Orthopedics Flashcards
newborn child has uneven gluteal folds; on P/E they can be displaced posteriorly and snapped back into place - dx?
developmental dysplasia of the hip
what test should be ordered if you suspect developmental dysplasia of the hip?
USG
tx. of developmental dysplasia of hip
Pavlik harness - abduction splinting
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?
suspect Legg-Perthes disease (avascular necrosis of the capital femoral epiphysis)
what test do you do if you suspect Legg-Perthes disease?
AP and lateral XR of the hip
tx. of Legg Perthes disease
controversial
- contain the femoral head w/in the acetabulum with casting and crutches
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?
slipped capital femoral epiphysis
- order AP and lateral XR
what do you find on PE in slipped capital femoral epiphysis?
there is limited hip motion and when the hip is flexed, the leg goes into external rotation and cannot be internally rotates
tx. for slipped capital femoral epiphysis
orthopedic surgery - pin the femoral head into place
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?
septic hip
- his ESR will be elevated
tx. for septic hip in a toddler
aspiration under general anesthesia and open arthrotomy for drainage if pus present
a child with a febrile illness (no history of trauma) present with persistent, severe localized pain in a bone - dx?
acute hematogenous osteomyelitis
how do you confirm dx. of osteomyelitis? and how would you tx it?
MRI
- give antibiotics
a 2 year old child is brought in by concerned parents bc he is bow-legged
genu varum - normal up to age of 3
Blount disease
genu varum that persists after age 3
- disturbance of the medial proximal tibial growth plate
- should be tx. surgically
a 5 yo child is brought in by parents because he is knock-kneed
genu valgus is normal between ages 4-8 and no treatment is needed
physical exam findings in Osgood-Schlatter disease
aka. osteochondrosis of tibial tubercle
- persistent pain/localized tenderness over tibial tubercle that is aggravated by contraction of quadriceps
tx. of Osgood-Schlatter disease
first - RICE
second - immobilization of knee in an extension or cylinder cast for 4-6 weeks
deformities present in club-foot (4)
plantar flexion of ankle inversion of foot adduction of the forefoot internal rotation of tibia - both feet are turned inward
tx. of clubfoot deformity
serial plaster casts in the neonatal period
- if surgery done, it should be done after age 6-8 months but before age 1-2
what is the most important thing in management of scoliosis?
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
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?
nothing… kids have tremendous ability to heal and remodel broken bones
what kind of fracture can you suspect in a young patient who breaks their arm by hyperextension injury?
supracondylar fracture of humerus
why is a supracondylar fracture in a child worrisome?
may produce vascular or nerve injuries resulting in Volkmann contracture
Tx. of fracture of long bone, involving the growth plate and epiphysis (laterally displaced but in one piece)
closed reduction and cast
tx. of fracture that goes through the growth plate
precise alignment with open reduction and internal fixation (or else growth will be disturbed)
MC primary malignant bone tumor
osteogenic sarcoma
- location: around knee (lower femur, upper tibia)
patient population that usually gets osteogenic sarcoma
young adolescents - between age 10-25
second MC primary malignant bone tumor
Ewing Sarcoma
- young children 5-15 yo
- usually in diaphysis of long bones
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?
- think of bone tumor (usually metastatic in older patients)
- order XR, whole body bone scans and CT scans to find the primary tumor
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?
- think of soft tissue sarcoma
- order MRI and refer to experts
where is the most common location of a clavicle break?
at the junction of the middle and distal thirds
- will demonstrate point tenderness over this area
tx. of clavicle fracture
arm sling
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?
anterior shoulder dislocation
besides for movement, what should you check for when examining anterior shoulder dislocation/
numbness over deltoid muscle - could demonstrate axillary nerve damage
how can you confirm diagnosis of anterior shoulder dislocation?
