Ortho Flashcards
Connaître les noms communs des fractures les + fréquentes
Début chap.42
Détailler le grade de Fracture de Gustillo et traitement/atb associés
Grades
Grade I: Wound less than 1 cm long, punctured from below
Grade II: Laceration 5 cm long; no contamination or crush; no excessive soft tissue loss, flaps, or avulsion
Grade III: Large laceration, associated contamination or crush; frequently includes a segmental fracture
IIIA: Involves extensive soft tissue stripping of bone
IIIB: Periosteal stripping has occurred
IIC: Major vascular injury present
Management
1.
Control hemorrhage in field with sterile pressure dressing after carefully removing gross debris (eg, wood, clothing, leaves).
2.
Splint without reduction, unless vascular compromise is present.
3.
Irrigate with saline, cover with saline-soaked sponges after arrival in the emergency department.
4.
Begin IV antibiotic prophylaxis, usually a first-generation cephalosporin for grade I, with the addition of an aminoglycoside for grades II and III. Ajout ampi ou PNC si blessure dans ferme (clostridium)
5.
Administration of tetanus prophylaxis, including tetanus immune globulin, for large crush wounds
Associé la fracture au nerf lésé
Nommer 10 causes de compartiment
Increased Compartment Content
Bleeding: lésion vasculaire, tr coagulation, A/C
Reperfusion post ischémie: pontage, post coro, embolectomie, post choc
Trauma: fx, convulsion
Utilisation muscles prolongées: exercise, convulsion, eclampsie, tétanie
Brûlures: thermiques, électriques
Chx ortho
Morsure serpent
Obstruction veineuse
Decreased Compartment Volume
Closure of fascial defects
Excessive traction on fractured limbs
Miscellaneous
Infiltrated infusion
Pressure transfusion
Leaky dialysis cannula
Muscle hypertrophy
Popliteal cyst
External Pressure
Tight casts, dressings, or air splints
Lying on limb
Nommer 10 compartiments pouvant être touchés
Lower Extremity
Leg
Anterior compartment
Lateral compartment
Deep posterior compartment
Superficial posterior compartment
Thigh
Quadriceps compartment
Buttock
Gluteal compartment
Upper Extremity
Hand
Interosseous compartment
Forearm
Dorsal compartment
Volar compartment
Arm
Deltoid compartment
Biceps compartment
Nommer 5 complications des fractures et 5 complications reliées à l’immobilité
Fractures
Hemorrhage
Vascular injuries
Nerve injuries
Compartment syndrome
Volkmann’s ischemic contracture
Avascular necrosis
Reflex dystrophy
Fat embolism syndrome
Immobility
Pneumonia
Deep venous thrombosis
Pulmonary embolism
Urinary tract infection
Wound infection
Decubitus ulcers
Muscle atrophy
Stress ulcers
L,aponévrose palmaire de la main est l’extension de quelle structure?
