Ortho continued Flashcards
if you suspect fracture, what types of X-rays should you get
two views at 90 degrees to one another. include joints above and below the broken bone. also include bones in the line of force (feet-> lumbar spine)
when can you do closed reduction
bones that are not badly displaced or angulated and can be satisfactorily alligned by external manipulation in a cast
when do you do open reduction and fixation
broken bones that are severely displaced or angulated and cannot be easily aligned. need surgical intervention to reduce and fix the fracture
tx for clavicular fractures
usually at junction of distal and middle thirds. tx: place arm in sling. young women might get surgery for cosmetic reasons
pt holds arm close to body but rotated outward as if about to shake hands. numbness over small area in deltoid.
anterior dislocation of shoulder. MC shoulder dislocation. numbness from stretching of axially nerve. dx: AP and lateral X-rays. some people develop recurrent dislocations with minimal trauma.
pt s/p seizure or electrical burn with arm close to body and internally rotated.
posterior shoulder dislocations. regular X-rays can miss it, axillary or scapular lateral views are needed.
tx for developmental dysplasia of the hip
pavlik harness for 6 months. sono is dx- X-rays don’t work
6 year old with insidious development of limp, decreased hip motion, and hip or knee pain. antalgic gait.
legg-calve-perthe dz. dx by AP and lateral hip X-rays. tx controversial- contain femoral head within the acetabulum by casting and crutches
chubby 13 year old boy with groin or knee pain and limping. sit- sole of affected leg inverts. limited hip internal hip rotation.
Slipped capital femoral epiphysis. dx: X-ray. tx: emergency! surgical tx to pin femoral head back into place.
toddler with febrile illness who refuses to move his hip. hip flexed in slight abduction and external rotation.
septic hip. surg emergency! elevated ESR. dx: aspirate hip under general anesthesia. do further open drainage if pus is obtained.
little kid with hx of febrile illness. shows up with severe localized pain in a bone and no hx of trauma to that bone.
acute hematogenous osteomyelitis. dx: MRI (X-rays don’t show anything for a couple of weeks). tx: antibiotics
legs that bow outwards
genu varum. normal up to age 3- no tx needed. after age 3 it is called blount dz- disturbance of medial proximal growth plate- surgery must be done
knock knees
genu valgus. normal between age 4-8- no tx needed.
baby born with both feet turned inward with plantar flexion of ankle, inversion of foot, adduction of forefoot , and internal rotation of tibia.
clubfoot (talipes equinovarus). tx: serial plantar csts. often achilles tenotomy and part time long term use of braces. non responders get surgery 9-12 months.
old osteoporotic woman falls on hand and has deformed and painful wrist that looks like “dinner fork”
colles fracture. main lesion is dorsally displaced dorsally angulated fracture of distal radius. treat with close reduction and long arm cast
direct blow to ulna fracture. pt has a raised protective arm against a nightstick.
monteggia fracture. diaphyseal fracture of proximal ulna with anterior dislocation of radial head. broken bone needs ORIF while dislocated one needs closed reduction.
galeazzi fracture
mirror image of monteggia fracture. distal third of radius gets direct blow and has the fracture and there is direct dislocaition of distal radioulnar joint.
young adult falls on an outstretched hand and complains of wrist pain.
fracture of the scaphoid (carpal navicular). physical exam shows localized tenderness to palpation over the anatomical snuff box. X-rays negative in undisplayed fx, will show in three weeks. thumb spica cast is indicated with just h&p. if original X-rays show displaced and angulated fx, ORIF needed. scaphoid fx notorious for a high rate of nonunion.
pt hits a hard surface like a wall with fist. the hand is swollen and tender. dx? tx?
metacarpal neck fractures- usually fourth or fifth or both. X-rays are diagnostic. tx depends on degree of angulation, displacement, or rotary malalignment. closed reduction and ulnar gutter splint for mild. kirscHner wire or plate fixation for bad ones.
old pt had a fall- laying on stretcher with and shortened and externally rotated leg
hip fracture! get X-ray. treatment depends on specific location.
