Orthopedics Flashcards
What is the next imaging step for babies with uneven gluteal folds and a hip that jerks and clicks?
Ultrasound! (X ray not helpful because the hip is not calcified in the newborn)
What is the treatment of developmental dysplasia of the hip?
Abduction splinting with Pavlik harness for 6 months
Hip pathology may show up as pain in these two places:
hip or knee
What is Legg-Calve-Perves disease and how is it diagnosed?
avascular necrosis of the capital femoral epiphysis; occurs around age 6yo. Diagnosis by AP and lateral hip xrays
What is the treatment of SCFE?
Surgical treatment to pin the femoral head back into place
When the hip is flexed and turns externally, cannot be turned internally, chubby teenager, think:
SCFE; X rays diagnostic
What is genu varum? Genu valgus?
Genu varum = bow legged
Genu valgus = knock kneed
What is genu varum past age 3?
Blount disease (a disturbance of the medial proximal tibial growth plate); treatment is surgery
Genu valgus is normal between ages _______. No treatment is necessary
4-8`
What is Osgood-Schlatter disease? What is the treatment?
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
Those infants whose club foot (talipes equinovarus) do not respond to serial plaster casting require surgery, typically done between which ages?
9-12 months
At the onset of menses, skeletal maturity is about ___%
80%
T/F: Sometimes Achilles tenotomy is required for talipes equinovarus.
True
= clubfoot
What fracture can lead to Volkmann’s contracture (permanent flexion of the hand at the wrist)?
supracondylar fracture of the humerus
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:
supracondylar fracture of the humerus
This primary bone tumor is described with a typical “sunburst” pattern:
Osteogenic sarcoma (usually around the knee–> lower femur or upper tibia)
When do you use closed vs open reduction in fractures involving the growth plate in children?
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.
What is the most common primary malignant bone tumor?
Osteogenic sarcoma (sunburst)
What is the second most common primary malignant bone tumor and what is its characteristic X ray appearance?
Ewing sarcoma; diaphyses of long bones; onion-skinning seen on X rays
Most malignant bone tumors in adults are metastatic; from where in women and where in men?
lytic lesions from breast in women
blastic lesions from prostate in men
X rays showing multiple punched out lesions. Treatment?
Multiple myeloma! Treatment is chemotherapy; thalidomide can be used if chemo fails
Where do soft tissue sarcoma metastasize?
Lungs, but not to lymph nodes!!
How do you treat clavicular fractures?
sling; typically at junction of middle and distal thirds
In anterior shoulder dislocation, might have rotated outward arm with numbness in a small area over the deltoid, from stretching of the __________ nerve
axillary
What is the most common etiology of posterior shoulder dislocation?
epileptic seizure or electrical burn
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?
axillary or scapular lateral views
Old osteoporotic woman falls on outstretched hand. X ray looks like dinner fork: dorsally displaced, dorsally angulated fracture of distal radius:
Treatment?
Colles fracture! Treat with closed reduction and long arm cast`
Fracture resulting from direct blow to the ulna (such as on a raised protective arm hit by a nightstick).
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
Distal third of radius gets direct blow and fractures with dorsal dislocation of the distal radioulnar joint.
Galeazzi fracture: open reduction and internal fixation with closed reduction of dislocated ulna
What is the treatment of carpal navicular fracture?
scaphoid fracture! thumb spica cast if X ray negative; open reduction and internal fixation of X ray shows fracture
Metacarpal neck fractures (typically the fourth, fifth, or both) happen when
a closed fist hits a hard surface (like a wall)
What is the treatment of metacarpal neck fractures?
closed reduction and ulnar gutter splint for mild ones; Kirschner wire or plate fixation for bad ones
Patient in stretcher with affected leg shortened and externally located:
hip fracture!
Which is more likely to lead to avascular necrosis of the femoral head: intertrochanteric fractures or femoral neck fractures?
femoral neck fractures
How are intertrochanteric fractures treated?
ORIF and post-op anticoagulation (necessary immbilization during healing)
How are femoral shaft fractures treated?
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.
Medial blows to the knee disrupt the (medial/lateral) collateral ligaments.
medial blows disrupt lateral, and vice versa
Abduction demonstrates (medial/lateral) injuries to the leg, also known as the (valgus/varus) stress test.
Abduction –> lateral injury (medial blow) –> valgus stress test
Adduction –> medial injury (lateral blow) –> varus stress test
How are collateral ligament tears treated?
Isolated injury = hinged cast
Multiple injuries = surgical repair
(Anterior/posterior) cruciate ligament injuries are more common.
Anterior
In anterior cruciate ligament injuries, with the knee flexed 90*, the leg can be pulled (anteriorly/posteriorly).
Anteriorly! This is the anterior drawer test. Posterior cruciate ligament injuries produce opposite findings
Patients with this knee injury may describe catching and locking that limit knee motion, and a “click” when the knee is forcibly extended:
Meniscal tears. Try to save as much meniscus as possible in repair (open repair), otherwise predisposes to degenerative arthritis
Complete meniscectomy leads to late development of
degenerative arthritis
Which two knee injuries often occur simultaneously with damage to the anterior cruciate?
