Orthopedics

Question 1

What is the next imaging step for babies with uneven gluteal folds and a hip that jerks and clicks?

Answer 1

Ultrasound! (X ray not helpful because the hip is not calcified in the newborn)

Question 2

What is the treatment of developmental dysplasia of the hip?

Answer 2

Abduction splinting with Pavlik harness for 6 months

Question 3

Hip pathology may show up as pain in these two places:

Answer 3

hip or knee

Question 4

What is Legg-Calve-Perves disease and how is it diagnosed?

Answer 4

avascular necrosis of the capital femoral epiphysis; occurs around age 6yo. Diagnosis by AP and lateral hip xrays

Question 5

What is the treatment of SCFE?

Answer 5

Surgical treatment to pin the femoral head back into place

Question 6

When the hip is flexed and turns externally, cannot be turned internally, chubby teenager, think:

Answer 6

SCFE; X rays diagnostic

Question 7

What is genu varum? Genu valgus?

Answer 7

Genu varum = bow legged

Genu valgus = knock kneed

Question 8

What is genu varum past age 3?

Answer 8

Blount disease (a disturbance of the medial proximal tibial growth plate); treatment is surgery

Question 9

Genu valgus is normal between ages _______. No treatment is necessary

Answer 9

4-8`

Question 10

What is Osgood-Schlatter disease? What is the treatment?

Answer 10

Osteochondrosis of the tibial tubercle (persistent pain); esp with contraction of quadriceps
Treatment is RICE: rest, ice, compression, elevation, but extension or cylinder cast for 4-6 weeks if conservative measures unsuccessful

Question 11

Those infants whose club foot (talipes equinovarus) do not respond to serial plaster casting require surgery, typically done between which ages?

Answer 11

9-12 months

Question 12

At the onset of menses, skeletal maturity is about ___%

Answer 12

80%

Question 13

T/F: Sometimes Achilles tenotomy is required for talipes equinovarus.

Answer 13

True

= clubfoot

Question 14

What fracture can lead to Volkmann’s contracture (permanent flexion of the hand at the wrist)?

Answer 14

supracondylar fracture of the humerus

Question 15

Hyperextension of the elbow in a child who falls on the hand with the arm extended puts them at risk for this kind of fracture:

Answer 15

supracondylar fracture of the humerus

Question 16

This primary bone tumor is described with a typical “sunburst” pattern:

Answer 16

Osteogenic sarcoma (usually around the knee–> lower femur or upper tibia)

Question 17

When do you use closed vs open reduction in fractures involving the growth plate in children?

Answer 17

If the epiphyses and growth plate are displaced laterally from the metaphysis but are in one piece (does not cross epiphyses or growth plate and does involve the joint), closed reduction is fight. Otherwise open reduction and internal fixation.

Question 18

What is the most common primary malignant bone tumor?

Answer 18

Osteogenic sarcoma (sunburst)

Question 19

What is the second most common primary malignant bone tumor and what is its characteristic X ray appearance?

Answer 19

Ewing sarcoma; diaphyses of long bones; onion-skinning seen on X rays

Question 20

Most malignant bone tumors in adults are metastatic; from where in women and where in men?

Answer 20

lytic lesions from breast in women

blastic lesions from prostate in men

Question 21

X rays showing multiple punched out lesions. Treatment?

Answer 21

Multiple myeloma! Treatment is chemotherapy; thalidomide can be used if chemo fails

Question 22

Where do soft tissue sarcoma metastasize?

Answer 22

Lungs, but not to lymph nodes!!

Question 23

How do you treat clavicular fractures?

Answer 23

sling; typically at junction of middle and distal thirds

Question 24

In anterior shoulder dislocation, might have rotated outward arm with numbness in a small area over the deltoid, from stretching of the __________ nerve

Answer 24

axillary

Question 25

What is the most common etiology of posterior shoulder dislocation?

Answer 25

epileptic seizure or electrical burn

Question 26

Since X rays can easily miss posterior dislocation of shoulder (unlike anterior dislocation, in which AP and lateral x rays are diagnostic), you should do what views?

Answer 26

axillary or scapular lateral views

Question 27

Old osteoporotic woman falls on outstretched hand. X ray looks like dinner fork: dorsally displaced, dorsally angulated fracture of distal radius: Treatment?

Answer 27

Colles fracture! Treat with closed reduction and long arm cast`

Question 28

Fracture resulting from direct blow to the ulna (such as on a raised protective arm hit by a nightstick).

Answer 28

Monteggia fracture = Diaphyseal fracture of the proximal ulna, with anterior dislocation of the radial head: Open reduction and internal fixation; dislocated radial head is closed reduction

Question 29

Distal third of radius gets direct blow and fractures with dorsal dislocation of the distal radioulnar joint.

Answer 29

Galeazzi fracture: open reduction and internal fixation with closed reduction of dislocated ulna

Question 30

What is the treatment of carpal navicular fracture?

Answer 30

scaphoid fracture! thumb spica cast if X ray negative; open reduction and internal fixation of X ray shows fracture

Question 31

Metacarpal neck fractures (typically the fourth, fifth, or both) happen when

Answer 31

a closed fist hits a hard surface (like a wall)

Question 32

What is the treatment of metacarpal neck fractures?

