Neurology and Orthopedic Flashcards
Broca’s area function
Posterior part of anterior lobe, responsible for speech motor function.
Wernicke’s area function
Located in the temporal lobe, responsible for speech comprehension.
Pituitary adenoma treatment after XRT and in shock
Pituitary apoplexy; treatment is steroids.
Neuropraxia definition
No axonal injury; temporary loss of function, motor more than sensory; ex foot falling asleep.
Axonotmesis definition
Disruption of axon with preservation of myelin sheath; nerve must regenerate to improve= = Wallerian degeneration
Neurotmesis definition
Disruption of both axon and myelin sheath; whole nerve is disrupted and may need surgery for recovery. worst form
Most common cause of subarachnoid hemorrhage
Trauma is the most common cause; second is rupture of berry aneurysm.
Subarachnoid hemorrhage treatment
Prevent rebleed (open clip, endovascular coil), prevent vasospasm with CCB, nimodipine.
Asymptomatic cerebral aneurysm treatment
If < 1 cm, treatment is to leave alone.
Neurogenic shock injury level
Occurs only in injury above T5.
Brown-Sequard syndrome characteristics
MCC is penetrating injury; ipsilateral motor and proprioception loss, contralateral pain and temperature loss below the lesion. 90% recover to ambulation
Anterior Cord Syndrome cause
MCC is vascular injury to anterior spinal artery; loss of motor, pain, and temperature below the level of injury.
Central Cord Syndrome cause
MCC is hyperextension of the cervical spine; bilateral loss of motor and sensation in upper extremities, lower extremities spared. Cape-like distribution.
Spinothalamic tract function
Transmits pain and temperature sensory neurons; will be contralateral. (dorsal=afferent)
Corticospinal tract function
Rubrospinal tract
Responsible for motor function.
Ventral
Dorsal nerve roots function
Afferent sensory.
Ventral nerve roots function
Efferent motor.
Most common primary brain tumor in adults
Glioma, subtype Astrocytoma.
Most common brain tumor in children
Medulloblastoma.
Most common metastasis to brain in children
Neuroblastoma.
Acoustic neuroma origin
Arises from CN VIII at the cerebellopontine angle; symptoms include hearing loss, unsteady gait, vertigo, N/V. Tx: surgery
Spine tumor characteristics
Most are benign; #1 is neurofibroma.
Intradural vs. extradural tumors
Intradural tumors are more likely to be benign; extradural tumors are more likely to be malignant.
Paraganglioma
Check for metanephrines in urine.
Palmar and axillary hyperhidrosis treatment
First use anti-perspirant for 3 months; if affecting lifestyle, consider T2-T4 sympathectomy.
-AVOID T1: Will cause Horner’s syndrome
Complication of sympathectomy for hyperhidrosis
Most common complication is compensatory sweating in lower extremities or abdomen.
Nerve of Kuntz significance
Accessory pathway between T1 and T2; can cause refractory palmar sweating after sympathectomy. Make sure to coagulate nerve of kuntz on the bottom of the 2nd rib
Complex regional pain syndrome progression
Reflex sympathetic dystrophy –> Causalgia; severe burning in limb caused by injury to peripheral nerve. Usually after trauma, amputation (PHANTOM pain), frostbite, surgery
Complex regional pain syndrome treatment
Gabapentin and amitriptyline; TENS; sympathectomy only if pain is dramatically relieved by nerve blocks.
- NOT USED FOR DIABETIC ULCERS
- Location of sympathectomy depends on location of pain
- Unresectable pancreatic CA causing pain lumbar sympathectomy
Salter-Harris fracture types III, IV, and V
Cross the epiphyseal plate and can affect the growth plate of the bone; need ORIF.
I and II = closed reduction
Fractures that result in non-union
Clavicle and 5th metatarsal (Jones fracture).
Biggest risk factor for non-union
Smoking.
Metaphysis, diaphysis, epiphysis definition
Metaphysis: has epiphyseal growth plate; diaphysis is the mid portion; epiphysis is the round end of long bone.
Superior gluteal nerve function
Hip abduction.
Inferior gluteal nerve function
Hip extension.
