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KChan Saves the World > KC Ortho > Flashcards

KC Ortho Flashcards

1
Q

*What is the upper limit for compartmental pressures?

A

Normal is 0 mmHg
Fasciotomy may indicated when compartmental pressures are 30mmHg
or
when the difference between diastolic blood pressure and compartment pressure (perfusion pressure, also known as the ΔP) is less than 30 mm Hg
If tissue pressure is greater than dBP - tissue perfusion ceases

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2
Q

*What are the contents of the compartments of the lower leg? Name the compartment, one artery, one nerve and one muscle.

A
  • Anterior: Tibialis anterior, long toe extensor muscles, anterior tibial artery, and deep peroneal nerve, which supplies sensation to first webspace of foot
  • Lateral: Peroneus longus and brevus, which evert the foot, superficial peroneal nerve, which supplies sensation to dorsum of foot (no vessel noted)
  • Superficial posterior: Gastrocnemius, plantaris, and soleus muscles, and sural nerve, which supplies lateral side of foot and distal calf (no vessel noted)
  • Deep posterior: Tibialis posterior muscle, long toe flexor muscles, posterior tibial and peroneal arteries, and tibial nerve, which supplies sensation to the plantar aspect of foot
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3
Q

*4 things to do to optimize care pre-fasciotomy

A
  1. Place limb slightly below level of the heart (slight dependency)
  2. Relieve all external pressure on compartment (cast, bandage)
  3. Supportive - analgesia, fluids to maintain normotension
  4. Oxygen to maintain good arterial oxygenation
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4
Q

*Describe appropriate XR view associated with the following:
1. Tibial spine #
2. Scapholunate dislocation
3. Hook of hamate fracture
4. Scaphoid fracture
5. Acetabular fracture

A
  • Tibial spine fracture: Tunnel view
  • Scapholunate dissociation: Clenched first view
  • Hook of hamate fracture: Carpal tunnel view
  • Scaphoid fracture: Scaphoid view
  • Acetabular fracture: Judet view
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5
Q

*What is most common compartment for compartment syndrome in lower leg

A

Anterior compartment

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6
Q

*How would you test the function of the nerve contained in the anterior compartment?

A

Anterior compartment, deep peroneal nerve
Test sensation at dorsal webspace between 1st and 2nd digits of foot

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7
Q

*Recognize a Tillaux fracture and describe the Salter Harris class

A

SH III

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8
Q

*What age is associated with Tillaux fractures?

A

12-15

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9
Q

*What is the pathophysiology of Tillaux fracture?

A

Avulsion of the anterolateral tibia at the site of attachment of the anterior inferior tibiofibular ligament (AITFL).
The medial portion of the epiphysis is closed and so not involved.

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10
Q

vWhat is another injury of the ankle in this age group (similar to Tillaux)?

A

Triplane (younger age group though)

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11
Q

*What is the mechanism of injury in Tillaux fracture?

A

Supination and external rotation

think S-EX

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12
Q

*What are the most common nerves injured in the fractures and dislocations listed below?
A) Radius
B) Olecranon
C) Anterior shoulder dislocation
D) Humerus Fracture
E) Acetabular
F) Posterior Hip
G) Knee Dislocation
H) Tibial Plateau Fracture

A

A) Radius - Median
B) Olecranon – Ulnar or Median
C) Anterior shoulder dislocation - Axillary
D) Humerus Fracture - Radial
E) Acetabular - Sciatic
F) Posterior Hip – Sciatic or Femoral
G) Knee Dislocation – Peroneal or Tibial
H) Tibial Plateau Fracture - Peroneal

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13
Q

*Which bones get AVN?

A
  • Scaphoid
  • Femoral Head
  • Navicular
  • Capitate
  • Lunate
  • Talus
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14
Q

Describe the Salter Harris classification of fractures

A

Used to describe epiphyseal fractures in a child: Straight across, Above, Lower, Through both upper and lower segments (Two!), Erasure of the growth plate

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15
Q

Describe the classification of open fractures

A

Gustilo and Anderson
Grade 1 wound <1 cm
Grade 2 would 2-10 cm
Grade 3 wound >10 cm, extensive soft tissue damage, periosteal stripping
Grade 3a adequate soft tissue coverage and vascular
Grade 3b inadequate soft tissue coverage, vascular intact
Grade 3b inadequate soft tissue coverage, arterial damage

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16
Q

What antibiotics should be used in open fractures

A

Grade 1 and 2: Ancef
Grade 3: Anceft + Gentamicin
Consider tenatus and tetanus immunoglobulin for large wounds, penicillin for farm wounds

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17
Q

List the complications of fractures

A

Hemorrhage, vascular injury, avascular necrosis, nerve injury, infection/osteomyelitis, compartment syndrome, fat emobolism

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18
Q

List causes of compartment syndrome

A

Increased compartment contents: bleeding, fractures, drug injection, snakebites, burns
Decreased compartment volume: closure of fracture defects, traction of limbs
External pressure: casts, limb compression tourniquet

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19
Q

Define dislocation and subluxatiobn

A

Dislocation: complete loss of continuity between two articulating surfaces, subluxation is partial loss of continuity

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20
Q

Define ‘sprain’ and describe its classification

A

A sprain is injury to the fibers of the ligaments in the joint
First degree: minor tearing, swelling and pain but no laxity
Second degree: partial tear, some abnormal motion
Third degree: complete tear, abnormal joint motion and instability

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21
Q

Define strain

A

Injury to the muscle/tendon unit

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22
Q

List risk factors for tendon injury

A

Meds (steroids, fluoroquinolone), smoking, diabetes, malignancy, chronic kidney disease, lupus

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23
Q

Describe the process of fracture healing

A

Hematoma, inflammation with granulation tissue, callus (2-4 weeks), resorption of callus, remodelling (2-4 months)

