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Surgery NBME > Orthopedics > Flashcards

Orthopedics Flashcards

1
Q

newborn child has uneven gluteal folds; on P/E they can be displaced posteriorly and snapped back into place - dx?

A

developmental dysplasia of the hip

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2
Q

what test should be ordered if you suspect developmental dysplasia of the hip?

A

USG

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3
Q

tx. of developmental dysplasia of hip

A

Pavlik harness - abduction splinting

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4
Q

6 yo boy comes in due to development of limping and decreased hip motion; he also complains of knee pain on the same side and walks with an antalgic gait - dx?

A

suspect Legg-Perthes disease (avascular necrosis of the capital femoral epiphysis)

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5
Q

what test do you do if you suspect Legg-Perthes disease?

A

AP and lateral XR of the hip

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6
Q

tx. of Legg Perthes disease

A

controversial

- contain the femoral head w/in the acetabulum with casting and crutches

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7
Q

a 13 yo obese/lanky boy comes in because he recently started limping and has pain in his groin; when he sits you notice the sole of the foot on the affected side points toward the other foot - what do you suspect? what test should you order?

A

slipped capital femoral epiphysis

- order AP and lateral XR

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8
Q

what do you find on PE in slipped capital femoral epiphysis?

A

there is limited hip motion and when the hip is flexed, the leg goes into external rotation and cannot be internally rotates

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9
Q

tx. for slipped capital femoral epiphysis

A

orthopedic surgery - pin the femoral head into place

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10
Q

a mother brings her toddler in because he refuses to move one of his legs; he was recently sick with the flu and now he is in pain and holds the leg with the hip flexed, in slight abduction and external rotation - what do you suspect?

A

septic hip

- his ESR will be elevated

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11
Q

tx. for septic hip in a toddler

A

aspiration under general anesthesia and open arthrotomy for drainage if pus present

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12
Q

a child with a febrile illness (no history of trauma) present with persistent, severe localized pain in a bone - dx?

A

acute hematogenous osteomyelitis

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13
Q

how do you confirm dx. of osteomyelitis? and how would you tx it?

A

MRI

- give antibiotics

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14
Q

a 2 year old child is brought in by concerned parents bc he is bow-legged

A

genu varum - normal up to age of 3

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15
Q

Blount disease

A

genu varum that persists after age 3

  • disturbance of the medial proximal tibial growth plate
  • should be tx. surgically
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16
Q

a 5 yo child is brought in by parents because he is knock-kneed

A

genu valgus is normal between ages 4-8 and no treatment is needed

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17
Q

physical exam findings in Osgood-Schlatter disease

A

aka. osteochondrosis of tibial tubercle

- persistent pain/localized tenderness over tibial tubercle that is aggravated by contraction of quadriceps

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18
Q

tx. of Osgood-Schlatter disease

A

first - RICE

second - immobilization of knee in an extension or cylinder cast for 4-6 weeks

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19
Q

deformities present in club-foot (4)

A 
plantar flexion of ankle
inversion of foot
adduction of the forefoot
internal rotation of tibia
- both feet are turned inward
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20
Q

tx. of clubfoot deformity

A

serial plaster casts in the neonatal period

- if surgery done, it should be done after age 6-8 months but before age 1-2

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21
Q

what is the most important thing in management of scoliosis?

A

the disease will continue progressing until skeletal maturity is reached, so if you patient is before puberty they should be braced to prevent progression
- surgery for severe cases

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22
Q

what do you do if you do an XR on a child with a broken bone in a cast and it shows significant angulation of the broken bone?

A

nothing… kids have tremendous ability to heal and remodel broken bones

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23
Q

what kind of fracture can you suspect in a young patient who breaks their arm by hyperextension injury?

A

supracondylar fracture of humerus

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24
Q

why is a supracondylar fracture in a child worrisome?

A

may produce vascular or nerve injuries resulting in Volkmann contracture

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25
Q

Tx. of fracture of long bone, involving the growth plate and epiphysis (laterally displaced but in one piece)

A

closed reduction and cast

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26
Q

tx. of fracture that goes through the growth plate

A

precise alignment with open reduction and internal fixation (or else growth will be disturbed)

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27
Q

MC primary malignant bone tumor

A

osteogenic sarcoma

- location: around knee (lower femur, upper tibia)

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28
Q

patient population that usually gets osteogenic sarcoma

A

young adolescents - between age 10-25

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29
Q

second MC primary malignant bone tumor

A

Ewing Sarcoma

  • young children 5-15 yo
  • usually in diaphysis of long bones
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30
Q

a 66 yo woman picks up a bag of groceries and breaks her arm - what should you immediately think of and what further tests are needed?

