Orthopedic Surgery Flashcards
Hawkins and Near shoulder tests for what?
Impingement
Yergason test Speed test for shoulders tests?
Biceps instability or tedinopathy
What does Trandelenberg gait indicate re: muscle weakness?
Weak abductor
Thomas test for hip/pelvis tests what?
Flexion contracture
What is FABER hip/pelvis test and what does it test for?
Flexion, ABduction, External Rotation and Extension
for SI joint
What does Lachman test for re: knee?
Anterior/posterior instability
What does McMurrary test for re: knee?
Meniscal injury
Thompson test re: ankle for what?
Achilles tendon rupture
What is windlass test re: foot for?
Plantar fasciitis
Investigations for infectious workup
CBC, CRP, ESR, blood cultures
Rheumatology workup for what differential?
Inflammatory
How many vertebrae? What are the segments?
33
- 7 cervical
- 12 thoracic
- 5 lumbar
- 5 sacral
- 4 coccygeal
What joint is most neck flexion/extension through?
Atlanto-occipital joint
What is most neck rotation through?
C1 and C2
What is spondylolysis?
Stress fracture in pars interarticularis
- caused by hyperextension/ rotation
- common in young athletes
What is spondylolisthesis?
Anterior or posterior slippage of vertebra relative to vertebra below
What is spinal stenosis?
Narrowing of spinal canal
What is disc herniation?
Herniation of vertebral disc
- causing compression/ irritation to adjacent nerve roots
Cervical radiculopathy sx and tx
- radiating pain down arm
- dermatomal sensory loss
- myotomal muscle weakness
tx - rest, activity modification, nerve root steroid injections, analgesia (NSAIDs, GABA inhibitors)
+/- discectomy +/- fusion
Lumbar radiculopathy definition and sx
= sciatica
- compression of nerve root by herniated disc
sx - back pain with leg pain along distribution of irritated nerve
- pain = burning, electrical and shooting
Is inflammatory back pain worse with rest or activity? Morning stiffness?
Worse with rest and better with activity
- severe morning stiffness for hours
Ddx inflammatory back pain
- ankylosing spondylitis
- psoriatic arthritis
- reactive arthritis
- enteropathic arthritis
Risk factors for infection re: back pain
- immunocompromised
- IVDU
- TB exposure
- age
Infectious cause of back pain - ddx
- discitis
- osteomyelitis
- epidural abscess
- > often hematogenous spread
Cauda equina syndrome
- compression of nerve bundle extending from bottom of spinal cord
- caused by ruptured or herniated disc, tumor or abscess
back pain with saddle anesthesia, bowel/bladder sx (incontinence, retention)
-> surgical emergency
Sx Cauda Equina
- saddle anesthesia
- loss of voluntary bladder and bowel function
- bilateral radicular pain, loss of sensation, weakness
- hypo/areflexia
Where are common sites of metastasis to spine?
- breast
- prostate
- lung
- renal
- thyroid
Red flags re: back/neck pain on history
- acute onset localized back pain
- night pain that wakes pt
- malignancy hx
- progressive neurologic deficit
- immunosuppression
- constitutional sx
- fever
- hx trauma
- bladder or bowel sx
- saddle anesthesia
- motor weakness
- point vertebral tenderness
What does straight leg raise test for?
Nerve root irritation
What does occiput to wall distance above 0 suggest?
Osteoporotic degeneration
What does Schober test assess?
Amount of movement in lumbar spine
Canadian C-spine rules
Major risk factors -> if yes then XR
- > 65yo
- complaining of parenthesis in extremities
- experience a dangerous mechanism of injury: fall from 1m/ 5 stairs, axial load to head (diving), MVA >100km/h/ rollover/ ejection, motorized recreational vehicle accident, bicycle collision with immovable object (parked car, tree)
Minor risk factors -> if no then XR
- simple rear end motor vehicle accident
- in sitting position at ED
- ambulating at any time
- delayed onset neck pain
- no pain in midline cervical spine
If minor risk factor and not able to actively rotate neck 45 degrees left and right -> XR
Define dislocation
complete loss of contact between articular surfaces of a joint
Define subluxation
incomplete dislocation
Define open fracture
soft tissue wound penetrates to fracture site
Stages of secondary fracture healing
- hematoma: bleeding from bone and soft tissue
- inflammation: hematopoietic cells produce GF; fibroblasts, mesenchymal cells and osteoprogenitor cells recruited to # site
- callus: action of osteoblasts and osteoclasts; bridging soft callus (wks) and becomes replaced by woven bone (hard callus)
- remodelling: lamellar bone replaces woven bone (wk - yrs); responds to mechanical stress through the bone (Wolff’s law)
What is Wolff’s Law?