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24
Q

List terms that can be used to describe a fracture

A

Openor close, anatomic location, direction, simple vs. comminutes, angulation, displaced

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25
Q

What are false positives for fractures on x ray

A

Nutrient vessel, anomalous bones, pseudofractures due to soft tissue folds/bandages

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26
Q

*Man had a splinter in his finger a week ago. He used a pair of scissors to remove the splinter, now coming to ED because of increasing tenderness to finger. 3 Ddx

A

Felon
Paronychia
Herpetic whitlow
FB

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27
Q

*Most common organism

A

Staph aureus

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28
Q

*2 managements

A

I&D
Abx
Removal of FB
Soaks

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29
Q

*2 complications of I&D

A

Deep incision may injure the flexor tendon sheath. Incision and drainage of structures crossing the DIP flexor crease increases the risk of infection spread, flexor tenosynovitis, septic arthritis, and proximal osteomyelitis. Incisions affecting the neurovascular bundle may result in vascular insufficiency, fingertip anesthesia, or neuroma. Longitudinal volar fat pad incisions can result in thick scarring and fingertip anesthesia.

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30
Q

*5 complications of not treating it

A

Skin necrosis,
Sinus tract formation,
Chronic drainage.
Dorsal spread can lead to phalangeal tuft necrosis and osteomyelitis.

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31
Q

*2 ddx herpetic whitlow

A

HSV
dyshidrotic eczema
burn
VZV

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32
Q

*How to Dx or confirm herpetic whitlow

A

PCR

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33
Q

*What is a boxer’s fracture and what age and gender sustains the injury the most?

A

Fracture of the 5th metacarpal neck, occasionally the 4th. Males 10-19

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34
Q

*Woman had a cat bite to finger. Concern now for flexor tenosynovitis. Name 4 signs suspicious for flexor tenosynovitis (i.e., list Kanavel’s sign).

A

(1) palpable tenderness along the tendon sheath; (2) pain on passive extension of the digit; (3) symmetric digital swelling; and (4) digit fixed in a semiflexed position.

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35
Q

*What is the mechanism of injury of a boxer’s fracture?

A

Punching with the dominant hand in a clenched fist. Falls are the most common mechanism for patients younger than 9 and older than 50 years.

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36
Q

*What are two anatomical reasons why a boxer’s fracture is unstable

A
  • Degrees of motion permitted at MCP joints (abduction-adduction, flexion- extension)
  • Unstable fracture patterns (e.g. comminuted, spiral, oblique, intra- articular)

Neck is weakest part of the bone
Extrinsic flexors pull distal segment dorsally

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37
Q

*5 management things you would do once patient with boxer’s fracture has had analgesia and anesthesia?

A

• Analgesia/anesthesia
• Reduction
•. Recheck NV status
• Splinting (wrist extended 30 degrees, MCP joint flexed to 90 degrees, PIP/DIP kept in extension)
• Post-reduction X-rays
• Follow-up with hand surgeon

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38
Q

*What are 4 complications of boxer’s fracture

A

Avascular necrosis, nonunion, misalignment, interosseous muscle or tendon injury or fibrosis, and chronic stiffness may occur.

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39
Q

*What is the timeline for referral for boxer’s fracture

A

1 week

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40
Q

*What are the instrinsic hand muscles innervated by the median nerve?

A

LOAF
Lateral two lumbricals
Opponens pollicis
Adbuctor pollicis brevis
Flexor pollicis brevis

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41
Q

*What is one test that you can do to determine if there is an UCL injury?

A

Valgus stress testing

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42
Q

*How do you determine if it is complete or incomplete UCL injury?

A

• UCL laxity on valgus stress (e.g. gentle abduction of stabilized MCP joint):
- > 15 degrees than unaffected side, suggests incomplete injury
- > 35 degrees than unaffected side, suggests complete injury

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43
Q

*What is the x-ray finding associated with a complete UCL injury?

A

Stener lesion

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44
Q

*Describe the pathophysiology of why a complete UCL injury (Stener lesion) does not heal

A

the avulsed ligament is displaced above the aponeurosis

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45
Q

*What is the emergency department management of a complete UCL rupture vs. incomplete UCL rupture?

A

• Incomplete: Thumb spica immobilization and outpatient hand service referral, may not require surgery
• Complete: Thumb spica immobilization and outpatient hand service referral, likely will need surgery

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46
Q

*Name two long-term complications of UCL injury

A

• Chronic instability
• Chronic pain
• Decreased pinch strength

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47
Q

*List 2 absolute contraindications to reimplantation of an amputated limb

A

• Amputations in unstable patients secondary to other life-threatening injuries
• Multiple-level amputations
• Self-inflicted amputations
• Single-digit amputations proximal to FDS insertion
Severely crushed, avulsed or mangled parts
Prolonged warm ischemia time
Severely arteriosclerotic vessels

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48
Q

*4 indications for reimplantation of an amputated limb

A

• Multiple digits
• Thumb
• Wrist and forearm
• Sharp amputations with minimal to moderate avulsion proximal to the elbow
• Single digits amputated between PIP joint and DIP joint (distal to flexor digitorum superficialis [FDS] insertion)
• All pediatric amputations

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49
Q

*How should an amputated part be transported?

A

The amputated part should then be wrapped in normal saline–moistened gauze, sealed in a dry plastic bag, and placed on ice in an insulated container. The stump should be covered with saline-moistened sterile dressings and elevated to reduce edema and control bleeding.

