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ortho Flashcards

1
Q

MC location and mechanism of compartment syndrome

A

i. Can occur in any extremity
1. Lower leg most common.

any kind of fracture but most frequently you see it with a crush injury

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2
Q

other than crush injuries, what are common etiologies of compartment syndrome

A
  1. Crush injury
  2. Fracture
  3. External compression i.e. casts that are too tight, splints, dressings.
  4. Bleeding/hematoma
  5. Burns
  6. Positional – overdose found down.
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3
Q

what do we look for with compartment syndrome? what is the BEST indicator

A

1 –>PAIN TO PASSIVE STRETCH

b. Paresthesias (numbness or tingling in the extremity)
c. Pain
d. Peripheral pulses absent (very late finding)
e. Paralysis (late finding)

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4
Q

why is an absent peripheral pulse such a late finding

A

compartment pressures are usually not higher than blood pressure

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5
Q

gold standard for dx compartment syndrome

A

Gold standard Diagnostic: Compartment Pressure Measurement

DIAGNOSIS = If pressures within 30mmHg of diastolic BP it is positive for compartment syndrome.

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6
Q

what is the pathophys of compartment syndrome exactly

A

muscle encapsulated in fascia and the fasica can’t expand very much

too much swelling causes pressure push inward causing increased pressure on A/V/N and damage

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7
Q

what is the first step in the management of compartment syndrome

A
  1. Operate immediately
    a. Call attending get scheduled for OR now

fasciotomy

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8
Q

how can you determine the pressure with comaprtment syndrome

A
  1. Diastolic BP 88, Intracompartment pressure 68.

a. 88 – 68 = 20mm Hg Compartment syndrome.
b. Emergency Fasciotomy of all 4 compartments
c. Take intraoperative pressures to confirm release.

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9
Q

initial management of open fracture (up to splinting)

A
  • ER washout, remove any visible foreign material, and cover.
  • Check and apply pressure if active bleeding.
  • Check neurovascular distal to the fracture. If compromised reduce and recheck.
  • Splint and then prep for OR
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10
Q

what else do you need to do with a open fracture

WHAT DO YOU NEED TO ASK

A
  • Apply external traction if needed.
  • Start antibiotics (tobramycin, ancef) per facility protocol. We use IV Tobramycin and Ancef.
  • Give Tetanus if needed.
  • Make pt. NEED TO ASK–> NPO, ask last meal.
  • Call your attending.
  • Don’t forget the XR
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11
Q

Radial Nerve does what (3)

A

Extend elbow
supinate
and extend wrist and fingers.(wrist drop)

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12
Q

ulnar nerve is responsible for (2)

A

Flexion of 4th &5th fingers,

and adductors. (Claw hand)

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13
Q

medial nerve is responsible for (3)

A

Pronation
flexes &
abducts 1st, 2nd, 3rd fingers. (Carpal Tunnel)

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14
Q

Femoral Nerve

A

Extends knee, some hip flexion.

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15
Q

Hip extension is governed by what nerve

A

Superior Gluteal Nerve-

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16
Q

Sciatic/Tibial N

A

Flexes knee, foot, & toes. (Must find during THA)

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17
Q

Deep Peroneal N

A

Plantar flexion. (Foot Drop)

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18
Q

eversion of foot.

A

v. Superficial Peroneal N-

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19
Q

how do you check for vascular compramise un UE, LE

A
  1. Check skin, pulses, and capillary refill.
  2. Upper Ext- Radial and brachial if needed.
  3. Lower Ext.- Dorsalis Pedis and posterior tibial. Use Doppler if needed.
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20
Q

what do you need with a posterior knee dislocation

A
  1. Get CT angio of knee if posterior knee dislocation** (to look for posterior tibial artery – complications from that being torn)
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21
Q

management of dislocations

A

i. Get them reduced then no longer an emergency.
1. Always get XR before reduction

if you have a fracture of the coronoid you need to know if it is from the reduction or occured before

(hill sach’s, fx the humoral head)

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22
Q

where do most septic joints occur

A

i. Septic joint can happen in any joint. Most common in knee >50% of cases.

