ORIF, bone grafting) is indicated if there is displacement, proximal pole involvement, or nonunion
• Key complications include avascular necrosis, nonunion, chronic instability, and wrist arthritis

Calcaneal Fracture (Hindfoot Injury)

• Typically results from a fall from height with axial load to the heel
• Manifests as severe heel pain, inability to bear weight, and bruising
• Bruising may be present on the plantar surface ("Mondor sign")
• Associated lumbar spine compression fractures should be checked for, with an incidence of about 10-15%
• X-rays include lateral and axial (Harris) views of the calcaneus, and Böhler's angle (depression if <20°) should be measured
• CT is the gold standard for defining articular extension and displacement
• The Ottawa Ankle/Foot rules help determine imaging if there is uncertainty
• Immobilization is achieved with a bulky splint, non-weight bearing, elevation, and ice
• Orthopedic consultation for ORIF is necessary if significant displacement or subtalar joint involvement is present
• Monitoring for compartment syndrome of the foot is important due to high compartment pressures
• Complications include chronic pain, malunion, wound healing issues, posttraumatic arthritis, and nerve entrapment

Acute Compartment Syndrome

• Presents as severe, progressively worsening pain out of proportion to the injury
• Pain is exacerbated by passive stretch of the involved muscles
• Often follows fractures, crush injuries, or tight casts/bandages
• The "5 P's"—pain, paresthesia, pallor, paralysis, pulselessness—are indicators, though pulselessness is a late sign
• Compartment pressure measurement is used for diagnosis
• Delta pressure (diastolic BP - compartment pressure <30 mmHg) strongly suggests compartment syndrome
• Clinical diagnosis is paramount, and treatment should not wait for pulselessness to develop
• Immediate fasciotomy to decompress all involved compartments is required, ideally within 4-6 hours to prevent permanent injury
• Constrictive dressings or casts should be loosened or removed
• Elevate the limb at heart level
• Monitor for rhabdomyolysis

Femoral Neck/Hip Fracture in an Older Adult

• Occurs in elderly patients after a fall, resulting in inability to bear weight and severe hip/groin pain
• The leg is often shortened and externally rotated if a femoral neck or intertrochanteric fracture is present
• High mortality if not managed promptly, also watch for delirium and other comorbidities
• Diagnosis involves X-ray of the hip (AP pelvis and lateral views)
• MRI is used if X-ray is negative but suspicion remains for an occult fracture
• Labs include CBC (anemia), electrolytes, and type & cross for likely need for surgery
• Management includes analgesia, IV fluids, and stabilization
• Surgical repair (hemiarthroplasty, total hip replacement, or internal fixation) is typically performed within 24-48 hours
• DVT prophylaxis
• Rehab is needed for physical therapy and early mobilization
• Complications include avascular necrosis of the femoral head, nonunion, pneumonia, VTE, and delirium

Knee Dislocation with Multi-Ligament Injury

• Results from high-energy trauma, typically presents with severe knee pain and obvious deformity
• May result in large effusion, instability, possibly absent pulses if popliteal artery injured
• Is potentially catastrophic if vascular injury is missed
• X-ray (AP, lateral, sunrise) rules out fracture
• Physical exam for ligament testing is necessary, but can be limited by pain
• Vascular assessment includes checking popliteal pulses, ABIs, or CTA if pulses are diminished
• MRI is used after vascular issues stabilized, to evaluate ACL/PCL/MCL/LCL
• Immediate vascular assessment is needed, and emergent surgical intervention if compromised
• Reduction of dislocation, likely external fixator if unstable, is needed
• Definitive ligament reconstruction occurs once soft tissues and vasculature are stabilized
• Complications include popliteal artery injury, peroneal nerve damage, chronic instability, and arthrofibrosis

Traumatic Amputation (Below the Knee)

• Results from severe industrial or high-energy trauma causing partial or complete amputation
• There is significant hemorrhage risk and possible contamination
• Check for associated injuries and shock
• Primary survey (ABCs) and hemorrhage control (tourniquet if needed) are crucial in the initial assessment
• X-rays of the stump are used to evaluate bone ends and debris
• Vascular assessment confirms perfusion of remaining limb segments

