ORTHO Flashcards
fractures of the shaft of radius or ulna tx
surgical tx
ORIF in adults
conservatively –> ages 12-14
what’s the biggest concern in a radius or ulna fx
nerve injury
Fracture of distal radial shaft with dislocation of distal radio-ulnar joint
galeazzi
prominenece of ulnar head and lack of pronation/supination
Galeazzi
galeazzi fx tx
ORIF
fracture of the proximal ulnar shaft with radial head dislocation
monteggia fx
monteggia fx tx
ORIF
distal radius fx AKA
colles fx tisk tisk
FOOSH areas of concern
scaphoid
distal radius
radial head
proximal humerus
3 varieties of FOOSH fx
palmar/dorsal displacement
extra/intra-articular
radial styloid
distal radius fx, non-displaced w/o comminution tx
longarm cast to immobilize –> short arm cast
what is an outcome predictor for distal radius fx
more disrupted the angle, worse prognosis
extra-articular distal radius fx tx
closed
intra-articular distal radius fx tx
anatomic reduction to resolve to same length (open reduction)
complications of distal radius fx
compression of median nerve
malunion –> limit of wrist ROM
joint degeneration in intra-articular fx
a cause of acute carpal tunnell radius fx
distal radius fx
what may you see on initial xray of a scaphoid fx
nothing?… repeat in 10-14 days
FOOSH, pain in anatomical snuffbox
scaphoid fx
XRAYs needed to assess scaphoid
AP
Lateral
AP in ulnar deviation
Clenched fist view
how to treat scaphoid fx if non-displaced and acute
thumb spica
how long to keep hand in thumb spica for scaphoid fx
12 weeks!
can you treat scaphoid fx with surgery?
yes, if want recovery in
scaphoid fx complications
AVN
non-union
where does blood supply innervate the scaphoid?
distally
tx of non-union scaphoid fx
ORIF and bone graft
complication of non-union scaphoid fx
arthritis
chronic tendinitis of 1st dorsal compartment of wrist
dequervain’s stenosing tenosynovitis
2 tendons in 1st dorsal compartment of wrist
abductor pollicis and extensor pollicis brevis
pain radially with use of wrist, 1st dorsal compartment sore, + finkelstein’s
dequervain’s stenosing tenosynovitis
tx for dequervain’s?
rest, ice, NSAIDs consider thumb spica steroid injection useful for dx and tx US and PT therapy surgery if persistent
saturday night palsy deficit
radial nerve –> wrist drop
neuropraxia
bruise of the nerve
inhibits conduction but doesn’t destroy nerve fiber
how long for neuropraxia to resolve?
2 weeks after removal of compression
damage severe enough to kill axon but myelin sheath intact
axonotmesis
severing both nerve axon and myelin sheath, usually by physical disruption of nerve (laceration)
neurotmesis
does reconnecting the two pieces of nerve together repair the nerve fiber?
no, it reapirs the myelin sheath which continues to grow inward
how fast do peripheral nerves gro?
1 inch/month
when does the growth of peripheral nerves halt?
18 months
carpal tunnel syndrome associated with
occupation pregnancy thyroid dz RA DM
where is the numbness in Carpal tunnel
thumb through middle finger
cause of carpal tunnel
pressure on median nerve under transverse carpal ligament
3 tests for carpal tunnel
Tinel’s
Phalen’s
EMG/NCV
small needle into into the muscle to read the electrical activity
EMG
looks at the velocity of the nerve
NCV
differentiates between carpal tunnel and other DDXs
NCV
only motor innervation of the median nerve
to the thenar eminence
thenar eminence motion
ADDuction
treatment progression for carpal tunnel
Rest, NSAIDs, night splints
PT
steroid injection
surgical release
what is cut in the surgical release of carpal tunnel?
transverse carpal ligament
name of canal in which ulnar nerve passes through
guyon’s canal
what nerve does saturday night palsy affect
radial
complications of saturday night palsy
sensory: numbness of radial forearm and dorsum of hand
motor: inability to extend wrist and fingers
neck fracture of the small finger metacarpal, apex dorsal angulation
boxer’s fracture
fight injury scenerio
boxer’s fracture
up to what angle of a boxer’s fracture is acceptable?