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50
Q

*List 3 nerves that supply the hand and the best sensory and motor test for each

A

Median - index finger pad - OK sign
Ulnar - pinky finger pad - spread fingers against resistance
Radial - Dorsal hand near 1st webspace - Thumb or wrist extension

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51
Q

*What are stages of carpal instability

A

Mayfield classification: Each of four stages (I–IV) represents a sequential intercarpal ligament injury proceeding around the lunate.
1. Terry Thomas sign (scapho-lunate widening)
2. Perilunate dislocation
3. Dislocation triquetrum
4. Lunate dislocation

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52
Q

*List types of distal radius fractures and their mechanisms of injury

A
  • Colles’ fracture: Transverse fracture of distal radial metaphysis that is dorsally displaced and angulated (FOOSH)
  • Smith’s fracture: Transverse fracture of distal radial metaphysis that is volarly displaced and angulated (FOFlexedH)
  • Barton’s fracture: Oblique, intra-articular fracture of the rim of the distal radius, with displacement and dislocation of the carpus along with the fracture fragment (FOOSH)
  • Chauffeur’s fracture: Intra-articular fracture of the radial styloid (now FOOSH)
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53
Q

*Criteria to reduce a Colles fracture

A
  • Neurovascular compromise
  • Significant deformity
  • Soft tissue tension or tenting of skin
  • Radial shortening significant
  • Correction of dorsal angulation, especially when greater than 20 degrees
  • Restoration of anatomic volar tilt
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54
Q

*Identify all the carpal bones on a diagram.

A

Straight line to pinky, here comes the thumb

Scaphoid
Lunate
Triquitrium
Pisiform
Hamate
Capitate
Trapezoid
Trapizium

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55
Q

*Volar laceration to wrist: List 6 tendons that could be affected and how to test for this

A

Palmaris longus
Flexor carpi ulnaris and radialis
Flexor digitum profundus (4) and superficialis (4)
Flexor pollicis longus

Think
Flex fingers long, flex fingers short, flex hand on ulnar side, flex hand on radial side, flex thumb long, flex palm long

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56
Q

What bones in the hand are at a risk of avascular necrosis?

A

Scaphoid, capitate, lunate

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57
Q

Describe the difference between lunate and perilunate dislocation?

A

Perilunate: lunate continues to articulate with the radius, capitate is displaced
Lunate: capitate and radius continue to stay aligned, lunate is displaced

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58
Q

What nerve injury is associated with 1) Colles fracture 2) Smith fracture 3) Monteggia fracture 4) pisiform fracture

A

1) Median nerve injury
2) Median nerve injury
3) Posterior interosseous nerve
4) Ulnar nerve injury; runs in Guyon’s canal close to the pisiform

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59
Q

Which wrist fractures are intra articular by definition?

A

Barton’s, Chauffeur

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60
Q

Which wrist injuries are associated with DRUJ instability?

A

Colle’s (not all), Essex-Lopresti, Galeazzi

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61
Q

What are the compartments of the forearm?

A

Volar: pronators and flexors of the hand and wrist; ulnar, median, superficial radial, and anterior interosseous nerve; ulnar, radial, and anterior interosseous artery
Dorsal: Finger extensors and long thumb abductor, posterior interosseous nerve, posterior interosseous artery
Mobile (lateral): extensor carpi radialis brevis and longus, brachioradialis

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62
Q

Compare Monteggia, Galeazzi, and Essex-Lopresti forearm fractures

A

Monteggia: Fracture in ulnar with dislocation of radial head at the elbow
Galeazzi: Fracture in the distal radius with dislocation in the DRUJ
Essex-Lopresti: Fracture in distal radius with dislocation in the DRUJ AND disruption of interosseous membrane

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63
Q

What are six risk factors for carpal tunnel

A

Acromygaly
Hypothyroidism
Obesity
DM
Pregnany
Renal failure
RA

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64
Q

*What is the most common nerve injured in humerus fracture? In Elbow dislocation?

A

Radial, Median > Ulnar

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65
Q

List the nerves injuries associated with the follow fractures 1) humerus 2) supracondylar fracture 3) olecranon fractures 4) elbow dislocation

A

1) Radial nerve 2) anterior interosseous nerve (part of the median nerve) 3) ulnar nerve 4) median nerve

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66
Q

What is the presentation of a radial nerve injury?

A

Wrist drop

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67
Q

List 4 radiographic signs of supracondylar fractures

A

1) Displaced anterior humeral line 2) Displaced radiocapitellar line 3) Posterior sail sign 4) Abnormal Baumann’s angle

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68
Q

Explain the classification system for supracondylar fractures

A

Based on Gartland. Type 1 - no displacement. Type 2 - displaced but posterior cortex intact. Type 3 - no cortical contact

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69
Q

List the order of ossification in the Elbow

A

CRITOE Capitellum age 1, radial head age 3, internal (medial epicondyle) age 5, trochlea age 7, olecranon, age 9, external (lateral) epicondyle age 11

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70
Q

What is Volkmann’s contracture

A

Permnanent contracture of the hand and wrist, resulting in a claw like deformity due to ischemia of the muscles of the forearm. Associated with brachial artery injury in supracondylar fractures

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71
Q

*What nerve is injured with anterior shoulder dislocation and what muscle does it innervate?

A
  • Axillary nerve – Deltoid
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72
Q

*What findings on x-ray are suggestive of increased risk for future (shoulder) dislocations?

A
  • Hill-Sachs lesion
  • Bankart lesion
  • Glenoid rim fracture
  • Flattened or shallow anterior bony contour
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73
Q

*5 reduction techniques for anterior shoulder dislocations

A
  • Stimson (hanging weight)
  • Traction/countertraction
  • Scapular manipulation
  • External rotation
  • Cunningham
  • Milch
  • FARES
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74
Q

*List 3 long term complications of shoulder dislocation

A
  • Fractures (Hill-Sachs, Bankart, glenoid)
  • Neurovascular injury (axillary nerve, brachial Plexes)
  • Rotator cuff tear
  • Recurrence
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75
Q

*List 3 common mechanisms for posterior shoulder dislocation

A
  • Fall onto outstretched hand with arm held in flexion, adduction, and internal rotation
  • Direct blow
  • Convulsive seizures
  • Electrical shock
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76
Q

*What are 3 acute complications of anterior shoulder dislocations?