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23
Q

RF for septic joints

A 
Risk factors include
 elderly
immune compromised
RA
hx of joint replacement
 IV Drug users.
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24
Q

complications of septic joint

A

iii. Can Cause significant cartilage damage within 8hrs, can lead to sepsis and death.
iv. Most common cause Staph Aureus.

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25
Q

common pathogens with septic joint

A

iv. Most common cause Staph Aureus.

v. Don’t forget Neisseria Gonorrhea! (in young adults, anyone who is sexually active)

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26
Q

exam findings with septic joint

A
  1. Pain in absence of trauma
  2. Red, Hot, Swollen Joint.
  3. Fevers, malaise, may appear toxic.
  4. Inability to bear weight or tolerate passive ROM.

can’t passively move the joint–> a lot of pain

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27
Q

work up for septic joint (what is the study of choice and 3 others)

A
  • WBC often elevated
  • ESR
  • CRP
  • Joint aspiration is study of choice.
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28
Q

why is CRP is helpful

A

Most helpful as it will rise within hours of infection. (rise the fastest and falls the fastest in response to inflammation)

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29
Q

WBC indicative of septic joint

A

• WBC >50K, gram +, absence of crystals, +Cult confirms.

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30
Q

If low white count and a bunch of crystals think

A
  1. If low white count and a bunch of crystals  think about gout
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31
Q

Tx for septic joint

A

Empiric treatment based on risk factors. Remember staph Aureus is #1 cause but think Gonorrhea in young people.

MRSA in IVDU

Pseudomonas in immune compromised (HIV, elderly, etc.).

Needs to go to surgery ASAP!!

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32
Q

what is a huge complicating factor for septic joint management

A

a. Operative irrigation and drainage.
b. In presence of hardware be prepared to do revision surgery or staged procedure if necessary.

Hardware = magnet for bacteria

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33
Q

cauda equina is caused by (MC) and 4 others

A

i. Caused by compression to nerve roots at the lumbosacral region.

Disc herniation (most common)

but also
trauma/fx
 tumor
 epidural abscess 
or hematoma.
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34
Q

sxs of cauda equina

A

Saddle numbness, bowel and bladder incontinence, impotence, bilateral leg pain, lower extremity weakness.

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35
Q

exam to rule out cauda equina

A
  • Muscle atrophy
  • Lower ext. weakness
  • Absence of pin prick sensation at perianal region.
  • Lack of rectal tone or voluntary contracture.
  • Lack of anal wink ;)
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36
Q

study of choice for nerve compression

A

• MRI is study of choice, to look for nerve compression.

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37
Q

tx of cauda equina (best if done within ___)

A

Emergent surgery to decompress nerve roots. Discectomy or laminectomy.

Best prognosis if done within 48hrs of onset.

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38
Q

RF for neck fasc

A
  1. Immune compromised- Diabetes, AIDS, cancer.
  2. IV Drug users or skin poppers.
  3. Trauma to skin.
  4. Obesity
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39
Q

mortality rate with nec fasc

A
  1. Mortality rate 32%!
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40
Q

exam findings in nec fasc

A
  • Cellulitis progressing rapidly. (“started last night and now it feels like my leg is on fire”) really quickly will see within hours (day or two max)
  • Severe pain out of proportion to exam.
  • Absence of trauma.
  • Skin erythema, ischemia, bullae, induration (late findings)
  • Subcutaneous air on XR (CLASSIC FINDING)
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41
Q

treatment of nec fasc

A
  • Emergent surgery to radically excise area of necrosis
  • Treat with broad based IV Antibiotics
  • Will need multiple trips to OR for debridement and eventual closure.
  • May result in amputation.
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42
Q

ortho HPI

A

Date of injury
mechanism
complaint
last meal. (have to NPO for at least 8 hours)

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43
Q

PMH ortho

A

Important to note heart dz
DM and how well controlled
immune suppressant illness.

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44
Q

PSH ortho

A

Any prior ortho surgeries in area of current issue

Especially important if a revision case.

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45
Q

MEDs Hx need to note for ortho

A

Blood thinners**, immunosuppressant meds, Vit. D, Ca.

