Ortho/Rheum Flashcards

Question

Colles fx: MOI sx, PE, dx, tx

Answer 1

o Fall onto an outstretched hand (FOOSH) o Radial fracture with dorsal displacement and angulation S/Sx: do the OK sign on PE and try to break the circle  Pain, swelling  Deformity – dinner fork Dx: Based on PE and plain-film XR  AP, lateral, and oblique views Tx: Closed reduction

Answer 2

Fall onto a flexed wrist or direct blow to the wrist Radial fracture with volar displacement S/Sx: do the OK sign on PE and try to break the circle  Pain, swelling  Deformity – dinner fork v garden spade deformity  Abnormal function of the median nerve * Numbness to tip of index finger * Weakness with thumb and finger pinching Dx: Based on PE and plain-film XR  AP, lateral, and oblique views Tx: Closed reduction  If the fracture is open or if closed reduction is unsuccessful, open reduction with internal fixation (ORIF) by orthopedics may be necessary  Volar splint with the wrist at 15-30 ̊ extension

Answer 3

Diagnosis  Hx and PE with typical findings are sufficient to diagnose Management  Closed reduction of a nursemaid’s elbow Supination/flexion technique: Fully extend and supinate elbow and then take elbow into flexion * Procedure is done while maintaining slight pressure over radial head; often, provider will feel a “click” in elbow * Typically, child will be moving arm normally within 15 minutes Hyperpronation technique: * While applying mild pressure over radial head, provider holds elbow in a flexed position & hyperpronates forearm

Answer 4

Sx:  Pain  Swelling  Hyperesthesia: excessive sensitivity that can be persistent  Bleeding between nail plate and nail bed = subungual hematoma Dx: Based on PE and XR (AP, lateral, and oblique views of affected finger) Tx: Protective covering to affected finger for 2-4 weeks

Answer 5

o Usually result from axial load (punching with a clenched fist) o Document the mechanism of injury → punching someone in the mouth with resulting MCP wound = fight bite → start antibiotics o 5th metacarpal is MC common metacarpal fracture (Boxer’s fracture) Sx:  Pain  Swelling  Sometimes rotational deformity  Deviation of one or more of these lines, suggests a metacarpal fracture  Associated extensor tendon laceration look @ open & closed hand to see if there’s a tendon injury Dx: Based on PE and XR (AP, lateral, and oblique views of affected finger) Tx: o Immobilization with ulnar gutter splint for 4th and 5th metacarpal fractures for 4 weeks o Reduction is required for:  Rotational deformity of any metacarpal  Fractures of the 2nd and/or 3rd metacarpals with angulation

Answer 6

MOI o Most commonly injured carpal bone o Wrist hyperextension injury (fall onto an outstretched hand (FOOSH)) o Possible severe complications: Cx: Osteonecrosis due to disruption of the blood supply (dorsal branch of the radial artery) which enters the distal pole of the bone * More proximal the fracture = greater the risk for osteonecrosis * Nonunion Sx: * Radial side of the wrist: o Pain o Swelling * Specific signs o Pain with axial compression of the thumb o Pain during wrist supination against resistance o Tenderness in the anatomical snuffbox during ulnar deviation Dx: Based on PE and plain-film x-rays * PA, PA ulnar deviation, lateral, and oblique views  Tx: For confirmed or suspected fracture, pt is placed in a thumb spica splint

Answer 7

o Bones of finger or thumb are forced out of their normal position o Causes: trauma ie. direct blow or a fall. Can also occur if there is a problem with ligaments o Previous injuries to hand/fingers increase risk of further injury Sx: Pain/stiffness. Deformity PE: Obvious deformity. Pain  Inability to use the digit/joint Dx: XR will be needed, possible MRI get multiple views after reduced it Tx: Reduction as soon as possible (longer joint or digit is dislocated = more difficult to reduce)  XR and Splinting after reduction  Avulsion fracture is typical

Answer 8

* Common fractures of older patients, particularly pts w. osteoporosis as result of minimal force ○ Trauma in younger ○ Fracture locations: o Femoral head o Femoral neck – weakest part of femur o Intertrochanteric o Subtrochanteric Complications: * Osteonecrosis of femoral head * Fracture nonunion * Osteoarthritis S/Sx: * Groin pain – Increased pain with passive hip rotation & resistance of hip flexion * Inability to ambulate * Shortening and external rotation of the affected leg Dx: Based on PE and plain-film XR * AP pelvis and lateral view of the affected hip ie. Right hip with pelvis * A full femur view is obtained if a fracture is identified * CT or MRI is obtained for hips with negative plain XR, but high clinical suspicion Tx: * Open reduction with internal fixation (ORIF) * Nondisplaced and impacted fractures in older patients * All femoral neck fractures in younger patients * Intertrochanteric fractures * Total hip replacement * Displaced femoral neck fractures in older patients

