Orthopedics Flashcards
Why do humeral fractures usually occur at the distal portion?
The humerus is thinnest at the olecranon fossa. Adolescents are particularly vulnerable to this because they have growth spurts that cause the long bones to be thinner.
In children, ______________ humeral fractures can usually be treated nonoperatively (even ones that are quite angulated).
proximal
What is neuropraxia?
A temporary loss of peripheral nerve function
Example: Radial nerve injuries with humeral shaft fractures are most commonly neuropraxia that resolves in 6-8 weeks.
Supracondylar fractures peak at which ages?
The highest incidence from 3 to 10 with peak years of 5-7. It’s thought that the bone is weaker from growth during this period.
In examining a child suspected of having a supracondylar fracture, what do you need to do?
- First look for signs of compartment syndrome. A grossly swollen elbow with hematomas raises the concern, as does pain with movement of the fingers.
- Next, do a neurovascular exam:
- Motor: radial (wrist extension), ulnar (wrist flexion and adduction, finger spread), median (wrist flexion and adduction, PIP flexion, opponens [thumb to pinky]), and anterior interosseous (flexion of the thumb DIP)
- Sensory: radial (dorsal web space), ulnar (ulnar aspect of palm/dorsum), and median (radial aspect of palm)
- Vascular: cap refill, radial pulse
In suspected supracondylar fractures, you need to also get __________ x-rays.
forearm
Concurrent forearm fractures are positive in 10-15% of supracondylar fractures.
In an elbow radiograph, the ___________ fat pad is always abnormal.
posterior
It is normally hidden in the olecranon fossa.
Review the types of supracondylar fractures.
- I: non-displaced fracture, can sometimes see the fracture but more commonly the fat pads or abnormal elbow lines
- II: displaced fracture with intact posterior cortex
- III: displaced fracture with both anterior and posterior cortices fractured
The three most common elbow fractures in children are _______________________.
lateral condylar fracture, medial epicondylar fracture, and radial neck fracture
Review the basic principles of splinting.
- The goal of splinting is to stabilize both above and below the fracture. If either is free, then movement can stress the fracture and cause displacement.
- Obtain the following supplies: stocking or cotton wrap, splinting material (either orthoglass, fiberglass, or plaster), ace wrap, tape, scissors, water, basin, chucks
- Wrap initially with stocking or cotton padding, then splint, then wrap cotton or stocking around splint edges, and finally wrap splint in ace wrap
- Check neurovascular status afterward
What are red flag symptoms/signs of lower back pain?
- Neurologic dysfunction: saddle anesthesia, incontinence, weakness
- Infectious signs: fever, leukocytosis, chills
- Malignant features: known malignancy, weight loss, night sweats, fever, point tenderness on spinous process
- Hematoma risk factors: trauma, bleed risk
- Ask about PMH of cancer, osteoporosis, IVDU, and bleeding risk factors
Nursemaid’s elbow is technically _________________.
radial head subluxation
Radial head subluxation does not need to be evaluated with ______________.
x-rays
In practice, though, young children may need x-rays because they can’t tell you what hurts.
Radial head subluxation usually presents in children younger than ________.
5 years
The two methods to reduce nursemaid’s elbow are _____________.
hyperpronation and elbow flexion and supination
Hyperpronation: Hold the child’s extended elbow with one hand and put gentle pressure on the radial head. With your other hand, hyperpronate the forearm.
Flexion and supination: With the same hand positioning as earlier, apply gentle longitudinal traction then supinate the child’s forearm and flex the elbow.
Success is judged by the child moving the affected arm.
When shoulder pain improves with abduction, you should be concerned for what type of pain?
Cervicogenic
Shoulder pain that worsens with flexion of the elbow is typical of what kind of shoulder pain?
Bicipital tendinitis
Adhesive capsulitis is suggested by what physical exam features?
Limited passive and active ROM that is not due to pain
This is associated with immobilization of the shoulder (such as from a surgery), diabetes, autoimmune disorders, and hypothyroidism.
The empty can tests the _________ muscle.
supraspinatus
(Think of someone drinking a can in a Toyota Supra.)
Difficulty with internal rotation of the shoulder is indicative of what rotator cuff injury?
Subscapularis
Inability to supinate and probate the hand along with shoulder injury is suggestive of what two rotator cuff injuries?
Teresminor and infraspinatus
True or false: Neer’s test (placing one hand on the scapula and raising the patient’s arm passively) tests for cuff tear.
False
It tests for impingement of the rotator cuffs.
What test evaluated the labrum of the shoulder?
O’Brien’s
Arm brought up to eye level, 10 degrees in, thumb down
The Thessaly test looks for _______ injury.
Meniscus
Have them stand on the leg in question, flex to 20 degrees, and rotate both directions.
True or false: the tests for MCL and LCL injury (varus and valgus stress) are positive with pain.
False
They are positive with laxity.
What are the T scores for osteopenia and osteoporosis?
- Osteopenia: -1 to -2.5
- Osteoporosis: less than -2.5
What is spondylolisthesis?
Displacement of one vertebral body in relation to another.
Anterolisthesis is anterior displacement of the vertebral body relative the body below it. Posterolisthesis is the posterior displacement of the vertebral body relative to the body below it.
About ___% of ER visits are related to back pain.
3
What are the five emergency causes of back pain?
- Infection: meningitis, osteomyelitis, and spin epidural abscess
- Fracture: pathologic or traumatic
- Disc herniation with cord compression
- Cancer
- Vascular: AAA, epidural hematoma, retroperitoneal bleed
What physical exam things do you need to do in assessing someone with back pain?
- Full neurologic exam
- Palpate the spinous processes
- Test for saddle anesthesia
- DRE (if traumatic or concerning sx of cauda equina syndrome)
- Post void residual (if concerned at all for cord compression)
- Straight leg test
For cord compression, what imaging modality is needed?
MRI
CT is insufficient. Note this includes cord compression from any cause – masses, bleeds, abscesses.
Review the HPI for back pain by diagnosis.
