Ortho Flashcards

1
Q

Axillary nerve,

Motor, sensory, root

A

M: deltoid, teres minor, triceps long head

S: lateral upper arm

R: C5, C6

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2
Q

Musculocutaneous nerve

Motor, sensory, root

A

M: biceps, brachialis

S: lateral forearm

R: C5, C6

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3
Q

Median nerve

Motor, sensory, root

A

M: Wrist flexor, Wrist abductor, flexion of 1,2,3 digits

S: palmar thumb to radial half of 4th digit. Dorsal tips of digit 1 to radial half of digit 4
OK sign (AIN)

C6, C7

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4
Q

Ulnar nerve

Motor, sensory, root

A

M: wrist flexor, wrist adductor, Flexion of 4th, 5th digit

S: medial palm, dorsum of hand, 5 th digit and medial half of 4th digit
Spread fingers

R: C8, T1

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5
Q

Radial nerve

Motor, sensory, root

A

M: triceps (medial/lateral heads). Wrist, thumb, finger extensors

S: lateral dorsum of hand. Medial upper forearm. Thumbs up (PIN)

R: C5, C6,C7, C8

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6
Q

Tibial nerve

Motor, sensory, root

A

M: ankle plantar flexion, knee flexion, great toe flexion

S: sole of foot

R: L5, S1

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7
Q

Superficial peroneal nerve

Motor, sensory, root

A

M: ankle eversion

S: dorsum of foot

R: L5, S1

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8
Q

Deep peroneal

Motor, sensory, root

A

M: Ankle dorsiflexion and eversion

S: 1st web space

R: L5-S1

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9
Q

Sural nerve

Motor, sensory, root

A

M: -

S: lateral foot

R: S1, S2

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10
Q

Saphenous nerve

Motor, sensory, root

A

M: -

S: anteromedial ankle

R: L3, L4

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11
Q

Signs suggestive for open fx

A

Continuous bleeding from puncture site

Fat droplets in blood

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12
Q

Angulation in transverse fx

A

< 30°

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13
Q

Angulation in oblique fx

A

30-60°

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14
Q

Fx description

A
  1. Name of injured bone
  2. Integrity of skin/soft tissue
  3. Location in bone
  4. Orientation/pattern
  5. Alignment
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15
Q

Indications for open reduction

A

Non-union

Open fx

Neurovascular compromise

Displaced intraarticular

Salter-Haris 3,4,5

Polytrauma

Failed close reduction

Not able to cast or apply traction due to site

Pathologic fx

Potential for improved function with ORIF

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16
Q

Evaluation of fx healing

A

No longer tender on palpation/ stressing

Xray: teabecula cross fx site, visible callus

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17
Q

Normal healing time course of fx

A

0-3 wk: hematoma, macrophages

3-6 wk: osteoclasts remove sharp edges. Callus forms

6-12 wk: Bone forms within the callus, bridging fragments

6-12 mo: cortical gap bridged by bone

1-2 y: normal architecture achieved through remodeling

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18
Q

CRPS/RSD clinic

A

Exaggerated response to an insult

Hyperalgesia

Allodynia

Autonomic dysfunction:
Temperature asymmetry
Mottling
Hair/nail changes

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19
Q

Swimmer’s view Xray

A

Helps to see C7-T1 junction

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20
Q

Controversial Initial Mx if open fx

A

1st generation cephalo or clinda. Upon arrival until 24 h after each debridement.

Culture from: delayed injury (>24 h), infected injury

Debridement of open fx ASAP

Wound closure: within 7 d ( after soft tissue stabilization and all non-viable tissue removal

Negative pressure wound therapy: decreases infection rate

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21
Q

Initial Mx of open fx

A

ABC, primary survey

Removal of obvious foreign material

Irrigate with NS

Cover with sterile dressing

Immediate IV AB

Tetanus

Reduce and splint fx

NPO and prepare for OR:
Blood work, consent, ECG, CXR

Operative irrigation and debridement within 6-8 h

Wound left open to drain OR vacuum-assisted closure dressing

Re-examine + irrigation + debridement in 48 h

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22
Q

AB for open fx

A
If < 10 cm:
Cefazolin for 3 d
Or
Quinolone (if penicillin allergy)
Or
Vanco (if MRSA positive)

If > 10 cm:
Cefazolin + Genta for 3 d
+ penicillin if soil contamination (clostridium)

