Orthopedic Surgery Flashcards
subluxation definition
partial dislocation
fracture-dislocation definition
peri-articular fracture resulting in subluxation or dislocation of the joint
displacement definition
translation of the 2 fragments in relation to each other in one or more planes
angulation definition
2 fracture fragments are not aligned and an agular deformity is present
rotation definition
torsional relationship btw the 2 fracture fragments
what does this type of fracture say about the mechanism of injury: spiral
torsional
what does this type of fracture say about the mechanism of injury:avulsion
tension (eg. ACL tear)
what does this type of fracture say about the mechanism of injury: transverse
bending
what does this type of fracture say about the mechanism of injury: oblique
bending w/compression
what does this type of fracture say about the mechanism of injury: segmental/comminuted
high energy
Greenstick fracture
incomplete fracture involving the cortex of 1 side (tension side), most commonly seen in kids
Buckle/torus fracture
Buckling of the compression side of the cortex of a long bone
Salter-Harris fractures
fracture of the growth plate in kids
What are the types of salter-harris fractures?
I (S) - straight across the physis II (A) - above the physis III (L) - lower than the physis IV (T) - through metaphysis/physis/epiphysis V (R) - cRushed physis
Where are stress fractures the most common?
- 2nd metatarsal
- femoral neck
- proximal tibia
In which people do you see the most stress fractures?
- runners
- military recruits
- anorexic patients
Pathologic fractures can be 2/2 to ___(3)
- tumor/mets
- previously infected bone
- osteoporosis
What are the 5/6 P’s of compartment syndrome?
- Pain out of proportion to exam
- parasthesia
- pallor
- poikilothermia (inability to regulate core body temp)
- paralysis
- pulselessness (later finding)
compartment syndrome has pain with ______ stretch
PASSIVE
Tx of compartment syndrome
emergent fasciotomy
what happens to arteries that are injured?
- arterial injury rare becuase they usually slide out of the way
- damage to the walls leads to intramural hematomas that require vein grafts or prostheses
With what bone injuries are you most concerned about vascular trauma?
- clavicle
- supracondylar region of elbow
- femoral shaft
What vascular trauma do you worry about with supracondylar fractures of the elbow?
- damage to the brachial artery that could cause Volkmann’s contracture (compartment syndrome of the forearm causing ischemia/necrosis of the forearm muscles resulting in FLEXION OF THE WRISTS AND FINGERS)
What’s more common - nerve or vascular injury?
nerve
What are the 3 types of nerve injury from most likely to recover to least likely?
- neuropraxia - disruption of nerve function
- axonotmesis - anatomic disruption of the axonal sheath
- neurotmesis - anatomic disruption of the nerve itself
What nerve do you worry about injury to with the following injuries:
- humerus shaft fracture
- knee dislocation
- hip dislocation
- radial nerve
- peroneal nerve
- sciatic nerve, peroneal division
myositis ossificans definition. Where is it most common?
heterotopic bone forms within the damaged muscle which leads to the ossification of muscle
- quadriceps, brachialis
Where is the most likely damage to muscle/tendon (i.e., where in the muscloskeletal system) in the following age groups:
- kids
- adults
- elderly
- growth plate (physis)
- ligaments
- bones
describe the 3-step process of fracture healing
- vascular phase
- metabolic phase
- mechanical phase
Describe the vascular phase of bone healing
- hematoma development
- cellular infiltrate
- vascularization/organized hematoma
- soft callous formation
Describe the metabolic phase of bone healing
soft callous –> hard callous
Describe the mechanical phase of bone healing
mechanical stress is required to produce skeletal remodeling and solid bone
What are the orthapedic emergencies (6)
VC SCOreD
- fractures a/w Vascular injury
- Compartment syndrome
- Septic arthritis
- Cauda equina syndrome
- Open fractures
- Dislocation of major joints
what is a glycocalyx
can form on implants and provides substrate for colonization. It’s inaccessible to abx and culture
Tx of infection after fractures
- surgical debridement
- remove infected bone
- abx
in what bones do you see avascular necrosis
- head of the femur
- dome of the talus
- scaphoid
What is reflex sympathetic dystrophy?
- trivial trauma resulting in abnormal sympathetic tone
Describe complex regional pain syndrome
- exquisite pain
- erythema, swelling
- idiopathic cause
- often a/w minor trauma/surgery
Clavicular fractures:
- in whom are they most common
- how do you treat them
- kids, cyclists
- usually sling, figure 8 strap
- surgical tx if open, widely displaced, or a/w lower or ipsilateral fractures
How do you treat:
- simple proximal humerus fractures
- proximal humerus displacement
- sling, early range of motion (ROM)
- open reduction, internal fixation (ORIF)
Acromioclavicular separation:
- what is it injury of and how is caused
- in whom are these most common
- how do you treat them
- injury of acromaclavicular and coracoclavicular ligament 2/2 falling on acromion
- atheletes, football players
- sling + early motion
What type of shoulder dislocation is the most common?