A

• Fracture (e.g. Hill-Sachs deformity, Bankart’s lesion, glenoid rim)
• Neurovascular injury (e.g. axillary nerve injury)
• Rotator cuff tears
• Recurrence

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77
Q

*What are 3 intrinsic (i.e. MSK) causes of shoulder pain

A

• Dislocation (e.g. anterior, posterior, inferior)
• Fracture (e.g. Hill-Sachs deformity, Bankart’s lesion, glenoid rim)
• Rotator cuff tear
• Impingement syndrome
• Arthritis (e.g. OA, Rh arthritis, gout, pseudogout, septic)
• Biceps tendonitis
• Calcific tendonitis
• Adhesive capsulitis (e.g. frozen shoulder)
• Bursitis

78
Q

*What are 3 extrinsic (ie. Non-msk) casuse of shoulder pain

A

• C-spine
• Thoracic outlet syndrome
• Pancoast tumors
• MI
• Diaphragmatic irritation (pneumonia, subphrenic abscess, splenic hematoma, ruptured ectopic, gallbladder)

79
Q

*What are 2 clinical exam findings of a complete rotator cuff tear?

A

• Drop-arm test: Passively abduct arm to 90 degrees and ask patient to hold harm in position (particularly sensitivity for supraspinatus tear)
• Point tenderness at site of rupture
• Inability to abduct shoulder

80
Q

*What imaging would you use to diagnose complete rotator cuff tear?

A

MRI

81
Q

*List complications of shoulder dislocation

A

rotator cuff tear, axillary nerve injury, associated fracture (ex. Bankhart), adhesive capsulitis

82
Q

*What are 6 red-flag history or physical exam findings for a serious cause of low back pain?

A
  • History of malignancy
  • Fever with localized back pain
  • Back pain with history of IV drug use, recent tattoo, or bacterial source
  • New neurological deficit (loss of bowel or bladder function or saddle anesthesia)
  • Direct trauma
  • Worsening pain after spinal surgery
  • Sudden onset of back pain in patients on anti-coagulants
  • Recent spinal procedure, such as epidural injection
83
Q

*Besides MSK causes, list 6 causes of acute extraspinal low back pain

A
  • Chest: Aortic dissection, pulmonary embolism, pneumonia, pleural effusion
  • Abdominal: Ruptured or expanding aortic aneurysm, penetrating peptic ulcer disease, pancreatitis, pancreatic cancer, biliary colic, cholecystitis
  • Genitourinary: Renal colic, prostatitis, perinephric abscess, pyelonephritis, ovarian torsion or tumor, pelvic inflammatory disease, endometriosis, “back labour during contractions”
  • Other: Herpes zoster, retroperitoneal hemorrhage, psoas abscess
84
Q

*What are 4 physical exam findings of epidural compression?

A
  • Urinary retention (post-void residual greater than 100-200 ml)
  • Loss of rectal sphincter tone
  • Loss of sensation in saddle distribution
  • Weakness in multiple, bilateral nerve roots
  • Severe pain in multiple, bilateral nerve roots
85
Q

*Young and Burgess categories and mechanism for each

A

AP compression
Lateral compression
Vertical shear

86
Q

*4 ways to treat pelvic hemorrhage in trauma

A

Reversal of ACO
Pelvic binding
Angiography
Pelvic packing in OR

87
Q

*Avulsion fracture of the anterior inferior iliac spine (AIIS): pathophysiology of this injury

A

The incidence of avulsion fractures is increasing as a result of the growth of competitive sports participation, especially in teenage athletes. The muscular origin of this type of injury commonly involves the pelvic apophyses, which might not fully ossify until age 25. Avulsion at the site of the growth plate is the result of sudden maximal muscular exertion. It can occur with rapid acceleration or sudden changes in speed or direction. The athlete classically experiences a sudden piercing pain at the site of injury, along with a “snapping” or “popping,” and frequently falls to the ground because of the intensity of this pain.

88
Q

*What are other pelvic/hip injuries of this nature: Avulsion fracture of the anterior inferior iliac spine (AIIS)

A

• Iliac crest/abdominal muscles
• Anterior superior iliac spine/sartorius
• Anterior inferior iliac spine/rectus femoris
• Greater trochanter/gluteus medium and minimus
• Lesser trochanter/iliopsoas
• Symphysis/adductor
• Ischial tuberosity/hamstring

89
Q

*Label parts of a pelvis diagram

A

1 - iliac fossa
2 - iliac crest
3 - anterior superior iliac spine
4 - anterior inferior iliac spine
5 - symphysis pubis
6 - superior ramus of pubis
7 - inferior ramus of pubis
8 - ramus of ischium
9 - ischial tuberosity
10 obturator foramen

90
Q

*What are FOUR radiographic clues to a posterior arch fracture?

A
  • Avulsion of L5 transverse process
  • Avulsion of ischial spine
  • Avulsion of lower lateral lip of sacrum (sacrotuberous ligament)
  • Displacement at the site of a pubic ramus fracture
  • Asymmetry or lack of definition of bone cortex at superior aspect of sacral foramina
91
Q

*Other than vascular injuries, list five pelvic injuries associated with pelvic fractures

A

Bladder disruption
Urethral disruption
Gynecologic injury
Plexopathy
Radioculopathy

92
Q

*List three diagnostic modalities other than AP pelvic XR in the diagnosis of pelvic fractures

A

Inlet/outlet views
CT
?MRI

93
Q

*What are the 4 types of hip dislocation?

