Ortho 1: ECEs Flashcards
1
Q
List 4 key radiologic findings of OA
A
joint space narrowing
subchondral sclerosis
subchondral cysts
osteophytes
2
Q
How does inflammatory arthritis present?
A
Pain at rest, relieved by motion Morning stiffness >1 h Warmth, swelling, erythema Mal alignment/deformity Extra-articular manifestations Nighttime awakening
3
Q
How does degenerative arthritis present?
A
Pain with motion, relieved by rest Morning stiffness < 1⁄2 h Joint instability, buckling, locking Bony enlargement, mal-alignment/deformity Evening pain
4
Q
List 8 common risk factors for development of OA (12 listed)
A
Age Genetic susceptibility Obesity Female gender Trauma Repetitive knee trauma Muscle weakness Joint laxity Mechanical forces Kneeling Squatting Meniscal injuries
5
Q
What is the pathophysiology of obesity’s role in OA?
A
Mechanical, but also hormonal
(obesity linked to more hand OA as well as leg joint OA)
May also explain higher prevalence in women (more adipose tissue)
6
Q
What is the OA management hierarchy?
A
Non-pharm, pharm, surgery
7
Q
Name 3 non-pharm ways to manage OA
A
Weight reduction
PT
activity modification
walking aids
8
Q
Name 4 pharm ways to manage OA
A
Oral analgesics (acetaminophen/NSAIDs)
Joint injections (corticosteroid, hyaluronic acid)
Topical: capsaicin, NSAIDs
Treat neuropathic pain if present (anti-depressants, anti-epileptics, etc)
9
Q
Name 3 operative approaches to the management of OA
A
Realign = osteotomy Replace = arthroplasty fuse = arthrodesis
10
Q
What are the complications of arthroplasty?
A
Component loosening Dislocation Heterotopic ossification thromboembolism infection neurovascular injury limb length discrepancy
11
Q
Name 4 methods of reducing a shoulder
A
Cunningham
Stimson
FARES
Traction-countertraction
12
Q
What is the Cunningham method for shoulder reduction?
A
Calm, quiet, massage and traction
Learned in Wilderness
13
Q
What is the Stimson method for shoulder reduction?
A
while patient lies prone with arm hanging over table edge, hang a 5 lb weight on wrist for 15-20 min
14
Q
What is the FARES method for shoulder reduction?
A
traction, AP oscillation, abduction, external rotation – named for “FAst REliable Safe”
15
Q
What is the traction-countertraction method for shoulder reduction?
A
assistant stabilizes torso with a folded sheet wrapped across the chest while the surgeon applies gentle steady traction
16
Q
What is dislocation?
A
severe injury where articular surfaces of a joint are no longer in contact with one another
17
Q
What is subluxation?
A
articular surfaces of a joint are partially out of place (i.e. “partial dislocation” – often unstable and requires reduction)
18
Q
What is a shoulder separation?
A
“partial or complete separation of clavicle and scapula, at AC joint, due to damage to the ligaments.
There are 6 grades of AC joint separation; I is least severe, and I, II, and III are most common”
19
Q
What are the features of grade I, II, and III AC Joint Separations?
A
I: Joint sprain, absence of complete tear of either ligament
II: Complete tear of AC ligament, incomplete tear of CC ligament, without marked elevation of lateral clavicular head
III: Complete tear of AC and CC ligaments, >5 mm elevation at AC joint, superior aspect of acromion is below the inferior aspect of the clavicle (step deformity)
20
Q
When would a shoulder separation be operative?
A
Severe: Grade IV-VI
Some Grade III, if labourer or athlete
21
Q
What are the steps in a closed reduction?
A
- apply traction in the long axis of the limb
- reverse the mechanism that produced the fracture
- reduce with IV sedation and muscle relaxation (fluoroscopy can be used if available)
22
Q
What are the indications for an open reduction?
