Ortho 2: Modules Flashcards
What is a general approach to reading & reporting XR in ortho?
- Pt ID
- Views and body part (eg AP, lateral)
- Sufficient vs not (long bone: joint above and below, 2 perpendicular views)
- Soft tissue: swelling?
- Cortex: discontinuity?
- Medulla: lucent areas?
What is a general approach to describing fractures?
- Which bone
- Where along the bone
- Type of fracture
- Displacement
- Angulation
- Shortening
How is displacement or translation described (in a fracture)?
Position of distal segment relative to proximal (Anterior, posterior, medial, lateral)
Apposition (% of contact between fragments)
What does angulation of a fracture describe?
Which direction the apex of the angulated # is facing
How do you describe where on a bone a fracture is?
Epiphyseal, metaphyseal, diaphyseal
What is a segmental fracture?
Fracture composed of at least two # lines that together isolate a segment of bone
What is the difference between a segmental vs a comminuted fracture?
Segmental has a single segment, comminuted has multiple
What are the main fracture types?
Transverse Linear Oblique (displaced or non-displaced) Spiral Greenstick Comminuted
What is the 11-22-11 rule of the normal wrist?
Radial height 11mm
Radial inclination 22 degrees
Volar tilt 11 degrees
What is the Garden classification?
Classifies subcapital femoral neck fractures
Garden stage I: incomplete fracture, undisplaced (including valgus impacted fractures)
Garden stage II: complete fracture, undisplaced
Garden stage III: complete fracture, incompletely displaced
Garden stage IV: complete fracture, completely displaced
How does prognosis change with Garden stage I & II vs III & IV fractures?
In general:
stage I and II: stable fractures – can be treated with internal fixation (head-preservation)
stage III and VI: unstable fractures – treated with arthroplasty (either hemi- or total arthroplasty)
What is the Shenton line?
Imaginary curved line along inferior anterior pelvis & femur – should be continuous
What is the Weber classification?
Classifies ankle fractures by level of fibular fracture relative to syndesmosis
A: below syndesmosis
B: level of syndesmosis
C: above syndesmosis
Which part of the physis is the most susceptible to fracture?
Hypertrophic
What is the Salter-Harris classification of fractures?
Classifies growth plate fractures I: physis (eg transverse along physis) II: physis into metaphysis III: physis into epiphysis IV: physis into both metaphysis and epiphysis (eg obliguely through all three) V: physis crush injury
Mnemonic: SALTR Straight through / Stable Above Low Through and through Ram
In which patients should you assume cervical spine injury?
Head trauma High energy trauma Neuro deficit Neck pain Obtunded LOC
What additional precaution must be taken when immobilizing a child with suspected spinal injury (pediatric spines)?
Head larger, so they must be on pad or must be hole in the board to avoid neck flexion (see module for diagram)
What are the key elements of an urgent ortho exam for a pt presenting to emerg with ortho injuries?
Remove from spine board
Log roll
Inspect and palpate spine
Secondary survey (all bones and joints)
What are the features to note when inspecting and palpating the spine of a trauma pt?
Deformity, swelling
Tenderness
Gap/step off
Crepitus
What are the basic 5 steps of fracture management?
- Inspect skin
- Detailed neurovascular exam
- Align/splint
- Xray
- Repeat detailed neurovascular exam
How is a painful splint or cast managed?
Must be removed
What is a key difference in splints and casts, especially with acute injuries?
Splints allow for swelling, casts (which fully encircle limb) don’t
What should you tell the pt to do after applying a splint or cast?
Elevate the limb to minimize swelling
How long does metaphyseal bone take to heal? List some examples
6 weeks
Wrist, ankle, proximal humerus
How long does cortical bone take to heal? List some examples
12 weeks
Humeral shaft, radial and ulnar shafts
Femur & tibia may take 16-24w
What are clinical criteria for fracture healing?
No tenderness on palpation or toggling
No pain on weight bearing
What are radiologic criteria for fracture healing?
Briding bone / callus across fracture
How long does it take bone to remodel?
