Ortho Final Part 1 Flashcards
- Most common fracture in elderly pts is ___
- The incident ___ past age ___ with ___ affected more than ___
Hip fracture
incidents doubles past age 50 and with F>M
__ in __ pts with a hip fracture die between one year after fracture and ___% of them never return to previous level of ambulation and independence.
1 in 4
50%
*Can reduce mortality if fixed w/in 24-48 hrs
Treatment for Intertrochanteric Fx require
intra-meduallary nail with cannulated screws
Intracapsular (femoral neck) fx associated w/ high risk of __
non-union secondary to AVN
*Extracapsular requires stronger fixation
Most hip dislocations are ___
Pelvic fxs hold a high risk of ___ so do this:
posterior
high risk of bleed–> tx w/ pelvic binder/clamp
Forefoot (Metatarsals) Pain: Symptomatic in __ more than __
-Bunions (hallux valgus deformity) occurs more in __ than __
females 9x more than males (“Da shoes”)
F>M, 10:1
Sx: pain and tightness w/ 1st step in the morning
Disease and its tx
Plantar fascitis
- More than 95% of cases can be managed with non-surgical treatment.
- commonly takes 6 to 12 months for symptoms to resolve–> PT and stretch +/- night splint
Lisfranc fracture-dislocation
lateral shift of the 2nd metatarsal w/ WB xrays
Morton’s Neuroma: most common between __ and _ metatarsals
3rd and 4th Metatarsals
Sx” “walking on a marble”
Tarsal tunnel syndrome is a compression, or squeezing on the ____ nerve that produces symptoms anywhere along the path of the nerve.
Posterior Tibial Nerve
Achilles Tendon Rupture: (+) ___ test: squeeze of calf with no plantar flexion noted, most reliable within __ hrs of injury.
Thompson
48 hours
Talus Fracture: ___ waiting to happen”
“AVN (Avascular Necrosis)
Too many toes sign= __
Posterior tibial tendon deficiency
Flatfoot = __–> hyperpronation and tight heel cord
pes planus (hindfoot pain)
MC fx of base of 5th Metatarsal–> ___ fracture–> TX ___
Dancers Fx
TX: SLC-NWB
- Hyperextension Spine Injury: ___ (“hangman’s” fracture) and Hyperextension fracture-dislocation.
- Vertical compression: Jefferson bursting fracture= ___ fracture and must lower cervical spine fractures
Traumatic spondylolisthesis
*The commonly applied terms “hangman’s” and bilateral “pedicle” fracture are each misnomers. Because a traumatic spondylolisthesis is not the injury of the judicial hanging.
C1Burst
Most severe lower cervical spine injury.
Flexion Teardrop fracture:
fracture involves the pars interarticularis of C2
Hangman’s fracture
What is a jefferson Burst fx
: Pathology is bilateral fractures of both the anterior and posterior arches of C1
What is a Odontoid fx (MC type)
Type II fracture (more than 60% of cases) is a fracture occurring at the base of the odontoid as it attaches to the body of C2. (“My head is going to fall off”
Symptoms: neck pain with associated numbness and paresthesias in the upper extremity. May also describe a sharp pain between shoulder blades.
Cervical radicuopathy
Thoracic Spine: ___ disease squeeze through the vertebral end plate, which is often weaker in patients with this disease and forms pockets of disc material inside the vertebral body, called ___
Scheuermann’s
Schmorl’s nodes.
The most common form of scoliosis is __
Adolescent Idiopathic Scoliosis
Characterstics of Ankylosing spondylitis
- involves Sacroiliac joints
- > 90% of patients are positive for HLA/B27 antigen and negative for the rheumatoid factor (RF).
- X-rays with bilateral SI joint fusion (hallmark of AS) and a “bamboo lumbar spine”.
A ___ causes __ radiculopathy, which may reveal ankle plantar flexion weakness (foot drop)
L5-S1 HNP
S1 radiculopathy
PE findings of cauda equina syndrome
- Saddle parasthesia or anesthesia
- post-void residual usually high (nl <100cc)
- rectal tone loss
Spondylolisthesis: Most commonly affects ___ level.
