Orthopedics Flashcards
Common causes diminished arm use in Newborn/infants
clavicle fracture, brachial plexus injury, septic arthritis/OM
Common causes diminished arm use in children
nursemaid elbow, fracture, soft tissue injury
Life and limb threatening causes diminished arm use
Septic arthritis Osteomyelitis Necrotizing cellulitis or fasciitis Leukemia or bone malignancy Fracture with neurovascular compromise Child abuse Stroke
Work-up for back pain
Urinalysis and urine culture
Infection or arthritis: CBC, CRP, ESR, blood culture (fever)
Neoplastic: CBC, liver function, CRP, LDH, uric acid
Plain film xray: AP and later views of spine, chest xray if pneumonia
CT scan if acute, high force trauma to back
MRI study of choice to evaluate back pathology (sensitive for spinal cord lesions, bone infections, discitis, vertebral fractures)
How does osteoid osteoma present?
back pain - not worse with activity, may wake at night, better with NSAIDs
Red flags for back pain
constant pain, at night, severe, morning pain (suggest CVD), radiation down leg, fever
List 4 causes of back pain in a female patient with no history of trauma.
Infectious: Spinal and Non Spinal: Osteomyelitis, Spinal Epid Abscess, Pyelonephritis, Pneumonia, Appendicitis, Viral myalgia, Pancreatitis
Reactive Arthritis: Ankylosing Spondylitis, Arthritis of IBD
Neoplastic: Osteoid osteoma, Leuk/Lymphoma, Osteogenic sarcoma
Other: Sickle cell, Nephrolithiasis
5 causes of acquired torticollis
Infections: cervical adenitis, RPA, discitis/vertebral osteomyelitis, strep pharyngitis, lemierres syndrome (pharyngitis, septic pulm. Emboli, persistent fever despite abx, fusobacterium necrophorum
Trauma: muscular injury (injury to SCM/trap most common cause of acquired tort in children), fracture, spinal epidural hematoma
Cervical spine injury or alantoaxial rotary subluxation
CNS tumour
Dystonia
Give 2 differential diagnoses for congenital torticollis other than sternocleidomastoid tumor.
- congenital muscular torticollis
- postural torticollis
- hemivertebrae, congenital scoliosis, Klippel-Feil syndrome
- Clavicle #
- Cystic hygroma, branchial cleft cyst
- C1-C2 rotary displacement
What is Spondylolysis? How does it present?
Stress fracture of the pars interarticularis caused by repetitive spinal extension and rotation (scotty dog)
Insidious onset of extension-related back pain, Hamstring flexibility is reduced, can be pain with impact activities (running, jumping).
2 common organisms in Discitis? Best test for diagnosis?
S. aureus and kingella. MRI spine (xrays often normal)
Treatment of an open fracture
Urgent ortho consult, clean open wounds, sterile dressing applied, antibiotics given, tetanus prophylaxis (ex. ancef with addition of gentamicin for large open fractures)
Common pediatric injuries that cause compartment syndrome
displaced type III SCF (Volkmann contracture), forearm fractures, fracture tibia/fibula, open fracture, crush injuries, soft tissue trauma, burns, poisonous snakebites (pit vipers), deep tissue infection (myositis or fascitis)
5 symptoms of compartment syndrome?
5 P’s: pain out of proportion to injury (exacerbated by full extension), paresthesia, pallor, paralysis, pulselesness
Tx of compartment syndrome
Remove cast and place extremity at level of heart (neither elevated or dependent) Consult ortho for fasciotomy Analgesia Supplemental O2 Avoid hypotension
Volkmann’s contracture - what common injury causes it?
Supracondylar humeral # (ischemia of flexor muscles) –> claw-like hand
Indication for fasciotomy for compartment syndrome?
- High clinical suspicion (ie. symptoms of compartment syndrome)
- Compartment pressure within 30 mmHg of diastolic pressure.
Usual compartment pressure 0-8.
