42 Orthopedics Flashcards
osteoblasts vs osteoclasts
blasts = synthesize nonmineralized bone cortex … clasts = reabsorb bone
stages of bone healing
inflammation —> soft callus formation —> mineralization of the callus —> remodeling of the callus
cartilage receives nutrients from
synovial fluid, osmotic
Salter-Harris fracture classifcation and treatment
big picture = 1 & 2 are tx w closed reduction, 3-5 cross epiphyseal plate and can impact growth, need ORIF …. 1 = epiphysiolysis of the involved growth plate without assoc fracture …. 2 = additional metaphyseal fracture fragment … 3 = fracture through growth plate and epiphysis … 4 = fracture crosses epiphysis, growth plate (physis), and metaphysis …. 5 = crush of growht plate without a fracture, detected late by asymmetric or premature closure of the growth place
fractures assoc w AVN
scaphoid, femoral neck, talus
fractures assoc with nonunion
clavicle, 5th metatarsal fracture (Jones’ fracture)
fractures assoc with compartment syndrome
supracondylar humerus, tibia
biggest risk factor for nonunion
smoking
important lower extremity nerves with function
obturator = hip aDduction … superior glutel = hip aBduction …. inferior gluteal = hip extension … femoral = knee extension
number of discs in spine
33 … 7 cervical, 12 thoracic, 5 lumbar, 4 coccygeal
lumbar disc herniation: px
back pain, sciatica
lumbar disc herniation: pathophys
herniated nucleus pulposus
weak hip flexion 2/2 lumbar disc herniation
L3 nerve compression, L2-3 disc
weak knee extension (quadriceps), weak patellar reflex 2/2 lumbar disc herniation
L4 nerve compression, L3-4 disc
weak dorsiflexion (foot drop), decreased sensation in big toe web space 2/2 lumbar disc herniation
L5 nerve compression, L4-5 disc
weak plantar flexion, weak Achilles reflex, decreased sensation in lateral foot 2/2 lumbar disc herniation
S1 nerve compression, L5-S1 disc
lumbar disc herniation: nerve root compression and sx
affects 1 nerve below disc … L3 nerve compression (L2-3 disc) = weak hip flexion … L4 nerve compression )L3-4 disc) = weak knee extension (quadriceps), weak patellar reflex …. L5 nerve compression (L4-5 disc) = weak dorsiflexion (foot drop), decreased sensation in big toe web space … S1 nerve (L5-S1 disc) = weak plantar flexion, weak Achilles reflex, decreased sensation in lateral foot
lumbar disc herniation: dx
MRI for pts with neuro findings
lumbar disc herniation: tx
NSAIDs, heat, rest … surgery - for substantial/progressive neurologic defects, refractory cases, severe sciatica, or disc fragments that have herniated into the cord
terminal branches of the brachial plexus: list
ulnar, median, radial, axillary, musculocutaneous nerves
ulnar nerve: motor, sensory, injury
motor = intrinsic musculature of hand (palmar interossei, palmaris brevis, adductor pollicis, hypothenar eminence), finger abduction (spread fingers), wrist flexion …. sensory = all of the 5th and 1/2 4th fingers, back of the hand …. injury = claw hand
median nerve: motor, sensory, injury
motor = thumb apposition (anterior interosseous mucle, OK sign), finger flexors …. sensory = most of palm and 1st 3 and 1/2 4th fingers on palmar side … injury involved in carpal tunnel syndrome
radial nerve: motor, sensory
motor = wrist extension, finger extension, thumb extension, triceps, NO hand muscles … sensory = 1st 3 and 1/2 4th fingers on dorsal side
axillary nerve: motor
motor to deltoid (abduction)
musculocutaneous nerve: motor
biceps, brachialis, coracobrachialis
nerve injury that results in claw hand
ulnar nerve (motor = intrinsic musculature of hand (palmar interossei, palmaris brevis, adductor pollicis, hypothenar eminence), finger abduction (spread fingers), wrist flexion …. sensory = all of the 5th and 1/2 4th fingers, back of the hand)
nerve involved in carpal tunnel
median nerve (motor = thumb apposition (anterior interosseous mucle, OK sign), finger flexors …. sensory = most of palm and 1st 3 and 1/2 4th fingers on palmar side)
which nerve? - motor = intrinsic musculature of hand (palmar interossei, palmaris brevis, adductor pollicis, hypothenar eminence), finger abduction (spread fingers), wrist flexion …. sensory = all of the 5th and 1/2 4th fingers, back of the hand …. injury = claw hand