1-2 years (compares bone formation after fracture to cement, vs remodelling to rebar)
Name 3 early local fracture complications (list of 5)
Neurovascular injury Infection Compartment syndrome Hardware failure Fracture (soft tissue) blister
Name 5 late local fracture complications (7 listed)
Malunion Nonunion Avascular necrosis Ostemyelitis Heterotopic ossification Post-traumatic arthritis Complex regional pain syndrome
Name 5 early systemic fracture complications (5 listed)
Sepsis DVT/PE Fat embolus ARDS Hemorrhagic shock
What medications and practices adversely affect bone healing and can lead to non-union of a fracture?
NSAIDs, bisphosphonates, and smoking
A non-union fracture is one that has not healed by …
6 months
How is malunion treated?
Corrective osteotomy, if clinically significant
What is the impact of malunion (of a fracture)
May lead to
- altered function
- arthritis of adjacent joints
How long can osteomyelitis be quiescent?
In some cases, decades
Extremely difficult to eradicate
What is osteomyelitis?
Bone infection:
Osteomyelitis is inflammation and destruction of bone caused by bacteria, mycobacteria, or fungi.
Common symptoms are localized bone pain and tenderness with constitutional symptoms (in acute osteomyelitis) or without constitutional symptoms (in chronic osteomyelitis)
What are the stages of long bone healing?
- Hematoma
- Subperiosteal and endosteal proliferation
- Callus
- Consolidation
- Remodelling
What is cancellous bone? What does it do? Name 3 examples of cancellous bones.
Bone with uniform spongy texture & no medullary canal
Forms RBC
Aka spongy bone, trabecular bone
Eg: pelvis, ribs, vertebrae, skull, and ends of long bones
What is different about cancellous bone healing? (May list stages as well)
Union forms between 2 surfaces (no callus)
- Hematoma formation
- Osteoblasts lay down matrix
- calcification, woven bone formation
How can fractures be stabilized?
Cast K-wires/percutaneous pins (e.g. pediatric elbow) External fixation Plates & screws / ORIF Intramedullary nail/rod (femur, tibia)
Name 3 indications for operative treatment of a fracture (4 listed)
Open fracture
> 2mm intra-articular displacement
Trauma
Inability to achieve or maintain an acceptable reduction
Why is trauma an indication for surgical treatment of fracture?
Stabilizes the injuries and makes nursing care and pt mobilization easier
Why delay weight bearing and aggressive activities in some fractures? (some that have had hardware)
All constructs will break eventually if the bone doesn’t heal (metal fatigue)
Gives bone healing a good “head start” before it is stressed
Pt presents with fracture to ED. What do you do first, splint or image?
Splint
What do you do after a reduction?
Re-image to assess adequacy
F/u in # clinic in 1w
What ankle fracture is stable?
Isolated undisplaced malleolar fracture
How is a stable ankle fracture managed?
Splint, then casting for 6w
What ankle fractures are unstable?
Displaced
Mortise disrupted
Weber Type C
Bimalleolar/Trimalleolar
How are unstable ankle fractures managed?
Reduce
Splint
ORIF
What consults do you want before taking a patient to the OR for # surgery?
Medicine
Anesthesia
consider Thrombo if on anticoag
What is particularly risky about an intracapsular femoral head fracture?
Blood supply may be compromised → AVN
What are the risks of surgery?
Ortho: Infection, fracture, dislocation, AVN, neurovascular injury
General: DVT/PE, MI, stroke, death
What are the benefits of doing ortho surgery?
Simple: to restore mobility and reduce pain
What percentage of pt with fracture will require admission to LTC in the subsequent year?
Approx 25%
How are open fractures managed?
STAND:
Splint Tetanus Abx Neurovascular / NPO Dressing -- irrigate, remove gross debris, photo, cover with sterile dressing
What is the Gustilo-Anderson Classification?
Classifies open fractures based on wound size, contamination, soft tissue injury, and bone injury.
Types I, II, III, with subtypes ABC for type III.
What is Gustilo-Anderson Type I?
<1cm open wound
Clean
Minimal soft tissue injury
Simple # or minimal comminution
What is Gustilo-Anderson Type II?