Answer 9

* Cause: high energy injury ie. MVC or fall from height * 50% reduce spontaneously before presenting to ED = so must have high suspicion if have high energy injury to knee PE: Recurvatum (hyperextension) of knee to more than 30° when examiner lifts foot off the examination table suggests gross instability * If laxity of at least 3 out of 4 of major knee ligaments (ACL, MCL, LCL, PCL) is present, one should assume that pt had a dislocation that has reduced Tx: reduction and knee splint with 15–20 degrees of flexion * Complications: vascular injury, peroneal nerve injury, and compartment syndrome; long-term complications include instability and arthrofibrosis.

Answer 10

* Common fractures that results from multiple mechanisms of injury o Inversion or eversion of the ankle o Direct blow o Medial or posterior malleolus fractures of the tibia o Lateral malleolus fracture of the fibula * May be stable or unstable o Fractures that disrupt ≥ 2 of the ankle ligaments will be unstable o Disruption of the medial deltoid ligament may cause instability S/Sx: o Pain and swelling at the injury site initially, then extension diffusely around the ankle o +/- unable to bear weight o Tenderness at the proximal fibula  Proximal fibula fracture (spiral fracture) with an unstable ankle injury (widening of the ankle mortise on x-ray), often comprising ligamentous injury (deep deltoid ligament) and/or fracture of the medial malleolus → Maisonneuve fracture Dx: Based on PE and plain-film XR ■ AP, lateral, and oblique views of the affected ankle Tx: Depends on stability of ankle ● Weber classification based on the lateral malleolus ● Weber Type B & C = goes to Ortho + surgery. Type A = walking boot. o Walking boot o Casting with no weight bearing o Orthopedic consultation o Open reduction with internal fixation (ORIF) – Maisonneuve fracture  Some Weber B fractures  All Weber C fractures

Answer 11

o Fractures resulting from great force (axial load) o Falling from a height onto the heels o Often associated w. other injuries (ie. Thoracolumbar compression fracture) ○ If not diagnosed and treated properly → long-term disability Sx:  Tenderness and swelling to the heel and hindfoot  Unable to bear weight “don’t even want to put weight onto toes”  Mondor sign – a hematoma formed that extends distally along the sole of foot * Pathognomonic finding for calcaneal fracture ○ Diagnosis & Treatment Dx:  Based on physical examination and imaging  Axial and lateral XR views of the affected foot  CT scan is done if: ● X-ray is negative, but clinical findings suggest a calcaneal fracture Tx:  Casting with no weight bearing  Orthopedic consultation

Answer 12

Zone I – Base/Tuberosity Zone II – Metaphysis Zone III - Diaphyseal

Answer 13

MOI * Can be acute or stress fractures o Forced inversion of the foot and ankle Sx: o Pain, swelling, and tenderness well-localized to fracture site o Ecchymosis may be present o Pain is worse with weight bearing can put some weight but might want to only put weight on toes, not on back foot Dx: Based on PE and plain-film XR o AP, lateral, and oblique views of the affected foot o Zone I fracture – Pseudojones fracture (Dancer’s fracture)  Fracture through base (tuberosity) of 5th metatarsal d/t plantar flexion and inversion ○ Common fracture & less serious than other 5th metatarsal fractures o Zone II fracture – Jones fracture  Fracture at the metaphyseal-diaphyseal junction that often occurs with ankle sprains ○ Higher risk for nonunion d/t zone being avascular o Zone III fracture – stress fracture Tx: oZone I fracture / Pseudojones o Weight bearing as tolerated o Walking boot. Send them home w. crutches too oZone II or III fracture ● Casting with no weight bearing ● Orthopedic or podiatry consultation