- Indications for surgery are __, __ and __
- Anterior subluxation of one vertebral body upon another secondary to a pars defect. Posterior subluxation is called ___
L5 on S1
(Test L4 &5 by walking on heels, test S1 by walking on toes)
radiculopathy or pain unresponsive to non-operative treatment and sometimes for cosmetic reasons.
retrolisthesis.
Neuromuscular disorders: commonly leads to __ and __
-Many pediatric neuromuscular disorders such as cerebral palsy, myelomeningocele, and muscular dystrophy cause __ and __
progressive flexion contractures and hip disclocation
muscle weakness and muscle imbalance (example: hip adductor/flexor vs. adductor/extensors).
Legg-Calve-Perthes Disease (LPD): leads to ___
(idiopathic avascular necrosis)
___ are by far the most common malignant tumors involving the skeleton.
Benign tumors, Giant Cell Tumor: Most often occur after skeletal bone growth is completed and they account for ___% of benign bone tumors.
Metastases from carcinoma
20 percent
___ is the most aggressive of all primary bone cancers. This cancer starts in the bone cells and is highly malignant.
Osteosarcoma (also called osteogenic sarcoma)
___ The tumor is derived from red bone marrow, and is most frequently observed in children and adolescents aged 4-15 years and rarely develops in adults older than 30 years old
Ewing’s Sarcoma:
Of all chondrosarcomas, ___% are primary tumors
90%
___ is the most common primary malignant bone tumor.
Multiple myeloma
__ is a chronic bone disorder secondary to irregular breakdown and formation of bone tissue.
Paget’s disease (Osteitis Deformans)
___ is a developmental dysplastic disorder of bone in which immature woven bone is formed directly from abnormal fibrous connective tissue.
Fibrous dysplasia
__ fracture: Bilateral fractures of both the anterior and posterior arches of C1
-Displacement of lateral masses may result in either disruption of ___ or an avulsion fracture of one of the lateral masses of C1
Jefferson Fracture (C1)
transverse atlantal ligament
- Caused by hyperextension or rebound hyperflexion
- All three types involve the pars interarticularis which is the piece of bone between the superior and inferior facets of C2
Hangman’s fracture (C2)
AKA brittle bone disease
Osteogenesis imperfecta
OI is a disorder with congenital bone fragility caused by mutations in the genes that codify ___
the type 1 procollagen
-At least 4 types of OI are described ranging from __ to __
Multiple fractures, multiple sites, and multiple surgeries
-Some forms may include a ___
mild forms to lethal forms in the perinatal period
blue sclera
Benign bone tumors
- Osteocondroma (MC benign bone tumor**)
- Endochondroma
- Chondroblastoma
- Giant Cell tumor
- Osteoid osteoma
- Non-ossifying Fibroma/ Fibrous Cortical Defect
- Intraosseous lipoma
Osteocondroma have a 10% chance of transformation into ___
secondary malignant chondrosarcoma
__ is an overgrowth of cartilage and bone near the end of the growth plate
-Usually occurs during skeletal growth between ages of __
Osteocondroma
10-25, M:F 1:1
- Affects cartilage that lines the inside of the bones
- Most often affects long bones of hands and feet, but may also involve other bones like femur, humerus, or tibia
-Most common between ages ___ but can affect any age, M:F 1:1
Endochondroma
10-20 years of age,
Most common type of hand tumor
Endochondroma
*XRAY: weird bony knuckles in hands
- Large number of non-cancerous cells that form an aggressive tumor usually near the end of the bone or near a joint
- Most often occur after skeletal bone growth is completed and they account for 20 percent of benign bone tumors
Giant Cell tumor
HAND Tumor: think Giant cell or Enchondroma
Most common benign bone lesion in children
Non-ossifying fibroma
*Also known as “Fibrous Cortical Defect”
- Defect of periosteal cortical bone development which leads to failure of ossification
- When the tumor occupies more than 50% of the diameter of bone, much greater risk for pathological fracture
Non-ossifying fibroma
*Also known as “Fibrous Cortical Defect”
Classical appearance: presence of well defined lytic lesion with central calcification resembling a cockade (shape like a rosette, or knot)
Intraosseous lipoma
Patients usually experience one or more of the following symptoms:
- Numbness or tingling, burning, or a sensation similar to an electrical shock on ankle
- Pain, including shooting pain
Tarsal tunnel syndrome
US of spine on a baby, newborn, “looks like a monster is coming out of spine”
*most frequently occurring permanently disabling birth defect
spina bifida
Disabling birth defect of spinal column resulting from failure of the spinal column to close properly during first month of pregnancy
spina bifida
*Severe cases: spinal cord protrudes through the back
Left Xray: Onion-skin, bone is trying to contain the tumor so it keeps layering bone over the tumor but it cannot keep up. The tumor is too aggressive
Ewing Sarcoma
Multiple myeloma is not a “true” bone tumor because is a cancer of __ cells, and is an ___ disease.