A

Anterior, posterior, central, and inferior types

94
Q

*Name 4 complications of hip dislocation?

A

AVN, traumatic arthritis, sciatic nerve palsy (foot drop), and joint instability, acetabular fracture, femoral head fracture

95
Q

*What is the blood supply to the femoral head?

A

Branches of the deep femoral artery

96
Q

*What are 3 mechanisms of ACL injury

A

Plant and pivot
Jump and stop
Blow to flexed knee
Turf injury with knee flexed and ankle plantar flexed

97
Q

*Three XR findings of ACL injury

A

Effusion?
Lateral capsular sign
Fracture of the posterior aspect of the lateral tibial plateau
Deep lateral sulcus
Actuate fracture
Segond fracture

98
Q

*Knee is maybe dislocated, 3 initial steps

A

Check NV status
Reduce
Recheck NV status
Immobilize

99
Q

*Associated injuries with ACL injury (2)

A

“Unhappy triad”: ACL, MCL and meniscus (medial or lateral)

100
Q

*3 signs of dislocation on exam or XR

A

NV injury
Large effusion
Grossly disfigured
Large knee ecchymosis
(these are all guesses)

101
Q

*What abnormality is often associated with a Segond fracture?

A

ACL/MCL injuries, ACL being the more common

102
Q

*What are 4 complications of a tibial plateau fracture?

A

Varus/valgus deformities
Popliteal artery injury
Peroneal nerve injury
Ligamentous injruy (ACL/MCL)

103
Q

*Subtalar dislocation: why might reduction be impossible?

A

Closed reduction may be impossible because of buttonholing of the talus through the extensor retinaculum, entrapment in the peroneal tendons, or associated fractures.

104
Q

*What is the most common cause of lateral ankle pain following mild trauma?

A

ATFL (anterior talo-fibular liagement) sprain

105
Q

*What is your differential diagnosis for traumatic lateral ankle pain

A
  • Lateral collateral ligament sprain (i.e. anterior talofibular ligament, calcaneofibilar ligament, posterior talofibular ligament)
  • Peroneal tendon dislocation
  • Osteochondral lesion of the talar dome
  • Fracture of the posterior process of the talus
  • Fracture of the lateral process of the talus
  • Fracture of the anterior process of the calcaneous
  • Midtarsal joint injury
  • Fracture of the base of the fifth metatarsal
106
Q

*List 4 immediate management priorities for knee dislocation

A
  • NV status pre and post reduction (e.g. pedal pulses, cool/mottled foot, expanding popliteal hematoma, popliteal hemorrhage, asymmetrical pedal pulses, paresthesias, ankle-brachial index)
  • Reduction
  • Immobilization with knee in 15-20 degrees of flexion
  • Orthopaedic surgery/Vascular surgery consultation
107
Q

*What is the most common vascular injury in knee dislocation

A

Popliteal artery injury

108
Q

*What is the best test to assess for popliteal artery injury in patient with cold foot and knee dislocation

A

CT angiogram/Direct to OR for surgical exploration

109
Q

*List 5 complications of knee dislocation

A

Deep venous thrombosis (delayed)
Arterial thrombosis (delayed)
Compartment syndrome
Pseudoanuerysm
Heterotopic ossification (delayed)
Multiple ligament injuries
Common peroneal nerve injury, posterior tibial nerve injury
Limb ischemia
Femur and tibia fractures

110
Q

*What 6 bones make up the lisfranc joint?

A

This joint is composed of the articulations of the bases of the first three metatarsals with their respective cuneiforms and the fourth and fifth metatarsals with the cuboid.

111
Q

*What are the 3 most common mechanisms of a lisfranc injury

A

Lisfranc injuries arise from three mechanisms—rotational forces, whereby the body twists around a fixed forefoot; axial loads, whereby the weight of the body drives the hindfoot into the bases of the metatarsals; and crush injuries.

112
Q

*What are three physical exam findings of lisfranc injury?

A
  • Inability to weight bear, particularly on the toes
  • Edema and ecchymosis in the midfoot
  • Tenderness along the affected tarsometatarsal joints
  • Pain with passive abduction and pronation of the forefoot, sometimes with pathologic mobility
  • Dorsalis pedis pulse may be absent
113
Q

*List one abnormality you would see on an X-ray with a lisfranc injury for each of the following views: AP, lateral, and oblique.

A

Anteroposterior View
Loss of alignment of the medial border of the second metatarsal with the medial cuneiform
Presence of a fleck sign from avulsion of the Lisfranc ligament
Diastasis > 2 mm between base of the first and second metatarsals
Compared to the uninjured foot: difference > 1 mm between base of the first and second metatarsals
Oblique View
Loss of alignment between the medial border of the fourth metatarsal and medial border of the cuboid
Lateral View
Loss of alignment between the plantar aspect of the fifth metatarsal and the medial cuneiform
Loss of dorsal alignment of tarsals with their respective metatarsals (step off sign)

114
Q

*What are three other imaging options other than x-ray for Lisfranc?

A
  • CT scan
  • MRI
  • Weight-bearing X-rays
115
Q

*What are 4 management steps for Lisfranc?