A
NO CAST Non-union Open fracture Neurovascular Compromise Displaced intra-Articular fracture Salter-Harris 3,4,5 PolyTrauma
Also,
– failed closed reduction
– not able to cast or apply traction due to site (e.g. hip fracture)
– pathologic fractures
– potential for improved function with ORIF
23
Q
What must you ALWAYS do after a reduction?
A
re-check and document NVS after reduction and obtain post-reduction x-ray
24
Q
When should the Ottawa Ankle Rules be followed?
A
If there is question of the need for imaging for ankle and/or foot trauma
25
What kinds of injury should point to the Ottawa rules for assessment?
Knee, Ankle, and Foot
26
What are the Ottawa Ankle rules?
An ankle X-Ray series is only required if there is any pain in the malleolar zone and...
Bone tenderness at the posterior edge or tip of the lateral malleolus
OR
Bone tenderness at the posterior edge or tip of the medial malleolus
OR
An inability to bear weight both immediately and in the emergency department for four steps
27
What are the Ottawa Foot rules?
A foot X-Ray series is only required if there is any pain the midfoot zone and...
Bone tenderness at the base of the fifth metatarsal
OR
Bone tenderness at the navicular
OR
And inability to bear weight both immediately and in the emergency department for four steps
28
When should clinical judgment prevail over the criteria, according to the Ottawa Ankle and Foot rules?
When the patient...
- is intoxicated or uncooperative
- has other distracting painful injuries
- has diminished sensation in their legs
- has gross swelling which prevents palpation of the malleolar bone tenderness
29
How much of the distal tibia and fibula should be palpated for a full assessment, according to the Ottawa rules?
6cm
30
Your patient limps: is that "walking", according to the Ottawa rules?
Yes
31
True or false: medial malleolar tenderness is not as important as the other features, according to the Ottawa rules
False: do not neglect the importance of medial malleolar tenderness
32
What are the Ottawa Knee Rules?
A knee X-Ray series is only required for knee injury patients with any of these findings:
Age 55 or older
OR
Isolated tenderness of the patella
(No bone tenderness of knee other than patella)
OR
Tenderness of the head of the fibula
OR
Cannot flex to 90 degrees
OR
Unable to bear weight both immediately and in the emergency room department for 4 steps
33
What is the significance of the 4 steps in the Ottawa rules (what will the patient be doing)?
What are the 3 grades for supracondylar humerus fracture?
34
What is the classic MOI and presentation of collateral ligament knee injury?
- Valgus or varus force (MCL and LCL)
- Swelling/effusion, tenderness above and below joint line (over MCL or LCL)
- Laxity
35
What is the classic MOI and presentation of ACL knee injury?
MOI: Sudden deceleration, or "plant and turn" (hyperextension and internal rotation of tibia)
Audible "pop", immediate swelling, knee giving way
Exam: hemarthrosis, posterolateral joint line tenderness, postive anterior drawer and Lachmann, pivot shift
36
What is the classic MOI and presentation of PCL knee injury?
Sudden posterior displacement of tibia when knee is flexed or hyperextended (eg dashboard MVC injury)
Audible pop, immediate swelling, pain with push off, cannot descend stairs
Exam: hemarthrosis, anteromedial joint line tenderness, positive posterior drawer test, reverse pivot shift
37
What is the classic MOI and presentation of meniscal knee injury?
MOI: twisting force on the knee when it is partially flexed
Immediate pain, difficulty weight-bearing, instability, clicking, incr pain with squatting/twisting
Exam: Insidious swelling (24-48h later), joint line tenderness, knee locking
38
What are key elements of the history and physical exam that would suggest the origin of leg pain is due to peripheral nerve pathology, spinal stenosis, intra-/peri-articular pathology, muscular strain?
[Not sure when making flash cards, beyond HPI PMHx and ROS Ask on rotation!]
39
What exams assess shoulder impingement?
Neers and Hawkins-Kennedy
40
What exams assess shoulder rotator cuff tear?
