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Clinical Medication: HEENT > Introduction to Ortho > Flashcards

Introduction to Ortho Flashcards

1
Q

Orthopedics is the study of

A

The study of the musculoskeletal system including bone, joints, ligaments, tendons, muscles, and supporting neurological and vascular structures

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2
Q

Sprain
Common where?
Uncommon in who?
Treatment of sprains

A

Sprain is injury to ligaments (connects 2 or more bones) and typically occurs in the ankle, knee, or wrist as result of trauma.

Uncommon in children or those with osteoporosis dt bone being more fragile than ligament.

I: Partial tear, no instability, symptomatic tx
II: Partial tear, instability, immobilize to protect.
III: Complete tear, immobilize/repair

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3
Q

strain:
Common where?

Grades I -IV

A

Strain is injury to tendon (connects muscle to bone).

Commonly seen with gastrocnemius, hamstring, and quadriceps.

I: Tear of a few muscle fibers
II: Tear of moderate amount of muscle fibers
III: Tear of all muscle fibers
IV: Tear of all muscle fibers – “rupture”

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4
Q

what is the clinical presentation of sprain or strain?

A

With sprain and strain, have hx of traumatic event with reports of snapping, popping, tearing sensation at time of injury

Associated with pain, swelling, stiffness, difficulty bearing weight. Ecchymosis may appear.

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5
Q

what are you PE findings of sprains and strains

A

Compare exam findings of swelling/tenderness w/contralateral side & examine for joint instability. Able to contract affected musculature- if they can’t its a higher grade strain

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6
Q

what is used for diagnosing strains and sprains?

A

X-ray to r/o fracture.
Consider w/II, III, IV strain or II, III sprain

MRI to evaluate soft tissue injury

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7
Q

what are the Ottawa Ankle Rules

A

guidelines of when to get an X-ray

if 1 or more of the following is +
pain at lateral malleolus
pain at medial malleolus
cannot bear weight for 4 steps
pain at navicular 
Pain in the mid foot at the base of the 5th metatarsal
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8
Q

Treatment of sprains and strains

A

PRICE
Minor: sprains can be treated with elastic compression bandage, bracing or brief periods of immobilization

Strains should be immobilized where muscle is stretched to minimize bleeding of injured muscle

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9
Q

What types of strains or sprains do you reef?

A

grade III or severe grade II

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10
Q

Contusion

Result of:
Presents with:

A

-Result of direct, blunt trauma causing bleeding & soft tissue damage

Presents with activity related pain, swelling, ecchymosis, possible hematoma

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11
Q

Diagnostic evaluation of a contusion?

A

X-ray to rule out fracture

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12
Q

Treatment of a contusion?

A

Conservative treatment, drainage if large hematoma

Monitor for compartment syndrome and join instability

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13
Q

Fracture
describe:
Often a/w:

A

Described as a Disruption in continuity or structural integrity of bone that occurs when stress applied to bone is greater than bone’s intrinsic strength

Often time is a/w injury to surrounding tissue (muscle, blood vessels, neurological structures)

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14
Q

Closed v Open Fractures

A

Closed: Skin over and near the fracture is intact

Open: Skin over or near fracture is lacerated or abraded by injury & requires expedient care & evaluation by specialist.

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15
Q 
types of fractures
1:
2:
3:
4:
5:
A

Non displaced: In alignment

Displaced: Not in alignment

Angulated: Fractures are malaligned and angulated

Bayonetted: Distal fragment overlaps proximal fragment

Distracted: Distal fragment separated from proximal by gap

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16
Q

Treatment of fractures:

A

Specialist to determine if manipulation, reduction, stabilization is needed

Depends on bone involved- in general involves immobilization, reduction and rehab

Immobilize, reduction, rehab. Open fractures → URGENT tx

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17
Q

Open fractures are

A

URGENT treatment!

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18
Q

What are some factors that improve stability/ increase likelihood of good prognosis?

A

Young,
1 fracture in forearm/lower leg,
nondisplaced,
Thoracic spine fracture

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19
Q

What factors that worsen tability/ increase likelihood of poor prognosis?