40-60 degrees
treatment of a boxer’s fracture
ulnar gutter splint or metacarpal splint
clue on xray of a rotational alignment issue from a metacarpal or phalangal fx
diameter discrepancy
tx for phalangeal fx
pin for 4-5 wks
hyper-extension, jamming injury of finger scenerio
volar plate injury at PIP joint
where does one have pain in volar plate injury
palmar part of the joint
tx for volar plate injury at PIP
buddy tape and early ROM
complications of volar plate injury
stiffness if taped for too long –> wont be able to make a fist
permanent knuckle swelling
most common finger to get crush injury
middle
how to tx a subungal hematoma if more than 50%
remove nail, repair nail bed
threshold for abx usage with subungal hematomas
if tx w/in 6H or not grossly contaminated
when do you replace fingertips
kids, thumbs, and if it’s the majority of the finger
open oblique fracture at the base of the thumb MC w/ dislocation of radial portion of articular surface
bennet fx
tx of bennet fx
surgery! pinning!
Y or T shaped fx at the base of the first metacarpal
rolando fx
what is the mechanism most likely involved in bennet and rolando fx?
hyper-extension
most common place of finger dislocations
IP joints
how to tx finger dislocations
reduce by pulling on the finger & buddy-taping it
no man’s land
area of flexor tendons between the attachment of the FDP to the distal phalanz & the distal carpal tunnel
where does the FDP attach?
DIP
where does the FDS attach?
PIP
avulsion of the extensor tendon from distal phalanx
mallet finger
MOA of mallet finger
jamming injury (trying to catch a ball)
does a mallet finger have passive ROM?
yes
tx of mallet finger
splint for 6-8 wks
when to tx a mallet finger with a pin
unreliable
more than 50% of joint involved
rugger jersey finger
avulsion of FDP from Distal phalanx
what limit in ROM does rugger jersey finger cause
unable to flex but full passive ROM
tx of rugger jersey finger
surgery
rupture or attrition of ulnar collateral ligament of MCPJ of thumb
gamekeeper’s thumb
pain and instability of thumb in pinch
gamekeeper’s thumb
tx for gamekeeper’s thumb
surgery if displaced or unstable
closed if non-displaced or no fx
degenerative nodule impinging on A1 pulley
trigger finger
who is trigger finger more common in
older people, alcoholics, degenerative arthritis
ROM limitation in trigger finger
can flex but not extend
tx of trigger finger
50% cured with steroid injection
some need surgical release of A1 pulley NOT removal of nodule
what happens if you remove the nodule from a trigger finger
tendon rupture
trigger finger more common in M or W
Women
idiopathic fibrosis of palmar fascia
dupuytren disease
dupuytren dz associated with what other 2 diseases
peyronie’s & plantar fibromatosis
who is dupuytren’s most common in
northern europeans men over 50 epilepsy DM pulm dz alcoholics vibrational trauma
painless nodules in palm –> cord –> finger contraction
dupuytren dz
most common finger associated with dupuytren’s dz
ring finger, then small, then middle
tx of dupuytren dz
surgery when over 30 degrees or any contracture of PIP
disruption of central extensor mechanism allowing the PIP to protrude through extensor hood
boutonniere deformity
what is flexed and what is extended in boutonniere deformity
DIP extended
PIP flexed
causes of boutonniere deformity
rupture of central slip (from RA weakening of tendons)
forced flexion
tx of boutonniere deformity
acute: splint in extension
chronic: more complicated
when ordering x-rays image what areas
joints above and below point of concern
5 types of salter harris fractures
- through physis
- through physis and metaphysis (corner sign)
- through physis and epiphysis
- through physis, metaphysis, and epiphysis
- compression/ crush
salter harris fx open to joint
3 and 4
most common salter harris fx
2
tx of salter harris fx
RICE
splint
pain management
traction (for larger joints)
gustillo classification pertains to…
open fractures
explain gustillo classification
- less than 1 cm
- 1-10cm
3a. >10cm, no periosteal stripping, adequate soft tissue coverage
3b. >10c, soft tissue loss w/ free tissue flap
3c. >10c, vascular damage
where does most of the bone healing come from
periosteum
tx for uncomplicated open fractures
1st gen cephalosporin