Emergent etiologies:
— Epidural abscess: fever, FND, immunocompromised state, IVDU, hemodialysis, recent LP, recent bacteremic episode, cauda equina symptoms
— Vertebral osteomyelitis or discitis: fever, IVDU, immunocompromised state, IVDU, hemodialysis, recent LP, recent bacteremic episode
— Epidural hematoma: anticoagulant use, trauma, FND, cauda equina symptoms
— Cancer: PMH of cancer, B symptoms, behind on cancer screens, FND, age >50 or <16 w/ new onset pain
— Cauda equina syndrome (can be compression from many causes): saddle anesthesia, incontinence, LE weakness
— Pregnancy and associated complications: child bearing age, vaginal bleeding/discharge
— Non-MSK etiologies: nephrolithiasis, pyelonephritis, zoster, pancreatitis, aortic dissection
Less emergent but specific etiologies:
— Vertebral compression fractures: history of osteoporosis, advanced age, women, steroid use, point tenderness on exam
— Radiculopathy: weakness, pain, or paresthesia in a dermatomal pattern
— Spinal stenosis: worsens with leaning forward, neurogenic claudication
— Ankylosing spondylitis: men younger than 40, rheumatologic pattern (morning stiffness, improves with movement), can present with uveitis
How should you manage lumbosacral strain?
Conservative management:
- Heat
- NSAIDs
- +/- muscle relaxants
- Massage
- Physical therapy (gentle stretching daily, advancement of activity as tolerated, core/leg/back strengthening exercises when in less pain)
- Expectation management: the acute phase of back pain lasts 4-6 weeks. Tell patients to expect bad pain during this interval.
Note: always instruct patients about return precautions.
True or false: any radicular symptoms with back pain warrant emergent MRI.
False
If you suspect uncomplicated disc herniation then it’s ok to plan for PCP or spine center referral for planning for outaptient imaging.
How should you manage uncomplicated disc herniation?
Same as lumbosacral strain.
Conservative management:
- Heat
- NSAIDs
- +/- muscle relaxants
- Massage
- Physical therapy (gentle stretching daily, advancement of activity as tolerated, core/leg/back strengthening exercises when in less pain)
- Expectation management: the acute phase of back pain lasts 4-6 weeks. Tell patients to expect bad pain during this interval.
Only difference is referral to the spine center.
Note: always instruct patients about return precautions.
The straight leg test is positive when pain happens at an angle less than _______.
60 degrees
Note: only positive with radicular pain.
Review the differences between conus medullaris syndrome and cauda equina syndrome.
Conus medullaris affects more because the defect is higher:
- Bilateral and symmetric
- Less likely to have radicular pain
- Hyperreflexia
- Urinary and fecal incontinence
CES:
- Unilateral and asymmetric
- Radicular pain
- Areflexia
- Urinary retention only
How do you ask about saddle anesthesia?
“Does it feel numb when you wipe?”
True or false: Never get an x-ray for traumatic back pain.
True with a caveat
X-rays are sensitive for pathologic fractures, but only about 40% sensitive for other kinds of traumatic fractures. Hence CT everyone who presents with back pain after a trauma.
Back pain w/ spasm can be treated with __________.
valium
Try 5 mg tablets. Can repeat if needed.
If you are suspecting mild disc herniation, you can treat with what non-analgesic modality?
Steroids
A one-time dose of Decadron can help with nerve impingement syndrome.
If a patient with a spinal complaint cannot get an MRI, then consider a _______________.
CT myelogram
This involves an LP with contrast.
____________ is the main treatment for fat embolism.
Supportive care
This is of course in addition to the correction of the long-bone fracture.
A prominent olecranon is a sign of a __________ elbow dislocation.
posterior
Review the differences in how anterior and posterior hip dislocations appear on physical exam.
Anterior:
- Externally rotated, abducted, and extended
Posterior:
- Internally rotated, adducted, and flexed
Open fracture should be assumed when there is a ______________ near a fracture site.
wound
Open fractures should be managed with what initially?
Immobilization, covering in a moist sterile dressing, and IV antibiotics
Which two injuries are most at risk of compartment syndrome?
Tibia and forearm fractures
Other than firm swelling, what are signs of compartment syndrome?
Paresthesia and pallor distal to the swelling
Pain with passive flexion
Pain out of proportion to injury and exam
Weakness
You are concerned about traumatic arthrotomy. Review the workup algorithm.
- First, examine the wound for obvious penetration through the joint capsule. This can be difficult due to pain with the examination but if it reveals an obvious arthrotomy no further workup is needed.
- Second, obtain a CT. CT has poor sensitivity but again if it is positive then no further workup is needed.
- Third, attempt a saline load. To do this, inject 100 mL of saline into the joint in question. If leakage is present then this is a positive. If negative you have essentially done all you can to rule out arthrotomy.
In the lower leg, the most likely compartment to develop compartment syndrome is the ____________.
anterior
Everyone always palpates the calf which will usually not develop compartment syndrome.
People with ____________ (a genetic disease) are at increased risk of compartment syndrome.
hemophilia
If someone with hemophilia has a bleed into an extremity and pain out of proportion to exam then get orthopedics involved early.
Open fractures need what antibiotics?
- Cefazolin
- Gentamicin
Which of the P’s of compartment syndrome are first and last?
Pain with passive motion is usually first.
Pulselessness is usually last.
Paresthesia, pallor, poikilothermia, and paralysis are in the middle.
What are the complications of anterior and posterior hip dislocations?
Anterior displacement causes vascular compromise to the CFA. Posterior displacement disrupts the sciatic nerve.
Chest x-ray may miss up to ____________ of rib fractures.
75%
What is the pathophysiology of nursemaid’s elbow?
Radial head subluxation
Review the T scores for osteoporosis.
- Normal: -1 and greater
- Osteopenia: -2.5 to - 1
- Osteoporosis: less than -2.5
The neurovasculature of the fingers runs along which aspect(s)?
The lateral and medial edges
A scoliometer reading of greater than ____ degrees is clinically significant and warrants follow up.
7
_____________ presents with a thoracic or lumbar “prominence” on forward bend.
Scoliosis
Describe the method of obtaining the Cobb angle and its utility.