A
  • Orthopedic surgery consultation (in ED if high energy/displaced)
  • Immobilization in below-knee cast pending orthopedic follow-up
  • Non weight-bearing for 12 weeks (6 weeks for sprain)
  • Orthotic for 1 year
116
Q

*What are the elements of the Ottawa ankle rules

A
  • Bone tenderness at posterior edge or tip of distal 6 cm of lateral malleolus
  • Bone tenderness at posterior edge or tip of distal 6 cm of medial malleolus
  • Inability to bear weight for at least 4 steps both immediately and in the emergency department
117
Q

List 6 potential limb threatening conditions requiring hand consultation

A

Compartment syndrome, crush injury, high pressure injection injury, open fracture, amputation, vascular injury, limb threatening infection, burns, dislocation, complex fractures

118
Q

List the components of the carpal tunnel

A

4x flexor digitorum profundus, 4x flexor digitorum superficialis, flexor pollicis longus, median nerve

119
Q

Which flexors are NOT in the carpal tunnel

A

Flexor carpi radialis, flexor carpi ulnaris, palmaris longus

120
Q

Explain how finger extension is possible despite a complete tendon laceration

A

Junction tendinum connects the extensors of the fingers; a laceration proximal to this will allow for preserved extension

121
Q

What are the borders of the anatomic snuffbox

A

Abductor pollicis longus, abductor pollicis brevis, extensor pollicis longus

122
Q

Describe the difference between a Bennett and Rolando fracture

A

Bennett: intra-articular fracture to the base of the thumb
Rolando: comminuted Bennett involving at least 3 fragments, often in a T or Y configuration

123
Q

Which flexor tendons can be repaired in the ED

A

None

124
Q

Which extensor tendons can be repaired in the ED

A

Zone 4-6 (PIP, MCP/PIP join, and over MCP)

125
Q

List two extensor tendon injuries of the hand

A

Mallet finger: forced flexion of an extended finger, results in a swan neck deformity and inability to extend the DIP joint. Needs dorsal splint

126
Q

List a flexor tendon injury of the hand

A

Jersey finger: forced extension of a flexed finger (ex. grabbing a jersey). Unable to flex DIP.

127
Q

What palsy would result from a radial, median, and ulnar nerve injury

A

Wrist drop, claw hand, benediction sign

128
Q

What are the 4 muscle groups of the hand and how are they innervated

A

Thenar, hypothenar, interosseous, lumbricals. All hand muscles are innervated by the ulnar nerve except the LOAF: lateral two lumbricals, opponens pollicis, abductor pollicis brevis, flexor pollicis brevis

129
Q

List the muscles of the rotator cuff, their actions, and innervation

A

Supraspinatus: abduction, subscapularis
Infraspinatus: external rotation, subscapularis
Teres Minor: external rotation, axillary
Subscapularis: internal rotation and adduction, subscapular

130
Q

What is the motor and sensory function of the axillary nerve

A

Motor (deltoid) arm abduction. Sensory deltoid muscle

131
Q

Describe the classification of acromioclavicular joint separation

A

Rockwood classification
Grade 1: strain, some tear of the ligaments but the joint is intact
Grade 2: partial tear with subluxation of the AC ligament
Grade 3: full tear and dislocation (<100%) of the AC ligament and CC ligament
Grade 4: Grade 3 + posterior displacement
Grade 5: Grade 3 + anterior displacement >100%
Grade 6: Grade 3 + inferior displacement

132
Q

Describe the classification of clavicular fractures

A

Allman classification
Group 1: middle third of the clavicle
Group 2: lateral third of the clavicle. Type 1 - CC ligament intact. Type 2 - CC ligament is torn + clavicle is displaced. Type 3 - involves the articular surface
Group 3: medial third of the clavicle

133
Q

Describe the classification of humeral head fractures

A

Neers: based on the number of displaced parts regardless of number of fracture lines
1 part: Minimal displacement (any number of fracture lines)
2 part: 2 displaced parts; can be through the anatomic neck (anatomic is near the articular surface), surgical neck, greater tuberosity, or lesser tuberosity
3 part: 3 displaced parts; i.e. floating greater or lesser tuberosity
4 part: 4 displaced parts

134
Q

What are clinical signs of impingement syndrome

A

Provocative tests: painful arc, Hawkins Kennedy, empty can

135
Q

What are clinical signs of rotator cuff tear

A

Reduced active ROM (passive is usually preserved). Pain with provocative tests ex. painful arc

136
Q

List x ray findings of an anterior shoulder dislocation

A

AP: humeral head not in glenoid fossa, Transcapular: humerus anterior the glenoid, Hill-Sachs or Bankart

137
Q

List x ray findings of posterior shoulder dislocation

A

AP: Lightbulb sign (internal rotation causes the humeral head to lose its asymmetrical appearance), Rim sign (distance between the glenoid rim and humeral head is increased), Reverse Hill Sachs, Trough sign (compression fracture through medial humeral head), Transcapular: posterior displacement

138
Q

How would you reduce a posterior dislocation

A

Traction, adduction, internal rotation. Needs to be splinted

139
Q

List complications of humeral head fracture

A

Adhesive capsulitis, AVN, neurovascular injury, myositis ossificans

140
Q

List indications for emergent ortho consult for clavicular fractures

A

Tenting, open, neurovascular compromise, interposition of soft tissue, comminuted, severe displacement

141
Q

Describe the difference between anterior and posterior sternoclavicular dislocations

A

Grade 1: mild sprain, Grade 2: partial tear with subluxation, Grade 3: complete rupture
Anterior: clavicle displaced anteriorly. more common. May have cosmetic outcomes, but often can be managed with a sling and outpatient orthopedics
Posterior: clavicle displaced posteriorly. Less common. More dangerous and risk of intrathoracic and mediastinal injuries ex. subclavian laceration, pneumothorax, esophageal rupture, myocardial contusion, brachial plexopathy, tracheal tear, thoracic outlet syndrome. Orthopedic emergency and may require reduction

142
Q

List indications for advanced imaging studies in the ED

A

History of malignancy, fever with localized back pain, hx of IV drug use, new neurologic deficit (ex. loss of bladder or bowel function, saddle anesthesia), direct trauma, worsening pain after surgery, sudden onset back pain in a patient on anticoagulants, recent spinal procedure ex. epidural injection

143
Q

What is the most common site of disc herniation

A

L4/L5, L5/S1

144
Q

List 6 causes of cauda equina syndrome

A

Disc herniation, epidural abscess, epidural hematoma, tumor/malignancy, spinal stenosis from aging, vertebral body fracture

145
Q

List 3 types of primary spinal tumor

A

Osteosarcoma, Ewing sarcoma, Multiple myeloma

146
Q

List 8 sources of vertebral metastasis

A

Lung, breast (top 2), lymphoma, multiple myeloma, melanoma, prostate, kidney, GI

147
Q

List the ligaments that make up the posterior pelvic ring

A

SacroSpinous ligament, sacroTuberous ligament, Anterior sacroIliac ligament (STI)

148
Q

What is the vascular injury associated with a posterior pelvic arch fracture? pubic rami injury?