Answer 32

closed reduction and ulnar gutter splint for mild ones; Kirschner wire or plate fixation for bad ones

Question 33

Patient in stretcher with affected leg shortened and externally located:

Answer 33

hip fracture!

Question 34

Which is more likely to lead to avascular necrosis of the femoral head: intertrochanteric fractures or femoral neck fractures?

Answer 34

femoral neck fractures

Question 35

How are intertrochanteric fractures treated?

Answer 35

ORIF and post-op anticoagulation (necessary immbilization during healing)

Question 36

How are femoral shaft fractures treated?

Answer 36

Intramedullary rod fixation, but if bilateral and comminuted, may lead to shock so require external fixation. If open, they are an orthopedic emergency requiring surgery within 6 hours. Can produce fat emboli.

Question 37

Medial blows to the knee disrupt the (medial/lateral) collateral ligaments.

Answer 37

medial blows disrupt lateral, and vice versa

Question 38

Abduction demonstrates (medial/lateral) injuries to the leg, also known as the (valgus/varus) stress test.

Answer 38

Abduction --> lateral injury (medial blow) --> valgus stress test Adduction --> medial injury (lateral blow) --> varus stress test

Question 39

How are collateral ligament tears treated?

Answer 39

Isolated injury = hinged cast | Multiple injuries = surgical repair

Question 40

(Anterior/posterior) cruciate ligament injuries are more common.

Answer 40

Anterior

Question 41

In anterior cruciate ligament injuries, with the knee flexed 90*, the leg can be pulled (anteriorly/posteriorly).

Answer 41

Anteriorly! This is the anterior drawer test. Posterior cruciate ligament injuries produce opposite findings

Question 42

Patients with this knee injury may describe catching and locking that limit knee motion, and a "click" when the knee is forcibly extended:

Answer 42

Meniscal tears. Try to save as much meniscus as possible in repair (open repair), otherwise predisposes to degenerative arthritis

Question 43

Complete meniscectomy leads to late development of

Answer 43

degenerative arthritis

Question 44

Which two knee injuries often occur simultaneously with damage to the anterior cruciate?

Answer 44

1) anterior cruciate 2) medial collateral 3) medial meniscus

Question 45

These fractures are seen in young men subjected to forced marches and feature tenderness to palpation over a very specific point on the bone:

Answer 45

Tibial stress fractures. X ray initally normal; cast or crutches

Question 46

These fractures are often seen when a pedestrian is hit by a car:

Answer 46

leg fractures involving the tibia and fibula; beware of compartment syndrome! (lower leg and forearm are very common locations for development)

Question 47

Out-of-shape middle-aged men who subject themselves to severe strain (tennis, for instance) are subject to this injury: (loud popping, palpation of tendon reveals gap)

Answer 47

achilles tendon rupture! Casting in equinus position heals in several months; surgery = quicker.

Question 48

T/F: In an ankle fracture, both malleoli break.

Answer 48

True

Question 49

In the lower leg, the most common cause of compartment syndrome is:

Answer 49

fracture with closed reduction

Question 50

Pain under a cast is always handled by

Answer 50

removing the cast and examining the limb

Question 51

Open fractures require cleaning in the OR and suitable reduction within ___ hours

Answer 51

6

Question 52

What is the difference in presentation between a broken hip and a posteriorly dislocated hip?

Answer 52

Both cases the leg is shortened, but the posterior dislocation = INTERNAL rotation fracture = EXTERNAL rotation

Question 53

What is the treatment of gas gangrene?

Answer 53

Copious IV penicillin, emergency surgical debridement, and hyperbaric oxygen

Question 54

Oblique fractures of the middle to distal thirds of the humerus can injure the

Answer 54

radial nerve (inability to extend the wrist)

Question 55

Posterior dislocations of the knee should prompt attention to integrity of pulses, Doppler studies, or CT angio because it can be associated with injury to

Answer 55

the popliteal artery

Question 56

Falls from a heigh landing on feet may have obvious foot or leg fractures, but fractures of ____________ may be less obvious and need to be looked for.

Answer 56

lumbar or thoracic spine

Question 57

How might posterior dislocation of the hip?

Answer 57

Head-on-collision in a car where knees hit the dashboard

Question 58

Facial fractures and closed head injuries should always prompt evaluation of

Answer 58

the cervical spine

Question 59

Patients with carpal tunnel have numbness and tingling in the hands, particularly at night, and in the distribution of the medial nerve (which fingers??)

Answer 59

radial 3 1/2 fingers

Question 60

Patients wake up in the middle of the night with the finger acutely flexed. Have to use other hand to straighten it out with painful "snap": Treatment?

Answer 60

Trigger finger! Steroid injection is first line; surgery last resort

Question 61

What is De Quervain tenosynovitis? How can the pain be reproduced? Treatment?

Answer 61

Often seen in young mothers with hand in forced flexion to breast feed. Pain along the radial side of the wrist and first dorsal compartment. Reproduced by fist with thumb inside and then forcing ulnar deviation of wrist. Treatment = steroid injection; splint and anti-inflammatory; surgery rarely needed

Question 62

What is Dupuytren contracture?