Cauda Equina Syndrome

• Presents with severe lower back pain, often with sciatica (shooting pain) in one or both legs
• Saddle anesthesia (perineal numbness) and bladder/bowel dysfunction may be present
• Possible leg weakness and decreased reflexes
• MRI of the lumbar spine is the gold standard for diagnosis
• Post-void residual volume should be checked (urinary retention >300 mL suspicious)
• Evaluate for major disc herniation, tumor, abscess, or severe stenosis compressing the nerve roots
• Surgical decompression (urgent laminectomy/discectomy) should be performed ideally within 48 hours to improve outcomes
• Steroids are sometimes used if there is an inflammatory or compressive lesion
• Bladder function should be monitored, and a Foley catheter may be needed if there is retention
• Complications include permanent incontinence, erectile dysfunction, and lower limb paralysis if not treated promptly

Key Points Across All Orthopedic Cases

• Early recognition and prompt imaging are crucial
• Always assess neurovascular status
• Immobilization and early consultation with orthopedics or vascular surgery when needed
• Red flags include threatened circulation, increasing compartment pressures, and neurological deficits

NSTEMI (Non-ST-Elevation Myocardial Infarction)

• Commonly occurs in older patients with exertional chest pain
• The chest pain sensation is central "pressure", can radiate to jaw/neck/back
• May have dyspnea, diaphoresis, or nausea
• Elderly or diabetic patients often present atypically (fatigue, epigastric discomfort, etc.)
• Risk Stratification should be assessed with TIMI, GRACE, HEART scores to estimate short-term risk
• Cardiac biomarkers should be measured, Troponin (preferred) and measured serially at 0, 3–6 hours
• ECG should be performed looking for ST depressions, T-wave inversions, or transient ST elevation and performed serially if suspicion remains
• CXR should be performed to rule out alternate causes (pneumothorax, pneumonia)
• Possible Stress Testing is performed if ECG and troponins remain nondiagnostic and high suspicion persists
• Hospital admission is required for intermediate/high-risk patients
• Anti-ischemic therapy should be initiated in hospital

New Onset Atrial Fibrillation

• Typically presents with irregularly irregular pulse, palpitations, as fatigue, possible dyspnea or even asymptomatically
• Can present with rapid ventricular response leading to hypotension
• Risk factors include hypertension, CAD, valve disease, thyrotoxicosis, sleep apnea, and obesity
• ECG shows absent P waves, fibrillatory baseline, irregularly irregular R-R intervals
• Labs include TSH/free T4 (exclude hyperthyroidism), electrolytes (K+, Mg++), and renal function (impacts anticoagulation)
• Stroke risk scoring is determined by CHA2DS2-VASc to guide anticoagulation
• Treatment is either Rate vs Rhythm Control
• Rate control: Beta-blockers, non-DHP Ca²+ blockers (diltiazem/verapamil) adjusting Goal HR <110 (if asymptomatic) or <80 (if symptomatic)
• Rhythm control: Electrical or pharmacologic cardioversion if symptomatic, unstable, or highly symptomatic
• Anticoagulation requires clinicians Decide based on CHA2DS2-VASc to determine if DOACs (apixaban, rivaroxaban, etc.) or warfarin if mechanical valve or moderate/severe mitral stenosis should be initiated
• Cardioversion: require Urgent electrical cardioversion for hemodynamic instability
• Elective cardioversion occur after ≥3 weeks of anticoagulation or TEE to exclude LA thrombus if AF >48 hours
• Long-term: Consider catheter ablation if refractory or intolerant to meds, especially in younger or highly symptomatic patients
• Complications: Stroke, heart failure (due to tachycardia-induced cardiomyopathy), systemic emboli, bradyarrhythmias if overtreated with rate control drugs.