A

Superior gluteal artery, obturator and pudendal artery injury

149
Q

Describe the Tile Classification of Pelvic fractures

A

See notes

150
Q

Describe the Young-Burgess Classification of Pelvic fractures

A

See notes

151
Q

List the tendons associated with the following avulsion fractures 1) ASIS 2) Anterior inferior iliac spine 3) less trochanter 4) pubis 5) ischial tuberosity 6) iliac crest

A

1) Sartorius 2) rectus femoris 3) iliopsoas 4) adductors and gracilis 5) hamstrings 6) abdominal muscles

152
Q

Describe the classification for acetabular fractures

A

Type A: fracture of one column, anterior or superior
Type B: transverse through both columns, but a portion of the acetabulum is still attached to the ileum
Type C: transverse through both columns but no piece remaining is attached to the ileum

153
Q

Describe the classification for vertical sacral fractures

A

1) Lateral to the foramina 2) involving the foramina 3) involving the central canal (high risk of neurologic injuries)

154
Q

List 6 things on the differential for a painful hip without a fracture

A

Hip: AVN, transient synovitis, septic arthritis, bursitis, tendonitis, SCFE, Perthes disease
Hip: AVN, transient synovitis, septic arthritis, bursitis, tendonitis, SCFE, Perthes disease
MSK: Referred pain (back or knee), herniated disk, inguinal hernia
Vascular: DVT, arterial insufficiency, retroperitoneal hematoma
Infection: psoas abscess, discitis, inguinal lymphadenopathy

155
Q

List 8 causes of AVN

A

Femoral neck fracture, posterior dislocation, steroid use, alcohol use, lupus, sickle cell, antiphospholipid syndrome, infections (HIV, pancreatitis)

156
Q

List 5 cancers that metastasize to bone

A

Lung, kidney, breast, thyroid, prostate (the ‘double’ organs)

157
Q

LIst 5 methods for relocating a hip

A

Allis: pull up on the leg when knee and hip flexed to 90 degrees while an assistant pushes down on the ASIS, rotate the femur internally. Often need to stan on the bed
Bigelow: wrap your arm under the leg when knee and hip are flexed to 90 degrees and pull up while an assistant pushes on the ASIS
Captain morgan: flex the knee and hip 90 degrees over your knee. Lift up with your knee while pulling down on the patient’s ankle
Stimon: place the patient prone with hips and knees hanging off the bed and flexed to 90 degrees. Provide downward traction on the femur while an assistant stabilizes the pelvis
Whistler: bend the patient’s knee over your arm and rest your hand on their ipsilateral bent knee. Use your arm as a fulcrum to lift the hip up and out

158
Q

Describe 4 types of hip dislocation

A

Posterior: most common (esp in dashboard MVC injuries). Leg is internally rotated and adducted. X ray shows smaller LT and femoral head with disruption in Shenton’s line. Risk of sciatic/peroneal injury
Anterior: less common, leg is externally rotated and abducted (like a frog). X ray shows a larger femoral head and LT. Risk of femoral nerve damage
Central: entire head is forced through a comminuted fracture of the acetabulum. Not a true dislocation
Inferior: luxatio erecta femoris, very rare

159
Q

List the structures in the compartments of the thigh

A

See notes

160
Q

What is the significant of an intracapsular vs. extracapsular fracture

A

Intracapsular: higher risk of AVN, blood supply to femoral head is compromised, lower risk of hypotension. Ex. femoral head and neck
Extracapsular: lower risk of AVN, but higher risk of hypotension

161
Q

What are contraindications for traction in a femur fracture

A

Open fracture, pelvic fracture, distal tib/fib fracture, knee ligamentous injury

162
Q

What nerves are blocked in a fascia iliaca block

A

Femoral, lateral cutaneous, and obturator nerve

163
Q

What fascias do you go through in a fascia iliaca block

A

Fascia lata and fascia iliac

164
Q

List the differential for sudden onset calf pain with swelling

A

Fracture, compartment syndrome, necrotizing fasciitis, DVT, thrombophlebitis, achilles tendon rupture, plantaris strain, gastrocnemius strain, baker’s cyst rupture

165
Q

List risk factors for extensor tendon rupture

A

Steroid use, fluoroquinolones, RA, gout, lupus, hyperparathyroidism, immunosuppression

166
Q

List the compartments of the lower leg and their components

A

Anterior: tibialis anterior (toe extension), anterior tibial artery, deep peroneal nerve (sensation to first webspace)
Lateral: foot evertors (peroneus longus and brevis), superficial peroneal nerve (sensation to dorsum of the foot)
Superficial posterior: gastrocnemius, plantaris, soleus, sural nerve (sensation to lateral foot)
Deep posterior: tibialis posterior (plantar flexion), posterior tibial and peroneal arteries, tibial nerve (sensation to plantar foot)

167
Q

List 6 overuse syndromes

A

Patellofemoral pain, IT band syndrome, peri patellar tendonitis, plica syndrome, popliteus tendinitis, bursitis

