Chapter 2 - Orthopedics (Part 1) Flashcards
Presentation of developmental dysplasia of the hip?
Family history
Uneven gluteal folds
Physical exam shows that hips can be easily dislocated posteriorly with a jerk and a “click” and returned to normal with a “snap”
If H&P are equivocal in the setting of suspected developmental dysplasia, what should be done?
Sonogram is diagnostic.
Why are x-rays useless in assessing developmental dysplasia of the hip?
The hip is not calcified in the newborn
Treatment of developmental dysplasia?
Abduction splinting with Pavlik harness for ~6 months
Hip pathology in children may present with hip pain or with ___ pain.
Knee
What is Legg-Calve-Perthes disease?
Avascular necrosis of the capital femoral epiphysis
Presentation of Legg-Calve-Perthes disease?
Occurs around age 6
Insidious development of limping, decreased hip motion, and hip/knee pain
Antalgic gait
Passive motion of hte hip is guarded
Dx Legg-Calve-Perthes disease?
AP and lateral hip X-rays
Rx Legg-Calve-Perthes disease?
Controversial; usually containing the femoral head within the acetabulum by casting and crutches
Presentation of slipped capital femoral epiphysis?
Typically a chubby or lanky boy around age 13
Groin or knee pain, noted to be limping
When they sit with the legs dangling, the sole of the foot on the affected side points toward the other foot
Limited hip motion
As the hip is flexed, the thigh goes into external rotation and cannot be rotated internally
Dx slipped capital femoral epiphysis?
X-rays
Rx slipped capital femoral epiphysis?
Orthopedic emergency
Pin the femoral head back into place
Presentation of septic hip in a child?
Little toddlers who have had a febrile illness and then refuse to move the hip
Hold the leg with the hip flexed in slight abduction and external rotation
Do not let anybody try to move it passively
Elevated ESR
Dx septic hip?
Aspiration of the hip under general anesthesia, further open drainage if pus is obtained
Presentation of acute hematogenous osteomyelitis in children?
Little kids who have had a febrile illness
Severe localized pain in a bone and no history of trauma to that bone
Dx acute hematogenous osteomyelitis?
MRI
X-rays will not show anything for a few weeks
Rx acute hematogenous osteomyelitis?
ABX
Genu varum (bowlegs) is normal up to age ___. Genu valgus (knock-knee) is normal betwen ages ___.
3; 4-8
Persistent varus beyond age is 3 is most commonly Blount disease - what is this?
Disturbance of the medial proximal tibial growth plate
What is Osgood-Schlatter disease?
Osteochondrosis of the tibial tubercle
Presentation of Osgood-Schlatter?
Teenagers
Persistent localized pain right over the tibial tubercle, aggravated by contraction of the quads
No knee swelling
Management of Osgood-Schlatter?
First responders use conservative management (rest, ic, compression, elevation)
If unsuccessful, refer to an orthopedic surgeon, who at most would use an extension or cylinder cast for 4-6 weeks
How does club foot (talipes equinovarus) appear?
Seen at birth
Both feet are turned inward with plantar flexion of the ankle, inversion of the foot, adduction of the forefoot, and internal rotation of the tibia
Management of club foot?
Serial plaster casts started in the neonatal period provide sequential correction starting with the adducted forefoot, then the hindfoot varus, and last the equinus
Often Achilles tenotomy and part-time, long-term use of braces are added
Those with club foot who do not respond to casting require surgery, typically done between what ages?
9 and 12 months
Scoliosis is seen primarily in what patient population and why?
Adolescent girls, whose thoracic spines are curved toward the right
Most sensitive screening finding for scoliosis?
Observe from behind while the patient bends forward - a hump will be noted over the right thorax
What is the natural history of scoliosis in a young woman?
Deformity progresses until skeletal maturity is reached (80% complete at the onset of menses)
Management of scoliosis?
Bracing to arrest progression
Surgery in severe cases
Degrees of angulation that would be unacceptable in the adult may be okay in children with fractures - why?
Remodeling occurs to an astonishing degree, healing process is much faster
In which areas do children have special problems with remodeling of fractures?
Supracondylar fractures of the humerus
Fractures of any bone that involve the growth plate
Cause of supracondylar fractures of the humerus in children?
Hyperextension of the elbow in a child who falls on the hand, wtih the arm extended
Complications of supracondylar fractures of the humerus in children?
Vascular or nerve injuries can easily occur
Could lead to Volkmann contracture
Management of supracondylar fractures of the humerus in chidlren?
Treat with the appropriate casting/traction (seldom need surgery)
Carefully monitor vascular and nerve integrity; monitor for compartment syndrome
Management of fractures that involve the growth plate in children?
