Introduction to Ortho Flashcards
Orthopedics is the study of
The study of the musculoskeletal system including bone, joints, ligaments, tendons, muscles, and supporting neurological and vascular structures
Sprain
Common where?
Uncommon in who?
Treatment of sprains
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
strain:
Common where?
Grades I -IV
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”
what is the clinical presentation of sprain or strain?
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.
what are you PE findings of sprains and strains
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
what is used for diagnosing strains and sprains?
X-ray to r/o fracture.
Consider w/II, III, IV strain or II, III sprain
MRI to evaluate soft tissue injury
what are the Ottawa Ankle Rules
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
Treatment of sprains and strains
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
What types of strains or sprains do you reef?
grade III or severe grade II
Contusion
Result of:
Presents with:
-Result of direct, blunt trauma causing bleeding & soft tissue damage
Presents with activity related pain, swelling, ecchymosis, possible hematoma
Diagnostic evaluation of a contusion?
X-ray to rule out fracture
Treatment of a contusion?
Conservative treatment, drainage if large hematoma
Monitor for compartment syndrome and join instability
Fracture
describe:
Often a/w:
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)
Closed v Open Fractures
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.
types of fractures 1: 2: 3: 4: 5:
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
Treatment of fractures:
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
Open fractures are
URGENT treatment!
What are some factors that improve stability/ increase likelihood of good prognosis?
Young,
1 fracture in forearm/lower leg,
nondisplaced,
Thoracic spine fracture
What factors that worsen tability/ increase likelihood of poor prognosis?
Older, displaced, compartment syndrome, osteonecrosis, oblique, neurologic/vascular injury
Stress Fractures:
Occurs as a result of:
May occur with hx of:
Present:
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
What will a stress fracture present as?
May report > in activity level, gradual onset of localized, activity related pain that progresses to pain at rest
what is the Diagnosis of stress fractures?
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
what is the treatment of stress fractures?
early intervention
Low risk
High risk
Re - evaluate
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
Dislocations
Joint injury that forces ends of bones out of position, commonly dt trauma. May involve ankle, knee, shoulder, hip, elbow, jaw, and finger.
what is the clinical presentation of a dislocation?
Pain, swelling, deformity, < ROM, numb/tingling if nerve involved
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
Subluxation
Occurs when a joint begins to dislocate (partial dislocation) and can occur d/t trauma or underlying conditions that predispose to join laxity
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
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
Risk factors for septic arthritis?
> 80 y.o., DM, RA, gout, prosthetic joint, skin infection, > alcohol
Bacteria in septic arthritis?
Virus, bacteria, or fungi.
Staph Aureus is the most common in those 2 y.o. and older
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
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
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
Treatment of septic arthritis
Empiric IV ABX for 14 days, then 14 days of oral abx
Surgical decompression, splinting of joint
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.
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.
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
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
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.
Treatment of bursitis
Modify activity, analgesia (NSAIDS), splinting, corticosteroids, and surgical excision if relapsing.
If infectious, use broad spectrum abx and/or surgical drainage
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
Presentation of Tendinopathy
Pain > with palpation of affection tendon and tendon loading.
Palpable tendon thickening may be present.
how do you dx Tendinopathy
US and MRI
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
what is the prognosis of tendiopathy?
o Slow, chronic disorder requiring months for complete healing
o Symptoms worsen initially with rehab
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
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”
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
Treatment of tenosynovitis?
Surgical intervention, empiric abx therapy
Osteomyelitis
define:
-
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
Osteomyelitis in children is seen in
in adults?
in long bones of extremity in children
vertebrae in adults.
Risk Factors for osteomyelitis
Injury, sx, circulation problems, invasive medical tubing, IVDU, splenectomy, immunosuppressed, malignancy, bacteremia
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
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
PE of osteomyelitis?
Tenderness & warmth, < ROM, spasms of muscle, draining sinus tract
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
Treatment of osteomyelitis
Analgesia, abx (must debride first!), possible bony reconstruction
Serial inflammatory markers to assess treatment response
Prognosis of osteomyelitis?
Acute > chronic. Chronic may relapse over many years → amputation
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!
Animal Bite Presentation
Irregular, jagged wound, fever, erythema, swelling, tender, draining, lymphadenopathy, streaking up the arm (wound infection)
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
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
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
Human bite Presentation
Semicircular or oval area of erythema/bruising
Skin may or may not be intact
Tenderness, erythema, swelling, drainage, streaking/fever = infection
Human bite Diagnose
X-ray if bite is close to bone
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 +
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
tumor Presentation
Asymptomatic oftentimes. If symptoms, dull/aching pain, fever and malaise, weight loss → Metastatic disease!
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,
tumor treatment
Benign:
Metastatic
Benign: Monitor, resect
Metastatic: < pain and preserve function. Radiation, chemo, sx
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
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
Avascular Necrosis PE
Nonspecific, < ROM, pain w/ROM
Altered gait
Antalgic: Shorter time on affected foot
Trendelenberg: Wide base gait to shift hip over
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
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.
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.
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
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!
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
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!!!!
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
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
Chronic Exertional Compartment Syndrome Diagnosis
Measure compartment pressure for diagnosis
Must do > 1x, look for change → pre and post exercise
Chronic Exertional Compartment Syndrome Treatment
Initiate conservative measure, cessation of provocative activity if able, refer for surgical muscle compartment release
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
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!)
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
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!
