Orthopedics Flashcards
Congenital dysplasia of the hip runs in families, and should be ideally diagnosed right after birth. Children have uneven __ ___, and physical exam of the hips show that they can be easily dislocated ___ with a jerk and a “click” and returned to normal with a “snapping.”
If signs are equivocal, ____ is diagnostic (do not order __ on babies - their hips are not calcified yet).
Treatment is abduction splinting with a __ harness for ~__ months.
Congenital dysplasia of the hip runs in families, and should be ideally diagnosed right after birth. Children have uneven gluteal folds, and physical exam of the hips show that they can be easily dislocated posteriorly with a jerk and a “click” and returned to normal with a “snapping.”
If signs are equivocal, sonogramis diagnostic (do not order Xrayson babies - their hips are not calcified yet).
Treatment is abduction splinting with aPavlik harness for ~6months.
Legg-Calve-Perthes disease is __ __ of the capital ___ epiphysis and occurs around age __, with insiduous development of limping, decreased hip motion, and hip or knee pain.
Patients talk with an __ gait and passive motion of the hip is guarded. Diagnosis is confirmed by __ and ___ ___ xrays. Tx is controversial, usually containing the ___ ___ within the ___ by casting and crutches.
Legg-Calve-Perthes disease is avascular necrosis of the capital femoral epiphysis and occurs around age 6, with insiduous development of limping, decreased hip motion, and hip or knee pain.
Patients talk with an antalgic gait and passive motion of the hip is guarded. Diagnosis is confirmed by APand lateral hipxrays. Tx is controversial, usually containing the femoral headwithin the acetabulumby casting and crutches.
SCFE
- orthopedic emergency.
- typical patient is ___ or ___ boy around age __, who complains of groin or knee pain, and who ambulates with a limp.
- on PE, there is limited hip motion, and as the hip is flexed, the thigh goes into ___ rotation and cannot be rotated ___.
Dx: ___ are diagnostic.
Tx: Surgical treatment ___ the femoral head back in place.
SCFE
- orthopedic emergency.
- typical patient is chubby or lanky boy around age 13, who complains of groin or knee pain, and who ambulates with a limp.
- on PE, there is limited hip motion, and as the hip is flexed, the thigh goes into externalrotation and cannot be rotatedinternally.
Dx: X raysare diagnostic.
Tx: Surgical treatment pins the femoral head back in place.
Septic hip is an orthopedic emergency.
- Seen in ___ who have had a ___ ___ in the past and then refuse to move the ___.
They hold the leg with the hip ___, in slight abduction and external rotation, and do not let anybody move it passively.
___ and ___ are elevated.
Dx: made by ___ of the hip under general anesthesia, and further open drainage is performed if pus is obtained.
Septic hip is an orthopedic emergency.
- Seen in toddlers who have had a febrile illness in the past and then refuse to move the hip.
They hold the leg with the hip flexion, in slight abduction and external rotation, and do not let anybody move it passively.
WBC and ESR are elevated.
Dx: made by aspiration of the hip under general anesthesia, and further open drainage is performed if pus is obtained.
Acute hematogenous osteomyelitis is seen in small children who have had __ __ in the past and presents as severe localized pain in a bone with no history of ___ to that bone.
____ will not show anything for severeal weeks.
___ reveals prompt diagnosis.
Tx is with ___
Acute hematogenous osteomyelitis is seen in small children who have had febrile illness and presents as severe localized pain in a bone with no history of trauma to that bone.
Xray will not show anything for several weeks.
MRI reveals prompt diagnosis.
Tx is with IV Abx
Genu varum (bow legs) is normal up to age ___. No treatment is needed. Persistent varus (age >3) is most commonly ___ disease, a disturbance of the medial proximal ____ growth plate, for which ___ is corrective.
Genu varum (bow legs) is normal up to age 3. No treatment is needed. Persistent varus (age >3) is most commonly Blount disease, a disturbance of the medial proximal tibial growth plate, fo which surgery is corrective.
Genu valgus (knock knee) is normal between age __-___ years old.
Treatment?
Genu valgus (knock knee) is normal between age 4-8 years old.
