Pestana- 2. Orthopedics Flashcards
When should developmental dysplasia of the hip be diagnosed?
ideally right after birth (it runs in families)
How do you diagnose developmental dysplasia of the hip?
- Children have uneven gluteal folds
- Can jerk the hip down and dislocate with a “click” and it returns to normal with a “snap”
- Use ultrasound (NOT x-ray)
How do you treat developmental dysplasia of the hip?
abduction splinting with Pavlik harness for around 6 months
What are the two ways that hip pathology in children may present?
hip pain or knee pain
What is Legg-Calve-Perthes disease?
avascular necrosis of the capital femoral epiphysis
When and how does Legg-Calve-Perthes disease usually present?
Around 6 years old with insidious limping (passive motion of hip is guarded when walking), decreased hip motion and hip/knee pain
How do you diagnose Legg-Calve-Perthes disease?
AP and lateral hip x-rays
How do you treat Legg-Calve-Perthes disease?
containing the femoral head within acetabulum by casting and crutches
What should you think if a 13 y/o boy presents with groin pain, limping, and when legs dangle while sitting, the sole of the foot on the affected side points toward the other foot?
slipped capital femoral epiphysis
What is the characteristic physical exam finding in slipped capital femoral epiphysis?
as hip is flexed, thigh goes into external rotation and cannot be rotated internally
How do you diagnose slipped capital femoral epiphysis?
x-ray (THIS IS AN ORTHOPEDIC EMERGENCY)
How do you treat slipped capital femoral epiphysis?
pinning the femoral head back in place
What should you suspect if a toddler has a febrile illness then holds the leg with the hip flexed (slight abduction and external rotation) and will not allow it to be moved?
septic hip
How do you diagnose septic hip?
aspiration of hip under general anesthesia
How do you treat septic hip?
if aspiration shows pus, do open drainage
What should you suspect if a young child has a febrile illness and it is followed by severe localized pain in a bone with no history of trauma?
acute hematogenous osteomyelitis
How do you diagnose acute hematogenous osteomyelitis?
MRI (x-rays will not show anything for a couple of weeks)
How do you treat acute hematogenous osteomyelitis?
antibiotics
What is genu varum?
bow legs
Up to what age is genu varum considered normal?
3
What should you think of if genu varum persists after age 3?
Blount disease
What is Blount disease?
disturbance of medial proximal tibial growth plate
What is genu valgus?
knock knee
When is genu valgus commonly seen?
between ages 4 and 8 (normal)
What should you suspect in a teenager with persistent pain right over the tibial tubercle that is aggravated by contraction of the quadriceps?
Osgood-Schlatter disease
What is Osgood-Schlatter disease?
osteochondrosis of the tibial tubercle
What does physical exam show in Osgood-Schlatter disease?
localized pain over the tibial tubercle and NO KNEE SWELLING
What is the definitive treatment for Osgood-Schlatter disease (if RICE does not work)?
extension or cylinder cast for 4-6 weeks
What is talipes equinovarus?
club foot
When does talipes equinovarus present?
birth
What is the more conservative treatment for talipes equinovarus?
serial plaster cases in neonatal period with possible Achilles tenotomy and part-time, long-term use of braces
If casting does not work for talipes equinovarus, when is the ideal time for surgery?
between age 9-12 months
In scoliosis, what part of the spine is affected and to what direction is it curved?
thoracic spines are curved toward right
For how long does scoliosis progress until it stops?
skeletal maturity (so a little after the onset of menses in girls)
What is the treatment for scoliosis?
bracing can arrest progression but severe cases need surgery
What is a complication of scoliosis left untreated?
decreased pulmonary function
Who experiences more remodeling after fractures, children or adults?
children
What are the two fractures that children have special problems with during the healing process?
1) supracondylar fractures of humerus
2) fractures of any bone that involve the growth plate
How does a child get a supracondylar fracture of the humerus?
when a child falls on his hand with his arm extended (hyperextension of the elbow)
If a nerve is injured during a supracondylar fracture of the humerus in a child, what could result?
Volkmann contracture
How are supracondylar fractures of the humerus treated?
casting/traction BUT you need to monitor for integrity of nerve and vessels and watch out for compartment syndrome
When must you use open reduction and internal fixation in a fracture for a child?
if the fracture puts the growth plate in two pieces
What is the most common primary malignant bone tumor in children?
osteogenic sarcoma
Where do osteogenic sarcomas usually occur?
around the knee (lower femur or upper tibia)
How old are patients who get osteogenic sarcomas?
10-25 y/o
What x-ray finding is characteristic of osteogenic sarcoma?
“sunburst” pattern
What is the second most common primary malignant bone tumor in children?
Ewing sarcoma
Where do Ewing sarcomas usually occur?
diaphyses of long bones
How old are patients who get Ewing sarcoma?
5-15
What is the characteristic x-ray finding in Ewing sarcoma?
