KC Ortho Flashcards
*What is the upper limit for compartmental pressures?
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
*What are the contents of the compartments of the lower leg? Name the compartment, one artery, one nerve and one muscle.
- 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
*4 things to do to optimize care pre-fasciotomy
- Place limb slightly below level of the heart (slight dependency)
- Relieve all external pressure on compartment (cast, bandage)
- Supportive - analgesia, fluids to maintain normotension
- Oxygen to maintain good arterial oxygenation
*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
- 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
*What is most common compartment for compartment syndrome in lower leg
Anterior compartment
*How would you test the function of the nerve contained in the anterior compartment?
Anterior compartment, deep peroneal nerve
Test sensation at dorsal webspace between 1st and 2nd digits of foot
*Recognize a Tillaux fracture and describe the Salter Harris class
SH III
*What age is associated with Tillaux fractures?
12-15
*What is the pathophysiology of Tillaux fracture?
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.
vWhat is another injury of the ankle in this age group (similar to Tillaux)?
Triplane (younger age group though)
*What is the mechanism of injury in Tillaux fracture?
Supination and external rotation
think S-EX
*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) 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
*Which bones get AVN?
- Scaphoid
- Femoral Head
- Navicular
- Capitate
- Lunate
- Talus
Describe the Salter Harris classification of fractures
Used to describe epiphyseal fractures in a child: Straight across, Above, Lower, Through both upper and lower segments (Two!), Erasure of the growth plate
Describe the classification of open fractures
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
What antibiotics should be used in open fractures
Grade 1 and 2: Ancef
Grade 3: Anceft + Gentamicin
Consider tenatus and tetanus immunoglobulin for large wounds, penicillin for farm wounds
List the complications of fractures
Hemorrhage, vascular injury, avascular necrosis, nerve injury, infection/osteomyelitis, compartment syndrome, fat emobolism
List causes of compartment syndrome
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
Define dislocation and subluxatiobn
Dislocation: complete loss of continuity between two articulating surfaces, subluxation is partial loss of continuity
Define ‘sprain’ and describe its classification
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
Define strain
Injury to the muscle/tendon unit
List risk factors for tendon injury
Meds (steroids, fluoroquinolone), smoking, diabetes, malignancy, chronic kidney disease, lupus
Describe the process of fracture healing
Hematoma, inflammation with granulation tissue, callus (2-4 weeks), resorption of callus, remodelling (2-4 months)
List terms that can be used to describe a fracture
Openor close, anatomic location, direction, simple vs. comminutes, angulation, displaced
What are false positives for fractures on x ray
Nutrient vessel, anomalous bones, pseudofractures due to soft tissue folds/bandages
*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
Felon
Paronychia
Herpetic whitlow
FB
*Most common organism
Staph aureus
*2 managements
I&D
Abx
Removal of FB
Soaks
*2 complications of I&D
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.
*5 complications of not treating it
Skin necrosis,
Sinus tract formation,
Chronic drainage.
Dorsal spread can lead to phalangeal tuft necrosis and osteomyelitis.
*2 ddx herpetic whitlow
HSV
dyshidrotic eczema
burn
VZV
*How to Dx or confirm herpetic whitlow
PCR
*What is a boxer’s fracture and what age and gender sustains the injury the most?
Fracture of the 5th metacarpal neck, occasionally the 4th. Males 10-19
*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).
(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.
*What is the mechanism of injury of a boxer’s fracture?
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.
*What are two anatomical reasons why a boxer’s fracture is unstable
- 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
*5 management things you would do once patient with boxer’s fracture has had analgesia and anesthesia?
• 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
*What are 4 complications of boxer’s fracture
Avascular necrosis, nonunion, misalignment, interosseous muscle or tendon injury or fibrosis, and chronic stiffness may occur.
*What is the timeline for referral for boxer’s fracture
1 week
*What are the instrinsic hand muscles innervated by the median nerve?
LOAF
Lateral two lumbricals
Opponens pollicis
Adbuctor pollicis brevis
Flexor pollicis brevis
*What is one test that you can do to determine if there is an UCL injury?
Valgus stress testing
*How do you determine if it is complete or incomplete UCL injury?
