Ortho Flashcards
Picture labels
Salter Harris mnemonic
prognostic significance
negative x-rays for types?
Most common type
Prognosis for growth disturbance worsens with increasing grade; injuries affecting epiphysis have worse outcomes as the blood supply traverses it
types 1 and 5
type 1
Recurrent median nerve function
amputated part care
indications for replant (6)
Helps oppose thumb
inside plastic bag inside another plastic bag with ice
replant
–Multiple digits
–Thumb
–Single digit between PIP & DIP (distal to the superficialis insertion)
–Metacarpal (palm)
–Wrist, forearm
–Almost any part in child
Pictured entity and labels
treatment
Paronychia acute versus chronic cause
Splint PIP in extension, referral
staph versus candida and other fungi with chronically moist hands
Pictured entity
jersey finger - what (see picture)
mallet finger-what, treatment
Herpetic whitlow
jersey: FDP avulsion from the distal phalanx “grabbing a jersey” leaving fingertip unable to flex
Mallet: extensor tendon disruption at the DIP, splint in extension
Likely associated injury
Mallet finger - disruption of extensor tendon
Pictured entity, Rose Gardner; tx
gamekeeper’s thumb, what? tx (2)
Sporotrichosis, itraconazole
UCL disruption +/- avulsion; tx thumb Spica +/- surgery
Metacarpal neck fractures
maximum angulation for 5th, 4th, 3-2nd
additional indication for surgical repair
metacarpal shaft fractures modification of above
45°, 35°, 15°
any rotational deformity
metacarpal shaft: above tolerances minus 5°; surgery often needed for 2nd-3rd
Metacarpal head fractures
tx
picture 1: what, tx (2)
picture 2: what, tx (2)
Prognosis
tx: all require hand referral, likely surgery
Bennett’s: ulnar aspect thumb baseline with dislocation CMC; thumb spica + ORIF
Rolando: similar but comminuted
Bennett’s is Bad but Rolando is Really bad
Pictured entity
fingertip injury zone 1 vs 2&3
DIP dislocation, splint position, can’t reduce?
MCP dislocation, why difficult to reduce?
Flexor tenosynovitis
zone 1 > 2/3 proximal nail bed preserved, no exposed bone, heals with secondary intention
Zone 2-3: needs surgery
DIP: 30° flexion; entrapment of volar plate
MCP: volar plate almost always entrapped
Finger flexion, FDP vs FDS
intrinsic plus position - description, indication
FDP goes to the Point (tip) -> DIP, FDS Stops short -> PIP
wrist 20° extension, MCP 90° flexion, fingers straight
metacarpal and unstable proximal/middle phalange fractures; NOT for DRF
Pictured injury, most commonly injured nerve
Guyon’s Canal Syndrome - what, tx (2)
Colles fracture, median nerve
Guyon’s: entrapment of the ulnar nerve in Guyon’s canal between pisiform and hamate due to cyst or rope the trauma (cyclist, golf, baseball)
splint, surgical decompression
Injury type, most commonly injured structures (2)
Smith’s fracture, median nerve, flexor tendons
Injury?
Mechanism
diagnostic criteria
treatment (2)
Scapholunate dissociation
FOOSH
> 3 mm space between scaphoid and lunate as pictured
thumb spica, refer
Injury
mechanism
associated injury (2)
distinction from similar injury
Perilunate dislocation
forceful hyperextension
scaphoid fracture, median nerve injury
Perilunate: lunate still lined up with radius
Lunate: lunate is displaced from radius
Injury
snuff box tenderness with negative x-ray @ 2 weeks, next steps?
High-pressure injection injury - tx
Perilunate dislocation
CT/MRI (or bone scan at 3 days)
emergent debridement and decompression (imaging for radiopaque substance)
Tinel’s and Phalen’s sign suggest ? Sign definitions
+ Finkelstein’s test suggest? define
Carpal tunnel - entrapment of median nerve
Tinel’s sign: Tap volar wrist -> paresthesias
Phalen’s sign: hyperflex wrist -> paresthesias
+Finkelstein’ (ulnar deviation of fisted hand reproduces dorsal/radial pain) -> DeQuervain’s tenosynovitis
Pictured injury, difference from “cousin” injury
full injury description
complication
Tx:
GRUM: Galeazzi- (distal)Radial fx; (proximal)Ulnar fx - Monteggia
Galeazzi: distal radius shaft fracture with disrupted radio-ulnar joint
complication: all are nerve injury
Tx: ORIF
Pictured injury, description
associated mnemonic
complications (3)
tx
Monteggia fracture; proximal ulnar with the radial head dislocation/annular ligament disruption
GRUM: Galeazzi- (distal)Radial fx; (proximal)Ulnar fx - Monteggia
radial nerve injury, radial head fracture, nonunion
ORIF
Injury type?