tx for contaminated open fx
+ aminoglycoside
+ 3rd gen cephalosporin or fluroquinolones
tx for barnyard open fx
clostridium, add penicillin
process of bone healing
hematoma –> sticky and fibrous after a week
tosft tissue doesn’t image well so won’t see that until 2-3 wks
deformity that remodels the least
rotation
where do clavicle fractures take place
midshaft
treatment of clavicle fx
use sling
ice, avoid elevation,
pain meds
how long should a clavicle take to heal
within 6 wks
what does clavicle fx surgery increase the risk of
non-union
infxn
where does a proximal humeral fracture usually take place
surgical neck
tx for uncomplicated proximal humeral fx
sling
where does most growth occur in the humerus
proximal epiphysis
MOA for proximal humerus fx in adults
FOOSH (tx w/ sling)… careful they don’t get stiff
neer fx classification
based on location and number of fracture fragments anatomical neck surgical neck greater and lesser tuberosity articular surface involvement "two part, three part, four part fx"
how to treat proximal humerus fx in elderly people
can try with screws but may need joint replacement
tx for humeral shaft fx
initially with coaptation splint and sling
more often with surgery
what nerve injury must you worry about with a humeral shaft fx
radial
how to test the radial nerve
extension of wrist and fingers
sensation of dorsum of the hand
fracture that is a sign of significant, high energy injury that makes you suspicious to examine chest, mediastinum, and aorta
first rib or scapula fx
what kind of mechanism are first rib and scapular fx associated with
decelaration injuries
tx for scapular fx
not much…
how will a shoulder dislocation present
painful, won’t move shoulder
what must you examine before reducing a shoulder dislocation
neurovascular
mechanism of shoulder dislocations
falls or arm pull
nerve most commonly affected by shoulder dislocation
axillary
how to test axillary nerve
sensory of chevron area
second most common nerve associated with shoulder dislocations
musculocutaneous
innervation of musculocutaneous nerve
anteriolateral forearm sensation
biceps
XRAY for soulder dislocation?
yes! unless witnessed on field
most shoulder dislocations anterior or posterior
anterior
what kind of sedation do you need for reducing shoulder dislocation
IV!…
some people you can just talk them through it and some need the OR
hypocratic method
reducing shoulder with foot in the axilla and pulling straight out
2 other techniques of shoulder reduction
put patient in a prone position and weight their arm to create traction
manipulate scapula to put the glenoid on the humeral head
after reducing shoulder
sling, confirm with xrays (MUST GET LATERAL)
who has high risk of recurrent instability in shoulder dislocations
young people
when should you get elderly people moving after shoulder dislocation
4-5 days
most common reasons for posterior dislocations
seizures or violent muscle contraction
grades 1-3 of acromioclavicular dislocation
1: no displacement (AC sprain)
2: displacement about 50% but less than 100%
3: more than 100% displacement tear of AC and CC
tx of AC dislocation
sling, don’t reduce, ice, pain meds
tx of residual pain from AC dislocation
mumford incision ( take out distal 1-2cm clavicle)
most common bursitis in shoulder
subacromial bursa
older patient, pain out of the blue in the anterolateral arm and shoulder
subacromial bursitis
tx of bursitis
anti-inflammatories, cortisone
secondary cause of subacromial bursitis
rotator cuff tendonitis
4 muscles of rotator cuff
supraspinatus
infraspinatus
subscapularis
teres minor
spectrum of rotator cuff disease
intermittent inflammation
chronic inflammation
tendinosis
tear
rotator cuff dz associated with what activity
overhead
where is the pain in impingement syndrome/rotator cuff dz
anterolateral shoulder
positive impingement signs (4)
neer
hawkins
painful arc
empty can
positive impingement test
subacromial injection of lido relieves pain
any reliable clinical test for full thickness tear
drop arm is the closest but not really
rotator cuff tx (intermittent inflammation)
rest avoid overhead activities NSAIDs PT steroid inj
if no relief in 6 weeks of intermittent rotator cuff inflammation what is the next step?