Femoral nerve function
Knee extension, hip flexion.
Obturator nerve function
Hip adduction.
Knee dislocation management
If ABI is >0.9 and pulse is good, just observe; if < 0.9 or weak pulse, then CT angio; if no pulse, OR.
Cervical nerve roots exit pattern
Exit at the level above the corresponding vertebra, except for C8, which exits below.
All others exit BELOW corresponding vertebra e.g. L5 nerve root exits below L5 vertebra in the L5/S1 space
Nerve root compression in herniations
The nerve root that gets compressed is the one that exits the foramen below the herniated disc. E.g. L4/L5 herniation causes L5 compression
L1-L3 nerve root function
Hip flexion
Compression= weak hip flexion.
L4 nerve compression symptoms
Weak knee extension (quadriceps) and weak patellar reflex.
L5 nerve compression symptoms
Weak dorsiflexion (foot drop) and decreased sensation in the big toe web space.
S1 nerve compression symptoms
Weak plantarflexion, weak Achilles reflex, and decreased sensation of lateral foot.
MRI indication for nerve issues
Need MRI if neuro deficit; conservative management for 6 weeks, if fails, consider discectomy.
Brachial plexus nerve roots
C5-T1.
Ulnar nerve function
Wrist flexion
Fingers abduction. Intrinsic muscle of hand palmar interossei, palmaris brevis, and hypothenar eminence
Sensory to ALL OF 5th and ½ of 4th digit
Injury leads to claw hand cubital tunnel syndrome at elbow
MC nerve associated with neurogenic thoracic outlet syndrome
Median nerve function
Motor to thumb apposition, OK sign, flexes fingers; sensory to 1-4 digits only on palm.
Radial nerve function
Motor for wrist extension, finger extension, thumb extension, triceps; NO HAND muscles, sensory to 1-4 digits only on back of hand.
Axillary nerve function
Motor to deltoid (abduction).
Musculocutaneous nerve function
Motor to biceps, brachialis, and coracobrachialis.
Radial artery supply
Radial nerve roots
Radial artery: supplies the deep palmar arch.
Radial nerve roots - on superior portion of brachial plexus
Ulnar artery supply
Ulnar nerve roots
Ulnar artery: Supplies the superficial palmar arch, the main supply to the hand.
Ulnar nerve roots – on inferior portion of brachial plexus
Anterior shoulder dislocation
90% of cases; risk of axillary nerve injury; treatment is closed reduction.
Posterior shoulder dislocation cause
Occurs after seizures; risk of axillary artery injury; treatment is closed reduction.
Acromioclavicular separation management
Treatment is a sling; risk of brachial plexus and subclavian vessel injury.
Scapula fracture management
Sling unless glenoid fossa involved, then internal fixation.
Proximal humerus fracture management
Non-displaced requires a sling; displaced or comminuted requires ORIF. Risk of axillary nerve injury
Midshaft humerus fracture management
Almost all require a sling; surgery only for failed reduction or neurovascular symptoms. Risk of radial nerve injury: weak wrist extension and finger extension
Supracondylar humeral fracture management
Adults require ORIF; children and non-displaced require closed reduction; unless displaced, then closed reduction with internal fixation with Kirschner wire
-Risk of Volmann’s contracture (forearm compartment syndrome) – anterior interosseous artery. Median nerve most affected. Tx: forearm fasciotomy
Monteggia fracture definition
Proximal ulnar fracture and radial head dislocation; requires ORIF.
Colles fracture characteristics
Most common fracture in children; occurs from a fall on an outstretched hand; distal radius fracture with possible distal ulnar dislocation; requires closed reduction.
Combined radial and ulnar fracture management
Requires ORIF; in children, closed reduction.
Greenstick fracture definition
Fracture in young, soft bone; buckling of the cortex; common in children with distal radius fracture; treatment is cast for 3 weeks.
Scaphoid fracture characteristics
(wrist fracture, perilunate wrist fx)
MC carpal bone fracture, MC fx in wrist. Tenderness in snuffbox. Can have negative xray initially
Scaphoid fracture management
Negative x-ray requires all patients to get a spica cast to elbow; follow up x-ray in 2 weeks; non-displaced scaphoid or lunate fracture requires spica cast for 6-8 weeks; displaced scaphoid or lunate requires ORIF.