The Cobb angle is used to guide treatment of scoliosis. To obtain it, you obtain a PA x-ray of the area of their spine that is affected. You draw a line perpendicular to the spine from the most displaced lower vertebra and the most displaced upper vertebra. You then draw iines perpendicular to those lines. The angle superior to the angle of those lines crossing is the Cobb angle.
A Cobb angle less than 10 degrees is considered normal and no treatment is required.
A Cobb angle 10 - 39 degrees is significant and warrants brace and follow up.
A Cobb angle 40 degrees or more warrants surgical evaluation.
Describe the imaging findings of stress fracture.
Stress fractures usually occur in young athletes who suddenly increase their training. It can also occur in people who have to walk a lot for their jobs.
X-rays will usually be negative for the first four weeks of symptoms. After that period, you can see bone sclerosis, periosteal elevation, cortical thickening, and a thin fracture line.
Those with untreated hip dysplasia will develop a ___________ gait.
Trendelenburg
This is a gait in which stress on the hip abductors leads to the good hip dropping and the bad hip rising.
Classically, lumbar spinal stenosis improves with ___________.
sitting down and bending forward
True or false: lumbar x-ray can help diagnose spinal stenosis.
False
Remember, MRI is the only study that can visualize the spine. X-ray might show some findings in extreme cases, but MRI is the only thing that can show the osteophytes and discs’ proximity to the spine, which is the factor needed to diagnose spinal stenosis.
The socket on the scapula that holds the humerus is the ___________ fossa.
glenoid
Anterior dislocation of the shoulder can cause what nerve impingement syndrome?
Axillary nerve compression, leading to numbness over the lateral aspect of the shoulder
Review the physical exam for de Quervain tenosynovitis.
The Finkelstein test
Have the patient flex their thumb and deviate their wrist in the ulnar direction. If they have pain over the dorsal compartment of the wrist then this is a positive.
Review the treatments for osteoarthritis.
Non-pharmacologic:
- Weight loss
- Exercise
- Physical therapy
Pharmacologic:
- Oral and topical NSAIDs
- Topical capsaicin
- Intra-articular injections
- Duloxetine
Operative:
- Joint replacement
True or false: avascular necrosis of the hip requires urgent surgical intervention.
False
Hip brace placement and orthopedic follow-up are the only things needed from an ED standpoint.
What is the Klein line?
The line drawn from the superior edge of the femoral neck on an AP XR (the Klein line) should intersect the femoral head. If it doesn’t, this suggests SCFE.
A patient presents w/ loss of extension of the thumb, wrist, and fingers after a supracondylar fracture. What nerve is injured?
Radial
The rib is most likely to break at which point?
The posterior angle
Numbness along the deltoid = which nerve palsy?
Axillary
What is luxatio erecta?
Inferior dislocation of the shoulder
This happens in falls in which someone grabs onto something.
The “light bulb sign” is seen in what kind of dislocation?
Posterior shoulder dislocation
This happens because the humerus is forced to be internally rotated and looks symmetric when seen on an AP XR.
Describe the FARES method for reducing anterior shoulder dislocations.
The FARES method is an effective way to reduce shoulder dislocations that can be done without sedation.
With the patient supine, have them extend their elbow and externally rotate the should 90º. Gradually abduct the shoulder and use gentle anterior-posterior oscillations. The shoulder is usually reduced at 120º abduction.
Describe the classic physical exam findings of anterior shoulder dislocation.
Slight abduction and external rotation of the shoulder with a depressed and “squared off” appearance of the shoulder.
Review the basics of orthopedic physical exam.
- Compare the joint to the contralateral joint
- Palpate the joint in question as well as the more proximal and distal joints/bones
- Range the joint with passive and active ROM exercises
- Feel for numbness
- Feel pulses distal to the injury
Gout presents with ___________ birefringent crystals.
negatively
(Remember, Positive = Pseudogout.)
List the four signs of flexor tenosynovitis.
- Pain with passive extension
- Pain along the flexon tendon sheath
- Finger held in flexion
- Fusiform swelling of the finger (sausage-shaped finger)
What is the usual management for pubic rami fractures?
Conservative (WBAT, PT, f/u w/ ortho)
Typically you only need to surgically stabilize if it is displaced or there are other injuries.
A crush fracture of the distal phalanx without nailbed involvement is called what?
Tuft fracture
A displaced distal phalanx fracture with nailbed involvement is called what?
Seymour feacture
How do you manage a Seymour fracture?
- Antibiotics (this is an open fracture)
- Nail replacement
- Close ortho follow up
Review the types of Salter-Harris fractures.
- I: Straight across
- II: Above the growth plate
- III: beLow the growth plate
- IV: Through the growth plate
- V: ERasure of growth plate or cRushed growth plate
Forceful hyperextension of a finger can cause a ____________ avulsion injury.
Volar plate
This can cause tendon injury that decreases pinch strength and requires physical therapy.
Hyperabduction of the fifth digit can cause what type of fracture?
The “extra octave” fracture, which is a fracture of the proximal phalanx of the fifth digit
Use a pencil as a fulcrum to reduce and buddy tape.
Hyperabduction of the thumb can cause what injury?
Radial collateral and ulnar collateral ligmabrt injuries
This is called gamekeeper’s thulb or skier’s thumb.
Treat with thumb spica immobilization.
What disease presents with irregular ossification of the femoral head on X-ray?
Legg-Calvé-Perth
Collies fractures have angulation in the __________ aspect.
dorsal
A distal radius fracture that is the opposite angulation of the collies is the ___________.
Smith
A Galeazzi fracture is what?
Dital third radius fracture with ulnar jount disruption
Greenstick means what?
Bend with one cortex broken
Review the procedure of hematoma block.
- Palpate the fracture
- Inject needle about one finger breadth proximal to the fracture
- Aspirate until you get blood return
- Inject lidocaine
What predicts instability of a distal radius fracture (and need of reduction).
- Radial shortening > 5 mm
- Displacement > 1 cm
- Dorsal angulstion > 20 degrees
What nerve innervates the volar tip of the index finger?
Median
What is the most common mechanism of injury and site of compartment syndrome?
The anterior compartment of the lower leg from a closed tibial fracture
What diagnostic pressure is diagnostic of compartment syndrome?
