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IPAP JUNIOR SEM. > Block 4 Ortho > Flashcards

Block 4 Ortho Flashcards

1
Q

Define Achilles Tendon Tear

A

Disruption of the tendon 5-7 cm proximal to insertion of the tendon on the calcaneus

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2
Q

A pt present with “gun shot pain” at the distal posterior leg

Sudden and severe pain from playing sports

+positive Thompson test

Think ? Tx?

A

Achilles’ tendon tear

Tx:
Cam boot with heel lift until foot reaches neutral

Rehab consult, RICE, Crutches x5-6 days

Operative: if high level athlete/ active duty

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3
Q

When is a Thompson test most reliable for Dx a tendon rupture

A

Within 48 hrs

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4
Q

When is rereputure of the Achilles after Tx most common

A

Re-rupture with non-op management more common

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5
Q

When should all Achilles tears be referred

A

All complete ruptures within 24 hrs.

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6
Q

What are the common injuries for an inversion ankle sprain

A

Inversion injury- ATFL and CFL

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7
Q

What is the common injury in a high ankle sprain

A

High ankle sprain= AITFL

Requires Increased recovery time

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8
Q

What are the long term ADE of Ankle Sprain

A

Chronic instability
Chronic Pain
Development of Ankle OA

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9
Q

What are the two most commonly torn ligaments in an ankle Sprain

A

ATFL and CFL

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10
Q

How do you screen for a fx in an ankle injury

A

Palpate lateral/medial malleoli, base of 5th metatarsal
Pain at the navicular

(Ottawas Criteria)
(+inability to bear wt x 4 steps)

Get an X-ray

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11
Q

Syndesmosis squeeze test evals what tendon tear

A

AITFL (high ankle sprain)

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12
Q

What are the 3 phases of non op treatment of ankle sprains

A
  1. NSAIDs + rest, brace/air stirrup (2-3wks)
  2. ROM + strength (2-4 wks after injury and patient can bear weight without pain)
  3. Proprioception, agility, endurance (4-6 wks after injury)
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13
Q

What is the most important part of rehab in an ankle injury

A

To control inflammation in phase 1!

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14
Q

What is the most common cause of chronic instability in ankle sprains

A

Incomplete rehab

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15
Q

Define bunionette

A

AKA Tailor’s bunion

Deformity of the 5th MTP joint that is analogous to a bunion deformity of the great toe

Characterized by prominence of the lateral aspect of the 5th MT head and medial deviation of small toe

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16
Q

What does a bunionette look like on XR

A

Medial deviation of 5th proximal phalanx

lateral deviation of 5th MT shaft and/or prominence on the lateral aspect of the 5th MT head

Normal joint space

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17
Q

What is the Tx appraoch to Bunionettes

A

Non-operative-
Advised patients to select roomy toe box shoe

Orthotics- modified metatarsal pads, arch support for flatfoot

Operative-
Osteotomy if continued symptoms despite non-operative treatment

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18
Q

A pt presents with skin ulcerations, infections, and Charcot arthropathy

Think?

A

Diabetic Foot

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19
Q

What is the progression of Charcot arthropathy

A

results from repetitive stress in a patient who doesn’t perceive pain and proprioception normally

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20
Q

Autonomic dysfunction in the feet of DM pts leads to what…

A

Autonomic dysfunction- dry, scaly, and cracking skin predisposes to ulceration

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21
Q

What are the ADE of Diabetic Foot

A

Skin Ulcers,
Charcot Joint
Osteomyelitis
Gangrene

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22
Q

How can you Dx Charcot vs Cellulitis

A

Charcot: 1 minute elevation above heart= loses redness

infection stays red despite elevation

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23
Q

A red hot swollen foot with mild or absent pain

Think

A

Charcot Foot

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24
Q

What is the imaging W/u for Diabetic Foot

A

Plain films to help r/o osteomyelitis and Charcot

Vascular studies appropriate- absent pulses or non-healing ulcer

Nuclear medicine to differentiate (tagged WBC)
—cold for Charcot
—hot for osteomyelitis

MRI for osteomyelitis, confirm deep abscess

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25
Q

What is the Tx approach to Diabetic foot

A

Non-operative-
Education and prevention
Serum glucose control

Once neuropathy occurs, its irreversible

Accommodative footwear, orthotics

Total contact casting

Treatment of deep infection

Operative-
Debridement of osteomyelitis
Amputation

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26
Q

Most diabetic feet are painless, so a pt with diabetic foot that presents with pain should prompt…

A

Referral!

