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.
Cauda equina syndrome
Distended bladder, flaccid rectal sphincter,
perineal saddle anesthesia. A surgical emergency requiring immediate decompression.
Ankylosing Spondylitis
Seen in young men in their thirties or forties who c/o chronic back pain and morning stiffness. Pain is worse at rest, and improves with activity. Symptoms are progressive, and xrays eventually show a “bamboo spine.” Antiinflammatory agents and physical therapy are used.
What antigen is associated with ankylosing spondylitis, and what else is it associated with?
HLA B-27. Also associated with uveitis and inflammatory bowel disease
Where will diabetic ulcers develop, and why
Pressure points (heel, metatarsal head, tip of toes). They start because of the neuropathy, and they fail to heal because of the microvascular disease.
Where will ulcers from arterial insufficiency develop, and what will they look like.
As far away from the heart as they can be: at the tip of the toes. They look dirty, with a pale base devoid of granulation tissue. The patient has other manifestations of arteriosclerotic occlusive disease (absent pulses, trophic changes, claudication or rest pain)
How does workup begin for ulcers from arterial insufficiency
Doppler studies looking for a pressure gradient (if there isn’t one, there is microvascular disease not amenable to surgical therapy).
Where do venous stasis ulcers develop, and what does the clinical picture look like
Chronically edematous, indurated, and hyperpigmented skin above the medial malleolus. The ulcer is painless, with granulating bed. The patient has varicose veins and suffers from frequent bouts of cellulitis.
What 2 medical conditions need to be looked for in the workup of chronic foot ulcers
Diabetes and arteriosclerotic occlusive disease
What causes a Marjolin ulcer
Squamous cell carcinoma of the skin developing in a chronic leg ulcer
Suspect this in a pt with many years of healing and breaking down, such as seen in untreated third-degree burns that underwent spontaneous healing, or in chronic draining sinuses secondary to osteomyelitis. A dirty-looking, deeper ulcer develops at the site, with heaped up tissue growth around the edges.
Marjolin ulcer: squamous cell carcinoma of the skin developing in a chronic leg ulcer
Suspect this in an older, overweight patient who complains of disabling, sharp heel pain every time their foot strikes the ground. The pain is worse in the mornings.
Plantar Fasciitis
X-ray and PE results for plantar fasciitis
Bony spur matching the location of the pain, and physical exam shows exquisite tenderness to palpation over the spur. Interestingly, the bony spur is not the problem.
Suspect this in a patient with inflammation of the common digital nerve at the third interspace, between the third and fourth toes. The spot is very tender. The cause is typically the use of pointed, highheeled shoes (or pointed cowboy boots) that force the toes to be bunched together.
Morton’s neuroma.
Conservative management of Morton’s neuroma
Analgesics and more sensible shoes, but, if needed, surgical excision can be done
Pathophysiology and symptoms of gout
Uric acid chrystals build up in the fluid of joints. Swelling, redness, and exquisite pain of sudden onset at the first metatarsal-phalangeal joint, in a middle-age obese man with high serum uric acid
Treatment for gout
Acutely, indomethacin and colchicine. Chronically, allopurinol and probenicid.
Suspect this in a patient w/ mid or distal humerus fxr who can’t dorsiflex wrist or extend metacarpophalangeal joints
Radial nerve injury
Suspect this in a pt w/ this classic triad 24-72 hours after a trauma: respiratory symptoms, neurological changes, and a reddish-brown petechial rash.
Fat embolism syndrome. Respiratory findings such as hypoxemia, dyspnea, and tachypnea are the earliest manifestations. A chest x-ray may demonstrate Acute Respiratory Distress Syndrome (ARDS). Neurologic abnormalities develop afterwards, most often manifested by confusion, drowsiness or altered level of consciousness, and, in severe cases, seizure or paralysis. Lastly, the classic petechial rash develops, but in only 50–60 % of cases. The petechial rash results from extravasation of erythrocytes secondary to the occlusion of dermal capillaries by fat emboli. The rash, in the proper clinical context, is pathognomonic for fat embolism syndrome.
6 Ps of compartment syndrome
pain out of proportion to injury with gentle passive stretch of the involved muscles, pressure (swollen and tense compartments), paresthesia, pulselessness, poikilothermia, and paralysis. This is a surgical emergency.
Seddon’s Three Basic Categories of Nerve Injury
Neuropraxia, axonotmesis, neurotmesis.
