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.