PAIN MEDS

46
Q

social hx need to note for ortho injury

A

Tobacco use is the big one!

Also IV drug use, and alcoholism makes for high fall risk and poor compliance.

47
Q

why does tobacco use really impedes bone-healing?

A

Nicotine is a vasoconstrictor even down to the capillaries (the capillaries that supply your bones and tendons are really small so if you constrict those, you impede blood flow even more)

48
Q

important family hx for ortho

A

Bleeding disorders, bad reactions to anesthesia.

49
Q

PE ortho

A 
Vitals 
general
chest
heart
abdomen,
extremities (stick to the one involved)
imaging
labs
diagnosis
plan
50
Q

important pre OP steps

A

NPO status
Antibiotics if given
Blood thinners

What imaging has been done. Any further imaging needed?

Medically cleared? Need any more consults i.e. cardiology, pulmonology, hospitalist.

Is the patient consented do they need DPOA (Durable power of attorney) to sign?

Has the rep been notified do you have the right equipment available?

Remember the side RIGHT or LEFT

51
Q

post op management of pt in clinic

A
  1. Check on pain, wounds, suture removal, weight bearing status, Range of motion (ROM), Immobilization (cast/brace). XR results
  2. Plan: PT, return to work, follow-up appointment.
52
Q

who get’s clavicle fxs and what xrays do you want

A

i. Young active adults

XR:
2vw clavicle
standing/upright AP and cephalic tilt
Bilateral standing view to see shortening

53
Q

when do you operate on a clavicle fx

A

iii. <100% displaced –non-op

iv. 100% displacement, comminution, >2cm shortening, skin tenting. Surgical.

54
Q

non-op mngmt of clavicle fx

A
  • Sling for comfort, gentle ROM 2-4 weeks

* Begin strength training at 6-8 weeks or when callus seen on XR.

55
Q

operative clavicle fx managment

A
  • Clavicle ORIF
  • Wound care for 2 weeks
  • Same limitations and progression of activity.
  • 30% of cases need hardware removal 6-12mos after surgery due to irritation.
56
Q

proximal humerus fx- who gets these

A

Common low energy injury in elderly ground level fall.

seen as high energy injury in young adults

57
Q

what do you need to check with proximal humerus fx

A
  1. Look for brachial plexus or axillary nerve injury.

2. Fracture dislocations

58
Q

exam for proximal humerus

A
  1. Pain, swelling, ecchymosis shoulder, upper arm, and chest.
  2. Neurological exam
59
Q

xray for proximal humerus fx

A
  1. XR: True AP, Scap Y, Axillary.

Humeral head position (valgus angulation is bad)
Greater tuberosity position

might need a CT scan for pro op planning

60
Q

how many proximal humerus fx are non-op

-who get’s non op treatment

A
  • 85% of cases
  • Minimally displaced surgical neck fx (part1,2,3)
  • Greater tuberocity fx <5mm displaced.
  • Poor surgical candidates
  • Ask about patients functional goals.
61
Q

non operative management for proximal huemrus fx

A

Sling/shoulder immobilizer.

Sarmiento brace/Coaptation brace - plastic device which squeezes the shoulder down

Hanging Arm cast-– big, bulky cast (used as a weight – it pulls the arm down and holds it out to length)

62
Q

what are you concerned about with a humeral shaft fx

A

the radial nerve

63
Q

radial nerve injury sxs

A

cannot extend wrist or fingers, pronates and extends elbow.

Can’t extend at the MCP joints but can extend the PIP and DIP joints (move the thumb)

64
Q

Holstein-Lewis Fx

A

Spiral, distal third humerus fx (Holstein-Lewis) most common radial nerve injury. 22%

good thing is that it usually returns in a couple of months unless it is totally distracted
85-95% return in 3 mos

65
Q

conservative treatment with a humeral fx

A

d. Initial splint/sling 7-10 days then Sarmiento brace 6-8 weeks.
e. When stable begin shoulder PROM, elbow AROM.