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23
Q

Time of muscle necrosis in compartment syndrome

A

4-6 h

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24
Q

First symptom of compartment syndrome

A

Pain out of proportion to injury

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25
The most sensitive sign of compartment syndrome
Pain with passive stretch
26
Inv for compartment syndrome
A clinical diagnosis Don’t wait for five Ps If child or if unconscious: Compartment pressure monitoring with catheter AFTER clinical diagnosis is made Normal: 0 Elevated: 30 or higher
27
Treatment of compartment syndrome
Non-operative: Remove constrictive dressings, Elevate limb at the level of the heart Operative: Urgent fasciotomy 48-72 h post-op: wound closure +/-necrotic tissue debridement
28
Volkmann’c contracture
Complication of compartment syndrome: ischemic necrosis of muscles followed by secondary fibrosis and finally calcification. especially following supracondylar fracture of humerus
29
The most common cause/ mechanism of spread of osteomyelitis
S. Aureus | Hematogenous
30
Plain film of osteomyelitis
Soft tissue swelling Lytic bone destruction (after 10-12 d) Periosteal reaction (after 10-12 d)
31
Inv for osteomyelitis
CBC, diff ESR, CRP B/C Aspirate culture/bone Bx
32
Tx of acute osteomyelitis
IV AB 4-6 wk +/- surgery (abscess, significant involvement) Hardware removal
33
Tx of chronic osteomyelitis
Surgical debridement AB: systemic (IV) and local
34
Most common cause of septic arthritis in adults
S. Aureus If prior joint replacement: consider Staph coagulase negative If newborn or sexually active adult: N. Gonorrhea The most common route: hematogenous
35
Inv for septic joint
``` Xray ESR, CRP WBC B/C Joint aspirate ```
36
Joint aspirate in septic arthritis
``` Cloudy Yellow WBC > 50,000 PMN > 90% Protein > 4.4 mg/dL Glucose < 60% of blood No crystal Positive Gram stain ```
37
Tx of septic arthritis
IV AB joint aspiration (if early Dx and superficial joint) Arthroscopic/open irrigation, irrigation and drainage, decompression
38
Most common joint in infective arthritis
Knee > hip > elbow > ankle> sternoclavicular joint
39
Plain film of septic joint
Day 0-3: Normal +/- soft tissue swelling, joint space widening Day 4-6: Joint space narrowing, destruction of cartilage
40
Monitoring response of septic joint to treatment by
CRP
41
Shoulder passive ROM
``` Abduction 180° Flexion 180° Extension 45° Addiction 45° Internal rotation T4 External rotation 40-45° ```
42
Most common type of shoulder dislocation
Anterior
43
Mechanism of anterior shoulder dislocation
Abducted arm is externally rotated/extended Or Blow to posterior shoulder
44
Symptoms of anterior shoulder dislocation
Arm slightly abducted and externally rotated. Inability to internally rotate Squared off shoulder Positive apprehension test Positive relocation test Positive sulcus sign Axillary/ musculocutaneous nerve malfunctions
45
Imaging in anterior shoulder dislocation
Axillary view: humeral head is anterior Trans-scapular Y view: humeral head anterior to the centre of Mercedes-Benz sign AP view: subcoracoid lie of humeral head Hill-Sachs lesion: compression fx of posterior humeral head Bony Bankart lesion: avulsion of anterior glenoid acetabulum
46
Tx of anterior shoulder dislocation
Close reduction Post-reduction Xray Post-reduction NVS check Sling 3 wk (avoid abduction and external rotation) Shoulder rehabilitation
47
Mechanism for posterior shoulder dislocation
Adducted, internally rotated, flexed arm Epileptic seizure Electrocution EtOH Blow to anterior shoulder FOOSH
48
Clinic of posterior shoulder dislocation
Arm: held in internal rotation and adduction External rotation blocked Anterior shoulder flattening Prominent coracoid Palpable mass posterior to shoulder Positive posterior apprehension test: only used to test recurrent posterior instability and NOT ACUTE INJURY Axillary/ musculocutaneous nerves dysfunction
49
Radiology of posterior shoulder dislocation
Axillary view: humoral head posterior Trans-scapular Y view: head posterior to centre of Mercedes-Benz AP view: partial vacancy of glenoid fossa. > 6mm space between anterior glenoid rim and humeral head (positive rim sign). Light bulb sign Reverse Hill-Sachs lesion (anterior humeral head) Reverse bony Bankart: avulsion of the posterior glenoid labrum
50
Tx of posterior shoulder dislocation
Close reduction Post-reduction Xray and NVS Sling in abduction and external rotation x3 wk Shoulder rehabilitation
51
Recurrence rate in shoulder dislocation
Depends on age of first dislocation More if age <20 yr
52
Complications of shoulder dislocation
Rotator cuff/ capsular/ labar tear Shoulder stiffness Axillary nerve/artery, brachial plexus injury Most common complication: recurrent dislocation
53
Rotator cuff nerve supply
Teres minor: axillary All others: suprascapular nerve
54
Function of rotator cuff muscles
Supraspinatus: abduction Infraspinatus: external rotation Teres minor: external rotation Subscapularis: internal rotation
55
Rotator cuff examinati
Passive movements permitted Pain worse with active movements, esp overhead Weakness and loss of ROM, esp between 90-130° Tenderness over greater tuberosity R/O biceps tendoniosis
56
Inv for rotator cuff disease
X-ray: AP view: high riding humerus indicative of large tear MRI +/- arthrogram( geyser sign) Arthrogram: can assess full thickness tear
57
Tx of rotator cuff disease
If mild or mod: PT, NSAID, +/- IACS If severe or refractory to 2-3 mo PT and 1-2 IACS: arthroscopic/ open surgical repair
58
Tests for supraspinatus
Jobe’s test Lift-off or belly press test
59
Tests for infraspinatus and teres minor
Posterior cuff test
60
Rotator cuff impingement tests
Neer’s test: Passive shoulder flexion. Pain between 130-170° Hawkins-Kennedy Test: Shoulder flexion to 90° and passive internal rotation. Pain suggests impingement
61
Test for rotator cuff tendinopathy
Painful arc test: Pt actively abducts shoulder. Pain with abduction > 90°
62
Speed’s test
Apply pressure to the forearm when arm is in forward flexion (90°) with elbow fully extended. If pain in bicipital groove = biceps tendon pathology
63
Test with greatest specificity and sensitivity for rotator cuff disease
Painful arc test
64
O’Brien’s test
SLAP lesion Forward flexion of arm to 90°, while keeping arm extended, arm adducted to 10-15°. Internally rotate the arm so thumb is facing down. Apply downward force. Repeat test while externally rotated. Pain or clicking in glenohumsral joint in internal but not external rotation = glenohumeral labral tears (superior labral tear from anterior to posterior)