A

Older, displaced, compartment syndrome, osteonecrosis, oblique, neurologic/vascular injury

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20
Q

Stress Fractures:
Occurs as a result of:

May occur with hx of:

Present:

A

Occurs as a result of repetitive stress loads to healthy bone

May occur with hx of prior stress fracture, < level of fitness, > volume/intensity of activity, female, menstrual irregularity, poor diet of calcium, poor biomechanics, poor bone health

Present insidiously compared to acute fracture

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21
Q

What will a stress fracture present as?

A

May report > in activity level, gradual onset of localized, activity related pain that progresses to pain at rest

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22
Q

what is the Diagnosis of stress fractures?

A

It will take 2-3 weeks to show up on Radiograph, it is recommended as initial study, but if it is negative and highly suggestive MRI is the diagnostic study of choice

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23
Q

what is the treatment of stress fractures?

early intervention

Low risk

High risk

Re - evaluate

A

Early intervention : < pain, promote healing, prevent future damage

Conservative management is recommended for low risk: 2nd-4th metatarsal shaft, posteriormedial tibial shaft, fibula, proximal humerus or shaft, ribs, sacrum, pubic rami

Specialist consult for high risk or complete or want to return quickly: Pars interarticularis (between vertebrae), femoral head or neck, patella, anterior tibia, medial malleolus, talus, proximal 5th metatarsal, sesamoids on great toe, base of 2nd metatarsal

Reevaluate every 1-3 weeks, Possible >12 weeks for return of activity

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24
Q

Dislocations

A

Joint injury that forces ends of bones out of position, commonly dt trauma. May involve ankle, knee, shoulder, hip, elbow, jaw, and finger.