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27
Q

Define Hallux Rigidus

A

Degenerative OA of the 1st MTP

Most common arthritis of the foot
-Second most common foot malady

Principle symptoms are pain and stiffness, especially with toe dorsiflexion

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28
Q

A pt presents with stiff 1st toe with loss of decreased extension at the 1st MTP

Think ?
Tx?

A

Hallux Rigidus
Rads will show osteophytes

Tx: Non-operative-

  • Wearing shoe with soft, roomy toe box
  • Stiff soled shoe modified with steel shank or rocker bottom limits dorsiflexion of the great toe and decreases pain
  • Avoid wearing high-heeled shoes
  • NSAIDS, contrast baths

Operative-
-Dorsal osteophyte excision w/ Cheilectomy

-Arthrodesis

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29
Q

Define Hallux Valgus

A

Aka Bunion
-Most common malady of the great toe

  • Lateral deviation of great toe at 1st
  • MTP may lead to painful prominence pf the medial aspect of 1st MT head

10x more common in women

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30
Q

What are the NML valgus angles in Hallux Valgus

A

Hallux valgus angle (HVA)
normal = less than 15 degrees

Intermetatarsal angle (IMA) 
normal = less than 10 degrees
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31
Q

What is the Tx approach to Hallux Valgus

A

Non-operative-
No treatment is needed for asymptomatic hallux valgus

Education and shoe wear
modifications

Roomy toe box
Avoid high heels

Operative-
Osteotomy

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32
Q

Persistent pain despite shoe modifications should prompt

A

referral

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33
Q

Describe Interdigital neuroma

A

AKA Morton Neuroma

Due to Tight shoes

Not a true neuroma, but a perineural fibrosis of common digital nerve as it passes between metatarsal heads

Most common is between 3rd and 4th toes (3rd web space)

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34
Q

A pt states it feels like they are walking on a marble or a wrinkle sensation in their sock when walking
On the plantar side of their foot

With toe numbness adjacent to the involved web space

+plantar forefoot pain
+metatarsal head compression Test

Think ?
Tx?

A

Interdigital neuroma

Tx:
Non-operative-
-Low-heeled, well-cushioned shoe with a wide toe box
-Metatarsal/Decompression pad
-Steroid Injection (diagnostic and therapeutic)

Operative-
-Neuroma excision or plantar nerve release

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35
Q

Define metatarsalgia

A

Forefoot pain localized under one or more of the lesser metatarsals

Lesser MT heads (2-5)

Causes

  • Abnormal MT length
  • Toe deformities- claw toe, hammer toe
  • Metatarsal fat pad atrophy
  • Callus formation
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36
Q

A pt presents with activity related pain to the plantar aspect of the forefoot with TTP over the Metatarasal heads

States it feels like walking on pebbles

Think?
Dx?
Tx?

A

Metatarsalgia

Dx: WB Ap/Lat Rads 
Tx: 
Non-operative-
-Accommodative, roomy toe box shoes
-Metatarsal pad, orthotic device
-Pare thickened callus

Operative-

  • Toe/MT head realignment
  • Remove condyle (condylectomy)
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37
Q

Describe plantar fasciitis

A

Inflammation of the PF

PF- arises from medial tuberosity of the calcaneus and extends to the proximal phalanges of the toes

Provides support to the foot

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38
Q

What is the most common heel pain in adults

A

Plantar fasciitis followed by tendinosos

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39
Q

A pt presents with focal pain over the medial calcanea tuberosity
And distal along the fascia

Most intense during the first steps of the morning

+TTP at plantar calcaneus
+/- Achilles’ tendon tightness

Think?
Dx?
Tx?

A

Plantar fasciitis

Dx:
Rads may show a calcaneal heal spur,
Order rads before steroid injection

Tx: 
Non-operative (95% effective)-
-Orthotic + stretching
-Night splint
Steroid injection
-Shock wave therapy/Botox

Rehab consult- control pain and increase ROM

Resolves 6-12 months

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40
Q

Describe Plantar warts

A

Hyperkeratotic lesions on sole of foot

Common from Human papilloma virus

Common in Young athletes, 2nd decade of life

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41
Q

When should you order Rads in plantar fasciitis

A

Should be obtained before steroid injection (lateral)

Symptoms after 6-8 weeks of non-operative treatment

Systemic symptoms or pain at rest

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42
Q

What is the Tx approach to plantar warts

A

Non-operative-
-Most lesions resolve spontaneously in 5-6 months
-Superficial paring then keratolytic (salicylic acid) with occlusion
—Two times a day for 1 month