No treatment is needed.
Osgood-Schlatter Disease (Osteochondrosis of the tibial tubercle) is seen in ___ with persistent pain right over the ___ ___, which is aggravated by contraction of the quadriceps.
PE shows localized pain right over the __ __ in the absence of knee __.
Tx: initially with ___. If conservative management fails, treatment is immobilization of the knee in an extension or cylinder case for __-__ weeks.
Osgood-Schlatter Disease (Osteochondrosis of the tibial tubercle) is seen in teenagers with persistent pain right over the tibial tubercle, which is aggravated by contraction of the quadriceps.
PE shows localized pain right over the tibial tubercle in the absence of knee swelling.
Tx: initially with RICE. If conservative management fails, treatment is immobilization of the knee in an extension or cylinder case for 4-6 weeks.
Club foot
- 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. Serial plaster casts started in the neonatal period provide sequential correction starting with the adducted forefoot, then the hindfoot varus, and last equinus.
About 50% of patients are fully corrected this way. The other 50% require surgery after age 6-8 months, but before age <1-2 years.
Club foot
- 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. Serial plaster casts started in the neonatal period provide sequential correction starting with the adducted forefoot, then the hindfoot varus, and last equinus.
About 50% of patients are fully corrected this way. The other 50% require surgery after age 6-8 months, but before age <1-2 years.
Scoliosis
- seen primarily in __ __ whose thoracic spines are curved toward the ___. The most sensitive screening finding is to look at the girl from behind while she ____ forward (Adams test)
A hump will be noted over her right thorax. The deformity progresses until skeletal maturity is reached (at the onset of menses skeletal maturity is ~80%). In addition to the cosmetic deformity, severe cases develop decreased ___ function.
___ is used to arrest progression; severe cases may require surgery. Early treatment is mandated.
Scoliosis
- seen primarily in adolescent girls whose thoracic spines are curved toward the right. The most sensitive screening finding is to look at the girl from behind while she bends forward.
A hump will be noted over her right thorax. The deformity progresses until skeletal maturity is reached (at the onset of menses skeletal maturity is ~80%). In addition to the cosmetic deformity, severe cases develop decreased pulmonary function.
Bracing is used to arrest progression; severe cases may require surgery. Early treatment is mandated.
__ ___
- SCF of the humerus occurs with hyperextension of the elbow in a child who falls on the hand with the arm extended. The injuries are particularly dangerous due to the proxmity of the ____ artery and ____ nerve. Although these fractures are treated with standard casting or traction and rarely need surgery, they require careful monitoring of vascular and nerve integrity and vigilance regarding development of compartment syndrome.
Supracondylar fractures
- SCF of the humerus occurs with hyperextension of the elbow in a child who falls on the hand with the arm extended. The injuries are particularly dangerous due to the proxmity of the brachial artery and ulnar nerve. Although these fractures are treated with standard casting or traction and rarely need surgery, they require careful monitoring of vascular and nerve integrity and vigilance regarding development of compartment syndrome.
Fractures that involve the growth plate or epiphysis can be treated by ____ reduction if the epiphysis and growth plate are displaced ____ from the metaphysis but they are in ___ piece (i.e. the fracture does not cross the ___ or growth plate and does not involve the ___).
If the growth plate is fractured into ___ pieces, open-reduction and internal fixation will be required to ensure precise alignment and even growth to avoid chronic deformity of the extremity.
Fractures that involve the growth plate or epiphysis can be treated by closed reduction if the epiphysis and growth plate are displaced laterally from the metaphysis but they are in one piece (i.e. the fracture does not cross the epiphysis or growth plate and does not involve the joint).
If the growth plate is fractured into two pieces, open-reduction and internal fixation will be required to ensure precise alignment and even growth to avoid chronic deformity of the extremity.
X-ray for suspected fracture in adults should always include the following:
- Two views at ___ degrees to one another
- Joints __ and ___ the broken bone
- If suggested by the mechanism of injury, bones that are in the “line of force” which might also be broken (e.g. the ___ spine must be evaluated for fracture following a fall from a significant height with __ fractures).