65
AC joint injury mechanism
Fall onto shoulder with adducted arm
66
Clinic of AC injury
Tenderness Pain with adduction Step deformity on AC (if dislocated) Limited ROM
67
Inv of AC injury
Xray: bilateral AP, axillary view, Zanca view
68
Tx of AC injury
Sling 1-3 wk, ice, analgesia, early ROM and rehabilitation Surgery if complete tear + displacement
69
Most common fx site in clavicle
Middle third
70
Mechanism of clavicular fx
Fall on shoulder FOOSH Direct trauma
71
Inv for clavicle fx
NVS of entire upper arm Xray CT: if medial physeal fx, sternoclavicular injury
72
Tx of clavicle fx
Medial and middle third: Sling 1-2 wk Early ROM and strengthening If > 2cm shortened: ORIF Distal third: Undisplaced: sling 1-2 wk Displaced: ORIF
73
Complications of clavicular fx
``` Cosmetic bump Shoulder stiffness Weakness with repetitive activity Pmeumothorax Brachial plexus injury (esp with proximal third fx) Subclavian vessel injury ```
74
Pt with arm clasped to chest
Clavicular fx
75
Course of adhesive capsulitis
Progressive pain and stiffness Spontaneous resolution after 18 mo Freezing phase, frozen phase, thawing phase
76
Mechanism of frozen shoulder
Primary: Associated with DM ``` Secondary: Prolonged immobilization most significant) CRPS/RDS MI Stroke Shoulder trauma AI disease Hyperthyroidism Cervical disc disease Poorer outcome ``` F> M Age > 49
77
Inv for adhesive capsulitis
Xray: Nl or bone demineralization
78
Tx of frozen shoulder
Freezing phase: Active and passive ROM NSAID and IACS to manage pain Thawing phase: Manipulation under anesthesia Early PT Arthroscopy for debridement/decompression
79
Clinic of frozen shoulder
Gradual onset Diffuse shoulder pain Pain worse at night, prevents sleeping on affected side Decreased active and passive ROM Increased stiffness as pain subsides :stiffness continues for 6-12 mo after pain has disappeared
80
Proximal humerus fx mechanism
Young: high energy trauma Elderly: FOOSH
81
Inv for proximal humeral fx
Axillary nerve Xray CT: to evaluate articular involvement and fx displacement
82
Tx for proxima humerus fx
Treat osteoporosis If non-displaced: broad arm sling immobilization. Begin ROM within 14 d. If minimally displaced (most common): close reduction, sling 2wk, gentle ROM If anatomic neck fx, displaced, dislocated glenohumeral joint: ORIF, +/- arthroplasty
83
Complications of proximal humeral fx
AVN (esp if anatomical neck fx) Nerve palsy Malunion Post-traumatic arthritis
84
Humeral shaft fx mechanism
Young: high energy Elderly: low energy: FOOSH, twisting, mets
85
Inv for humeral shaft fx
Radial nerve Brachial artery Xray
86
Tx of humerus shaft fx
Generally non-operatively +/- reduction. Can accept deformity Hanging cast, collar and cuff sling immobilization After swelling subsides, Samiento functional brace, then ROM Surgery if: Pathological fx, floating elbow ORIF: plating, IM rod, external fixation
87
If radial nerve palsy in humeral shaft fx
Recovery expected within 3-4 mo Otherwise: EMG Other complications: non-union, decreased ROM, compartment syndrome
88
Distal humeral fx mechanism
Young. High energy Elderly: FOOSH
89
Inv for distal humeral fx
Assess brachial artery Xray CT: when suspecting shear fx of capitulum/trochlea
90
Tx of distal humeral fx
Goal: restore ROM 30-130° flexion Cast immobilization Surgical if: Displaced Supracondylar Bicolumnar Closed reduction+ percutaneous pinning, ORIF, +/- total elbow arthroplasty
91
Supracodylar fx mechanism
FOOSH | Most common in children around 7 yr
92
Inv in suprachondylar fx
Median nerve (esp AIN) Radial nerve Radial artery Xray: disruption if anterior humeral line. Fat pad sign
93
Tx of suprachondylar fx
If non-displaced: Long arm plaster slab in 90° flexion x 3 wk ``` surgery: percutaneous pinning, ORIF in adults if: Displaced Vascular injury Open fx Unacceptable angulation ```
94
Complications of suprachondylar fx
``` Stiffness (most common) Brachial artery injury Median, ulnar nerve injury Compartment syndrom Malalignment Cubitus varus ```
95
Radial head fx mechanism
Common in young adults FOOSH
96
Inv of radial head fx
Xray: enlarged anterior fat pad (sail sign) Presence of posterior fat pad
97
Tx of radial head fx
If comminuted: excision and prosthesis If displaced: ORIF If non-displaced: elbow slab or sling x 3-5 d with early ROM
98
Complications of radial head fx
Myositis issificans Recurrent instability ( if MCL injured and head excised)
99
Do not immobilize elbow more than
2-3 wk
100
Olecranon fx mechanism
Direct trauma Fall onto elbow FOOSH
101
Inv for olecranon fx
X ray
102
Tx of olecranon fx
If non-displaced (< 2mm, stable): Cast, 3 wk (elbow 90°) then gentle ROM If displaced: ORIF, early ROM if stable
103
Elbow dislocation mechanism
hyperextension (via FOOSH) Or Vulgar/supination stress during elbow flexion Monteggia: radial head dislocated. Ulna remains
104
Inv for elbow dislocation
Xray Radial/ ulnar arteries Brachial artery Median, ulnar nerves
105
Tx of elbow dislocation
Close reduction, Parvin’s method Then long arm splint, forearm in neutral rotation, elbow 90° Early ROM (<2wk) ORIF if: Complex dislocation Persistent instability after close reduction
106
Complications of elbow disloction
Stiffness Intraarticular loose body NVS injury Rasial head fx Recurrent instability
107
Tennis elbow
Lateral epicondylitis Common extensor tendon
108
Golfer’s elbow
Medial epicondylitis Common flexor tendon
109
Course of epicondylitis
Self limited, but may take 6-18 mo to resolve
110
Tx of epicondylits
``` Rest Ice NSAID Brace, strap PT, stretching, strengthening CS injection ``` Operation if: Failed 6-12 mo conservative therapy Release of common tendon
111
Radius and ulna shaft fx mechanism
High energy Usually accompanied by displacement
112
Inv for radius/ulna shaft fx
Xray | CT if close to joint
113
Tx of ulna/radius shaft fx
Goal: anatomic reduction ORIF with plate and screws Poor results for close reduction (except in children)
114
Complications of forearm fx
Soft tissue contracture resulting in limited forearm rotation
115
Monteggia fx
Fx of proximal ulna with dislocation of radial head. Proximal radioulnar joint injury Children: more common and better prognosis Mechanism: direct blow. Hyperpronation. Fall on hyperextended elbow
116
Inv for monteggia
Xray PIN injury
117
Tx if monteggia
Adults: ORIF of ulna, indirect reduction/ORIF of radius Early post-op ROM if stable. If not, 6 wk immobilization Children: Attempt close reduction and immobilization
118
Complications of monteggia