-Electrocautery, cryotherapy with liquid nitrogen, laser ablation, curettage for resistant warts

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43
Q

describe posterior tibial tendon dysfunction

A

Posterior tibial tendon- one of the main supporting structures of the medial ankle and arch

Primary cause of medial ankle pain in middle-aged patient

Classic presentation- overweight female older than 55 years old

Tendon dysfunction results in flatfoot

Other risk factors include flexible flatfoot, steroid injections, DM, HTN, previous trauma

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44
Q

What is the primary cause of medial ankle pain in the middle aged pt

A

Posterior tibial tendon dysfunction

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45
Q

A pt presents with pain and swelling of the medial ankle, with loss of foot arch with a “rolling in “ of the ankle

Think ?
Tx?

A

Posterior Tibial tendon Dysfunction

Tx: 
Non-operative-
NSAIDs and activity limitations
-4 weeks short leg cast/cast brace
NOT steroid!

-Orthotic with medial longitudinal arch support

Operative-

  • Flexible = tendon transfer + osteotomy
  • Rigid = arthrodesis
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46
Q

What are the long term ADE of Post. Tib. Tendon dys.

A

Progressive, painful flatfoot with gait disturbance

Valgus ankle with possible OA

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47
Q

What are the prominent risk factors for post. Tibial, tendon dysfunction

A

Obesity, female, age over 55,

DM, HTN, steroid injections, Flatfoot, previous trauma

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48
Q

what does pes planus mean

A

Flatfoot

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49
Q

Describe sesamoiditis

A

Embedded in the flexor hallucis brevis tendon beneath first MT head (plantar surface)

Disorders include inflammation, fracture, osteonecrosis, and OA

Occurs due to repeated stress and the subsequent inflammation

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50
Q

A pt presents with pain UNDER teh 1st MT head of the foot
+/-swelling

Pt is a long distance runner or dancer

Think?
Tx?

A

Sesmoiditis of the 1st MT head

Tx: 
Non-operative-
-Avoid wearing high-heeled shoes
-Sesamoid/decompression pad
-Stiff-soled/rocker bottom shoe

Operative-
Sesamoid excision

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51
Q

What are the sesamoid s of the 1st mt imbedded in

A

Flexor Hallucis brevis tendon sheath

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52
Q

What are the three main types of toe deformities

A

Claw toe, Hammer toe, Mallet toe

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53
Q

A toe deformity with fixed extension at the MTP, and flexible flexion at the PIP with flexion at the DIP

Think. ?

A

Claw toe

Most common in Charcot Marie Tooth
Or RA

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54
Q

A toe deformity with Flexible extension at the MTP with Fixed flexion at the PIP

Think ?

A

hammer Toe

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55
Q

A toe deformity with Fixed flexion at the DIP

Think

A

Mallet toe

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56
Q

What is the Physical Exam approach to Toe deformities

A

Evaluate standing and sitting

Note alignment, joint ROM (fixed v flexible)

Neurovascular exam (sensory/motor function)

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57
Q

What is the Tx appraoch to Toe deformities

A

Non-operative-

  • Soft, roomy toe box shoe
  • Avoid 2 ¼” heels
  • Decompression pads for corns
  • Toe splints

Rehab consult- Toe strength and flexibility

Operative-
-Proper toe alignment to accommodate for shoe wear (not cosmetic)

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58
Q

A pt presents with a claw toe + high arch

Think what condition should you r/o

A

Neurogenic cause, think Charcot Marie Tooth

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59
Q

What is turf toe

A

1st MTP sprain following hyperextension but can occur with any force ROM

Artificial turf on playing fields

Account for more missed playing time than ankle sprains

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60
Q

A pt presents with swelling, tenderness, and limited ROM of the 1st MTP
From playing sports on improved fields

Think ?
Tx?

A

Turf Toe

Graded:
1= stretch injury or capsule, continue playing with mild symptoms
2= partial plantar tear
3= complete tear, can’t play or walk normally

Tx:
Non-operative-
-RICE
-Early ROM when symptoms allow
-Stiff soled/rocker bottom shoe (Grade 1 & 2)

Grade 3=
Protected weight bearing or immobilization x 1-2 weeks
-4-6 weeks no play

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61
Q

What are the ADE of Dz for turf toe

A

OA, Hallux Rigidus

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62
Q

Define os trigonum

A

Accessory ossicle of the posterior talus that usually is a normal anatomic variant

Causes boney ankle impingement

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63
Q

A pt presents with pain on plantar flexion between the tibia and the talus

Think

A

Os trigonium

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64
Q

A pt presents with Tenderness, swelling at medial aspect of the navicular (insertion of tibialis posterior)

