Ortho 2: Modules Flashcards
1
Q
What is a general approach to reading & reporting XR in ortho?
A
- 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?
2
Q
What is a general approach to describing fractures?
A
- Which bone
- Where along the bone
- Type of fracture
- Displacement
- Angulation
- Shortening
3
Q
How is displacement or translation described (in a fracture)?
A
Position of distal segment relative to proximal (Anterior, posterior, medial, lateral)
Apposition (% of contact between fragments)
4
Q
What does angulation of a fracture describe?
A
Which direction the apex of the angulated # is facing
5
Q
How do you describe where on a bone a fracture is?
A
Epiphyseal, metaphyseal, diaphyseal
6
Q
What is a segmental fracture?
A
Fracture composed of at least two # lines that together isolate a segment of bone
7
Q
What is the difference between a segmental vs a comminuted fracture?
A
Segmental has a single segment, comminuted has multiple
8
Q
What are the main fracture types?
A
Transverse Linear Oblique (displaced or non-displaced) Spiral Greenstick Comminuted
9
Q
What is the 11-22-11 rule of the normal wrist?
A
Radial height 11mm
Radial inclination 22 degrees
Volar tilt 11 degrees
10
Q
What is the Garden classification?
A
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
11
Q
How does prognosis change with Garden stage I & II vs III & IV fractures?
A
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)
12
Q
What is the Shenton line?
A
Imaginary curved line along inferior anterior pelvis & femur – should be continuous
13
Q
What is the Weber classification?
A
Classifies ankle fractures by level of fibular fracture relative to syndesmosis
A: below syndesmosis
B: level of syndesmosis
C: above syndesmosis
14
Q
Which part of the physis is the most susceptible to fracture?
A
Hypertrophic
15
Q
What is the Salter-Harris classification of fractures?
A
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
16
Q
In which patients should you assume cervical spine injury?
A
Head trauma High energy trauma Neuro deficit Neck pain Obtunded LOC
17
Q
What additional precaution must be taken when immobilizing a child with suspected spinal injury (pediatric spines)?
A
Head larger, so they must be on pad or must be hole in the board to avoid neck flexion (see module for diagram)
18
Q
What are the key elements of an urgent ortho exam for a pt presenting to emerg with ortho injuries?
A
Remove from spine board
Log roll
Inspect and palpate spine
Secondary survey (all bones and joints)
19
Q
What are the features to note when inspecting and palpating the spine of a trauma pt?
A
Deformity, swelling
Tenderness
Gap/step off
Crepitus
20
Q
What are the basic 5 steps of fracture management?
A
- Inspect skin
- Detailed neurovascular exam
- Align/splint
- Xray
- Repeat detailed neurovascular exam
21
Q
How is a painful splint or cast managed?
A
Must be removed
22
Q
What is a key difference in splints and casts, especially with acute injuries?
A
Splints allow for swelling, casts (which fully encircle limb) don’t
23
Q
What should you tell the pt to do after applying a splint or cast?
A
Elevate the limb to minimize swelling
24
Q
How long does metaphyseal bone take to heal? List some examples
A
6 weeks
Wrist, ankle, proximal humerus
25
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
26
What are clinical criteria for fracture healing?
No tenderness on palpation or toggling
| No pain on weight bearing
27
What are radiologic criteria for fracture healing?
Briding bone / callus across fracture
28
How long does it take bone to remodel?
1-2 years (compares bone formation after fracture to cement, vs remodelling to rebar)
29
Name 3 early local fracture complications (list of 5)
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Neurovascular injury
Infection
Compartment syndrome
Hardware failure
Fracture (soft tissue) blister
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30
Name 5 late local fracture complications (7 listed)
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Malunion
Nonunion
Avascular necrosis
Ostemyelitis
Heterotopic ossification
Post-traumatic arthritis
Complex regional pain syndrome
```
31
Name 5 early systemic fracture complications (5 listed)
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Sepsis
DVT/PE
Fat embolus
ARDS
Hemorrhagic shock
```
32
What medications and practices adversely affect bone healing and can lead to non-union of a fracture?
NSAIDs, bisphosphonates, and smoking
33
A non-union fracture is one that has not healed by ...
6 months
34
How is malunion treated?
Corrective osteotomy, if clinically significant
35
What is the impact of malunion (of a fracture)
May lead to
- altered function
- arthritis of adjacent joints
36
How long can osteomyelitis be quiescent?