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25
what is the clinical presentation of a dislocation?
Pain, swelling, deformity, < ROM, numb/tingling if nerve involved
26
what is the treatment of a dislocation?
Depends on severity and joint involved – Emergent, Analgesia, Manipulation and/or surgical intervention followed by immobilization & subsequent rehab
27
Subluxation
Occurs when a joint begins to dislocate (partial dislocation) and can occur d/t trauma or underlying conditions that predispose to join laxity
28
Arthritis cause: manifestations: Most common types:
Degenerative process a/w aging or acute infections & inflammation Disability can range from minimal to crippling Most common are osteoarthritis and rheumatoid arthritis
29
Septic Arthritis aka: caused by: Commonly affected joints:
# define: an infection of the going space Also called pyogenic or suppurative arthritis caused by infection to the joint space by either direct inoculation, hematogenous spread, or extension from adjoining bone infection. Common joints include knee, hip, shoulder, elbow, wrise
30
Risk factors for septic arthritis?
> 80 y.o., DM, RA, gout, prosthetic joint, skin infection, > alcohol
31
Bacteria in septic arthritis?
Virus, bacteria, or fungi. Staph Aureus is the most common in those 2 y.o. and older
32
Presentation of septic arthritis? Early on: Children: Systemic Symptoms:
Symptoms early on are typically mild join pain, swelling, < ROM. Children may refuse to bear weight or move affected joint. Systemic symptoms such as fever & tachycardia
33
PE findings of Septic Arthritis?
Red hot swollen joint that doesn't move Watch for possible primary infection – skin defect, penetrating injuries, skin abscess, tooth abscess
34
Dx of septic arthritis?
* > WBC, > ESR, > CRP, Blood culture * If you suspect gonococcus, need cultures from other than mouth, cervical or utrethra Joint aspiration: crystal analysis, gram stain, culture, cell count (>50,000) Radiographs are often normal, may see soft tissue swelling US, CT, MRI may reveal joint effusion
35
Treatment of septic arthritis
Empiric IV ABX for 14 days, then 14 days of oral abx Surgical decompression, splinting of joint
36
Septic arthritis due to a periprostetic joint can result form: consider in: dx: tx:
can result from intraoperative contamination, local infection or hematogenous spread consider if pt with prosthetic joint who presents with new onset of pain Dx: similar to systemic Treatment Generally attempt surgical debridement.
37
Septic Arthritis due to gonococcal infection can lead to: common cause: dx: tx:
can lead to a vartiey of clinical manifestation including arthritis, tenosynovitis and or dermatitis Common cause of acute poly arthalgia, poly arthritis or oligoarthritis in young healthy patient DX: Hx and PE and cultures Treatment: Cefriaxone x 7-14 days and a single dose of azithomycin.
38
Bursitis define: may follow: fluid can be:
Inflammation of synovial tissue lining bursa resulting in increased fluid production and subsequent pain/swelling May be seen following injury or repetitive motion Sterile (acute – > trauma, crystal disease, bleeding) or infectious
39
Presentation of Bursitis
Pain on motion and at rest with < ROM. Swelling, local tenderness, hx of trauma or repeat injury if infection/fever → septic bursitis
40
Diagnostic evaluation of Bursitis
Aspiration of bursal fluid for gram stain, culture, cell count, crystal eval Imaging studies not helpful if superficial. If deep, x-ray/MRI may help. If superficial – inflammation. If deep – Unexplained pain w/motion.
41
Treatment of bursitis
Modify activity, analgesia (NSAIDS), splinting, corticosteroids, and surgical excision if relapsing. If infectious, use broad spectrum abx and/or surgical drainage
42
Tendinopathy define: d/t: risk factors:
clinical syndrome characterized by tendon thickening and chronic localized tendon pain can occur d/t: Acute trauma or more commonly d/t overuse Risk factors:include > age, > BMI, biomechanical abnormalities, prior tendon lesion, fluoroquinolone use, training errors or poor equipment
43
Presentation of Tendinopathy
Pain > with palpation of affection tendon and tendon loading. Palpable tendon thickening may be present.
44
how do you dx Tendinopathy
US and MRI
45
What is the treatment of Tendinopathy?
Conservative measures (rest, correction of biomechanical factors, rehab, gradual return to activities), NSAIDS, sx if refractory cases AVOID glucocorticoids due to > risk of tendon rupture
46
what is the prognosis of tendiopathy?
o Slow, chronic disorder requiring months for complete healing o Symptoms worsen initially with rehab
47
Tenosynovitis Define: Occurs most freq in: Due to:
inflammation of a tendon and its synovial sheath Occurs most frequently in hands and wrist on extensor & flexor side Infectious or non-infectious
48