Think

A

Accessory navicular

+/- pes planus

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65
Q

What is the best view to see os trigonum

A

Lateral view

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66
Q

What is the best view to see accessory navicular

A

Ap is the best view

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67
Q

Describe Calcaneal apophysits

A

Aka Sever disease

Affects active, prepubertal children

Pain posterior aspect of heel that occurs after activity

Typically will resolve once fusion occurs (9-year-old girls or 11-year-old boys)

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68
Q

What is the NML age for calcaneal epiphysis closure

A

(9-year-old girls or 11-year-old boys)

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69
Q

What is the Tx approach to calcaneal apophysitis

A

Non-operative-
-Short term activity modification
¼ in heel lifts/cushion

-Rarely casting, but can be used for 4-6 weeks if pain and limp do not improve with activity modifications, heel lifts.

Operative-
-Almost never surgery

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70
Q

Define pes cavus

A

abnormally high arch resulting from plantar flexion (equinus) of the forefoot or midfoot in relation to the hindfoot

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71
Q

A pt comes in with frequent ankle stairs, lots of callous on the foot with a high ankle arch

Think?
Tx

A

Cavus deformity

Non-operative-
Based on the underlying disorder

Mild & flexible deformities- shoe modifications, arch supports, rehabilitation

Operative-
Most will need – will likely recur due to neuromuscular disease

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72
Q

Define Clubfoot

A

Congential clubfoot or talipes equinovarus

Characterized by four clinical components
CAVE- 
-midfoot Cavus (high arch)
-forefoot Adduction
-heel Varus (adduction of calcaneus)
-ankle Equinus (plantar flexion)
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73
Q

What is the W/u for pes clavus

A

WB ap/lat foot or the meary angle

74
Q

What is the Tx for CLub foot ?

A

Non-operative-
Ponseti method
(treatment of choice) = serial casting + Achilles release

After casting- Foot abduction brace full time for 3 months then at night for 3 years

Operative-
Most older and those with persistent or recurrent deformities

Soft-tissue release, osteotomies, arthrodesis

Adverse outcomes of treatment-
Recurrence

75
Q

Define flatfoot

A

Abnormally low or absent loss in the ankle or foot

Most kids is a normal variant

76
Q

When deos the foot arch develop and mature

A

Arch develops at age 4 and develops to age 10

77
Q

What is the MC type of flat foot

A

Flexible is most common

Flat foot means its congenital, tarsal coalition, or vertical talus, NMD, or inflammatory dz like RA

78
Q

What type of flat foot is seen in obesity

A

Idiopathic rigid flat foot

79
Q

A pt presents with loss of arch on WB, with valgus alignment of the hind fort with a medial mall prominence
With abduction of the forefoot

Think

A

Flat form classic findings (may look like a posterior tendon dysfunction without too many toes sign)

80
Q

What is the special test to assess flatfoot

A

Jack test to assess arch formation

81
Q

What is the Tx appraoch to Flatfoot

A

If young just observe to age 10

Can use inserts in the shoe

If Rigid, evaluate for other etiology then SRGRY

If untreated may lead to Achilles’ tendon contracture

82
Q

define metatarsus adductus

A

Most common foot deformity in infancy characterized by medial deviation of the forefoot

Most often due to intrauterine positioning

83
Q

A newborn presents with adduction of the forefoot relative to the hind foot with a convex lateral foot border

Think

A

Metatarsus adductus

Graded on the heel bisector line

84
Q

Bisector line of the heel that goes through the middle toe

What severerty metatarsus adductus

A

Middle for mild

85
Q

A Bisector line of the heel goes through between the 3rd and 4th toe

Think what level severity metatarsus adductus ?

A

Moderate

86
Q

Define severe metatarsus adductus

A

A bisector heel line that goes through the last toe or between the last two toes

87
Q

how do you track the progression of metatarsus adductus

A

Photocopy machine

88
Q

When should you get radiographs for metatarsus adductus

A

Radiographs rarely needed but indicated when deformity cannot be passively corrected or fails non-operative treatment

89
Q

What are the treatment options for metatarsus adductus

A

Most newborns do not require active treatment due to spontaneous resolution (flexible)

Rigid
casting v surgery (very few cases)

90
Q

A pt with metatarsus adductus that persist for 3-6 months

What is the approach

A

Referral, and also for rigid

91
Q

Define Osteochondral Lesions of the talus

A

Osteochondral lesions of the hyaline cartilage and underlying subchondral bone of the WB surface of the talus can occur after trauma or due to idiopathic avascularity

Cause collapse of the joint surface, delamination of cartilage, loos fragment formation

92
Q

A pt presents with ankle pain, recurrent effusions in the ankle joint space

With a sensation of popping, catching, or giving away of the ankle
With anterior joint line pain
With painful ROM in every direction

and started to occur acutely after injury or intermittently with vigorous activity over weeks to months

Neg ligamentous stress tests

Think ? Tx?

