Ortho/MSK Flashcards
Slater Harris classification
define subluxation
partial dislocation, where some contact remains between articular surfaces
Pediatric bone anatomy
Describe how to calculate fracture angulation
Median, radial and ulnar nerve motor test
fist = median
peace sign = ulnar
ok = anterior interossei
radial = thumbs up
Median, radial and ulnar nerve sensory test
median = tip of first finger
radial = dorsal first web space
ulnar= tip of pinky
splint for flexor tendon injurys in hand
dorsal blocking splint
splint for extensor tendon injuries
volar slab, ulnar gutter depending on the splint –> in position of safety
what is a jersey finger
rupture of FDP, inability to flex at DIP
flexor tendon zones of the hand
1 to 5, distal to proximal
1: distal to FDS insertion
2: no mans land (poorer outcomes) - overlying prox and middle phalanx
3: palm of hand - better outcomes
4: carpal tunnel
5: proximal to carpal tunnel
Mallet finger is?
how is it treated?
rupture of extensor tendon over distal phalanx –> leads to inability to extend at DIP
-tx= splinting in extension for 6-8/52
what is a swan neck deformity?
results from chronic/untreated Mallet finger over-extension of PIP, flexion of DIP
what is boutonniere’s deformity?
central rupture of extensor tendon over PIP… lateral parts of tendon displace volar and become flexors along with unopposed FDP
looks life flexion of PIP and extension of DIP
how to reduce MCP joint dislocation
flex wrist then apply pressure over dorsum of prox phalanx in a distal/volar direction
then splint in flexion
mgmt of PIP joint dislocation?
reduce, split in 30 degrees flexion
what is game keepers or skier’s thumb
rupture of ulnar collateral ligament of 1st MCP joint.
should be referred to plastics, should have thumb spica splint
(test radial angulation vs other side and more than 10 degrees then suspect full rupture)
if subungual hematoma of > ____ % with intact nail bed, you should trepinate
50
if nail plate is disrupted, might need to remove and suture nail bed.
Boxer’s #: description, mgmt.
of 5th metacarpal neck (distal), reduce if needed (>40 degrees angulation), splint and f/u with plastics.
Bennett’s fracture: description, mgmt
intraarticular # and dislocation of CMC… thumb spica and refer
mgmt of proximal and middle phalanx #’s
buddy taping or splinting
indications:
-extraarticular fractures with < 10° angulation
- < 2mm shortening
-no rotational deformity
-non-displaced intraarticular fractures
technique
3 weeks of immobilization followed by aggressive motion
Rule of 11’s (for normal wrist anatomy)
Volar tilt =11 degrees (assessed on lateral)
Radial height is 11 mm
Radial inclination is 22°
There are normal values: +/- 5 deg or mm for acceptable reduction
Wrist Sprains are mostly centered around what bone
Lunate
Exam findings for scaphoid fracture
-Examine with ulnar deviation for snuff box tenderness
-tubercle tenderness
-axial load of thumb pain
Complication of scaphoid fracture and mgmt
AVN
Thumb spica cast
Does blood supply meter scaphoid proximal or distal
Distal! Therefore prox part most at risk for AVN
What to do if negative xray and clinical suspicion for scaphoid fracture
16% of initial X-rays normal
Thumb spica and refer for f/u imaging
Best view to see triquetrium avulsion fracture
Lateral!
Should be casted or sugar tong short arm splint
Mgmt of carpal bone fracture
4 fracture characteristics that make a colles to lose its reduction
Marked comminution
More than a cm of shortening
Intra articular involvement
>20 degrees angulation
Describe colles vs Barton vs smiths fracture
Bony anatomy of elbow
Median radial and ulnar nerve motor and sensory testing/function
Two lines to look at in elbow X-rays
Radio-capitellar
Anterior humeral
Which elbow fat pad can be normal, which is always pathological
Anterior can be normal
Posterior always pathologic
Are most biceps injuries, proximal or distal?
Proximal
More specific motor movement lost with bicep tendon rupture
Forearm supination
What is a terrible triad in elbow
Dislocation, radial head and coronoid fracture
Direction of most elbow dislocation
90% are posterolateral
Thing to check before and after any joint reduction
Neurovascular status
Splint type after elbow dislocation reduction
Long arm posterior slab. Elbow at slightly less than 90° with wrist neutral.
What is volkmann’s ischemia?
What signs indicate it?
Serious complication of supracondylar fracture, compartment syndrome of forearm.
Refusal to open hand, pain with passive extension of fingers and forearm pain out of proportion to exam findings are signs of this
What’s the Maisonneuve fracture of the arm called?