Answer 14

sx:  Sudden onset of pain (often nocturnal) “burning type pain & don’t want anything to touch it! No socks/sheets on foot)  Typically monoarticular  commonly occurs in lower extremities, most often at base of great toe (1st metatarsophalangeal joint) or knee  Other sites: ankle, wrist, and elbow  Intensely inflammation, causing severe pain, redness, warmth, swelling, and disability Diagnosis  Suspected in patients with acute monoarticular arthritis Arthrocentesis / Joint aspirate microscopic analysis (diagnostic), which removes synovial fluid from joint capsule & shows: * Crystals of MSU, which are negatively birefringent (yellow when parallel to polarizing light) & needle-shaped (yellow & parallel both have 2 L’s) * WBC > 2,000/μL with > 50% neutrophils (an acute inflammatory synovial fluid) * only tap joint to establish diagnosis... don’t need to tap joint again if have established diagnosis XR: Shows no changes early in the disease (so only get XR if they’ve had some trauma) ■ Punched-out erosions with an overhanging rim of cortical bone develop with progressive disease  Blood work may show: don’t have to get blood work  Hyperuricemia (may be normal or low during a flare; best to measure 2 weeks after flare) (normal during acute flare, elevated 2 wks after) ■ Elevated WBC  Elevated erythrocyte sedimentation rate (ESR) Treatment for Acute Gout  Goal is to reduce inflammation  NSAIDs * High-dose. Given for several days following resolution of pain & signs of inflammation to prevent relapse * Contraindicated in gastric bypass, active peptic ulcer disease, impaired kidney function, CHF, & elevated INR  Colchicine (next option after NSAIDs) * Inhibits WBC migration * Most effective if given within 12-24 hours of an acute flare * Contraindicated in severe renal or liver disease

Answer 15

Allopurinol – Most commonly prescribed and preferred initial urate-lowering therapy * Drug class: xanthine oxidase inhibitor * Works by reducing the production of uric acid in the body * Inhibits xanthine oxidase, an enzyme in the purine catabolism pathway Febuxostat * Drug class: xanthine oxidase inhibitor * Works by reducing production of uric acid in the body * Inhibits xanthine oxidase, an enzyme in purine catabolism pathway * Must give NSAIDs or colchicine concurrently to prevent acute flares. Probenecid * Drug class: uricosuric. Only uricosuric drug approved by FDA * Works by inhibiting active transport sites of proximal tubules → reuptake of uric acid is blocked and increased amounts are excreted * Give NSAIDs or colchicine concurrently to prevent acute flares

Answer 16

Chronic:  Structural most common cause – disc degeneration leading to intervertebral disc herniation or degenerative spondylolysis. Increased strain resulting of nucleus pulposus herniation. Acute: large force on healthy disc causing extrusion of disc material o Clinical manifestations  Radicular back pain: usually unilateral, may radiate down the leg with paresthesia’s or numbness in a dermatomal pattern

Answer 17

PE  Positive SLR  Positive crossover test (pain of involved limb of hip flexion of uninvolved limb) Dx  Clinical. Imaging necessary if severe weakness  XR: normal or loss of disc height  MRI: test of choice, reserved for suspected herniation, persistent pain, or refractory pain Tx  Conservative: preferred initial management is NSAIDs, plus supportive tx  Epidural injection: second line  Operative: if not responding to anything

Answer 18

L4  Anterior thigh pain into knee and medial aspect of leg. Sensory loss to the medial ankle  Weakness in ankle dorsiflexion  Reflex diminishes: loss of knee jerk. Weak knee extension. L5  Lateral thigh/leg, hip groin paresthesia and pain  Dorsum of foot, esp btw 1 and 2 toes  Weakness in big toe extension. Walking on heels more difficult than toes  Reflexes usually normal S1  Loss of sensory in posterior leg/calf and plantar surface of the foot  Weakness in plantar flexion. Walking on toes more difficult than on heels.  Loss of ankle jerk—diminished reflexes

Answer 19

Non-hematogenous osteomyelitis (MC in adults)  Direct inoculation of bacteria due to: Surgery, Prosthetic devices, Trauma, Hardware for fracture fixation, Soft tissue infection  Polymicrobial: “more than 1 bacteria on a knife” * Staphylococcus aureus (>50%) Hematogenous osteomyelitis (MC in children)  Bacteria spread via blood supply from primary site of infection  Monomicrobial: * S. aureus (most common)

Answer 20

Acute – evolves over days or weeks * Onset may be gradual * S&Sx: o Fever and chills o Localized swelling o Warmth o Erythema o Dull pain o Limitation of function loss of function Chronic – persists over months to years → bone ischemia and necrosis, bone loss, and/or sinus tract formation * Similar to acute osteomyelitis * Intermittent bone pain * Draining sinus tract (pathognomonic) * Fever and chills (less common)