- anterior
describe anterior shoulder dislocations, how are they treated?
- axillary nerve damage possible
- often recurrent
- tx: closed reduction + sling. Recurrent dislocations may need surgery
posterior shoulder dislocations are usually a/w _____. How are they treated?
- seizures, electrocution
- closed reduction + sling. Recurrent dislocations may need surgery
W/humeral shaft fractures check for _____ damage
- radial nerve
humeral shaft fractures are treated with
- closed treatment w/either hanging arm cast or functional (Sarmiento) brace
Distal humeral fractures have many complications such as ____ (4)
- nerve palsies
- posttraumatic arthritis
- heterotopic ossification
- stiffness
Distal humerus fractures are treated with _____(3)
- anatomic reduction
- stable fixation
- early motion
Supracondylar fractures are usually seen in ______ (what group) as a result of ____.
- kids
- monkey bar fall
What is a risk a/w supracondylar fractures
- injury to brachial artery causing Volkmann’s contracture
How do you treat supracondylar fractures?
- closed reduction
- cast for 4-6 wks
What is a Monteggia fracture/dislocation and how is it treated?
- ULNA fracture, RADIUS dislocation
- ORIF of ulna, closed reduction of radial head
What is a Galeazzi fracture/dislocation and how is it treated?
- RADIUS fracture, ULNA dislocation
- ORIF of radius and casting
Colles fracture
- definition,
- cause,
- popular age groups
- Classic findings
- treatment
- distal radius fracture
- FOOSH
- kids and elderly
- dorsal displacement of distal fragment, dorsal angulation, radial shortening
- closed reduction + cast (if stable); open reduction if fracture is intra-articular
Scaphoid fracture
- presentation
- tx
- high risk of….
- tenderness in anatomic snuffbox
- thumb-spica cast
- high risk of nonunion and AVN requiring OR for displaced fractures
Nightstick fracture
- definition
- results from
- Tx
- ulnar shaft fracture
- self defense with arm against a blunt object
- ORIF if significant displacement
Vertebral fractures
- tx if one vertebra is fractured (therefore stable)
- tx if 2-3 vertebra are fractured (therefore unstable)
- tx if nerve damage involved
- use brace
- surgery
- surgery
What is considered a stable pelvic fracture? How is it treated?
- one break in pelvic ring
- bed rest
What is considered an unstable pelvic fracture? What is this a/w? How is it treated?
- 2+ breaks in pelvic ring
- significant blood loss
- stabilization with external fixator or through surgical means
What are the 2 types of hip fractures?
- femoral neck
- intratrochanteric
Risk of femoral neck (intracapsular) fracture _____. Tx?
- AVN
- younger patient - fixation; older patient - hemiarthroplasty
Risk of intertrochanteric (extracapsular) fracture _____. Tx?
- NO RISK OF AVN
- surgery
Hip dislocation is usually a result of ______.
- complications include (2)
- tx
- impact between a knee and dashboard in an MVA
- AVN, sciatic nerve palsy
- emergent closed reduction
Femoral shaft fractures are usually caused by ______.
- Watch for ______
- Tx.
- direct trauma
- FAT EMBOLI
- intramedullary nailing of the femur
Tibial or “bumper” fractures are usually the result of ______
- Tx if minimal displacement
- Tx if lots of displacement
- Tx if tibial shaft, what is a common AE of this?
- direct trauma
- nonoperative
- ORIF
- intramedullary nailing - high nonunion rate
W/knee dislocations check for ____(2)
- vascular injury (popliteal pulse, ABI)
- nerve injury (peroneal)
Calcaneous fracture:
- Tx if extra articular, minimal displacement
- Tx if extra articular, lots of displacement
- non-weight bearing
- ORIF
What is the etiology of osteoarthritis? (8 steps)
- age –> decreased proteoglycans/collagen –> decreased cartilage formation –> bone stress/formation –> sclerosis (bone hardening) –> cracks –> synovial fluid inside bone –> subchondral cysts w/bone repair along edges (osteophytes)
what is lamina splendens?
- top protective layer of articulating cartilage
What are the 4 main radiographic characteristics of OA
- subchondral cysts
- osteophytes
- sclerosis
- joint space narrowing
What do patients w/OA present w/?