MRI
tx of rotator cuff tear
surgery if full thickness and symptomatic
what is an imitator of a rotator cuff dz
subluxation from subtle instability
mechanism of a calcaneal fx
from a fall or MVA
what to inspect with a calcaneal fx from a fall
follow the chain -> tibial plateau, hip, lumbar spine
presentation of a calcaneal fx
unable to walk, huge swelling, ecchymoses
tx of calcaneal fx
surgery if any displacement
bohler’s angle
angle between front and back of calcaneous
normal 20-40
less in fx
poor prognosis for calcaneal fx
persistent foot pain
mechanism of talus fx
fall or twist
why are talar fx hard to dx
unseen on plain film
complication of talar fx
AVN of talar dome
collapse of ankle
ankle arthritis
worst place for talar fx
neck
presentation of talar fx
swelling, pain, unable to weight bare
best imaging for talar fx
CT
most common stress fx
metatarsal
march fx
metatarsal stress fx
where are metatarsal stress fx most common
2nd metatarsal
best test for immediate dx of metatarsal stress fx
MRI
won’t show up on xray for 10-14 days
tx of metatarsal stress fx
casting
evulsion of the base of 5th metatarsal
dancer’s fx
transverse fx of 5th metatarsal
jones fx
difference between jones and dancers fx
no ligament involvement in jones
oblique fx of the metatarsal due to fall or twist
trauma fx
metatarsal fx involving the joint
neck fx
most common MT involved in comminuted fx
1st
most important toe for ambulation
1st
high energy injury, minimal xray signs, common in MVAs, compression fx
lisfranc dislocation
huge swollen foot w/o obvious pathology
lisfranc dislocation
medial dislocation of 1st metatarsal
lisfranc dislocation
which xrays do you need for lisfranc dislocation
AP
oblique
lateral
achilles rupture, occurs to healthy or diseased tendons
ones that have had chronic achilles tendonitis
comes down from jump, feels like he/she was kicked from behind
achilles rupture
can pts ambulate after achilles rupture
yes, but cant resume play
test to confirm achilles rupture
thompson sign
tx for achilles rupture
closed or surgery
which achilles tx is prefered for young people, athletes
surgical (faster recovery)
which tx for achilles has higher chance of re-rupture
closed
pain in arch and sole of the foot, pain/burning in medial ankle into arch and plantar foot
tarsal tunnel syndrome
dx of tarsal tunnel syndrome
EMG/NCV
tx of tarsal tunnel
rest, ice, NSAIDs, shoe modification
first few steps out of bed are very painful, better with walking around
plantar fasciitis
where does plantar fascia insert
calcaneus
tender acutely mid-plantar heel pad
plantar fasciitis
windlass phenomenoin
pain made worse with doriflexion of ankle and toes (plantar fasciitis)
tx for plantar fasciitis
shoe modification rest ice taping stretching NSAIDs maybe steroid inj
pain over 6 months of plantar fasciitis
consider surgery
pain in forefoot, expecially with tight foods
interdigital neuroma (morton’s)
dx of interdigital neuroma
squeeze interspace and squeeze metatarsals together
where is interdigital neuroma most common
2-3 interspace of toes
tx of interdigital neuroma
metatarsal bar
steroid injection
some warent excision
flexion of PIP
hammer toes
flexion of PIP and DIP
claw toes
how long must you pin hammer or claw toes for
6-8 wks
first metatarsal in valgus
bunion
cause of bunions
tight shoes adolescent bunions (genetics)
ottawa ankle xray rules
only xray if..
pain in malleolar zone on either side and any one of the following..