lamellar bone replacing woven bone responds to mechanical stress through the bone
When does primary bone healing occur and what is it?
- seen with rigid internal fixation (plate and screw fixation)
- begins with remodelling process
- if external callus evident and pt continues to have pain, fixation may be loose and aseptic or septic nonunion
What does rate of fracture depend on?
- biologic factors - blood supply, soft tissue coverage, pt age, comorbidities, nutrition, smoking, about of bone loss, neuromuscular status
- mechanical factors - stability, amount of comminution
What is a pathologic fracture? Causes?
- abnormal bone + normal force
- generalized bone disease - Paget, metabolic bone disease (osteoporosis, hyperparathyroidism, osteomalacia), EtOH use, poor nutrition
- local disease - infection (TB), bone cyst
- malignancies - primary (sarcoma, multiple myeloma), metastatic (breast, lung, prostate, renal, thyroid)
What is fragility fracture?
- # occurring after fall from standing height or less, or in absence of trauma
- associated with low bone density
- often distal radius, hip, spine
Saltar-Harris classification
Pediatric # around growth plates
I = physis (through growth plate) II = metaphysis (proximal) III = epiphysis (distal) IV = ME (metaphysis + epiphysis) V = crush
Can greenstick # occur in adults?
No - unique to peds
- # on one side of bone and plastic deformation on other side of bone (i.e. both cortices not broken)
What are consequences of # through growth plate?
risk of growth deformities or growth arrest
Compartment syndrome
- pain out of proportion to injury, increasing analgesia required
- tense compartments on palpation, loss of active function of muscles in compartment, pain on passive stretch of muscles in compartment
- puleslessness and parenthesis are very late sx and should never be relied on for dx
- clinical dx -> if pt obtunded measure compartment pressures
tx = fasciotomy
Are the 5 Ps of vascular injury the same as compartment syndrome?
NO
- but compartment syndrome can occur with prolonged warm ischemia and revascularization (repercussion edema -> compartment syndrome)
Describe a fracturw
- which bone
- where is the bone
- # pattern: transverse vs. oblique vs. spiral vs. avulsion
- relationship of fragments: angulation, translation, rotation, shortening
- number of fragments: amount of comminution
- intra-articular vs. extra-articular
- open or closed
Lab investigations for pathologic #
Serum calcium, phosphate, alkaline phosphatase, PTH, TSH, T3/T4, SPEP and UPEP
- DEXA for bone density with osteoporotic #
What are fracture blisters caused from?
shear forces on skin at time of injury
Ottawa Ankle Rules - ankle
Ankle X-ray indicated if
- bony tenderness along posterior edge or tip of distal 6cm of lateral malleolus OR
- bony tenderness along posterior edge or tip of distal 6cm of medial malleolus OR
- unable to weight bear immediately after injury and in ED
Ottawa Ankle Rules - foot
Foot X-ray indicated if
- bony tenderness at base of 5th metatarsal OR
- bony tenderness at navicular OR
- unable to weight bear immediately after injury and in ED
Management in open # re: ?antibiotics
Antibiotics and tetanus immunization
- Ancef +/- amino glycoside +/- anaerobic coverage
Malunion vs. nonunion
Malunion = healing in non anatomic position Nonunion = failure of fracture healing
Hand bones?
8 carpals
5 metacarpals
3 phalanges per finger (proximal, middle, distal)
2 phalanges per thumb
Carpal bones?
