Intro to Ortho Flashcards by Fatema Arastu

population that sprains are uncommon in

those with osteoporosis and in children- because bone more fragile than ligament

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ottawa ankle rules for foot SPRAIN

pain at navicular bone and midfoot, base of 5th metatarsal and midfoot, or cannot bear weight for 4 steps

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ottawa ankle rules for ankle SPRAIN

pain at lateral or medial malleolus, or cannot bear weight for 4 steps

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MRi helpful for evaluating (2 things)

soft tissue injury and non-displaced stress fractures

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types of fractures

non-displaced, displaced, angulated, bayonetted, and distracted

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difference between bayonneted and distracted fracture

bayonneted- distal fragment overlaps proximal fragment. distracted-distal fragment separated from proximal by gap

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factors that worsen stability of fracture

older, displaced fracture, oblique fracture, neuro-vasc injury, osteonecrosis, or compartment syndrome

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GRADUAL onset of localized, activity related pain that progresses to pain at rest. what kind of fracture does this describe?

stress. much more insidious than acute.

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Man training for army comes in with pain in his proximal humerus. The pain began 2 months ago and has been progressing gradually. You suspect a stress fracture but xray comes out neg. what is your next step?

MRI- highly sensitive and specific. First choice if negative xray! proximal humerus is low risk, so should be treated concervatively- analgesics, PT referral, avoid activities that provoke injuryribs, sacrum, pubic rami

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RICE is not helpful in what kind of fracture tx?

stress

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low risk stress fractures that should be treated conservatively include

2-4th metatarsal shaft, posteriomedial tibial shaft, fibula, proximal humerus or shaft, ribs, sacrum, pubic rami

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high risk stress fractures that should be referred to speciality

pars interarticularis (between vertebrae), femoral head or neck, patella, anterior tibia, medial malleolus, talus, 5th metatarsal, base of 2nd metatarsal, and sesamoids on great toe

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F/U with stress fracture

re-evaluate every 1-3 weeks. may not resolve for more than 3 months

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most common bacteria in septic arthritis

staph (2 and older)

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risk factors for septic arthritis

D.M, gout, R.A., over 80, prosthetic joint, skin infection, increased alcohol

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how to tell difference between acute gout attack and septic arthritis

septic arthritis will have fever, tachycardia. also look at history- may have had recent skin infection, skin abscess, tooth abscess. joint aspiration will definitely differentiate

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labs in septic arthritis

increased WBC, high ESR, high CRP, blood culture, joint aspiration, MRI, US, or CT- joint effusion

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if suspect gonococcal infection in septic arthritis, what to do? tx?

take culture from both mouth and synovial fluid (2 spots). ceftriaxone 1-2 weeks and azithromycin

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tx for septic arthritis

IV emperic abs for 2 weeks, then 2 weeks of oral abx, surgical decompression, splinting of joint

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If septic arthritis d/t periprosthetic joint, how to manage?

treat with surgical debridement and salvage of prosthetic joint. may need revision surgery and possible prosthesis removal

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What is bursitis?

inflammation of synovial tissue lining bursa resulting in increased fluid production and sebsequent pain/swelling

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Knee pain on motion and at rest, decreased ROM, swelling, local tenderness, repeat injury to knee hx, and infection and FEVER

septic bursitis

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how to diagnose bursitis or septic bursitis

aspiration of bursal fluid for gram stain, crystal eval, cell count, culture.

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are imaging studies helpful in bursitsi?

not if superficial. if deep, MRI or xray might help

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tx of bursitis

analgesia, splint, judicious corticosteroid infections. if SEPTIC bursitis- broad spectrum abs and/or surgical drainage

what condition is stress fracture often seen with?

tendinopathy

what is tendinopathy?

tendon thickening and chronic localized tendon pain which may occur d/t trauma or overuse

what medication use is risk factor for tendinopathy and what med inc risk of tendon RUPTURE?

fluoroquinolone use, glucocorticoids

patient presents with increased pain with palpation of affected tendon, there is palpable tendon thickening. Also has stress fracture. Overweight, and uses fluoroquinolones. dx and tx?

use MRI or US for soft tissue imaging. tendinopathy- tx is conservative measures. avoid glucocorticoids use to decrease risk of tendon rupture

prognosis of tendinopathy

slow chronic, requires months for complete healing. Symptoms WORSEN initially with rehab

most common location of tenosynovitis

flexor tendon sheath, occurs most freq in hands and wrist on extensor and flexor side

Patient presents with tenderness along flexor sheath, enlargement of 4th digit, finger is slightly FLEXED at REST. On PE, upon inspection, fingers look "sausage like." - very swollen. there is pain at tendon with passive movement. Patient has fever.how to dx and treat?

gram stain/culture because there is inflammation. could be infection. tx- surgical intervention, empiric abx therapy

what is tenosynovitis

inflammation of tendon and its synovial sheath

3 diff ways of spread in osteomyelitis and septic arthritis

hematogenous spread, contiguous spread, direct inoculation

where does osteomyelitis affect adults vs. children?

long bones of extremitity (proximal femur) in children, and vertebrae in adults

most common bacteria in osteomyelitis and septic arthritis?

staph

different in hematogenous vs. contiguous osteomyelitis

hematogenous- monomicrobial. contiguous- either

someone using street drugs- worried about what kind of infection?

