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EM Board exam > Ortho > Flashcards

Ortho Flashcards

1
Q

Picture labels

A
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2
Q

Salter Harris mnemonic

prognostic significance
negative x-rays for types?

Most common type

A

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

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3
Q
A
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4
Q

Recurrent median nerve function

amputated part care

indications for replant (6)

A

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

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5
Q

Pictured entity and labels

treatment

Paronychia acute versus chronic cause

A

Splint PIP in extension, referral

staph versus candida and other fungi with chronically moist hands

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6
Q

Pictured entity

jersey finger - what (see picture)
mallet finger-what, treatment

A

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

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7
Q

Likely associated injury

A

Mallet finger - disruption of extensor tendon

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8
Q

Pictured entity, Rose Gardner; tx

gamekeeper’s thumb, what? tx (2)

A

Sporotrichosis, itraconazole

UCL disruption +/- avulsion; tx thumb Spica +/- surgery

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9
Q

Metacarpal neck fractures

maximum angulation for 5th, 4th, 3-2nd

additional indication for surgical repair

metacarpal shaft fractures modification of above

A

45°, 35°, 15°
any rotational deformity

metacarpal shaft: above tolerances minus 5°; surgery often needed for 2nd-3rd

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10
Q

Metacarpal head fractures

tx

picture 1: what, tx (2)

picture 2: what, tx (2)

Prognosis

A

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

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11
Q

Pictured entity

fingertip injury zone 1 vs 2&3

DIP dislocation, splint position, can’t reduce?

MCP dislocation, why difficult to reduce?

A

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

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12
Q

Finger flexion, FDP vs FDS

intrinsic plus position - description, indication

A

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

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13
Q

Pictured injury, most commonly injured nerve

Guyon’s Canal Syndrome - what, tx (2)

A

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

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14
Q

Injury type, most commonly injured structures (2)

A

Smith’s fracture, median nerve, flexor tendons

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15
Q

Injury?
Mechanism
diagnostic criteria
treatment (2)

A

Scapholunate dissociation

FOOSH

> 3 mm space between scaphoid and lunate as pictured

thumb spica, refer

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16
Q

Injury

mechanism

associated injury (2)

distinction from similar injury

A

Perilunate dislocation

forceful hyperextension
scaphoid fracture, median nerve injury
Perilunate: lunate still lined up with radius

Lunate: lunate is displaced from radius

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17
Q

Injury

snuff box tenderness with negative x-ray @ 2 weeks, next steps?

High-pressure injection injury - tx

A

Perilunate dislocation

CT/MRI (or bone scan at 3 days)

emergent debridement and decompression (imaging for radiopaque substance)

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18
Q

Tinel’s and Phalen’s sign suggest ? Sign definitions

+ Finkelstein’s test suggest? define

A

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

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19
Q

Pictured injury, difference from “cousin” injury

full injury description

complication

Tx:

A

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

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20
Q

Pictured injury, description

associated mnemonic

complications (3)

tx

A

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

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21
Q

Injury type?

Classic clinical presentation

Tx

A

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
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22
Q

Injury?
Missed associated injury and complications

A

Nightstick fracture

–Missed Monteggia fracture

(radiohumeral dislocation)

– Radial nerve injury

– Nonunion

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23
Q

Injury

force required?
Treatment

feared complication

A

Both bone forearm fracture

high energy

ORIF except sometimes in children

compartment syndrome

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24
Q

Injury, cause, tx

A

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)

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25
Q

Bursitis, contraindicated/preferred procedure

procedure distinguishes between?

Tennis elbow =

Little League elbow =

treatment for both

A

Don’t I&D, aspirate

septic and non-septic bursitis

lateral epicondylitis
medial epicondylitis
avoid overuse/rest, NSAIDS

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26
Q

Elbow dislocation, most common position
vascular injury
nerve injury
associated fracture in children

stability depends on

A

Posterior

vascular injury - brachial artery
nerve injury - ulnar nerve
children - medial upper condyle

stability depends on presence of coranoid fracture

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27
Q

Elbow radiography

fat pad that is always abnormal and indicates (3+)

radial head fracture types (4) and tx

A

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

28
Q

Pictured entity and radiographic finding

complications (5) -> precaution

A

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

29
Q

Subacute shoulder pain, cause categories (2) and key PEX diference

muscles of the rotator cuff acronym

A

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

30
Q

Pictured entity and clinical significance

A

Hill-Sachs deformity; predisposes to recurrent dislocation

31
Q

Pictured entity, cause, clinical significance

shoulder dislocation, complications (4)

posterior dislocation, classic mechanisms (3)

compared to anterior, posterior neurovascular injury frequency

posterior xray sign

A

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

32
Q

Clavicle fracture - most common location

may need ORIF when

location: look for associated injuries and reasons

A

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

33
Q

Humerus fracture
nerve injury, proximal, test
nerve injury mid the shaft, test

rotator cuff injury, most compromised motions (2)

most commonly injured muscle

A

Axillary nerve, deltoid sensation
radial nerve, wrist extension

motions: external rotation, abduction

supraspinatus

34
Q

Thoracic outlet syndrome what
clinical test

A

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

35
Q

Pelvic fractures - types (4) and tx

pictured entity

A

1: avulsion - conservative
2: single ring-conservative
3: double ring-fixation, hemorrhage control
4: acetabular fracture, ORIF if displaced

