Orthopedic - 8% Flashcards
Acromioclavicular Joint Sprains
Direct blow to tip of shoulder or upward force on long axis of radius
Sxs:
- Pain/point tenderness over tip of shoulder
- +/- deformity
- can’t reach above head
Dx:
- weight X ray
Tx
- Sling
- analgesics
- PT
- +/- Surgery
Ankle Sprain
Inversion sprain - Lateral malleolus strain AFTL
Ecchymosis and edema
Xray to r/o fracture
Dx - Canadia-Ottawa ankle to get X ray
- Pain in malleolar zone +
- pain in lateral malleolus (tip or posterior edge)
- pain in medial malleolus (tip or posterior edge)
- inability to bear weight immediately or in EM for 4 steps
Tx:
- RICE
- Splinting and casting
- PT
- acute vs chronic
Back Strain/Sprain
Thoracic and Lumbar MCC
Sxs:
- D/t lifting, twisting or strenuous activity
- worse with activity, better with rest
- Stiffness, Axial back pain, Difficulty bending
- No radicular sxs, No neuro changes (below knee)
Tx
- Bed Rest < 2 days
- NSAIDs
- +/- muscle relaxant - cyclobenzaprine or short term Benzo Re-eval if no improvements in 4 wks
- Resume activities as tolerated
Bicep Tendonitis
Sxs
- Pain at bicep groove
- Ant shoulder pain - r-> biceps
- Pain w/ resisted supination of elbow
- Popeye deformity
Dx
- Speed’s + pain in bicep groove when elevate shoulder against examiner’s resistance
- Yergason’s - elbow flexed at 90degrees, wrist supination against resistance, + if pain produced
Tx
- NSAIDs
- PT strengthening
- Steroid injections
- Surgical release
Carpal Tunnel Syndrome
Compression of Median Nerve, dt overuse, repetitive motions
SxS:
- numbness thumb to mid of ring finger (no pinky)
- tingling
- thenar wasting
Dx:
- Tinel’s
- Phalen’s
- Electrodiagnostic studies - gold standard
Tx
- wrist splint - cock up
- NSAID
- ergonomic adjustments
- PT, steroid
- Surgery
Cervical Radiculopathy
MC C5-C6 or C6-C7, nerve root irritation or impingement
Posterolateral
Sxs:
- pain into arms/shoulders
- tingling with pain at rest, +/- numbness
- Loss of reflexes
- C7 is nerve root
Dx:
- lateral X-Ray - must see all 7 vertebrate
- Spurling’s test - Compression Test (head pressed backwards towards spine) = Pain reproduced
- Cervical distraction = pain relieved
- MRI - soft tissue, nerves
Tx:
- Rest - immobilization
- NSAIDs/ analgesics
- CS and PT
Cervical Sprain/Strain
Sxs
- Headache, Stiffness in Neck
- Paraspinal muscle
- Tenderness and spasms
- Numbness and tingling in extremities
Dx
- Spurling test for cervical radiculopathy
- Lateral X ray - 7 vertebrae
Tx
- Rest
- NSAIDs
- muscle relaxants - cyclobenzaprine
- PT = gental ROM
Compartment Syndrome
Pressure incr in compartment - EMERGENCY
MC anterior compartment in Lower leg
Sxs
- 5 P-s
- Volkman’s contracture
Dx
- Normal pressure < 10mm Hg
- Delta pressure - diastolic BP - measured compartment pressure - if > 30 mmhG, fasciotomy
Tx
- Fasciotomy
Costochondritis
Acute inflammation of the costochondral, costosternal or sternoclavicular joints
Common after viral infx or MSK trauma
sxs:
- Pleuritic chest pain - sharp, stabbing
- Worse with inspiration, coughing, & certain mvmts
Dx:
- localized tenderness and pain 2-5th costochondral junction
- no edema
-
pain reproducible with palpation
- Tietze’s Syndrome is at 2-3rd ICS
- R/o cardiac and PE = EKG, Trop, echo