Answer 21

Dx * Lab tests: o ↑ WBC w. left shift & incr. neutrophils o ↑ESR o ↑ CRP – Correlates w. clinical response to therapy (decreases); used to monitor during tx o Blood cultures – (+) in 50% – Obtain prior to initiating antibiotics o Tissue culture – Obtain prior to initiating antibiotics o Bone biopsy – best way to identify etiology o Wound or abscess cultures are not reliable * Imaging Plain-film XR (1st-line) o May not show changes in first 2 weeks of disease (false negative) → normal x-ray does NOT rule out osteomyelitis MRI – Most sensitive & specific modality (gold standard) what you need to definitively diagnose  Allows for identification of an assoc. abscess  Detects infection within 3–5 days of onset  Use is limited if surgical hardware is present Key findings on x-ray: § Regional osteopenia § Loss of trabecular architecture § Bone destruction § Soft tissue gas (air = osteomyelitis) o New bone apposition (cortical thickening) – Increase in diameter of bones by addition of bony tissue at surface of bone Tx o Vancomycin PLUS a 3rd or 4th generation cephalosporin  Treat duration on average is 6 weeks; first 2 weeks via IV

Answer 22

o Joint infection due to direct inoculation, contiguous extension, or hematogenous spread of infectious organisms into joint space o Surgical emergency: irreversible damage to tissue after 24 hours o Etiology: majority of septic arthritis infections are monomicrobial  Staphylococcus aureus (most common)  Neisseria gonorrhoeae → Young, sexually active patient will present with more than 1 septic joint!  Salmonella species → Sickle cell anemia o Invasion through joint occurs through  Hematogenous seeding (most common) Clinical Presentation  Constitutional symptoms: * Fever * Fatigue * Tachycardia  Signs and symptoms: * Moderate-to-severe joint pain and effusion * Erythema and warmth * Tenderness to palpation * Limited active and passive ROM * Usually monoarticular, but may be oligo- or polyarticular Dx: Arthrocentesis w. synovial fluid analysis  Gram stain  WBC count > 50,000 cells/μL  Neutrophil predominance o Imaging  Plain-film XR: see osteopenia type changes & joint narrowing * Joint-space narrowing or widening * Subchondral bony changes, osteopenia * Periarticular soft tissue swelling * Normal studies do not rule out septic arthritis o Ultrasound: To identify & help aspirate joint effusion o MRI: (gold standard) (septic joint MRI = shouldn’t have difficulty ordering in ER)  Sensitive for early identification of joint effusion  Evaluates the extent of bone and soft-tissue abnormalities  Assesses for associated osteomyelitis Antibiotic therapy – Antibiotic selection based on initial Gram stain and tailored based on culture data  Empiric regimen if Gram stain is negative: Vancomycin PLUS 3rd- or 4th-generation cephalosporin

Answer 23

 Tear of rotator cuff tendon related to repetitive trauma (think impingement) or acute trauma S/sx: * Pain with shoulder motion overhead activities * Deltoid pain * Diminished AROM with decreased strength PE: * + Neer, Hawkins, empty can, drop arm ■ Good PROM, poor AROM  Testing: * MRI, injecting with contrast (arthrogram) will improve visibility of tears, * XR will show proximal migration of humeral head “see high-riding humeral head” Treatment: * Partial thickness tears – typically non-operative and managed with PT and cortisone injections * Full thickness tears – require surgery to prevent osteoarthritis and restore proper function – debridement and repair (8- to-12-week recovery, 6-to-12 month return to normal activity) ○ Pearls:  Supraspinatus is MC * Usually distinct injury with young, healthy people and slow, degenerative problem with middle-aged & elderly patients

Answer 24

* Varus stress to the medial knee tears the LCL * Traumatic blow to medial knee * Most often seen in gymnasts & tennis players * Sx: o Pain/swelling along lateral knee o Instability near full knee extension – difficulty using stairs & cutting/pivoting o Swelling Physical Exam: Effusion o TTP over lateral joint line of knee o Pain with varus stress o Effusion, ecchymosis * Tests: MRI – most tears are the fibular insertion Tx: o Incomplete tear – NSAIDs, rest, PT, bracing with immobilization or hinged brace. Return to sports 6-8 weeks

Answer 25

* Forceful valgus stress to lateral aspect of the knee (direct lateral blow to knee) * MC ligamentous injury * Common in athletes – skiing, rugby, soccer, football Sx: o Pain at medial knee o Instability o Edema PE: o Medial joint line TTP o Instability with valgus stress (pushing medially) o Effusion, Ecchymosis * Tests: MRI Tx: o Incomplete tear: NSAIDs, rest, PT, bracing with immobilization or hinged brace o Complete tears +/- need surgery, depends on if it is isolated or unstable with other structures are damaged * Pearls: Typically, will have medial meniscus or ACL damage, Often not an isolated injury