Pictured: Malgaigne Disruption

36
Q

Hip dislocation: Less common type and position

pictured entity - name and pathophysiology
common age, sex, presentation
tests if x-rays negative

A

Anterior, externally rotated

Legg-Calve-Perthes: avascular necrosis of the femoral head
boys 4 to 8 years, limp
MRI or bone scan

37
Q

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

A

Tip septic arthritis, staph aureus, salmonella, gonorrhea

slipped capital femoral epiphysis
adolescent obese boys
frog leg view
ORIF

38
Q

Children, most common cause painful hip
cause categories
presentation
diagnosis
treatment

A

Toxic synovitis
postviral, allergic, trauma
limp/inability to bear weight
arthrocentesis to rule out septic arthritis
conservative treatment: rest, NSAIDs

39
Q

Pictured entity
increase risk in?
Treatment (3)

A

Traumatic myositis ossificans - formation of bone in muscle after injury

thrombocytopenia, hemophilia
nonweightbearing, wrapped from foot to groin knee at 90°, elevation

40
Q

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

A

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

41
Q

McMurray test-injury type, what

Apley compression/distraction test - what and purpose

A

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

42
Q

Ottowa knee rules (4)

Baker’s cyst - what, management

A

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

43
Q

Pictured entity - what, tx (avoid….)

Osteochondritis Dissecans - symptom (2), location, what

A

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

44
Q

Knee dislocation

often _______

commonly associated with

caveat

pictured entity

A

Reduces spontaneously
no vascular injury (popliteal artery peroneal nerve)
caveat: signs of vascular injury initially absent

quadriceps tendon rupture with high riding patella

45
Q

Tibial plateau fracture complications (2) and test

most common location/cause of compartment syndrome

compartment: earliest symptom, indication for surgery

A

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

46
Q

Positive Thompson test =

most commonly injured ligaments, ankle sprain (3)

Ottawa Ankle Rules (4)

A

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

47
Q

Medial ankle pain, swelling, x-ray shown, consider?

Describe injury and mechanism

xray finding

tx

A

Maisoneuve Fracture

external ankle rotation -> deltoid ligament rupture + prox fib fx

widened medial mortise
likely surgery

48
Q

Calcaneal fracture - x-ray type and finding

dancers versus Jones fracture, tx; xray shows?

A

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

49
Q

Pictured entity and description
treatment

describe:

tarsal tunnel

March fracture
Morton’s neuroma
severs disease

A

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

50
Q
A
51
Q

Osteomyelitis - best early test, lab

frequent fractures misdiagnosed as child abuse - disease and other pex findings (2)

A

Bone scan

osteogenesis imperfecta; blue sclera, flaccid joints

52
Q

Cervical spine distances

predental space adults and kids
pre-vertebral soft tissue space

A

Adults < 3 mm, Peds < 5 mm

6 mm at C2, 22 mm at C6

53
Q
A
54
Q
A
55
Q

Cervical spine NEXUS criteria (5)

unstable cervical spine fractures mnemonic (6)

A

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
56
Q

Atlantoaxial dislocation - associated underlying conditions (2)

pictured injury

Clay shoveler’s =

A

Atlantoaxial rheumatoid arthritis, ankylosing spondylitis

bilateral facet dislocation-high incidence of associated injuries

Clay shoveler’s = spinous process, usually C6-T1

57
Q

Pictured injury

Jeffersons = ?; Seen best on what view

Odontoid fx, types (3), stability, xray finding?

A

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)

58
Q

Most common pediatric cervical spine fracture

pictured entity, diagnostic key

Brown-Sequard Syndrome - what

key findings

A

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

59
Q

Pictured entity

anterior cord-key findings, others, mech

A

Unilateral facet dislocation-bowtie deformity-can be unstable

anterior: complete motor paralysis below injury, vibration proprioception preserved
mechanism: retropulsion

60
Q

Spinal cord anatomy

A
61
Q

Central cord - key finding, associated finding

posterior cord-key finding, nontraumatic mechanisms (2)

A

Arm > leg weakness; loss of bladder control, sacral sparing

loss of position/vibration; B12 deficiency, tertiary neurosyphilis

62
Q

SCIWORA - dx, tx

etiology of neurogenic shock; location of injury

skin findings (2)

tx

A

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

63
Q

Lumbar fractures - burst versus chance
mechanism

stability

associated injuries

pictured injury

What is a chance fx

A

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

64
Q
A
65
Q

Wedge fracture

stable?

Unique treatment

burning of the lateral thigh suggests

Common sufferers

A

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

66
Q

Pictured entity, main sx, calcium level

lumbar disc syndromes, shortcuts for L4-S1

A

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

EM Board exam (18 decks)

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