Le tendon du long palmaire
Nommer les muscles intrinsèques de la main
Éminence thénar: opposant pouce, abd, add, fléchisseur
Hypothénar: fléchisseur du 5e doigt, abd, opposant
4 lumbricaux: flexion MCP et extension IPP
3 interrosseux palmaires: add
4 interrosseux dorsaux : abd
Nommer les tendons extenseurs et les compartiments du poignet
Indications de consultation en plastie pour retrait CE dans main
•
Large or multiple foreign bodies
•
Evidence of tendon or neurovascular injury
•
Penetration of deep space of the hand, including deep palmar, thenar, and hypothenar space
•
Suspected joint penetration
•
Presence of fracture or bone penetration
•
Highly contaminated wound
•
Immune compromised patient
•
Lead foreign body
•
Liquid foreign body (eg, paint)
Dfn Jersey Finger
Tx: SOP
dfn mallet finger et tx
Tx:immobilisation en extension 10 deg pour 6-8 sem, consultation ortho/plastie en 7 jours
Décrire Seymour fracture
Décrivez l’angulation des fractures de la phalange proximale et moyenne (base et distale)
Prise en charge fx métacarpes
consult ortho pour tous sauf fx boxer (col du 5e méta)
Réduction - immobilisation position intrinsèque plus (extension poignet 30deg, MCP 90 et extension ipp, ipd)
Diaphyse, cible de : moins de 10º angulation dorsale doigts 2-3 et moins de 20º doigts 4-5 et pas de déformation en rotation
( doigts 2 à 5 = 10,20,30,40 deg)
Col: moins de 15º angulation dorsale doigts 2-3 et moins de 35º doigts 4 et 45 doigt 5
bennett vs rolando
Prise en charge subluxation/luxation IPP/IPD
IPD : rare, réduire, référer
IPP:
Dorsal and lateral dislocations should be immobilized in 20 to 30 degrees of flexion or with an extension block splint—dorsal splint allowing flexion but restricting extension—for 2 to 3 weeks, followed by active movement. Reduced volar dislocations should be splinted in full extension. Open or irreducible dislocations, unstable reductions, dislocations with volar plate avulsion and intraarticular fractures involving more than 30% of the joint surface should receive hand service referral.
Comment réduire subluxation dorsale MCP?
Hyperextension and longitudinal traction should be avoided because the volar plate of the MCP joint may become entrapped in the joint space. Rather, simple subluxed MCP joints should be reduced with the wrist in flexion, relaxing the flexor tendons, and applying direct dorsal pressure on the proximal phalanx. To stabilize, the hand should be splinted with 90 degrees of MCP joint flexion (see Fig 43.28). Hand service referral should be requested for complex dorsal and volar dislocations because both may require operative reduction for stabilization
Expliquer la lésion de stener
Associé à la lésion du ligament collatéral ulnaire du 1er MCP
Si lésion partielle - immobilisation spica 3 sem
Si lésion complète ou stener - immobilisation - référence
Prise en charge les lésion des tendons extenseurs selon les zones
Zone 1: mallet finger, immobilisation extension 6-8 sem, réparation si lésion ouverte, en chronique - déformation col de cygne ( par déplacement des bandes latérales vers l’aspect dorsal)
Zone 2: The central band inserts on the middle phalanx and the lateral bands extend to the base of the distal phalanx. Rarely, lacerations transecting all the tendons will produce a mallet deformity. Treatment options are similar to those for zone I injuries
Zone 3: cf autre question
Zone 4: réparation avec suture 5.0, rarement rétraction
Zone 5: lésion clenched fist ad preuve du contraire, exploration en SOP. Clavulin ou clinda + doxy/cipro/bactrim
Zone 6: réparation si facilement visible
Zone 7-8: référence en ortho/plastie
décrire la lésion des extenseurs zone 3
The Elson test may identify a central slip rupture; with the patient’s PIP joint in 90 degrees of flexion over the edge of a counter, the patient is asked to extend the middle phalanx actively. Weak extension with rigid DIP joint extension is suggestive of a central slip injury (Fig. 43. 37). Closed PIP joint injuries should be immobilized in extension, leaving the DIP joint free, with referral to a hand specialist
Identifier les zones des fléchisseurs a/n main
Expliquer comment tester fléchisseur profond et superficiel des doigts
Tx
Traitement: référence en plastie pour déterminer réparation immédiate ou retardée
Nommer les indications et CI de réimplantation après amputations
Indications
•
Multiple digits
•
Thumb
•
Wrist and forearm
•
Sharp amputations with minimal to moderate avulsion proximal to the elbow
•
Single digits amputated between PIP joint and DIP joint (distal to flexor digitorum superficialis [FDS] insertion)
•
All pediatric amputations
Contraindications
•
Amputations in unstable patients secondary to other life-threatening injuries
•
Multiple-level amputations
•
Self-inflicted amputations
•
Single-digit amputations proximal to FDS insertion
Nommer les zones du fingertips
Nommer les os du carpe
Nommer les 3 surfaces articulaires du radius a/n poignet
The radius has three articular surfaces at the wrist—radiocarpal joint, DRUJ, and an interface with the triangular fibrocartilage complex (TFCC), also known as the articular disk.