PIN: mist common nerve injury Radial head instability Radioulnar synostosis
119
Tx of PIN injury
Observe for 3 mo
120
Nightstick fx
Isolated ulna fx, without radial head dislocation
121
Tx of nightstick fx
If non-dislocated: Below elbow cast x 10d, then brace ORIF: if displaced, angulation
122
Galeazzi fx
Fx of distal radial shaft, disruption of distal radioulnar joint Mechanism: FOOSH Inv: Xray
123
Tx of Galeazzi fx
All ORIF If DRUJ stable and reducible: Splint x 10-14 d, early ROM If DRUJ unstable: Pinning, ORIF. Long arm cast x6 wk
124
Most common wrist fx in women > 40
Colles’ fx (dinner fork deformity) FOOSH transverse distal radius fx with dorsal displacement +/- ulnar styloid fx Inv: Xray
125
Tx of colles’ fx
Goal: restore radial height, radial inclination, volar tilt, DRUJ stability, forearm rotation Closed reduction: 1. Traction with extension 2. Traction with ulnar deviation 3. Pronation, flexion Then dorsal slab, below elbow cast for 5-6 wk Xray: 1 wk, 3 wk, at cessation of immobilization Repeat reduction if necessary Operative if: Failed closed reduction, loss of reduction
126
Smith fx
Volar displacement of distal radius Mechanism: fall onto the back of the flexed hand Inv: Xray Tx: ORIF If poor candid for surgery, attempt closed reduction Long arm cast in suppination x 6 wk
127
Complications of wrist fx
``` Poor grip strength Stiffness Radial shortening Compartment syndrome EPL rupture Acute CTS Venous block CRPS/RSD ```
128
Scaphoid fx examination
Pain with resisted pronation Pain with long axis compression into scaphoid Snuff box tenderness
129
Scaphoid fx inv
Xray AP, Lat, scaphoid view (wrist extension and ulnar deviation) +/- CT, MRI Rarely bone scan
130
If suspicion of scaphoid fx
If negative Xray: treat as if positive Repeat Xray 2 wk later. If still negative: CT or MRI
131
Tx of scaphoid fx
Non displaced: long arm thumb spica cast x 4wk. Then short arm cast until radiographic evidence of healing (2-3 mo) If displaced: ORIF
132
The most common complication of scaphoid bone fracture
Nonunion/malunion (use bone graft) others: AVN of proximal fragment (if fx through proximal third) Delayed union (recommend surgical fixation) Scaphoid nonunion advanced collapse and arthritis
133
Special testing for cervical radiculopathy
Compression test: Pressure on head worsens radicular pain Distraction test: Traction on head relieves symptoms Valsalva test: Increases symptoms
134
C5 motor, sensory, reflex function
S: axillary nerve (patch over lateral deltoid) M: deltoid, biceps, wrist extension R: biceps
135
C6 motor, sensory, reflex function
M: biceps, brachioradialis S: thumb R: biceps, brachioradialis
136
C7 motor, sensory, reflex function
M: triceps, wrist flexion, finger extension S: index, middle finger R: triceps
137
C8 motor, sensory, reflex function
M: interossei, digital flexors S: ring and little fingers R: finger jerk
138
Abnormal findings on cervical Xray
Lateral: Translation if vertebra body > 3.5 mm Angulation between adjacent vertebral bodies > 11° Anterior soft tissue space > 3 mm at C3 or > 8-10 mm at C4
139
Special tests for thoracolumbar spine
SLR (pain in 30-70°) Lasegue maneuver: dorsiflexion of leg during SLR brings makes symptoms worse, or brings on symptoms in less elevation Femoral stretch test: pt prone, flex knee, extend hip results in pain in anterior thigh
140
L4 motor, sensory, reflex
M: quadriceps, S: medial malleolus R: patellar Screen: squat and rise Test: femoral stretch
141
L5 motor, sensory, reflex
M: extensor hallucis longus, gluteus medius (hip abduction), tibialis anterior (ankle inversion + dorsiflexion) S: 1st dorsal webspace, lateral leg R: medial hamstring Screen: heel walking Test: SLR
142
S1 motor, sensory, reflex
M: peroneus longus/brevis (ankle eversion), gastrocnemius/soleus (plantar flexion) S: lateral foot
143
Degenerative disc disease symptoms
Axial back pain Pain worse with axial loading and flexion Negative SLR
144
Inv for degenerative disc disease
Xray MRI Provocative discography Change in alignment of facet joints Osteophyte formation
145
Tx of degenerative disc disease
Staying active with modified activity Back strengthening NSAIDs Operative: rare: decompression, fusion
146
Clinic of spinal stenosis
+/- bilateral back and leg pain ``` Neurogenic claudication: Worse with standing, exercise. Walking distance variable. Alleviation with flexion, sitting, lying down. Relief in 10 min ``` +/- motor weakness Normal back flexion Difficulty back extension Positive SLR Pain not worse with valsalva
147
SLR in spinal stenosis
Positive
148
Inv for spinal stenosis
Gold std : CT myelography CT/MRI
149
Tx of spinal stenosis
Vigorous PT: Flexion exercise Stretch/strength exercise NSAID epidural CS Decompressive surgery if: Non-operTive failure > 6 mo
150
Relief time in neurogenic claudication
10 min | 2 min in vascular claudication
151
Mechanical back pain clinical features
Not due to prolapsed disc or any other clearly defined pathology Dull backache Aggravated by activity and prolonged standing Morning stiffness No neurologic sign
152
Tx of mechanical back pain
PT Analgesic Resolves in 4-6 wk or becomes chronic
153
Most common location for disc herniation
L5-S1 > L4-5 > L3-4
154
Features of disc herniation
Back dominant pain (central herniation) Or Leg dominant pain (lateral herniation) Muscle spasm Loss of lumbar lordosis Tenderness between spinous processes at affected level Cauda equina syndrome in 1-10%
155
Disc herniation tests
``` Positive: SLR Contralateral SLR Lasegue Bowstring ```
156
Disc herniation investigation
Xray MRI Post-void residual volume (to check for urinary retention) If PVR > 100 ml, suspicious for cauda equina
157
Tx of disc herniation
Extension protocol NSAID Surgery if: progressive neurological deficit Failure of symptoms to resolve within 3 mo Cauda equina
158
Neurogenic claudication is worse by
Position
159
Vascular claudication is worse by
Exercise
160
Prognosis of disc herniation
90% improve within 3 mo
161
Mechanical back pain, disc origin | Pattern 1
Aggravated with flexion Gradual onset Long duration Treatment: exercise, relief of strain
162
``` Mechanical back pain Facet origin (pattern 2) ```
Worse with extension, standing, walking More sudden onset Shorter duration (days, weeks) Tx: exercise, relief of strain
163
Low back pain with direct nerve root compression, root compression (Pattern 3)
Dominant in leg Worse with flexion Acute onset Short episodes (attacks taking minutes) Tx: relief of strain, exercise, surgical decompression if progressive/severe
164
Back pain with direct nerve root compression, spinal stenosis (pattern 4)