Chronic Venous Insufficiency (CVI)

• Manifests as lower leg edema that worsens throughout the day, aching/heaviness, and varicose veins
• Stasis dermatitis, brownish discoloration, eczematous changes, possible venous ulcer near medial malleolus may be present
• Risk factors include DVT history, obesity, prolonged standing, and older age
• Diagnostic measures include: Venous Duplex Ultrasound to evaluate for reflux >0.5 sec, rule out active DVT and Ankle-Brachial Index (ABI) to exclude significant arterial disease (ABI < 0.9 suggests PAD)
• If an ulcer is present determine if a Wound culture should be taken for suspicious infections
• Compression therapy (30-40 mmHg stockings)
• Elevation of legs reduces edema
• Wound care: Debridement of ulcer, dressings should maintain moisture balance
• Lifestyle: Weight reduction, smoking cessation, glycemic control in diabetics should occur to prevent complications
• Cellulitis, ulcer enlargement, recurrent infections, progressive skin changes are possible complications

Acute Decompensated Heart Failure (ADHF)

• Presents with Worsening dyspnea, orthopnea, fatigue, possible acute pulmonary edema
• Hypotension, cool extremities and altered mental status can indicatate Low output states
• A physical exam will reveal: S3 gallop, elevated JVP, rales, peripheral edema if volume overloaded
• Elevated BNP / NT-proBNP is indicative of ADHF and assess EF (HFrEF vs HFpEF), valvular function Via an Echocardiogram
• Chest X-ray may show Pulmonary edema, Kerley B lines, cardiomegaly, pleural effusions
• ECG would be performed to Rule out ischemia/arrhythmias and Labs: CBC, renal function, electrolytes, troponin if ischemic cause suspected can be taken
• Hospitalization if hypotension, significant volume overload, or end-organ hypoperfusion may be required
• Administer Oxygen / NIPPV if hypoxic or in respiratory distress or Diuretics (e.g., IV furosemide) if volume overloaded
• Provide Inotropes (dobutamine) or vasopressors (norepinephrine) if cardiogenic shock
• Optimize chronic HF meds once stable: ACEi/ARB/ARNI, beta-blocker, aldosterone antagonist as medication
• Monitor for arrhythmias, renal function changes, electrolyte disturbances
• Complications: Cardiogenic shock, arrhythmias, acute kidney injury, respiratory failure

Hypertensive Emergency

• Presents with Severe BP elevation (often >180/120 mmHg) with acute end-organ dysfunction (encephalopathy, pulmonary edema, ACS, etc.)
• Severe headache, confusion, dyspnea, chest pain, or neurologic deficits
• Measure BP in both arms/legs and conduct Labs (renal, electrolytes, troponin, BNP)
• Evaluate via ECG for ischemia/strain and Chest X-ray to assess pulmonary edema/aortic contour
• Neurologic/renal components should then be assessed
• Reduce BP to lower MAP by 25% in 1st hour-IV antihypertensives
• Specific scenarios occur in aortic dissection, ischemic CVA, and preeclampsia/eclampsia

Acute Pericarditis

• Presents with Sharp, pleuritic chest pain, worse when supine and improved by leaning forward
• Patient may have a Mild fever, shortness of breath, and recent viral URI
• Their vitals may produce a Mild fever and tachycardia
• A physical exam will show:
  • Pericardial friction rub: Classically heard with the diaphragm at the left lower sternal border, best at end-expiration with patient leaning forward.
  • Distant or muffled heart sounds and possible jugular venous distension (JVD) if a large effusion is present.
  • Pulsus paradoxus (exaggerated drop in systolic BP > 10 mmHg on inspiration) in tamponade.
• An ECG will show Diffuse ST-segment elevations and PR depressions
• No specific reciprocal changes (unlike STEMI) will appear
• Lab tests would show Elevate inflammatory markers, Troponin can be normal or slightly elevated (if myopericarditis), and CBC: Mild Leukocytosis
• An Echocardiogram (TTE) would Identify pericardial effusion, can detect right atrial or right ventricular collapse in tamponade, and determines the size of effusion
• If the patient has high-risk features and signs of tamponade, then they will have a Hospital Admission
• A Pericardiocentesis occurs for tamponade relief, as well as Anti-inflammatory therapy (NSAIDs) and Frequent ECHOs to monitor effusion size