What is neuropraxia
Minimal injury (myelin), but not axon or nerve sheath. Temporary nerve conduction block, loss of motor and sensory function, but not autonomic. Full recovery expected, hours to months.
What is Axonotmesis?
Myelin plus axon disrupted, nerve sheath intact. Wallerian degeneration with motor sensory and autonomic paralysis. Recovery often incomplete, weeks to months, axon sprouts within nerve sheath.
What is Neurotmesis?
Myelin, axon, and nerve sheath also damaged. Recovery variable and incomplete at best, usually requires surgery or results in permanent paralysis.
What antibiotics should be given for class 1, 2, or 3 open fractures? For how long?
1 and 2 get cephalosporins, grade 3 gets cephalosporin+aminoglycoside. Given 24 hours after closure of wound.
What antibiotic should be added to the regimen if farm or soil contamination of an open fracture has taken place?
Penicillin (or equivalent) to cover anaerobes, especially clostridium perfringens which could cause gas gangrene.
Also consider tetanus immune globulin (TIG) and tetanus toxoid (TT) depending on their immunization status.
Treatment for fat embolism syndrome
Supportive care including ventilatory support with high PEEP and early stabilization of the fractures. Corticosteroids can help in certain cases.
suspect this if Anterior drawer sign+.
ACL tear
suspect this if McMurray test +
Medial meniscal tear
suspect this if Posterior drawer sign +
PCL tear
suspect this if Varus instability is present
Lateral collateral ligament tear
suspect this if Valgus instability is present
Medial collateral ligament tear
Suspect this if foot drop is present
Damage to peroneal nerve
“Unhappy triad” of the knee
ACL tear, MCL tear, and medial meniscus injury
“Terrible triad” of elbow
Elbow dislocation, coronoid and radial head fracture
Suspect these 2 things if patient is unWILLING to bend their knee
Fracture or septic arthritis. Consider arthrocentesis
What radiographic sign is pathognomonic for ACL injury?
Segond sigmoid fracture (a small fleck of bone avulsed from the lateral tibial plateau)
Patella alta vs patella baja
The patella may ride high (alta) due to unopposed pull from the quadriceps in the setting of a patellar tendon rupture.
Conversely, it may ride low (baja) with quadriceps rupture.
Characteristic Radiographic Features of Osteoarthritis of the Knee (list 4) and Why Is It Important to Consider After ACL Injury?
Joint space narrowing, osteophytes (bone spurs), subchondral sclerosis, and subchondral cysts. These changes are critical to recognize as ACL surgery is not appropriate in the setting of significant arthritis of the knee.
What test do you do in the case of a hot, swollen knee with no history of trauma? What are you looking for?
Arthocentesis, which looks for WBC (->infection) and crystal analysis (looking for monosodium urate crystals in gout and calcium pyrophosphate crystals in pseudogout).
Acute symptomatic conservative treatment for ACL tears and such
RICE: Rest, Ice, Compress, Elevate
Tumors that frequently metastasize to the bone
“BLT and Kosher Pickle”: Breast, Liver, Thyroid, Kidney, Prostate.
What disorders should be looked for in a kid with a slipped capital femoral epiphysis (SCFE)
Endocrine disorders, like hypothyroidism, growth hormone abnormalities, renal osteodystrophy, hypopituitarism, and hyper- or hypoparathyroidism.
Pain originating around the groin and traveling to the knee suggests which joint as the main cause?
Hip joint
Most common cause of hip pain in childhood, and what will precede it?
Transient synovitis. Will be preceded by a respiratory infection or viral infection.
What infectious diseases should you consider on the differential of hip pain?
Lyme disease, TB
What does steroid use predispose children to, joint wise?
Avascular necrosis of the femoral head AKA osteonecrosis
Genetic risk factors for AVN of the femoral head
Sickle cell disease, Gaucher’s disease
Knee pain should be considered referred from the ____ until proven otherwise
Hip
X-ray finding: Asymmetry of the femoral head on the neck. The ice cream appears to slide off the cone.
Slipped Capital Femoral Epiphysis (SCFE)
X-ray finding: Subluxation or dislocation of the femoral head from the acetabulum. Difficult to assess on x-ray in infants
Developmental dysplasia of the hip
X-ray finding: Subchondral (under the cartilage) collapse of the bone of the femoral head
Legg-Calve-Perthes disease
Most Common Nerve Entrapment Syndrome in the Upper Extremity
Carpal tunnel syndrome
Classic PE signs of Carpal Tunnel
Tinel’s: percussing over median nerve at the carpal tunnel, pt feels electrical shock sensation in the median nerve distribution.