plasma
incurable but treatable
- Cyst/lump consisting of membranes surrounding the spinal cord pokes through the open part of the spine
- Cyst holds the nerve roots of the spinal cord and often the cord itself. May also not be a cyst, but only a fully exposed section of the spinal cord and nerves
Meningocele associate w/ Spina bifida
*These babies are at high risk of infection until the back is closed surgically. In spite of surgery, varying degrees of leg paralysis and bladder and bowel control problems remain
Neonates are asymptomatic, but may develop limp, waddling gait and a limb discrepancy noticed when the infant begins to walk= ___
Xrays not accurate until age __
hip dysplasia
*X-rays not accurate until age 4-8 months. Use US to confirm reduction and after placement of Pavlik harness
Hip dysplasia most commonly affects what gender, what side, and ___ birth position
More common on:
- Left hip 3:1 ratio
- Females 5:1 ratio
- 20% occurring from frank breech presentation
Diskitis–>___ is the answer
infection
*Infection around inter-vertebral disk
MC cause of diskitis
-Most often bacterial infection of hematogenous origin (Staph aureu)
- Most common between ages 2-7 years and can be treated with oral antibiotics (more commonly with IV antibiotics – cephalosporins followed by oral meds)
- Labs: WBC wnl, ESR and CRP elevated, Blood cultures may be positive in more severe cases
Bone scan of the hip that has a stress fracture of the neck. Is stress fracture on one side is called what? If it on the other side what is it called?
Superior aspect is “tension”–
this is worse fracture and will often go to full blow fracture every time
Inferior portion is “compression”
*Common in marathon runners
Tx of stress fx in the femoral neck
- Can put in screws to hold the fracture together
2. Tx: tell them to stop running, tell them to be non-weight bearing (put on crutches) and get a MRI
SCFE versus LPD (remember the age groups of each)
SCFE: usually obese, around 13y/o AA males involved in sports
LPD: Disease is bilateral in 10-20% of patients and usually effects children 4-8 y/o
- Displacement of femoral head, typically occurs during adolescent growth spur
- sometimes endocrine disorder related: hyppthyroidism, GH deficiency, etc.
- Symptoms of anterior-proximal thigh pain (most common
SCFE
tx of SCFE
- “A child with groin and leg pain always gets an x-ray”
- Xray: ice cream falling off ice cream cone
-Tx: In situ stabilization or osteonomy in more severe cases (may also required emergent reduction)
-Childhood hip disorder that results in infarction of the bony epiphysis of the femoral head (idiopathic avascular necrosis)
legg-calve perthes diease
- When both hips involved, usually involved successively, not simultaneously
- Family history present in 6% of patients
- In adults, corresponding condition is termed Chandler’s disease
What are the MC Salter Harirs fractures
Type II most common (50% of all physeal fractures) followed in descending order by Type I, III, IV, V
What are Salter Harris fxs
stratifies injuries according to their relative risk of growth disturbances
Salter Harris Type __ and __ have low risk of growth disturbance and relative risk increases from Type __ to __
I and II
II to V
What type of Salter Harris Fracture?
Fracture across the physis with no metaphysical or epiphyseal injury
type 1
What type of Salter Harris Fracture?
Fracture across the physis which extends into the epiphysis
Type 3
What type of Salter Harris Fracture?
Fracture through metaphysis, physis, and epiphysis
Type 4
What type of Salter Harris Fracture?
Fracture is across the physis which extends into the metaphysis (across growth plate)
type 2
What type of Salter harris fracture?