Answer 26

* Tear of ACL, usually because of twisting injury or direct blow to the knee o Often because of sport injury – basketball. Soccer. d/t pivoting & turning ○ Sx: Sx: Pain deep in knee (not always) o Instability o Hear a “pop” in the knee when it happens o Immediate swelling/effusion PE: o Effusion. Little to no TTP o + Lachman o + Anterior drawer o “Quadriceps avoidance” – do not want to extend knee Tests: MRI Tx: Almost always need surgical repair (unless older & inactive) o Femoral/tibial tunnel, graft fixation o Bone-Patella-Bone autograft*, quad tendon/ham autograft, allograft (from cadaver) o Repair associated damaged structures (meniscus/MCL) o ACL brace during recovery controversial o Physical therapy after surgery * Pearls: Often associated with MCL or medial meniscus injury (50%)

Answer 27

* Tear of the PCL related to hyperextension or direct blow to flexed knee (dashboard from car or athletic injuries) ○ Sx: Posterior knee pain, instability, swelling sx/PE: o Pain w/effusion o Feeling of instability with posterior movement o +posterior drawer o +sag test (tibia sags in image on right) * Tests: MRI Tx: Usually does not require surgery (unlike ACL) unless an athlete o Surgical intervention typically if multiple ligaments are compromised o Can manage conservatively o Rest, ice, bracing, PT – quad strengthening exercises o 6-12 months for full recovery

Answer 28

* Tear of the cup-like structure as a result of twisting or deep squat * Acute sports injuries in younger patient, degenerative condition in older population * Medial more common (except in ACL tears). Bucket handle is common. Sx: o Pain o Clicking/locking/pop/catching o Knee “giving out” sensation “pops, locks & gives out” o Delayed/intermittent swelling PE: o Vague localized pain at joint line o Delayed swelling o +McMurray test. Pressure on femur/pushing down on lateral knee joint line... externally & internally rotating tibia, trying to push against femur... trying to get pain response... most times you get a “pop” sound o + Apley grinding test o + Thessaly Test (most sensitive) o Can occasionally get popping/locking reproducible when squatting Tests: o MRI Tx: o Conservative: Rest, NSAIDs, PT o Operative: if symptoms do not resolve or tear is very large (there’s not a lot of vasculature to meniscus “see red & white zones of image) ... with time it leads to = arthritis... then total joint repair o Arthroscopy can be diagnostic and therapeutic o Repair for large tears in outer third; debridement for other tears typically just have to remove the tear bc there’s no vasculature

Answer 29

* Tension overload during activity (flexed or overload of extensor mechanism) * Quad tendon 2x more likely than patellar tendon rupture Sx: “basketball player went to go jump...” o Felt/hear a pop & noticed immediate visible abnormality o “Jumper’s knee” – sudden quad contraction with knee flexed ie. from basketball PE: quad fires & bulges just above the knee o Patella – difficulty w/ knee flexion, patella alta o Quad – difficulty with straight leg raise, can’t extend knee, sulcus sign noted, patella baja o +/- swelling, bruising o Hemarthrosis Tests: typically can identify w/o imaging! o XR – abnormal patellar positioning o MRI confirms tendon rupture – complete vs partial Tx: Immobilization in KI o Conservative tx w/ intact extensor mechanism o Operative: surgical repair of tendon – suture anchor, end to end, graft

Answer 30

Inversion injury “rolled my ankle” (lateral injury) o Turning of foot inward o Tears lateral ligaments – anterior talofibular ligament (MC) o Can have an associated talar dome fracture Eversion injury (medial injury) o Turning the foot outward o More often causes an avulsion fracture of medial malleolus than a ligament sprain d/t strength of deltoid ligament

Answer 31

* Sx: o Audible “pop” at time of injury o Pain – Location is variable with the type of injury o Inversion – maximal at anterolateral ligament o Eversion – maximal over deltoid ligament o Swelling o Ecchymosis will go below injury over time d/t gravity o Ligament injury: tenderness is maximal over damaged ligaments rather than over bone more anterior to malleolus o Fracture: tenderness is maximal over bone rather than over ligaments pain right over malleolus  Healing: 6-8 weeks Dx: Based on hx and PE o Ankle anterior drawer test o Plain-film XR to exclude fractures (don’t have to if using Ottawa rules)  AP, lateral, and oblique Tx: o Protection, rest, ice, compression, & elevation o Splinting alleviates pain o Early mobilization for mild sprains o Ice: applied for 15-20 minutes every 4-6 hours for the first 24-28 hours acute injury = ice o Orthopedic referral – Evaluate for surgical repair for moderate to severe sprains