Tx:
- NSAIDs, tylenol
- heating pads
- PT, and Steroids
deQuervain’s Tenosynovitis
W 30-50yo
Sxs:
- pain, swelling, point tenderness along dorsal aspect of wrists
Dx:
- +Finkelstein’s
Tx:
- Rest
- Thumb spica/splint immbolization
- NSAIDs, PT, CS
Epicondylitis
Medial and Lateral
Lateral Epicondylitis - Tennis Elbow
overuse of injury of extensors and supination
Medial Epicondylitis - Golfer’s / Litter league
Pronator and flexor muscles groups
Tx
- ICe/Heat
- NSAID, PT
- Elbow scrap
- Steroid injection
Fifth Metatarsal Fracture vs Jones
heels and twisting ankle inversion
Jones Fracture
- base of 5th MT at metaphyseal diaphyseal junction
- ORIF = high risk of avascular necrosis
Boxer’s Fracture
Fracture of neck of 5th/4th metacarpal;
Eikenella, Staph and Strep
- Punch with clenched fist
- no knuckle sign
Tx:
- Reduce to anatomic position
- Abx if skin breakdown - with Augmentin
- Ulnar gutter split w/ joints in 60 degree flexion
- Immobilization 4-6 wks
- Surgical repair => cast immobilization
Colle’s Fracture
FOOSH - distal radius fracture
- Dorsal angulation (top of hand) extra-articular
- dinner fork deformity
Dx - lateral xray
Tx
- Conservative
- close reduction
- sugar tong splint, immobilization with cast for 4-6 wks
- Surgery
- ORIF followed by cast/splint immobilization for 4-6 weeks
Shoulder Fracture (Proximal Humerus)
MC in elderly for low velocity
complications = adhesive capsulitis/RC Tear
Sxs:
- inability to hold wrist up = radial n palsy aka wrist drop
Dx:
- Xray
Tx
- immobilize 4-6 wks - sling and swathe
- then begin gentle passive ROM and modalities
- Progress to light strengthening after 6 wks
- Surgery if displaced or rotated
Scaphoid Fracture
FOOSH
Sxs:
- pain on radial surface of wrist at anatomical snuffbox
- leads to avascular necrosis - radial artery
Dx:
- X-Ray = Fracture may not be evident for >2wks, if no frx on Xray - tx as fracture and immobilize.
- Repeat Xray in 2 wks
Tx:
- Non-displaced = Long vs short thumb spica 10-12wks
- Displaced = surgical fixation
Smith’s fracture
Fracture of distal radius w/ volar angulation and displacement
garden spade deformity - fall w/ palm closed, hands flexed, blow to back of wrist
Median n injury –> develop carpal tunnel over time
Sugar tong Splint
Supracondylar Fracture
eti, sxs
MC Peds elbow frx - FOOSH
Gartland Classification:
- I, II, III - Extension Type
- IV - Flexion Type
*Anterior Interosseous Nerve (AIN) MC injured in Type I-III
Brachial Artery MC Vascular Structure Damaged → Volkmans Contracture (Radial nerve contracture)
- Type I - FOOSH, non-displaced, posterior fat pad sign
- Type II - FOOSH, angulated fx w/ distal posterior segment
- Type III - FOOSH, complete frx through cortext and posterior displacement of distal frx
- Type IV - Flexed frx, fall on flexed elbow, anterohumeral line falls posteriorly to capitulum
Supracondylar Fracture
Dx, tx
Lateral X Ray
Type I:
- Without NV compromise
- Cast in flexion <90 degrees for 3wks
- Re-evaluate & x-ray
Type II:
- Refer same day
- Closed Reduction and +/- pinning/fixation
- Casting
Type III:
- Refer same day
- Reduction and Internal Fixation
- Casting
Type IV:
- Refer same day
Radial Head Fracture
Pain and tenderess along lateral aspect of elbow; limited ROM elbow/forearm