“onion skinning” of periosteum
What are the two most common mets to bone in adults?
Breast (lytic) in women
Prostate (blastic) in men
What should be suspected in an old man who is tired, anemic and has localized pain at specific places in several bones?
multiple myeloma
What does an x-ray show in multiple myeloma?
multiple punched-out lytic lesions
What is found in the urine in a patient with multiple myeloma?
Bence-Jones proteins
What should be done to the blood of a patient with suspected multiple myeloma?
serum immunoelectrophoresis to look for abnormal immunoglobulins
How do you treat multiple myeloma?
chemo or thalidomide (if chemo fails)
What is the term used to describe a firm soft tissue mass that fixes to surrounding structures and have relentless growth anywhere in the body?
soft tissue sarcomas
Where do soft tissue sarcomas metastasize?
lung
How do you treat soft tissue sarcomas?
wide local excision, radiation and chemo
When is it okay to use a closed reduction (cast) of a broken bone in an adult?
if it is not badly displaced/angulated or can be satisfactorily aligned by external manipulation
Where is the location of most clavicular fractures?
at the junction of the middle and distal thirds
What is the traditional treatment for fracture of the clavicle?
figure-of-eight device (pulls back both shoulder to align the bone)
What is the more common shoulder dislocation?
anterior
How do people with anterior shoulder dislocation hold their arms?
arm is adducted but forearm is rotated outward
What nerve may be stretched in an anterior dislocation (what is the result)?
axillary nerve (numbness in small area over deltoid)
What causes a posterior shoulder dislocation?
epileptic seizures or electrical burn (things that cause massive uncoordinated muscle contractions)
How do people with posterior shoulder dislocations hold their arms?
arm adducted and forearm internally rotated
How do people get Colles fractures?
fall on outstretched hand
Who gets Colles fractures?
old osteoporotic women
What bone is involved in Colles fracture?
distal radius is fractured and dorsally displaced and angulated (wrist looks like “dinner fork”)
How do you treat Colles fracture?
close reduction and long arm cast
How do you get a Monteggia fracture?
direct blow to the ulna (protective arm)
What bones are affected in Monteggia fracture?
diaphyseal fracture of proximal ulna and anterior dislocation of radial head
What is the mirror image of a Monteggia fracture (fracture to distal third of radius with dorsal dislocation of distal radioulnar joint) called?
Galeazzi fracture
How do you treat Monteggia and Galeazzi fractures?
open reduction and internal fixation of broken bone with closed reduction of dislocated bone
What is a carpal navicular?
scaphoid
How do you fracture your scaphoid?
fall on outstretched hand
How long does it take a scaphoid fracture to show up on x-ray?
3 weeks
How do you treat scaphoid fractures?
thumb spica cast
Which metacarpal necks are usuallly fractured when you punch a wall?
4th, 5th or both
How does a person look who has fractured his hip?
affected leg is shortened and externally rotated
What is tricky about femoral neck fractures?
has a tenuous blood supply
What can lead to faster healing and earlier mobilization in femoral neck fractures?
replacing the femoral head with a prosthesis
How do you treat intertrochanteric fractures?
open reduction and internal fixation (need anticoagulation after surgery because patient will be immobilized for a while)
How do you treat femoral shaft fractures?
intramedullary rod fixation
How are collateral ligament injuries commonly sustained?
sideways blow to the knee
What is the test for medial collateral ligament injury?
valgus
How do you treat isolated collateral ligament injuries?
hinged cast
Which is more common, injury to ACL or PCL?
ACL
What are the two tests for ACL injury?
anterior drawer and Lachman test
What is the best way to image and diagnose a meniscal tear?
MRI
What is the typical description of meniscal tear symptoms?
protracted pain and swelling with a catching and locking sensation that limits knee motion (“clicks” when knee is forcefully extended)
Which 3 knee injuries are commonly associated with a single injury?
Medial meniscus
MCL
ACL
What type of fracture is commonly seen in young men subjected for forced marches?
tibial stress fractures
How do you diagnose tibial stress fracture?
x-rays usually normal– patient will have TTP over very specific point int he bone
How do you treat tibial stress fracture?
cast or non-weight bearing (crutches)
What do you have to worry about in tib-fib fractures after long leg cast is applied?
compartment syndrome (remove case immediately)
What motion is limited with Achilles tendon rupture?
plantarflexion
How do you treat ruptured Achilles tendon?
Surgery (quick)
Casting in equinus position
What is the most reliable physical exam finding in compartment syndrome?
excruciating pain with passive extension
What will pulses be in compartment syndrome?
can be normal
How long do you have before you need to be in the OR to reduce an open fracture?
6 hours
What injury occurs during head on collision when the knees hit the dashboard?
posterior dislocation of the hip
How will a patient with a posterior hip dislocation position themselves?
leg shortened, adducted and internally rotated (different than broken where it will be externally rotated)
How do you treat gas gangrene (deep, penetrating dirty wounds after around 3 days)?
