Orthopedics Flashcards
Likely diagnosis if there is a baby with uneven gluteal folds, and physical examination of the hips shows that they can be easily dislocated posteriorly with a jerk and a “click,” and returned to normal with a “snapping.”
Developmental dysplasia of the hip
Suspect this in a kid (usually 6 y.o.) who walks with a limp, decreased hip motion, antalgic gait, and passive motion of the hip is guarded.
Legg-Calve-Perth disease (Avascular necrosis of the capital femoral epiphysis)
What to suspect in an obese boy, around age 13, complains groin (or knee) pain and limps. When they sit with the legs dangling, the sole of the foot on the affected side points toward the other foot.
On physical exam there is limited hip motion, and as the hip is flexed the
thigh goes into external rotation and cannot be rotated internally.
Slipped capital femoral epiphysis (SCFE). it’s an orthopedic emergency
Suspect this in little toddlers who have had a febrile illness and then refuse to move the hip. They hold the leg with the hip flexed, in slight abduction and external rotation, and do not let anybody try to move it passively. They have elevated sedimentation rate.
Septic hip
Suspect this in little kids who have had a febrile illness, but it shows up with severe localized pain in a bone (and no history of trauma to that bone). X-rays will not show anything for a couple of weeks. MRI gives prompt diagnosis.
Acute hematogenous osteomyelitis
Genu varum is normal in kids up to what age? Past that, what is a likely diagnosis?
Normal in kids up to 3 years old. Past that, probably Blount disease, a disturbance in the medial proximal tibial growth plate.
Genu valgus is normal in what age group?
Ages 4-8
Osgood-Schlatter disease
Osteochondrosis of the tibial tubercle. Seen in teenagers with persistent pain right over the tibial tubercle, which is aggravated by contraction of the quadriceps. Physical exam shows localized pain right over the tibial tubercle, and there is no knee swelling. Tell athletes to stop doing their sport
Conservative management for Osgood-Schlatter disease
RICE: Rest, Ice, Compression, Elevation
Club foot: When it presents, description, and management
Seen at birth. Both feet are turned inward, and there is plantar flexion of the ankle, inversion of the foot, adduction of the forefoot, and internal rotation of the tibia. Plaster casts, sometimes achilles tenotomy, leg braces.
Scoliosis: usual patient, description, treatment
Adolescent girls, curvature of the spine usually to the right, use braces and possibly need surgery
Bone remodeling in children compared to adults
Remodeling occurs to an astonishing degree in children, so degrees of angulation in children that would be unacceptable in an adult is permissible in children when they are reduced and immobilized.
When a kid falls on an extended arm and hyperextends it, what is a common fracture?
Supracondylar fracture, on the humerus
How do you treat a fracture of a growth plate?
Closed reduction, if the epiphyses and growth plate are displaced laterally from the metaphysis but are in one piece (i.e., the fracture does not cross the epiphyses or growth plate and does not involve the joint). If the growth plate is in two pieces, open reduction and internal fixation will be required, for precise alignment. Otherwise, growth will occur unevenly, resulting in deformity of the extremity.
Suspect this in a young person with persistent low-grade pain for months, and have a “sunburst” pattern or “onion skinning” on X-ray
Primary malignant bone tumors: think Osteogenic Sarcoma or Ewing Sarcoma
Most common malignant bone tumor. Usually 10-25 year olds, around the knee. Shows “sunburst” pattern on X-ray.
Osteogenic sarcoma
Second most common malignant bone tumor. Usually 5-15 year olds, in diaphyses of long bones. Shows “onion skinning” on X-ray.
Ewing sarcoma
Bone tumors in humans are usually:
Metastatic from other areas
Suspect this in an old man with fatigue, anemia, and localized pain at specific places on several bones. X-rays show multiple punched-out lytic lesions. They also have Bence-Jones protein in the urine and abnormal immunoglobulins in the blood, shown by serum immunoelectrophoresis.
Multiple Myeloma
Suspect this bone cancer in a cancer with relentless growth (several months) of soft tissue mass anywhere in the body. They are firm, fixed to surrounding structures. They metastasize to lungs but not to lymph nodes.
Soft tissue sarcomas
What is closed reduction and when do you do it
Immobilization of a broken bone to let it heal. You can do a closed reduction when the fracture is not badly displaced or angulated or it can be aligned by external manipulation.
When do you have to fix a bone fracture with open reduction and internal fixation
When the fracture leaves the bone severely displaced, angulated, or unable to be aligned
Most common shoulder dislocation
Anterior dislocation of the shoulder
Fracture of the distal radius, dorsally displaced and dorsally angulated. Typically happens when old osteoporitic ladies fall with outstretched hands. Tx?