bone tenderness in distal 6cm of tibia or fibula
inability to bear weight both immediately and in the ER for 4 steps
foot xray rules
pain in midfood zone and any one of the following
bone tenderness at base of 5th metatarsal OR
bone tenderness at navicular OR
inability to bear weight immediately or in ER for 4 steps
fracture of distal tibia
pilon fx
mechanism of pilon fx
longitudinal impact
tx of pilon fx
surgery
tx of ankle fx
ORIF unless very distal (below mortise and evulsion fx)
bimalleolar fx
deltoid ligament disruption and distal fibular fx
high ankle sprain aka
maisonneuve fx
maisonneuve fx
deltoid injury to medial evulsion to interosseous membrane to proximal fibula fx
tx of maisonneuve fx
surgery
which ligament sprains are most common in ankle
90% are lateral
anterior talofibular
calcaneofibular
posterior talofibular
degree of ankle ligament sprains
- injury w/o lengthening
- stretching w/o failure
- complete rupture
ankle sprain pain w/o instability
1st degrere
ankle sprain instability and echymosis
3rd degree
when see medial ankle sprain what do you look for
maisonneuve fx
tx of ankle sprains
RICE, NSAIDs, activity as tolerated, PT, brace
persistent pain ater sprain
talar dome injuries (chondral fx)
AVN of talus
occult fx
tendon injuries
best way to evaluate persistent pain after ankle sprain
MRI
CT if you suspect fx
positive varus stress test
calcaneofibular ligament
anterior drawer test positive
anterior talofibular ligament
Brostrom repair
chronic instability from ankle sprain, tightens everything up
two fx associated with the knee
distal femur
tibial plateau
tx of tibial plateu and distal femur fx
surgery
tx of patellar fx
fixation
ottawa rules for knee
age 55+ tenderness of fibular head tenderness of patella inability to flex to 90 degrees inability to bear weight immediately or in ER
most common knee fx
lateral tibial plateu fx
best imaging to detect tibial plateau
CT
lateral xray
most common site of open fx of tibia
distal 1/3 because poor soft tissue coverage
sudden increase in activity point tenderness of tibia
stress fracture (most commonly in distal 3rd of tibia)
three of 4 major ligaments of the knee are torn
dislocation
what must you carefully evaluate with knee dislocation
vasculature
popliteal artery damage is common
where does popliteal artery run
along back-side of tibia
precaution to take with popliteal artery in a knee dislocation
artery may clot off at any time
get a vascular surgeon involved!
arteriogram to rule out intimal tear
overuse injury to muscle or bone in leg
shin splints
are shin splints a diagnosis or symptom
symptom
cause of most overuse injuries in leg
shin splints
three causes of shin pain in athletes
periostitis
tibial stress fx
chronic exertional compartment syndrome
inflammation where muscle attaches to bone
periostitis (most common cause of shin pain in athletes)
acute swelling anterior to patella and tendon
red, hot, good ROM, pain in full flexion
pre-patellar bursitis
pre-patellar burisits aka
housemaid’s knee
tx for housemaid’s knee
ice, rest, NSAIDs
may aspirate and inj steroid if resistant
medial ligaments of the knee
sartorius, gracillus, semitendinosis
bursitis caused by running
pes anserine
where is the pes anserine bursitis
medial knee
tx of pes anserine bursitis
ice, NSAIDS, change training schedule, inj if persistent
pain worsened with climbing stairs
pes anserine bursitis
jumper’s knee aka
patellar tendinitis
disabling inflammation of patellar tendon at inferior pole of patella
patellar tendinitis
seen in athletes who perform repetitive jumping, running, or kicking activities
patellar tendinitis
pain distal to patella exacerbated by deep knee bends or stair climbing
patellar tendinitis
inferior patellar pain
patellar tendinitis
tx for patellar tendinitis
rest
NSAIDs
PT
strengthen squads and stretch hamstrings
steroid injections contraindicated in what knee pathology
patellar tendinitis because it may rupture
lateral knee pain in runners especially when going downhill
iliotibial band syndrome
tx for IT band syndrome