IV penicillin
Extensive emergency surgical debridement
Hyperbaric oxygen
How do you treat mucormycosis?
IV amphotericin B
What nerve can be injured in oblique fractures of the middle and distal thirds of the humerus?
radial nerve
What do you do if dorsiflexion of the wrist is present even after reduction of humerus fracture (radial nerve injury)?
you need to do surgery because the nerve is entrapped
If you have a popliteal artery injury but there is delayed restoration of flow, what must you do?
prophylactic fasciotomy
What must you do with every diagnosis of carpal tunnel syndrome?
wrist x-rays
What is the first line of therapy for trigger finger?
steroid injection
What hand position causes De Quervain tenosynovitis?
wrist flexion and thumb extension (like holding a baby’s head)
How do you treat De Quervain tenosynovitis?
steroid injections
splint + anti-inflammatory agents
Who gets Dupuytren contracture?
older men of Norwegian ancestry
What can you feel on physical exam with Dupuytren contracture?
palmar fascial nodules
WHen does a patient with Dupuytren contracture need surgery?
when the hand can no longer be placed flat on the table
What is a felon?
abscess in pulp of a fingertip
What ist he treatment for a felon?
urgent surgical drainage (pressure can build up and lead to tissue necrosis)
What is Gamekeeper thumb?
injury of ulnar collateral ligament due to forced hyperextension of the thumb
How do you treat Gamekeeper thumb?
casting
How does Jersey finger occur?
forcefully extending flexed finger
How does Mallet finger occur?
forcefully flexing extended finger (volleyball)
WHat is ruptured in Mallet finger?
extensor tendon
What is the treatment for Jersey and Mallet fingers?
splinting
What are the most common levels for lumbar disk herniation?
L4-L5 or L5-S1
How do patients with lumbar disk herniation present?
months of vague aching pain (discogenic pain) followed by sudden onset of electric shooting pain (neurogenic pain) precipitated by event (lifting, etc).
Where does the neurogenic pain “exit” in lumbar disc herniation?
big toe (L4-L5) or little toe (L5-S1)
How can you tell for sure if a patients pain is due to disc herniation by physical exam?
if it is worse with coughing, sneezing or defecating
What maneuver is used to evaluate for lumbar disc herniation?
straight leg test
How do you diagnose lumbar disc herniation?
MRI
What is the treatment for disc herniation?
body reabsorbs extruded disc with 3 weeks of strict bed rest (need to do pain management)
What are the symptoms of cauda equina sndrome?
distended bladder
flaccid rectal sphincter
perineal saddle anesthesia
What is the treatment for cauda equina syndrome?
emergency surgical decompression
Who gets ankylosing spondylitis?
young men in 30s-early 40s
When does the back pain occur with ankylosing sphonylitis?
early morning stiffness and pain that improves with activity
What does an x-ray of ankylosing spodylitis show?
bamboo spine
How do you treat ankylosing spondylitis?
anti-inflammatory agents and PT
What antigen is associated with ankylosing spondylitis?
HLA-B-27
Where are diabetic ulcers typically located?
pressure points (heel, metatarsal head, tip of toes)
What is the cycle of diabetic ulcers?
neuropathy causes them to occur, microvascular disease causes them to not heal properly
How may you treat a diabetic ulcer?
controlling DM and keeping leg clean and elevated for weeks to months
What should you expect to be the cause of dirty looking ulcers with bases devoid of granulation tissue located at the tip of the toes?
arterial insufficiency
How do you workup ulcers 2/2 arterial insufficiency?
Doppler studies looking for pressure gradients (if none, then you cannot operate)
What is the treatment for ulcers 2/2 arterial insufficiency?
surgical revascularization or angioplasty and stents
Where do venous stasis ulcers typically develop?
in the skin above the medial malleolus
What other problems will a patient with venous stasis ulcers typically have?
varicose veins and cellulitis
What is the first line treatment for venous stasis ulcers?
support stockings (physical support to empty veins)
What is the name for a squamous cell carcinoma of the skin developing in a chronic leg ulcer?
Marjolin ulcer
How do you treat a Marjolin ulcer?
wide local excision and skin grafting
What coniditon is seen in older, overweight patients who complain of disabling, sharp heel pain every time their foot hits the ground?
plantar fasciitis
What will you see on x-ray in a patient with plantar fasciitis?
bony spur in location matching the pain
What is the treatment for plantar fasciitis?
can remove the spur (but will not always help!)
usually resolve spontaneously in 12-18 months
What is the site of inflammation in a Morton neuroma?
common digital nerve (third interspace–between 3rd and 4th toes)
What causes Morton neuroma?
heels or pointed shoes that bunch the toes together
What will be high in a patient with gout?
serum uric acid
What is the treatment for acute gout attack?
indomethacin and colchicine
What are the drugs used to chronically control gout?
allopurinol and probenicid