Avoir une vue d’ensemble des ligaments du poignet
Examen clinique des nerfs médian, radial, ulnaire
Bordures de la snuffbox anatomique
Radial: court extenseur du pouce et abd du pouce
ulnaire: long extenseur du pouce
Expliquer la position du radius et ulna distal en temps normal
Nommez les angles scapholunaire et capitolunaires normaux
Nommer 3 vues radiologiques du poignet additionnelles
Lésions possibles associes à une fx du pisiforme
The pisiform is unique in the carpus because it is the only sesamoid-like bone and attaches to the FCU tendon, articulating on its dorsal surface with the triquetrum. Although pisiform injuries are rare, occurring in less than 1% of all carpal fractures, given the important role of forming the lateral wall of Guyon’s canal, ulnar arterial damage and neurapraxias may be associated.
Décrire la dissociation scapholunaire ( stade 1)
Signe de Terry Tomas (gap > 2-3 mm) et signet ring sign ( anneau créé par scaphoid)
Décrire la luxation périlunaire, stade 2
et stade 3
Semi-lunaire aligné avec le radius mais capitatum luxé dorsalement
A stage III injury appears identical to a stage II injury but includes a dislocation of the triquetrum that is seen best on the PA view, with overlap of the triquetrum on the lunate or hamate. This injury may be associated with a volar triquetral fracture.
Décrire luxation lunaire stade 4
PA: semi-lunaire apparait triangulaire, piece of pie sign
latéral: lunaire luxé en antérieur, spilled cuptea sign
Décrire la fracture de Hutchinson ou du chauffeur
tx
Hutchinson’s fracture, or chauffeur’s fracture, is an intraarticular fracture of the radial styloid.
Tx: sugar tong splint - possible fixation chirurgicale selon stabilité et si atteinte ligaments périlunaires
Lésions DRUJ
Acute dislocation of the DRUJ can occur as an isolated injury, which is rare, or in association with a fracture to the distal radius (Colles’ fracture), radial diaphysis (Galeazzi’s fracture), or radial head (Essex-Lopresti injury)
This forcible rotation of the wrist causes disruption of the TFCC, the major stabilizer of the DRUJ, and may result in an associated avulsion fracture of the ulnar styloid.
With a dorsal dislocation of the ulna, the ulnar styloid appears more prominent than on the unaffected side, and significant pain and limitation of movement are noted on supination of the wrist. With a volar dislocation of the ulna, there is loss of the normal ulnar styloid prominence, with pain and limitation of movement on pronation. These characteristic clinical findings should alert the emergency clinician to the possibility of DRUJ disruption and prompt the appropriate investigations to confirm the presence or absence of injury.
Tunnel carpien
Contient 9 tendons (4 FDS, 4 FDP, long fléchisseur pouce) + nerf médian
conditions systémiques: grossesse, ménopause, rheumatoid arthritis, hypothyroidism, diabetes mellitus, renal failure, congestive heart failure, acromegaly, and collagen vascular diseases.
Décrire le syndrome d’intersection
clinically manifests with pain on the radial side of the wrist, approximately 4 to 8 cm proximal to the site of de Quervain’s disease.
Pathophysiologically, intersection syndrome occurs secondary to inflammation where the muscle bellies of the APL and EPB cross over the muscle bellies of the extensor carpi radialis longus and brevis proximal to the retinaculum.
Mêmes tendons pour DeQuervain
Nommer et décrire le contenu des 3 compartiments de l’avant-bras
Tx fracture Monteggia et Galeazzi
SOP
Décrire la lésion d’Essex-Lopresti
The Essex-Lopresti lesion, or longitudinal radioulnar disassociation, refers to an unstable forearm as a result of a triad of injuries to the radial head, disruption of the interosseous membrane, and violation of the DRUJ.