" some lovers try positions that they cannot handle" Scaphoid Lunate Triquetrum Pisiform Trapezium Trapezoid Capitate Hamate
Hand/ finger joints
- MCP
- PIP
- DIP
- thumb only has IP between phalanges and CMC joint
Tendons in hand/ fingers
12 extensors
12 flexors
Nerves in hand
medial
radial
ulnar
Blood supply to hand
radial and ulnar arteries
Where do you check on exam for suspected scaphoid injuries?
snuffbox (dorsal) scaphoid tubercle (volar)
What tests for carpal tunnel?
Tinels and Phalens
What is Finkelstein test for?
De Quervain tenosynovitis
What does Kanavel cardinal signs assess for?
Purulent tenosynovitis
Test radial nerve
- thumb extension (motor = EPL muscle)
- 1st dorsal webspace (sensation)
Test median nerve
- thumb abduction (motor = APB muscle)
- volar aspect of index finger (sensation)
Test ulnar nerve
- finger abduction (motor = interossei muscles)
- volar aspect 5th digit (sensation)
What is position of safety for hand splinting?
Wrist 35 degrees
MCP joints 45-70 degrees
DIP and PIP 10 degrees
Thumb abducted
What is deQuervain tenosynovitis?
- inflammation of 1st dorsal extensor compartment, usually from overuse, posttraumatic
- increase risk in females
Finkelstein + test - radial-sided wrist pain
tx - immobilize, NSAIDs, activity modification, steroid injections
- may need surgical release of 1st dorsal extensor compartment
What is Trigger finger?
- irritation or inflammation of flexor tendon sheath
- repetitive use or direct pressure
sensation of ‘snapping’, finger locking in flexion, loss of smooth ROM
tx - immobilize, steroid injection - may need surgical release
What is infectious tenosynovitis?
- often streptococcal or staphylococcal
- can be from skin wound
usually volar side of tendon sheath - Kanavel sign +
tx- abx, I&D
What is carpal tunnel syndrome?
compression of medial nerve in carpal tunnel
RF - occupation, pregnancy, obesity, hypothyroidism, renal disease, diabetes, RA, female
- pain/sensory loss in median nerve distribution, worse at night
- thenar atrophy
- weak thumb abduction
- decreased two point discrimination
- positive Tinel, Phalen, carpal compression
tx- splint, activity modification, NSAIDs, steroid injection
- carpal tunnel release may be needed
Divide spinal column into how many columns?
3
- anterior
- middle
- posterior
Anterior spinal column consists of what?
- anterior longitudinal ligament
- anterior vertebral body
- anterior annulus
Middle spinal column consists of what?
- posterior longitudinal ligament
- posterior vertebral body
- posterior annulus
Posterior spinal column consists of what?
- pedicles
- facets
- lamina
- posterior ligamentous complex
What level does spinal cord end?
L1/L2 in adult - cause equina begins
What does it mean if normal physiologic loads do not cause neurologic injury, pain or deformity re: spine
Spinal stability
What causes primary injury to spinal cord?
Mechanical forces
What causes secondary injury to spinal cord?
Additional damage to cord from response initiated by primary injury
Where are injuries to vertebral column most likely to occur?
Transitional areas
Define spinal shock
- temporary loss of spinal cord function and reflexes below level of injury
sx - absent reflexes, flaccid paralysis
- often resolves 24-48h
What is bulbocavernosus injury and what does it indicate?
Return of reflexes below level of injury after spinal shock
- indicates end of spinal shock
Define neurogenic shock
- loss of sympathetic tone leading to hypotension, bradycardia
- can be life threatening
Grade muscle strength
0 - total paralysis
1 - palpable or visible contraction
2 - active movement, full ROM with gravity eliminated
3 - active movement, full ROM against gravity
4 - active movement, full ROM against gravity, moderate resistance in muscle-specific position
5 - active movement, full ROM against gravity, full resistance in muscle-specific position expected from otherwise unimpaired person (normal)
Criteria for clearing spine
- full and nontender ROM
- no posterior midline tenderness
- no focal neurologic deficits
- not intoxicated or otherwise obtunded
- no distracting injuries
Neurologic level classification based on what?