• 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
*What is the x-ray finding associated with a complete UCL injury?
Stener lesion
*Describe the pathophysiology of why a complete UCL injury (Stener lesion) does not heal
the avulsed ligament is displaced above the aponeurosis
*What is the emergency department management of a complete UCL rupture vs. incomplete UCL rupture?
• 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
*Name two long-term complications of UCL injury
• Chronic instability
• Chronic pain
• Decreased pinch strength
*List 2 absolute contraindications to reimplantation of an amputated limb
• 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
*4 indications for reimplantation of an amputated limb
• 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
*How should an amputated part be transported?
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.
*List 3 nerves that supply the hand and the best sensory and motor test for each
Median - index finger pad - OK sign
Ulnar - pinky finger pad - spread fingers against resistance
Radial - Dorsal hand near 1st webspace - Thumb or wrist extension
*What are stages of carpal instability
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
*List types of distal radius fractures and their mechanisms of injury
- 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)
*Criteria to reduce a Colles fracture
- 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
*Identify all the carpal bones on a diagram.
Straight line to pinky, here comes the thumb
Scaphoid
Lunate
Triquitrium
Pisiform
Hamate
Capitate
Trapezoid
Trapizium
*Volar laceration to wrist: List 6 tendons that could be affected and how to test for this
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
What bones in the hand are at a risk of avascular necrosis?
Scaphoid, capitate, lunate
Describe the difference between lunate and perilunate dislocation?
Perilunate: lunate continues to articulate with the radius, capitate is displaced
Lunate: capitate and radius continue to stay aligned, lunate is displaced
What nerve injury is associated with 1) Colles fracture 2) Smith fracture 3) Monteggia fracture 4) pisiform fracture
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
Which wrist fractures are intra articular by definition?
Barton’s, Chauffeur
Which wrist injuries are associated with DRUJ instability?
Colle’s (not all), Essex-Lopresti, Galeazzi
What are the compartments of the forearm?
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
Compare Monteggia, Galeazzi, and Essex-Lopresti forearm fractures
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
What are six risk factors for carpal tunnel
Acromygaly
Hypothyroidism
Obesity
DM
Pregnany
Renal failure
RA
*What is the most common nerve injured in humerus fracture? In Elbow dislocation?
Radial, Median > Ulnar
List the nerves injuries associated with the follow fractures 1) humerus 2) supracondylar fracture 3) olecranon fractures 4) elbow dislocation
1) Radial nerve 2) anterior interosseous nerve (part of the median nerve) 3) ulnar nerve 4) median nerve
What is the presentation of a radial nerve injury?
Wrist drop
List 4 radiographic signs of supracondylar fractures
1) Displaced anterior humeral line 2) Displaced radiocapitellar line 3) Posterior sail sign 4) Abnormal Baumann’s angle
Explain the classification system for supracondylar fractures
Based on Gartland. Type 1 - no displacement. Type 2 - displaced but posterior cortex intact. Type 3 - no cortical contact
List the order of ossification in the Elbow
CRITOE Capitellum age 1, radial head age 3, internal (medial epicondyle) age 5, trochlea age 7, olecranon, age 9, external (lateral) epicondyle age 11
What is Volkmann’s contracture
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
*What nerve is injured with anterior shoulder dislocation and what muscle does it innervate?
- Axillary nerve – Deltoid
*What findings on x-ray are suggestive of increased risk for future (shoulder) dislocations?
- Hill-Sachs lesion
- Bankart lesion
- Glenoid rim fracture
- Flattened or shallow anterior bony contour
*5 reduction techniques for anterior shoulder dislocations
- Stimson (hanging weight)
- Traction/countertraction
- Scapular manipulation
- External rotation
- Cunningham
- Milch
- FARES
*List 3 long term complications of shoulder dislocation
- Fractures (Hill-Sachs, Bankart, glenoid)
- Neurovascular injury (axillary nerve, brachial Plexes)
- Rotator cuff tear
- Recurrence
*List 3 common mechanisms for posterior shoulder dislocation
- Fall onto outstretched hand with arm held in flexion, adduction, and internal rotation
- Direct blow
- Convulsive seizures
- Electrical shock
*What are 3 acute complications of anterior shoulder dislocations?