MCC FOOSH
- Usu see anterior fat pad sign/sail sign
- Posterior Fat pad sign - occult elbow fracture
Tx
- Splint, sling
- Analgesic
- PT
Galeazzi Fracture
Distal radial shaft fracture, dislocation of ulna d/t FOOSH on pronated hand
sxs:
- wrist pain
- swelling
- pain with extension/flexion
Radial n injury
ORIF
Ganglion Cyst
Painless, swelling on wrist and hand, dorsal MC
Dx - transilluminate
Tx
- observe and reassurance
- Surgical excision if pt really bothered
Hip Dislocations
High impact trauma - usu from MVA dashboard => 90% posterior
Sxs:
- limbed shortened
- internally rotated
Dx:
- XR and CT r/o frx
Tx:
- Reduction promptedly
Hip Fractures
Subcapital/Femoral Neck = wary of avascular necrosis of femoral neck
intertrochanteric; Subtrochanteric
Sxs:
- Pain
- inability to wb
- shortened leg - external rotation
Dx:
- XR
Tx - ORIF
Hip Osteoarthritis
breakdown, loss of articular cartilage btwn bones - age, injury
Sxs:
- pain in groin region
- decrease ROM, abduction
- pain with ambulation, climbing stairs
Dx:
- X-ray
Tx
- Activity mod
- Shoewwear
- NSAIDs
- Wt loss
- joint CS injection
- Total joint replacement
Humerus Shaft fracture
MOI - direct blow
MCC radial n. injury, posterior fat pad/sail sign
- pain, swelling, deformity, shortened extremity
- motion at fracture site
Tx with sugar tong splint
ortho f/u in 24-48 hrs
Anterior Cruciate Ligament Tear
Twisting motion - change in motion/speed, direction
Sxs:
- Pain with instability - knee giving out
- Hemarthrosis - swell up with blood
Dx:
- Anterior drawer
- Lachman’s
Tx:
- RICE, PT, bracing, Progressive return to activity
- Surgical reconstruction w/ patellar tendon or hamstring or cadaver’s tendon
Medial and Lateral Collateral Ligament Injury
Knee forced into VALGUS - hit on outside of knee L
- MCL tear
Knee forced into VARUS - hit on inside of knee (inner thigh)
- LCL tear
Dx - MRI gold ***
Tx
- RICE
- Brace
- WBAT - crutches
- PT/surgery
Meniscus Injury
Traumatic vs degenerative
Sxs:
- Twisting injury
- Triad
- joint line pain
- effusion - 6-24 hrs post injury
- locking
Dx:
- MRI- Gold ****
-
McMurray’s - knees flexed and
- Tibial Externally rotated - medial meniscus
- Tibia Internal rotated - lateral meniscus
-
Apley’s Compression
- axial loading = pain
Tx:
- Rest
- Activity Mod
- NSAIDs
- PT
- CS
- Surgery
Lisfranc Injury
Fracture/dislocation of 1st/2nd TMT joint
MOI - MVA, fall from height
Low energy - stepping off curb or hole
Swelling in mid foot, non WB
Dx:
- X ray
- CT
Tx:
- Displacement > 2mm not good = surgery ORIF
- Non-displaced NWB cast immobilization x 4-6wks
Lumbar Radiculopathy
Compression of nerve caused by disc
pain in dermatomal region
incr pain with coughing, straining, sitting, bending
Dx
- MRI - non contrast
- Straight Leg Raise = + if numbess and tingling
- 15-30 degrees = severe
- 30-60 degrees = mild to moderate
- red flags of back pain
Tx:
- Rest
- NSAIDs
- CS injection - epidural steroid injections
- PT
Monteggia Fracture
Proximal 1/3 ulnar shaft fracture w/ radial head dislocation d/t FOOSH
sxs
- elbow pain and swelling
- tenderness to palp along elbow
- decreased elbow ROM
tx
radial n injury
ORIF
Nightstick Fracture (ulna)
MCC Direct blow to midshaft of ulna