Sugar tong splint* Coaptation splint,*

66
Q

ORIF W/ humeral fx

A

ORIF with plate

i. Anterolateral
1. Proximal third to midshaft fx.
2. Identify the radial N.

ii. Posterior
1. Distal to middle third

67
Q

Intramedullary Nail (IMN) for humeral fx pros and cons

A

i. Typically antegrade
ii. Higher incidence of shoulder pain.
iii. Some believe higher incidence of nonunion.
iv. Radial N. at risk with lateral to medial distal locking screw
v. Musculocutaneous N. with anterior to posterior

68
Q

distal humerus fx (4 types)

A

very complex

  1. Supracondylar
  2. Single column (condyle)
  3. Bicolumn
  4. Coronal Shear
69
Q

what ROM limitations to you see with a distal humerus fx

A

Most people only regain 75% ROM/strength.
Realistic ROM is 30-130°

—->getting them out to extension is very rare

70
Q

distal humerus fx exam needs to include

A
  • Gross deformity and instability often seen.
  • If seen AVOID ROM test due to possible neurovascular compromise.
  • Check radial, ulnar, and median nerve.
  • Distal pulses
  • Monitor for forearm compartment syndrome
71
Q

imagining needed for distal humerus fx

what XRAY views
when would a CT be indicated

A
  • AP/Lateral of humerus and forearm.
  • Oblique views of elbow helpful.
  • In complex fx CT scan with 3D recon good for surgical planning.
72
Q

nondisplaced supracondylar fx MC seen in

A
  1. Most common seen in kids.
  2. Immobilize in supination for lateral condyle fx
  3. Immobilize in pronation for medial condyle fx.
73
Q

supracondylar- later fx Immobilize in

A

Immobilize in supination for lateral condyle fx

74
Q

supracondylar-medial fx Immobilize in

A

pronation

75
Q

CRPP would be utilized for what type of fx

A

Closed Reduction and Percutaneous Pinning

  1. Extra-articular fx
  2. Non-fragmented
  3. Common technique with kids
76
Q

when would a ORIF be used for supracondylar

A
  1. Displaced supracondylar fx
  2. Intra-articular fx
  3. Segmented displaced fx
  4. For intra-articular involvement often need to do olecranon osteotomy
77
Q

F/U for supracondylar fx

A
  1. Immobilization for 48hrs. Then passive, and active
    assisted ROM for 6 weeks.
  2. Begin progressive strengthening at 6 weeks
  3. If osteotomy, no active elbow extension for 6 weeks.

passive because you don’t want to displace the olecranon by pulling on the tendon

78
Q

Terrible Triad

what is it and what is the MOA

A

i. Elbow dislocation or LCL tear.
ii. Radial head or neck fx
iii. Coronoid fx

fall on extended arm

79
Q

TERRIBLE TRIAD TX

A
  1. Reduce the elbow, splint.
  2. Consider CT scan
  3. ORIF or arthroplasty of radial head. Coronoid ORIF, LCL reconstruction.
  4. Prognosis is often poor due to stiffness and instability.
80
Q

Monteggia Fx

A
  1. Proximal 1/3 ulna fx with radial head dislocation.

Most common in kids

81
Q

Monteggia Fx TX

A
  1. Non-op: MC with kids, if ulna can be reduced and radial head hold position in cast.
  2. Cast in supination
  3. Operative: Almost always in adults. Open, comminuted, or unstable fx.
82
Q

Galeazzie Fx

A

Distal 1/3 Radius fx with distal ulna dislocation

2. Associated with Distal Radio-Ulnar Joint (DRUJ) dislocation.

83
Q

Galeazzie TX

A

Tx: Surgically fix the radius. Stabilize the ulna immobilized in supination for 6 weeks.

84
Q

Both bone forearm fx

what is important consideration in reduction

A
  1. Very common in kids, monkey bars are usually the culprit.
  2. Kids - can attempt closed reduction under sedation.
  3. Need to maintain the bow of the bones.
    if they fuse can’t pronate or supinate
85
Q

tx of forearm fx in adults

A
  1. Adults almost always need ORIF.

usually will get a plate on both (at least the ulna)

86
Q

MC distal radius fx

A

Colles Fx-

Dorsal offset, MC, FOOSH

87
Q

what is a smith’s

A

fall with hand flexed

ventral or Volar tilt. Fall on a flexed hand.