osteomyelitis

Types of clinical presentation in osteomyelitis?

acute, subacute, chronic

patient presents with back pain that has been getting worse over the last 2 weeks. it is worse at night, and with activity. DULL pain. Has DM. Decreased mobility mildly and no fever but does have chills. tenderness and warmth over lower back. increased WBC, ESR, and CRP. what other labs do you do and dx, tx?

acute osteomyelitis. GOLD standard- isolate bacteria from bone biopsy. also do blood culture, echo to r/o endocarditistx- analgesia, debridement and abx

patient presents with back pain that has been getting worse over the last 4 weeks. there is swelling and ulcers that have developed. 2 fractures that also failed to heal. Has fever and is IVD user. tenderness and warmth over low back.

chronic osteomyelitis. GOLD standard- isolate bacteria from bone biopsy. also do blood culture, echo to r/o endocarditistx- analgesia, debridement and abx

is acute or chronic osteomyelitis better?

acute. chronic may relapse over many years, lead to amputation

if osteomyelitis extends into joint, could get..

septic arthritis

child presents with irregular, jagged wound on arm with erythema, swelling, lymphadenopathy, draining. there is streaking up the arm. and has fever. dx and tx?

ask if got bit by animal. get gram stain/culture, blood culture (if fever), Xray to r/o cat teeth, US to identify abscess formation. TX- would irrigation, debridement. abx prophylaxis if high risk of infection suspected. tetanus prophylaxis if needed.

most common cause of infection from animal bites

pasteurella multocida from cat bite

Patient presents with semicircular/oval area of erythema and bruising on face. There is tenderness, swelling, draining, streaking up the arm and fever. dx and tx?

Get Xray if bite is close to bone. Irrigation with debridement, abx prophylaxis if through dermis. DO NOT suture. consider tetanus prophylaxis, and hep B if not immunized. do not suture.

tx if clenched fist injury

immobilization

most common organism in human bite

eikenella corrodens

most common location with human bites

face, UE, trunk of young kids

Most commonly found bone tumors are..

metastatic

dx in bone tumors- list diff tests/labs you can order

Bone biopsy for definitive diagnosis. Xray initially, with CT to further assess lesions. MRI- soft tissue damage. US- lesion cystic or solid. Bone scan- identifies multiple skeletal lesions. CBC, ESR, CRP for inflammation.

most common location of avascular necrosis

anterolateral femoral head

avascular necrosis etiology can be traumatic or non-traumatic. what are most common non-traumatic causes?

corticosteroid use and excessive alcohol intake

most common presenting symptom in avascular necrosis?

PAIN- most commonly occurs with weight bearing or movement

"Crescent sign" on xray is pathognomonic for...and what does it show?

avascular necrosis. shows subchondral collapse

why is avascular necrosis a serious problem?

asymptomatic and diagnosis is incidental. can go unnoticed for long time

avascular necrosis is often asymptomatic. may present bilaterally or unilaterally. pain is most common presenting symptom. PE is often non-specific. have decreased ROM or pain with ROM. describe gait:

altered. antalgic (shorter time on affected foot) and trendelenberg (wide base gait to shift hip over)

Dx of avascular necrosis

Xray- first line, but can remain normal for months after symptom onset. may show "crescent sign." if negative, consider bone scan if clinical suspicious high. GOLD standard- MRI

what is gold standard of diagnosing avascular necrosis

MRI

TX of avascular necrosis

preserve blood supple to prevent further necrosis, non-op management, surgery-joint preserving procedures and joint replacement

most common locations of compartment syndrome affected

anterior leg and anterior (volar) arm

Patient presents with anterior thigh pain that is out of proportion, sensory hypoesthesia in foot, paresthesia, weakness of R leg. increased pain with passive stretching, pain upon palpation and feels like WOOD. symptoms just began 2 hours ago. dx and tx?

dx- measure compartment pressure. acute compartment syndrome delta pressure= diastolic BP- measured compartment pressure= less than 20-30--- immediate fasciotomy. High levels of oxygen may be used (HBO). woulds left open with delayed closure

what 2 things does compartment syndrome affect

circulation and function of the tissue within that space- impaired

compartment syndrome most commonly d/t

TRAUMA

new army recruit presents with pain out of proportion in anterior leg. has tightness, cramping, aching, squeezing. Starts when starts to exercise, but relived upon rest. affects both legs. dx and tx?

prob chronic exertional compartment syndrome. occurs in people who have a MAJOR change in activity level. measure compartment pressure for diagnosis (pre and post exercise). tx- conservative messures, then cessation of provocative activity- slower training

most common location of chronic exertional compartment syndrome

anterior and lateral compartments of leg

Majority of patients with PAD have disease of the

PAD patient presents with pain in buttock of hip region- indicates

aortoiliac disease

PAD patient presents with pain in thigh, calf, or both. indicates

disease in common femoral artery

DX of PAD

ABI

PE of PAD patient

diminished or absent pulses below level of stenosis, bruits over steonic lesions, poor wound healing, cool extremity, prolonged venous filling time, shiny atrophied skin, decreased hair on body, nail changes

tx PAD

risk factor modification, exercise therapy. drugs- Ciostazol (suppresses platelet aggregation), antiplatelet agents (ASA still preferred however), pentoxifylline (relief of claudication), revasculazization

buerger test. what is it and a/w what disease

foot pallor with leg elevation. positive in PAD