Delta pressure < 30 mm Hg
Delta pressure = (diastolic blood pressure) - (compartment pressure)
True or false: greenstick fractures are characterized by no cortical breaks.
False
One cortex is broken in greenstick fractures.
Another name for torus fractures is __________.
buckle fractures
Falling onto a flexed knee can cause what ligamentous injury?
Patellar ligament rupture
Signs of this include inability to extend the knee and a high-riding patella on clinical exam or X-ray.
In a normal, extended knee X-ray, the superior aspect of the patella should align with ___________.
the superior border of the femoral condyles
What two maneuvers evaluate for scaphoid fracture?
Tenderness of the anatomical snuffbox
Axial loading of the thumb
What wrist x-ray is best for evaluating the scaphoid?
Ulnar deviation
What test evaluates for achilles tendon injury?
Thompson test: squeeze the calf and see if the foot plantar flexes
How do you treat an achilles tendon tear?
Splint in plantarflexion and ortho follow up
What is the approach for ankle arthrocentesis?
Medial to the tendon of the tibialis anterior, directed to the anterior edge of the medial malleolus
What is the pathology of a greenstick fracture?
Compression of the trabecular network without violation of the cortex
Why do scaphoid fractures occur more often on the proximal end?
The blood supply enters distally
Idiopathic AVN of the scaphoid is known as what?
Preiser disease
____________ are pedunculated pieces of bone that arise from the growth plate.
Osteochondromas
How can you tell the difference between an osteochondroma and an osteoid osteoma on an XR?
Osteochondromas are pedunculated or sessile lesions that grow out of growth plates and will stick out from bone. Osteoid osteomas are lucent areas within bone.
The opposite of traction is __________.
load
Nursemaid’s elbow (radial head subluxation) presents with no ___________ on exam.
deformity
True or false: kids who have had reduction of their nursemaid’s elbow usually need to have a sling at home.
False
90% have complete reduction of symptoms within 30 minutes. Tell parents and caregivers to not put axial traction forces on the arm for the next 1-2 weeks.
What position do kids with nursemaid’s elbow hold their arms in?
Slight flexion of the elbow and pronation of the forearm
The ______________ sits in the lunate.
capitate
Explain the “apple in a cup on a saucer” view of the wrist.
In a side view of the wrist, the capitate should sit in the lunate which sits on the radius like an apple in a cup on a saucer. If either carpal bone is dislocated then the alignment is off.
When evaluating bursitis, what do you need to rule out?
- Septic bursitis (does the person have fever, erythema, leukocytosis, elevated CRP, or intense tenderness to the bursa)
- Septic arthritis (fever, chills, erythema, leukocytosis, elevated CRP, and pain
How are displaced fractures named?
The distal part in relation to the proximal part.
What do oblique and transverse mean in terms of fractures?
Oblique: at an angle
Transverse: straight across
What things do you need in naming a fracture?
- Closed vs open
- Comminuted (if applicable)
- Location on bone (proximal, mid-shaft, distal)
- Bone affected
- Displacement
- Angulation
- Articular involvement
For example a closed, comminuted, angulated fracture of the distal radius with dorsal displacement and intraarticular extension
At the wrist, which forearm bone has a larger articular surface (the radius or ulna)?
Radius
One of the biggest pitfalls in reading x-rays is satisfaction syndrome. What is this?
Seeing one fracture and missing associated fractures
What is a Monteggia fracture-dislocation?
Fracture of the proximal ulnar shaft and dislocation of the radial head
Pathology: FOOSH or direct blow to the forearm
Most commonly seen in 5-10 yos
The anterior humeral line should bisect the ___________.
capitellum (of the humerus)
The midshaft line of the radius should bisect the __________.
capitellum
On a lateral view of the wrist, the distal radius ulnar junction should overlap ______.
by at least 50%; if not, a dislocation is likely
In a wrist view, what is the DR RUCAS mnemonic?
Distal radius
Radio-ulnar junction
CArpal Spaces
What is a Galeazzi fracture-dislocation?
Distal radius fracture with ulnar dislocation
How can you remember which is Galeazzi and which is Monteggia?
MUGR
Monteggia = ulna
Galeazzi = radius
What is the management of Galeazzi and Monteggia?
Urgent ortho consult for likely ORIF
What is the eponym for a comminuted radial head fracture w/ interosseous membrane rupture and DRUJ injury?
Essex-Lopresti
The oblique view of the hand is for evaluating which structure?
The base of the thumb
A PA view can miss fractures to the 1st metacarpal where it meets the trapezium.
True or false: for a boxer’s fracture, you can accept up to 40 degrees of rotational injury.
False
You can accept up to 40 degrees angulation. Rotational injury must be corrected.
In a normal closed hand, all the fingers should point to what?
The scaphoid
What two blocks can help you reduce a boxer’s fracture?
Hematoma and ulnar nerve
The ulnar nerve runs _______ to the ulnar artery.
medial
Pull on the ______________ to reduce a metacarpal fracture.
finger distal to the affected metacarpal
What is a Bennett fracture?
1st MCP base fracture
Requires thumb spica and urgent ortho follow-up.
How is a Rolando different from a Bennett?
Rolando is split into at least 3 pieces
By what two mechanisms can a mallet finger happen?
Mallet finger is a disruption of the extensor tendon of any one of the fingers. In some cases this happens because there is an avulsion of bone of the DIP (the part that the extensor tendon anchors on). In other cases the tendon itself is disrupted and the XR can appear normal.
What is the treatment for mallet finger?
Splint the DIP straight (keep the PIP mobile) and ortho follow up
Make sure the ortho follow up is timely because in some cases (such as when the distal phalanx has >25% of the articular surface avulsed) they need surgical fixation.
What nerve innervates the posterior aspect of the skin overlying the first metacarpal?
Radial nerve
The median does the anterior portion.
Scapular fractures are frequently associated with what other types of injury?
Rib fractures, head injuries, and ipsilateral arm juries
Treatment for scapular fractures?
If the glenohumeral joint is stable and intact, then sling for 2-3 weeks and ortho f/u
The lesser tubercle (of the humerus) is __________ to the greater tubercle.
anterior/medial
Review the 3 views of the typical shoulder series and what each allows you to assess.
