chapter 42: orthopedics Flashcards
synthesize non mineralized bone cortex
osteoblasts
reabsorb bone
osteoclasts
stages of healing
1) inflammation
2) soft callus formation
3) mineralization of the callus
4) remodeling of the callus
receives nutrients from synovial fluid (osmotic)
cartilage
fractures: cross the epiphyseal plate and can affect the growth plate of the bone; need ORIF
Salter-Harris fractures 3, 4, and 5
fractures: closed reduction
Salter-Harris fractures 1 and 2
epiphysiolysis of the involved growth plate without associated fracture
salter-harris type 1 fracture
epiphysiolysis of the involved growth plate without associated fracture; additional metaphysical fracture fragment
salter-harris type 2 fracture
salter harris fracture: good prognosis and are usually treated with closed reduction and casting
type 1 and 2 fractures
injury results in a fracture through the growth plate and epiphysis
type 3 fracture
fracture cross the epiphysis, growth plate (physis), and metaphysis
type 4 fracture
injuries require careful ORIF if displaced
type 3 and 4 fractures
involves a crush of the growth plate without a fracture and is usually detected late by asymmetric or premature closure of the growth plate
type 5 injury
fractures associated with avascular necrosis (AVN)
scaphoid, femoral neck, talus
fractures associated with nonunion
clavicle, 5th metatarsal fracture (Jones’ fracture)
fractures associated with compartment syndrome
supracondylar humerus, tibia
biggest risk factor for nonunion
smoking
LE nerve: hip adduction
obturator nerve
LE nerve: hip abduction
superior gluteal nerve
LE nerve: hip extension
inferior gluteal nerve
LE nerve: knee extension
femoral nerve
presents with back pain, sciatica
herniated nucleous pulposus
nerve root compression affects 1 nerve root below disc
lumbar disc herniation
Lumbar disc herniation: weak hip flexion
L3 nerve compression (L2-3 disc)
Lumbar disc herniation: weak knee extension (quadriceps), weak patellar reflex
L4 nerve compression (L3-4 disc)
Lumbar disc herniation: weak dorsiflexion (foot drop), decreased sensation in big toe web space
L5 nerve compression (L4-5 disc)
Lumbar disc herniation: weak plantar flexion, weak Achilles reflex, decreased sensation in lateral foot
S1 nerve compression (L5-S1 disc)
dx: lumbar disc herniation
patients with neurologic findings need MRI
tx: lumbar disc herniation
NSAIDs, heat, and rest; surgery for substantial / progressive neurologic deficit, refractory cases, severe sciatica, or disc fragments that have herniated into the cord
motor: intrinsic musculature of hand (palmar interpose, palmar brevis, adductor pollicis, and hypothenar eminence); finger abduction (spread fingers); wrist flexion
sensory: all of 5th and 1/2 4th fingers, back of hand
ulnar nerve
injury results in claw hand
ulnar nerve
- motor: thumb apposition (anterior interosseous muscle, OK sign); finger flexors
- sensory: most of palm and 1st 3 and 1/2 4th fingers on palmar side
median nerve
nerve involved in carpal tunnel syndrome
median nerve
- motor: wrist extension, finger extension, thumb extension, and triceps; no hand muscles
- sensory: 1st 3 and 1/2 4th fingers on dorsal side
radial nerve
motor to deltoid (abduction)
axillary enrve
motor to biceps, brachialis, and coracobrachialis
musculocutaneous nerve
cervical radiculopathy: neck and scalp pain
C1, C2, C3 and C4 nerve compression (C1-2, C2-3, C3-4 discs)
cervical radiculopathy: weak deltoid and biceps
- weak biceps reflex
C5 nerve compression (C4-5 disc)
cervical radiculopathy: weak deltoid and biceps, weak wrist extensors
- weak biceps reflex and brachioradialis reflex
C6 nerve compression (C5-6 disc)
cervical radiculopathy: weak triceps
- weak triceps reflex
C7 nerve compression (most common, C6-7 disc)
cervical radiculopathy: weak triceps, weak intrinsic muscles of hand and wrist flexion
- weak triceps reflex
C8 nerve compression (C7-T1 disc)
radial nerve
C5-8
median nerve
C6-T1
ulnar nerve
C8-T1
musculocutaneous nerve
C5-7
axillary nerve
C5-6
on the superior portion of the brachial plexus
radial nerve roots
on the inferior portion of the brachial plexus
ulnar nerve roots
tx: clavicle fracture
usually just treated with sling (risk of vascular impingement)
shoulder dislocation: risk of axillary nerve injury
- tx?
anterior (90%) - tx: closed reduction
should dislocation: risk of axillary artery injury
- tx?