Closed reduction if the eiphyses and growth plate are displaced laterally from the metaphysis but are in one piece (i.e., the fracture does not cross the epiphyses or growth plate and does not involve the joint)
If the growth plate is in 2 pieces, the very precise alignment provided by open reduction and internal fixation will be required. Otherwise, growth will occur unevenly, resulting in deformity of the extremity.
Presentation of primary malignant bone tumors?
Young people
Persistent low-grade pain, present for several months
Dx primary malignant bone tumors?
X-ray - invasion of the adjacent soft tissues, a “sunburst” pattern, periosteal “onion skinning”
What is the most common primary malignant bone tumor?
Osteogenic sarcoma
Osteogenic sarcoma is seen in ages ___, usually around the ___. A typical ___ pattern is seen on x-rays.
10-25; knee (lower femor or upper tibia); sunburst
What is the second most common primary malignant bone tumor?
Ewing sarcoma
Ewing sarcoma affects children ages ___ and it grows in the ___ (location). A typical ___ pattern is seen on X-rays.
5-15; diaphyses of long bones; onion skinning
Most malignant bone tumors in adults are metastatic from the ___ in women (___ lesions) and ___ in men (___ lesions).
Breast; lytic; Prostate; blastic
Presentation of malignant metastatic bone tumors in adults?
Localized pain (early finding) Some lytic lesions present with pathologic fracture out of proportion to the activity
Dx malignant metastatic bone tumors?
X-rays can be
CT better
MRI best
Presentation of multiple myeloma?
Old men with fatigue, anemia, and localized pain at specific places on several bones
Dx multiple myeloma?
X-rays (multiple punched-out lytic lesions)
Bence-jones protein in the urine
Abnormal Ig in the blood, best shown by serum immunoelectrophoresis
Rx multiple myeloma?
Chemo
Second-line - thalidomide
Natural history of soft tissue sarcomas?
Relentless growth over several months anywhere in the body
Firm, fixed to surrounding structures
Soft tissue sarcomas metastasize to the ___ but not to the ___.
Lungs; lymph nodes
Dx and Rx of soft tissue sarcomas?
MRI may help diagnose, but not specific type; incisional biopsy should be done by the expert who will do the Rx (includes very wide local excision, radiation, chemo)
X-rays for suspected fractures should always include what views?
2 views at 90 degrees to one another
Joints above and below the broken bones
If the mechanism of injury suggests it, other x-rays should be taken of the bones that are “in the line of force,” which might also be broken
As a general rule, broken bones that are not badly displaced or angulated or that can be satisfactorily aligned by external manipulation can be managed how?
Immobilized in a cast (closed reduction)
Broken bones that are severely displaced or angulated or that cannot be aligned easily require what management?
Surgical intervention to reduce and fix the fracture (open reduction and internal fixation)
Clavicular fractures are typically located where?
Junction of middle and distal thirds
What is the traditional treatment of clavicular fracture? Other options?
Figure-of-eight device that aligns the bone by pulling back on both shoulders; sling is more comfortable and works well
If a precise outcome is desired for cosmetic reasons, open reduction and internal fixation can be done
What is the most common shoulder dislocation?
Anterior dislocation of the shoulder
How does anterior dislocation of the shoulder present?
Patients hold the arm close to their body but rotated outward as if they were going to shake hands; there may be numbness in a small area over the deltoid
Anterior dislocation of the shoulder may present with numbness in a small area over the deltoid from stretching of the ___ nerve.
Axillary
Dx anterior shoulder dislocation?
AP and lateral x-rays
Posterior shoulder dislocation is rare and presents after what events?
Massive uncoordinated muscle contractions, such as epileptic seizure or electrical burn
Presentation of posterior shoulder dislocation?
Arm is held in the usual protective position (close to the body, internally rotated)
Dx posterior shoulder dislocation?
Regular X-rays can easily miss it -> axillary view or scapular lateral views are needed
Type of injury leading to a Colles fracture?
Fall on an outstretched hand, often in an old woman with osteoporosis
What is a Colles fracture and how does it appear?
Dorsally displaced, dorsally angulated fracture of the distal radius; deformed and painful wrist that looks like a “dinner fork”
Rx Colles fracture?
Close reduction and long arm cast
What is a Monteggia fracture?
Diaphyseal fracture of the proximal ulna, with anterior dislocation of the radial head
Type of injury leading to a Monteggia fracture?
Direct blow to the ulna (such as on a raised protective arm hit by a nightstick)
What is a Galeazzi fracture
Distal third of the radius fracture with dorsal dislocation of the distal radioulnar joint; mirror image of Monteggia fracture
Management of Monteggia and Galeazzi fractures?
