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Surgery Clerkship > Ortho > Flashcards

Ortho Flashcards

1
Q

What is the presentation of fat embolism syndrome?

A

Resp symptoms
Neuro changes
Reddish brown petechial rash

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2
Q

How long after injury does fat embolism present?

A

24-72 hours

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3
Q

What are the 4 functional components of the extremity exam after trauma?

A

Nerves
Vessels
Bones
Soft tissues

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4
Q

What is the pathophysiology of fat embolism syndrome?

A

Embolization of fat and marrow content from fractured long bones, especially femur - affects brain and lungs most

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5
Q

What are the 3 nerve injury types?

A

Neuropraxia
Axonotmesis
Neurotmesis

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6
Q

What sign is a humeral shaft fracture associated with?

A

Radial n injury –> wrist drop

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7
Q

Why does open fracture require special treatment?

A

Communication with environment disrupts soft tissue/skin and requires special treatment due to infection risk

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8
Q

Why is it important to do a thorough secondary survey after trauma?

A

To avoid missing additional fractures

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9
Q

What must the XR show in any bone fracture?

A

Joint above and below

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10
Q

What constitutes an open fracture?

A

Soft tissue wound + fracture

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11
Q

In patients with femoral neck fracture, what else must we look for?

A

Femoral neck fracture

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12
Q

What antibiotics are appropriate for open fracture?

A

First gen cephalosporin +/- aminoglycoside

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13
Q

Within what time frame should open fractures be managed?

A

W/in 6 hour

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14
Q

What is the protocol for treating an open fracture?

A
  • Antibiotics
  • Irrigation and surgical debridement
  • External fixation immediately if unstable
  • Internal fixation is definitive
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15
Q

Within how long should a closed fracture be managed?

A

Within 2-12 hours: intramedually nailing

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16
Q

Why is prompt management important for closed fracture?

A

Reduces risk of fat embolism syndrome

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17
Q

What are the main surgical risks of fracture repair?

A

Infection
Nonunion
Nerve or vessel injury
Amputation

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18
Q

What is a dangerous sequela of a tibia fracture?

A

Compartment syndrome

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19
Q

What is neuropraxia?

A

Minimal injury to myelin, but not axon or nerve sheath

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20
Q

What is axonotmesis?

A

Myelin + axon disrupted, nerve sheath intact. Wallerian degeneration

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21
Q

What is neurotmesis?

A

Myelon + axon + nerve sheath damaged. Wallerian degeneration

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22
Q

What is the most important determinant of severity for open fractures?

A

Energy imparted to the limb

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23
Q

Which grades of open fractures need additional antibiotic coverage with aminoglycoside?

A

Grade IIIA, B, C

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24
Q

Why is it important to have early stabilization of open fractures?

A

Protect soft tissues around the injury and prevent further damage secondary to mobile fracture fragments

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25
Q

What is reduction?

A

Putting displaced bones back to normal anatomic position
Open: through surgical incision
Closed: External manipulation of limb

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26
Q

What are 2 main concerns with femur fracture?

A
  • Fat embolism

- Blood loss: highly vascular: monitor for shock

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27
Q

What type of orthopedic fracture is at greatest risk for hemorrhagic shock?

A

Pelvic fractures

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28
Q

What is management for fat embolism syndrome?

A
  • Ventilatory support w/ high PEEP
  • Early stabilization of fractures
  • Possibly steroids
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29
Q

What is most important step to prevent fat embolism in poly trauma patient?

A

Early stabilization of long bone fractures w/in first 24 hours

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30
Q

What to watch out for in crush injuries?

A

Compartment syndrome

Rhabdo leading to kidney failure

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31
Q

What does acute trauma to the knee with anterior knee laxity suggest?

A

ACL injury

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32
Q

If a patient can bear weight, what can we assume?

A

Fracture less likely

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33
Q

What are the key components of the knee exam?