- AP: think “ABO”… alignment (of AC and GH), bones (clavicle, scapula, humerus, and ribs), and other (specifically soft tissue like subcu emphysema and lungs like PTX)
- Scapular Y view: assess for scapular fractures
- 30 degree oblique: assesses the GH joint
The appearance of a dislocated shoulder is usually more ____________.
of a stepoff compared to the rounded shoulder
In the scapular Y view, the head of the humerus should overlap what?
The intersection of the three points of the Y
What area of skin do you need to check for numbness in a shoulder dislocation?
Anterior deltoid area (the axillary nerve)
How long should you recommend shoulder sling after shoulder dislocation?
It depends on the age of the patient:
- Older than 40: 5-7 days
- Younger than 40: 7-10 days
The reason is that older people are more at risk of complications from immobility.
What is a Bankart fracture?
Avulsion of the glenoid rim (often seen in recurrent shoulder dislocations)
What is the pathophysiology of a Hill Sachs lesion?
If a shoulder remains dislocated for a long time (or there are recurrent dislocations), the glenoid can cause pressure fractures of the head of the humerus. This leads to a lumpy compression injury that leads to dips in the rounded head of the humerus.
Posterior shoulder dislocations appear __________ to the GH joint. Anterior dislocations appear ________ to it.
superior; inferior
The “lightbulb” appearance of the humerus suggests what pathology?
Posterior dislocation – get the Y view
What pathology presents with stuck abduction of the shoulder?
Inferior dislocation
With scapular fracture, you need to evaluate for which nerve injury?
Axillary (test sensation over anterior should and abduction of shoulder)
The anatomical neck of the humerus is ________ (proximal or distal) to the surgical neck.
proximal
Why is it important to differentiate between anatomical and surgical neck fractures of the humerus in the emergency department?
Anatomical neck fractures can impair blood flow to the humerus and cause avascular necrosis. They require orthopedic consultation in the ED. Surgical neck fractures, in contrast, do not impair blood flow and thus are less urgent.
True or false: most proximal humerus fractures require operative fixation.
False
About 85% of proximal humerus fractures are non-operative. The ones that do require surgery are as follows:
- Anatomical neck fractures
- Fracture-dislocations
- Badly comminuted
For shoulder dislocation reduction, you can do what type of block?
Hemarthrosis block
What two passive maneuvers can you do to ensure that a shoulder is properly reduced?
- Make the hand of the affected shoulder touch the contralateral shoulder
- Externally and internally rotate the shoulder
Being able to have them do both of these is reassuring that the shoulder is in place. Note, apply medial load to the shoulder while doing these maneuvers to prevent it from dislocating again.
What are the two hand motor functions of the radial nerve?
Thumbs up and wrist extension
True or false: mid shaft humerus fractures frequently damage the axillary nerve.
False
Proximal humerus fractures frequently damage the axillary nerve. Mid shaft fractures damage the radial nerve.
The capitellum of the humerus articulates with which other bone?
Radial head
The __________ of the humerus articulates with the ulna.
trochlea
The AP view of the elbow is best for seeing which structures?
The radial head and its articulation with the capitellum
In a lateral elbow XR, what fat pad is normal?
Small anterior
At the elbow, the radial nerve is ___________ to the median nerve.
lateral
It passes posterior to the midshaft of the humerus and courses anterior/lateral and the elbow. The median nerve passes medial to the humerus and then directly anterior to the humerus at the elbow.
The “ok sign” of the hand is mediated by which nerve?
Median
The grading system of tibial plateau fractures is ____________.
Schatzker (I-VI)
I-III can be put in knee immobilizer IV-VI likely need surgery.
What is the “terrible triad” of elbow injury?
Proximal radius fracture, coronoid process fracture, and posterior dislocation of the elbow
Why do olecranon process fractures almost always require surgery?
The olecranon is the insertion of the triceps tendon. Olecranon process fractures will avulse if not fixed.
What elbow injury is suggested by the “T rex arm” appearance?
Posterior elbow dislocation
The forearm is foreshortened and the elbow sticks out posteriorly.
What type of immobilization is needed after elbow reduction?
It depends on laxity. If there is laxity on the elbow (tested varus/valgus) then splint. If there is no laxity then sling.
Both for 2-3 weeks.
Posterior elbow dislocation causes which peripheral nerve injury?
Median
The capitate is ___________ to the hamate.
lateral
The longest (proximal-distal) carpal bone is which?
Capitate
The ___________ is directly lateral to the scaphoid.
lunate
Review the systematic approach to the PA view of the wrist XR.
DR RUCAS
DR RU: evaluate the distal radius (cortex) and RadioUlnar junction (is it wide).
CAS: evaluate the carpal lines and spaces. There should be a smooth arc proximal to the scaphoid, lunate, and triquetrum. There should be another smooth arc proximal to the capitate and hamate. The “spaces” refers to a lack of space between the bones. Normally, there should be visible gaps between the carpal bones on an AP view. Lack of this (i.e., overlapping carpal bones) suggests dislocation.
What two types of injuries can the lateral wrist XR diagnose?
DRUJ injury (a dislocation here will often show up because the bones frequently displace dorsally/ventrally)
Dislocations of the lunate or capitate.
Widening of the scapholunate junction is radiographically referred to as what?
Terry Thomas sign (from a 1950s comedian who had a widened tooth gap)
Note, scapholunate junction injury is the most common ligamentous injury of the wrist. Treat with thumb spica and urgent ortho f/u.
You are looking at a lateral wrist XR. You notice the lunate seems to jut in the palmar direction and that the capitate does not rest in the lunate. This is referred to as what?
Perilunate dislocation
What does the “pie sign” indicate on a wrist PA view?
Lunate dislocation
The pie sign is a bright white overlap of bone from the lunate overlapping with the capitate.
Why do lunate and perilunate dislocations need to be reduced urgently (as in, before they leave the ED)?
Prolonged dislocation increases the risk of two morbidities:
- Median nerve injury (“acute carpal tunnel”)
- Scapholunate advanced collapse (“SLAC”, basically AVN of these bones)
Treatment for scaphoid fracture?