A

Osteeochondral lesion of the talus

Order a mortise view of the ankle

Non-operative-
Skeletally immature
- Capacity to heal and only require immobilization

Operative-
Older, adolescent approaching skeletal maturity= surgery

Refer all

93
Q

define Tarsal coalition

A

Abnormal connection between two tarsal bones (fibrous, cartilaginous, osseous)

Most commonly- Calcaneus and navicular or Talus and calcaneus

More than one coalition is rare

94
Q

What are the most common tarsal coalitions

A

Most commonly

- Calcaneus and navicular or Talus and calcaneus

95
Q

A pt presents in late childhood or teen years with onset of insidious pain associated with activity/ injury

Has frequent ankle sprains and a limp

+rigid flat foot
+hindoot motion is markedly restricted
(Decreased inversion and eversion)

Think ?
Tx?

A

Tarsal coalition

Order a Harris Heel view
Ap/lat/oblique
Ct more helpful than mri

Tx:
Observation- asymptomatic or have minimal symptoms

Short leg cast immobilization- severe symptoms or for milder symptoms that persist
(4-6 weeks in cast)

Resection of the coalition- persistent symptoms that do not respond to non-surgical treatment

Arthrodesis- no response to resection or not candidates for resection due to size

96
Q

Define toe walking

A

Habitual toe walking

Idiopathic = otherwise healthy and no neurologic problems

Normal variation when they begin to walk

Persistent or toe walking that develops after child has been walking with feet flat can indicated underlying disease process

97
Q

Toe walking is typically benign

When is it not

A

Persistent beyond young age

Or acute onset

Look for Abnormal physical exam

Persistent toe walking despite stretching and rehab

Tight Achilles- may need heel cord lengthening

Unilateral- not normal

Other mental or developmental concerns

98
Q

What are the tx options for Toe walking

A

Depends on age of child and severity of the problem

Non-operative-
Occasional or toddler just beginning to walk =observation (resolves 3-6 months)

Serial casting

Especially if Achilles tendon contracture

99
Q

Where is the direction of a dislocation determined by

A

Direction of dislocation is described based on the distal (mobile) fragment

100
Q

Define a segmental fractures

A

3 distinct pieces of fracture

101
Q

Discribe the difference between butterfly and segmental Fx

A

Both are comminuted Fxs

Butterfly has an angular butterfly segment

Segmental has three distinct pieces

102
Q

How do you describe angular malalignment in fx

A

In relation to the apex (where does the arrow point)

103
Q

A fx through only the growth Plate is what type of fracture

A

Salter Harris 1

104
Q

Describe Salter Harris 2

A
105
Q

What does OTL RADS mean

A 
Open/ Closed 
Type (simple, comminuted ect) 
Location 
Rotation 
Angulation 
Displacement 
Shortening
106
Q

Outline salter Harris Type 1-6

A
107
Q

What are the ADE of growth plates (Fx)

A

Premature growth arrest leading to limb length discrepancy or angular deformity

Physeal bars

108
Q

When should you order CT for (fx)

A

When the fx is in a joint line

109
Q

What are the tx options for growth plate fx

A

Goals: anatomic reduction, maintenance of reduction, avoid growth arrest

Most fractures heal rapidly (4-6 weeks)

S-H 1 & 2-
Injury less than 7 days old= closed reduction and cast immobilization

Displaced and older than 7 days= refer (risk of growth plate reinjury causing arrest
Follow-up at one year (skeletally immature)

Operative-
S-H 3 & 4 (articular)- Open reduction internal fixation

110
Q

What should you suspect in all high energy trauma

A

Cervical Spine Fracture

111
Q

What must be done before you can ‘clear’ a pt

A

No clearance until you have examined a coherent patient

Most missed spinal injuries occur in patients who are obtunded, unconscious, and/or intoxicated

112
Q

What is a physical exam for cervical spine

A

Inspect for swelling, contusions

Step-off or gap = unstable

Neurologic exam 
—Upper and lower extremities
—perianal sensation
—sphincter tone 
—bulbocavernosus reflex
113
Q

What are the imaging for cervical spine fx

A

Initial X-ray
(cross table lateral view)
(Odontoid, or swimmers)

CT is mainstay!