X-ray for suspected fracture in adults should always include the following:
- Two views at 90 degrees to one another
- Joints above and below the broken bone
- If suggested by the mechanism of injury, bones that are in the “line of force” which might also be broken (e.g. the lumbar spine must be evaluated for fracture following a fall from a significant height with foot fractures).
Clavicular fractures is typically at the ___ of middle and distal thirds. It is treated by placing the arm in a ___.
Clavicular fractures is typically at the junction of middle and distal thirds. It is treated by placing the arm in a sling.
____ dislocation of the shoulder is by far the most common shoulder dislocation. Patients hold the arm close to their body but rotated ___ as if they were going to shake hands. There may be numbness in a small area over the ___, from stretching of the ____ nerve. AP and lateral Xrays are diagnostic. Some patients develop recurrent dislocations with minimal trauma.
Anterior dislocation of the shoulder is by far the most common shoulder dislocation. Patients hold the arm close to their body but rotated outwardly as if they were going to shake hands. There may be numbness in a small area over the deltoid, from stretching of the axillary nerve. AP and lateral Xrays are diagnostic. Some patients develop recurrent dislocations with minimal trauma.
___ shoulder dislocation is rare and occurs after massive uncoordinated muscle contractions, such as ___ ___ or __ __. The arm is held in the usual protected position (close to the body, internally rotated). Regular Xrays can easily miss it; ___ views or ___ lateral viewes are needed.
Posterior shoulder dislocation is rare and occurs after massive uncoordinated muscle contractions, such as epileptic seizure or electrical burn. The arm is held in the usual protected position (close to the body, internally rotated). Regular Xrays can easily miss it; axillary views or scapular lateral viewes are needed.
Colle’s Fracture results from a fall on an ____ hand, often in ___ ___ women. The deformed and painful wrist looks like a “__ __.”
The main lesion is an older, ___-displaced, dorsally angulated fracture of the distal radius.
Tx is with ___-reduction and long arm cast.
Colle’s Fracture results from a fall on an outstretched hand, often in old osteoporotic women. The deformed and painful wrist looks like a “dinner fork.”
The main lesion is an older, dorsaly-displaced, dorsally angulated fracture of the distal radius. Tx is with close-reduction and long arm cast.
Monteggia fracture
- results from a direct blow to the ___ (i.e. on a raised protective arm hit by a nightstick). There is ____ fracture of the proximal ulna, with ____ dislocation of the radial head.
Monteggia fracture
- results from a direct blow to the ulna (i.e. on a raised protective arm hit by a nightstick). There is diaphyseal fracture of the proximal ulna, with anterior dislocation of the radial head.
“Ey Mon! Don’t hit me with the club!”
Fracture of the scaphoid (carpal navicular) affects a young adult who falls on an out-stretched hand.
Chief complaint is typically wrist pain, with physical exam revealing localized tenderness to palptation over the __ __ ___.
In undisplaced fractures, X-rays are usually negative, but __ __ cast is indicated just with the history and physical findings.
Xrays will show the fracture __ __ later. If original Xrays show displaced and angulated fracture, __ reduction and internal fixation are needed.
Scaphoid fractures are notorious for a very high rate of nonunion secondary to __ __.
Fracture of the scaphoid (carpal navicular) affects a young adult who falls on an out-stretched hand. Chief complaint is typically wrist pain, with physical exam revealing localized tenderness to palptation over the anatomic snuff box. In undisplaced fractures, X-rays are usually negative, but thumb spica cast is indicated just with the history and physical findings. Xrays will show the fracture 3 weeks later. If original Xrays show displaced and angulated fracture, open reduction and internal fixation are needed. Scaphoid fractures are notorious for a very high rate of nonunion secondary to avascular necrosis.
Metacarpal neck fracture (typically the fourth or fifth, or both) aka “boxer fracture” happens when a __ __ hits a hard surface (like a wall).
The hand is swollen and tender, and Xrays are diagnostic.
Tx depends on the degree of angulation, displacement, or rotary mis-alignment: ___ reduction and ___ gutter splint for the mild fractures, with ___ wire or __ fixation for bad ones.