AP and lateral XR
what can cause posterior dislocation of shoulder?
massive uncontrolled muscle contractions such as in epileptic seizures and electrical burns (otherwise, rare)
in what position will the arm be with a posterior shoulder dislocation?
the pt will be holding their arm close to their body in a normal protective position
you suspect a posteriorly dislocated shoulder in a patient, but the XR appears normal - what should you do next?
order axillary view or scapular lateral XR - posterior dislocations are often missed on regular XR
Colles fracture
dorsally displaced, dorsally angulated fracture of distal radius often with small fracture of ulnar stylus
tx. of Colles fracture
closed reduction and long arm cast
Monteggia fracture
direct blow to ulna causing diaphyseal fracture of proximal ulna with anterior dislocation of radial head
tx. of Monteggia fracture
closed reduction of radial head
open reduction and internal fixation of ulnar fracture
Galeazzi fracture
fracture of distal third of radius and dorsal dislocation of distal radioulnar joint
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?
think scaphoid fracture (will not show on XR for 3 weeks) and put pt n thumb spica cast; re-order XR in 3 weeks
what do you do if XR shows displaced and angulated fracture of scaphoid bone?
open reduction and internal fixation
- scaphoid fractures are notorius for non-union
Boxer’s fracture
swollen and tender right hand with fracture of 4th and 5th metacarpal necks
tx. of Boxer’s fracture
mild cases - closed reduction and ulnar gutter splint
bad ones - Kirschner wire or plate fixation
old patient falls and hurts his hip; on exam, you note the affected leg is shorter and externally rotated
typical scenario for hip fracture
tx. for displaced femoral neck fracture
blood supply to femoral head is likely compromised and so tx involved a metal prosthesis instead of repair of femoral head
tx. for intertrochanteric fracture
- open reduction and pinning
2. postop anticoagulation - pt is immobilized
tx. of closed fracture of femoral shaft
intramedullary rod fixation
what should you be concerned about in bilateral, comminuted femoral fractures?
the patient could have massive bleeding and go into shock
- tx. with external fixation until patient is stable
tx. of open femur fractures
orthopedic emergency
- require OR cleaning and repair within 6 hours
what are you thinking of pt who sustained femoral fracture and subsequently goes into respiratory distress?
fat embolism
- respiratory support needed!
are you worried about a knee injury w/o swelling?
not really, these are rarely serious
what is the MC way to injure a collateral knee ligament?
a blow to side of the knee
how can you recognize a collateral knee ligament injury?
the knee will be swollen and tender to palpation over the affected side
- positive valgus (medial) or varus (lateral) stress test
varus stress test
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
valgus stress test
knee in 30 degrees, passive ABDUCTION elicits pain over medial knee and leg can be abducted further than normal contralateral leg
tx. of injury to MCL or LCL
hinged cast for isolated injury
- if several ligaments injured, surgical repair
anterior drawer test
when knee is flexed at 90 degrees, the leg can be pulled anteriorly
- seen with injury to ACL
Lachman test
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
tx. of ACL injuries
usually tx in atheletic patients with sugical reconstruction with graft from the patellar or hamstring tendons
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?
order MRI
-suspect meniscal tear
unhappy triad
injury to MCL, medial meniscus and ACL
MC finding in a stress fracture
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
tx. of stress fractures
tx. with cast and repeat XR in 2 weeks
- non weight bearing (crutches) also an option
what fracture is common when a pedestrian is hit by a car?
tibial and fibular fracture
tx. of tibial and fibular fractures
reduction and casting
- if difficult to reduce, intramedullar nailing may be needed
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?
you suspect compartment syndrome - take off cast immediately and do fasciotomy
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?
achilles tendon rupture
tx. of achilles tendon rupture
surgical repair followed by long leg cast for 6 weeks
fracture of both malleoli
common injury during ankle eversion or inversion
- tx. with open reduction and internal fixation
common precipitating events of compartment syndrome
- prolonged ischemia with reperfusion
- crush injuries
- fractures with closed reduction (esp. forearm and lower leg)
a patient who was just casted for a fracture develops pain under the cast - what should you do?
remove the cast and examine the extremity
- never resort to giving pain meds without further exam
patient in a MVA hits the dashboard with his knees - what injury are you afraid of?
posterior hip dislocation with potential avascular necrosis of femoral head
P/E findings in posterior hip dislocation
lower extremity is shortened, adducted and internally rotated
tx. of posterior hip dislocation
emergent reduction
tx. of gas gangrene
IV penicillin
immediate surgica debridement
hyperbaric O2 treatment
fractures to the humeral shaft can cause injury to what nerve?
radial nerve (which courses in the spiral groove right around the posterior aspect of the humerus)
characteristic finding in radial nerve injury
wrist drop - wrist cannot be extended
tx. of humeral fracture with wrist drop
hanging arm cast or coaptation splint
- if nerve function remains after reduction - proceed to surgery
a football player is hit straight on his right leg and he suffers posterior dislocation of the knee - what are you worried about?