Classic clinical presentation
Tx
Essex-Lopresti Injury
severe wrist pain after FOOSH with negative x-rays
Tx: ORIF
- Radial head fracture
- Dislocation of distal RU joint
- Interosseous membrane disruption
Injury?
Missed associated injury and complications
Nightstick fracture
–Missed Monteggia fracture
(radiohumeral dislocation)
– Radial nerve injury
– Nonunion
Injury
force required?
Treatment
feared complication
Both bone forearm fracture
high energy
ORIF except sometimes in children
compartment syndrome
Injury, cause, tx
Volkmann’s Contracture - forearm pronation, flexion of wrist and digits, paralysis of intrinsic muscles due to compression of forearm/poor circulation
presents similar to compartment syndrome
tx: remove source of compression (eg cast)
Bursitis, contraindicated/preferred procedure
procedure distinguishes between?
Tennis elbow =
Little League elbow =
treatment for both
Don’t I&D, aspirate
septic and non-septic bursitis
lateral epicondylitis
medial epicondylitis
avoid overuse/rest, NSAIDS
Elbow dislocation, most common position
vascular injury
nerve injury
associated fracture in children
stability depends on
Posterior
vascular injury - brachial artery
nerve injury - ulnar nerve
children - medial upper condyle
stability depends on presence of coranoid fracture
Elbow radiography
fat pad that is always abnormal and indicates (3+)
radial head fracture types (4) and tx
Posterior, occult radial head fracture, intra-articular or intra-capsular hemorrhage, gout
–Type I: nondisplaced - brief sling and early range of motion
–Type II: marginal impaction, displacement and angulation - same as type I, unless no improvement or mechanical block
–Type III: comminuted radial head - radial head excision
–Type IV: any of the above plus elbow dislocation - treated for both dislocation and fracture
Pictured entity and radiographic finding
complications (5) -> precaution
Supracondylar fracture, anterior humeral line test
complications: median nerve injury, brachial artery injury, compartment syndrome, Volkman’s contracture, vascular compromise
precaution: admit to hospital for neurovascular checks for any displaced fracture
Subacute shoulder pain, cause categories (2) and key PEX diference
muscles of the rotator cuff acronym
Impingement syndrome - impaired active, normal passive ROM due to rotator cuff tendinitis, subacromial tendinitis and bursitis
adhesive capsulitis after immobilization, impaired active and passive
rotator cuff - SITS
–Supraspinatus
–Infraspinatus
–Teres minor
–Subscapularis
Pictured entity and clinical significance
Hill-Sachs deformity; predisposes to recurrent dislocation
Pictured entity, cause, clinical significance
shoulder dislocation, complications (4)
posterior dislocation, classic mechanisms (3)
compared to anterior, posterior neurovascular injury frequency
posterior xray sign
Bankart lesion, labral tear + anterior glenoid rim fracture - > leads to joint laxity, recurrent dislocation
complications: axillary nerve injury, adhesive capsulitis, avascular necrosis, rotator cuff injury
mechanisms: fall, seizure, electric shock
less common
sign - see picture
Clavicle fracture - most common location
may need ORIF when
location: look for associated injuries and reasons
Middle third
distal third with significant displacement due to ruptured coraco-clavicular joint with significant medial elevation
associated injuries: medial third due to very high force required; subclavian artery and vein injuries
Humerus fracture
nerve injury, proximal, test
nerve injury mid the shaft, test
rotator cuff injury, most compromised motions (2)
most commonly injured muscle
Axillary nerve, deltoid sensation
radial nerve, wrist extension
motions: external rotation, abduction
supraspinatus
Thoracic outlet syndrome what
clinical test
Compression of brachial plexus, subclavian vein or artery usually due to cervical rib
EAST: elevated arm stress test and raised arm three minutes opening and closing fist; positive test is unable to complete due to paresthesia or claudication
Pelvic fractures - types (4) and tx
pictured entity
1: avulsion - conservative
2: single ring-conservative
3: double ring-fixation, hemorrhage control
4: acetabular fracture, ORIF if displaced
Pictured: Malgaigne Disruption
Hip dislocation: Less common type and position
pictured entity - name and pathophysiology
common age, sex, presentation
tests if x-rays negative
Anterior, externally rotated
Legg-Calve-Perthes: avascular necrosis of the femoral head
boys 4 to 8 years, limp
MRI or bone scan
Infants, most common cause of painful hip
normal etiology, etiology with sickle cell, adolescents
pictured entity
most common age, sex, habitus
helpful diagnostic x-ray view
treatment
Tip septic arthritis, staph aureus, salmonella, gonorrhea
slipped capital femoral epiphysis
adolescent obese boys
frog leg view
ORIF
Children, most common cause painful hip
cause categories
presentation
diagnosis
treatment
Toxic synovitis
postviral, allergic, trauma
limp/inability to bear weight
arthrocentesis to rule out septic arthritis
conservative treatment: rest, NSAIDs
Pictured entity
increase risk in?