168
Q

What is the Insall-Salvati ratio

A

Used to diagnose a high or low riding patella
Patella Baja (low lying) <0.8 - often indicates quads tendon rupture
Patella Alta (high lying) >1.2 - often indicates a patella tendon rupture

169
Q

Describe the classification of the tibial plateau fractures

A

1: split of the tibial plateau
2: split and depression
3: pure depression
4: pure depression of the medial side
5: pure depression of both sides of the tibial plateau
6: fracture through the metaphysis

170
Q

Describe the Ottawa Knee Rule

A

Inclusion: Adult patients with acute blunt injury to the knee
Exclusion: <18 y/o, pregnant, isolate soft tissue without bony involvement (ex. laceration), referred with radiographs already done, injury >7 days ago, return for reassessment of the same injury, altered LOC, paraplegic, multiple trauma, other fractures

A knee injury is needed if: inability to Weight bear, Age >55, inability to Flex knee to 90, Tenderness at the head of fibula or patella (WAIT)

Validated in children >5

171
Q

Describe the management of a knee dislocation

A

High risk of vascular injury, even if reduced in the field.
Hard signs of vascular injury -> CT
No signs of vascular injury + normal ABI -> observation

172
Q

What is a Segond fracture

A

Avulsion of the tibial plateau, may represent an ACL tear

173
Q

What is the classification scheme for fractures of the tibial tubercle

A

Watson:
1: incomplete avulsion
2: complete avulsion, extra articular
3: complete avulsion, intra articular

174
Q

List a differential for anterior knee pain

A

ACL sprain, extensor tendon rupture, patella fracture, patella dislocation, patellar tendonitis, patellofemoral pain, bursitis, Osgood-Schlatter

175
Q

List a differential for posterior knee pain

A

PCL strain, popliteal tendonitis, Baker’s cyst, gastrocnemius strain, DVT

176
Q

List a differential for lateral knee pain

A

LCL strain, torn meniscus, IT band syndrome

177
Q

List a differential for medial knee pain

A

MCL strain, torn meniscus, medial plica syndrome, pes anserine bursitis

178
Q

List indications for Zimmer immobilization

A

Quadriceps tendon rupture, patella tendon rupture, patella dislocation
fractured patella, tibial plateau

179
Q

List 3 x ray findings of knee dislocation

A

Subluxation of tibiofemoral joint, subluxation of patella, joint effusion

180
Q

Describe the Ottawa Ankle/Foot Rule

A

Inclusion: Adult patients with acute injury to ankle
Exclusion: Injury >48 hours, hindfoot and forefoot injuries, impairment of assessment (alcohol), impaired sensation (peripheral neuropathy)

An ankle radiograph is needed if: pain at the posterior distal 6 cm or tip of the lateral malleolus, pain at the posterior distal 6 cm or pain at the tip of the medial malleolus, inability to weight bear at least 4 steps after injury and at time of evaluation

A foot radiography is needed if: tenderness at the navicular bone, tenderness at the base of the fifth metatarsal, inability to weight bear at least 4 steps after injury and at the time of evaluation

Validated in children >5

181
Q

What is a Maisonneuve fracture

A

Rupture of deltoid ligament + proximal fibular fracture, often due to external rotation forces

182
Q

Describe the weber classification of lateral malleolar fractures

A

Weber A: fracture of lateral malleolus, below the ankle joint. Below knee cast + outpt ortho f/u
Weber B: fracture at the syndesmosis. Needs ED ortho consult
Weber C: fracture proximal to the syndesmosis with widening. Needs ED ortho consult

183
Q

Which bones in the foot are at risk of avascular necrosis

A

Talus, navicular

184
Q

List indications for ED ortho consult for an ankle fracture

A

All intra articular fractures with step deformity
All open fractures
All bimalleolar fractures
All trimalleolar fractures
Unimalleolar fracture + displacement (medial, lateral, or posterior)
Unimalleolar fracture + ligament disruption on the opposite side (lateral + deltoid, medial + lateral collateral)
Unimalleolar fracture + wide medial clear space
Unimalleolar fracture + wide syndesmosis
Unimalleolar fracture + Weber B or C

185
Q

List the structures of the hindfoot, midfoot, and forefoot

A

Hindfoot: talus + calcaneus
Midfoot: medial, middle, lateral cuneiforms, navicular, cuboid
Forefoot: metatarsals, proximal, middle, and distal phalanges

The Chopart joint separates the hindfoot from midfoot, and the Lisfranc joint separates the midfoot from forefoo

186
Q

What X ray findings suggest calcaneal fractures

A

Bohler’s angle <20
Angle between a line drawn from posterior tuberosity to apex of posterior facet and anterior process to apex of posterior facet

187
Q

What is the classification system for talar fractures

A

Type 1: non displaced
Type 2: displaced
Type 3: subluxed with the tibia
Type 4: subluxed with tibia and navicular

188
Q

What are the different types of Lisfranc injuries

A

Type 1: homolateral, all five metatarsals are displaced in the same direction
Type 2: isolated, one or more metatarsal is displaced from the others
Type 3: divergent, metatarsals are splayed outwards in medial and lateral directions

189
Q

What is a Jones fracture

A

Fracture through the base of the 5th metatarsal
Zone 1: fracture to the tuberosity
Zone 2: fracture at the level of the 4th and 5th metatarsal edge
Zone 3: fracture through the diaphysis of the metatarsal

190
Q

When should reduction be considered for a metatarsal fracture with displacement? What are acceptable ranges? What is name of reduction technique?

A

> 3mm of displacement or >10 degrees of angulation

> 5mm shortening also unacceptable
Jahss maneuver (thumb on top, push up under flexed PIP)

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