For each of the following categories, name two etiologies of a pathologic fracture: Non-malignant tumor, malignant tumor, hereditary disorders, metabolic, neuromuscular, infectious. oncology
Non-malignant tumor - Non-ossifying fibroma, Osteochondroma, UBC, ABC
Malignant tumor - Ewing’s Sarcoma, Osteosarcoma (ALL, NB)
Hereditary disorder - OI, NF
Metabolic- Rickets, Hyperparathyroidism
Neuromuscular - Cerebral palsy, Traumatic paraplegia or quadriplegia
Infectious - Osteomyelitis, Septic arthritis
Indication for ortho referral for clavicle fracture
open #, severe skin tenting, medial or lateral #, shortening > 1.5 cm, displacement > 2 cm, floating shoulder, comminuted, NV compromise
Most common nerve injury in shoulder dislocation?
Axillary nerve injury (deltoid weakness - loss of ABduction from 15-90 degrees, and numbness over shoulder cap)
List 3 complications of shoulder dislocation?
- Hills-Sachs lesion (# of humeral head due to compression during dislocation)
- Bankart lesion
- axillar nerve injury
List 5 techniques for reduction of shoulder dislocation
- External rotation
- Milch (added to ext rotation with arm overhead)
- Scapular manipulation
- Traction- countertraction
- Stimson (prone on bed with weight hanging off)
- Cunningham (massage)
What is Roos’ test?
As patient to signal for a touchdown, if develops paresthesia/pain - positive test - suggestive of thoracic outlet syndrome
Most common nerve injury with distal humerus #? Clinical findings of this nerve injury?
radial nerve (wraps around the humerus) -> wrist drop, loss of thumb extension, dec sensation on 1st webspace dorsum of hand
Complications of supracondylar fracture?
vascular injury, nerve injury, compartment syndrome cause Volkmann’s ischemic contracture (claw hand), cubitus varus deformity, infection of pins, post operative stiffness, pin migration
Most common nerve injury in Supracondylar fracture? Findings?
AIN (branch of median nerve) - can’t do OK sign (flexion distal phalanx index finger and thumb), hand of benediction
Nerve injury associated with medial epicondyle fractures?
Ulnar nerve
Which non-wrist # can cause referred wrist pain?
radial head/neck fracture - referred wrist pain but localized tenderness at the elbow.
Monteggia vs Galeazzi?
MUGR
Monteggia = ulnar shaft fracture and radial head dislocation (proximal)
Galleazi = radial fracture and radio-ulnar dislocation (distal)
How to reduce nursemaid’s elbow (2)?
Radial head subluxation
- supinate + flex
- hyperpronate
Distal radius and ulna fractures accetable angulation?
0-5 years old: < 20 degrees
5-10: < 15 degrees
>10: < 10 degrees
4 signs of tenosynovitis
Tenderness to palpation of the joint or tendon sheath and with passive extension Swelling around joint + tendon sheath Erythema around joint + tendon sheath Reduced ROM (slightly flexed at rest) “Locking” or “catching” of the tendon during ROM
3 common pelvic avulsion fractures?
Anterior superior iliac spine = Sartorius
Anterior inferior iliac spine = rectus femoris (long head)
Ischial tuberosity = hamstring
Treatment of pelvic avulsion fracture?
Crutches with partial or no weight bearing for 4-6 weeks then gradual return to activity; ortho referal should be made
If displacement greater 2-3 mm - consult ortho
Young Burgess Classification - 3 types of pelvic fractures?
- lateral compression
- AP compression
- vertical shear
Significant pelvic fracture - 4 potential injuries
- Anatomical landmark for pelvic binder
- vascular injury - hemorrhagic shock
- urethral injury, bladder
- spinal injury
- intraabdominal - bowel, liver spleen
Greater trochanters
What is a Malgaigne fracture?
Malgaigne fracture: unstable fractures occur when fracture of pubic rami or symphysis are associated with displaced sacroiliac joint dislocation or sacral fracture = risk pelvic vein injury and severe hemorrhage
How to reduce a patellar dislocation?
give benzo + analgesia, leg starts out flexed, then extend knee with medially upward force on lateral patella
- Imaging post reduction including patellar view (look for osteochondral fragment in 25%, especially if trauma)
- After reduction, immobilize in above knee posterior splint or knee immobilizer for 4 weeks; outpatient ortho for follow up
NV injury that can occur with fractures around the knee?
popliteal vessel and peroneal nerve (ankle dorsiflexion, sesation superior/lateral aspect of foot)
Features of patellofemoral syndrome?
