Orthopedics Flashcards
Discuss the presentation and management of an ACL tear
Mechanism:
- non-contact pivot injury
Presentation:
- “pop” with immediate pain and hemarthrosis
- avoidance of extension
- Lachman positive (may have initial difficulty due to swelling)
X-ray:
- Deep sulcus sign with impaction of anterior portion of lateral femoral condyle
MRI:
- disruption of the ACL
Treatment:
- physical therapy used for majority if non-active and stable
- ACL reconstruction
Discuss the presentation and management of meniscal injuries
Location:
- medial tears more common than lateral tears (unless acute with ACL tear than it is lateral)
Mechanism:
- repetitive injury
- Acute twisting injury
Classification:
- red-red zone is periphery (outer third)
- red-white zone is middle third
- white-white zone is inner third (a vascular)
Pattern:
- bucket handle
- vertical
- parrot beak (oblique)
Presentation:
- pain localizing to medial or lateral side with PwP along medial or lateral joint line
- Locking and clicking
- delayed swelling
- McMurray: ER and varus for medial and IR and valgus for lateral
MRI
- double PCL or double anterior horn sign
Treatment:
- rest, NSAIDs, physis
- Partial meniscetomy when in white-white
- Meniscal repair if have good vascular supply
Discuss the presentation of a disruption of the extensor mechanism
Mechanism:
- tensile overload with resisted knee extension
- quadriceps more common than patella (especially in older adults)
Presentation:
- sudden knee extension with “pop” and pain afterwards
- PwP and defect
- disruption of extension
X-ray:
- patella Alta or Baja (measured on lateral with longitudinal length of patella compared to patellar tendon which should be = 1)
Management:
- primary repair or reconstruction
Discuss the presentation and management of MCL injuries
Mechanism: - valgus stress to the knee - terrible triad: MCL, ACL and medial meniscus injury Presentation: - “pop” - medial joint line pain and PwP - valgus stress test positive Treatment: - mainly nonoperative unless associated injury - bracing for grade 2-3 injuries
Discuss the presentation and management of rotator cuff tears
Mechanism:
- chronic degenerative tear: SIT muscles
- chronic impingement
- acute avulsion: subscapularis in younger patients, SIT in those >40
Presentation:
- insidious onset of pain which increases with overhead activities
- night pain
- loss of active ROM, good passive ROM
- Supraspinatus: painful arc, drop arm test, Jobe
- Infraspinatus: ER resistance
- Teres minor: ER resistance
- Subscapularis: lift off
Investigations:
- US
Treatment:
- PT, NSAIDs, injection first line for most tears
- subacromial decompression
- rotator cuff repair
Discuss the presentation and management of AC joint injuries
Mechanism:
- Direct impact on shoulder
Presentation:
- pain
Classification:
- Type 1: pain, no instability require sling
- Type 2: increase in CC distance by <25%, sling
- Type 3: increase in CC distance by 25-100%, sling
- Type 4: superior displacement and skin tenting with posterior displacement, surgery
- Type 5: increase in CC distance >100%, surgery
- Type 6: inferior dislocation
Discuss the presentation and management of subacromial impingement
Mechanism:
- mix of extrinsic compression between numeral head and acromion/coracoacromial ligament/acromioclavicular joint and instrinsic degeneration of supraspinatus
Presentation:
- insidious onset of pain that is worse with overhead activities
- night pain
- Neer positive
- Painful arc
X-ray:
- type III hooked acromion
- proximal migration of humerus with rotator cuff arthropathy
Treatment:
- NSAIDs, PT, injection
- decompression/acromioplasty when failed for >4-6 months
Discuss the presentation and management of Achilles’ tendon rupture
Epidemiology
- Most common in middle aged men (weekend warrior)
- Risk with fluoroquinolone and steroid injections
Mechanism:
- Traumatic injury with forceful platanflexion or dorsiflexion
Presentation:
- “pop”
- weakness and limited weightbearing
- Palpable gap
- Decreased plantarflexion
- Thompson test
Investigations:
- X-ray to rule out avulsion
- Ultrasound to determine if complete or partial
Treatment:
- Functional bracing in equines (plantarflexed)
- Achilles’ tendon repair
What are the risk factors for developmental dysplasia of the hip
- Family history
- Breech positioning
- First born
- Female
What is the examination and investigation for DDH
Ortolani: Reducing hip
Barlow: Dislocating hip
Galeazzi: limb length discrepency when flexed to 90 degrees
Limitation to hip abduction when >3 months
Ultrasound: from birth to 4 months
X-ray from 4-6 months
- Hilgenreiner’s line (ossification inferior to line)
- Perkin’s line (ossification medial to this line)
- Shenton’s line (continuous line)
- Acetabular index (<25 degrees in >6 months)
- Centre edge angle (> 20 degrees in older >5)
Management:
- Pavlik harness beginning if less than 6 months
- Closed reduction if between 6-18 months
- Open reduction if >18 months
Discuss the presentation and management of osteomyelitis
Pathophysiology - have hematogenous spread of bacteria that get stuck in the spiral arteries along the metaphysis - staph aureus - salmonella typhi in sickle cell Presentation - localized extremity pain with associated skin erythema and swelling - fever Investigations - CBC, ESR, CRP - MRI Management - Require IV Ancef until CRP decreases by half and then PO for 4 weeks.
Discuss the presentation and management of SCFE
- type 1 salter harris injury
- occur during pubertal growth
Risk Factors - male
- obese
- hypothyroid
Presentation - sudden severe ipsilateral hip pain in acute setting
- limp with ipsilateal knee pain
- restricted ROM to internal rotation, abduction and flexion
- obligate external rotation of the hip with flexion
Investigation - X-ray show disruption of Klein line
Management - ORIF
Discuss the radiographic findings of a osteosarcoma
Malignant bone lesion found in 8-20 year olds.
- Mostly found in knee and shoulder
X-ray:
- aggressive osteoid matrix and sunburst periosteal reaction
What are the four signs that help to differentiate an aggressive vs non-aggressive bone lesion?
Cortical destruction:
- Less aggressive: no cortical destruction with white cortical border outlining lesion
- Aggressive: cortical destruction with no white border
Periosteal reaction:
- Less aggressive: thick and wavy reaction
- Aggressive: laminated (onion skin) or sunburst reaction
Axis:
- Less aggressive: long axis along length of bone
- Aggressive: short axis along width of bone
Margins: border between lesion and normal bone
- Less aggressive: narrow zone of transition with clearly defined sclerotic margin
- Aggressive: wide zone of transition with ill defined margin
List the density, matrix and bone destruction characteristics
Density:
- Lytic/lucent: area of low density so appears dark
- Sclerotic: area of high density so appears white
- Mixed: area of low and high density
Matrix:
- Osteoid: dense amorphous (uniform) sclerotic lesion with white spicules outside bone
- Chondroid: morphic (non-uniform) mixed lesion with grape clusters, little round white balls, arcs and rings
- Fibrous: ground glass
- Indeterminate: lytic lesion
Bone Destruction: only in lytic lesion
- Geographic: localized, concentrated lytic lesion with sharply defined borders with possible sclerotic margin
- Moth eaten: bone destruction with multiple sites and ragged borders
- Permeative: bone destruction at multiple sites with ill defined borders