Answer 62

contracture of the palm of the hand, and palmar fascial nodules can be felt

Question 63

Abscess in the pulp of a fingertip, caused by neglected penetrating injury: Treatment?

Answer 63

felon. Requires urgent surgical drainage

Question 64

Treatment of gamekeeper thumb (injury of ulnar collateral ligament caused by hyperextension of the thumb):

Answer 64

casting

Question 65

Flexed finger forcefully extended. Distal phalanx does not flex with others when fist made.

Answer 65

Jersey finger; splint

Question 66

Extended finger forcefully flexed (volleyball injury). Tip of affected finger remains flexed when hand extended:

Answer 66

Mallet finger; splinting

Question 67

Treatment of traumatically amputated digits:

Answer 67

clean with sterile saline, put in a saline moistened gauze, seal in plastic bag placed on ice (do not allow to freeze!). Electrical nerve stimulation can preserve muscular function, allowing entire amputated extremities to be reattached

Question 68

Lumbar disk herniation occurs at what level?

Answer 68

L4-L5 or L5-S1

Question 69

What is the vague aching pain of lumbar disk herniation?

Answer 69

Discogenic pain produced by pressure on the anterior spinal ligament, before onset of "neurogenic pain" precipitated by forced movement = like an electrical shock shooting down the leg

Question 70

T/F: If back pain is not exacerbated by coughing, sneezing, or defecating, then the problem is not a herniated lumbar disk.

Answer 70

True

Question 71

What is the test for lumbar disk herniation?

Answer 71

Straight leg raising test (gives excruciating pain)

Question 72

What is the treatmetn of lumbar disk herniation?

Answer 72

bed rest for 3 weeks, pain control with nerve blocks under radiologic guidance; surgical intervention if neurologic defecits are progressing, emergency intervention if there is a cauda equina syndrome

Question 73

When is emergency intervention for immediate decompression required for back pain?

Answer 73

If associated with cauda equina syndrome: 1) distended bladder 2) flaccid rectal sphincter 3) perineal saddle anesthesia

Question 74

T/F: The pain of ankylosing spondylitis improves with rest.

Answer 74

False!! Morning stiffness worse at rest, improves with activity

Question 75

Ankylosing spondylitis shows what on X ray?

Answer 75

Bamboo spine

Question 76

Many patients with ankylosing spondylitis have the ______ antigen, which is also associated with uveitis and inflammatory bowel disease.

Answer 76

HLA B-27

Question 77

What is the treatmetn of ankylosing spondylitis?

Answer 77

Anti-inflammatory agents and physical therapy

Question 78

______________ should be suspected in elderly who have progressive back pain that is worse at night and unrelieved by rest or positional changes.

Answer 78

Metastatic malignancy

Question 79

What other manifestations of arteriosclerotic occlusive disease will a patient with ulcers from arterial insufficiency on the tip of toes have?

Answer 79

1) absent pulses 2) trophic changes (loss of hair, dry skin) 3) claudication or rest pain

Question 80

What is the workup of ischemic ulcers?

Answer 80

Doppler studies looking for pressure gradient (without one, not amenable to surgical tx) CT angio/MRA/surgical revascularization, or angioplasty and stents

Question 81

Chronically edematous, indurated, hyperpigmented skin above the medial malleous ulcer:

Answer 81

venous stasis ulcer

Question 82

Untreated third-degree burns that underwent spontaneous healing or chronic draining sinuses secondary to osteomyelitis are two classic settings for:

Answer 82

Marjolin ulcer, squamous cell carcinoma

Question 83

What is the treatment for Marjolin ulcer?

Answer 83

Biopsy diagnostic; wide local excision and skin grafting

Question 84

Older, overweight patients who complain of disabling, sharp heel pain every time their foot strikes the ground:

Answer 84

plantar fasciitis

Question 85

The pain of plantar fasciitis is (better/worse) in the mornings.

Answer 85

Worse

Question 86

T/F: The bony spur seen on X ray matching the location of the pain in plantar fasciitis is the cause of the pain problem.

Answer 86

False! Many asymptomatic people have similar spurs

Question 87

Spontaneous resolution of plantar fasciitis can be expected in ______ months.

Answer 87

12-18 (during which time symptomatic treatment is offered). Bony spur can be removed.

Question 88

Inflammation of the common digital nerve at the third interspace (between the third and fourth toes), palpable as a tender spot there:

Answer 88

Morton neuroma

Question 89

What is the cause of Morton neuroma? What is the treatment?

Answer 89

Cause: pointed high-heeled shoes or cowboy boots that force toes to be bunched together Treatment: analgesics, more sensitive shoes, surgical excision if needed

Question 90

What is the treatment of an acute attack of gout? Chronic control?

Answer 90

Acute: indomethacin and colchicine (binds to microtubules, prevents mitosis, prevents neutrophil motility and activity) chronic: allopurinol (inhibitor of xanthine oxidase, which makes uric acid) and probenicid (increases uric acid excretion in urine)