ulnar (C8-T1)
which nerve? - motor = thumb apposition (anterior interosseous mucle, OK sign), finger flexors …. sensory = most of palm and 1st 3 and 1/2 4th fingers on palmar side … injury involved in carpal tunnel syndrome
median (C6-T1)
which nerve? - motor = wrist extension, finger extension, thumb extension, triceps, NO hand muscles … sensory = 1st 3 and 1/2 4th fingers on dorsal side
radial (C5-8)
which nerve? - motor to deltoid (abduction)
axillary (C5-6)
which nerve? - motor to biceps, brachialis, coracobrachialis
musculocutaneous (C5-7)
number of cervical nerves and discs
8 nerves, 7 discs
cervical radiculopathy: MC type
C7 nerve, C6-7
cervical radiculopathy: nerve compression that results in neck and scalp pain
C1, 2, 3, 4 (C1-2, 2-3, 3-4 discs)
cervical radiculopathy: nerve compression that results in weak deltoid and biceps, weak biceps reflex
C5 nerve, C4-5 disc
cervical radiculopathy: nerve compression that results in weak deltoid and biceps, weak wrist extensors, weak biceps reflex and bracioradialis reflex
C6 nerve, C5-6 disc
cervical radiculopathy: nerve compression that results in weak triceps, weak triceps reflex
C7 nerve, C6-7 disc, most common type
cervical radiculopathy: nerve compression that results in weak triceps, weak intrinsic muscle of hand, weak wrist flexion, weak triceps reflex
C8 nerve compression, C7-T1 disc …. remember 8 cervical nerves but 7 discs
clavicle fracture tx
usually just sling, risk of vascular impingement
shoulder dislocation types, causes, injure what, and tx
anterior = 90%, risk of axillary nerve injury, tx w closed reduction … posterior = seizures or electrocution, risk of axillary artery injury, tx w closed reduction
acromioclavicular separation tx
sling, risk of brachial plexus and subclavian vessel injury
scapula fracture mgmt
sling unless glenoid fossa involved, then need internal fixation
midshaft humeral fracture tx
sling almost all of them
supracondylar fracture tx
adults —> ORIF … kids nondispaced —> closed reduction … kid displaced —> ORIF
Monteggia fracture - describe, tx
proximal ulnar fracture w radial head dislocation, tx w ORIF
colles fracture - describe, tx
fall on outstretched hand, distal radius, tx w closed reduction
nursemaid’s elbow - describe, tx
subluxation of the radius at the elbow caused by pulling on an extended, pronated arm … tx w closed reduction
mgmt of combined radial and ulnar fracture
adults tx = ORIF … kids tx = closed reduction
scaphoid fracture - describe, tx
snuffbox tenderness, can have negative xray … tx = all patients require cast to elbow, may need fixation, risk of AVN
Volkmann’s contracture - describe, dx, nerve, tx
supracondylar humerus fracture —> occluded anterior interosseous artery —> closed reduction of humerus —> artery opens up —> reperfusion injury, edema, forearm compartment syndrome (flexor compartment most affected) …. sx = forearm pain with passive extension, weakness, tense forearm, hypesthesia … median nerve most affected by swelling … tx w forearm fasciotomies
forearm fasciotomies - what to do
need to open volar and doral compartments
dupuytren’s contracture - assoc with what, describe, tx
assoc w DM, etoh … progressive proliferation of the aplmar fascia of hand results in contractures that usually affect the 4th and 5th digits (cannot extend fingers) … tx w NSAIDs, steroid injections, extension of involved fascia for significant contraction
carpal tunnel syndrome - describe, tx
median nerve compression by transverse carpal ligament … tx = splint, NSAIDs, steroid injections … transverse carpal ligament release if that fails
trigger finger - describe, tx
tenosynovitis of the flexor tendon that catches at the MCP joint when trying to extend finger …. tx = splint, tendon sheath steroid injections (not the tendon itself), if that fails then release the pulley system at the MCP joint
suppurative tenosynovitis - describe, signs, tx
infection that spreads along flexor tendon sheaths of digits (can destroy tendon sheath) … 4 classic signs = tendon sheath tenderness, pain with passive motion, swelling along sheath, semi-flexed posture of the involved digit … tx w midaxial longitudinal incision and drainage
rotator cuff tears - anatomy, mgmt