injury to the popliteal artery (very little collateral flow in this area can result in vascular compromise of lower leg) –> do emergent reduction
what hidden fractures are you worried about in someone who falls from a height, landing on legs and breaking them?
compression fractures of thoracic and lumbar spine
what hidden fracture are you worried about with facial fractures and closed head injuries?
cervical spine fracture
- always order CT scan to R/O
female complains of waking up at night with numbness and tingling in her hand - dx?
suspect carpal tunnel syndrome
what findings on P/E suggest carpal tunnel syndrome?
percussion, pressure or hanging the hand limply causes numbness and tingling over the distribution of median nerve (radial 3.5 fingers)
what test should be ordered if you suspect carpal tunnel syndrome?
mostly a clinical diagnosis but wrist XR incl. carpal tunnel view should be ordered to R/O other things
tx. of carpal tunnel syndrome
wrist splint in neutral position and anti-inflammatories (NSAIDs)
- may use corticosteroid injections or surgical release
what test should be ordered before surgery for carpal tunnel syndrome?
electromyography
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
trigger finger
- tx. steroid injections
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?
de quervain tenosynovitis
what P/E finding confirms de quervain tenosynovitis
pain when thumb is held inside closed fist and wrist in ulnar deviation
tx. of de quervain tenosynovitis
splints and NSAIDS but corticosteroid injections are the best
- surgery rarely needed
gamekeeper’s thumb
injury to ulnar collateral ligament of the thumb sustained by forced hyperextension
P/E finding in gamekeeper’s thumb
collateral laxity at the thumb MCP joint
tx. of gamekeepers thumb
casting
- if not treated it can be very dysfunctional and painful with resultant arthritis
jersey finger
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
mallet finger
extended finger is forcefully flexed and extensor tendon is ruptured; tip of affected finger remains flexed
tx. of jersey and mallet fingers
splinting
proper care of amputated digit
- clean it with sterile saline
- wrap in saline soaked sterile gauze
- place it in plastic bag
- place bag on bed of ice
discogenic pain
pressure on anterior spinal ligament felt by patient as aching back pain
classic pain of lumbar herniation
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
MC locations of lumbar disc herniation
L4-L5 (to big toe) or L5-S1 (to little toe)
tx. of lumbar disc herniation
NSAIDs and physical therapy
- do not recommend bed rest!
when should you consider surgery for lumbar disc herniation?
if there is progressive neuromuscular weakness or spincteric deficits (suspicion of cauda equina)
in addition to symptoms of lumbar disc herniation, what signs suggest cauda equina syndrome?
perianal saddle anesthesia
distended bladder (overflow incontinence)
flaccid rectal sphincter (bowel incontinence)
impotence
tx of cauda equina syndrome
immediate surgical decompression
what kind of back pain is suggestive of malignancy?
progressive low back pain that is worse at night and not relieved by rest or positional changes
what is the common location of diabetic foot ulcers?
at pressure points - heel, metatarsal head and toes
what is the cause of diabetic foot ulcers?
neuropathy - but unlikely to heal due to poor microcirculation
ulcer at the tip of toe looks blue, with no granulation tissue; on further exam, there are no peripheral pulses in that extremity
ischemic ulcer
management of ischemic foot ulcer
- do Dopper study - measure pressure gradient
2. MRI or CT angio
what does it mean when you find no pressure gradient in an ischemic ulcer on Doppler?
it is due to microvascular disease that is not amenable to surgical treatment
a patient has a painless ulcer above her medial malleolus; the skin around it is thick, indurated and hyperpigmented
venous stasis ulcer
management of venous stasis ulcer
Duplex scanning
unna boot or compression stockings
- varicose vein surgery or endoluminal ablation may be needed
Marjolin ulcer
squamous cell carcinoma that develops at long standing chronic irritation sites (i.e. following third degree burn, chronic draining sinuses)
tx. of Marjolin ulcer
biopsy first! followed by wide local exicision and skin grafting
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
dx. plantar fasciitis
- order XR
XR finding in plantar fasciitis
usually a bony spur (however, this is not the cause of the pain and does not need to be surgically removed)
tx. plantar fasciitis
usually goes away on its own w/in 12-18 months
Morton neuroma
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