femoral neck fracture issues and treatment
compromise blood supply of femoral head! faster healing and earlier mobilization can be achieved by replacing the femoral head with a prosthesis.
intertrochanteric fracture issues and treatment
less likely to lead to avascular necrosis than femoral neck fractures. treat with ORIF. unavoidable immobilization that ensues gives a very high risk of DVT and PE, so post op anticoagulation is recommended
femoral shaft fracture issues and tx.
tx: usually intramedullary rod fixation. if b/l and comminuted, may produce enough internal bleeding -> shock, so need external fixation while pt is stabilized. if open, it is an ortho emergency with OR cleaning and closure within 6 hours. if multiple-> fat embolization.
knee pain w/o swelling
unlikely to be serious knee injury
best way to evaluate knee injury
MRI. swelling is “poor man’s MRI”
sideways blow to knee.
collateral ligament injury. medial blow will affect lateral ligament and vice versa. knee will be swollen and show localized pain on affected side.
physical exam maneuvers for collateral ligament injury.
flex knee 30 degrees. passsive abduction (valgus stress test shows medial injury) or adduction (varus stress test shows lateral injury) will produce pain on torn ligaments and allow further displacement that normal leg.
tx for collateral ligament injury
isolated injuries treated with hinged cast. when several ligaments are torn, surgical repair is preferred.
Pt has severe knee swelling and pain. Anterior drawer test positive and Lachlan test positive.
Anterior cruciate ligament injury. More common than posterior. MRIS are diagnostic. Tx: immobilization and rehab for sedentary patients but athletes need arthroscopic reconstruction
Pt has a knee injury- protracted pain and swelling- catching and locking that limits motion
Meniscal tears- difficult to dx clinically and on X-rays but show up beautifully on MRIS. Tx: repair, trying to save as much meniscus as possible. Complete meniscotomy leads to late development of degenerative arthritis. USMLE answer is open repair.
Young men subjected to forced marches. Tenderness to palpating over a specific part of bone. X-rays are normal.
Tibial stress fx. Treat with a cast and repeat X-ray in 2 weeks. Non weight bearing crutches is another option.
Out of shape middle aged man who subjects himself to severe strain. Plant foot, change direction, large popping noise is heard and they fall clutching the ankle. Limited plantarflexion is possible but pain swelling and limping.
Rupture of the Achilles’ tendon. Palpating tendon leaves a gap. Tx: casting in equinus position allows healing in several months- surgery achieves quicker cure
Fall on inverted or everted foot.
Both malleoli break in either case. Dx: AP, lateral, mortise x rays. To: if fragments are displaced, ORIF!
MC cause of compartment syndrome in LE. Physical exam findings?
Fracture with closed reduction. Patient has pain and limited use of the extremity. Most reliable physical finding= excruciating pain with passive extension. Pulses may be normal. Need emergency fasciotomy!
Pain under cast. Next steps?
Remove cast and exam limb
Bone sticking out of wound. Next steps?
Clean inOR and suitable reduction within 6 hours from time of injury
Pt after head on car collision where knees hit dashboard. Pt lies on stretcher with leg shortened adducted and internally rotated. Next steps?
Posterior dislocation of hip (in broken hip, the leg is also shorted but it is externally rotated). Bc of tenuous supply of femoral head, need emergency reduction to avoid avascular necrosis
3 days after deep penetrating dirty wound, pt gets sick, looking toxic and moribund. THe affected site is tender, swollen, discolored, and has gas crepitation
Gas gangrene! Tx: copious IV penicillin, extensive surgical debridement, and hyperbaric oxygen
Oblique fracture to middle distal third of humerus. Pt cannot dorsiflex (extend) the wrist. Next steps?
Radial nerve injury. Reduce fracture and place arm in hanging
Posterior dislocation of the knee. What do you worry about?
Popliteal artery injury. Attention to integrity of pulses, Doppler studies, CT Angio. Prompt reduction will minimize vascular compromise. Delayed restoration of flow requires prophylactic fasciotomy.