Acute Limb Ischemia

• Sudden onset of severe left leg pain with numbness and coldness, over ~6 hours
• Past Medical History: Atrial fibrillation, peripheral artery disease, CKD, diabetes
• The Patient may present the “6 Ps” (Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia).
• Physical Exam & Ankle-Brachial Index (ABI) -Very low ABI (< 0.2) indicates severe ischemia
  • Normal pulses are normal in Contralateral leg , suggesting an embolus, rather than bilateral chronic PAD
• An Ultrasound should be used to confirm the absence of flow and CTA or MRA should be used to Visualize the occlusion location.
• Coagulation profile: INR may be subtherapeutic, so assess and elevate lactate if prolonged ischemia
• CK can be high if there is muscle damage, or rhabdomyolysis
• Immediate IV heparin to prevent propagation of clot, and Surgical embolectomy is required with Supportive treatment for IV fluids to control compartment syndrome/reperfusion
• Long-term: Switch to an appropriate oral anticoagulant for stroke prevention and cessation of statins, as well as smoking.

Hypertrophic Cardiomyopathy (HCM)

• Patients often indicate problems of Exertional syncope, or a Family History indicating a fatal “heart problem."
• Patient exams will show patients with Harash crescendo-decrescendo systolic murmur and crescendo'ing w/ Valsalva
• ECG displays Signs of LVH, possibly abnormal Q waves in lateral/inferior leads.
• An Echocardiogram may produce that is 15mm
• Holter Monitor may show non-sustained VT
• Beta-blockers assist in reducing HR's and Non-dihydropyridine CCBs if beta-blockers not tolerated may indicate the presence of nitrates and diuretics
• Septal myectomy is used to reduce obstruction persists and ICD placement to reduce risk

Stanford Type A Aortic Dissection

• Patients often have complaints of Sudden, severe “tearing” chest pain radiating to the back, with a Past Medical History of Hypertension
• Patients often present a Exam with a Difference in systolic BP between arms, a new diastolic murmur, and possible aortic regurgitation
• A CT Angiography of the Chest that Reveals an intimal flap or a Transesophageal Echo (TEE) to determine a diagnosis, with lab tests showing non-specific D-dimer
• An ECG may show non-specific ST/T change and examination shows pulse deficit
• The patients must undergo Examination and Immediate BP/HR Control followed by Urgent Surgical Repair of aorta

Acute Severe Mitral Regurgitation (MVP)

• Patients often present Chief complaints related to known Mitral Valve Prolapse (MVP)
• The patients examination will reveal a murmur for severe heart conditions, with tests showing a echocardiogram an xray to determine the extent of the damage

Severe Aortic Stenosis

• Progressive exertional dyspnea, angina, possible syncope, Known history of AS, with an crescendo murmur that causes delayed Carotid Upstroke
• Tests display Severe reduced valve area, hypervalvular gradient,Concentric LV hypertrophy, enlarged QRS voltages, with a x-ray showing some calcification

Restrictive Cardiomyopathy

• Patients present with symptoms of Progressive dyspnea, orthopnea, edema, right-sided heart failure as well as Past Medial History of myeloma, CKD
• examination produces elevated JVP,S3,hepatomegaly,diastolic dysfunction Cardiac MRI shows Diiffuse late gadolinium
• Lab testing shows high levels of BNP, mild Troponin, and elevated AL Amylodosis
• Low diuretic dose to reduce heart
• In cases of Amyloidosis a chemist transplant reduces the presence of amylodosis and reduces pacemaker dependency

Left Atrial Myxoma

• Progressive dyspnea, occasional stroke with symptoms that mimic mitral stenosis
• Findings show Intermittent arrhythmias(AFib) and positional changes, with the Interatrial Sectrum is attached to the PEDUNCULATED
• Lab Tests show the non-specific as the patients is Mild Annemic, the patient may undergo surgery and require aftercare