Metacarpal neck fracture (typically the fourth or fifth, or both) happens when a closed fist hits a hard surface (like a wall).
The hand is swommen and tender, and Xrays are diagnostic.
Tx depends on the degree of angulation, displacement, or rotary misalignment: close reduction and ulnar gutter splint for the mild fractures, with Kirschner wire or plate fixation for bad ones.
Hip fractures typically occur in the elderly following a fall. The hip hurts, and the patient’s position in the stretcher is classic: the affected leg is shortened and ___ rotated. Specific treatment depends on specific on locations.
Hip fractures typically occur in the elderly following a fall. The hip hurts, and the patient’s position in the stretcher is classic: the affected leg is shortened and externally rotated. Specific treatment depends on specific on locations.
Femoral neck fracture
- particularly if displaced, compromises the very tenuous blood supply of the femoral head. Faster healing and earlier mobilzation can be achieved by replacing the femoral head with a ___
Femoral neck fracture
- particularly if displaced, compromises the very tenuous blood supply of the femoral head. Faster healing and earlier mobilzation can be achieved by replacing the femoral head with a prosthesis.
____ fracture is less likely to lead to avascular necrosis, and is usually treated with open reduction and pinning.
The unavoidable immobilzation that ensues poses a very high risk for _____ and pulmonary emboli, thus post-op ____ is recommended.
Intertrochanteric fracture is less likely to lead to avascular necrosis, and is usually treated with open reduction and pinning.
The unavoidable immobilzation that ensues poses a very high risk for DVTs and pulmonary emboli, thus post-op anti-coagulation is recommended.
Femoral shaft fracture is often treated with ____ ___
If bilateral, and comminuted, it may produce enough __ __ __ to lead to shock (external fixation may help while the patient is stabalized).
If open, it is an orthopedic emergency, requiring OR irrigation and closure within __ hours.
If multiple, __ embolism syndrome may develop, in which severe respiratory distress occurs secondary to marrow fat entering the blood stream and embolizing to the pulmonary vasculature.
Tx?
Femoral shaft fracture is often treated with intermedullary rod fixation.
If bilateral, and comminuted, it may produce enough internal blood loss to lead to shock (external fixation may help while the patient is stabalized).
If open, it is an orthopedic emergency, requiring OR irrigation and closure within 6 hours.
If multiple, fat embolism syndrome may develop, in which severe respiratory distress occurs secondary to marrow fat entering the blood stream and embolizing to the pulmonary vasculature.
Tx: supportive care.
Tibial stress fractures are seen in young men subjected to forced marches. There is tenderness to palpation over a very specific point on the bone, but Xrays are initially __.
Treat with a __, and repeat the Xrays in ___ weeks. Non-weight bearing with crutches is another option.
Tibial stress fractures are seen in young men subjected to forced marches. There is tenderness to palpation over a very specific point on the bone, but Xrays are initially normal.
Treat with a cast, and repeat the Xrays in 2 weeks. Non-weight bearing with crutches is another option.
Leg fracture
- often seen in who?
PE shows ____; ___ imaging is diagnostic.
____ takes care of the ones that are easily reduced;
__ ___ is needed for the ones that cannot be alligned.
The lower leg (along with the forearm) is one of the most common locations for development of the ____ syndrome.
Increasing pain after a long leg cast has been applied always requires immediate removal of the cast and appropriate assessment.
Leg fracture
- often seen in pedestrians is hit by a car.
PE shows angulation; Xray is diagnostic.
Casting takes care of the ones that are easily reduced; intramedullary nailing is needed for the ones that cannot be alligned. The lower leg (along with the forearm) is one of the most common locations for development of the compartment syndrome.
Increasing pain after a long leg cast has been applied always requires immediate removal of the cast and appropriate assessment.
Rupture of Achille’s Tendon
- seen in an out of shape middle aged man who subject themselves to severe strain (tennis, for example). As they plant the foot and change direction, a loud ___ noise is heard (like a rifle shot), and they fall clutching the ankle.
Limited __ ___ is still possible, but pain, swelling, and limping brings them to seek medical attention. Palpation of the tendon reveals a __.