MRI for radicular or ligamentous injury

114
Q

What is the Tx approach to cervical spine injury

A

Non-operative-
Trauma =
—immobilization until cleared
—C-collar and spine board

Normal rads but pain persists
-C-collar for 7-10 days then follow-up imaging

Operative-
Unstable patterns
-Soft tissue OR fracture

115
Q

What are the likely high energy thoracic spine fx

A

MVA, fall from height

Flexion-distraction = unstable and associated with abdominal injury

116
Q

A finding of hematoma +step off/gap in the thoracic spin indicates

A

Unstable flex/ distraction fx or burst fx

117
Q

What is often the initial modality of choice to image a thoracic or lumbar fx

A

Often CT in the ER

118
Q

What is the Tx approach to Thoracic or lumbar spine Fx

A

restoring normal function

Compression-
Less than 20 degrees of wedging and no posterior involvement
—brace 8-10 weeks

Treat osteoporosis

Operative-
Unstable burst fractures, flexion-distraction, fracture-dislocations

119
Q

What is the gen appraoch for any type of fracture

A

Before you do ANYTHING do a neurovascular exam distally

Always get x rays

Be kind, anesthetize

Make it anatomic= “reduce”

Repeat the neurovascular exam

Repeat x rays

120
Q

What are the ADE of Fx at the joint

A

Secondary Osteoarthritis

121
Q

What are the ADE of Fx at the proximal humerus

A

Osteonecrosis

Also in femoral head

122
Q

When should you always get a CT for a Fx

A

Always at a joint

123
Q

Define high e energy vs low energy lower extremity Fx

A

Low energy usually stable

high energy poly trauma usually unstable

124
Q

What are the ADE of LE (Fx)

A

At a Joint = Secondary Osteoarthritis

Proximal femur= Osteonecrosis of the femoral head

Joint instability

125
Q

What is the approach to Fractures

A

Always 1st do a neuro vasc exam

Then get X-rays

Sedation then reduction

Then post reduction neuro vasc exam

Then repeat X-ray + CT

126
Q

What nerve should be checked in a pos hip dislocation

A

Sciatic nerve

127
Q

What nerve should be checked in an ant hip dislocation

A

femoral nerve

128
Q

What nerve should be checked in all knee injuries

A

Tibial nerve

129
Q

What special imaging should be ordered for pelvic ring fx

A

Inlet and outlet views

130
Q

Special imaging for mid foot fx

A

Midfoot fracture/dislocations- bilateral weight bearing

131
Q

Special imaging for a ankle injury

A

Ankle- Mortise view

132
Q

Special imaging for a calcaneus fx

A

Calcaneus- Harris heel view

133
Q

Special imaging for a great toe sesamoid fx

A

Great toe sesamoids- Sesamoid view

134
Q

Should you order a frog lateral view for a hip Fx

A

NO! Will cause displacement

135
Q

Every fx at the acetabulum should get what imaging

A

CT

136
Q

When should you order a MRI for a lower leg injury

A

MRI can be used on non displaced knee fractures to eval soft tissue concern

137
Q

When would you likely see changed on plain films, bone scan, or MRI for a Fx

A

plain Film : 2-4 wks
Bone scan: 24-28 hrs
MRI: 72 hrs

138
Q

WHen is non operative tx appropriate for Lower Exteremit Fx

A

Stable, non-displaced

-Stress fractures non-weight bearing for 6 weeks

Stable, minimally displaced
-Pelvis weight bearing as tolerated for 4-6 weeks

Incomplete (torus or greenstick)

139
Q

What is the major ADE of lower extremity FX

A

DVT!

140
Q

Describe Posterior Vs anterior Dislocation of the hip

A

High energy MVA is most common

Fall from great ht

Posterior-
Affected limb is short, flexed, aDducted and internally rotated

Anterior-
flexed, aBducted and externally rotated

141
Q

What is the Tx appraoch to Dislocation of the Hip

A

Emergency!