1) anterior cruciate
2) medial collateral
3) medial meniscus
These fractures are seen in young men subjected to forced marches and feature tenderness to palpation over a very specific point on the bone:
Tibial stress fractures. X ray initally normal; cast or crutches
These fractures are often seen when a pedestrian is hit by a car:
leg fractures involving the tibia and fibula; beware of compartment syndrome! (lower leg and forearm are very common locations for development)
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)
achilles tendon rupture! Casting in equinus position heals in several months; surgery = quicker.
T/F: In an ankle fracture, both malleoli break.
True
In the lower leg, the most common cause of compartment syndrome is:
fracture with closed reduction
Pain under a cast is always handled by
removing the cast and examining the limb
Open fractures require cleaning in the OR and suitable reduction within ___ hours
6
What is the difference in presentation between a broken hip and a posteriorly dislocated hip?
Both cases the leg is shortened, but the posterior dislocation = INTERNAL rotation
fracture = EXTERNAL rotation
What is the treatment of gas gangrene?
Copious IV penicillin, emergency surgical debridement, and hyperbaric oxygen
Oblique fractures of the middle to distal thirds of the humerus can injure the
radial nerve (inability to extend the wrist)
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
the popliteal artery
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.
lumbar or thoracic spine
How might posterior dislocation of the hip?
Head-on-collision in a car where knees hit the dashboard
Facial fractures and closed head injuries should always prompt evaluation of
the cervical spine
Patients with carpal tunnel have numbness and tingling in the hands, particularly at night, and in the distribution of the medial nerve (which fingers??)
radial 3 1/2 fingers
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?
Trigger finger! Steroid injection is first line; surgery last resort
What is De Quervain tenosynovitis? How can the pain be reproduced? Treatment?
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
What is Dupuytren contracture?
contracture of the palm of the hand, and palmar fascial nodules can be felt
Abscess in the pulp of a fingertip, caused by neglected penetrating injury:
Treatment?
felon. Requires urgent surgical drainage
Treatment of gamekeeper thumb (injury of ulnar collateral ligament caused by hyperextension of the thumb):
casting
Flexed finger forcefully extended. Distal phalanx does not flex with others when fist made.
Jersey finger; splint
Extended finger forcefully flexed (volleyball injury). Tip of affected finger remains flexed when hand extended:
Mallet finger; splinting
Treatment of traumatically amputated digits:
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
Lumbar disk herniation occurs at what level?
L4-L5 or L5-S1
What is the vague aching pain of lumbar disk herniation?
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
T/F: If back pain is not exacerbated by coughing, sneezing, or defecating, then the problem is not a herniated lumbar disk.
True
What is the test for lumbar disk herniation?
Straight leg raising test (gives excruciating pain)
What is the treatmetn of lumbar disk herniation?
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
When is emergency intervention for immediate decompression required for back pain?
If associated with cauda equina syndrome:
1) distended bladder
2) flaccid rectal sphincter
3) perineal saddle anesthesia
T/F: The pain of ankylosing spondylitis improves with rest.
False!! Morning stiffness worse at rest, improves with activity
Ankylosing spondylitis shows what on X ray?
Bamboo spine
Many patients with ankylosing spondylitis have the ______ antigen, which is also associated with uveitis and inflammatory bowel disease.
HLA B-27
What is the treatmetn of ankylosing spondylitis?
Anti-inflammatory agents and physical therapy
______________ should be suspected in elderly who have progressive back pain that is worse at night and unrelieved by rest or positional changes.
Metastatic malignancy
What other manifestations of arteriosclerotic occlusive disease will a patient with ulcers from arterial insufficiency on the tip of toes have?
1) absent pulses
2) trophic changes (loss of hair, dry skin)
3) claudication or rest pain
What is the workup of ischemic ulcers?
Doppler studies looking for pressure gradient (without one, not amenable to surgical tx)
CT angio/MRA/surgical revascularization, or angioplasty and stents
Chronically edematous, indurated, hyperpigmented skin above the medial malleous ulcer:
venous stasis ulcer
Untreated third-degree burns that underwent spontaneous healing or chronic draining sinuses secondary to osteomyelitis are two classic settings for:
Marjolin ulcer, squamous cell carcinoma
What is the treatment for Marjolin ulcer?
Biopsy diagnostic; wide local excision and skin grafting
Older, overweight patients who complain of disabling, sharp heel pain every time their foot strikes the ground:
plantar fasciitis
The pain of plantar fasciitis is (better/worse) in the mornings.
Worse
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.
False! Many asymptomatic people have similar spurs
Spontaneous resolution of plantar fasciitis can be expected in ______ months.
12-18 (during which time symptomatic treatment is offered). Bony spur can be removed.
Inflammation of the common digital nerve at the third interspace (between the third and fourth toes), palpable as a tender spot there:
Morton neuroma
What is the cause of Morton neuroma? What is the treatment?
Cause: pointed high-heeled shoes or cowboy boots that force toes to be bunched together
Treatment: analgesics, more sensitive shoes, surgical excision if needed
What is the treatment of an acute attack of gout? Chronic control?
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)