ice, nsaids, change running schedule, stretch
increased pressure laterally on knee and alteral patella rubs on the condyle
patellofemoral syndrome
who does patellofemoral syndrome occur most in
adolescent girls
pain, aching wien sitting with knees bent, squatting, going up stairs in an adolescent girl
patellofemoral syndrome
PE in patellofemoral syndrome
negative
pain with prolonged sitting with knee bent (theater sign)
patellofemoral syndrome
XRAY and MRI findings in patellofemoral syndrome
negative
patellofemoral syndrome tx
ice, nsaids, patellar braces or knee straps
quad strengthening
hamstring stretching
patellofemoral pain syndrome aka
chondromalacia patella
softening or destruction of cartilage on underside of patella
patellofemoral pain syndrome
tx for patellofemoral pain syndrome
quad strengthening (especially vastus medialis)
knee sleeve
NSAIDs
when do pts with patellofemoral pain syndrome need to see ortho
persistent symptoms
anatomic abnormalities
jerky painful patellar movements
is patellar instability short or long term
short term usually
how to tx recurrent dislocations of the patella
surgical realignment
how to dx subluxations of the patella
abnormal Q angle
Q angle
angle between the longitudinal axis of the quads and the patellar tendon
anterior knee pain in adolescents worsens with running or squatting
osgood schlatter’s
tenderness directly over the tibial tubercle, remainder of knee normal
osgood- schlatters
xray findings for osgood schlatters
nonezo
traction apophysis
…. no idea
toddler’s fx
sudden twisting of tibia
most common fx of toddler’s & preschoolers
tibia fx
suden refusal to bear weight or walk
swelling and warmth over fx site
toddler’s fx
tx for toddler’s fx
long leg cast 3-4 wks
are kids more likely to have a fx or ligament injury
fracture
pain decreased ROM edema fever red, hot, swollen
osteomyelitis
most common sites of bony malignnacy
long bones
distal femur
proximal tibia
tx for combined ligament injury
surgery for one (usually ACL or PCL)
unhappy triad of o’donoghue
ACL tear
MCL tear
medial meniscus tear
tx for unahppy triad of o’donoghue
reconstruct ACL, debride or repair meniscus
MCL or LCL more commonto tear
MCL
force that tears MCL
outside force
force that tears LCL
inside force
tx of isolated collateral ligament tears
closed, even in 3rd degree
brce with early ROM
how soon can one return to play after collateral ligament tear
6-8 wks
backwards force on knee, dashboard injury, fall on bent knee, extreme hyperextension, falling on bent knee
PCL tear
does PCL tear cause instability or disability
disability
exam to dx PCL tear
posterior drawer
long term complication of PCL tear
arthritis
ACL’s job
stabilizes tibia from coming forward on femur
mechanism of ACL
non-contact
pivoting
can people resume the game after ACL tear
no
what happens an hour or two after ACL tear
huge hemarthrosis
other causes of hemarthrosis besides ACL
fx
peripheral meniscus tear
capsular tears
PE for ACL tear
lachman and anterior drawer
best test that tells you whether ACL is torn or not
lachman
best test to tell you if one is ACL dependent or independent
pivot shift test
is MRI good or bad for ACL
okay, but since ACL is in the oblique plain it sometimes misses it
ACL tear tx
1/3 need surgery (reconstruction)
either autologous or allograft
how long does it take to rehab from ACL tear
about 6 months
who does meniscus tears occur in?
young athletes with contact injuries
older people because cartilage stiffens
most common torn meniscus
medial
which meniscus most common to be torn with ACL tear
lateral
can one go back into the game after a meniscus tear?
yes
which meniscus is fixed
medial
where is pain with a meniscus tear
posteromedial
with extension and flexion
PE tests you can use for meniscus tear
McMurrays
apply’s distraction
best dx tool for meniscus tear
MRI
locked knee with tear
meniscus from bucket handle tear lflipping to the front of knee
when does hemarthrosis occur with mensicus tear
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