Colles fracture. Closed reduction.
Fracture that results from a direct blow to the ulna (think a raised protective arm from a nightstick).
Monteggia fracture
Fracture that results from a direct blow to the radius, which gets the fracture, with dorsal dislocation of the distal radioulnar joint. Tx?
Galeazzi fracture. Open reduction and fixation of fracture, closed reduction of the dislocation.
Suspect this fracture in a person who fell on an outstretched hand, complains of wrist pain, with localized tenderness over the anatomic snuff box.
Scaphoid bone fracture. Open reduction and internal fixation.
Suspect this fracture in a person who punched a wall, hand is swollen and tender.
Metacarpal neck fractures
What do you have to worry about with a femoral neck fracture?
Compromising the blood supply of the femoral head, which is fragile. Could result in avascular necrosis
Most common treatment for femoral shaft fractures
Intermedullary rod fixation
Ligaments injured by sideways blows to the knee
Collateral ligaments (medial or lateral)
Anterior draw test and what it means
Pull the leg forward and it comes forward at the knee. Means ACL tear
Repair for a meniscal tear
open repair
Is seen in out-of-shape middle-aged men who subject themselves to severe strain (tennis, for instance). As they plant the foot and change direction, a loud popping noise is heard (like a rifle shot), and they fall clutching the ankle.
Achilles tendon rupture
Compartment Syndrome. When will you see it, signs and symptoms, physical findings.
Mostly in the forearm/lower leg. Can be caused by prolonged ischemia -> reperfusion, crushing injuries, or other trauma. In the lower leg, most common cause is a fracture with closed reduction. The patient has pain and limited use of the extremity. The compartment feels very tight and tender to palpation. The most reliable physical finding is excruciating pain with passive extension. Pulses may be normal.
Most reliable finding of compartment syndrome
Excruciating pain with passive extension.
Gas gangrene: What causes it, natural course, and treat it.
Caused by deep, penetrating, dirty wounds (stepping on a rusty nail, with lots of mud or manure). In about 3 days the patient is extremely sick, looking toxic and moribund. The affected site is tender, swollen, discolored, and has gas crepitation. Treatment includes copious IV penicillin, extensive emergency surgical debridement, and hyperbaric oxygen.
Carpal tunnel syndrome symptoms
Numbness and tingling in hands, esp. at night, and in the distribution of the median nerve (radial 31⁄2 fingers). The symptoms can be reproduced by hanging the hand limply for a few minutes, or by tapping, percussing or pressing the median nerve over the carpal tunnel.
Maneuver to reproduce DeQuervain Tenosynovitis
Asking her to hold her thumb inside her closed fist, then forcing the wrist into ulnar deviation
Occurs in older men of Norwegian ancestry. There is contracture of the palm of the hand, and palmar fascial nodules can be felt. Surgery may be needed when the hand can no longer be placed flat on a table.
Dupuytren Contracture
How to treat Felon, an abscess in the pulp of the fingertip
Urgent surgical drainage, since the pulp is a closed space with multiple fascial trabecula, and pressure can build up and lead to tissue necrosis
Injury of the ulnar collateral ligament sustained by forced hyperextension of the thumb, and how to treat it
If untreated it can be dysfunctional and painful, and lead to arthritis. Casting is usually done.
Jersey finger vs Mallet finger
Jersey finger: when the flexed fingers are forcefully extended, injuring the flexor tendon.
Mallet finger: when the extended finger is forcefully flexed, resulting in extensor tendon rupture. The finger tip remains flexed when the hand is extended, resembling a mallet.
Splint for both.
Common region for Lumbar disk herniation
Occurs almost exclusively at L4-L5 or L5-S1
Lumbar disk herniation sx
Several months of vague aching pain (the “discogenic pain” produced by pressure on the anterior spinal ligament) before sudden onset of the “neurogenic pain” precipitated by a forced movement. The latter is extremely severe, “like an electrical shock that shoots down the leg” (exiting on the side of the big toe in L4-L5, or the side of the little toe in L5-S1), and it is exacerbated by coughing, sneezing, or defecating (if the pain is not exacerbated by those activities, the problem is not a herniated disk). Patients cannot ambulate, and they
hold the affected leg flexed. Straight leg-raising test gives excruciating pain.
Lumbar disk herniation Tx
Bed rest for about 3 weeks. Often require pain control with nerve blocks. Surgical intervention is needed if neurologic deficits are progressing (progressive muscle weakness), and emergency intervention is required if there is a cauda equina syndrome.