posterior (seizures, electrocution)
- tx: closed reduction
tx: acromioclavicular separation
sling (risk of brachial plexus and subclavian vessel injury)
tx: scapula fracture
sling unless gleaned fossa involved, then need internal fixation
tx: midshaft humeral fracture
sling for almost all
tx: adults - supracondylar humeral fracture
ORIF
tx: children - supracondylar humeral fracture
nondisplaced -> closed reduction; displaced -> ORIF
proximal ulnar fracture and radial head dislocation
- tx: ORIF
monteggia fracture
fall on outstretched hand, distal radius
- tx: closed reduction
colles fracture
subluxation of the radius at the elbow caused by pulling on an extended, pronated arm
- tx: closed reduction
nursemaid’s elbow
adults: combined radial and ulnar fracture
ORIF
children: combined radial and ulnar fracture
closed reduction
snuffbox tenderness; can have negative XR
scaphoid fracture
tx: scaphoid fracture
all patients require cast to elbow, may need fixation; risk of avascular necrosis
supracondylar humerus fracture -> occluded anterior interosseous artery -> closed reduction of humerus -> artery opens up -> reperfusion injury, edema, and forearm compartment syndrome (flexor compartment most affected)
volkmann’s contracture
symptoms: forearm pain with passive extension; weakness, tense forearm, hypesthesia
volkmann’s contracture
what nerve is most affect by swelling in volkmann’s contracture?
median nerve
tx: volkmann’s contracture
forearm fasciotomies
management: forearm fasciotomies
need to open volar and dorsal compartments
- associated with diabetes, ETOH
- progressive proliferation of the palmar fascia of hand results in contractures that usually affect the 4th and 5th digits (cannot extend fingers)
dupuytren’s contracture
tx: dupuytren’s contracture
NSAIDs, steroid injections; excision of involved fascia for significant contraction
median nerve compression by transverse carpal ligament
carpal tunnel syndrome
tx: carpal tunnel syndrome
splint, NSAIDs, and steroid injection; transverse carpal ligament release if that fails
tenosynovitis of the flexor tendon that catches at the MCP joint when trying to extend finger
trigger finger
tx: trigger finger
splint, tendon sheath steroid injections (not the tendon itself); if that fails, can release the pulley system at the MCP joint
infection that spreads along flexor tendon sheaths of digits (can destroy sheath)
suppurative tenosynovitis
tendon sheath tenderness
pain with passive motion
swelling along sheet
semi-flexed posture of the involved digit
4 classic signs of suppurative tenosynovitis
tx: suppurative tenosynovitis
midaxial longitudinal incision and drainage
rotator cuff tears: what are the muscles?
supraspinatus
infraspinatus
teres minor
subscapularis
tx: acutely for rotator cuff tears
sling and conservative treatment
when do you consider surgical repair for rotator cuff tears?
surgical repair if the patient needs to retain a high level of activity or if ADL affected
infection under nail bed; painful
- tx: antibiotics; remove nail if purulent
paronychia
infection in the terminal joint space of the finger
- tx: incision over the tip of the finger and along the medial and lateral aspects to prevent necrosis of the tip of the finger
felon
patients have internal rotation and adduction of leg;
- risk of sciatic nerve injury
- tx?
posterior hip dislocation (90%)
- tx: closed reduction
patients have external rotation and abduction of leg; risk of injury to femoral artery
- tx?
anterior hip dislocation
- tx: closed reduction
tx: isolated anterior ring with minimal ischial displacement
weight bearing as tolerated
tx: femoral shaft fracture
ORIF with intramedullary rod
tx: femoral neck fracture
ORIF -> risk of avascular necrosis if open reduction delayed
what structures are at risk in lateral knee trauma?
can result in injury to ACL, PCL, and medial meniscus
positive anterior drawer test
- present with knee effusion and pain with pivoting action; MRI confirms diagnosis
anterior cruciate ligament injury
tx: anterior cruciate ligament injury
surgery with knee instability (reconstruction with patellar tendon or hamstring tendon); otherwise physical therapy with leg-strengthening exercise
positive posterior drawer test
- much less common than ACL injury; present with knee pain and joint effusion
posterior cruciate ligament injury
tx: posterior cruciate ligament injury
conservative therapy initially; surgery for failure of medical management
collateral ligament: lateral blow to knee
medical collateral ligament injury
collateral ligament: medial blow to knee
lateral collateral ligament injury
tx: collateral ligament
tx -
small tear: brace
large tear: surgery
what are collateral ligaments associated with?
these injuries are associated with injuries to the corresponding meniscus
joint line tenderness; can treat with arthroscopic repair or debridement
meniscus tears
what do you need to rule out in posterior knee dislocation?
all patients need angiogram to rule out popliteal artery injury
tx: patellar fracture
long leg cast unless comminuted, then need internal fixation
tx: tibial plateau fracture and tibia-fibula fracture
ORIF fixation unless open, then need external fixator until tissue heals
pain and mass below popliteal fossa (contracted planters) and ankle ecchymosis
plantaris muscle rupture
tx: ankle fracture
most treated with cast and immobilization; bimalleolar or trimalleolar fractures need ORGI
tx: metatarsal fracture
cast immobilization or brace for 6 weeks
tx: calcaneus fracture
cast and immobilization if non displaced; ORIF for displacement
tx: talus fracture
closed reduction for most; ORIF for severe displacement
nerve most commonly injured with lower extremity fasciotomy
superficial peroneal nerve (foot eversion)
nerve: foot drop after lithotomy position or after crossing legs for long periods or fibula head fracture
common perennial nerve (foot-drop)
components of anterior leg compartment
anterior tibilal artery, deep peroneal nerve
- muscles: anterior tibialis, extensor hallucis longus, extensor digitorum longus, and communis
components of lateral leg compartment
superficial peroneal nerve
- muscles: peroneal muscles
components of deep posterior leg compartment
posterior tibial artery, peroneal artery, and tibial nerve
- muscles: flexor hallucis longus, flexor digitorum longus, posterior tibilais
components of superficial leg compartment
sural nerve
- muscles: gastrocnemius, soleus, plantaris
what are the four compartments of the leg?