Supraspinatus: empty can test
Subscapularis: belly press/int rot & extension
Posterior cuff: ext rotation against resistance
41
What tests assess anterior shoulder instability?
Apprehension test
Relocation test
Sulcus sign
42
What tests assess posterior shoulder instability?
Positive posterior apprehension (“jerk”) test: with patient supine, flex elbow 90° and adduct, internally rotate the arm while applying a posterior force to the shoulder; patient will “jerk” back with the sensation of subluxation (test for recurrent posterior instability, NOT for acute injury)
On exam will note: Anterior shoulder flattening, prominent coracoid, palpable mass posterior to shoulder
43
What causes posterior shoulder dislocation?
Classically, 3 Es: epileptic seizure, EtOH, electrocution
Adducted, internally rotated, flexed arm
FOOSH
Blow to anterior shoulder
44
What are the symptoms of carpal tunnel syndrome?
wrist pain, paresthesia first 3 and 1⁄2 digits, ± radiation to elbow, worse at night
45
What tests/signs assess for carpal tunnel syndrome?
Tinel’s sign, Phalen’s test, thenar muscle wasting, sensory deficit
46
How is carpal tunnel syndrome managed?
Lifestyle: Nighttime splinting
Meds: NSAIDs, local corticosteroid injection, oral corticosteroids
Surgery: if SSx are persistent and not relieved by more conservative management
47
Name 3 etiologies for brachial plexus injury
Complication of childbirth
Trauma (eg sthg falling on shoulder)
Compression from tumour or ectopic rib
48
What nerve might an arthroscopic posterior glenoid labrum repair injure, and how would it present?
Axillary nerve
| Regimental badge anesthesia, weakness of abduction beyong 15 degreed
49
What nerve might be injured in a distal biceps repair and how would it present?
```
Lateral cutaneous (extension of musculocutaneous)
Sensation on lateral forearm
```
50
List the key findings found on inspection of a hip fracture.
shortened, externally rotated leg
51
What is a Maisonneuve fracture?
Proximal fibula fracture
52
What imaging should be ordered to properly assess ankle fractures?
AP
Lateral
Mortise view
53
What is the Mortise view, and why order it?
Ankle at 15° of internal rotation
- gives true view of ankle joint
- joint space should be symmetric with no talar tilt
54
Why is the scaphoid at particularly high risk for non-union?
Proximal pole of the scaphoid receives as much as 100% of its arterial blood supply from the radial artery that enters at the distal pole: # through the proximal third disrupts this blood supply and results in a high incidence of AVN/non-union
55
What are the classic findings for scaphoid fracture?
```
Hx of FOOSH in 15-40yo
Limited wrist/thumb ROM
Tenderness in anatomical snuffbox
Pain on scaphoid tubercle (volar)
Pain on axial loading of thumb
```
56
What are the 3 grades for supracondylar humerus fracture, and what purpose does this grading system serve?
Gartland classification
type I: undisplaced or minimally displaced
type II: displaced but with intact cortex
type III: completely displaced
57
What population is particularly at-risk for supracondylar humerus fracture?
Children 5-7
| Most commonly from FOOSH
58
What is the treatment for supracondylar humerus fracture?
Usually closed reduction and percutanous pinning (CRPP)
I can be treated with cast, II and III typically treated with CRPP
Urgency depends on whether the hand remains perfused or not
59
What is a Galeazzi fracture?
Fracture of the distal radial shaft with disruption of the DRUJ
60
What is a Monteggia fracture?
Fracture of the proximal ulna with radial head dislocation and proximal radioulnar joint injury
61
What is FOOSH (in context of a fracture)?
Fall On OutStretched Hand
62
What is a Colle's fracture?
Distal radial fracture with dorsal displacement
| Usually due to FOOSH
63
What is the appearance of Colle's fracture on exam?
Dinner fork deformity
64
What is the management of a Colle's fracture?