> 1cm open wound
Moderately contaminated
Moderate tissue injury
Moderate comminution of bone
What is Gustilo-Anderson Type III?
> 1cm, often >10cm
High contamination
ABC range from:
- ‘Severe soft tissue injury with crushing’ to ‘Very severe loss of coverage requiring repair’
- ‘Usually comminuted’ to ‘Bone coverage poor, moderate to severe comminution’
What Abx should you use for open fractures? (By type)
Cephazolin (gram + ): All types
Aminoglycoside (gram - ): all Type III
Penicillin (anaerobic): all Type III
What is the result of untreated compartment syndrome?
Ischemia and infarction
- Loss of sensation
- Contractures
- loss of function of limb
- rhabdomyolosis (potentially fatal)
What are the 6 (2 + 4) Ps of compartment syndrome?
Pain out of proportion
Pain with passive stretch
Late findings: Paresthesia Paresis Pallor Pulselessness
What is the delta P in compartment syndrome?
delta P = diastolic BP - compartment pressure
delta P of 30mmHg is considered compartment syndrome
When performing fasciotomy for compartment syndrome, which compartment(s) should be released
All (not just the one most affected)
What is tetanus?
Acute poisoning from a neurotoxin produced by Clostridium tetani.
Symptoms: intermittent tonic spasms of voluntary muscles. (Spasm of the masseters accounts for the name lockjaw)
How is tetanus treated?
Human tetanus immune globulin and intensive support
Where are tetanus bacilli (clostridium tetani) found?
Soil, animal feces; spores are durable and can remain viable for years
(Hx of farm wound: have high suspicion!)
Why is it important to administer tetanus IG early?
Tetanus toxin binds irreversibly to nerve terminals, and once bound, it cannot be neutralized – administer IG early to prevent binding
What XR views are required to assess the shoulder?
AP
Lateral ( Y view)
Axillary
Which types of acromion morphology develop rotator cuff tears?
Types II and III
What are the nonoperative management approaches to rotator cuff injury?
PT
Pain management
Modification of work/sports
What investigation diagnoses rotator cuff tear?
US or MRI (esp for cuff tear vs bursitis)
What is the goal of surgical management of rotator cuff tear?
Pain relief (not nec incr ROM or strength)
What is the function of the meniscus?
Load sharing Shock absorption Secondary stabilization Joint lubrication Articular cartilage nutrition
What does a positive McMurray test indicate?
Meniscal tear
pain on knee flexion and rotation
What nerve root does an L4-L5 disc herniation affect?
L5
When a vertebral disc herniates, does it affect the root above or below it?
Root below (eg L4-5 affects L5 root)
What is the initial treatment of an L4-5 disc herniation?
PT
Time
Symptomatic pain relief
How long should nonoperative treatment of disc herniation be trialed before referral to spine surgery?
3mo
What three features would you see on an advanced (operative) arthritic joint?
Narrowing of joint space
Osteophytes
Subchondral sclerosis
What is non-operative management of hip osteoarthritis?
PT, cane, NSAIDs, weight loss
What is foot position?
Direction of the foot relative to body’s line of progression during gait
External = out-toeing
Internal = in-toeing (v common in young children)
Neutral
Name 3 causes of rotational variation in gait
Bony: version (tilt or inclination within a bone), rotation
Capsular laxity/tightness
Muscle control
What are the common reasons for in-toeing?
Femoral anteversion
Internal tibial torsion
Metatarsus adductus
What is femoral anteversion?
Internal rotation of the femur. Congenital; many grow out of it
What is the DDx of in-toeing?
Normal development
Normal variant
Rarely: neuromuscular disease, disorders of the hip, residual foot deformity
What features of gait analysis are important in children?
Heel-toe gait / posturing (?underlying neuro disorder)
Limp (?hip pathology)
Foot progression angle
How do you assess femoral version in a child?
Lying prone, knee at 90 Externally rotate (fan out) and internally rotate (cross legs at ankle)
How is tibial torsion assessed in a child
Lying prone, knee at 90
Compare direction of foot to direction of thigh/femur; should be neutral (close to parallel)
What is metatarsus adductus?