Woman has numbness and tingling in hands, particularly at night, in distribution of the medial nerve
Probably carpal tunnel syndrome. Wrist X-rays to rule out other things. Preop should do electromyography
Woman has numbness and tingling in hands, particularly at night, in distribution of the medial nerve
Probably carpal tunnel syndrome. Wrist X-rays to rule out other things. Preop should do electromotive path
Woman wakes up in the middle of the night with a finger acutely flexed and unable to extend it unless they pull it with other hand. When they do so, there is painful snap.
Trigger finger. Tx: steroid injection first line. Surgery is last resort
Young mother has pain along radial side of wrist and first dorsal compartment
De quervains synovitis from holding Tx: steroid injection is best, but splint and anti inflammatory agents can help. Surgery rarely needed.
Young mother has pain along radial side of wrist and first dorsal compartment
De quervains synovitis from holding Tx: steroid injection is best, but splint and anti inflammatory agents can help. Surgery rarely needed.
Older Norwegian man has palmar fascial contracture of palm of hand and palmar fascial nodules can be felt
Duyputrens contracture. Surgery may be needed when hand can no longer be placed flat on a table
Pt with neglected penetrating finger injury has throbbing pain in finger and fever
Felon. Abscess in the pulp of a fingertip. Pressure can build up and lead to tissue necrosis. Surgical drainage must be urgently done
Skier falls and has collateral laxity at the thumb metacarpophalabgeal joint
Gamekeeper thumb- caused by forced hyperextension of the thumb. Casting is usually done. If untreated can be dysfunctional and painful and lead to arthritis
When making a fist, the distal phalanx of the injured finger does not flex with the others.
Jersey finger. Injury to flexor tendon when flexed finger is forcefully extended. Splinting!
The tip of the finger is flexed when the hand is extended
Mallet finger. When extended finger is forcefully flexed and extensor tendon is ruptured (common volleyball injury). Splinting!
Traumatically amputated digits next step
Clean digit with sterile saline and wrap in saline moistened gauze, place in sealed plastic bag, and keep on ice. Try to reattach whenever possible
Child FOOSH. Concern?
Supracondylar fx of the humerus. Vascular or nerve injury can occur and lead to volkmanns contracture. Tx: monitor vascular and nerve integrity, compartment syndrome: casting or traction! Rarely need surgery.
Osteogenic sarcoma vs Ewing sarcoma
OS more common. OS 10-25. EW 5-15. OS around knee. EW in diaphysis of long bones. OS X-RAY sunburst pattern. EW X-RAY onion skinning.
Bone tumor cause in children vs adults
In children they are primary but in adults they are metastatic
Old man with fatigue, anemia, and localized pain at specific places on several bones. Dx?
Multiple myeloma! Dx: X-rays show punched out lytic lesions, bence jones protein in urine, abnormal immunoglobulins in the blood (serum electrophoresis).
MM to
Chemotherapy. If that fails, can try thalidomide.
Soft tissue sarcoma
Relentless growth of soft tissue growth anywhere in the body. Firm, fixed to surrounding structures. Met to lungs not to LN. Dx: MRI, incisional bx. Tx: wide local incision, radiation, chemotherapy
Old person has several months of aching pain and then sudden onset electrical shock down leg with movement (coughin, sneezing, defecating)
Lumbar disc herniation- L4/L5. Dx: straight leg test, MRI. Tx: bed rest for 3 weeks, pain control.
When does lumbar disc herniation need surgery
Neuro deficits are progressing, caudal equina syndrome (distended bladder, flaccid rectal sphincter, perinatal saddle anesthesia).
Distended bladder, flaccid rectal sphincter, perineal saddle anesthesia
Cause equina syndrome- Surgical emergency requiring immediate decompression
35 yo man with chronic back pain and morning stiffness, worse with rest and better with activity.
Ankylosing spondylitis! X-ray shows bamboo spine. HLAB27 antigen, associated with uveitis, and IBd. To: anti inflammatory and physical therapy
Elderly person with progressive back pain worse at night and unrelieved by rest or positional changes.