A
  • think of bone tumor (usually metastatic in older patients)

- order XR, whole body bone scans and CT scans to find the primary tumor

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31
Q

an older woman presents with a soft tissue mass in her thigh that has been growing for months; it is firm and fixed to surrounding structures - dx? test?

A
  • think of soft tissue sarcoma

- order MRI and refer to experts

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32
Q

where is the most common location of a clavicle break?

A

at the junction of the middle and distal thirds

- will demonstrate point tenderness over this area

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33
Q

tx. of clavicle fracture

A

arm sling

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34
Q

a pt hurts their shoulder, they come in with their arm held close to their body but rotated outward as if going to shake hands - dx?

A

anterior shoulder dislocation

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35
Q

besides for movement, what should you check for when examining anterior shoulder dislocation/

A

numbness over deltoid muscle - could demonstrate axillary nerve damage

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36
Q

how can you confirm diagnosis of anterior shoulder dislocation?

A

AP and lateral XR

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37
Q

what can cause posterior dislocation of shoulder?

A

massive uncontrolled muscle contractions such as in epileptic seizures and electrical burns (otherwise, rare)

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38
Q

in what position will the arm be with a posterior shoulder dislocation?

A

the pt will be holding their arm close to their body in a normal protective position

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39
Q

you suspect a posteriorly dislocated shoulder in a patient, but the XR appears normal - what should you do next?

A

order axillary view or scapular lateral XR - posterior dislocations are often missed on regular XR

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40
Q

Colles fracture

A

dorsally displaced, dorsally angulated fracture of distal radius often with small fracture of ulnar stylus

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41
Q

tx. of Colles fracture

A

closed reduction and long arm cast

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42
Q

Monteggia fracture

A

direct blow to ulna causing diaphyseal fracture of proximal ulna with anterior dislocation of radial head

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43
Q

tx. of Monteggia fracture

A

closed reduction of radial head

open reduction and internal fixation of ulnar fracture

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44
Q

Galeazzi fracture

A

fracture of distal third of radius and dorsal dislocation of distal radioulnar joint

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45
Q

pt comes in bc they fell on their outstretched hand and now has pain in the anatomical snuffbox area ; XR are normal - what do you do?

A

think scaphoid fracture (will not show on XR for 3 weeks) and put pt n thumb spica cast; re-order XR in 3 weeks

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46
Q

what do you do if XR shows displaced and angulated fracture of scaphoid bone?

A

open reduction and internal fixation

- scaphoid fractures are notorius for non-union

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47
Q

Boxer’s fracture

A

swollen and tender right hand with fracture of 4th and 5th metacarpal necks

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48
Q

tx. of Boxer’s fracture

A

mild cases - closed reduction and ulnar gutter splint

bad ones - Kirschner wire or plate fixation

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49
Q

old patient falls and hurts his hip; on exam, you note the affected leg is shorter and externally rotated

A

typical scenario for hip fracture

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50
Q

tx. for displaced femoral neck fracture

A

blood supply to femoral head is likely compromised and so tx involved a metal prosthesis instead of repair of femoral head

51
Q

tx. for intertrochanteric fracture

A
  1. open reduction and pinning

2. postop anticoagulation - pt is immobilized

52
Q

tx. of closed fracture of femoral shaft

A

intramedullary rod fixation

53
Q

what should you be concerned about in bilateral, comminuted femoral fractures?

A

the patient could have massive bleeding and go into shock

- tx. with external fixation until patient is stable

54
Q

tx. of open femur fractures

A

orthopedic emergency

- require OR cleaning and repair within 6 hours

55
Q

what are you thinking of pt who sustained femoral fracture and subsequently goes into respiratory distress?

A

fat embolism

- respiratory support needed!

56
Q

are you worried about a knee injury w/o swelling?

A

not really, these are rarely serious

57
Q

what is the MC way to injure a collateral knee ligament?

A

a blow to side of the knee

58
Q

how can you recognize a collateral knee ligament injury?

