Ortho Flashcards
Leg-Calve-Perthes Disease
Aka avascukar necrosis of capital femoral epiphysis
Age 6
Features: insidious, limping, decreased hip motion, hip/knee pain, antalgic gait, guarded passive motion of hip.
Dx: AP and lateral hip X-rays.
Tx: cast and crutches to keep acetabulum in femoral head.
Developmental dysphasia of hip
Feature: uneven gluteal folds, hip easily dislocated posteriorly with jerk and click, snaps to return.
Dx: US
Tx: abduction splinting with pavlik harness 6 months.
Slipped capital femoral epiphysis
Ortho emergency Chubby boy, age 13. Features: groin or knee pain, limping, sole of foot on affected side points toward other foot, limited hip motion, thigh externally rotates as hip is flexed Dx: X-ray Tx: pin femoral head in place
Septic hip
Ortho emergency
Toddler who had febrile illness, won’t move hip.
Features: hold leg with hip flexed, slight abduction and external rotation, refuse to let you move it.
Dx: ⬆️ ESR, aspiration of hip.
Tx: drain if find pus.
Acute hematogenous osteomyelitis
Little kids, had febrile illness.
Features: severe localized pain in bone.
Dx: MRI
Tx: abx
Genu varum
Aka bow legged
Normal until age 3
Persists past 3yr usually Blount disease = disturbance of medial proximal tibial growth plate
Tx: surgery
Genu valgus
Aka knock-knee
Normal between 4-8
No tx
Osgood-Schlatter disease
Aka osteochondrosis of tibial tubercle
Teens with persistent pain over tibial tubercle, aggravated by contraction of quads.
Features: localized pain over tibial tubercle, no knee swelling
Tx: RICE, if not better then extension or cylinder cast 4-6wk
Club foot
Aka talipes equinovarus
At birth
Features: feet turned inward, plantar flexion of ankle, inversion of foot, addiction of forefoot, internal rotation of tibia.
Tx: serial casting, Achilles tenotomy, long term braces, surgery btw 9-12 months.
Scoliosis
Adolescent girls
Thoracic spine turned to right. Progresses until skeletal maturity.
Dx: bend forward, see hump on right thorax.
Tx: bracing, if severe then surgery.
Can cause ⬇️ pulmonary function.
Issues with bone remodeling in kids
Areas: suprachondylar fractures of humerus, fractures of growth plate.
Suprachondylar fractures of humerus
Cause: hyperextension of elbow in kid who falls on hand with arm extended
Can injure vasculature and nerves ➡️ Volkmann contracture
Tx: casting or traction
Watch out for problems with nerves/vasculature, compartment syndrome.
Growth plate fracture
Tx: if epiphysis and growth plate laterally deviated but in one piece = closed reduction.
Two pieces = open reduction for alignment and internal fixation.
Osteogenic sarcoma
Most common primary bone malignancy.
Ages 10-25, persistent low grade pain
Around knee ( lower femur or upper tibia)
Dx: sunburst on X-ray
Ewing sarcoma
Second most common primary bone malignancy
Ages 5-15
Grows in diaphysis of long bones
Dx: onion-skinning on X-ray
Malignant bone tumors adults
Women = breast metastasis, lytic, present with pathological fracture
Men = prostate metastasis, blastic.
Feature: localized pain
Dx: X-ray, CT, MRI
Multiple myeloma
Old men with fatigue, anemia, localized pain at specific places along multiple bones.
Dx: X-ray with punched out lytic lesions, bence-jones protein in urine, abnormal Ig in blood on immunoelectrophoresis.
Tx: chemotherapy, thalidomide if fails.
Soft tissue sarcomas
Relentless growth of soft tissue mass. Firm, fixed to surroundings. Metastasize to lung, not to lymph nodes. Dx: MRI, incisional biopsy. Tx: wide local excision, radiation, chemotherapy.
Closed reduction
Open reduction
Closed = immobilized in cast
Open with internal fixation = surgery
Clavicular fractures
At junction of middle and distal thirds
Tx: sling, surgery for cosmetic reasons.
Anterior dislocation of shoulder
Most common shoulder dislocation
Feature: hold arm close to body, rotated outward, numbness over small area of deltoid (stretched axillary nerve).
Dx: AP and lateral X-rays.
Posterior dislocation of shoulder
Rare, after massive uncoordinated muscle contractions (epileptic seizure or electrical burn)
Feature: held close to body, internally rotated.
Dx: axillary or scapular lateral X-rays.
Colles fracture
From fall on outstretched hand
Old osteoporotic women
Deformed, painful wrist, looks like dinner fork.
Dorsally displaced, dorsally angular fracture of distal radius.
Tx: closed reduction, long arm cast
Monteggia fracture
Cause: direct blow to ulna (raised protective arm)
Diaphyseal fracture of proximal ulna, anterior dislocation of radial head.
Tx: open reduction with internal fixation, closed reduction of dislocation.
Galeazzi fracture
Cause: direct blow to distal third of radius causing fracture and dorsal dislocation of distal radioulnar joint.