``` Presentation of tenosynovitis? Infection most commonly involves the: Cardinal Signs: 1: 2: 3: 4: 5: - - -Fingers look like ```
o Infections most commonly involve flexor tendon sheath. Cardinal Signs: 1: Tenderness along flexor sheath 2: symmetric enlargement of affected digit 3: slight flexed finger at rest 4: pain at tendon w/passive Extension Fever may be present Cutaneous sign of ischemia - skin necrosis may be present Fingers are “sausage like”
49
How do you diagnose tenosynovitis?
o Gram stain/culture o Radiograph is usually normal but r/o bony involvement or foreign body o MRI/US to confirm presence of tendon sheath abnormalities
50
Treatment of tenosynovitis?
Surgical intervention, empiric abx therapy
51
Osteomyelitis define: classified: - - D/t
Infection of bone most commonly occurring in long bones of extremity in children and vertebrae in adults. Classified according to duration of illness & mechanism of infection Acute: period prior to development of complications Chronic: period after development of complications Occur dt hematogenous seeding, contiguous spread, direct inoculation
52
Osteomyelitis in children is seen in | in adults?
in long bones of extremity in children | vertebrae in adults.
53
Risk Factors for osteomyelitis
Injury, sx, circulation problems, invasive medical tubing, IVDU, splenectomy, immunosuppressed, malignancy, bacteremia
54
Microbiology cause of osteomyelitis
o Staph aureus, coag (-) staph, arerobic gram (-) bacilli most common. o Hematogenous osteomyelitis is usually mono microbial o Contiguous may be poly or monomicrobial
55
Clinical Presentation of osteomyelitis acute: subacute: chronic:
Acute: Gradual onset, dull pain @ involved site, worsens at night & exacerbated w/movement. < mobility & possible systemic symptoms -Recent broken bones, immunosuppressed, use of street drugs Subacute: Mild pain over several weeks, minimal fever Chronic: Pain, erythema, swelling, ulcers & fractures that fail to heal
56
PE of osteomyelitis?
Tenderness & warmth, < ROM, spasms of muscle, draining sinus tract
57
Diagnosing of osteomyelitis?
o > WBC, > ESR, > CRP o Blood culture, sinus tract culture, sputum and urine culture to identify primary site of infection. May extend into joint (septic arthritis) o Gold Standard: Isolate bacteria from bone biopsy o X-ray may show osteopenia, soft tissue swelling o CT can detect bony changes earlier that x-ray o ECHO may determine endocarditis
58
Treatment of osteomyelitis
Analgesia, abx (must debride first!), possible bony reconstruction Serial inflammatory markers to assess treatment response
59
Prognosis of osteomyelitis?
Acute > chronic. Chronic may relapse over many years → amputation
60
``` Animal Bites most common in who? what type of animal is most common? what animal are you most concerned about? vaccination? ```
Most commonly in children. Incidence is higher in dogs than cats however infection more common w/cats (Pasteurella multocida) Must consider rabies!
61
Animal Bite Presentation
Irregular, jagged wound, fever, erythema, swelling, tender, draining, lymphadenopathy, streaking up the arm (wound infection)
62
Diagnosing of animal bites
o Gram stain/culture, blood culture o X-ray AP and lateral to r/o presence of foreign body (cat tooth) o US to identify abscess formation
63
what is the treatment of animal bites?
o Wound irrigation and debridement, let wound heal by itself. o ABX prophylaxis if high risk o Tetanus prophylaxis
64
Human Bites Most commonly found on the: Clenched fist injury concern: Infectious agents:
Most commonly found on face, upper extremities, trunk of young kids Clenched fist injury – teeth of one person come in contact with knuckles of another person during fight. When you open hand blood leaves and goes to heart → > chance for infection. Eikenella corrodens, aerobic gram positive cocci and anaerobes
65
Human bite Presentation
Semicircular or oval area of erythema/bruising Skin may or may not be intact Tenderness, erythema, swelling, drainage, streaking/fever = infection
66
Human bite Diagnose
X-ray if bite is close to bone
67
treatment of human bite
Irrigation w/debridement Abx prophylaxis if through dermis, especially if hand involved Do not suture, immobilize for clenched fist injury, and follow up! Tetanus prophylaxis, hepatitis B if not immunized or other person is +
68
Tumors Can arise from: types Metastatic is more common than: Commonly found:
Can arise from bone, cartilage, marrow, vascular structures, synovium Benign, malignant, inflammatory, traumatic Metastatic is more common than primary bone tumors! Commonly found incidentally
69
tumor Presentation
Asymptomatic oftentimes. If symptoms, dull/aching pain, fever and malaise, weight loss → Metastatic disease!
70
Diagnosis of tumor?
bone biopsy for definitive diagnosis X-ray initially, with CT to further assess lesions. MRI to see if soft tissue involved. Bone scan to identify multiple skeletal lesions US to see if lesion is cystic or solid CBC, ESR, CRP,
