Ortho/Rheum Quiz #1 Flashcards
what is orthopedic fixation?
what are the 2 broad types of orthopedic fixation? examples of each?
the use of medical devices to support and stabilize ortho injuries
internal fixation = devices placed inside the body (wires, screws, plates, nails etc.,)
external fixation = devices placed outside the body
(splint, cast, external frame)
External fixation, splint
- what is it?
- when do we use?
- is it definitive?
- what is it? non-circumferential immobilization that accommodates potential swelling
- when do we use? when we’re managing acute fractures/sprains –> displacement, unstable fx, sprain, reduced fx
- is it definitive? no, this is for acute tx/stabilization only, commonly used before definitive tx
external fixation, cast
- what is it?
- when do we use?
- is it definitive?
- complications?
- what is it? full circumferential immobilization, superior immobilization, does not accommodate swelling
- when do we use? complex and/or definitively non-sgx cases
- is it definitive? yes
- complications? pain, stiffness, muscle atrophy, etc., can lead to compartment syndrome if used before acute swelling goes down
sprain v. strain?
sprain = ligament injury (bone to bone attachment)
strain = straining muscles or tendon (muscle to bone attachment)
tx can be RICE method for both (rest, ice, compress, and elevate)
explain open growth plates
growth plates can be seen towards the end of long bones in children
they close in their teens (15-18ish)
these plates are made of cartilage and are prone to injury
external fixation, external fixators
- what is it?
- when do we use?
- is it definitive?
- benefits?
- complications?
- what is it? bone immobilizer via pins/screws into the bone on both ends, which is then connected to external frame (clamps and rods) on the outside
- when do we use? in many scenarios –> unstable fx, open fx, etc.,
- is it definitive? yes, can be
- benefits? quick, easy application
- complications? skin infection on both ends of bone (insertion points), not fractural infection
Internal fixation, open reduction internal fixation (ORIF)
- what is it?
- when do we use?
- is it definitive?
- what is it? used to term anytime skin is opened up and devices are placed inside (incision –> reduce –> hardware placed)
- when do we use? fractures, etc.,
- is it definitive? yes
internal fixation, intramedullary nail
- what is it?
- when do we use?
- is it definitive?
- benefit?
- what is it? nail inserted into bone marrow
- when do we use? align and stabilize extremity long bones
- is it definitive? yes, intended to leave in
- benefit? almost immediate ability to weight bear (as it shares the load with the bone), small incisions
explain indirect and direct bone healing
how do we determine if a case of direct bone healing is healing?
indirect = callus formation d/t micromotion
direct = no callus, virtually no motion between bone fragments that are compressed
in a case of direct bone healing, we assess healing progress by ability to weight bear. Also, lets say an internal medullary rod is bent, that shows that a lot of weight is being put on that and that the bone is not picking it up!
if you have a tib/fib fx, is the fibula always fixed up?
depends on case, but sometimes no b/c its non-weight bearing and will heal just fine if not contributing to any other pathology
what is “reduction”?
realignment of bones that are fractured or out of place, can be an open or closed procedure (regards to incision)
what is a compartment?
how many compartments does the leg have?
a grouped fascial compartment composing of muscle, nerves, and vasculature
the leg has 4 compartments
what causes compartment syndrome (CS)?
explain acute v. chronic CS
common causes of acute CS?
what are the diff types of CS?
high pressure inside a compartment (ex: d/t muscle swelling)–> this restricts blood flow and nerves –> can sometimes lead to irreversible damage
acute = emergency, very severe, permanent damage can happen
chronic = long lasting sx of pain and swelling, commonly d/t exertion and is reversible w/ rest
-severe injury (swelling)
-reperfusion (rapid swelling/flow back into area after tourniquet)
-outside compressive pressure (tight ace bandage)
iatrogenic (casts)
trauma (fracture)
non-trauma (DVT, infection)
what are the 6 p’s of CS?
what are the CLASSIC signs?
what are the 2 most sensitive sxs?
Pain (not manageable, extreme, may be out of proportion)
Pallor
Paresthesia
Poikilothermia
Paralysis
Pulselessness
classic sign = SEVERE pain when muscle is passively stretched (external force, like buddy pulling leg out a little)
non-proportional pain and tense compartment
initial dx for CS is based on?
definitive dx is based on?
tx for CS?
important ddx?
clinical judgement
needle manometry…not really used
- consult ortho surgeon
- remove restrictions
- make sure extremity is heart level
- provide bp support if needed
- serial physical exams and pressure check if pt is high risk
- *fasciotomy (gold standard and definitive tx) —> while you’re in there, look for necrosis
- place wound vac
- skin graft if needed
cellulitis, DVT
when dealing with a CS patient, what is the time frame we need to keep in mind?