Référence en ortho
Connaître l’anatomie du coude
Fx diaphyse humérale
Tx non conservateur dans plus de 80% des cas
Hanging cast ou sugar tong
Attention R/O atteinte nerf radial
Fx supracondylienne
Surtout 5-10a, extension (98%) ou flexion
In children with extension-type supracondylar fractures, the arm is held at the side and has a characteristic S-shaped configuration, whereas with flexion-type supracondylar fractures, the forearm is supported with the opposite hand with the elbow flexed to 90 degrees. There may be anterior angulation of the sharp distal end of the proximal fragment into the antecubital fossa, which could injure the brachial artery and median nerve
The anterior interosseous nerve is the most commonly injured, followed by the radial, median, and ulnar nerves. Most deficits seen at the time of injury are neurapraxias that resolve with conservative management.
Sauf si flexion: nerf ulnaire + fréquent
Gartland classification
Type I: Minimal or no displacement
Type II: Displacement of the fracture but with the posterior cortex intact
Type IIA: No rotational component
Type IIB: Some rotational component
Type III: Displaced, no cortical contact
Type IIIA: No rotation of the fracture
Type IIIB: Rotation present
En extension:
Type 1: immobilisation coude 80deg, mobilisation après 3 sem
type 2: conservateur vs fixation percut
En lfexion:
In type I fracture, the periosteum is minimally displaced. These injuries do not need to be immobilized in extension. The elbow can be comfortably flexed and should be immobilized in a splint as with extension injuries. Type II and III injuries should be referred to an orthopedist immediately. Type II injuries are manipulated into extension and then either in a long arm cast or with percutaneous pins. Type III injuries are treated with closed reduction and percutaneous pinning but will require open reduction if closed reduction fails
Décrire les 2 lignes à faire sur une RX du coude
Fx condyles du coude
Latéral + fréquent
Fixation SOP si déplacement sup 2 mm
condyle latéral: immobilisation coude extension, supination
condyle médial: coude extension, pronation, poignet flexion
Tx fracture épicondyle médiale
For epicondylar fractures, if the fracture fragment is minimally displaced (<5 mm), treatment with a posterior splint is appropriate. To minimize distraction of the fragment by the forearm flexors, the elbow and wrist are flexed with the forearm pronated.
Fx épicondyle latérale: très très rare
Prise en charge fx olécrâne
Attention nerf ulnaire
Si fx non déplacée, immobilisation 45-90 deg flexion 3 sem
Si déplacement de plus de 2mm ou déplacement en flexion - SOP
Nommer les ligaments de l’articulation acromioclaviculaire
Connaître les ligaments de l’articulation glénohumérale
Nommer les 3 types de fractures du 1/3 latéral de la clavicule
Connaître la classification de base des fractures de l’humérus proximal
(1 part, 2 part… et classification anatomique)
Expliquer la classification des luxations acromioclaviculaires et son nom
Traitement
Rockwood:
- entorse
- AC
- AC + CC
puis PSI (postérieur, supérieur, inférieur)
distance coracoclaviculaire normale 11 à 13 mm
Tx : type 1-2, immobilisation avec attelle, reprise mvt lorsque dlr diminuée 1,2 sem
The management of type III injuries is variable, although most favor initial nonoperative management.4 Selected patients who are young, are serious athletes, have severe displacement (more than 2 cm), and perform repetitive overhead activities may be candidates for surgical intervention. Treatment of type III injuries in the ED should consist of sling immobilization and sports medicine or orthopedic referral. Type IV, V, and VI injuries require early surgical treatment
Différencier Bankart et Hill Sach’s
Hill Sach: fx par impaction a/n aspect postéro-latéral tête humérale
Connaître les ligaments du bassin
Expliquer la classification de Tile pour les fx du bassin
Type A: Stable, posterior arch intact; includes avulsion fractures, isolated iliac wing fracture, pubic rami fractures, minimally displaced ring fracture, and transverse fractures of the sacrum or coccyx.
Type B: Partially stable, incomplete disruption of the posterior arch; includes anteroposterior injuries (“open-book” fracture) and lateral compression injuries; may be unilateral or bilateral; these injuries are rotationally unstable but vertically stable.