71
tumor treatment Benign: Metastatic
Benign: Monitor, resect Metastatic: < pain and preserve function. Radiation, chemo, sx
72
Avascular necrosis define: Types: Most common location:
Death of bone tissue due to lack of blood supply Traumatic or non-traumatic (corticosteroid use & > alcohol) Most common location: anterolateral femoral head but can occur elsewhere
73
``` Avascular Necrosis Presentation - - - - ```
Occasionally its are Asymptomatic & diagnosis is incidental If symptomatic – presents late in disease course Unilateral or bilateral Pain - most common symptom occurring w/ weight bearing exercise
74
Avascular Necrosis PE
Nonspecific, < ROM, pain w/ROM Altered gait Antalgic: Shorter time on affected foot Trendelenberg: Wide base gait to shift hip over
75
Avascular Necrosis Diagnosing
X-ray – can be normal for months after symptom onset. → Bone scan Pathognomic crescent sign shows subchrondral collapse MRI IS GOLD STANDARD FOR DIAGNOSIS
76
Compartment Syndrome
Group of 1> muscles and their associated nerves and vessels as well as surrounding fascia has > pressure within a compartment. Circulation and function is impaired.
77
Compartment Syndrome patho ACUTE
Insult occurs (trauma, infection) resulting in > compartment pressure. Venous pressure is elevated and cannot drain. Decreased arterial flow to the muscle Muscle ischemia develops → irreversible damage in 8 hours! Medical emergency! Can be due to constrictive dressing, thermal injury, and penetrating trauma. Anterior leg and anterior (volar) arm is most common.
78
Compartment Syndrome Presentation ACUTE
Pain out of proportion to apparent injury or PE findings Rapid progression of symptoms Sensory hyoesthsia distal to involved compartment Parasthesia Weakness
79
PE findings in acute compartment syndrome
Increased Pain with passive stretching of the muscle in the involved compartment palpation reveals tense compartment < sensation, muscle weakness, pallor is uncommon!
80
Diagnosis of Acute Compartment Syndrome?
Only way to definitely dx is to measure the compartment pressure. No specific measurement, surgeons assess this. Can measure acute compartment syndrome delta pressure: diastolic – measure compartment pressure Acute compartment syndrome pressure: <20-30mmHg → fasciotomy
81
Treatment of acute compartment syndrome:
o IMMEDIATE surgical fasciotomy o Wounds left open with delayed closure o HBO (hypobaric oxygen) may be used as adjunct therapy. Must be done inpatient for insurance to pay, 14 days!!!!
82
Chronic Exertional Compartment Syndrome
Occurs when muscles that are metabolically active during exercise swell pathologically, leading to compression of neurovascular structures within the same muscular compartment. Most common in anterior and lateral compartments Occurs when pt’s have major change in activity level
83
Chronic Exertional Compartment Syndrome Presentation
Gradually increasing pain in specific region – aching, squeezing, cramp Begins after starting activity, resolves with rest. Bilaterally Neurologic symptoms may develop – paraesthesia, numb, weakness
84
Chronic Exertional Compartment Syndrome Diagnosis
Measure compartment pressure for diagnosis | Must do > 1x, look for change → pre and post exercise
85
Chronic Exertional Compartment Syndrome Treatment
Initiate conservative measure, cessation of provocative activity if able, refer for surgical muscle compartment release
86
Peripheral arterial disease Associated with Risk Factors: Presentation:
Associated with lower extremity disease Risk Factors: Hyperlipidemia, smoking, HTN, DM, age Presentation: Asymptomatic, atypical leg pain, claudication, critical limb ischemia
87
Peripheral arterial disease PE May be] Diminished or absent May hear _______ test: (positive!)
May be normal Diminished or absent pulses below level of stenosis, may have normal groin pulses but decreased pulses distally. May hear bruits over stenotic lesion, may have evidence of poor wound healing, signs of ischemia (cool extremity, prolonged venous filling time, shiny atrophied skin, nail changes) Buerger test: Foot pallor with leg elevation (positive!)
88
Peripheral arterial disease Dx:
ABI – ankle brachial index Resting systolic blood pressure at ankle is compared to systolic brachial pressure. Ratio of the equals ABI Segmental pressure, volume recordings, US, CT angiography, MRA
89
Treatment of peripheral Arterial Disease:
oExercise (claudication exercise rehab) o Cilostazol suppresses platelet aggregation and vasodilates o Antiplatelet agents are superior to ASA, ASA still preferred bc cardioprotective. o Pentoxiflylline – relieves claudication o Angioplasty o Surgery o Lifestyle therapy first!

Clinical Medication: HEENT (39 decks)

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