Phalen’s: place the dorsal sides of each hand against each other in a position of maximal wrist flexion for 30–60 s. Patient reports new or worsening paresthesias in the median nerve distribution of the affected hand(s)
Durkan’s Median Nerve Compression Test
Squeezing the patient’s wrist with direct compression over the median nerve at the carpal tunnel using the examiner’s thumb. Positive if the patient reports new or worsening numbness or tingling in some portion of the median nerve sensory distribution to the hand within 30–60 s
How do you distinguish Carpal Tunnel Syndrome from proximal median nerve compression at the elbow (pronator syndrome)?
The palmar cutaneous branch of the median nerve branches prior to the carpal tunnel and travels above the transverse carpal ligament. It innervates the skin over the thenar eminence. Thus typical carpal tunnel syndrome will not show sensory dysesthesias in this area, whereas pronator syndrome will.
What is thoracic outlet syndrome?
Compression of the lower brachial plexus (ulnar symptoms predominate) or compression of the subclavian vessels between the anterior and middle scalene muscles, often associated with a cervical rib.
What nerve is compressed in carpal tunnel syndrome?
The Median Nerve
What does the median nerve innervate in the hand?
The thenar muscles (abductor pollicis brevis, flexor pollicis brevis – superficial head and opponens pollicis) and the two radial lumbricals.
What Is the Sensory Distribution of the Median Nerve in the Hand?
Sensory distribution provides sensation to the radial volar 3.5 fingers and dorsal tips (thumb, index, middle, and half of the ring).
What Is the Origin of the Median Nerve from the Cervical Spine Roots?
C5-T1
What Are the Boundaries of the Carpal Tunnel?
Carpus dorsally (floor) and transverse carpal ligament volarly (roof). The scaphoid, trapezium, and sheath of flexor carpi radialis form its radial margin. The ulnar boundary consists of the triquetrum, hook of the hamate, and the pisiform.
What Is the Significance of Thenar Wasting?
Since the recurrent motor branch of the median nerve innervates the thenar muscle mass, long-standing or severe carpal tunnel disease can result in denervation of the thenar muscles. The profile of the thenar eminence of both hands as well as the strength of abductor pollicis brevis (palmar abduction) should always be checked.
Three stages of median nerve compression
Stage 1: Sensory symptoms (numbness, pain, tingling) at night.
Stage 2: Symptoms occur also by day.
Stage 3: Motor symptoms of weakness and/or muscle wasting, too.
Froment’s sign
Examiner can easily pull a flat piece of paper from the hand of the patient who
uses thumb IP flexion via the FPL tendon of the median nerve (anterior interosseous branch) to grasp the paper.
What Systemic Condition Is Often Associated with CTS?
Hypothyroidism
First line, second line, and surgical treatment for carpal tunnel syndrome
First line: Splinting of the wrist (not hand) in a neutral position (reduces pressure in the carpal tunnel). NSAIDs and activity modifications.
Second Line: Carpal tunnel injection with local anesthetic and corticosteroid medication.
Indications for Surgical Intervention: Failure to respond adequately to conservative nonoperative management or thenar motor involvement.
What Is the Gold Standard Treatment for CTS?
Carpal tunnel release which is surgical cutting of the transverse carpal ligament, the roof of the carpal tunnel. This is performed through a small open incision or endoscopically.
Two nerves at risk of injury during transection of the carpal tunnel
Recurrent motor branch of the median nerve. The thumb will show greatly impaired function.
Palmar cutaneous branch of the median nerve. Leads to a very painful and difficult to treat neuroma despite improvement in carpal tunnel syndrome symptoms.
Tumor that could produce carpal tunnel syndrome symptoms
Pancoast tumor
Prosthetic joint infection, most common organisms: 1) <3 months after surgery 2) 3-12 months after surgery 3) >12 months after surgery
1) <3 months: Staph aureus, gram-neg rods, anaerobes.
2) 3-12 months: coag-neg staph, propionibacterium species, enterococci.
3) >12 months: Staph aureus, gram-neg rods, beta-hemolytic strep.
Neer test, and what to consider when it is positive
Patient internally rotates shoulder, with forearm pronated (thumbs towards floor), examiner flexes humerus. If positive (elicits pain) consider a rotator cuff tear.