Leg dominant Worse with exercise, extension, walking, standing Cngenital or acquired Acute or chronic Hx Tx: relief of strain, exercise, surgical decompression if progressive/severe deficit
165
Defect in spondylolysis
Pars interarticularis No movement if vertebral body
166
Most common symptoms of sciatica
``` Leg dominant pain Constant Burning Radiates down leg +/- foot Most common cause= disc herniation ```
167
Features of spondylolysis
Activity related back pain Pain worse with unilateral extension (Michelis’ test)
168
Inv for spondylolysis
Oblique Xray: Collar break in scottie dog’s neck Bone scan CT
169
Tx of spondylolystesis
Activity restriction Brace Stretching exercise
170
Adult isthmic spondylolisthesis
Defect in pars interarticularis with forward slippage of one vertebra on another L5-S1> L4-5 Congenital or acquired, teratogenic, traumatic
171
Features of spondylolisthesis
Low back pain radiating to buttocks Relieved with sitting Neurogenic claudication L5 radiculopathy May present as cauda equina
172
Inv for spondylolisthesis
Xray MRI
173
Tx of spondylolisthesis
Activity restriction Bracing NSAID IF intractable pain, > 50% operation: Operation: decompression, spinal fusion
174
Mechanism of pelvic injury
Young: high energy trauma Elderly: fall from standing height, low energy trauma
175
Inv for pelvic fx
Xray CT (posterior pelvic injury, acetabular fx) Assess GU injury (considered open fx)
176
Tear drop displacement in pelvic Xray
Acetabular fx
177
Tx of pelvic fx
``` ABCDE IV fluid/blood Pelvic binder/sheeting External fixation vs emergent angiography/embolization +/- laparotomy (if FAST/DPL + ) ``` If stable fx: Protected weight bearing ORIF if: Unstable pelvic ring injury Disruption of anterior and posterior SI ligament Symphysis diasthasis > 2.5 cm Vertical instability of the posterior pelvis Open fx
178
Complications of pelvis fx
``` Hemorrhage Injury to rectum/UG Obstetrical dificulties Sexual, voiding dysfunction Persistent SI joint pain Hip arthritis with acetabular fx High risk of DVT ```
179
Best time to reduce hip dislocation
Within 6 h (to decrease AVN)
180
Mx of hip dislocation
ABC NVS reduction within 6 h Hip precautions (no extreme flexion, adduction, internal or external rotation): avoid flexing > 90° or crossing legs for 6 wk
181
Anterior hip dislocation mechanism
Posteriorly directed blow to knee, with hip widely abducted
182
Symptoms of ant. Hip dislocation
Shortened, abducted, externally rotated limb
183
Tx of anterior hip dislocation
Closed reduction Post reduction CT
184
Posterior hip dislocation mechanism
Severe force to knee with hip flexed and adducted
185
Features of Posterior hip dislocation
Shortened Adducted Internally rotated
186
Posterior hip dislocation Tx
Close reduction ORIF if: Unstable, intraarticular fragments, posterior wall fx, Associated femoral neck fx, ipsilateral displacement Post-reduction CT If unstable reduction, put in traction x 4-6 wk
187
Rochester method
To reduce Posterior hip dislocation: Supine Hip and knee flexed Traction, internal rotation, then external rotation
188
hip dislocation complications
``` OA AVN Fx of femoral head, neck, shaft Sciatic nerve palsy HO DVT/PE ```
189
Clinic of hip fx
Unable to bear weight Leg: shortened, externally rotated Painful ROM
190
Femoral neck (subcapital) fx Tx
ORIF +/- total/hemi hip arthroplasty in elderly
191
Intertrochanteric hip fx
Closed reduction under fluoroscopy, | Then dynamic hip screw or IM nail
192
Subtrochanteric hip fx Tx
Close/open under fluoroscopy, then plate or IM
193
DVT prophylaxis for hip fx
LMWH on admission Do not give <12 h before surgery
194
AVN etiologies
Femoral neck fx, chronic CS, SCFE, Legg-Calvé-Perthes, SLE, RA
195
Pain reduction for hip fx
Nerve blockade seems effective Preoperative traction seems to not reduce acute pain
196
First motion lost in hip arthritis
Internal rotation
197
Features of hip arthritis
Pain (groin, medial thigh) Pain better with rest: OA morning stiffness > 1h, multiple joint swelling, hand nodules: RA Decreased ROM (first internal rotation) Crepitus Effusion Fixed flexion contracture Trendelenburg sign
198
Inv for hip arthritis
Xray ANA, RF
199
Tx of hip arthritis
Weight reduction, activity modification, PT, analgesics, walking aids If advanced disease: operative
200
Complications of arthroplasty
``` Component loosening Dislocation HO VTE infection NVS injury Limb length discrepancy ```
201
Xray of hip RA
Osteopenia Erosions Joint space narrowing Subchondral cysts
202
Xray of hip OA
Joint space narrowing Subchondral cysts Subchondral sclerosis Osteophytes
203
DVT prophylaxis in elective THA
Continue 10-35 d post-operative Fondaparinox LMWH Warfarin
204
Fx caused by bisphosphonate use
Femoral diaphysis fx
205
Femoral diaphysis fx mechanism
High energy Children: low energy (spiral) Pathologic: Malignancy, osteoporosis, bisphosphonate
206
Femoral diaphysial fx clinic and inv
Shortened, Externally rotated leg (if displaced) Inability to bear wt Often open Inv: Xray
207
Tx of femoral diaphysial fx
If non-displaced: long leg cast ORIF with IM nail External fixator if: unstable pt, open fx, highly vascular area Plate and screw: for open growth plate Early mobilization and strengthening
208
Complications of femoral diaphysial injury
Blood loss Fat embolism Extensive soft tissue damage Ipsilateral hip dislocation/fx Nerve injury
209
Mechanism, clinic, inv for distal femoral fx
High energy Pain, effusion, NVS deficit Xray, CT, Angio if diminished pulses
210
Tx of distal femoral fx
If non-displaced and extraarticular: hinged knee brace If displaced, intraarticular, non-union: ORIF Early mobilization and strengthening
211
Complications of distal femoral fx
Femoral/popliteal artery injury Nerve injury Extensive soft tissue injury Angulation deformities
212
DDx of knee locking
Torn meniscus Loose bode in joint Pseudo-locking: Effusion Muscle spasm Arthritis
213
Painful clicking
Torn meniscus
214
DDx of knee giving away
Torn meniscus Torn cruciate ligament Patellar dislocation
215
Anterior and posterior drawer sign
Knee 90° flexed If able to sublux tibia anteriorly: torn ACL If able to sublux tibia posteriorly: torn PCL
216
Lachman test
Knee 10-20° flexed Torn ACL more reliable than anterior drawer test
217
Pivot shift sign
Torn ACL
218
Reverse picot shift test
Torn PCL
219
Posterior sag sign
Torn PCL Flex knees and hips to 90°
220
Collateral ligament stress test
Opening felt on MCL or LCL while applying valgus and varus stress on knee respectively. Showing MCL or LCL damage
221
Thessaly test