Thumb spica and ortho f/u
Explain the difference between Colles and Smith.
Both are isolated distal radius fractures. Colles presents with dorsal angulation (from an extended wrist FOOSH) and smith presents with volar angulation (from flexed wrist with FOOSH).
What two ways do you need to check for scaphoid tenderness?
Axial loading of the thumb
Direct tenderness of the anatomical snuffbox
When might you order an MRI to evaluate for a scaphoid fracture?
If someone has a livelihood that depends on wrist mobility – think concert pianist, surgeon, fine artist, etc – then you should get an MRI to confirm diagnosis.
What are the typical exam findings for hip dislocation (anterior and posterior) and hip fracture?
Dislocation:
- Posterior: shortened and internally rotated
- Anterior: shortened and externally rotated
Fracture: lengthened and externally rotated
What is Daneille Campagne’s mnemonic for reading pelvic XRs?
RSSO:
- Rings: pelvic ring and obturator rings (no drop offs)
- Symphysis (no widening or malignalignment)
- Shenton’s lines: nice candy cane contour
- Other: ala, femoral head
Shenton’s lines extend from _____________ to the inferior edge of the anatomical neck of the femur.
inferior border of the superior pubic ramus
What are the three basic types of hip fractures?
Femoral neck: threat to blood supply, high risk of AVN
Intertrochanteric: lower risk of AVN but higher risk of shortening and malunion
Subtrochanteric: rarer (5-10%)
If you have a suspicion of hip fracture (like, patient can’t walk after a fall) but the XR is negative, what imaging modality should you consider next?
MRI
There can be subtle fractures that are missed on XR and CT.
Mortality for femoral neck fractures improves if done within _____ hours after an injury.
24
What is the name of the immobilization device for infants with LE fractures?
Pavlik harness (keeps the hip in flexion and abduction)
You need to reduce a native hip dislocation within ________________ to reduce the risk of AVN.
6 hours of the injury
What nerve is commonly injured in hip dislocations?
Sciatic
Check for sensory deficits (the lateral aspect of the lower leg and foot) and motor deficits (toe dorsiflexion and ankle)
What percent of hip dislocations have an associated acetabular fracture?
70%
In what cases do you get a hip CT after reduction of hip fracture?
All cases of native hip (because of the 70% incidence of acetabular fracture)
For prosthetic hip dislocations, when should you call orthopedics?
- Malposition of the prosthesis (like a periprosthetic fracture or slipped hardware)
- Recurrent instability
- Inability to reduce
What two motions do you need to prevent after reducing a prosthetic hip?
Hip adduction and flexion (use an abductor pillow at night and a knee immobilizer)
What is the classification system of ankle fractures?
Lauge-Hansen
This tells you how the injury happened and how to reduce it.
Review the three sets of ligaments that stabilize the ankle.
Lateral: ATF, PTF, calcaneofibular
Medial: deltoid ligament
Tib-fib: syndesmotic
Review the Ottawa ankle and foot rules.
- Inability to bear weight
- Tenderness over either malleoli, navicular bone, or base of 5th metatarsal
What is the EMRAP mnemonic for ankle AP view?
M&M’s Overlap
Malleoli: intact cortex?
Mortise (talar dome cortex smooth?)
Overlap: the fibula should overlap the tibia; the gap between the talar dome and the tibia and fibula should be less than 6 mm
What do you assess on a lateral ankle?
- Navicular and calcaneal cortex
- Tibia-talar gap uniform across the dome
- Bohler’s angle
- Posterior malleolus
The oblique view of the ankle is called the _________ view.
mortise
Greater than 6 mm gap in the mortise suggests _________ injury.
ligamentous
The space between the talus and the medial malleolus is the ___________.
medial clear space
What is the grading system (and the significance of the scores) of lateral malleolus fractures?
Weber ABC
- A: distal tip of fibula below the syndesmosis
- B: in the middle of the syndesmosis
- C: above the syndesmosis
The significance is that A is stable (because it doesn’t affect the ankle joint) and B and C are unstable. A gets a splint and WBAT. B/C boot and NWB.
What is a squeeze test and what does it signify?
You squeeze the tibia and fibula in the lower 1/3 of the leg. If the patient has shooting pain down the ankle it suggests a syndesmosis injury.
A person has an ankle injury. The ankle XR shows widening of the mortise. Physical exam shows a positive squeeze test. What is going on and what XR should you order?
Knee XR for r/o of maisonneuve fracture
Why is Maisonneuve an important injury to diagnose?
It creates an unstable ankle (because the fibula is unstable) and the proximal fibular fracture can injure the common peroneal nerve.
What sensation does the common peroneal nerve give?
The dorsal web space between 1st and 2nd toes
What ankle bone is sometimes broken in the maisonneuve fracture?
Medial malleolus
It’s not always broken. Sometimes it’s just the ligamentous injury to the deltoid ligament.
What splint do you need to apply for a maisonneuve?
Posterior long leg splint
What is the name of the fracture in which the articular surface of the tibia at the ankle is fractured?
Tibial plafond fracture
True or false: treat tibial plafond (aka pilon) fractures with short leg splint.
False
It is long leg. Flexing the knee can destabilize the tibiotalar junction.
Talar fractures are at high risk of ____________.
AVN
Treat talar fractures with ______________.
long posterior splint and urgent ortho consult
What are the Ottawa rules for the knee?
- Age > 55 years
- Tenderness over the head of the fibula or the patella (if isolated)
- Inability to flex the knee past 90 degrees
- Inability to bear weight
What is Danielle’s mnemonic for knee XR?
TAB
- Tibial plateau (both sides)
- Alignment (in the joint and the tibiofemoral line)
- Bones: femur, patella, tibia, and fibula
True or false: the tibiofemoral line (on an AP XR) should be measured on the medial side.
False
Lateral
The best view of the patella is the ________ knee XR.
lateral
On a lateral knee XR, what do you need to evaluate?
Effusion (often seen superior and posterior to the patella)
Bones (patella, femur, tibia, fibula)
Alignment (posterior-anterior)
Patella ligament (should be the same length as the patella, if longer then it suggests ligamentous injury)
What is the fabella?