In some cases, decades
| Extremely difficult to eradicate
37
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)
38
What are the stages of long bone healing?
1. Hematoma
2. Subperiosteal and endosteal proliferation
3. Callus
4. Consolidation
5. Remodelling
39
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
40
What is different about cancellous bone healing? (May list stages as well)
Union forms between 2 surfaces (no callus)
1. Hematoma formation
2. Osteoblasts lay down matrix
3. calcification, woven bone formation
41
How can fractures be stabilized?
```
Cast
K-wires/percutaneous pins (e.g. pediatric elbow)
External fixation
Plates & screws / ORIF
Intramedullary nail/rod (femur, tibia)
```
42
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
43
Why is trauma an indication for surgical treatment of fracture?
Stabilizes the injuries and makes nursing care and pt mobilization easier
44
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
45
Pt presents with fracture to ED. What do you do first, splint or image?
Splint
46
What do you do after a reduction?
Re-image to assess adequacy
| F/u in # clinic in 1w
47
What ankle fracture is stable?
Isolated undisplaced malleolar fracture
48
How is a stable ankle fracture managed?
Splint, then casting for 6w
49
What ankle fractures are unstable?
Displaced
Mortise disrupted
Weber Type C
Bimalleolar/Trimalleolar
50
How are unstable ankle fractures managed?
Reduce
Splint
ORIF
51
What consults do you want before taking a patient to the OR for # surgery?
Medicine
Anesthesia
consider Thrombo if on anticoag
52
What is particularly risky about an intracapsular femoral head fracture?
Blood supply may be compromised → AVN
53
What are the risks of surgery?
Ortho: Infection, fracture, dislocation, AVN, neurovascular injury
General: DVT/PE, MI, stroke, death
54
What are the benefits of doing ortho surgery?
Simple: to restore mobility and reduce pain
55
What percentage of pt with fracture will require admission to LTC in the subsequent year?
Approx 25%
56
How are open fractures managed?
STAND:
```
Splint
Tetanus
Abx
Neurovascular / NPO
Dressing -- irrigate, remove gross debris, photo, cover with sterile dressing
```
57
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.
58
What is Gustilo-Anderson Type I?
<1cm open wound
Clean
Minimal soft tissue injury
Simple # or minimal comminution
59
What is Gustilo-Anderson Type II?
>1cm open wound
Moderately contaminated
Moderate tissue injury
Moderate comminution of bone
60
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'
61
What Abx should you use for open fractures? (By type)
Cephazolin (gram + ): All types
Aminoglycoside (gram - ): all Type III
Penicillin (anaerobic): all Type III
62
What is the result of untreated compartment syndrome?
Ischemia and infarction
- Loss of sensation
- Contractures
- loss of function of limb
- rhabdomyolosis (potentially fatal)
63
What are the 6 (2 + 4) Ps of compartment syndrome?
Pain out of proportion
Pain with passive stretch
```
Late findings:
Paresthesia
Paresis
Pallor
Pulselessness
```
64
What is the delta P in compartment syndrome?
delta P = diastolic BP - compartment pressure
delta P of 30mmHg is considered compartment syndrome
65
When performing fasciotomy for compartment syndrome, which compartment(s) should be released
All (not just the one most affected)
66
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)
67
How is tetanus treated?
Human tetanus immune globulin and intensive support
68
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!)
69
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
70
What XR views are required to assess the shoulder?
AP
Lateral ( Y view)
Axillary
71
Which types of acromion morphology develop rotator cuff tears?
Types II and III
72
What are the nonoperative management approaches to rotator cuff injury?
PT
Pain management
Modification of work/sports
73
What investigation diagnoses rotator cuff tear?
US or MRI (esp for cuff tear vs bursitis)
74
What is the goal of surgical management of rotator cuff tear?
Pain relief (not nec incr ROM or strength)
75
What is the function of the meniscus?
```
Load sharing
Shock absorption
Secondary stabilization
Joint lubrication
Articular cartilage nutrition
```
76
What does a positive McMurray test indicate?
Meniscal tear
| pain on knee flexion and rotation
77
What nerve root does an L4-L5 disc herniation affect?
L5
78
When a vertebral disc herniates, does it affect the root above or below it?
Root below (eg L4-5 affects L5 root)
79
What is the initial treatment of an L4-5 disc herniation?