Meniscal teat Pt stands on one leg, flexes knee to 20°, rotates femur on tibia medially and laterally Discomfort in medial or lateral joint line = meniscal tear
222
Tests for meniscal tear
Joint line tenderness Crouch compression test (pain with squatting) McMurray test: Lateral meniscus tear: internally rotate foot, varus stress, extend knee Medial meniscus tear: externally rotate foot, valgus stress, extend knee Painful Pop/click: torn meniscus
223
Indications for Xray in acute knee injury
Age> 55 Tenderness at fibula head Isolated tenderness of patellainability to flex to 9° Inability to bear wt immediately and in ER
224
Torn ACL exam
Effusion Posterolateral joint lime tenderness Positive anterior drawer Positive lachmann Pivot shift
225
Tx of torn ACL
If stable knee with minimal functional impairment: 2-4 wk immobilization. Early ROM and strengthening If high demand lifestyle: ligament reconstruction
226
PCL tear exam
Cannot descend stairs Pain with pushoff Effusion Anteromedial joint line tenderness Positive posterior drawer Reverse pivot shift
227
Tx if torn PCL
Unstable knee, young person, high demand: ligament reconstruction
228
Inv for collateral ligament tear
Xray | MRI
229
Tx of collateral ligament injury
If partial tear: Immobilization 2-4 wk Early ROM and strengthening If complete tear: Immobilization at 30° flexion Multiple ligamentus injuries: Operative
230
Pain in partial vs complete ligamentous tear
Pain more severe in partial tear
231
Medial vs lateral meniscus tear
Medial > lateral
232
Hemarthrosis in meniscus tear
Insidious (after 24-48 h)
233
Inv in meniscus tear
MRI | arthroscopy
234
Tx of meniscus tear
If not locked: Non-operative ( ROM, NSAID, strengthening) ``` If locked or failed above measures: Arthroscopic repair (if peripheral longitudinal tear with good vascular response), partial meniscectomy (if complex, degenerative, radial tear) ```
235
RFs for quadriceps/patellar tendon rupture
``` Obesity DM RA SLE Steroid use RF on Dialysis ```
236
Mechanism of patellar/quadriceps tendon rupture
Forceful contraction of quadriceps while attempting to stop
237
Inv for quadriceps/patellar rupture
Unable to do SLR (if complete rupture) Knee Xray (to exclude patella fx) MRI (to distinguish between complete/partial rupture) ``` Lateral view: Patella alta (patellar tendon rupture) Patella baja (quadriceps tendon rupture) ```
238
Tx of patellar/quadriceps tendon rupture
If incomplete: Immobilization in brace If complete/loss of extensor mechanism: Early surgical repair (<6 wk)
239
Inv for dislocated knee
Xray ABI (<0.9 abn) Arteriogram/ CT angio if abnormal vascular exam
240
Tx of knee dislocation
Urgent closed reduction Assess: peroneal nerve, tibial artery, ligaments If vascular injury: emergent operative repair If open fx/dislocation: emergent OR non-reducible: emergent OR Compartment syndrome: emergent OR Knee immobilization x 6-8 wk
241
Complications of knee dislocation
Popliteal artery injury Peroneal nerve injury Capsular tear Chronic instability, stiffness, post traumatic arthritis
242
Patellar fx inv
Xray
243
Tx of patellar fx
``` Non-displaced: Straight leg immobilization, 1-4 wk with hinged knee brace. Wt bearing as tolerated Progress in flexion after 2-3 wk PT ``` Operative if: Displaced > 2mm Comminuted Disrupted extensor mechanism
244
Complications of patellar fx
``` Symptomatic wiring Loss of reduction Osteonecrosis (proximal) Hardware failure Knee stiffness Nonunion Infection ```
245
RFs for patellar dislocation
``` Young, female Obesity High-riding patella Genu valgus Q angle > 20° Shallow intercondylar groove Weak vastus medialis Tight lateral retinaculum Ligamentous laxity ```
246
Patellar dislocation features
Knee catches/gives way with walking Severe anteromedial pain/tenderness from rupture of capsule Positive patellar apprehension test Recurrent. Self reducing. Weak knee extension/ inability to extend unless patella reduced Concomitant MCL injury Increase Q angle J sign
247
Inv for patellar dislocation
Xray Check for medial patella and lateral femoral condyle fx
248
Tx of patellar dislocation
``` NSAID Activity modification Physical therapy Short-term immobilization, then 6 wk controlled motion Progressive wt bearing Isometric quadriceps strengthening ``` ``` Operative if: Recurrent Loose bodies present Surgical tightening of medial capsule Release if lateral retinaculum Tibial tuberosity transfer Proximal tibial osteotomy ```
249
RFs fir patellofemoral syndrome
``` Malalignment (Genu valgus, Q > 20°) Post-trauma Deformity of patella or femoral groove Recurrent dislocations Ligamentous laxity Excessive knee strain ```
250
Mechanism of chondromalacia patellae
Softening, erosion, fragmentation of articular cartilage. Predominantly medial aspect of patella. Common in active young females
251
Symptoms of patellofemural syndrome
Deep, aching anterior knee pain. Pain exacerbated by prolonged sitting (theatre sign), strenuous athletic activity, stair climbing, squatting, kneeling Insidious onset Vague Instability, pseudolocking Pain with extension against resistance through terminal 30-40° Pain with compression of patella with knee ROM Palpable crepitus NO/MINIMAL SWELLING
252
Inv for patellofemural syndrome
Xray CT MRI: best to assess articular cartilage
253
Tx of chondromalacia patellae
``` Rest Rehabilitation Non-impact activities NSAID PT: vastus medialis and core strengthening ``` ``` Operative: If failed non-operative treatment Tibial tubercle elevation Arthroscopic shaving/debridement Lateral release of retinaculum ```
254
Tibial plateau fx mechanism
Varus/valgus load +/- axial loading Lateral > bicondylar > medial
255
Inv for tibial plateau fx
Xray CT ABI
256
Complications of tibial plateau fx
``` Ligamentous injuries Meniscal lesion AVN infection OA Compartment syndrome ```
257
Tx if tibia plateau depression
If depression < 3mm or varus/valgus instability < 15°: Straight leg immobilization 4-6 wk, with progressive ROM Wt bearing If depression > 3mm or significant varus/valgus instability > 15°: ORIF (often with graft)
258
Tibial shaft fx mechanism
Low energy torsional High energy Inv: Xray
259
Tibial shaft fx Tx
If closed and minimally displaced or adequately reduced: Long leg cast 8-12 wk, tgen functional brace If open or displaced: ORIF + AB, I&D, vascular coverage of open fx defect
260
Tibial shaft fx complications
High incidence of: NVS injury Compartment syndrome Poor soft tissue coverage
261
Tx of ankle fx
If non-displaced, no history of dislocation: Below knee cast, non weight bearing ``` Operative if: Any fx-dislocation Trimalleolar Talar tilt > 10° Open fx Open joint injury Medial clear space on Xray greater than superior clear space ```