A

the knee will be swollen and tender to palpation over the affected side
- positive valgus (medial) or varus (lateral) stress test

59
Q

varus stress test

A

knee flexed at 30 degrees, passive ADDUCTION elicits pain over lateral aspect of knee and the leg can be adducted further than normal contralateral leg

60
Q

valgus stress test

A

knee in 30 degrees, passive ABDUCTION elicits pain over medial knee and leg can be abducted further than normal contralateral leg

61
Q

tx. of injury to MCL or LCL

A

hinged cast for isolated injury

- if several ligaments injured, surgical repair

62
Q

anterior drawer test

A

when knee is flexed at 90 degrees, the leg can be pulled anteriorly
- seen with injury to ACL

63
Q

Lachman test

A

knee flexed at 20 degrees, grasp thigh with one hand and pull the leg with the other (the leg can be pulled anteriorly)
- seen with injury to ACL

64
Q

tx. of ACL injuries

A

usually tx in atheletic patients with sugical reconstruction with graft from the patellar or hamstring tendons

65
Q

pt with a swollen knee and pain describes a catching and locking that limit motion in his knee; he feels a click when the knee is extended - you order XR and find they are normal - what dx test should you order next? dx?

A

order MRI

-suspect meniscal tear

66
Q

unhappy triad

A

injury to MCL, medial meniscus and ACL

67
Q

MC finding in a stress fracture

A

tender to palpation over a specific part of the bone; XR usually normal for first 2 weeks
- these kind of fractures tend to occur after repetitive movements

68
Q

tx. of stress fractures

A

tx. with cast and repeat XR in 2 weeks

- non weight bearing (crutches) also an option

69
Q

what fracture is common when a pedestrian is hit by a car?

A

tibial and fibular fracture

70
Q

tx. of tibial and fibular fractures

A

reduction and casting

- if difficult to reduce, intramedullar nailing may be needed

71
Q

a patient with a tibial fracture (or forearm) is casted and within a few hours complains of excruciating pain, esp on passive motion of toes (or fingers) - what should you do?

A

you suspect compartment syndrome - take off cast immediately and do fasciotomy

72
Q

a man playing tennis plants his foot down and turns in the other direction, he hears a loud pop and clenches his ankle in pain; on exam he has a positive thompson test and limited plantar flexion - dx?

A

achilles tendon rupture

73
Q

tx. of achilles tendon rupture

A

surgical repair followed by long leg cast for 6 weeks

74
Q

fracture of both malleoli

A

common injury during ankle eversion or inversion

- tx. with open reduction and internal fixation

75
Q

common precipitating events of compartment syndrome

A
  • prolonged ischemia with reperfusion
  • crush injuries
  • fractures with closed reduction (esp. forearm and lower leg)
76
Q

a patient who was just casted for a fracture develops pain under the cast - what should you do?

A

remove the cast and examine the extremity

- never resort to giving pain meds without further exam

77
Q

patient in a MVA hits the dashboard with his knees - what injury are you afraid of?

A

posterior hip dislocation with potential avascular necrosis of femoral head

78
Q

P/E findings in posterior hip dislocation

A

lower extremity is shortened, adducted and internally rotated

79
Q

tx. of posterior hip dislocation

A

emergent reduction

80
Q

tx. of gas gangrene

A

IV penicillin
immediate surgica debridement
hyperbaric O2 treatment

81
Q

fractures to the humeral shaft can cause injury to what nerve?

A

radial nerve (which courses in the spiral groove right around the posterior aspect of the humerus)

82
Q

characteristic finding in radial nerve injury

A

wrist drop - wrist cannot be extended

83
Q

tx. of humeral fracture with wrist drop

A

hanging arm cast or coaptation splint

- if nerve function remains after reduction - proceed to surgery

84
Q

a football player is hit straight on his right leg and he suffers posterior dislocation of the knee - what are you worried about?

A

injury to the popliteal artery (very little collateral flow in this area can result in vascular compromise of lower leg) –> do emergent reduction

85
Q

what hidden fractures are you worried about in someone who falls from a height, landing on legs and breaking them?

A

compression fractures of thoracic and lumbar spine

86
Q

what hidden fracture are you worried about with facial fractures and closed head injuries?

A

cervical spine fracture

- always order CT scan to R/O

87
Q

female complains of waking up at night with numbness and tingling in her hand - dx?

A

suspect carpal tunnel syndrome

88
Q

what findings on P/E suggest carpal tunnel syndrome?

A

percussion, pressure or hanging the hand limply causes numbness and tingling over the distribution of median nerve (radial 3.5 fingers)

89
Q

what test should be ordered if you suspect carpal tunnel syndrome?

A

mostly a clinical diagnosis but wrist XR incl. carpal tunnel view should be ordered to R/O other things

90
Q

tx. of carpal tunnel syndrome

A

wrist splint in neutral position and anti-inflammatories (NSAIDs)
- may use corticosteroid injections or surgical release

91
Q

what test should be ordered before surgery for carpal tunnel syndrome?