Crush injury to the physis
Type 5
Sunburst x-ray
Osteosarcoma (also called osteogenic sarcoma)
- The soft tissue mass in sclerotic lesions is calcified and has a typical “sunburst” appearance
- Bone scan and MRI will shown you more than x-ray
MOST AGGRESSIVE OF ALL PRIMARY BONE CANCERS
Osteosarcoma (also called osteogenic sarcoma)
- starts in the bone cells and is highly malignant
- very hard upon palpation and grows very fast
Who MC gets osteosarcomas
age: 10-30 and 10%- 60-70
M>F
Who is most at risk for child abuse?
- firstborn,
- premature,
- stepchildren,
- handicapped children, and
- if under 3 y/o
failure to recognize child abuse involves a __% risk of serious injury and __% risk of death
25%
5%
Signs of child abuse
- bruises on back of head, buttocks, abdomen, legs, arms, cheeks or genitalia
- Fractures at different stages of healing are the hallmark of child abuse and could also indicate abdominal injury
30% of ___ fractures in children younger than 4 y/o may be the result of child abuse
femoral shaft
most common cause of femur fractures in the non-ambulatory infant is __
NAT
Describe the PE/workup of suspected child abuse
- Head to toe with possible evidence of previous abuse
- Inspect for signs of sexual assault
- Look for signs of subdural hematoma, retinal hemorrhage
- AP and lateral x-rays of all long bones, hands, feet, spine and chest
- Also look for avulsion-type or “corner chip” fractures
Healthcare provider role: reporting child abuse case in good faith is protected from __ liability, but ___ does not offer any protection
*****Always get your supervising physician involved if there is any doubt of child abuse
both civil and criminal
failure to report it
Lisfranc (two types) one is a fracture dislocation and one is not à long question. Look at the x-ray. Can save 5 min of reading. Don’t need to read it
- Lateral shift of second metatarsal with WB x-rays
- More severe cases are when there are fractures of the metatarsals and dislocation of Lisfranc joint
*In the x-ray, big gap between 1st and 2nd metatarsals and worst case with dislocation of second metatarsal and takes 3rd and 4th metatarsal with it)
Tx of Stable and unstable Lisfranc fx dislocation
If stable: 6-8 weeks NWB casting
unstable ORIF and 6-8 weeks of NWB
- Disease of the thoracic spine
- Also known as adolescent kyphosis (common in __) -> results from wedging together of several consecutive vertebrae (bones of the spine)
males
Scheuermann’s disease
Hip fractures and risks for hip fracture. Grandma is a risk because of many reasons, but one reason is not a risk
- Elderly Patients (incidence doubles past age 50)
- Women > men
- Most likely due to fall (live alone? Have steps in the home? Rugs present?)
- One out of 3 adults > 65 y/o fall each year
5th metatarsal fractures
- Avulsion (Dancer’s)
- Jones’ fracture
- Stress fracture
What fracture and zone?
most common fx of the BASE of the 5th metatarsal. Usually nonsurgical and tend to heal well with SLC-NWB: zone __
Avulsion (Dancer’s) Fracture
zone 1
What fracture and zone?
involve an area of the bone a little more distal (or toward the toes) and most typically appear as horizontal or transverse fractures
Jones’ Fracture: Zone 2,
What fracture and zone?