Anterior knee pain
Pain worse with squatting, running, knee can “give away or buckle”
Patellar stress test (place hand just superior to patella and tell patient to contract quads while you apply pressure. Positive if elicits pain)
Gymnast hyperextends knee. By the time she is in the ED she is better. Prominent tibial tubercle. What nerve is at risk of injury and what vessel?
Infrapatellar branch of the Saphenous Nerve
Recurrent Anterior Tibial Artery
Ottawa ankle rules?
Ottawa ankle rules for obtaining foot and ankle xray for children over 5
Xray ankle:if pain in malleolar zone and bone tenderness at posterior edge or tip of lateral malleolus, bone tenderness at the posterior edge or tip of medial malleolus or inability to weight bear immediately and in ED
Xray foot: pain midfoot and bone tenderness at base of fifth metatarsal, bone tenderness over the navicular bone, or inability to weight bear both immediately an in ED
What is a Tillaux fracture? What is the management?
tillaux fractures are a traumatic condition characterized by a Salter-Harris III fracture of the anterolateral distal tibia epiphysis
management is posterior splint with ortho f/u vs ORIF (if > 2mm displacement)
What age is at risk for a Tillaux fracture?
more common in girls
seen in children nearing skeletal maturity (12-14 years old)
typically occur within one year of complete distal tibia physeal closure due to pattern of progression of physeal closure
older than triplane fracture age group
Management of a Triplane fracture?
Emergency orthopedic consultation
CT scan to assess fracture (esp if > 2mm displacement)
Likely will need ORIF
How are ankle sprains classified? Management for each class?
Grade I: stretching of ligaments = air splint or elastic wrap along with ice for 72 hours; crutches with partial weight bearing until not limping
Grade II: partial ligament tears without loss stability= walking cast/boot or posterior splint for up to three weeks with crutches ambulation
Grade III: complete tears with loss of stability = walking cast/boot or posterior splint for up to three weeks with crutches ambulation
Most common ligament sprained in the ankle?
ATFL (anterior talofibular ligament - pain distal fibula from foot inversion
What is the low-risk ankle rule?
The injury is acute (<3 days old)
The child is not at risk for pathological fractures (eg, osteogenesis imperfecta or known focal bone lesion such as an osteoid osteoma)
The child has no congenital anomaly of the feet or ankle
The child can reliably express pain or tenderness
Physical examination demonstrates tenderness or swelling confined to the distal fibula and/or adjacent lateral ligaments distal to the anterior tibial joint line
No gross deformity, neurovascular compromise, or other serious and potentially distracting injury are present
Which fractures are considered low-risk by the LRAR?
Distal fibular avulsion #
Non-displaced SH 1-2 fractures
ankle sprains
(tx with supportive splinting, crutches PRN, return to activities as tolerated)
What is a Jones’ fracture?
5th metatarsal fracture (risk of poor healing, risk or malunion, need immobilization)
What is a Maisonneuve fracture?
Ankle fracture + proximal fibular fracture with tear of interosseus membrane
What is a pseudo-Jones fracture?
Pseudo-Jones or Dancer’s fracture = tuberosity avulsion fracture of proximal tubercle of 5th metatarsal (non-union is NOT common)
Brace vs. cast for low-risk ankle injuries?
Boutis (Pediatrics 2007): for isolated fibular injuries, SH 1 and 2, avulsion fractures: ankle brace was more effective than casting
What is a Lisfranc injury? Complications?
Tarsometatarsal dislocation
Always consider this with fractures of the 2nd metatarsal esp at the base
Complications: compartment syndrome, injury to dorsalis pedis artery, injury to deep peroneal nerve, post-traumatic arthritis
What is a Chance fracture?
Chance fracture results from flexion-distraction mechanism resulting in anterior wedge fracture of vertebral body and horizontal split through and posterior element of a vertebra + associated intra-abdominal injury, *seat-belt sign
Imaging choices for suspected SCFE?