Treatment (3)
Traumatic myositis ossificans - formation of bone in muscle after injury
thrombocytopenia, hemophilia
nonweightbearing, wrapped from foot to groin knee at 90°, elevation
when medial pressure is applied over the lateral aspect of the knee in extension and the joint opens medially suggests ?
Anterior drawer versus Lachman test - injury type, which is better
Varus vs Valgus stress mnemonic
Disruption of MCL and PCL
for ACL injuries; AD = 90°, Lachman superior, done at 30° pulling tibia anterior
ValGUs stress push medially from lateral aspect towards the GUt
McMurray test-injury type, what
Apley compression/distraction test - what and purpose
Medial meniscus injury
popping/locking with internal leg rotation with Volga’s stress extending knee from 90°
patient prone, knee at 90°, examiner internally/externally rotates foot applying both compression and distraction to knee; pain worse with compression = meniscal injury, worse with the distraction equals ligamentous injury
Ottowa knee rules (4)
Baker’s cyst - what, management
Age greater than 55, patellar or fibular tenderness, unable to bear weight for steps immediately and in ED, unable to flex to 90°
Baker’s: gastrocnemius bursitis which often communicates to the knee joint and contains the synovial fluid (more common primary in children);
tx: joint aspiration with intra-articular steroid injection
Pictured entity - what, tx (avoid….)
Osteochondritis Dissecans - symptom (2), location, what
Osgood-Schlatter Disease
patellar tendon apophysitis at tibial tubercle, rest, NSAIDs, avoid forced extention
medial knee pain and locked joint due to loose body from subchondral fracture
Knee dislocation
often _______
commonly associated with
caveat
pictured entity
Reduces spontaneously
no vascular injury (popliteal artery peroneal nerve)
caveat: signs of vascular injury initially absent
quadriceps tendon rupture with high riding patella
Tibial plateau fracture complications (2) and test
most common location/cause of compartment syndrome
compartment: earliest symptom, indication for surgery
Neurovascular injury (pulses, angiogram), deep peroneal nerve injury with lateral plateau fracture (test sensation first dorsal webspace)
compartment: anterior tibial compartment due to tibial fracture
pain, pressure > 40-50
other sx: 5Ps - Pain, pallor, paresthesia, paralysis, pulselessness
Positive Thompson test =
most commonly injured ligaments, ankle sprain (3)
Ottawa Ankle Rules (4)
Lack of passive plantar flexion with calf squeeze -> Achilles tendon rupture
Anterior talofibular, Calcaneofibular, Posterior talofibular
rules: posterior edge distal 6 cm malleolar or fibular tenderness, fifth metatarsal base, navicular tenderness, inability to bear weight immediately and in emergency department
Medial ankle pain, swelling, x-ray shown, consider?
Describe injury and mechanism
xray finding
tx
Maisoneuve Fracture
external ankle rotation -> deltoid ligament rupture + prox fib fx
widened medial mortise
likely surgery
Calcaneal fracture - x-ray type and finding
dancers versus Jones fracture, tx; xray shows?
