Orthopedic Procedures Flashcards
What is the process leading to an accurate diagnosis related to an orthopedic injury?
History
What do complete before you obtain an x-ray?
History and physical
Correlating point tenderness to abnormalities on the x-ray increases what?
Diagnostic accurary
Do you feel/hear a “pop” with a sprain or strain?
Sprain
What is a sprain?
Ligaments stretch causing tearing
Within the tearing there is bleeding outside of the ligament -> bruising
Greater the tearing the most the bruising
What is a strain?
Muscle is stretching and contracting simultaneously
Do you have a “grabbing sensation” with a sprain or strain?
Strain
When do sprinters commonly get a hamstring injury?
During late swing phase as hamstring muscle contracts while lengthening to decelerate
Fractures tend to have what type of tenderness?
Point tenderness
What aspects of MSK eval require emergent assessment?
Loss of pulses or capillary refill distal to area of concern
When is an ankle x-ray series required (Ottawa Ankle Rules)?
1) Bone tenderness along the distal 6cm of posterior tibia OR tip of medial malleolus
2) Bone tenderness along the distal 6cm of the posterior fibula OR tip of the lateral malleolus
3) Inability to bear weight for four steps BOTH immediately after the injury and in the office
When is a foot x-ray series required (Ottawa Rules)?
1) Bone tenderness at the base of the fifth metatarsal bone
2) Bone tenderness at the navicular bone
3) Inability to bear weight for four steps BOTH immediately after injury and in the office
What is the process for analyzing foot/ankle x-rays?
1) Follow boney margins
2) Note any disruption or blurring
3) Identify joint spaces
Which degree of ankle sprain requires surgical intervention?
Third
What are the treatment options for ankle sprain?
Ice 48-72 hours Elevate Compression Rest Splint Aircast Stabilize with splint Referral for orthopedic eval
What does an ACE wrap do?
Limits swelling and movement
Reminds patients to slow down and protect the joint
In what direction do you wrap an ACE wrap?
Distal to proximal (with minimal stretching of material)
Buddy taping is used for what type of fractures?
Stable non-displaced fractures not involving the joint surface
How long is buddy taping recommended for?
2-3 weeks
Splints and casts usually involve what joints?
Joints above and below the fracture or injured joint
Can splints be for both sprains and fractures?
Yes
Is pain relief immediate with splints and casts?
Yes
For which injuries can you use splints?
Fractures Dislocations Injury of muscles, tendons, and ligaments Protection of vascular/nerve repair Wound protection postsurgically
Which ranges of motions are prevented in ankle stirrups?
Internal rotation
External rotation
Which splint is ideal for mild to moderate ankle sprains?
Ankle stirrup
What is a simple fracture?
Two fragment
What is a comminuted fracture?
More than two fragments
What is a torus fracture?
Buckle fracture
What is angulation?
Named for distal fragment
What is an avulsion?
Fracture at site of ligamentous origin or insertion
What is a compound fracture?
Opening of skin associated with fracture
What is a spiral fracture?
Twisting fracture caused by torque
What is an oblique fracture?
Caused by a force in the same direction as the long axis of bone
What is a transverse fracture?
Perpendicular to the long axis of the bone
Is a grade 3 ankle sprain with complete ligament disruption stable?
No
How do you treat a grade 3 ankle sprain?
Complete immobilization
Posterior splint
Ortho referral
For what injuries are a posterior leg splint appropriate?
Foot fractures
Ankle fractures
High grade ankle sprains
When is a short-arm cast with thumb spica appropriate?
Fracture of scaphoid, trapezium, or 1st metacarpal (wrist and thumb immobilization)
When is a sugar tong appropriate?
Fracture of distal radius and ulna
When is a long arm cast appropriate?
Fracture of navicular
Radius and ulnar shaft fracture
Colles fracture
When is an ulnar gutter appropriate?
Fracture of neck, shaft, and base of 4th/5th metacarpals
How does septic arthritis appear?
Painful, warm, and distended joint capsule
Are gonococcal arthritis or non-gonococcal arthritis more common?
Gonococcal arthritis
Does gonococcal arthritis occur in women or men more?
Women
Which joints are more commonly affected in gonococcal arthritis?
Large joints
Is gonococcal arthritis more or less destructive than non-gonococcal infections?
Less
How does non-gonococcal arthritis typically present?
Monoarticular in large joints
Which organisms make up 80% of non-gonococcal arthritis?
Gram-positive
Permanent joint destruction can occur in how many days if treatment is delayed in non-gonococcal arthritis?
3 days
If there is a high index of suspicion for gonococcal arthritis which sources should be collected for culture?