Essex-lopresti lesion
Montegia vs galleazzi
Mont: ulna fracture, radial head dislocation
Gal: radial head fracture, druj dislocation
Two types of sternoclavicular dislocations. Which one is serious and why
Anterior and posterior dislocations.
Posterior is serious because the clavicle impinges on the mediastinum, can present with shortness of breath, strider, or dysphasia
Most common type of clavicle fracture? Was its management and what our operative indications?
Middle clavicular fracture.
Managed with sling and orthopaedic follow up usually immobilized for 4 to 8 weeks.
If greater than 2 cm shortened or 100% displaced or significant skin tenting should get Ortho opinion immediately
Thing to consider a scapular fractures?
Usually, high impact trauma, so look for other injuries, particularly lung
What are type 1 and 2 AC joint injuries. What is the mgmt
Mgmt= sling, and then early ROM exercises after about 7 days
Type 3 ac joint injuries and their mgmt
Mgmt=usually trial conservative but get ortho f/u
Mgmt of type 4-6 AC injuries
Surgery, they’re bad
Most common glenohumeral dislocation?
Anterior. Posterior accounts for less than one percent (seizure, electrocution).
What nerve is most commonly injured with shoulder dislocation? How do you test it?
Axillary nerve. Test sensation over the deltoid.
Hill sachs vs bony bankart vs soft bankart
GH dislocation with:
Hill sachs= humeral head #
Bony bankart= glenoid #
Soft bankart= glenoid labrum tear
Mgmt of hill sachs and bankart
Nothing specific in ED. Often only seen on post reduction. Ortho f/u needed
Think of a few GH dislocation techniques
Modified hippocratic
FARES (know this one!)
Milch
Kocher
Stimson
Scapular manipulation
NEER classification of prox humerus
See presentation
Indications for conservative mgmt of middle humerus fractures
<20 degrees angulation and <2cm of shortening
Can normal bloodwork rule out shoulder infection?
Nope! WBC and crp can often be normal in septic shoulder
Young-Burgess pelvis fracture classification
Bleeding Management options for unstable pelvic fracture
All require orif eventually
Angiography with embolization
External fixation
Peritoneal packing
Balloon tamponade of aorta
Define hip # based on location. Intra vs extracapsular etc
Which hip # are more likely to result in AVN?
Intracapsular (also dislocations almost always need THA)
Femoral neck fracture finding on exam
Shortened, externally rotated, abducted
Contraindications to traction splinting of femur fractures
Open fracture, suspected neuro vascular injury or knee injury
Can you bleed to death from a femur fracture?
Yes
How quickly should you aim to relocate a native hip dislocation?
Within 6 hrs, but really asap! True ortho emergency
Name of 3 maneuvers for posterior hip dislocation reduction
Allis
Bigelow
Captain Morgan
Posterior hip dislocation exam finding
Shortened, internally rotated and adducted
Post reduction mgmt and
Dispo for hip dislocation
Post X-rays, immobilize hip with bedrest usually require admission to ortho. Ortho to dictate weight bearing status etc
Approach to prosthetic hip reduction?
If longstanding, can probably just reduce. If relatively new should talk to ortho. Dispo, per ortho
most common 2 carpal fractures
scaphoid and triquetrium avulsion (make up like 85%
Acceptable non op criteria for wrist reductions post colles
What is a Pilon fracture?
Aka Tibial plafond.
Distal fib fracture from compressive force. Kind of looks like bad ankle fracture but is a bit more proximal
3 components of Maisonneuve fracture?
Medial ankle (either med mall or deltoid ligament)
Interosseous membrane disruption
Proximal fibula fracture ( can actually be quite midshift)
Initial management of Achilles tendon rupture
Immobilization of joint from just below the knee to the metal tarsals with foot in plant flexion.
Crutches for nonweightbearing. Ice and analgesia as needed.
Risk factors for Achilles tendon rupture
Older age, prior fluoroquinolone use, prior steroid injection, 3 to 50-year-old male who is quotations weekend warrior”
To exam findings in Achilles tendon rupture.
Where does it usually rupture and why?
Ruptures 2 to 6 cm above the calcaneus because blood supply is weakest in that area.
Palpable gap in tendon or positive Thompson test
Ottawa knee rules criteria?
Tibial plateau fracture is not always seen on xray, what indirect sign is usually present?
Lipohemarthrosis on lateral view
How frequent is spontaneous reduction of knee dislocation?
What do you need to consider?
50%
Need to think of the diagnosis and its vascular consequence in severely injured knee that is unstable in multiple directions
Dispo for patellar dislocations?