• Fracture (e.g. Hill-Sachs deformity, Bankart’s lesion, glenoid rim)
• Neurovascular injury (e.g. axillary nerve injury)
• Rotator cuff tears
• Recurrence
*What are 3 intrinsic (i.e. MSK) causes of shoulder pain
• 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
*What are 3 extrinsic (ie. Non-msk) casuse of shoulder pain
• C-spine
• Thoracic outlet syndrome
• Pancoast tumors
• MI
• Diaphragmatic irritation (pneumonia, subphrenic abscess, splenic hematoma, ruptured ectopic, gallbladder)
*What are 2 clinical exam findings of a complete rotator cuff tear?
• 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
*What imaging would you use to diagnose complete rotator cuff tear?
MRI
*List complications of shoulder dislocation
rotator cuff tear, axillary nerve injury, associated fracture (ex. Bankhart), adhesive capsulitis
*What are 6 red-flag history or physical exam findings for a serious cause of low back pain?
- 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
*Besides MSK causes, list 6 causes of acute extraspinal low back pain
- 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
*What are 4 physical exam findings of epidural compression?
- 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
*Young and Burgess categories and mechanism for each
AP compression
Lateral compression
Vertical shear
*4 ways to treat pelvic hemorrhage in trauma
Reversal of ACO
Pelvic binding
Angiography
Pelvic packing in OR
*Avulsion fracture of the anterior inferior iliac spine (AIIS): pathophysiology of this injury
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.
*What are other pelvic/hip injuries of this nature: Avulsion fracture of the anterior inferior iliac spine (AIIS)
• 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
*Label parts of a pelvis diagram
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
*What are FOUR radiographic clues to a posterior arch fracture?
- 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
*Other than vascular injuries, list five pelvic injuries associated with pelvic fractures
Bladder disruption
Urethral disruption
Gynecologic injury
Plexopathy
Radioculopathy
*List three diagnostic modalities other than AP pelvic XR in the diagnosis of pelvic fractures
Inlet/outlet views
CT
?MRI
*What are the 4 types of hip dislocation?
Anterior, posterior, central, and inferior types
*Name 4 complications of hip dislocation?
AVN, traumatic arthritis, sciatic nerve palsy (foot drop), and joint instability, acetabular fracture, femoral head fracture
*What is the blood supply to the femoral head?
Branches of the deep femoral artery
*What are 3 mechanisms of ACL injury
Plant and pivot
Jump and stop
Blow to flexed knee
Turf injury with knee flexed and ankle plantar flexed
*Three XR findings of ACL injury
Effusion?
Lateral capsular sign
Fracture of the posterior aspect of the lateral tibial plateau
Deep lateral sulcus
Actuate fracture
Segond fracture
*Knee is maybe dislocated, 3 initial steps
Check NV status
Reduce
Recheck NV status
Immobilize
*Associated injuries with ACL injury (2)
“Unhappy triad”: ACL, MCL and meniscus (medial or lateral)
*3 signs of dislocation on exam or XR
NV injury
Large effusion
Grossly disfigured
Large knee ecchymosis
(these are all guesses)
*What abnormality is often associated with a Segond fracture?
ACL/MCL injuries, ACL being the more common
*What are 4 complications of a tibial plateau fracture?
Varus/valgus deformities
Popliteal artery injury
Peroneal nerve injury
Ligamentous injruy (ACL/MCL)
*Subtalar dislocation: why might reduction be impossible?
Closed reduction may be impossible because of buttonholing of the talus through the extensor retinaculum, entrapment in the peroneal tendons, or associated fractures.
*What is the most common cause of lateral ankle pain following mild trauma?
ATFL (anterior talo-fibular liagement) sprain
*What is your differential diagnosis for traumatic lateral ankle pain
- 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
*List 4 immediate management priorities for knee dislocation
- 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
*What is the most common vascular injury in knee dislocation
Popliteal artery injury
*What is the best test to assess for popliteal artery injury in patient with cold foot and knee dislocation
CT angiogram/Direct to OR for surgical exploration
*List 5 complications of knee dislocation
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
*What 6 bones make up the lisfranc joint?