Blood Cervical Urethral Rectal Pharyngeal
What are the therapeutic indications for joint arthrocentesis?
1) Relieve pain from effusion or hemarthroses
2) Improve accuracy of physical exam
3) Instill medications into joint capsule to treat inflammatory conditions
Are intraarticular antibiotics recommended?
No
What are the diagnotics indications for joint arthrocentesis?
1) Establish etiology of any joint effusion of uncertain cause
2) Distinguish infectious vs. noninfectious causes of effusion
What are the contraindications for joint athrocentesis?
1) Overlying skin infections/lesions
2) Cutaneous infection (unless source of skin infection is thought to be from joint)
3) Skin lesions (such as psoriasis plaques)
4) Abnormal coagulopathy (maybe)
5) Bacteremia (relative contraindication)
In what populations is gout seen in?
Middle-aged to elderly men
Postmenopausal women
What is gout associated with?
Alcohol consumption
Obesity
High purine diet
What are the symptoms of gout?
Acute episodic arthritis (monoarticular) Chronic arthritis (polyarticular)
What tissues are affected in gout?
Deposition of monosodium urate (MSU) crystals in joints and connective tissue (tophi)
Acute attack begins at night; joint becomes red, warm and tender that often mimics cellulitis
What are the joint aspirate findings in gout?
Needle shaped MSU crystals appear birefringement under polarized light
What joints are affected in gout?
1st metatarsal, fingers, knees
What are the x-ray findings with gout?
Chronic joint changes are cystic
Well-defined erosions w/sclerotic margins
What is the population for pseudogout?
Elderly (increases with age)
What are the symptoms with pseudogout?
Intense pain Redness Warmth Swelling Joint disability Subacute and chronic forms exist
What are the affected tissues in pseudogout?
Calcium pyrophosphage deposition rarely associated with soft tissue tophi
Polyarticular synovitis superimposed on chronically involved joints
What are the joint aspirate findings in pseudogout?
Small, polymorphic rhomboid, cuboid or rod crystals weakly birefreingement or non-birefringent
What are the x-ray findings in pseudogout?
Punctate and/or linear radiodense deposits within meniscus or hyaline cartilage (chondrocalcinosis)
Does not cause joint damage
What is the age for osteoarthritis?
> 50, increases with age
What is the symptoms for osteoarthritis?
Worse with activity, stiffness less than 30 minutes
What is the pathogenic abnormality with osteoarthritis?
Numerous abnormalities includes loss of articular cartilage, thickening of synovium, bone and soft tissue
What is the role of inflammation in osteoarthritis?
May be secondary, inflammatory mediators exacerbate cartilage damage
What is the path for osteoarthritis?
Cartilage degenerates and fragmentation, bone spurs, and subchondral cysts
Are there serum antibodies seen with osteoarthritis?
No
What is the age for RA?
50-75
What are the symptoms of RA?
Pain/stiffness > 1 hour in morning, improves with activity
MCP, PIP, and wrists
Decreased associated grip strength
What is the pathogenic abnormality with RA?
Autoimmune
What is the role of inflammation in RA?
Primary: cartilage destruction caused by T cells and antibodies reactive with joint antigens
What joints are impacted by RA?
Small joint of finger, toes then progresses
Which joints are impacted by osteoarthritis?
Weight bearing (hips, knees) most common
What is the path associated with RA?
Inflammatory pannus invading and destroying cartilage; severe inflammation; joint fusion (ankyloses)
What are the serum antibodies associated with RA?
ACPA= anti-CCP, RA
What other organs are affected by RA?
Heart
Lung
Are swan neck deformities associated with RA or OA?
RA
Is ulnar deviation associated with OA or RA?
RA
What are the anatomic landmarks for shoulder arthrocentesis?
Needle is inserted inferior and lateral to the coracoid process, and directly posteriorly towards the joint space
What are the anatomic landmarks for knee arthrocentesis?
Needle enters 1cm medial or lateral to the superior third of patella
What does normal synovial fluid look like?
Colorless/amber
Transparent
What does inflammatory fluid look like?
Amber/yellow/opaque
Grossly purulent if septic arthritis
Regardless of appearance, what should synovial fluid be submitted for?
1) Cell count and differential
2) Crystal analysis
3) Gram stain with culture and sensitivity
Do absolute cell counts have diagnostic value?
No
What does cell count tell you?
Presence/absence of an inflammatory arthritis
Should chemical analysis of synovial fluid be routinely ordered?
No
Does evaluation of serum uric acid have a role in the diagnosis of acutely inflamed joints?
No