Dupuytren’s contracture association
Associated with DM and ETOH; proliferation of palmar fascia; inability to extend fingers, especially 4th and 5th digits.
Dupuytren’s contracture treatment
NSAIDs, steroids, and surgery for refractory cases (excise palmar fascia).
Trigger finger definition
Tenosynovitis of flexor tendon that catches at MCP, preventing finger extension.
Trigger finger treatment
Splint, steroid injection, or split tendon at MCP joint if fails.
Suppurative tenosynovitis definition
Infection along the flexor tendon sheath, often after trauma or bite.
Suppurative tenosynovitis symptoms
Four classic symptoms: tendon sheath tenderness, pain with passive motion, swelling along sheath, and flexed finger.
Suppurative tenosynovitis treatment
Midaxial longitudinal incision and drainage; avoid lateral incision due to nerves.
Rotator cuff components
Supraspinatus, infraspinatus, teres minor, and subscapularis.
Rotator cuff injury management
Acute treatment is a sling; surgical repair if patients need to retain high level of activity or ADLs are affected.
Flexor tendon sheath injury management
No surgery if < 60% laceration; if greater, requires surgery; repair in < 2 weeks.
Paronychia definition
Infection where skin and nail meet; can progress to under nail bed.
Paronychia treatment
Local wound care if no abscess; if abscess, requires incision and drainage.
Felon definition
Abscess of terminal finger.
Felon treatment
Incision over tip of finger, along the center.
Posterior hip dislocation characteristics
90% of cases; thigh is internally rotated and adducted; risk of sciatic nerve injury.
Posterior hip dislocation treatment
Closed reduction.
Anterior hip dislocation characteristics
Thigh is abducted and externally rotated; risk of femoral artery injury.
Anterior hip dislocation treatment
Same as posterior, closed reduction.
Femoral shaft fracture management in children < 6
Requires spica cast.
Lateral knee trauma structures involved
Anterior cruciate, posterior cruciate, medial collateral ligament, and medial meniscus.
ACL injury diagnosis
Positive anterior drawer test; MRI confirms diagnosis.
ACL injury treatment
Reconstruction with patellar tendon or hamstring tendon if knee instability.
Patellar fracture management
Long leg cast unless comminuted, then requires internal fixation.
Ankle fracture management
Most require cast; unless bi- or trimalleolar, then requires ORIF.
Plantaris muscle rupture management
below popliteal fossa -> no repair
Metatarsal fracture management
Cast or immobilization for 6 weeks.
Calcaneus fracture management
Cast and immobilization if non-displaced; if displaced, requires ORIF.
Talus fracture management
Closed reduction for most; if severely displaced, requires ORIF.
Foot drop definition
Inability to dorsiflex; common peroneal nerve injury.
- lithotomy position
- after crossing legs for long period
- Fibular head fracture
Foot drop treatment
Foot brace.
Unicameral bone cyst characteristics
Painless, causes pathological fractures; cyst contains high level of cytokines that resorb bone.
Unicameral bone cyst treatment in young kids
Intraosseous injection of methylprednisolone.
Unicameral bone cyst treatment in adults
Curettage and bone grafting.
Most common bone tumor origin
Metastasis from breast.
Bone tumor treatment with impending fracture
ORIF with bone tumor and >50% cortical involvement, then XRT.
Most common primary malignant bone tumor
Multiple myeloma.
Most common bony tumor overall
Osteochondroma.
Most common malignant bone tumor in adults
Osteosarcoma; most common around knee, 80% in young < 20.
Osteosarcoma X-ray finding
Codman triangle.
Osteosarcoma treatment
Limb sparing resection; consider pre-op chemo-XRT.
Ewing sarcoma characteristics
Most common in adolescents; painful swelling; onion skin appearance on X-ray.
Ewing sarcoma most common location
Diaphysis of femur.
Ewing sarcoma treatment
Chemo-RAD is the mainstay of treatment, +/- resection.