- lowest spinal level with normal neurologic function bilaterally
Complete vs. incomplete SCI
complete = no voluntary motor or sensory function below level of injury incomplete = some function below level of injury after return of bulbocavernous reflex
What is tetraplegia/ quadriplegia?
Loss of sensory/motor function in cervical levels
What is paraplegia?
loss of sensory/ motor function in thoracolumbar levels
What sensory tests are done for spinal injury neurologic exam?
light touch and pinprick in distribution of dermatomes
Sequence of neurologic exam in spinal injury?
sensation -> motor -> neurologic level of injury -> complete vs. incomplete injury
How do you determine motor level?
- bilaterally the lowest key muscle function that has at least grade 3 on supine testing
How do you determines level of neurologic injury?
- most caudal segment of cord with intact sensation and muscle function of 3 or more
- intact sensory and motor function must be present rostrally
How do you determine complete vs. incomplete SCI?
- absence of voluntary anal contraction
- no sensory or motor function preserved in sacral segments S4-S5
- no deep anal pressure
Sensory grading
0 - absent
1 - altered
2 - normal
Nt - not testable
What are growing pains in kids?
poorly localized pain in lower limbs (esp lower legs) at night
most often 2-12 yo
Define limp
laboured, jerky, or strenuous way of walking
- due to pain, weakness, deformity
Epidemiology of limb in kids
2/1000
M>F
hip > knee > leg
Types of limp
- antalgic gait: due to pain in weight-bearing leg causing short stance phase in gait (most common cause)
- trendeleburg gait: weak abductor muscles such that when standing on affected side, the pelvis drops on opposite side
Workup limp in peds
- CBC, CRP/ESR
- rheumatology workup if ddx inflammatory arthritis
- blood culture if infection
- INR/PTT if coagulopathy ddx
+/- rheumatic fever, Lyme disease, gonococcal or reactive arthritis
US hip if suspect DDH in what age
<4-6mo
Legg-Calve-Perthes
4-8yo
- idiopathic AVN of proximal femoral epiphysis
- bilateral 12%
M>F
- painless limp
- loss of internal rotation and abduction
- Trendelenburg gait
X-ray - collapse of femoral head late in disease
tx - activity modification, PT
- may need femoral or pelvic osteotomy
SCFE
early teens
- slippage of epiphysis relative to femoral head
M>F, increased BMI, hypothyroid
- groin, thigh, knee pain
- loss of hip internal rotation, abduction, flexion
- Trendelenburg or antalgic gait
X-ray both hips
tx- percutaneous in situ fixation
DDH
0-4yo
- dysplasia and instability of hip (subluxation or dislocation)
F>M, breech, fam hx, first born, L hip
- Galeazzi+, Ortolani or Barlow +, hip clock, differences in hip abduction
US if <4mo, X-ray if >4mo
tx - Pavlik harness, closed or open reduction and spica casting, may need femoral or pelvic osteotomy
Septic arthritis re: limp
- knee and hip most common
- infection via hematogenous or direct spread
IVDU, sexual infection, TB - fever, systemic sx
- joint effusion, tenderness, warmth
- joint held in position that relaxes joint capsule
- refusal to walk
WBC, CRP/ESR
xrays
joint aspiration
tx - IV abx, I&D
Osteomyelitis
0-5yo - usually hematogenous spread - can have recent local infection or trauma DM, sickle cell, immnuocompromised - fever, systemic sx, refusal to walk - edema, warmth, tenderness in limb - decreased ROM due to pain
WBC, CRP/ESR
- X-ray +/- bone scan
- bone cultures
tx - IV abx, +/- I&D
Transient synovitis
2-5yo
- unknown cause; may be viral infection or trauma
- pain/refusal to walk
r/o infection
tx- NSAIDs, self-limiting
Osgood-Schlater
traction apophysitis
M>F, jumping/sprinting activities
- can be bilateral; anterior knee pain worse with kneeling
- prominent tibial tubercle
- pain with resisted knee extension
X-ray of knee
tx - NSAIDs, activity modification; self-limiting