Tx: open reduction with internal fixation, closed reduction of dislocation.
Fracture of scaphoid
Young adult who falls on outstretched hand
Feature: wrist pain, localized tenderness over an atomic snuff box.
Dx: clinical, X-ray.
Tx: thumb spica cast if undisplaced.
Displaced and angulated = open reduction and internal fixation.
Metacarpal neck fracture
Usually 4th, 5th, or both. Closed fist hits hard surface. Feature: hand swollen and tender. Tx: mild = closed reduction and ulnar gutter splint. Bad = kirschner wire or plate fixation.
Hip fractures
Elderly who fall
Features: hip hurts, affected leg is shorter and externally rotated.
Dx: X-ray
Femoral neck fracture
Displaced = compromise blood to femoral head.
Tx: femoral head replaced with prosthesis.
Intertrochanteric fractures
Less likely to cause avascular necrosis than femoral neck fracture.
Tx: open reduction with internal fixation. Post-op anticoagulation.
Risk of DVT, PE.
Femoral shaft fracture
Tx: intermedullary rod fixation.
Open = ortho emergency, ORA cleaning and closure within 6 hr.
Can cause fat emboli.
Collateral ligament injuries
Cause: sideways blow to knee, sports
Features: swollen knee, localized pain by direct palpation, pain with passive abduction or adduction when knee flexed at 30 degrees.
Abduction shows medial injuries, adduction shows lateral injuries.
Dx: MRI
Tx: only 1 affected = hinged cast.
More than 1 affected = surgery.
Anterior cruciate ligament injury
Features: severe swelling and pain of knee, positive anterior drawer test, pain when knee flexed at 20 degrees by grasping thigh and pulling leg with other hand (Lachman test).
Dx: MRI
Tx: immobilization and rehab, or surgery for athletes.
Opposite signs for PCL injury.
Meniscal tears
Features: protracted pain and swelling in knee, knee catches and locks with click to release.
Dx: MRI
Tx: open repair.
Complete meniscectomy ➡️ degenerative arthritis
Terrible triad
Medial meniscal tear, medial collateral tear, anterior cruciate tear
Tibial stress fracture
Young men on long marches
Features: tenderness to palpation over specific part of bone, normal X-ray.
Tx: cast, repeat X-ray in 2 weeks, crutches.
Leg fractures of tibia and fibula
Pedestrian hit by car.
Dx: angulation, X-ray.
Tx: casting, intramedullary nailing.
Be ware of compartment syndrome
Rupture of Achilles’ tendon
Out of shape middle aged men under severe stress (tennis).
They plant foot, change direction, hear pop like a gunshot, fall clutching ankle.
Features: limited plantar flexion, pain, swelling, limping.
Dx: gap on tendon palpation.
Tx: casting in equinus position for months, surgery
Ankle fracture
Falling on inverted or exerted foot.
Features: both malleoli break.
Dx: AP, lateral, and mortise X-rays
Tx: open reduction and internal fixation.
Compartment syndrome
Mostly in forearm or lower leg.
Causes: prolonged ischemia with repercussion, crushing injury, trauma, closed reduction of lower leg.
Features: excruciating pain with passive extension, limited use of extremity.
Tx: fasciotomy
Posterior dislocation of hip
Cause: femur driven backward, head in collision.
Features: hip pain, leg shortened, addicted, internally rotated.
Tx: emergency reduction to prevent avascular necrosis.
Gas gangrene
Cause: deep penetrating, dirty wounds.
Features: 3 days later extremely sick, toxic, moribund. Site is tender, swollen, discolored, gas crepitation.
Tx: IV penicillin, debridement, hyperbaric oxygen
Radial nerve injury
Cause: oblique fracture of middle to distal third of humerus.
Surgery if reduction does not relieve nerve involvement.
Popliteal artery injury
Cause: posterior dislocation of knee
Dx: integrity of pulses, Doppler, CT angio.
Tx: reduction.
Delayed restoration of flow requires fasciotomy.
Falls from height
Fractures of foot or leg
Fractures of lumbar or thoracic spine
Head on collision
Facial, head, torso injury
Femoral or pelvic injury
Facial fracture or closed head injury
Look at cervical spine as well
Carpal tunnel syndrome
Women doing repetitive hand work.
Features: numbness and tingling in hands, particularly at night, along median nerve (radial 3 1/2 fingers).
Dx: reproduced by hanging hands limply a few minutes or tapping median nerve in carpal tunnel, X-ray
Tx: splints, anti-inflammatory agents, electromyography then surgery
Trigger finger
Women
Features: wake up with flexed finger, can’t extend it unless pull on it causing snap.
Tx: steroid injection, surgery as last resort
De Quervain tenosynovitis
Young mothers carrying kids, force hand into wrist flexion and thumb extension.
Features: pain along radial side wrist and first dorsal compartment.
Dx: reproduced by holding thumb inside closed fist then forcing ulnar deviation of wrist.
Tx: splint, anti-inflammatory agents, steroid injection***
Dupuytren contracture
Older men, Norwegian ancestry
Contracture of palm and palmar fascial nodules felt.