A sesamoid bone in the posterior knee
What are sesamoid bones?
Bones that are embedded in tendon (like the patella)
The two physical exam tests for knee effusion are what?
The fluid sweep and patella ballottment
What three things do you need to examine for in the knee exam?
- Presence of effusion
- Ligamentous laxity
- Extensor mechanism intact
What type of injury leads to lipohemarthrosis?
Intraarticular fracture
Fat is within bone. You may develop a fat-fluid level in a joint that is broken.
What type of splint is needed for an Achilles tear?
Equinas spliint (with plantarflexion)
What causes ganglion cysts?
Herniation of connective tissue around tendons or joint capsules (the synovial sheath) that leads to the slow accumulation of cystic fluid
Most common over the scapholunate junction
What is the difference between a sprain and a strain?
Sprain: ligament
Strain: muscle/tendon
Both are injuries that cause partial tears in the tissue in question.
How do you reduce a lateral patellar dislocation?
Slowly extend the knee and apply pressure to the patella
Review the classification of Salter-Harris fractures.
SALTEr mnemonic
I: Straight across (parallel to) the growth plate (also “Slipped”)
II: into and Above (proximal to) the growth plate
III: Lower (distal to) the growth plate
IV: Through or in Two
V: ERasure of the growth plate (or cRush injury)
The other name for bucket handle fractures is what?
Corner fractures
These are distal femoral fractures in which shearing forces applied to the limb (such as being pulled or twisted) cause a chunk of the femur to pull off.
What nerve injury is classically seen in Galeazzi fractures?
Interosseous nerve (a branch of the median)
People with Galeazzi thus lose the motor function of the median nerve.
What is the mechanism of injury of mallet finger?
Hyperextension leads to disruption of the
Improperly treated mallet finger leads to what malformity?
Swan neck
In what two locations can you get ulnar neuropathy from nerve compression?
The cubital tunnel (the narrow passage between the olecranon and medial epicondyle) and the Guyon canal in the wrist.
The way to differentiate these is to tap the cubital tunnel when the elbow is flexed. If the patient’s symptoms worsen then it is likely that there symptoms are from cubital tunnel syndrome. Also, worsening with elbow flexion suggests more cubital tunnel syndrome.
What range of WBC is typical of septic bursitis (that is, from the aspirate)?
5-20 k
True or false: septic bursitis warrants admission for I&D.
False
Most cases can treated with outpatient antibiotics and follow up. OR is usually reserved for immunocompromised patients, failure of oral antibiotics, or concern for joint involvement.
What antibiotics treat septic bursitis?
Non-traumatic: Keflex (sor standard SSTI bugs)
Traumatic: fluoroquinolones (for polymicrobial and PsA)
What are the four muscles that make up the quadriceps?
Rectus femoris
Vastus medialis, intermedius, and lateralis
Which fracture is most common to cause compartment syndrome in kids?
Supracondylar
What criteria predict likelihood of septic arthritis in a child?
Kocher:
- WBC > 12
- ESR > 40 mm/hr
- Non-weight bearing
- Fever > 38.5
All four has a likelihood of 99% for septic arthritis.
What two compartments are most common to get compartment syndrome?
Anterior lower leg and volar forearm
What is the difference between epiphysis, apophysis, and metaphysis?
They are all types growth plates. Epiphysis is within a joint. Apophysis is a growth plate on a tuberosity or muscle insertion point that is not involved in lengthening. Metaphysis is growth plate involved in lengthening.
What is a toddler’s fracture?
A non-displaced spiral fracture in the distal 2/3 of the tibia in a child 1-3 yo.
If it is midshaft you must work up NAT.
In a ___________ fracture, one side of the bone is intact and the other is broken.
greenstick
Fraying of the distal metaphysis is seen in ____________.
Rickets
Review the Hawkins test.
Have the shoulder flexed 90 degrees forward, bend the elbow 90 degrees inward, and forcibly internally rotate. This tests for subacromial impingement syndromes (like subacromial bursitis).
Review the Neer impingement test.
Place Place your hand on the patients scapula and passively raise the arm. This tests for subacromial impingement.
What is the diagnostic maneuver for De Quervain’s tenosynovitis?
Eichoff (aka Finkelstein) test: point thumb towards pinky and deviate wrist in the ulnar direction
What is the management of De Quervain’s tenosynovitis?
Thumb spica splint
Review the management of sternoclavicular dislocations?
Anterior: nothing, just sling. Do not reduce – the redisl
Review the management of clavicle dislocations.
Grades 1-3: sling
Grades 4-6: sling and likely surgery
Grade 1: AC ligament sprain
Grade 2: AC ligament torn, coracoclavicular ligament intact
Grade 3: AC ligament torn, CC torn, clavicle displaced by distance but not anterior/posterior/superior/inferior Grades 4-6: AC and deltoid torn, clavicle displaced in different aspects
Review the management of clavicle dislocations.
Grades 1-3: sling
Grades 4-6: sling and likely surgery
Grade 1: AC ligament sprain
Grade 2: AC ligament torn, coracoclavicular ligament intact
Grade 3: AC ligament torn, CC torn, clavicle displaced by distance but not anterior/posterior/superior/inferior Grades 4-6: AC and deltoid torn, clavicle displaced in different aspects
True or false: a posterior fat pad indicates a radial head fracture.
True
How do you measure Klein line?
It is an arbitrary line drawn along the superior edge of the femoral neck. It should intersect the femoral head.
What is the pathophysiology of gamekeeper’s thumb?
Rupture of the ulnar collateral ligament
Requires surgery.
What is the difference between a lunate and perilunate dislocation?
In a perilunate, the lunate is still aligned with the radius.
When is trephination of a subungual hematoma indicated?
Injury < 48 hours, pain, and lack of spontaneous drainage
What is the most common cause of sail sign in an adult?
Occult radial head fracture
True or false: you should always aspirate bursitis to r/o infection.
False
If there is concern for septic bursitis (say, from fever, overlying erythema, recent puncture wound) then you should. But in the absence of all of those risk factors you do not need too.
Treatment for ASIS avulsion?