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.
*What are the 3 most common mechanisms of a lisfranc injury
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.
*What are three physical exam findings of lisfranc injury?
- 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
*List one abnormality you would see on an X-ray with a lisfranc injury for each of the following views: AP, lateral, and oblique.
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)
*What are three other imaging options other than x-ray for Lisfranc?
- CT scan
- MRI
- Weight-bearing X-rays
*What are 4 management steps for Lisfranc?
- 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
*What are the elements of the Ottawa ankle rules
- 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
List 6 potential limb threatening conditions requiring hand consultation
Compartment syndrome, crush injury, high pressure injection injury, open fracture, amputation, vascular injury, limb threatening infection, burns, dislocation, complex fractures
List the components of the carpal tunnel
4x flexor digitorum profundus, 4x flexor digitorum superficialis, flexor pollicis longus, median nerve
Which flexors are NOT in the carpal tunnel
Flexor carpi radialis, flexor carpi ulnaris, palmaris longus
Explain how finger extension is possible despite a complete tendon laceration
Junction tendinum connects the extensors of the fingers; a laceration proximal to this will allow for preserved extension
What are the borders of the anatomic snuffbox
Abductor pollicis longus, abductor pollicis brevis, extensor pollicis longus
Describe the difference between a Bennett and Rolando fracture
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
Which flexor tendons can be repaired in the ED
None
Which extensor tendons can be repaired in the ED
Zone 4-6 (PIP, MCP/PIP join, and over MCP)
List two extensor tendon injuries of the hand
Mallet finger: forced flexion of an extended finger, results in a swan neck deformity and inability to extend the DIP joint. Needs dorsal splint
List a flexor tendon injury of the hand
Jersey finger: forced extension of a flexed finger (ex. grabbing a jersey). Unable to flex DIP.
What palsy would result from a radial, median, and ulnar nerve injury
Wrist drop, claw hand, benediction sign
What are the 4 muscle groups of the hand and how are they innervated
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
List the muscles of the rotator cuff, their actions, and innervation
Supraspinatus: abduction, subscapularis
Infraspinatus: external rotation, subscapularis
Teres Minor: external rotation, axillary
Subscapularis: internal rotation and adduction, subscapular
What is the motor and sensory function of the axillary nerve
Motor (deltoid) arm abduction. Sensory deltoid muscle
Describe the classification of acromioclavicular joint separation
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
Describe the classification of clavicular fractures
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
Describe the classification of humeral head fractures
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
What are clinical signs of impingement syndrome
Provocative tests: painful arc, Hawkins Kennedy, empty can
What are clinical signs of rotator cuff tear
Reduced active ROM (passive is usually preserved). Pain with provocative tests ex. painful arc
List x ray findings of an anterior shoulder dislocation
AP: humeral head not in glenoid fossa, Transcapular: humerus anterior the glenoid, Hill-Sachs or Bankart
List x ray findings of posterior shoulder dislocation
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
How would you reduce a posterior dislocation
Traction, adduction, internal rotation. Needs to be splinted
List complications of humeral head fracture
Adhesive capsulitis, AVN, neurovascular injury, myositis ossificans
List indications for emergent ortho consult for clavicular fractures
Tenting, open, neurovascular compromise, interposition of soft tissue, comminuted, severe displacement
Describe the difference between anterior and posterior sternoclavicular dislocations
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
List indications for advanced imaging studies in the ED
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
What is the most common site of disc herniation
L4/L5, L5/S1
List 6 causes of cauda equina syndrome
Disc herniation, epidural abscess, epidural hematoma, tumor/malignancy, spinal stenosis from aging, vertebral body fracture
List 3 types of primary spinal tumor
Osteosarcoma, Ewing sarcoma, Multiple myeloma
List 8 sources of vertebral metastasis
Lung, breast (top 2), lymphoma, multiple myeloma, melanoma, prostate, kidney, GI
List the ligaments that make up the posterior pelvic ring
SacroSpinous ligament, sacroTuberous ligament, Anterior sacroIliac ligament (STI)
What is the vascular injury associated with a posterior pelvic arch fracture? pubic rami injury?