Reduction immediately
(+/- sedation PRN)

If no assoc fx then wt bearing as tolerated and f/u with pt

If there is a fx or neurovasc comp. Then operative for —Associated acetabulum fracture
Or Intraarticular bony fragments (arthroscopically)

142
Q

What are the ADE of Hip Dislocation

A

Adverse outcomes of treatment-
—Cartilage damage or fracture during reduction
—Osteonecrosis of the femoral head (even despite rapid reduction)

143
Q

Define femoral shaft fx and treatment

A

2/2 High-energy trauma-MVA

Associated with life-threatening pulmonary, intra-abdominal, and head injuries

Non-operative-
Immediate, temporary splinting for comfort and stabilization prior to surgical intervention

Operative-
Skeletal traction- pins in distal femur or proximal tibia
Usually always- Surgery

144
Q

Define Pelvis Fx

A

Include pelvic ring and acetabulum

  • Stable/low energy-Older patients
  • Unstable/high energy-Massive blood loss leads to hemodynamic instability which causes death
145
Q

What is the physical exam approach to Pelvis fractures

A

Neurovascular exam-Spinal nerve roots

Gentle pelvic compression

Blood in the perineal area= urology consult prior to foley placement!!
—Blood coming out of the urethral meatus
—Blood coming out of the anus

146
Q

What are the ADE of pelvis Fx

A

GU injury- pain/sexual dysfunction

Thromboembolism

Permanent neurological injuries

147
Q

What are the Tx approaches to pelvis Fx

A

Non-operative-
Stable/low energy- Analgesics, rest, protected weight bearing
(6 weeks)

Operative-
Unstable/high energy-
Hemodynamic stability then definitive surgical treatment

148
Q

Define proximal femur fx

A

Risk factors- white women, older than 50 years old, sedentary, smoking, alcoholism, psychotropic use, dementia, osteoporosis, living in urban area

Involve either the femoral neck or intertrochanteric region

1 year mortality = 10-30%

149
Q

What are the PE findings of a proximal femur Fx

A

Short, Ext Rotated, aBducted leg

With pin in the hip area

Unable to perform a straight leg raise

150
Q

What are the two areas that are involved in a proximal femur fx

A

Femoral neck or the pertorchanteric line

151
Q

What are the Tx approaches to Proximal femur Fx

A

Non-operative-
Non-ambulatory and/or have dementia with minimal pain associated with transfers

Operative-
Most treated surgically
Urgent surgical fixation within 48 hrs- increased mortality after 48 hrs

152
Q

What is the time frame for repair a proximal femur Fx

A

48 HRS!

Increased mortality after 48 hrs

153
Q

Define Stress Fx of the femoral neck

A

Tension- superior side, older, complete and then displace
(older pts more likely to displace)

Compression- young, active (military)
On the inferior side of the femoral neck

154
Q

What is the most sensitive imaging for a stress fx of the femoral neck

A

MRI

Sensitive for stress fractures and to differentiate tension vs compression

155
Q

What is the Tx approach to stress fractures of the femoral neck

A

Non-operative- Compression sided
—Cessation of activity with crutches, no weight bearing until fracture healed (6-8 weeks)

Operative- Tension sided whether displaced or nondisplaced
—High tendency to displace
Internal fixation

156
Q

Define fractures around the knesss

A

Can either be

Distal femur- supracondylar or intra-articular or periprosthetic (knee replacement)

Tibial plateau- usually valgus force that impacts less dense lateral tibial plateau

157
Q

What is the imaging approach to fractures of the knee

A

Radiographs- AP/lateral of the knee

CT- further assess fracture configuration and displacement of the joint surface

MRI- helps identify nondisplaced fracture and for concomitant meniscal/ligamentous injury

CT Angiography- if ABI less than 0.9

158
Q

When should you order a CT Angiography of knee Fx

A

When the ABI is less than 0.9

159
Q

What is the Tx approach to Fractures of the knee

A

Nonoperative

  • Nondisplaced or minimally displaced fractures
  • Partial weight bearing with crutches (6 weeks)

Operative

  • Displaced fractures
  • Open reduction internal fixation (ORIF)
  • Open fractures
  • Vascular injuries
160
Q

Define a stress Fx

A

Hairline/microscopic break in bone

Risk factors- overtraining, incorrect biomechanics, fatigue, hormonal imbalance, poor nutrition, vit D deficiency, osteoporosis

Anterior- tension side

Posterior medial- compression side

161
Q

What is the imaging work up for a stress fx

A

Radiographs- Stress fractures not visible until 3 weeks or longer after injury

Bone scan- increased uptake a the location of the stress fracture

MRI- can confirm but false-negative results can occur

162
Q

What is the tx approach to stress fx

A

Non-operative

  • Mild- Activity modifications
  • Pain with walking- Cast immobilization and limited weight bearing
  • Resume normal activities once pain has resolved

Operative
-Anterior tibial stress fracture may require surgical treatment

163
Q

What are the Tx options for pediatric femur Fx

A

Non-operative-
6 months to 5 years old= casting for non-displaced femoral neck, intertrochanteric, and shaft fractures