A

electromyography

92
Q

woman complains of a finger that becomes acutely flexed and she is unable to extend it unless she pulls on it at which time she feels a painful snap

A

trigger finger

- tx. steroid injections

93
Q

young woman complains of pain along the radial side of her wrist and first dorsal compartment of her wrist; pain is usually when she has her wrist flexed and thumb extended - dx?

A

de quervain tenosynovitis

94
Q

what P/E finding confirms de quervain tenosynovitis

A

pain when thumb is held inside closed fist and wrist in ulnar deviation

95
Q

tx. of de quervain tenosynovitis

A

splints and NSAIDS but corticosteroid injections are the best
- surgery rarely needed

96
Q

gamekeeper’s thumb

A

injury to ulnar collateral ligament of the thumb sustained by forced hyperextension

97
Q

P/E finding in gamekeeper’s thumb

A

collateral laxity at the thumb MCP joint

98
Q

tx. of gamekeepers thumb

A

casting

- if not treated it can be very dysfunctional and painful with resultant arthritis

99
Q

jersey finger

A

injury to flexor tendon sustained when the flexed finger is forcefully extended; when making a fist, the distal phalanx of injured finger does not flex

100
Q

mallet finger

A

extended finger is forcefully flexed and extensor tendon is ruptured; tip of affected finger remains flexed

101
Q

tx. of jersey and mallet fingers

A

splinting

102
Q

proper care of amputated digit

A
  1. clean it with sterile saline
  2. wrap in saline soaked sterile gauze
  3. place it in plastic bag
  4. place bag on bed of ice
103
Q

discogenic pain

A

pressure on anterior spinal ligament felt by patient as aching back pain

104
Q

classic pain of lumbar herniation

A

months of discogenic pain followed by severe neurogenic back pain that is aggravated by coughing, straining and sneezing; straight leg raise test reveals excruciating pain

105
Q

MC locations of lumbar disc herniation

A

L4-L5 (to big toe) or L5-S1 (to little toe)

106
Q

tx. of lumbar disc herniation

A

NSAIDs and physical therapy

- do not recommend bed rest!

107
Q

when should you consider surgery for lumbar disc herniation?

A

if there is progressive neuromuscular weakness or spincteric deficits (suspicion of cauda equina)

108
Q

in addition to symptoms of lumbar disc herniation, what signs suggest cauda equina syndrome?

A

perianal saddle anesthesia
distended bladder (overflow incontinence)
flaccid rectal sphincter (bowel incontinence)
impotence

109
Q

tx of cauda equina syndrome

A

immediate surgical decompression

110
Q

what kind of back pain is suggestive of malignancy?

A

progressive low back pain that is worse at night and not relieved by rest or positional changes

111
Q

what is the common location of diabetic foot ulcers?

A

at pressure points - heel, metatarsal head and toes

112
Q

what is the cause of diabetic foot ulcers?

A

neuropathy - but unlikely to heal due to poor microcirculation

113
Q

ulcer at the tip of toe looks blue, with no granulation tissue; on further exam, there are no peripheral pulses in that extremity

A

ischemic ulcer

114
Q

management of ischemic foot ulcer

A
  1. do Dopper study - measure pressure gradient

2. MRI or CT angio

115
Q

what does it mean when you find no pressure gradient in an ischemic ulcer on Doppler?

A

it is due to microvascular disease that is not amenable to surgical treatment

116
Q

a patient has a painless ulcer above her medial malleolus; the skin around it is thick, indurated and hyperpigmented

A

venous stasis ulcer

117
Q

management of venous stasis ulcer

A

Duplex scanning
unna boot or compression stockings
- varicose vein surgery or endoluminal ablation may be needed

118
Q

Marjolin ulcer

A

squamous cell carcinoma that develops at long standing chronic irritation sites (i.e. following third degree burn, chronic draining sinuses)

119
Q

tx. of Marjolin ulcer

A

biopsy first! followed by wide local exicision and skin grafting

120
Q

an older patient complains of sharp heel pain every time his foot strikes the ground; pain is worse in the mornings and he can barely put any weight on the heel

A

dx. plantar fasciitis

- order XR

121
Q

XR finding in plantar fasciitis

A

usually a bony spur (however, this is not the cause of the pain and does not need to be surgically removed)

122
Q

tx. plantar fasciitis

A

usually goes away on its own w/in 12-18 months

123
Q

Morton neuroma

A

inflammation of common digital nerve caused by wearing pointy shoes; P/E finding of very tender spot in third interspace between third and fourth toes

Surgery NBME (16 decks)

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