anterior, lateral, deep posterior, superficial posterior
most likely to occur in the anterior compartment of the leg (get foot drop) after vascular compromise, restoration of blood flow, and subsequent repercussion injury with swelling of the leg compartment
compartment syndrome
can occur from crush injuries
- symptoms: pain with passive motion; swollen extremity
compartment syndrome
what is the last thing to go in compartment syndrome
distal pusles can be present with compartment syndrome -> last thing to go
abnormal pressures in compartment syndrome
pressure > 20-30mmHg
dx: compartment syndrome
based on clinical suspicion
tx: compartment syndrome
fasciotomy
can occur in metaphysis of long bones in children; most commonly staph
- symptoms: pain, decreased use of extremity
osteomyelitis
dx: osteomyelitis
MRI, bone biopsy
tx: osteomyelitis
incision and drainage; antibiotics
prepubertal females, right thoracic curve most common, usually asymptomatic
idiopathic adolescent scoliosis
tx: idiopathic adolescent scoliosis - curves 20-45 degrees
need bracing to slow progression, which can occur with growth spurt
tx: idiopathic adolescent scoliosis - curves > 45 degrees or those likely to progress
spinal fusion
tibial tubercle apophysitis; caused by traction injury from the quadriceps in adolescents aged 13-15; most commonly have pain in front of the knee
Osgood-Schlatter disease
xr: osgood-schlatter disease
irregular shape or fragmenting of the tibial tubercle
tx: osgood-schlatter disease
mild symptoms -> activity limitation, severe symptoms -> cast 6 weeks followed by activity limitation
AVN of the femoral head; children 2 years and older
- can result form a hyper coagulable state; bilateral in 10%
- symptoms: painful gait limp
Legg-Calve-Perthes disease
xr: legg-calve-perthes disease
flattening of the femoral head
tx: legg-calve-perthes disease
maintain range of motion with limited exercise; femoral head will remodel without sequelae
when do you consider surgery for legg-calve-perthes disease?
surgery if femoral head is not covered by the acetabulum
males aged 10-13 ; increased risk of AVN of the femoral head; painful gait
slipped capital femoral epiphysis
xr: slipped capital femoral epiphysis
widening and irregularity of the epiphyseal plate
tx: slipped capital femoral epiphysis
surgical pinning
- more common in females
- tx: pavlik harness, which keeps the legs abducted and the femoral head reduced in the acetabulum
congenital dislocation of the hip
tx: clubfoot
serial casting
MCC bone tumors
most common is metastatic disease #1 breast #2 prostate
tx: bone tumors secondary to metastatic disease
internal fixation with impending fracture (> 50% cortical involvement); followed by XRT
most common primary malignant tumor of bone
multiple myeloma
tx: multiple myeloma
chemotherapy for systemic disease; internal fixation for impending fractures
tx: pathologic fracture from bone tumors
treat with internal fixation
management: pathologic fractures from bone tumors
XRT can be used for pain relief in patients with painful bony metastases
most common primary bone sarcoma, usually around the knee
osteogenic sarcoma
demographic of osteogenic sarcoma
80% in patients
xr: osteogenic sarcoma
codman’s triangle -> periosteal reaction
tx: osteogenic sarcoma
limb-sparing resection; XRT and doxorubicin-based chemotherapy can be used preoperatively to increase chance of limb-sparing resection
benign bone tumors treated with curettage +/- bone graft
osteoid osteoma, endochondroma (may be able to observe), osteochondroma (resection only if cosmetic defect or causing symptoms), chrondoblastoma, non ossifying fibroma (may be observed) and fibrodysplasia
tx: giant cell tumor of bone
total resection +/- XRT (Benign but 30% risk of recurrence; also has malignant degeneration risk)
formed by subluxation or slip of one vertebral body over another
spondylolisthesis
where does spondylolisthesis most commonly occur?
lumbar region
most common cause of lumbar pain in adolescents (gymnasts)
spondylolisthesis
tx: spondylolisthesis
depends on degree of subluxation and symptoms - ranges from conservative treatment to surgical fusion
tx: cervical stenosis
surgical decompression if significant myelopathy present
tx: surgical decompression for cases refractory to medical treatment
lumbar stenosis
tx: torus fracture
buckling of the metaphyseal cortex seen in children (i.e. distal radius)
tx: open fractures
need incision and drainage, antibiotics, fracture stabilization, and soft tissue coverage.