Harris view showing Bohler’s angle 20-40 (decreased with fracture)
both 5th metatarsal
D: avulsion fracture of base, cast shoe
J: transverse of proximal diathesis, ORIF or cast
Pictured entity and description
treatment
describe:
tarsal tunnel
March fracture
Morton’s neuroma
severs disease
Lisfranc’s - disruption of tarsal metatarsal joint +/- MT base fx
possible ORIF
tarsal tunnel: entrapment neuropathy of posterior tibial nerve, +Tinnel’s
March fracture: second metatarsal stress fracture from pushing off
Morton’s neuroma: interdigital nerve neuropathy
severs disease: Achilles apophysitis
Osteomyelitis - best early test, lab
frequent fractures misdiagnosed as child abuse - disease and other pex findings (2)
Bone scan
osteogenesis imperfecta; blue sclera, flaccid joints
Cervical spine distances
predental space adults and kids
pre-vertebral soft tissue space
Adults < 3 mm, Peds < 5 mm
6 mm at C2, 22 mm at C6
Cervical spine NEXUS criteria (5)
unstable cervical spine fractures mnemonic (6)
No midline tenderness, distracting injury, altered level of alertness, neuro- deficit, intoxication
Jefferson bit off a hangman’s toe
- J - Jefferson Fracture (burst of C1)
- B - Bifacet dislocation +/- fracture
- O - Odontoid types II and III
- A - Any fracture/dislocation
- H - Hangman’s fracture (posterior element C2)
- T - Teardrop fractures
Atlantoaxial dislocation - associated underlying conditions (2)
pictured injury
Clay shoveler’s =
Atlantoaxial rheumatoid arthritis, ankylosing spondylitis
bilateral facet dislocation-high incidence of associated injuries
Clay shoveler’s = spinous process, usually C6-T1
Pictured injury
Jeffersons = ?; Seen best on what view
Odontoid fx, types (3), stability, xray finding?
hangman’s = bilateral C2 pedicle fracture, C2 on C3 spondyloisthesis
C1 burst fracture from axial load, lateral masses of C1 displaced out on odontoid
Type I: tip avulsion
Type II: at neck of dens - unstable
Type III: through body of C2 - unstable
abnormal atlanto-dens space (3mm/5mm adults/kids)
Most common pediatric cervical spine fracture
pictured entity, diagnostic key
Brown-Sequard Syndrome - what
key findings
Odontoid fracture
pseudo-subluxation of C2 on C3
key (to the fact that it is normal) - normal spiinolaminal line
unilateral cord injury with crossed findings below level
iipsilateral weakness loss of position and vibration
contralateral loss of pain and temperature
Pictured entity
anterior cord-key findings, others, mech
Unilateral facet dislocation-bowtie deformity-can be unstable
anterior: complete motor paralysis below injury, vibration proprioception preserved
mechanism: retropulsion
Spinal cord anatomy
Central cord - key finding, associated finding
posterior cord-key finding, nontraumatic mechanisms (2)
Arm > leg weakness; loss of bladder control, sacral sparing
loss of position/vibration; B12 deficiency, tertiary neurosyphilis
SCIWORA - dx, tx
etiology of neurogenic shock; location of injury
skin findings (2)
tx
SCIWORA - MRI, often self-limited in children, consider surgery for disc herniation in adults
shock: unopposed parasympathetic, T1 and above
skin: warm and dry
tx: fluids
Lumbar fractures - burst versus chance
mechanism
stability
associated injuries
pictured injury
What is a chance fx
Lumbar fractures - burst versus chance
mechanism - axial load versus flexion/distraction (car accident)
stability -burst unstable
associated injuries - chance associated with intra-abdominal injury
horizontal fracture through entire vertebral body, usually L1-2
Wedge fracture
stable?
Unique treatment
burning of the lateral thigh suggests
Common sufferers
Stable if < 50% compression
Salmon calcitonin
•Meralgia paraesthetica - Lateral femoral cutaneous nerve compression where it passes between the ilium and inguinal ligament
– Pregnant women
– Workmen with belts
Pictured entity, main sx, calcium level
lumbar disc syndromes, shortcuts for L4-S1
Paget’s disease - –Rapid, chaotic bone resorption followed by chaotic bone formation, very frequent fractures, normal calcium
L4 : Absent knee jerk
L5 : Absent dorsiflexion of great toe
S1 : Absent ankle jerk, numbness
of lateral foot