- pain at the end of the day
- older people
- crepitus
- decreased ROM
- morning stiffness s nodes: PIP
Tx for OA (4)
- PT
- weight reduction
- NSAIDs
- arthroplasty - severe cases (efficacious for pain but not fxnl improvement)
The hallmark of septic arthritis is _____
resistance to active and passive motion
The organisms you think of when you think of septic arthritis
- S. aureus
- GC in sexually active
Describe the formation of RA joints
- inflammatory response/AI disease 2/2 hyperplasia of synovial cells –> increased synovial fluid + pannus formation –> bone erosion, cartilage destruction, ankylosis of joints
S/sx of RA (3)
- morning stiffness >1hr
- pain decreases w/use
- affects wrists, MCPs, PIPs
RA labs (2)
- increased RF
- increased anti-CCP antibodies
Tx of RA
- MTX/DMARDs
- NSAIDs
- Sulfasalazine
- Hydroxychloroquine
What is neurogenic arthritis?
- no feedback causes joint damage
- SNS dysfxn causes arteriole induced hyperemia and pain out of proportion to PE
What action do the following spinal nerves control?
- L2
- L3
- L4 (3)
- L5
- S1 (4)
L2: hip flexion
L3: leg extension (quads)
L4: foot dorsiflexion (AT), patellar reflex, sensation to medial aspect of lower leg
L5: toe dorsiflexion (Extensor Hallicus Longus - EHL), sensory to dorsum of foot + lateral aspect of lower leg
S1: sensation to plantar and lateral aspects of the foot, plantar flexion (gastroc + soleus), achille’s reflex, hip extension (glut max)
Nerve root irritation or injury is a ______
radiculopathy
How do radiculopathies affect motor, sensation and reflexes?
- motor: weakness
- sensation: parasthesias
- DTRs: decreased
How likely is it someone 60-80 yo will have a herniated nucleus pulposis (HNP)?
- 93%
RFs for HNP (3)
- Age
- cancer
- trauma
What are the 2 most common sites for HNPs?
- L4-L5
- L5-S1
Which nerve root is usually affected for HNPs? If central? If lateral?
- lower one (for ex - if it’s the L4-L5 disc than the L5 would most likely be affected)
- lower (ex L5)
- Upper (ex L4)
HNPs can result from (3)
- age
- degeneration
- disc dehydration
What is a physical exam finding w/HNPs?
- positive passive straight leg raise and if it’s on both sides this is more specific
S/Sx of HNP (7)
- sciatica
- parasthesias
- muscle weakness
- atrophy
- contractions
- spasms
- radiculopathy
How do you diagnose HNPs?
- clinical (MRIs only if indicated)
Tx of HNPs (5)
- NSAIDs
- PT
- steroid injections
- neurostimulator if necessary
- NO bedrest
How effective is surgery for HNP?
- 50-70%
How many HNPs resolve on their own?
- 90%
What are potential causes of cauda equina syndrome? (3)
- L4-L5 herniation
- tumor
- abscess
S/Sx of cauda equina syndrome
- b/l sciatic pain or saddle anesthesia
- urinary retention/bowel dysfunction
- impotence
Tx of cauda equina syndrome
- MEDICAL EMERGENCY
- requires rapid cord decompression
What is spinal stenosis and what’s it usually caused by?
- narrowing of the lumbar or cervical spinal canal causing compression of nerve roots and spinal cord
- usually caused by degenerative joint disease w/osteophyte formation
S/Sx of spinal stenosis (3)
- pain that radiates to arms, legs or butt
- pain increases w/standing or walking
- forward bend test - pain decreases w/flexion of the hips and bending forward (neuroclaudication)
Dx of SS
- MRI, CT
Tx of SS (for mild, moderate, and severe)
- mild - NSAIDs
- moderate - epidural steroid injections
- severe - surgical laminectomy
What is spondylitis?
- seronegative spondylo-arthropathy, meaning RF- (also included in this group is psoriatic arthritis, IBS, and reactive arthritis)
- a/w HLA-B27
What is ankylosing spondylitis. What are the s/sx? What other conditions is it a/w?
chronic inflammation of spine and sacroiliac joints causing spine stiffness 2/2 fusion of the joints- “bamboo spine”
- pain worsens w/inactivity and in the mornings
- a/w uveitis and aortic regurge
Tx of AS (4)
- NSAIDs,
- exercise
- TNF inhibitors
- Sulfasalazine
What is spondylosis
disc degeneration, the same as OA of the back
What is spondylolysis
defect in the pars interarticularis
What is spondylolisthesis
- slippage of the vertebral body forward
- degenerative in old, isthmic in children
Pain in the back when moving means ____ disease. Pain while sitting means ____ disease.