Operative-

  • Displaced femoral neck and trochanteric
  • Older than 6 years old
  • Distal femur
164
Q

What is the approach to pediatric Tibia

A

Conduct a NeuroVasc exam to assess compartment syndrome

CT at the joint

165
Q

Describe a Lis-Franc Fx

A

Lisfranc fracture-dislocation
Disruption of the tarsometatarsal joints

Critical injury is the 2nd tarsometatarsal joint

166
Q

What are the imaging for Lis Fanc Fx

A

Bilateral weight bearing
Widening between middle cuneiform and second metatarsal

Avulsion fracture

—CT or MRI if radiographs inconclusive

167
Q

What is Tx for a lis Franc Fx

A

Non-operative-
Non-displaced fractures
-6-8 weeks NWB in cast
-Rigid arch supports x 3 months after casting

Operative-
Displaced
-Open reduction internal fixation vs arthrodesis

168
Q

Define Ankle Fx

A

Injuries to lateral malleolus, medial malleolus, posterior malleolus, collateral ligaments, and/or talar dome

Stable v unstable

1 side vs. both sides of joint

-Maisonneuve- medial malleolus (deltoid ligament and syndesmosis) + proximal fibula fracture

169
Q

A fr to the medial mal, with a tear at the deltoid ligament, and the syndesmosis, + a proximal fibula fracture is called

A

maisonneuve Fx

170
Q

What is the imaging and tx for ankle Fx

A

XRay:
Ankle- AP, lateral and mortise
-Proximal tibia/fibula- for Maisonneuve fracture

Tx:
Stable distal fibula- WB cast for 4-6 weeks

Unstable but nondisplaced-NWB cast

Unstable and displaced-ORIF

171
Q

Describe Fxs to the calcaneus and talus

A 
Severe trauma (MVA, fall from height)
One or the other (seldom both)

Most are intra-articular

Calcaneus and spine fractures
Associated with compression fractures
(review spine compression fx)

172
Q

What is the tx option for calcaneus or talus fx

A

Splint then elevate then send to ortho with surgery

173
Q

What is the tx appraoch to metatarsal fxs

A

Most heal with nonsurgical treatment

Except proximal 5th MT Zone 2 (Jones Fracture)
-Acute zone 2= Non-weight bearing in a cast x 6-8 weeks

Zone 3- Stress fracture (nonunion or delayed union)
-operative

more than 4mm displacement or more than 10 deg angulation= formal closed or open reduction

174
Q

What is the Tx appraoch to zone 2 metatarsal fxs

A

Acute zone 2= Non-weight bearing in a cast x 6-8 weeks

175
Q

What are the referral criteria for metatarsal Fxs

A

Compartment syndrome
Multiple MT fractures
5th MT zones 2 and 3
Open fractures

176
Q

What is the Tx approach to Fxs of the phalanges

A

Non-operative-
-Buddy taping to adjacent toe
(padding between to avoid maceration)

Rotational deformity or angulation= reduction

Operative-

  • Great toe MTP intra-articular fractures
  • Open reduction and pinning
177
Q

Define sesamoid Fx

A

1st MTP joint-2 sesamoids

Surrounded by flexor hallucis brevis

Bipartite sesamoids normal variant

Fx Most common to medial

178
Q

What is the imaging approach to a sesamoid fx

A

AP, lateral, axial foot

Bone scan or MRI

  • Cold bone scan = bipartite
  • MRI= bone marrow edema
179
Q

What is the tx appraoch to a Sesmoid Fx

A

Non-operative-
Weight bearing as tolerated in boot/stiff- soled shoe x 4 weeks, then stiff-soled shoe with high toe box

-Then MT pad for up to 6 months after fracture clinically healed

Operative-
-Fracture with plantar plate rupture

Adverse outcomes of treatment-
-Hallux rigidus due to extended healing time

180
Q

Define Stress Fx of the Foot/ Ankle

A

Insufficiency or March fracture

Increase in activity, repetitive overloading

Young women at risk due to Female athlete triad-

  • Amenorrhea
  • Osteopenia
  • Disordered eating

Most common is 2nd MT

181
Q

What is the Tx approach to stress Fx of the foot and ankle

A

Non-operative-
-Most MT stress fractures- Weight bearing as tolerated CAM boot x 4 weeks

Calcaneus or fibula = Weight bearing as tolerated cast x 2-4 weeks

Navicular or 5th MT= Non-weight bearing cast x 4 weeks

Operative-
5th MT stress fracture

IPAP JUNIOR SEM. (43 decks)

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