262
Complication of ankle fx
High incidence of arthritis
263
Talar fx mechanism
Axial loading Hyperdorsiflexion Most common site: neck
264
Complication of talar fx
High risk of AVN if displaced
265
Inv for talar fx
Xray CT MRI (to define extent of AVN)
266
Tx of talar fx
If non-displaced: NWB, below knee cast x 6wk ORIF if: Displaced
267
Calcaneal fx mechanism
High energy axial load
268
Calcaneal fx inv
Calcaneal fx of other side Compression fx of thoracic and lumbar spine Xray (oblique view is mandatory) Gold std: CT
269
Tx of calcaneal fx
NWB cast x 3 mo, early ROM Close vs open reduction controversial
270
Achilles tendonitis mechanism
Activity Poor-fitting footware +/- heel bumps (retrocalcaneal bursitis)
271
Inv for achilles tendonitis
Xray (lateral: bone spurs, calcification) U/S MRI
272
Tx of achilles tendonitis
Rest NSAID Shoewear modification Main stay of non-operative treatment: heel sleeves and pads Gentle gastrocnemius-soleus stretching Eccentric training with physical therapy Deep tissue calf massage Shockwave therapy in chronic tendonitis
273
Forbidden treatment in achilles tendonitis
Steroid injection
274
Achilles tendon rupture mechanism
Loading activity Stop and go sports Chronic tendonitis Steroid injection
275
Thompson test
Prone Squeeze calf If no passive plantarflexion= rupture
276
Achilles rupture inv
Xray U/S MRI (partial vs complete)
277
Tx for achilles rupture
If low athletic demand or elderly: Non operative. Cast in plantar flexion x 8-12 wk If high athletic demand: Surgical repair, then cast in plantar flexion x 6-8 wk Surgical repair reduces risk of rerupture
278
Plantar fasciitis definition (heal spur syndrome)
Inflammation of plantar aponeurosis at calcaneal origin
279
Plantar fasciitis associations
Athletes Obesity DM Seronegative, seropositive arthritis
280
Mechanism of plantar fasciitis
Repetitive strain injury causing microtears and inflammation of plantar fascia
281
Nerve injury in achilles rupture
Sural
282
Clinical features of plantar fasciitis
Insidious onset of heel pain Pain when getting out of bed Stiffness Intense pain when walking from rest Pain subsides as patient continues to walk Pain worse at the end of day with prolonged standing Swelling/tenderness over soal Greatest at medial calcaneal tubercle and 1-2 cm distal along plantar fascia Pain with toe dorsiflexion
283
Inv for plantar fasciitis
Xray Often there is bony exostosis Spur is secondary to inflammation (not the cause of pain)
284
Tx of plantar fasciitis
1st line: Pain control, stretching programs ``` Rest Ice NSAIDs Steroid injection PT Orthotics with heel cup ``` Surgical release of fascia if failed non-operative treatment
285
Bunion associations
Poor fitting footwear (high heel, narrow toe box) Hereditary (70%) 10 x more frequent in women
286
Features of bunion
Painful bursa over medial eminence of 1st MT head Pronation of great toe Numbness over medial aspect of great toe Toe deviation angle > 15°
287
Inv for bunion
Xray
288
Tx of bunion
Indications: painful (corn, bunion), overriding 2nd toe 1st line: properly fitted shoes and toe spacer Operative: Goal: to restore normal anatomy. Osteotomy with realignment of 1st MTP Arthrodesis
289
Foot stress fxs
Midshaft 5th metatars Shaft 2nd, 3rd metatars
290
Tx of avulsion of base of 5th metatars
ORIF if displaced
291
Tx of march fx (shaft of 2nd, 3rd fx)
Symptomatic
292
Tx of 5th metatars midshaft fx
NWB BK cast x 6wk ORIF if athlete
293
1st metatars fx Tx
If displaced:ORIF if non-displaced: 3 wk NWB BK cast then walking cast
294
Lisfranc fx
Tarso-metatarsal fx-dislocation
295
Most common fx site in children
Distal radius 2nd: phalanges
296
Fxs in children suspicious of abuse
Hallmark: metaphyseal corner fx Femur fx < 1yr Humeral shaft < 3 yr Sternal fx Posterior rib fx Spinous process fx
297
Most common site of stress fx
Tibia
298
Dx of stress fx
Localized pain and tenderness Xray may not show fx for 2 wk Bone scan positive in 12-15 d
299
Tx of stress fx
Rest (from strenuous activity)
300
Salter-Harris type I fx Tx
Closed reduction and cast immobilization Exception: SCFE which requires ORIF
301
Salter-Harris type II Tx
Closed reduction and cast If failure: ORIF
302
Salter-Harris type III Tx
ORIF Avoid fixation across growth plate
303
Salter-Harris type IV Tx
Closed reduction and cast if anatomic Otherwise: ORIF
304
Salter-Harris type V Tx
No specific Tx
305
Most common adolescent hip disorder
SCFE
306
RFs for SCFE
Male Obesity (#1 factor) Hypothyroid (risk of bilateral involvement) AD Black Trauma (acute slip) (Sex hormone secretion which stabilizes physis, not yet begun)
307
Clinical features of SCFE
Acute: sudden severe pain with limp Chronic: groin/anterior thigh pain, knee pain. Positive trendelenburg on affected side Tender over joint capsule Restricted: internal rotation, abduction, flexion (whitman sign: obligatory external rotation during passive hip flexion)
308
Inv for SCFE
Xray ( including frog leg) Disruption of Klein line
309
Tx of SCFE
If mild-moderate slip: Stabilize physis with pins in current position If severe slip: ORIF Or Pin physis without reduction, osteotomy after epiphyseal fusion
310
Complications of SCPE
AVN Chondrolysis Pin penetration Premature OA Loss of ROM
311
Most common orthopedic disorder in children
Developmental dysplasia of the hip
312
If painful DDH
Suspect septic dislocation
313
Tests for DDH
Limited abduction of the flexed hip Barlow Ortolani Galeazzi (> 1yr) Trendelenburg test and gait (> 2y)
314
Predisposing factors to DDH
``` Female FHx Frank breech First born Left hip ```
315
Inv for DDH
U/S in first few month Xray at 4-6 mo
316
Tx of DDH
0-6 mo: reduce hip with Pavlic harness (maintains abduction and flexion 6-18 mo: reduction under GA, hip spica cast 2-3 mo (if pavlic fails) > 18 mo: open reduction, pelvic/femoral osteotomy
317
Complications of DDH
Inadequate reduction Stiffness Redislocation AVN
318
Legg-Calvé-Perthes (coxa plana)
AVN of femoral head Idiopathic 4-8 y M>F
319
Associations of Legg-Calvé-Perthes (coxa plana)
``` FHx LBW Abn pregnancy/delivery ADHD Delayed bone age Second hand smoke Asian Inuit Central European ```
320
Legg-Calvé-Perthes (coxa plana) symptoms
Antalgic or Trendelenburg gait +/- pain Intermittent hip/knee/groin/thigh pain Flexion contracture Decreased internal rotation Decreased abduction of hip Limb length discrepancy
321
Legg-Calvé-Perthes (coxa plana) inv
Xray (including frog leg) May be negative early If high index of suspicion, bone scan/MRI
322
Tx of Legg-Calvé-Perthes (coxa plana)