A 
Gait
Observation
Palpation
ROM
Joint line tenderness
Neurovascular
Knee maneuvers
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34
Q

What is the major concern with a knee dislocation?

A

Vasculature damage: dysvascular limb risking amputation

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35
Q

How do ligament and meniscal injuries differ with regard to swelling?

A

Ligament: immediate swelling
Meniscal: delayed swelling

36
Q

What are the 2 causes of ACL injury?

A

Contact

Non contact: pivoting injuries

37
Q

What is the unhappy triad of the knee?

A

MCL
ACL
Medial meniscus

38
Q

What is the imaging workup for a suspected ACL injury?

A
  1. Radiograph: look for fracture, alignment/deformity, infection and tumor
  2. MRI to confirm
39
Q

What is the treatment for ACL tear?

A

Individualized: conservative or surgery

40
Q

What conservative management principles should every ACL patient get?

A

RICE: Rest Ice Compression Elevation

41
Q

Which patients with ACL tear are better candidates for non-op management?

A

Elderly, low-demand patients

42
Q

Which patients with ACL tear are better candidates for surgery?

A

Young, healthy people who want to return to athletics

43
Q

What type of surgery is ACL surgery?

A

Reconstruction, NOT repair

44
Q

What are the concerns after ACL surgery?

A

Infection
Knee stiffness
Graft failure

45
Q

If a complication is present after ACL surgery, what is the principle guiding management?

A

Exhaust all conservative options before re-operating

46
Q

What to consider in patients with recurrent fractures?

A

Neoplastic lesion e.g. osteosarcoma weakening the bone

47
Q

What is the distribution of blood supply to the meniscus, and why is it important?

A

Outside-in: only 25-30% of diameter gets blood:
Red zone: gets blood
White zone: less blood flow: not repaired but debrided if necessary

48
Q

What is the significance of being unwilling (vs. unable) to range the knee?

A

Unwilling: suspect fracture or septic arthritis

49
Q

What radiographic sign is pathognomonic for ACL injury?

A

Segond fracture or small fleck of bone avulsed from lateral tibial plateau

50
Q

What is classic presentation of SCFE?

A 
Obese, adolescent male aged 10-16
Groin pain
Painful limp
Externally rotated hip
Not irritable (allows ROM)
51
Q

What is the thinking re: knee pain in young children?

A

Hip pathology causing referred knee pain

52
Q

What is the pathophysiology of slipped capital femoral epiphysis?

A

Excess loading across the physis causes slippage of the head on the neck of the femur (epiphysis on metaphysics)

53
Q

What are predisposing factors for weak physis?

A

Endocrine disorders
Osteodystrophy
Hypothyroid/ hypopituitarism

54
Q

What is the workup for suspected SCFE?

A
  • XR: AP and/or frog lateral view of the hip: shows displacement of proximal femoral epiphysis on metaphysis
  • Rule out septic arthritis
55
Q

What is the management of SCFE?

A
  • Admit to hospital: urgent surgical pinning of the hip w/ a single screw
  • Short period of protected weight bearing with crutches
56
Q

What are possible complications of fixing SCFE?

A
  • Screw too short
  • Inadequate fixation
  • Additional slippage
  • Avascular necrosis
57
Q

In a peds patient, complaint of knee pain should prompt what?

A

Clinical/radiographic exam of the hip

58
Q

Hip pain plus history of steroid use, what to think?

A

Avascular necrosis of the femoral head (osteonecrosis)

59
Q

What is the significance of leg length discrepancy with hip pain?

A

mechanical pathology: disruptions in structural integrity of the long bones of the lower limb can lead to leg length discrepancy

60
Q

What to think: inability to bear weight on the hip or range motion?

A

Septic arthritis or unstable SCFE

61
Q

What is an antaglic gait?

A

Limping due to pain: short stance phase on the affected limb to minimize time on the painful limb

62
Q

What is Legg-Calve-Perthes disease?