6 hrs
before = ~100% recovery possible
after = 100% recovery not possible
how will you describe fxs?
what are the diff types of deformities/angulations?
right or left –> (ex: left)
bone –> (ex: L femur)
location –> (ex: mid-shaft L femur)
pattern –> (ex: spiral mid-shaft L femur)
deformity –> (ex: spiral mid-shaft L femur fx with apex varus angulation)
intra or extra-articular –> (ex: extra-articular spiral mid-shaft L femur fx w/ varus apex angulation)
displaced? –> (ex: non-displaced extra-articular spiral mid-shaft L femur fx w/ varus apex angulation)
``````````````Angulations
- varus = inwards
- valgus = outwards
- volar = specifically to indicate towards palm side for hands/wrist
tx for open fx?
check neurovascular status before
- copious bedside irrigation
- closed reduction
- wound care/dressing
- IV antibiotics
- tetanus shot
check neurovascular status after
Dislocations, anterior shoulder
- stat?
- caused by?
- anything at risk?
- imaging?
- tx?
- anterior m/c, ~90%
- abduction, extension, external rotation (all face away from core of body)
- axillary nerve
- AP, must get axillary view to distinguish if ant/post
- reduce via milch maneuver (elbow bent towards you, then out, this shifts it back into the glenoid cavity gently) –> sling for 1-2 wks –> progressive ROM exercises
Dislocations, posterior shoulder
- stat?
- caused by?
- anything at risk?
- dx?
- tx?
- rare
- forced adduction, internal rotation (m/c presentation is shoulder locked in this position), seizures, electric shock (think going inwards to core of body)
- idk
- light bulb sign on AP, axillary view
associated injuries w/ shoulder injuries?
bankart lesion - anterior glenoid labrum is injured during an anterior dislocation creating a soft or bony protrusion. This is an indication for sgx and normally comes with a hill sach’s lesion as well.
hill sach’s lesion - when the humeral head gets dented by the glenoid rim during an anterior dislocation.
these are specific to anterior shoulder dislocations
clavicle
- m/c part that’s injured?
- m/c MOI?
- tx?
- physical exam finding that’s an absolute indication for sgx and you can’t tx conservatively w/ sling? what do we want to r/o?
- are there relative indications for sgx?
- middle (mid-shaft)
- MVC, bike, direct shoulder trauma, FOOSH
- sling or figure 8 brace
- tenting/bump deformity. you want to r/o brachial plexus injury by doing a NV exam
- yes. full displacement, greater than 2 cm shortening, comminution, NV compromise, nonunion with pain after 4 months, limited ROM after 4 months, pt preference
m/c MOI for distal clavicular fx?
do distal clavicular fxs come together nicely most of the time?
fall onto lateral shoulder
no, high nonunion rate
are medial clavicular injuries common? m/c MOI?
no, it’s uncommon
high impact anterior chest injury
proximal humeral fx
- m/c in what population?
- MOI?
- what NV issue is this associated with m/c?
- if a young pt has a proximal humeral injury, what are we thinking for MOI?
- tx?
- elderly w/ osteoporosis, F > M
- low energy fall from standing up, FOOSH
- axillary n. injury esp at the surgical neck site (2 part surgical neck fx are common –> 2 segments)
- very high energy trauma, prob has soft-tissue and NV injuries as well
- usually no-sgx (unless high energy trauma situation w/ lots of comminution or something), usually good with sling and gradual ROM
humeral shaft fx (mid-shaft)
- m/c populations?
- what NV structure is most at risk?
- m/c angulation?
- tx?
- healing time?
- what is criteria for non-sgx acceptable alignment?
- when do we have to tx surgically?
- what are we most worried about with sgx?
- young pt w/ high energy trauma OR elderly pt with osteopenia and low energy fall
- radial nerve –> wrist drop, sensory
- varus (inwards)
- most are non-sgx –> acutely managed w/ coaptation splint, then transition them into a sarmiento brace once the swelling goes down
- 3+ months to heal
- less than 20 degrees anterior angulation, less than 30 degrees varus/valgus angulation, less than 3 cm shortening (aka, bone overlap)
- if it’s open, NV injury, doesn’t meet criteria for conservative tx, if they also have a forearm fx resulting in a floating elbow, or if there is CS
- radial nerve damage
radial head fractures (aka, proximal radial fx)
- m/c in what population?
- what do you expect to find on PE?
- tx?
- adults w/ elbow fx
- hard time extending and supinating
- usually treated conservatively w/ a posterior splint (textbook tx), or sling for early ROM (real life tx)
tell me about anterior and posterior fat pad on elbow XR
anterior fat pad = usually normal when its thin and lying next to distal humerus. HOWEVER, if it is enlarged, this suggests elbow joint effusion –> suggests occult non-displaced intra-articular fracture (sail sign!)
posterior fat pad = should not normally be visible as it is hidden by the olecranon fossa. If seen –> suggests occult intra-articular trauma to the elbow –> (in children this is m/c in the condyles and in adults this is m/c in the radial head)
olecranon fx
- MOI?
- what do you expect to find on PE?
- when to not do sgx?
- when to do sgx?
- direct trauma (–> sudden separation of triceps brachii muscle tendon off the olecranon bone), high energy if young, low energy if elderly
- cannot extend elbow
- if extension is still possible, if its a non-displaced fx
- if extension ability is lost, if its a displaced fx
elbow dislocation
- m/c in what population?