Metastatic malignancy. W: from breast, M: from prostate. Get MRI. X-ray will show advanced lesions
Dirty ulcer at tip of toes looking dirty and devoid of granulation tissue
Ulcer from arterial insufficiency. Work up: Doppler looking for pressure gradient. If yes- surgery. CT Angio, MRI Angio, or arteriograms. Surgical revascularization or angioplasty and stents
Painless ulcer with granulating bed in edematous, indurated, and hyperpogmented skin above medial malleolus. Pt has varicose veins and suffers from frequent cellulitis.
Venous stasis ulcer. Dx: duplex scan. Tx: support stockings, ace bandage, in a boot. Surgery- vein stripping, grafting of ulcer. Endo vascular ablation with laser or radiofrequenxg may be used.
Pt with chronic foot ulcers. What else to look for?
Work up for DM and arteriosclerotic disease.
Many years of healing and breaking down in skin, as in untreated third degree burn, or chronic draining sinus from osteomyelitis. Dirty ulcer at site with heaped up tissue around edges.
Marjolin ulcer. Type of SCC. Dx: bx. Tx: wide excision and skin grafting
Old person has several months of aching pain and then sudden onset electrical shock down leg with movement (coughin, sneezing, defecating)
Lumbar disc herniation- L4/L5. Dx: straight leg test, MRI. Tx: bed rest for 3 weeks, pain control.
When does lumbar disc herniation need surgery
Neuro deficits are progressing, caudal equina syndrome (distended bladder, flaccid rectal sphincter, perinatal saddle anesthesia).
Distended bladder, flaccid rectal sphincter, perineal saddle anesthesia
Cause equina syndrome- Surgical emergency requiring immediate decompression
35 yo man with chronic back pain and morning stiffness, worse with rest and better with activity.
Ankylosing spondylitis! X-ray shows bamboo spine. HLAB27 antigen, associated with uveitis, and IBd. To: anti inflammatory and physical therapy
Elderly person with progressive back pain worse at night and unrelieved by rest or positional changes.
Metastatic malignancy. W: from breast, M: from prostate. Get MRI. X-ray will show advanced lesions
Dirty ulcer at tip of toes looking dirty and devoid of granulation tissue
Ulcer from arterial insufficiency. Work up: Doppler looking for pressure gradient. If yes- surgery. CT Angio, MRI Angio, or arteriograms. Surgical revascularization or angioplasty and stents
Painless ulcer with granulating bed in edematous, indurated, and hyperpogmented skin above medial malleolus. Pt has varicose veins and suffers from frequent cellulitis.
Venous stasis ulcer. Dx: duplex scan. Tx: support stockings, ace bandage, in a boot. Surgery- vein stripping, grafting of ulcer. Endo vascular ablation with laser or radiofrequenxg may be used.
Many years of healing and breaking down in skin, as in untreated third degree burn, or chronic draining sinus from osteomyelitis. Dirty ulcer at site with heaped up tissue around edges.
Marjolin ulcer. Type of SCC. Dx: bx. Tx: wide excision and skin grafting
Pt with chronic foot ulcers. What else to look for?
Work up for DM and arteriosclerotic disease.
Old fat person complains of disabling sharp heel pain every time foot strikes the ground. Pain worse in mornings.
Plantar fasciitis. X-ray shows Bony spur matching location of pain. Physical exam shows ttp. Bony spur is not the problem! Tx: spontaneous repairing in 12-18 months with sx tx.
Inflammation of the common digital nerve at the third interspace
Morton neuroma. Tx: conservative more comfy shoes. Or surgical excision can be done.
Middle Aged man with swelling. Redness and pain at first metatarsal phalangeal joint.
Gout. Fluid from joint shows Uric acid. Tx: indomethacin and colchicine. Chronic control: allopurinol and probenicid
ankle is fractured and both malleoli break and fragments are displaced. next steps?
ORIF if fragments are displaced
what do you cover burn near eye with
triple antibiotic ointment bc silver sulfadiazine is irritating to the eyes.
guy was kicked in the stomach a lot and is in shock with is helped with fluids. now he is HD stable. next step?
get CT scan of abdomen for intrabdominal bleed. it will tell you if there is bleed and where. if he were HD unstable, get FAST- it will tell you if there is bleed.