Tx: surgery if hand can’t lay flat on table
Felon
Abscess in pulp of fingertip from neglected penetrating injury
Features: throbbing pain, abscess features (fever).
Can cause tissue necrosis.
Tx: surgical drainage.
Gamekeeper thumb
Injury of ulnar collateral ligament by forced hyperextension of thumb.
Skiing injury.
Features: collateral laxity at thumb metacarpophalangeal joint.
Can lead to arthritis if untreated.
Tx: casting.
Jersey finger
Injury to flexor tendon when finger forcefully extended ( grabbing jersey).
Dx: making fist, distal phalanx doesn’t flex with others
Tx: splinting
Mallet finger
Extended finger is forcefully flexed. Volleyball.
Extensor tendon is ruptured.
Dx: tip of finger remains flexed when others are extended.
Tx: splinting.
Lumbar disc herniation
At L4-L5 or L5-S1.
Age 45-46
Features: months of vague aching pain then sudden severe pain that shoots down leg, exacerbated by coughing/sneezing/defecating, cannot walk, hold leg flexed.
Dx: straight leg test positive, MRI
Tx: pain control via nerve blocks, surgery if progressing neuro deficits, emergency if get cauda equina syndrome.
Cauda Equina Syndrome
Distended bladder, flaccid rectal sphincter, perineal saddle anesthesia.
Tx: immediate decompression.
Ankylosing spondylitis
Young men in 30’s and 40’s.
Many have HKA- B27 antigen, associated with uveitis and IBD.
Features: chronic back pain, morning stiffness, worse at rest, improves with activity, progressive.
Dx: bamboo spine on X-ray.
Tx: anti-inflammatory agents, PT.
Metastatic malignancy of back
Elderly with progressive back pain, worse at night, not relieved by rest or positional changes, weight loss.
Dx: X-ray shows lesions (lytic breast cancer at pedicles, blastic from prostate), MRI
Traumatically amputated digits
Tx: surgically reattach.
Clean with saline, wrap in moist gauze, keep on ice.
Lumbar Disk Herniation
usually L4-L5 or L5-S1
peak age 45-46
Features: months of vague aching pain, sudden onset neurogenic pain from a forced movement, pain shoots down leg, exacerbated by coughing, sneezing, defecating. Can’t walk, hold leg flexed.
Dx: straight leg test +, MRI
Tx: bed rest for 3 wks, pain control via nerve blocks, surgery if progressive neuro deficits or cauda equina syndrome.
Cauda Equina Syndrome
distended bladder, flaccid rectal sphincter, perineal saddle anesthesia
Tx: surgical decompression
Ankylosing Spondylitis
young men in 30’s or early 40’s
Features: complain of chronic back pain and morning stiffness, worse at rest, improves with activity, progressive.
Dx: ‘bamboo spine’ on x-ray
Tx: antiinflammatory agents, PT
HLA B-37 antigen associated with uveitis and IBD.
Back pain from Metastatic Malignancy
Features: elderly with progressive back pain, worse at night, unrelieved by rest or positional changes, weight loss.
Dx: lytic breast cancer in pedicles, blastic prostate cancer on MRI
Diabetic Ulcers
At pressure points (heel, metatarsal head, tip of toes) from neuropathy. Don’t heal because of microvascular disease.
Tx: keep clean and elevated, amputation.
Arterial Insufficiency Ulcers
at tip of toes
Features: look dirty, pale base without granulation, features of arteriosclerotic occlusive disease (absent pulses, trophic changes, claudication or rest pain).
Dx: Doppler, CT angio, MRI angio, arteriograms.
Tx: surgical revascularization, angioplasty, stents
Venous Stasis Ulcers
in chronically edematous, indurated, hyperpigmente sin above medial malleolus.
Features; painless ulcer with granulating bed, varicose veins, frequent bouts of cellulitis.
Dx: duplex scan
Tx: support stockings, ace bandages, unna boot, vein stripping, grafting, endovascular ablation, radiofrequency ablation
Marjolin Ulcer
squamous cell carcinoma of skin in a chronic leg ulcer.
Features: dirty looking, deep ulcer with heaped up tissue growth around edges.
Dx: biopsy
Tx: wide local excision, skin grafting.
Plantar Fasciitis
older, overweight patients with disabling, sharp heel pain when foot strikes ground, worse in morning.
Dx: x-ray shows bony spur at location of pain, tenderness to palpation over spur
Tx: spontaneous in 12-18 months, treat symptoms, remove spur.
Morton Neuroma
inflammation of common digital nerve at third interspace btw 3rd and 4th toes.
Features: palpably tender spot, from high heels that are pointed.
Tx: analgesics, sensible shoes, surgical excision
Gout
Features: swelling, redness, exquisite pain suddenly at first emtatarsal phalangeal joint in middle age obese man, high serum uric acid.
Dx: uric acid crystals in joint fluid.
Tx: indomethacin and colchicine if acute. chronic = allopurinol and probenicid.