88
Q

distal radial fx need to assess

A
  • 5-20° dorsal angulation
  • Radial Inclination <5° change
  • <5mm Shortening
  • <2mm articular step off or split

volar tilt - naturally 10 degree volar tilt so if it is back or flat you have an issue

89
Q

how would you do a closed reduction distal radius

A

a. Hematoma block or conscious sedation.
b. Hang in finger traps for traction.
c. Hyperextend the wrist and pull distal portion up and over. Often feel and hear a crack.

Splint with plaster or fiberglass, with 3 point fixation mold

need to basically recreate fx and then pull up and over
need someone holding counter traction

90
Q

surgical tx with distal radiation

A

usually if you can’t get a closed reduction

Volar Plate is MC.
Some cases need dorsal plate or both.
Kids may need perc pins or flexible rods.
With kids watch growth plate over time if fuses could develop ulnar positive wrist.

91
Q

acceptable angulation of 5th finger

A

5th (pinky) finger- 40°

i. Can tolerate 60 degree angulation

92
Q

acceptable angulation of 4th finger

A

4th (ring) finger- 30°

93
Q

acceptable angulation of 2nd and 3rd finger

A

c. 2nd/3rd (index/middle) fingers- 10-20°

94
Q

tx of boxer’s fx

A

d. Attempt reduction. Can try hematoma block if you’re nice.
e. Hang in finger traps and push back into position.

hematoma block (done breaks and htere is blood if you get blood you are in the right spot)

   10ccs of lidocaine
    more effective in fresh fxs 
    easy in radius wiht step off
95
Q

highest rate of mortality for hip fxs in this age group

A
  1. 20-30% in first year

2. Up to 50% in ppl >85yo

96
Q

artery that we are worried about with hip fx

A

If medial circumflex A. is compromised can lead to AVN.

wraps around the neck

97
Q

types of hip fx

A
  1. Femoral head fx – very rare
  2. Femoral neck fx
  3. Intertrochanteric hip fx
  4. Subtrochanteric hip fx
98
Q

femoral neck fx managemnet

A

non-displaced–> screws
can still have risk of AVN

displaced at risk for AVN

—> Hemi-hip arthroplasty (partial hip replacement because you’re just replacing the head not the cup )

99
Q

Intertrochanteric hip fx mangment

A

Sliding Hip Screw/ Dynamic hip screw

or if unstable

Intramedullary Nail/ Cephalomedullary Nail.

100
Q

Intramedullary Nail for femur fx pros and cons

A

Antegrade IM Nail:
Enter superior trochanter.

Retrograde IM Nail:
better for obese

101
Q

common mngmt of femur fxs in children

A

Flexible Rods

102
Q

External Fixation -when would we use this for the tx of a femur fx

A

Good to delay surgery if other injuries exist, or poor surgical candidate.

103
Q

important tibial fx managment pearl

A
  1. Non-op if completely nondisplaced, or poor sx candidate.

6. Always NWB x12 weeks.

104
Q

associated injuries with tibial fx

A
  1. Associated injuries: meniscal, LCL, MCL, ACL tear, compartment syndrome.
  2. Think about compartment syndrome.
105
Q

conservative and surgical treatment of tibial plateau lecture

A

Conservative tx:
Long leg cast followed by boot 4-8 weeks

Tibial ORIF

  i. IM Nail
   ii. Percutaneous plating 
  iii. Flexible rids (kids)
106
Q

Medial Malleolus fx- when would it be NWB

A
  1. NWB if true med. Mal fxWBAT if tip avulsion and ligaments intact.
107
Q

If tibiotalar joint space widening with lateral mal fx

A

a. Transmalleolar screw fixation or tension band fixation.

108
Q

Isolated lateral malleolus fx with <3mm tx with

A

Isolated lateral malleolus fx with <3mm displacement treat with walking cast/boot.
a. NWB for 6-8 weeks

109
Q

Maisonneuve Fracture

A

Medial malleolar fx, or syndesmosis disruption with associated proximal fibular fx.

110
Q

how to rule out Maisonneuve Fracture

A

get a knee xray

surgery (18 decks)

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