SITS = supraspinatus, infraspinatus, teres minor, subscapularis … acutely, sling and conservative mgmt … surgical repair if the pts needs to retain a high level of activity or if ADL affected
paronychia - describe, tx
infection under nail bed, painful, tx = abx, remove nail if purulent
felon - describe, tx
infection in the terminal joint space of the finger … tx = incision over the tip of the finger along the medial and lateral aspects to prevent necrosis of the finger tip
MC dislocation: shoulder vs hip
90% anterior shoulder, 90% posterior hip
hip dislocation - types, px, injures what, tx
posterior = 90%, internal rotation and aDduction of leg, risk of sciatic nerve injury, tx w closed reduction … anterior = external rotation and aBduction of leg, risk of injury to femoral artery, tx w closed reduction
tx of isolated anterior ring fracture with minimal ischial displacement
weight-bearing as tolerated
tx of femoral shaft vs femoral neck fracture
shaft = ORIF with intramedullary rod …. neck = ORIF - risk of avascular necrosis if open reduction delayed
lateral knee trauma results in what
injury to anterior cruciate ligament, posterior cruciate ligament, and medial meniscus injuries
ACL injury: physical exam, px, workup, tx
+anterior drawer test … p/w knee effusion and pain with pivoting action … MRI confirms dx … tx = surgery with knee instability (reconstruction with patellar tendon or hamstring tendon) o/w PT with leg-strengthening exercises
PCL injury: physical, occurrence rate, px, tx
+posterior drawer test …. mech less common than ACL injury …. p/w knee pain and joint effusion … tx w conservative therapy initially, surgery for failure of medical mgmt
collateral ligaments in knee: how do you injure them? tx? assoc with what?
medial collateral ligament / MCL - injure 2/2 lateral blow to knee … LCL - medial blow to knee …. tx = brace for small tear, surgery for large tear … injuries assoc with injury to corresponding meniscus
meniscal tear - px, tx
joint line tenderness … can tx w arthroscopic repair or debridement
posterior knee dislocation - workup
need angiogram to r/o popliteal artery injury
patellar fracture mgmt
long leg cast unless comminuted, then need internal fixation
tibial plateau fracture and tib-fib fracture tx
ORIF fixation unless open, then need external fixator unless tissue heals
plantaris muscle rupture - px
pain and mass below popliteal fossa (contracted plantaris) and ankle ecchymosis
ankle fracture mgmt
most reated with cast and immobilization, bimalleaolar or trimalleolar fractures need ORIF
metatarsal fracture mgmt
cast immobilization or brace x6 weeks
calcaneus fracture mgmt
case and immobilization if nondisplaced … ORIF if severe displacement
nerve MC injured with lower extremity fasciotomy
superficial peroneal nerve - foot eversion
footdrop after lithotomy position or after crossing legs for long periods or fibula head fracture
common peroneal nerve (foot-drop)
common vs peroneal nerve injury: px, commonly 2/2 what injuries
common = foot-drop = 2/2 lithotomy position, corssing legs for long periods, fibular head fracture … superficial = foot eversion = 2/2 lower extremity fasciotomy
leg compartments: list
4 = anterior, lateral, deep posterior, superficial posterior
leg compartments: artery, nerve, muscles - anterior compartment
anterior tibial artery … deep peroneal nerve … muscles = anterior tibialis, extensor hallicus longus, extensor digitorum longus, communis
leg compartments: artery, nerve, muscles - lateral compartment
no artery … superficial peroneal nerve … peroneal muscles
leg compartments: artery, nerve, muscles - deep posterior compartment
posterior tibial artery, peroneal artery …. tibial nerve … muscles = flexor hallicus longus, flexor digitorum longus, posterior tibialis
leg compartments: artery, nerve, muscles - superficial posterior compartment
no artery … sural nerve … muscles = gastrocnemius, soleus, plantaris
anterior vs posterior tibial arteries - run in which compartments
anterior artery = anterior compartment … posterior artery = deep posterior compartment
compartment syndrome: pathophys
most likely to occur in anterior compartment of the leg (get footdrop) after vascular compromise, restoration of blood flow, and subsequent reperfusion injury with swelling of the leg compartment … can also occur 2/2 crush injuries