occur distal to the ligaments which firmly bind the 4th and 5th metatarsals together: usually occur in shaft of metatarsal bone
Stress fracture
Zone 3
___ fracture: tibia goes up, explodes and the x-ray there is just for you to see
Pilon fracture
- Talar right into tibia and explodes into many pieces
- Never communited and swells right away (within 24 hours)
- Need to wait for swelling to go down before operating
Pilon fracture
sx of Charcoats
- Has neuropathy and no pain
2. Erodes everything around the foot and ankle joint
in Charcoats, All pressure of weight in different area right on the ulcer, cannot operate until __
whole process is over (often have osteomyelitis)
AP, lateral and mortise views with special interest to medial clear space on the mortise view and tenderness over Deltoid ligament and proximal tibia –> ___ fx
Masionneuve fracture
**ankle fracture
Lateral Malleous fracture:__ usually determines need for ORIF
location
Tx of Massonneuve fracture
- unstable medial clear space
1. May need tib/fib x-ray if fractured either bone
2. Close the gap with screw
Most common location of spondylithisis
L4-L5/L5-S1
*****MOST COMMONLY AFFECTS L5 ON S1 LEVEL
- Anterior subluxation of one vertebral body upon another secondary to a pars defect
- Posterior subluxation is called ___
spondylithisis
retrolisthesis
*Often seen in gymnasts & football players (grade 1)
Sx of spondylithisis
- Pain in low back and buttoks with obvious defect
- Aggravated by lumbar extension
- Usually no neurological signs, unless grade 3 or 4
What is the difference between a greenstick and buckle fracture
-Buckle Fracture: you don’t crack the cortex, wall of bone is bent
- Greenstick Fracture: elastic, cortex actually snaps
- One side of fracture has broken and one side is bent
-Torus/Buckle Fracture: very stable and reduction is unnecessary unless angulation exceeds 15 degrees
- Extremely common fracture in children
- Children have softer bones, so one side may ___ upon itself without disrupting the other side (incomplete fracture)
- If injury is ____ hrs old (decreased swelling), short arm cast can be applied safely at the first visit
“buckle”
> 48 hours
Tx of Greenstick fx
- Non-displaced distal radial greenstick fracture can be treated with a short arm cast and any angulation > 15 degrees should be corrected by closed reduction followed by immobilization in a long arm cast
- Obtain FU radiographs 3-7 days after injury and then every one to two weeks to be sure position is maintained
- 10% of all fractures in children
- Usually managed by orthopedics
- Complexity of these fractures are primarily related to ossification centers
Elbow fractures in the pediatric population
*Look for the hour glass on images
elbow growth center and approximate age at ossification by age of patient in years
"Come Read My Tale of Love” o Capitellum 1 o Radial head 3 o Medial Epicondyle 5 o Trochlea 7 o Olecranon 9 o Lateral epicondyle 11
Weakest part of the elbow joint is __
supracondylar area where the humerus flattens and flares
Most common type of supracondylar fracture is the __ type
extension–> hyperextended position drives the olecranon into the supracondylar portion of the humerus resulting in a fracture
Tx of Supracondylar fx
- Most supracondylar fractures in children are displaced and need surgical intervention
- Watch for any signs of compartment syndrome
___ are most common fracture in children and adolescents (35-47% of all fractures)
Fractures of distal radius
- M>F
- Increased incident with age in both groups
- Sports and leisure activities accounted for 36% of fractures, assaults 3.5%, and traffic accidents 1.4%
Toddler fracture occurs most commonly in children younger than 2 years old who are learning to walk
- No definite history usually of traumatic event and the child is bought to the office because of reluctance to bear weight on the leg
- Typical findings are:
a NON DISPLACED FRACTURE OF THE TIBIA** AND NO FIBULAR FRACTURE
Osgood schluetors is anterior knee pain that Results from:
repetitive injury and small avulsion injuries at the patellar tendon insertion
*Early in adolescent years
Tx of osgood schluetor
activity modification, Short term immobilization for 4-8 weeks
Characteristics of multiple myeloma
- diffuse osteoporosis, usually in the pelvis, spine, ribs, and skull
- “Bite” on x-ray. Cortical destruction and expansion of lesion
Letter A of the next question is rieter’s syndrome, but that isn’t the answer!!!! Not Pott’s syndrome either!!!!! So I guess we have a 50-50 shot on this one.
So I guess we have a 50-50 shot on this one.
Can present in the newborn period, especially following a difficult delivery, and nearly half of all these fractures occurs in children __y/o
clavicle fracture
younger than 7 years old
-In young children, clavicle fracture is often __ or __
deformity without definite fracture
incomplete (greenstick) or bowing
Clavicle fractures are usually mid-shift and almost always _ or __
heals or with a clinically insignificant malunion
*Remodels within 1 year and complications are very rare
complications of talus fractures
- AVN waiting to happen
- commonly involved w/ Charcots foot and often collapsed
- Watch out for compartment syndrome
- Even when you fix it, the talar begins to die
Tx of talus fractures
May need to take out what is left, do a bone graft and infuse it