- joint
- disc
You only image people with back pain after ______ wks of sx or if _____ are present
- 6 wks
- red flags
What is the difference in long term outcomes in surgery vs. medical management of back pain?
- no difference
metatarsus adductus
Pediatrics
- pigeon toed walk 2/2 defect in the foot
- it’s a ‘packaging defect’ meaning that it arose d/t positioning of the baby inside the mom’s womb
What are the 3 types of metatarsus adductus
- actively correctable - no needed tx
- passively correctable - stretching exercises
- ridgid - casts or braces
What is the triad of club foot?
- equinus = plantar flexion deformity, pt walks on their toes
- metatarsus adductus
- heel varus
Is club foot a packaging defect like metatarsus adductus?
NO
club foot is a/w
DDH (developmental dysplasia of the hip)
tx for club foot
manipulation of the foot, surgery
Blounts disease
- tx?
- unknown cause
- dysfxn of the medial tibia physis causing varum
- tx: surgical realignment
What is genu verum (verus)
bowlegs
what is genu vulgum (valgus)
knock kneed
Pes planus
- what causes this?
flat feet
- ligamentous laxity causes the rigid flat feet which stay flat, most are static, tarsal bone fusion
DDH is a hip dislocation that results from poor development of the hip d/t _____ and ______ which causes _____ and excessive stretching of the ______
- lax muscles of the hip
- shallow acetabulum
- contractures
- posterior hip capsule
What fxn of the hip do the following PE tests test:
- Barlow
- Ortolani
- Galeazzi’s sign
- adduction
- abduction
- knees at unequal heights when hips and knees are flexed
Other than Barlow, ortolani, and galeazzi’s sign, what might you find on the PE of someone with DDH?
- asymmetric skin folds
DDH is most commonly seen in ______
first born females born BREECH
What is the tx for DDH. What happens if you don’t treat this?
<6 mos old: Pavlik Harness (maintains hip flexed and abducted)
6-15 mos old: spica cast
15-24 mos old: open reduction + spica cast
No tx leads to early OA of the hip
What is slipped capital femoral epiphysis (SCFE)
separation of the proximal femoral epiphysis through the growth plate causing inferior and posterior displacement of the femoral head relative to the femoral neck. The epiphysis remains in the acetabulum
What are RFs for SCFE (4)
- obesity
- ages 11-13
- male gender
- AA
What is SCFE a/w (2)
- hypothyroidism
- other endocrinopathies
S/Sx of SCFE (5)
- Insidious or acute groin or knee pain
- painful limp
- decreased ROM
- inability to bear weight
- often b/l (40-50%)
- limited internal rotation and abduction of the hip
How do you dx SCFE (2)
- XR: AP and frog-leg lateral views
- will show posterior and inferior displacement of the femoral head
- check TSH levels
How do you treat SCFE (2)
- no weight bearing
- percutaneous screw fixation
What is Legg-Calve Perthes Disease?
- idiopathic AVN of the femoral head
W/regard to Legg-Calve Perthes Disease:
- most commonly affected group
- natural hx of the disease
- what indicates better prognosis?
- boys 4-10 yo
- usually self-limited w/sx present for <18 mos.
- early onset
S/sx of Legg-Calve Perthes Disease (5)
- painless limp
- pain can exist in the groin or anterior thigh
- limited abduction and internal rotation
- atrophy of affected leg
- usually unilateral
Tx of Legg-Calve Perthes Disease
Observation if full ROM intact.
If full ROM not intact, consider bracing, hip abduction w/petrie cast or osteotomy
Define scoliosis
Lateral curvature of the spine >10 degrees
Possible etiologies of scoliosis (5)
- usually idiopathic
- can be congenital, a/w neuromuscular, vascular, or spinal cord disease
What indicates a better prognosis for scoliosis?
- late onset
If a pt presents w/congenita scoliosis, also check ____ & ______ because ____
- kidneys
- heart
- they develop at the same time
how does the prevalence of scoliosis differ between males and females?
ratio of 1:7
What test can you use to check for scoliosis?
- forward bending test: rib hump (clinical hallmark of scoliosis)
How do you treat scoliosis?
- 50º - surgical correction
Osteomyelitis is most commonly d/t _____
staph
Rigidity of the bone causes ___ to move down the path of least resistance, so it rapidly pressurizes spread to medullary canal through the cortex, and into the subperiosteal space to form an abscess in osteomyelitis
pus
You rarely see osteomyelitis in the ____ because _____
epiphysis
- physis acts as a barrier
Dx of osteomyelitis
- t-99m bone scan is sensitive and specific
- ESR
- CRP
Tx of chronic osteomyelitis
surgical debridement