Type C: Unstable, complete disruption of the posterior arch; includes iliac, sacroiliac, and vertical sacral injuries that result from vertical shearing forces; may be unilateral or bilateral. These injuries are both rotationally and vertically unstable.
Expliquer classification Young-Burgess
Anteroposterior Compression
I.
Symphysis diastasis <2.5 cm
II.
Symphysis diastasis >2.5 cm, sacrospinous and anterior sacroiliac ligament disruption, results in rotational instability
III.
Symphysis diastasis >2.5 cm, with complete disruption of the anterior and posterior sacroiliac ligament, results in complete rotational and vertical instability
Lateral Compression
I.
Sacral crush injury on ipsilateral side
II.
Sacral crush injury with disruption of posterior sacroiliac ligaments; iliac wing fracture may be present (crescent fracture); rotationally unstable
III.
Severe internal rotation of ipsilateral hemipelvis with external rotation of contralateral side (“windswept” pelvis), rotationally unstable
Vertical Shear
Vertical displacement of symphysis and sacroiliac joints resulting in complete rotational and vertical instability
Combined Mechanisms
Any combination of the aforementioned mechanisms
Nommer les sites d’avulsion a/n bassin avec les muscles associés
Décrire les types de fx du sacrum et la principale complication associée
Fracture transverse: n’implique pas “ pelvic ring” mais fx verticale oui
Nommer les 3 types de fx de l’acetabulum
Nommer les 3 comopartiments de la cuisse et les structures contenues dans chacun
Décrire la fx de Segond
The avulsion occurs at the site of attachment of the lateral capsular ligament.
Most Segond fractures are caused by sports injuries; the mechanism is almost always knee flexion with excessive internal rotation and varus stress.
Décrire les 4 compartiments de la jambe et les structures contenues dans chacun
The anterior compartment contains the tibialis anterior, long toe extensor muscles, anterior tibial artery, and deep peroneal nerve, which supplies sensation to the first web space of the foot.
The lateral compartment contains two muscles that evert the foot, the peroneus longus and brevis, and the superficial peroneal nerve, which supplies sensation to the dorsum of the foot.
The superficial posterior compartment contains the gastrocnemius, plantaris, and soleus muscles and sural nerve, which supplies the lateral side of the foot and distal calf.
The deep posterior compartment contains the tibialis posterior muscle, long toe flexor muscles, posterior tibial and peroneal arteries, and tibial nerve, which supplies sensation to the plantar aspect of the foot.
Nommer les 3 types de fx tubérosité tibiale
Anatomie cheville
Évaluation mortaise au RX
Syndesmose A = clear space
Syndesmose B = overlap
Expliquer classification de Danis Weber
Weber A fractures involve inversion-adduction forces. Weber B fractures involve abduction forces. Weber C fractures involve eversion-abduction forces
Décrire la lésion de Maisonneuve
Os et articulations du pied
Éversion et inversion a/n subtalaire
Add/Abd a/n midtarse
Anatomie du talus
Décrire une fx mineure du talus
Décrire classification hawkins des fx du col du talus
PEC fx talus
Neck: Type 1 fractures, which are nondisplaced, are the only talar neck fractures amenable to nonoperative treatment, which initially consists of 6 weeks of nonweightbearing in a cast. Close outpatient orthopedic follow-up is essential.40 Hawkins types 2 to 4 fractures or talar neck fractures with any displacement are managed surgically
Head + body: controversé, consultation ortho
Comment calculer l’angle de Boehler?
Types de Lisfranc
Fx base 5e méta
Zone 1: fx par avulsion bande latérale de l’aponévrose plantaire. Tx non chirurgical, botte de marche 3 sem
Zone 2 (Jones) minimalement 15 mm de l’extrémité proximale. Immobilisation 3 mois vs chx selon ortho
Zone 3: svt secondaire fx stress, immobilisation prolongée vs chx selon ortho