A

Idiopathic osteonecrosis of the femoral head: ages 4-8

63
Q

What are the 4 Kocher criteria to diagnose pediatric septic arthritis?

A

Fever > 38.5 C
Inability to bear weight
ESR > 20 mm/h
WBC > 12,000

3% with 1, 40% with 2, 93% with 3, 99% with 4

64
Q

What are the classic x-ray findings of developmental dysplasia of the hip?

A

Subluxation or dislocation of femoral head from acetabulum

65
Q

What is the classic x-ray finding of Legg-Calve-Perthes disease?

A

Subchondral collapse of the bone of the femoral head

66
Q

What is the classic x-ray finding of SCFE?

A

Asymmetry o femoral head on the neck: ice cream appears to slide off of the cone

67
Q

What is the treatment of Legg-Calve-Perthes disease?

A

Usually none: advanced disease contains the hip: casting/bracing or femoral/pelvic ostomies

68
Q

What other imaging should be done to the hip if diagnosis is unclear?

A

MRI

Bone scan for bone pathology

69
Q

What are key symptoms of carpal tunnel?

A
  • Sensory dysthesias in median nerve distribution
  • Dropping things
  • Symptoms worse at night
  • Job involving repetitive wrist/hand movements
70
Q

What is Tinel’s sign?

A

Gently percussing over median nerve at carpal tunnel: positive if the patient describes an electrical shock sensation in the median nerve distribution

71
Q

What is Phalen’s sign?

A

Patient places dorsal sides of hands against each other in maximal wrist flexion for 30-60s: positive if the patient reports new or worsening paresthesias in the median nerve distribution of affected hand

72
Q

What is Durkan’s test?

A

Squeezing the patient’s wrist w/ direct compression over the median nerve over the carpal tunnel w/ examiner’s thumb
Test is positive if patient has new or worsening symptoms

73
Q

How do we diagnose carpal tunnel?

A

Clinically: history and exam

74
Q

If the diagnosis is unclear clinically for carpal tunnel, what is the next step?

A

EMG / NCS

75
Q

What must we rule out with suspected carpal tunnel?

A

Rule out spinal disease / medical neuropathy with:

  • MRI
  • Labs
76
Q

What are the treatments for carpal tunnel in order of 1st line first?

A

NSAIDs / Wrist splinting
Carpal tunnel injection
Surgical release

77
Q

When is surgical release the first management option for carpal tunnel?

A

Thenar wasting is present

78
Q

What are the important complications of carpal tunnel?

A
  • Painful scar / neuroma
  • Injury to recurrent motor branch
  • Inadequate release (particularly endoscopic technique)
  • Recurrence
79
Q

What are important things NOT to overlook in carpal tunnel?

A

Myelopathy
Pancoast tumor
Treatable peripheral neuropathy

80
Q

What form of carpal tunnel is an emergency?

A

Acute: after fracture or dislocation

81
Q

What form of carpal tunnel is an emergency?

A

Acute: after fracture or dislocation

82
Q

Which test is most sensitive for carpal tunnel?

A

Durkan’s Median Nerve Compression Test

83
Q

How to distinguish between proximal vs. carpal tunnel median nerve compression?

A

Palmar cutaneous branch of median nerve: branches before carpal tunnel to innervate thenar eminence
* Typical carpal tunnel: no sensory dysthesias in thumb

84
Q

What is thoracic outlet syndrome?

A

Compression of the lower brachial plexus: ulnar symptoms predominate, or compression of subclavian vessels between anterior and middle scalene muscles (associated often with cervical rib)

85
Q

What are risk factors for carpal tunnel syndrome?

A 
Women
Obesity
Pregnancy
Smoking
Repetitive wrist movements
RA
Hypothyroidism
Alcoholism
CKD
86
Q

What are the 3 stages of median nerve compression?

A

1: Sensory symptoms at night
2: Symptoms also occur by day
3: Motor symptoms of weakness and/or muscle wasting

Surgery Clerkship (16 decks)

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