Broken bone often requires open reduction and internal fixation; dislocated bone is typically handled with closed reduction
Typical injury leading to fracture of the scaphoid (carpal navicular)?
Young adult who falls on an outstretched hand
Presentation of fracture of the scaphoid?
Wrist pain
Localized tenderness to palpation over the anatomic snuffbox
Management of fracture of the scaphoid?
In undisplaced fractures, X-rays are usually negative, but thumb spica cast is indicated with H&P findings. X-rays will show the fracture 3 weeks later. If the original x-rays show displaced and angulated fracture, open reduction and internal fixation are needed
Scaphoid fractures are notorious for a very high rate of ___.
Non-union
Typical injury leading to a metacarpal neck fracture (typically the 4th or 5th, or both)
Closed fist hits a hard surface (like a wall)
Presentation of metacarpal neck fracture?
Hand is swollen and tender
Dx and Rx of metacarpal neck fracture?
X-rays
Rx depends on the degree of angulation, displacement, or rotary malalignment: closed reduction and ulnar gutter splint for the mild ones, Kirschner wire or plate fixation for the bad ones
Classic presentation of a hip fracture?
Eldelry person who sustained a fall
Painful hip
Affected leg is shortened and externally rotated
Rx hip fractures?
Depends on the specific location as shown by x-rays
Femoral neck fractures, particularly if displaced, compromise the very tenuous bloody supply of the femoral head. Faster healing and earlier mobilization can be achieved with what intervention?
Replacing the femoral head with a prosthesis
Intertrochanteric fractures are less likely to lead to avascular necrosis and are usually treated with ___.
Open reduction and internal fixation
The unavoidable immobilization that ensues from intertrochanteric fractures poses a very high risk for ___, thus ___ is recommended.
DVT/PE; post-op anticoagulation
Rx femoral shaft fractures?
Intramedullary rod fixation
If bilateral and comminuted, they may produce enough internal blood loss to lead to shock (external fixation may help while the patient is stabilized)
If open, they are an emergency, require OR cleaning and closure within 6 hours
Multiple femoral shaft fractures may lead to the ___ syndrome.
Fat embolism
Presentation of knee injuries in general?
Swelling of the knee (knee pain without swelling is unlikely to be a serious knee injury) - described as the “poor man’s MRI” due to its clinical reliability
Typical injury leading to collateral ligament injuries?
Sideways blow to the knee (common sports injury)
Medial blow disrupts the lateral and vice versa
Presentation of collateral ligament injuries?
Knee will be swollen
Localized pain by direct palpation on the affected side
Physical exam findings of collateral ligament injuries?
With the knee flexed 30 degrees, passive abduction or adduction will produce pain on the torn ligaments and allow further displacement than the normal leg
Abduction demonstrates the medial injuries (valgus stress test)
Adduction diagnoses lateral injuries (varus stress test)
Rx collateral ligament injuries?
Isolated - hinged cast
Several ligaments torn - surgical repair is preferred
Which is more common - ACL or PCL injuries?
Anterior
Presentation of ACL injuries?
Severe knee swelling and pain
Physical exam findings in ACL injuries?
Anterior drawer test (with the knee flexed 90 degrees) - leg can be pulled anteriorly
Similar finding can be elicited with the knee flexed at 20 degrees by grasping the thigh with one hand and pulling the leg with the other (Lachman test)
Note - PCL injuries produce the opposite findings
Dx ACL injury?
MRI
Rx ACL injury?
Sedentary patients may be treated with immobilization and rehabilitation. Athletes require surgical reconstruction. Almost all are sports-related and require surgery.
H&P findings of meniscal tears?
Protracted pain and swelling after a knee injury
Experience of “catching and locking” that limit knee motion and a “click” when the knee is forcefully extended
Dx meniscal tears?
MRI
Rx meniscal tears?
Repair is done, trying to save as much meniscus as possible
Complete meniscectomy leads to late development of ___.
Degenerative arthritis
What three knee injuries often occur simultaneously?
Medial meniscus
Medial collateral
Anterior cruciate
___ are seen in young men subjected to forced marches.
Tibial stress fractures
Presentation of tibial stress fractures?
Tenderness to palpation over a very specific point on the bone with initially normal x-rays
Management of tibial stress fractures?
Cast, repeat x-rays in 2 weeks
Non-weight bearing crutches is another option
Leg fractures involving the tibia and fibula are often seen with what injury?
When a pedestrian is hit by a car
Physical exam findings of tibia and fibula fractures?
Angulation
Dx leg fractures involving the tibia and fibula?