Step 1: X-rays 2 views (AP and frog leg)
Step 2: MRI (may pick up “pre-slip” SCFE that are not yet seen on X-rays)
4 xray findings in SCFE?
- widening of the physis (epiphysiolysis)
- Klein Line
- Steel Sign: metaphyseal blanch sign
- Southwick Angle: head-shaft angle of the affected side is subtracted from the head-shaft angle of the normal side
- Chondrolysis of femoral head/acetabulum
- osteonecrosis
4 classic risk factors for SCFE?
Male
Early adolescent (growth spurt)
African American
Obese
4 RF for SCFE in a younger kid?
Atypical SCFE:
- hypothyroidism
- GH deficiency
- hypopit
- steroid use
- renal failure
4 complications of SCFE?
- AVN of femoral head
- leg length discrepancy
- chondrolysis
- osteoarthritis
Tapping a knee - 2 indications.
Remove effusion causing severe pain/ limiting function. Obtain fluid to dx suspected arthritis
2 labs to r/o endocrine cause of SCFE?
TSH, free T4
Common organisms for septic arthritis?
S. Aureus/Strep pneumo (most common), GAS, Kingella, Neisseria in sexually active teens
Salmonella in sickle cell
GBS in neonate
Work-up of possible septic arthritis?
CBC, diff, blood culture, ESR, CRP, joint aspirate (WBC > 100,000, positive gram stain), +/- Lyme serologies
xray, US to detect effusion
What is the Kocher criteria?
fever, inability to weight bear, ESR > 40, WBC > 12
1/4 = 3% 3/4 = 93% 4/4 = 99%
3 mechanisms for osteomyelitis?
- Hematogenous (most common – bacteria enter at metaphysis)
-Direct spread from adjacent infection - Inoculation through penetrating wound
Trauma may be a pre-disposing factor
Xray findings in osteomyelitis
xrays normal in 1st 10 days
deep soft-tissue swelling, elevation of muscle planes from bone, lytic lesions (10-14 days into course), periosteal elevation (day 10-21)
Abx choice for osteomyelitis?
Cefazolin (or clindamycin)
DDx of polyarthritis?
serum sickness, collagen vascular disease, rheumatic fever and HSP
4 complications of septic arthritis?
Acute: osteomyelitis, bacteremia, sepsis
Chronic: Growth arrest, joint destruction
Why are neonates more at risk for osteomyelitis?
due to thin cortex and transphyseal vessels
What are four complications of casting/ splinting?
Joint stiffness Muscle atrophy Skin breakdown Tight cast = acute compartment syndrome, pain, compression neuropathy, vascular compromise Pressure ulcers/sores Loss of reduction
How to handle amputated limb en route to hospital?
Handle the amputated part with care, do not debride it, irrigate with normal saline and pack loosely with sterile saline soaked gauze. Place in a water-tight plastic bag and store in an ice water slurry. Ensure ice does not directly contact the amputated part.
What is Osgood Schlatter? How does it present?
apophysitis of the tibial tubercle
Localized tenderness at tibial tubercle, pain worse when jumping, squatting, going up stairs. Can develop callus and prominent tibial tubercle
What is Sinding-Larsen-Johansson disease
similar to Osgood Schlatter but affecting inferior pole of patella instead. Xray can show fragmentation or small avulsion at distal pole of patella - differentiate from acute sleeve fracture of patella or bipartite patella
What is Little league elbow?
medical epicondylitis or apophysitis from repeat valgus stress on elbow (from repeat pitching).
What is Thoracic outlet syndrome?
compression of lower roots of brachial plexus (C8 to T1), or axillary vein or artery. Occurs in pitchers, swimmers, weight lifters (repetitive overhead use of arms). Can develop thrombosis of vein +/- embolus .
What is a “burner” or a stinger”
Acute brachial plexus injury - from high-impact sports (ie. football), stretching of the brachial plexus. Immediate arm weakness/paralysis, paresthesias or numbness along a dermatome (usually C5 or C6), sx may resolve quickly before ED assessment. R/O c-spine injury.