Zimmer splint
Toe touch or non-weight bearing
Ortho f/u
How to relocate dislocated patella
Hip flexion, knee extension, pushing patella back into midline (usually dislocate laterally)
Management of complete and incomplete quadriceps and or patellar tendon rupture
Complete= ortho consult in ED
Incomplete = with extensor mechanism intact can be treated with immobilization and Ortho follow up
Exam finding of patellar and or quadriceps tendon rupture
Cannot extend knee, cannot maintain passively extended knee, cannot straight leg race
A positive anterior drawer test in the angle indicates injury to what structure?
What indicates a positive anterior drawer?
ATFL sprain – high-grade
More than 2 mm of movement compared to the other side
Ankle pain, but no ankle, spelling or ecchymosis you need to think of what?
Syndesmosis injury. Think of the squeeze test (squeeze just above the ankle, pain indicates injury to syndesmosis)
What would a peroneal nerve injury cause?
Foot drop or weakness with dorsiflexion
Describe Ottawa ankle rules
Pain over posterior tip of either malleoli.
Pain at the base of the fifth metatarsal.
Pain at the navicular.
Inability to walk four steps both immediately and in the emergency department
Clinical presentation of peroneal tendon subluxation/dislocation
Mechanism: superior retinaculum, which holds the tendon in place is torn. This happens with hyper dorsiflexion and eversion as in skiing presents with pain with ecchymosis or tenderness over posterior edge of lateral malleoli, but no TFL ligament pain
Often requires operative repair
treatment protocol for lateral ankle sprain with stable joint
discuss both pts who weight bear and those who cant
weight bear:
PRICE protocol
protection: tensor bandage or lace up ankle brace or aircast
rest, ice, compression, elevation
PRICE for 24 hrs
then ROM exercise and strengthening for 48 hrs
then gradual return to activity
Non weight bearing:
PRICE with crutches (probably do aircast or brace not tensor) and f/u with PCP/ortho in 1 week
why are isolated medial ankle sprains so serious?
high rate of associated fracture (think Maisonneuve) & high rate of syndesmotic injury
mgmt of isolated medial ankle sprain
outpatient ortho f/u.
PRICE protocol
mgmt of unstable ankle joint (often ATFL injury with + anterior drawer)
although usually its hard to examine, so just make sure they have follow up
posterior splint and ortho f/u (probs call ortho to arrange)
who should reduce ankle dislocations?
if good pulses –> ortho (?maybe not in most places?)
if no pulses or other signs of vascular compromise –> needs to be done emergently in ED even if no xrays yet
management of isolated small fibular avulsion fractures?
if minimally displaced (<3mm) and no medial injury –> treat like ankle sprain
timing of consultation in various ankle fractures
non op mgmt for ankle fractures
air cast or short leg cast, non weight bearing for 4-6 weeks, ortho follow up.
Why is it important not to mis lisfranc injury
Can lead to debilitating midfoot dysfunction affecting walking and standing
What is the Lisfranc joint?
It divides the midfoot and forefoot.
Aka divides tarsals and metatarsals
Describe Boehler angle
<25 degrees think fracture. Look up a google image
Big complication to look for in calcsneal fracture
Compartment syndrome!
Keep foot elevated
What is Charcot foot
Disease in diabetics were mid foot injuries go untreated. Leads to lifelong complications with ambulating/standing.
Where to look for lisfranc injury
Widening between bases of first and second metatarsal or bony fragment in the space (fleck sign)
Step off sign (raised base of second metatarsal on lateral view)
Spectrum of lisfranc injuries
Range from ligamentous injury to fracture dislocation
Potential complication of navicular fracture?
A vascular necrosis and nonunion because central part of bone is relatively vascular
What is a Jones fracture? What is the management?
Fracture at the fifth metatarsal metaphase/diaphyseal junction
If non-displaced is managed with non-weight-bearing in a cast for 6 to 8 weeks.
If displaced non-weight-bearing and posterior slab/cast with Ortho follow up for ORIF
Foot fracture mgmt (mostly for reference)
Most sensitive clinical finding in compartment syndrome
Pain with passive stretch of tendons running through compartment
So distal pulses or limb color change in compartment syndrome?
Only if it’s dead… compartment pressures don’t exceed arterial pressure
Science/symptoms of compartment syndrome (four)
Pain with passive stretch.
Paresthesias.
Pain out of proportion.
Firm compartment
Compartment pressure under what value rules out need for surgical mgmt
<30 mmHg
Management of compartment syndrome
-Remove restrictive clothes/casts
-Get affected limb at the the level of the heart (not above)
-fasciotomy
plantar ecchymosis indicated what?
Lisfranc!, actually look for this
complications that is specific to femur shaft fracture
fat embolism