PT
Time
Symptomatic pain relief
80
How long should nonoperative treatment of disc herniation be trialed before referral to spine surgery?
3mo
81
What three features would you see on an advanced (operative) arthritic joint?
Narrowing of joint space
Osteophytes
Subchondral sclerosis
82
What is non-operative management of hip osteoarthritis?
PT, cane, NSAIDs, weight loss
83
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
84
Name 3 causes of rotational variation in gait
Bony: version (tilt or inclination within a bone), rotation
Capsular laxity/tightness
Muscle control
85
What are the common reasons for in-toeing?
Femoral anteversion
Internal tibial torsion
Metatarsus adductus
86
What is femoral anteversion?
Internal rotation of the femur. Congenital; many grow out of it
87
What is the DDx of in-toeing?
Normal development
Normal variant
Rarely: neuromuscular disease, disorders of the hip, residual foot deformity
88
What features of gait analysis are important in children?
Heel-toe gait / posturing (?underlying neuro disorder)
Limp (?hip pathology)
Foot progression angle
89
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)
```
90
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)
91
What is metatarsus adductus?
Medial deviation of the forefoot relative to the hindfoot
| Most spontaneously resolve by 3-4y
92
Are normal variant rotational variations symmetric or asymmetric?
Symmetric
93
What might diminished hip abduction mean, in context of femoral anteroversion?
Might indicate true hip pathology, eg DDH
94
What additional exam is important in assessment of rotational variations?
Neuro exam, especially clonus
95
What Hx suggests non-physiologic problems in a child with rotational variation?
Abn development (incl prenatal, delivery, postnatal)
Sudden onset
Sx like pain
96
When should metatarsus adductus be treated?
Flexible: observation alone
Rigid: stretching, consider braces or cast manipulation; if severe consider surgery
97
What is the spectrum of DDH?
```
Developmental Dysplasia of the Hip:
Dislocated
Dislocatable
Subluxed
Subluxable
Dysplastic
```
98
What is a dislocated hip (in DDH)?
Dislocated: femoral head is not in contact with the acetabulum
99
What is a subluxed hip (in DDH)?
Subluxed: femoral head is within the acetabulum, but not in its proper position
100
What is a dysplastic hip (in DDH)?
Dysplastic: although the femoral head is in the proper position, the acetabulum is abnormally developed
101
Name 4 risk factors for DDH (6 listed)
```
Female
Firstborn
Breech
Big baby
Fluid: low amniotic fluid
FHx
```
102
What exam maneuvers assess for DDH?
Barlow and Ortolani
103
What imaging should be ordered for workup of DDH?
<4-6mo: US
| >4-6mo: XR
104
What are the treatments for DDH?
Pavlik harness (very successful <6mo)
Closed reduction
Open reduction
Osteotomies
105
What is the prevalence of scoliosis?
>10 degrees: 2-3%
>20 degrees: 0.3-0.5%
> 30 degrees: 0.2-0.3%
106
Approx how many years do girls grow after menarche?
Approx 2y
107
What is the Risser classification?
Classifies ossification of iliac wing: lower class indicates less ossification, and more remaining growth
108
What are the three types of scoliosis?
Infantile (0-3y)
Juvenile (4-10y)
Adolescent Idiopathic Scoliosis, AIS (> 10 years)
109
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
110
What is the treatment for AIS?
```
Small curves: observe with XR q4mo (for Cobb angle)
Larger curves (still <45degrees), or progression: orthotics
```
111
When would surgery be indicated for AIS?
Curves >50 degrees, or progression despite bracing
112
What is a severe complication of slipped capital femoral epiphysis (SCFE)?
Avascular necrosis
113
What pain pattern does SCFE present with?
Usually hip/groin
| May present with knee or thigh pain
114
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
115
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
116
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
117
What is the treatment of SCFE?
Acute: immediate bed rest (avoid worsening)
Surgery: fuse epiphysis on metaphysis, usually with one or more screws
118
What is the history of joint sepsis?
Pain: refusal to bear weight, liming
Recent illness
Possible decreased immunity
Possible trauma
119
What is the physical exam of a septic joint?
```
Temp: Febrile
Antalgic gait, disuse of joint
Erythema, swelling
Tenderness
Decreased ROM
```
120
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
121
What is the treatment for a septic joint?
Abx (targeted to culture)
| Surgical irrigation and debridement