No weight bearing
What is the maximum amount of cold ischemic time for amputation re-implantation?
12 hours
Which nerve is most often injured in anterior shoulder dislocation?
Axillary
Review the Ottawa ankle criteria?
Inability to bear weight immediately after the injury
Tenderness at the posterior lateral malleolus
Tenderness at the posterior medial malleolus
What are the Ottawa foot criteria?
Inability to bear weight immediately after the injury
Tenderness at the 5th metatarsal base
Tenderness at the navicular bone
The two physical exam tests that detect subacromial impingement are what?
Hawkins-Kennedy and Neer
Compare the appearance of Ewing and osteosarcoma on XR.
Ewing:
- Cortical lifting (“onion skin”)
- Moth eaten
Osteosarcoma:
- Lytic destruction of the cortex
True or false: the Guyon tunnel is just distal to the medial epicondyle.
False
It’s near the wrist. The dorsal surface is the flexor retinaculum. The volar surface is the volar carpal ligament. Pisiform bone forms the radial and ulnar walls.
Fibular head fractures can cause what nerve dysfunction?
Fibular head fractures can injure the common peroneal nerve before it splits in the superficial and deep peroneal nerves. These nerves provide motor innervation to the tibialis anterior, so loss of its function causes foot drop. These nerves also innervate the anterior portion of the lower leg.
Which of the Italian forearm fractures involves the elbow?
Monteggia (“Mont-Elbow”)
What vascular complication can result from pinning of the hip?
Disruption of the lateral epiphyseal artery leading AVN
True or false: if an avulsed finger tip has no capillary refill then you should remove it.
False
It still may grow back, and if it doesn’t then the reattached portion can act as a dressing.
Which is on the glenoid, Bankart or Hill-Sachs?
Bankart
(Think “BAnkart on the BAse of the joint”.)
What is the pathology of gamekeeper thumb?
Rupture of the ulnar collateral ligament (a capsular ligament on thee MCP)
Review the need for emergent and urgent orthopedic consultation for clavicle fractures.
Emergent:
- Open
- Neurovascular compromise
- Skin tenting
Urgent:
- Superiorly displaced (often requiring repair)
- Distal fracture or dislocation with greater than 25% bone width displacement (type II or greater)
What complication can arise in treating a type II-IV supracondylar with splinting in hyperflexion?
Volkmann contracture
Ischemia from compartment syndrome leads to permanent flexing of the wrist and fingers.
How does Pagets present on X-ray?
Mixed areas of lucency and sclerosis
What bony malformations does pagets cause?
Bowing long bones and frontal bossing
What peripheral nerve injury causes the “claw hand” deformity?
Ulnar
Weak wrist flexors lead the wrist to hyperextend and along with paucity of control of the lumbricals leads to a claw appearance.
What is the way to differentiate between lunate and perilunate?
The easiest way: perilunate still has one articular surface maintained (the radiolunar joint) while lunate dislocation has neither surface maintained.
Splint for lunate dislocation?
Sugar tong.
Splint for trimal?
Short-leg with stirrup
How do you describe displacement of a fracture?
The distal portion in relation to the proximal portion
Review the ABO of a shoulder XR.
Alignment:
- GH joint
- AC joint
Bones:
- Examine cortices of humerus, clavicle, ribs, and scapula
Other:
- PTX
- Soft tissue air
What three things make the “Y” in a scapular Y view?
Coracoid, acromion, and scapular body
How long should someone remain in a sling after anterior shoulder reduction?
Younger than 40: 5-7 days
Older than 40: 7-10 days
What is the eponym of the AC joint separation grading system?
Rockwood grading system (I - VI)
True or false: the surgical neck of the humerus is superior to the anatomical neck.
False
The anatomical neck is superior – it connects the ball to the greater and lesser tuberosities.
Why is the distinction between anatomical neck and surgical neck of the humerus important?
Anatomical neck is more likely to impair blood supply and lead to avascular necrosis of the humeral head.
What three types of humeral head fractures warrant urgent ortho consult (i.e., in the ED)?
Anatomical neck fractures
Fracture-dislocation injuries
4-part fractures
What is the motor exam for the axillary nerve?
Resisted shoulder abduction
What two maneuvers can you do to assess if a dislocated shoulder is reduced?
Have them touch the opposite shoulder – you cannot do this if the shoulder is out.
Have them internally and externally rotate it.
What area of sensation do you need to test to evaluate for radial nerve injury?
Dorsolateral hand
The coronoid process articulates with the _______________.
trochlea
The ____________________ articulates with the radial head.
capitellum
Posterior elbow dislocations are associated with which nerve injury?
Median nerve (check for sensation on the palmar 1st-3rd and the ok sign)
Anterior elbow dislocations are associated with which nerve injury?
Ulnar (check for sensation on the palmar and dorsal aspect of the medial palm and the lumbricals)
In the ______________ view, the radius and ulna should overlap by at least 50%.
lateral
What are the two things you look for to rule-out radioulnar dissociation?
Wrist PA: they should touch
Wrist lateral: they should overlap by 50%
What nerve complication can perilunate/lunate dislocation cause?
Acute carpal tunnel (medial neuropathy)
If this is present, emergent surgical consultation is indicated.
Other than tenderness of the snuffbox, what test suggests scaphoid fracture?
Axillary loading of the thumb
Which ligament flexes the DIP of the 2nd-5th digits?
Flexor digitorum profundis (P for Point)
The flexor digitorum superficialis flexes the PIP.
What is the pathophysiology of a central slip injury (also called Boutonniere deformity)?
The extensor of the PIP is severed and the DIP is spared. As such, the DIP is stuck in extension when the PIP is stuck in partial flexion.
What is the pathophysiology of gamekeeper’s thumb?
Ulnar collateral ligament tear (of the thumb MCP)
When doing a felon I&D, which side do you cut on?
The goal is to preserve pinch strength. As such, you incise on the ulnar aspect of digits 2-5 and the radial aspect of the thumb.
What are the three parts of a bone (ending in -physis)?
Middle section: diaphysis
End section: epiphysis
Between the middle and end: metaphysis
The radius normally has a ___________ tilt.
palmar