compartment syndrome: px
pain with passive motion, swollen exremity … distal pulses may be present (last thing to go) … P >20-30 mmHg abnormal
compartment syndrome: dx
based on clinical suspicion
compartment syndrome: tx
fasciotomy
pediatric ortho: list common issue
osteomyelitis, idiopathic adolescent scoliosis, osgood-schlatter disease, legg-calve-perthes disease, slipped capital femoral epiphysis (SCFE), congenital hip dislocation, clubfoot
osteomyelitis: describe, sx, dx, tx
can occur in metaphysis of long bones in kids, MC staph … sx = pain, dec use of extremity … dx w MRI, bone bx … tx = I&D, abx
idiopathic adolescent scoliosis: px, mgmt
prepubertal F, R thoracic curve most common, usually a-sx …. 20-45 degree curves need bracing to slow progression, which can occur w growth spurt …. >45 degree curves or those likely to progress need spinal fusion
osgood-schlatter disease: describe, workup, tx
tibial tubercle apophysitis, cause by traction injury from the quad in adolescents aged 13-15, MC have pain in front of the knee … x-ray shows irregular shape or fragmenting of the tibial tubercle … tx = activity limitation for mild sx, cast x6 weeks then activity limitation for severe sx
legg-calve-perthes disease: describe, sx, imaging, tx
AVN of the femoral head, kids 2yo and older, b/l in 10%, can be 2/2 hypercoagulable state …. sx = painful gait limp … xray shows flattening of femoral head … tx = maintain range of motion with limited exercise, femoral head will remodel without sequelae, surgery if femoral head is not covered by the acetabulum
SCFE: describe, imaging, tx
slipped capital femoral epiphysis, M ages 10-13yo, inc risk of AVN to femoral head, painful gait …. xray show widening and irregularity of the epiphyseal plate .. tx w surgical pinning
congenital dislocation of hip: MC in which pts, tx
MC in F, tx w Pavlik harness (keep the legs aBducted and the femoral head reduced in the acetabulum)
clubfoot tx
serial casting
describe 2 causes of femoral head AVN in kids
boht p/w painful gait …. legg-calve-perthes disease = 2yo and older, xray shows flattening of femoral head, tx w ROM exercise, surgery if femoral head not covered by acetabulum ….. vs …. SCFE = M 10-13yo, inc risk of AVN, xray shows widening and irregularity of epiphyseal plate, tx w surgical pinning
bone tumors: MC types
met disease - #1 breast, #2 prostate … MC primary = multiple myeloma
bone tumors: mgmt of mets
internal fixation with impending fracture (>50% of cortical involvement), followed by XRT
bone tumors: multiple myeloma - describe, tx
MC primary bone tumor, tx = chemo for systemic disease, internal fixation for impending fractures
bone tumors: pathologic fractures
tx w internal fixation, XRT can be used for pain relief in pts w painful bony mets
bone tumors: osteogenic sarcoma
MC primary bone sarcoma, usually around the knee, 80% in patients <20yo … xray shows Codman’s triangle (2/2 periosteal reaction) … tx = limb-sparing resection, XRT and doxorubicin-based chemo can be used preop to increase chance of limb sparing resection
bone tumors: list benign bone tumors that are treated with curettage +/- bone graft
osteoid osteoma, endochondroma (may be able to observe), osteochondroma (resection only if cosmetic defect or causing sx), chondropbalstoma, nonossifying fibroma (may be observed) and fibrodysplasia
bone tumors: giant cell tumor of bone - mgmt
total resection +/- XRT (benign but 30% risk of recurrence, also has malignant degeneration risk)
MC cause of lumbar pain in adolescents (gymnasts)
spondylolisthesis
spondylolisthesis - describe, tx
formed by subluxation or slip of one vertebral body over another … MC in lumbar region … MC cause of lumbar pain in adolescents (gymnasts) … tx = depends on degree of subluxation and sx (ranges from conservative tx to surgical fusion)
cervical stenosis mgmt
surgical decompression if significant myelopathy present
lumbar stenosis mgmt
surgical decompression for cases refractory to medical tx
torus fracture - describe
buckling of metaphyseal cortex seen in kids (i.e. distal radius)
open fractures - mgmt
need I&D, abx, fracture stabilization, soft tissue coverage