Goal: preserve ROM and keep femoral head contained in acetabulum Non-operative: PT, brace in flexion and abduction x2-3 mo Operative: Femoral or pelvic osteotomy (> 8y or severe)
323
Who has better prognosis in Legg-Calvé-Perthes (coxa plana)
Male <6 yr < 50% of femoral head involved Abduction > 30°
324
Complications of Legg-Calvé-Perthes (coxa plana)
Early OA | Decreased ROM
325
Osgood Schlatter (tibial tubercle apophysitis
Inflammation of patellar ligament at insertion point on tibial tuberosity M> F Boys 12-15y Girls 8-12y Mechanism: repetitive tensile stress, causing minimal avulsions and the inflammation
326
Osgood Schlatter symptoms
Tender lump on tuberosity Pain on resisted leg extension Anterior knee pain, exacerbated by jumping, kneeling, relieved by rest Mist common in adolescent athletes (jumping, sprinting)
327
Inv for Osgood Schlatter
Xray: fragmentation of tibial tubercle | +/- ossicle in patellar tendon
328
Osgood Schlatter Tx
``` Benign Self limited (does not resolve until growth halts) ``` Restrict activities (cycling, basketball) NSAIDs Rest Flexibility, isometric stretch exercise Casting if no resolution If refractory: ossicle excision (if skeletally mature)
329
Congenital talipes equinovarus
M: more common F: more severe ``` CAVE: Midfoot Cavus Forefoot Adductus Hindfoot Varus Hindfoot Equinus ``` Talar neck medial and plantar deviated Calcaneus: varus, medially rotated Navicular and cuboid: medially displaced
330
Inv for talipes equinovarus
DDH Knee deformities Back dysraphism
331
Tx of club foot
Ponseti technique Correct deformities in CAVE order Change strapping/cast q1-2 wk If refractory, surgical release (delayed until 3-4mo)
332
Scoliosis
F> M F: more severe 10-14 y
333
Most common cause of scoliosis
Idiopathic
334
Inv for scoliosis
Xray (3foot standing. AP. Lateral) +/- Associated kyphosis Cobb angle
335
Tx of scoliosis
Based on Cobb’s angle <25° : observe with serial radiographs > 25° or progressive: bracing (do not reverse deformity, but halt/slow progression) > 45° or cosmetically unacceptable or respiratory problem: surgical correction
336
Benign bone lesion on Xray
No periosteal reaction Thick endosteal reaction Well developed bone formation Intraosseous and even calcification
337
Malignant bone lesions on Xray
Acute periosteal reaction: Codman’s triangle Onion skin Sunburst Broad border between lesion and normal bone Varied bone formation Extraosseous and irregular calcification
338
Inv for bone tumor
``` Xray Blood work including liver enzymes CT bone scan Bone Bx MRI ```
339
Red flags in bone pain
Persistent pain Localized tenderness Spontaneous fx Enlarging mass/soft tissue swelling
340
Osteoid osteoma
Osteoblasts M>F Proximal femur, tibia diaphysis Radiolucent nidus, surrounded by dense sclerotic bone (bull’s eyes) Severe intermittent pain, mostly at night Tx: NSAIDs, surgical resection
341
Fibrous cortical defect (non ossifying fibroma)
Children Asymptomatic M> F Femur, proximal tibia
342
Xray of fibrous cortical defect
Metaphyseal eccentric, bubbly lytic lesion Near physis Margin: thin, smooth, lobulated, well defined, sclerotic
343
Tx of fibrous cortical defect
Resolves spontaneously
344
Most common bone tumor in children
fibrous cortical defect (35%)
345
Osteochondroma
2nd and 3rd decades M>F Painless slowgrowing mass Most common benign tumor Pdunculated or sessile (risk of malignant transformation) Distal femur, proximal tibia, proximal humerus (metaphysis, near tendon attachment) Risk of malignant degeneration if multiple
346
Xray of osteochondroma
Mushroom
347
Tx of osteochondroma
Observation Excision if symptomatic
348
Howlong does osteochondroma grow
Until skeletal maturity
349
Enchondroma
Hyaline cartilage Asymptomatic 2nd-3rd decades Chondroblast In medullary cavity Single/multiple
350
Most common sites for enchondroma
Small tubular bones of hand and foot Others: femur, humerus, ribs
351
Enchondroma Xray
Rarefied area Lytic Sharp margins Irregular central calcification (stippled/punctate/popcorn) 1-2% malignant degeneration to chondrosarcoma (pain without fx)
352
Tx of enchondroma
Serial Xray If symptom/grow: curretage
353
Solitary bone cyst
Children, young adults (1st 2 decades) M>F Proximal humerus Distal Femur
354
Xray of solitary bone cyst
Lytic/translucent Metaphyseal side of growth plate Thinned cortex Expanded cortex Well defined
355
Tx of bone cyst
Aspiration, steroid injection Curettage +/- bone graft
356
Giant cell tumor
Peak 3rd decade Skeletal maturity Xray: eccentric, lytic, epiphysis, adjacent to subchondral bone Enhanced on T2 MRI 3% pulmonary mets
357
Osteoblastoma
3rd decade Skeletal maturity Distal femur, proximal tibia, distal radius, sacrum, tarsal bones, spine Xray: non-specific, calcified central nidus, radiolucent halo, sclerosis
358
Aneurusmal bone cyst
Solid with fibrous/granular tissue or blood filled Cray: Expanded with honeycomb shape
359
Tx of benign aggressive bone tumors
Gian cell tumor Osteoblastoma Aneurysmal bone cyst Tx: curettage + bone graft or cement Wide local excision of expandable bones
360
Most common age group for osteosarcoma
2nd decade
361
Sites of osteosarcoma
Distal femor, proximal tibia, proximal humerus
362
Predisposing factors for osteosarcoma
Paget (elderly) RT
363
Xray of osteosarcoma
Codman’s triangle Sunburst May cross epiphyseal plate
364
Tx of osteosarcoma
Complete resection (limb salvage) Neoadjuvant chemo Bone scan (R/O mets) CT (R/O mets)
365
Chondrosarcoma
Primary (2/3) > 40 yr Or Secondary (from osteochondroma or enchondroma) 25-45 yr
366
Xray of chondrosarcoma
Popcorn calcification in medullary cavity
367
Tx of chondrosarcoma
Aggressive surgical resection + reconstruction Regular F/U Xrays: chest. Excision site.
368
Ewing sarcoma
5-25 yr Small round cells Florid periosteal reaction Metaphysis of long bones, diaphysial extension Mets frequent
369
Inv in ewing sarcoma
Fever Increased WBC, ESR, LDH Xray: moth-eaten. Periosteal lamellated pattern
370
Tx of Ewing
Resection, chemo, RT
371
Most common primary malignant bone tumor in adults
MM > 40 M> F African-Americans
372
Xray of MM
Multiple punched out, welldemarkated lesions No surrounding sclerosis
373
Inv
Xray CT guided Bx Ca ESR Cr CBC SPEP/UPEP
374
Tx of MM
Chemo Bisphosphonate RT Surgery (impending fx, symptomatic lesion)
375
Most common cause of bone lesion in adults age > 40
Mets (2/3 breast, prostate)
376
Inv in bone mets
Bone scan | MRI for spine
377
Tx of bone mets
Pain control Bisphosphonates Surgery ( if impending fx)
378
Prevention of heterotopic ossification
Misoprostol + indomethacin