Medial deviation of the forefoot relative to the hindfoot
Most spontaneously resolve by 3-4y
Are normal variant rotational variations symmetric or asymmetric?
Symmetric
What might diminished hip abduction mean, in context of femoral anteroversion?
Might indicate true hip pathology, eg DDH
What additional exam is important in assessment of rotational variations?
Neuro exam, especially clonus
What Hx suggests non-physiologic problems in a child with rotational variation?
Abn development (incl prenatal, delivery, postnatal)
Sudden onset
Sx like pain
When should metatarsus adductus be treated?
Flexible: observation alone
Rigid: stretching, consider braces or cast manipulation; if severe consider surgery
What is the spectrum of DDH?
Developmental Dysplasia of the Hip: Dislocated Dislocatable Subluxed Subluxable Dysplastic
What is a dislocated hip (in DDH)?
Dislocated: femoral head is not in contact with the acetabulum
What is a subluxed hip (in DDH)?
Subluxed: femoral head is within the acetabulum, but not in its proper position
What is a dysplastic hip (in DDH)?
Dysplastic: although the femoral head is in the proper position, the acetabulum is abnormally developed
Name 4 risk factors for DDH (6 listed)
Female Firstborn Breech Big baby Fluid: low amniotic fluid FHx
What exam maneuvers assess for DDH?
Barlow and Ortolani
What imaging should be ordered for workup of DDH?
<4-6mo: US
>4-6mo: XR
What are the treatments for DDH?
Pavlik harness (very successful <6mo)
Closed reduction
Open reduction
Osteotomies
What is the prevalence of scoliosis?
> 10 degrees: 2-3%
20 degrees: 0.3-0.5%
30 degrees: 0.2-0.3%
Approx how many years do girls grow after menarche?
Approx 2y
What is the Risser classification?
Classifies ossification of iliac wing: lower class indicates less ossification, and more remaining growth
What are the three types of scoliosis?
Infantile (0-3y)
Juvenile (4-10y)
Adolescent Idiopathic Scoliosis, AIS (> 10 years)
What is the impact of AIS?
no sig evidence to link AIS with mortality, or with cardiac and respiratory outcomes
> 50 degree curve: worse on PFTs
>80 degree curve: increased SOB
> 50 degree curves can progress after maturity; may have more pain, dissatisfaction with appearance
What is the treatment for AIS?
Small curves: observe with XR q4mo (for Cobb angle) Larger curves (still <45degrees), or progression: orthotics
When would surgery be indicated for AIS?
Curves >50 degrees, or progression despite bracing
What is a severe complication of slipped capital femoral epiphysis (SCFE)?
Avascular necrosis
What pain pattern does SCFE present with?
Usually hip/groin
May present with knee or thigh pain
What is the physical exam in SCFE?
Gait: Trendelenburg, Shortened, external rotation
ROM: decreased abduction, internal rotation
Passive flexion leads to thigh abduction, external rotation
What imaging is needed for SCFE?
XR: AP and cross-table lateral
Avoid frog leg (may worsen slip)
May require CT or MRI if subtle finding
What are the XR findings in SCFE?
Physeal plate widening & irregularity
Decrease in epiphyseal height
Blanch sign of Steel: Crescent-shaped hyperdensity in proximal femoral neck (?from overlap)
Apparent lateral displacement of femoral epiphysis
What is the treatment of SCFE?
Acute: immediate bed rest (avoid worsening)
Surgery: fuse epiphysis on metaphysis, usually with one or more screws
What is the history of joint sepsis?
Pain: refusal to bear weight, liming
Recent illness
Possible decreased immunity
Possible trauma
What is the physical exam of a septic joint?
Temp: Febrile Antalgic gait, disuse of joint Erythema, swelling Tenderness Decreased ROM
What Ix should be ordered for suspected septic joint?
CBC (WBC)
CRP, ESR
Blood cultures
Aspirates: Gram stain, culture, crystals
Imaging: XR/US/MRI; Bone scan if concerned for osteomyelitis
What is the treatment for a septic joint?
Abx (targeted to culture)
Surgical irrigation and debridement