- what indicates conservative management? what is conservative tx?
- what indicates sgx? what is sgx tx?
- what is the m/c treatment for this in the ER?
- what is the m/c complication of this type of fx?
- m/c in kids, second m/c in adults
- if its simple dislocation without a fx –> long arm splint at 90 degrees for 7-10 days, *early ROM
- if dislocation is associated with a fx, if the pt got it non-sgx reduced, but there is still persistent instability, failed closed reduction
- provide sedation, then do a closed reduction
- loss of elbow extension
names of adult and pediatric forearm fx
adult = both, monteggia, galeazzi, and nightstick
pediatric = both, greenstick and buckle
both bone forearm fx, adult
1. must evaluate this pt for?
2. tx?
- compartment syndrome as we’re about to apply a slightly compressive splint
- split initially with sugar tong splint for stability, then sgx –> ORIF as adults need absolute precise fixation to heal properly
both bone forearm fx, kids
1. stat?
2. MOI?
3. imaging?
4. tx?
- very common in kids
- fall from height (playground tingz)
- XR elbow and wrist
- kids can usually accept much higher angulation and displacement before sgx is needed when compared to adults, kids have more periosteum –> therefore, most can do with closed reduction. If need sgx, place a flexible intramedullary nail (minimally invasive and can be left as the flexible bone hugs this nail and grows as it is more forgiving)
forearm fracture, buckle fx in kids
1. what is it?
2. stat?
3. MOI?
4. tx?
- fx almost always near the growth plate (physis) and on the dorsal cortex
- m/c lower forearm fx in kids (buckle fx of distal metaphysis in radius and ulna of kids), HOWEVER, the volar cortex stays intact as this is more forgiving even though it gets initial impact.
- FOOSH
- volar splint or short arm cast
Remember, this fx is specific to kids, usually used to describe radial/ulnar fx (although it technically be be used to describe any long bone fx of same pathology/MOI)
forearm fx, greenstick fx in kids
1. what is it?
2. what do we want to be cautious of during tx?
3. tx?
- incomplete fx of the cortex usually in the radius or ulna
- be careful not to over correct as this may complete the fx, yikes!
- usually most are nonsgx and placed in long arm cast for 4-6 wks
Galeazzi fracture, adults
(think of a fancy gala!)
- what is it?
- MOI?
- tx?
- fx of the distal radius w/ injury of the radioulnar joint (DRUJ)
- FOOSH
- open reduction internal fixation as it is basically universally unstable
Monteggia fx, adults
(think of climbing a mountain!)
- what is it?
- MOI?
- tx?
- proximal ulna fx w/ dislocation of the radial head
- hyperpronation
- sgx as it is usually unstable
nightstick fx, adults
(think of an adult driving stick at night to go the distance)
- what is it?
- MOI?
- tx?
- distal ulnar fx
- direct blow while trying to block
- if less than 50% displaced = non sgx
if more than 50% displaced = sgx
distal radius fx
1. stat?
2. MOI?
3. tx?
4. non-sgx indications?
5. sgx indications?
- very common
- FOOSH esp with elderly pts w/ osteoporosis
- reduce and immobilize ASAP via sugartong splint
- extra articular, less than 5 mm shortening, less than 5 degrees of dorsal angulation
- open, comminuted, displaced intra-articular of more than 2 mm, greater than 5 mm of shortening, dorsal angulation greater than 5 degrees, ulna is longer than radius at the wrist (ulnar positive variance)
explain Colles’s fx and MOI
(think of Cole collapsing on outstretched hands)
transverse distal radius fx that is dorsally displaced, extra articular
FOOSH
explain Smith’s fx and MOI
(think of Smith swinging hands!)
transverse distal radius fx that is volarly displaced, extra articular
explain Barton’s fx
(think of Tim Burton’s twist!)
fx-dislocation of radiocarpal joint, intra-articular
can be displaced dorsally or volarly
explain Chauffer’s fx
(this chauffer rides this car in style!)
radial styloid fx
(radial styloid is at the distal end btw)
scaphoid bone fx
1. stat?
2. MOI?
3. PE/sx?
4. why is this important to recognize?
5. imaging
6. what should you do if pt presents with snuff box pain, but has normal XR?
7. tx?
8. healing time?
- m/c carpal bone fx, m/c at the waist of the scaphoid bone
- FOOSH
- dorsal snuff box pain and scaphiod tubercle volarity
- NV structures and high risk for necrosis and nonunion d/t retrograde blood flow. This is why wrist injuries present vascular problems in this area.
- hard to see on initial XR, *MRI most sensitive, CT for pre and post-op
- thumb spica splint them and re-XR in 2 wks as there is a possible occult fx
- usually nonsgx with long arm thumb spica cast for 6 wks –> then short arm thumb spica cast for 6 wks –> then removable thumb spica splint for 4-6 wks.
- around 18 wks (memory trick = scaphoids sounds like “scaffold”, which takes around 18 wks to make)