Pain and bruising at site
eval for abuse victims
Tx
- functional brace w/ good interosseous mold for isolated/nondisplaced
- ORIF for displaced
Olecranon Bursitis
Painless inflammation of bursa;
swelling dev’s gradually (chronic) or acutely (infx)
Dx:
- X ray if trauma
- Aspirate and culture if septic
Tx:
- RICE
- elbow pad***
Osgood-Schlatter Syndrome
Pain at tibial tuberosity d/t growth spurt
Self limiting
ice
quad strengthening
Knee patellar strap
Osteomyelitis
Infection and inflammation of bone and bone marrow
d/t hematogenous spreading or inoculation from trauma/surgery
MCC S aureus, Pasteurella for dog/cat bites, Mycobact TB - vertebral involvement; human bites mixed anaerobes
Sxs:
- Fever
- Throbbing pain, mvmt restriction
Dx
- Bone aspiration and bx - gold std
- MRI
- XR (lags 7-10d after sxs) triad - demineralization, bone destruction, periosteal rx
- ele CRP 4-6 wks, ESR, WBC
Tx
- Empiric abx for targeted organism
- Amox-Clauv (Augmentin) = Dog/cat and human bites
- Targeted after cultures
- IV Abx 4-6 wks for acute OM, > 8 wks for chronic OM or MRSA
Osteoporosis
Body loses too much bone or doesn’t make enough
F > M, White and Asian, smoking, etoh, underlying dz
Sxs
- more likely to have compression fractures
Dx
- Radiographs
- DEXA - bone mineral density, bone loss, risk of fracture
- < -2.0 is osteoporosis
Tx
underlyiing patho
Patellar tendinitis
eti, sxs
anterior knee pain - activity related @ focal patellar tendon Jumper’s knee
Swelling over tendon tenderness at inferior border of patella
Plantar Fasciitis
Plantar heel pain - worse in morning, better with moving stretching - overuse activity
Dx - XRay
Tx:
- Stretching
- PT
- NSAID
- CS injection
- Patience
Prepatellar Bursitis
MC in wrestlers
Sxs:
- Pain w/ direct pressure on knees (kneeling)
- Swelling over patella
Dx
- Septic bursitis - aspiration Gram stain and culture
Tx:
- Compressive wraps
- NSAIDs +/- aspiration and immobilization
Radial head Subluxation (Nursemaid’s Elbow)
MC young children < 4yo
MOI - pulling upwards motion
Lateral elbow pain
hold elbow in slight flexion and forearm pronated
Pain and tenderness in lateral asp of elbow
Red flag signs of Herniated Disc
- fecal/urinary incontinence
- Saddle anesthesia
- Urinary retention
- IVDU
- Fevers
- Chronic steroid use
- focal neuro deficitys
- hx of Cancer
- weight loss
- no improvements after 6 wks of conservative management
Rotator Cuff Injuries
Stabilizes the shoulder; Comprised of Four muscle groups
- Supraspinatus - MCC of tears - ext rot, abdc
- Infraspinatus - ext rot, abd
- Teres minor - ext rot, abd
- Subscapularis - internal rotation
Eti:
- <40 yo = Impingement, tendonitis
- >40 yo = cuff tears
Sxs:
- Can’t abduct arm above horizontal plane
- pain when elbow higher than shoulder
Dx:
- Special tests
- Drop Arm
- Empty can
- Neer Impingement Test
- Radiographs - shoulder series
- MRI - gold standard
Tx
- Conservative - NSAID, PT, Rest, Steroid
- Surgical - arthroscopic vs open
Sciolosis
Lateral curvature of spine - F MC, R side more common than left
paravertebral humping
20 < PT and bracing
40 degress + typically surgical
Septic Arthritis
EMERGENCY
Direct bacterial invasion of joint space MC knees and hips