```
Reduction to restore radial length and correct dorsal angulation
Immobilize with splint
Ortho followup (outpt, or immediate referral if complicated)
```
65
When does a Colle's fracture require emergent Ortho referral?
Articular surface involvement
66
Which type of Salter-Harris is associated with the worst prognosis and why?
V: Crush injury of growth plate
High incidence of growth arrest; no specific treatment
Types III and IV also more likely to cause growth arrest and progressive deformity (than I and II)
67
What is a hematoma block?
Special type of local infiltration for pain control during manipulation of certain fractures
Hematoma created by fracture is infiltrated with LA to anesthetize surrounding tissues
Commonly used for Colles' fracture and ankle fractures
68
What are some limitations of a hematoma block?
sensory blockade may only be partial
| no muscle relaxation
69
What are the indications for a hematoma block?
Need for closed reduction or manipulation of any diaphyseal or metaphyseal fracture
70
What are the contraindications to joint injection/aspiration?
bacteremia
inaccessible joints
joint prosthesis
overlying infection in the soft tissue
71
What conditions can be diagnosed by joint aspirate?
- Inflammatory arthritis (gout, spondylarthritis)
- Non-infl arthritis (eg effusion from OA)
- Septic arthropathy
- Hemorrhage (eg due to ligamentous injury)
72
What is the first Canadian C-spine rule?
1. Any high-risk factor
65 or older
Dangerous mechanism
Paresthesias in extremities
73
What is the second Canadian C-spine rule?
2. Any low-risk factor which allows safe assessment of ROM?
```
Simple rearend MVC
Sitting position in ED
Ambulatory at any time
Delayed onset of neck pain
Absence of midline C-spine tenderness
```
74
What is the third Canadian C-spine rule?
3. Able to actively rotate neck?
45 degrees to L and R
75
What do you do if someone does or doesn't clear the rules?
If not cleared: send for imaging
| If cleared: no imaging needed
76
In which patients can you apply the Canadian C-spine rules?
Alert (GCS=15) and stable trauma patients, with concern for cervical spine injury
77
What are "dangergous mechanisms" according to the Canadian C-spine rules?
```
Fall from elevation > 3ft or 5 stairs
Axial load to head, e.g. diving
MVC at high speed (>100km/h), rollover, ejection
Motorized recreational vehicles
Bicycle struck or collision
```
78
What are the deadly spinal causes of back and neck pain?
Cauda equina and spinal cord compression
Meningitis
Vertebral osteomyelitis
Transverse myelitis
79
What can cause cauda equina syndrome and spinal cord compression?
Spinal metastasis
Epidural abscess or hematoma
Disc herniation
Spinal fracture with subluxation
80
What are the deadly vascular/thoracic causes of back and neck pain?
Aortic dissection
Ruptured AAA
Pulmonary embolism
Myocardial infarction
81
What are the red flags for back pain?
```
BACK PAIN:
Bowel or bladder dysfunction
Anesthesia (saddle)
Constitutional symptoms
K - Chronic disease, Constant pain
```
Paresthesia
Age >50 and mild trauma
IV drug use/infection
Neuromotor deficits
82
What components of the history are important for back pain?
Fracture history, CA risk, infection risk
| Any other from red flags
83
What physical exam components are important for the evaluation of back pain?
```
Vitals + pulse deficits
Inspect skin for infection/trauma
Abdo exam for AAA
Cardiac exam
MSK lower back exam
Neuro exam (lower extremity, reflexes, rectal tone)
Post-void residual
```
84
What labs are done for back pain?
None, usually
| unless indicated by clinical suspicion, eg for PE or infection
85
What investigations are done for back pain?
Bedside U/S: r/o AAA, assess PVR
86
Why is PVR a good test for cauda equina syndrome?
PVR >200 ml 90% sensitive for CES
87
What is the acute management of cauda equina syndrome?
Urgent MRI
Spine consult
Analgesia
IV dexamethasone