Superior gluteal artery, obturator and pudendal artery injury
Describe the Tile Classification of Pelvic fractures
See notes
Describe the Young-Burgess Classification of Pelvic fractures
See notes
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
1) Sartorius 2) rectus femoris 3) iliopsoas 4) adductors and gracilis 5) hamstrings 6) abdominal muscles
Describe the classification for acetabular fractures
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
Describe the classification for vertical sacral fractures
1) Lateral to the foramina 2) involving the foramina 3) involving the central canal (high risk of neurologic injuries)
List 6 things on the differential for a painful hip without a fracture
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
List 8 causes of AVN
Femoral neck fracture, posterior dislocation, steroid use, alcohol use, lupus, sickle cell, antiphospholipid syndrome, infections (HIV, pancreatitis)
List 5 cancers that metastasize to bone
Lung, kidney, breast, thyroid, prostate (the ‘double’ organs)
LIst 5 methods for relocating a hip
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
Describe 4 types of hip dislocation
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
List the structures in the compartments of the thigh
See notes
What is the significant of an intracapsular vs. extracapsular fracture
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
What are contraindications for traction in a femur fracture
Open fracture, pelvic fracture, distal tib/fib fracture, knee ligamentous injury
What nerves are blocked in a fascia iliaca block
Femoral, lateral cutaneous, and obturator nerve
What fascias do you go through in a fascia iliaca block
Fascia lata and fascia iliac
List the differential for sudden onset calf pain with swelling
Fracture, compartment syndrome, necrotizing fasciitis, DVT, thrombophlebitis, achilles tendon rupture, plantaris strain, gastrocnemius strain, baker’s cyst rupture
List risk factors for extensor tendon rupture
Steroid use, fluoroquinolones, RA, gout, lupus, hyperparathyroidism, immunosuppression
List the compartments of the lower leg and their components
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)
List 6 overuse syndromes
Patellofemoral pain, IT band syndrome, peri patellar tendonitis, plica syndrome, popliteus tendinitis, bursitis
What is the Insall-Salvati ratio
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
Describe the classification of the tibial plateau fractures
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
Describe the Ottawa Knee Rule
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
Describe the management of a knee dislocation
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
What is a Segond fracture
Avulsion of the tibial plateau, may represent an ACL tear
What is the classification scheme for fractures of the tibial tubercle
Watson:
1: incomplete avulsion
2: complete avulsion, extra articular
3: complete avulsion, intra articular
List a differential for anterior knee pain
ACL sprain, extensor tendon rupture, patella fracture, patella dislocation, patellar tendonitis, patellofemoral pain, bursitis, Osgood-Schlatter
List a differential for posterior knee pain
PCL strain, popliteal tendonitis, Baker’s cyst, gastrocnemius strain, DVT
List a differential for lateral knee pain
LCL strain, torn meniscus, IT band syndrome
List a differential for medial knee pain
MCL strain, torn meniscus, medial plica syndrome, pes anserine bursitis
List indications for Zimmer immobilization
Quadriceps tendon rupture, patella tendon rupture, patella dislocation
fractured patella, tibial plateau
List 3 x ray findings of knee dislocation
Subluxation of tibiofemoral joint, subluxation of patella, joint effusion
Describe the Ottawa Ankle/Foot Rule
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
What is a Maisonneuve fracture
Rupture of deltoid ligament + proximal fibular fracture, often due to external rotation forces
Describe the weber classification of lateral malleolar fractures
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
Which bones in the foot are at risk of avascular necrosis
Talus, navicular
List indications for ED ortho consult for an ankle fracture
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
List the structures of the hindfoot, midfoot, and forefoot
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
What X ray findings suggest calcaneal fractures
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
What is the classification system for talar fractures
Type 1: non displaced
Type 2: displaced
Type 3: subluxed with the tibia
Type 4: subluxed with tibia and navicular
What are the different types of Lisfranc injuries
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
What is a Jones fracture
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
When should reduction be considered for a metatarsal fracture with displacement? What are acceptable ranges? What is name of reduction technique?
> 3mm of displacement or >10 degrees of angulation
> 5mm shortening also unacceptable
Jahss maneuver (thumb on top, push up under flexed PIP)