XR
Management of tibia and fibula fractures?
Casting for the ones that are easily reduced
Intramedullary nailing for the ones that cannot be aligned
What are 2 of the most common locations for development of the compartment syndrome?
Forearm
Lower leg
What is the next best step in managing increasing pain after a long leg cast has been applied?
Immediate removal of the cast and appropriate assessment
What injury commonly leads to rupture of the Achilles tendon?
Out-of-shape middle-aged men with severe strain (tennis, for example)
Presentation of Achilles tendon rupture?
Loud popping noise (like a rifle shot) as the foot is planted and change direction, fall clutching the ankle
Limited plantarflexion
Pain, swelling, limping
Palpation of the tendon reveals a gap
Management of Achilles tendon rupture?
Casting in equinus position allows healing in several months; surgery achieves quicker cure
How does a fractured ankle typically occur?
Falling on an inverted or everted foot - both malleoli break in either case
Dx ankle fracture?
XR: AP, lateral, mortise
Rx ankle fracture?
Open reduction and internal fixation if the fragments are displaced
Events that can precipitate compartment syndrome?
Prolonged ischemia followed by reperfusion
Crush injuries
Other types of trauma
In the lower leg, what is the most common cause of compartment syndrome?
Fracture with closed reduction
Presentation of compartment syndrome?
Pain and limited use of the extremity
Compartment feels very tight and tender to palpation
Pulses may be normal
Most reliable physical exam finding indicating compartment syndrome?
Excruciating pain with passive extension
Rx compartment syndrome?
Emergency fasciotomy
How is pain under a cast handled?
Always by removing the cast and examining the limb
What is an open fracture?
Broken bone sticking out through a wound
Rx open fracture?
Requires cleaning in the OR and suitable reduction within 6 hours from the time of the injury
Cause of posterior dislocation of the hip?
Occurs when the femur is driven backward, such as in a head-on car collision where the knees hit the dashboard
Presentation of posterior dislocation of the hip?
Hip pain
Lies in the stretcher with the leg shortened, adducted, and internally rotated
Compare the appearance of a posterior dislocation of the hip vs. a broken hip.
Both are shortened
Broken: externally rotated
Dislocation: internally rotated
Posterior dislocation of the hip requires emergency reduction - why?
Tenuous blood supply of the femoral head, to avoid avascular necrosis
Gas gangrene occurs with what types of wounds?
Deep, penetrating, dirty wounds (stepping on a rusty nail, with lots of mud or manure)
Presentation of gas gangrene?
~3 days after injury, the patient is extremely sick, looking toxic and moribund
Affected site is tender, swollen, discolored, and has gas crepitation
Rx gas gangrene
Penicillin, clindamycin
Extensive emergency surgery debridement
Hyperbaric oxygen
Other galloping soft tissue infections are seen primarily in immunocompromised patients (DM, AIDS), the most common being __ and ___.
Synergistic bacterial gangrene; necrotizing fasciitis
Patients debilitated by extensive burns or widespread trauma may suffer fulminating ___ infections, the most feared of which is ___.
Fungal infections; mucormycosis
Presentation and Dx of mucormycosis?
Affected areas turn black; Dx confirmed by tissue biopsy
Manage galloping soft tissue infections?
All of these conditions require repeated, massive surgical excisions of dead tissue in addition to appropriate antibiotics (broad spectrum for synergistic bacterial gangrene and necrotizing fasciitis, IV amphotericin B for mucormycosis)
What nerve can be injured in oblique fractures of the middle to distal thirds of the humerus?
Radial
Management of radial nerve injury in the setting of humerus fracture?
If the patient comes in unable to dorsiflex the wrist and regains function when the fracture is reduced and the arm is placed on a hanging cast or coaptation sling, no surgical exploration is needed. However, if nerve paralysis develops or remains after reduction, the nerve is entrapped and surgery has to be done
___ artery injuries can occur in posterior dislocations of the knee. Attention to the integrity of pulses, Doppler studies, or CT angio are key. What should be done for management?
Popliteal; prompt reduction (minimize vascular compromise), delayed restoration of flow requires prophylactic fasciotomy
The direction of force that produces an obvious injury may produce another one that is less obvious and needs to be sought. Falls from a height landing on the feet may have obvious foot or leg fractures. What other fractures must be looked for?
Fractures of the lumbar or thoracic spine
Head-on automobile collisions may produce obvious injuries in the face, head, and torso. What other injuries must be looked for?
If the knees hit the dashboard, the femoral heads may be driven backwards into the pelvis or out of the acetabulum.
Facial fractures and closed head injuries should always prompt evaluation of the ___.
Cervical spine