Casting in ____ position allows healing in several months. Surgery achieves quicker cure.
Rupture of Achille’s Tendon
- seen in an out of shape middle aged man who subject themselves to severe strain (tennis, for example). As they plant the foot and change direction, a loud popping noise is heard (like a rifle shot), and they fall clutching the ankle.
Limited plantar flexion is still possible, but pain, swelling, and limping brings them to seek medical attention. Palpation of the tendon reveals a gap.
Casting in equinous position allows healing in several months. Surgery achieves quicker cue.
Fracture of ankle occurs when falling on an ___ or ___ foot. In either case, both ___ break.
AP, lateral, and mortise Xrays are diagnostic. Open reduction and internal fixation are needed if the fragments are displaced.
Fracture of ankle occurs when falling on an inverted or everted foot. In either case, both malleoli break. AP, lateral, and mortise Xrays are diagnostic. Open reduction and internal fixation are needed if the fragments are displaced.
Posterior dislocation of the hip occurs when the femur is driven ____, such as in a head on car collision, where the knees hit the dashboard.
The patient has hip pain and lies in the stretcher with the leg ___, adducted and internally rotated (in a broken hip the leg is also shortened, but it is externally rotated). Because the weak blood supply of the femoral head, emergency reduction is needed to avoid __ __.
Posterior dislocation of the hip occurs when the femur is driven posteriorly, such as in a head on car collision, where the knees hit the dashboard.
The patient has hip pain and lies in the stretcher with the leg shortened, adducted and internally rotated (in a broken hip the leg is also shortened, but it is externally rotated). Because the weak blood supply of the femoral head, emergency reduction is needed to avoid avascular necrosis.
Venous stasis ulcer develops in chronically ___, indurated and hyperpigmented skin above the __ __.The ulcer is painless/painful? with a granulating bed. The patient has__ veins and suffers from frequent bouts of __. Duplex scan is useful in the workup.
Tx: ___ ___ to keep the veins empty; support stockings, __ bandages, and __ boots.
Surgery may be required (vein stripping, grafting of the ulcer, injections sclerotherapy); endovascular ablation with laser or radiofrequency may also be used.
Venous stasis ulcer develops in chronically edematous, indurated and hyperpigmented skin above the medial malleolus. The ulcer is painless with a granulating bed. The patient has varicose veins and suffers from frequent bouts of cellulitis. Duplex scan is useful in the workup.
Tx: Physical support to keep the veins empty; support stockings, Ace bandages, and Unna boots.
Surgery may be required (vein stripping, grafting of the ulcer, injections sclerotherapy); endovascular ablation with laser or radiofrequency may also be used.
Marjolin Ulcer
- __ cell __ of the skin that has developed from a chronic __ ulcer.
The classic setting is one of the many years of healing and breaking down, such as seen in untreated __-degree burns that underwent spontaneous healing, or in chronic draining sinuses secondary to osteomyelitis. A dirty looking, deeper ulcer developers at the site, with heaped up tissue growth around the edges.
___ is diagnostic.
Tx is wide _____and skin ___ if necessary.
Marjolin Ulcer
- squamous cell carcinoma of the skin that has developed from a chronic leg ulcer.
The classic setting is one of the 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 developers at the site, with heaped up tissue growth around the edges.
Biopsy is diagnostic.
Tx is wide excisions and skin grafting if necessary.
Morton’s Neuroma
Inflammation of the common digital nerve at the ___interspace, between the __ and __ toes. The neuroma is palpable and exquisitely tender to palpation.
The cause is typically the use of ___, high heel shoes (or pointed boots) that force the toes to be bunched together.
Management: ___ and more sensible shoes, but __ __ can be performed if conservative management fails.
Morton’s Neuroma
Inflammation of the common digital nerve at the third interspace, between the third and fourth toes. The neuroma is palpable and exquisitely tender to palpation.
The cause is typically the use of pointed, high heel shoes (or pointed boots) that force the toes to be bunched together.
Management: analgesics and more sensible shoes, but surgical excision can be performed if conservative management fails.