MCC - S aureus, N gonorrhea in sexually active YA, streptococcus; Pseudomonas
sxs:
- Single, swollen, warm, painful joint, TTP
- constitutional sxs (fever, sweats, myalgia, malaise, pain)
Dx:
- Arthrocentesis - joint fluid aspirate - gold std
- WBC > 50k, primarily PMNs
- WBC > 1000 is + for prosthetic joints
Tx:
- 2-4 wks of abx + arthrotomy w/ joint drainage
- S aureu - Vanco/Nafcillin (vanco or clindamycin if pcn allergic)
- Gonorrrhea - ceftriaxone
- IVDU - cipro/levaquin
Shoulder Dislocation (Glenohumeral Joint)
MC anterior - arm is abducted and externally rotated
Posterior - arm is adducted and interally rotated
Sxs:
- Pain, deformity, loss of function
Dx:
- XRay - AP, Axillary and Y-view
- Bankart Lesion - tear on shoulder; anterior inferior labrum
- Hill-Sachs Lesion - divet in humerus - prev shoulder d/l
- Axillary nerve assessment
Special Tests - to dx prev shoulder d/l
- Apprehension test
- Relocation test
- Sulcus test
Tx:
- Reduce
- postreduction films
- Sling and swath
- PT
Slipped Cap Femoral Epiphysis
Obese kid, adolescent
Bilateral within 18 mos
Xray - slipped femoral cap
Tx - ORIF
Spinal Stenosis
narrowing of spinal canal w/ impingement on nerve root; >60yo
Sxs
- Back pain w/ paresthesias in one or both extremities
- R-> thighs
- Pain worse with extension - prolonged standing/walking
- relieve with flexion - sitting, walking uphill/on cart (Hoffman’s)
Tx
- Rest, NSAIDs, PT
- epidural injection of CS
- decompression laminectomy
Subacromial Bursitis
Btwn superior surface of supraspinatus tendon & coracoacromial ligament, acromion, and coracoid (acromial arch)
Pain on motion and at rest - fluid to accumulate
Not a/w trauma
Tx
- Prevention of precipitating factors
- NSAIDs
- Rest Brace/support
- Steroid injections
Thoracic Outlet Syndrome
Idiopathic compression of bracial plexus, subclavian vein, or subclavian artery as they exit out shoulder girdle and 1st rib
MC Young F 20-50
Sxs
- Nerve compression - pain/paresthesia to forearm, arm, or ulnar side of hand
- Vascular compression - swelling/discoloration of arm, w/ abduction of arm
- +adson test = loss of radial pulse w/ head rotated to affected side
Dx - MRI
Tx
- ortho consult +/- surgery
Torticollis
Wry neck - unilat contraction of Sternocleidomastoid muscle (shorten)
Breech deliveries, and adults and slept weird
Sxs - r/o radicular sxs
Dx - XR to r/o bone abn
Tx
- passive stretching
- self limited in 2-4 wks
Legg Calve-Perthes Syndrome
Interruption of blood to proximal femoral epiphysis
3-12 yo (young kids, ~5yo)
Painless limp but knee pain
decr internal rotation and abduction
Tx
- Rest
- PT
- Bracing/casting
- Sx
Developmental Hip Dysplasia
Barlow
adduct - dislocation hip
Ortolani
abduct - reduce the hip
Salter Harris Fracture
Type II is more common
I - physis
II - Metaphysis + physis
III - Physis + epiphysis
IV - physis + metaphysis + epiphysis
V - compressed
Osteoarthritis
Loss of cartilage from old age causing bone breakdownf rom friction
MC in hips, knees, hands; a/w Baker’s cyst
Sxs
- pain worse with weight bearing, better w/ rest
- pain & stiffness lasting < 30 mins
- Heberden (DIP) and Bouchard (PIP) Nodes
Dx
- XRay - narrowing of joint, osteophytes
- normal CRP/ESR
Tx
- Acetaminophen or NSAID
- definitive - Total joint replacement
