Pestana Orthopedics Flashcards
infant presents with uneven gluteal folds; hips can be easily dislocated posteriorly with a “jerk and click” and returned to normal position wiht “snapping”
next best step in management and treatment?
developmental dysplasia of the hip
get a sonogram (xrays will not work because the hip is not calcified)
Pavlik harness for 6 mo
6 year old with insidious development of limping, decreased hip motion, and hip/knee pain.
Diagnosis, next best step in management, and treatment?
Legg-Calve-Perthes disease
(idiopathic disruption blood flow to femoral head -> avascular necrosis and cessation of growth -> collapse and deformity of the femoral head)
get AP and lateral hip X-rays
cast the femoral head within the acetabulum
(removes mechanical pressure from the joint until the disease has run its course and reduces risk of developing a severe degenerative arthritis as adult can be reduced)
chubby teenager boy limps and complains of groin pain; sits with legs dangling wtih the sole of the foot on the affected site
Diagnosis, next best step in management, and treatment?
Slipped capital femoral epiphysis (SCFE) - orthopedic emergency
X-ray
Surgery - pin femoral head back into place
toddler with a recent episode of fever refuses to move the hip and holds the leg with the hip flexed, in slight abduction, and external rotation. Gets very upset if anybody tries to move it passively
Diagnosis, next best step in management, and treatment?
Septic Hip
ESR + aspiration of hip under general anesthesia
Open drainage if pus is obtained during aspiration
5 year old with recent fever presents with severe, localized pain in a bone
Diagnosis, next best step in management, and treatment?
Acute hematogenous osteomyelitis
MRI
Antibiotics
Physical finding in a 2 year old
Diagnosis and treatment?
Genu Varum (bowlegs)
no treatment
physical finding in a 5 year old
Diagnosis, next best step in management, and treatment?
Blount disease - persistent varus beyond age 3; actually a growth disorder of the tibia (shin bone) that causes the lower leg to angle inward, resembling a bowleg
Surgery - may involve cutting the tibia to realign it and/or lengthen it
physical finding in a 4-8 year old
Diagnosis and treatment?
Genu Valgus (knock knee)
No treatment
teenagers with persistent pain over the R tibial tubercle, aggravated by contraction of the quadriceps. No knee swelling
Diagnosis and treatment?
Osgood-Schlatter Disease
RICE (rest, ice, compression, elevation); if it does not work, can use an extension or cylinder cast for 4-6 weeks
Physical finding in a newborn infant
Diagnosis and treatment 3?
Club foot (talipes equinovarus)
serial plaster casts (started in the neonatal period to provide sequential correction), Achilles tenotomy, and Braces
Surgery if not responding to casting (usually 9-12 mo)
complications of scoliosis
treatment? 2
deformity can progress until skeletal maturity is reached; severe cases can result in decreased pulmonary function
bracing to arrest progression, surgery for severe cases
two fractures that are the most concerning in children
supracondylar fracures of the humerus
fractures involving the growth plate
child trips and falls on the hand with the arm extended
Diagnosis and why is this of concern?
Next best step in management, and treatment?
think supracondylar fractures of the humerus
concerning b/c of vascular/nerve injuries that could result in Volkmann Contractures
casting w/ careful monitoring of vascular and nerve integrity, and development of compartment syndrome
Fractures of the eipiphyseal growth plate
Treatment?
Diagnosis made based on SALTER classification
- S: slipped (type I)
- A: above (type II)
- L: lower (type III)
- T: through or transverse or together (type IV)
- R: ruined or rammed (type V)
Treatment depends on the classification
- If fracture does not cross the epiphysis or growth plate (type I) -> closed reduction
- If fracture does cross the epiphysis or growth plate (type II-IV) -> open reduction and internal fixation (to precisely align the pieces)
teenager presents with low grade skeletal pain for the last several months. What should be your major concern?
malignant bone tumors (osteogenic sarcoma or ewing sarcoma)
teenager presents with dull but consistent pain in his knee for the last several months.
X-ray findings are shown.
Diagnosis?
osteogenic sarcoma - typically affects 10-25 age group
X-ray usually shows “sunburst” pattern
child presents with dull but consistent pain in his thigh for the last several months.
X-ray findings are shown.
Diagnosis?
Ewing Sarcoma - typically affects children 5-15
X-ray shows “onion-skinning” pattern
common areas: pelvis, femur, humerus, ribs and clavicle
type of bone pattern observed in metastatic breast canacer
lytic lesions - often presents as a pathologic fracture (ie someone breaks their arm because they lifted a bag of groceries)
type of bone pattern observed in metastatic bone canacer
blastic lesions
old man presents with fatigue, anemia, and localizable pain in several bones
Diagnosis, diagnostic tests 3, and treatment 2?
Multiple myeloma
Diagnostic tests
- XRay - multiple punched out lesions
- Urine - bence-jones protein
- Serum Igs
Treatment
- chemoRx
- Thalidomide
How do soft tissue sarcomas present?
Diagnosis, diagnostic tests 2, and treatment 3?
relentless growth of a mass that is firm and fixed to surrounding structures.
Diagnosis with MRI and incisional biopsy
Treat with very wide local incision, radTx, and chemoRx
How do you determine if a fracture can be surgically treated with a closed reduction vs open reduction with internal fixation?
closed: broken bones that are not badly displaced or angulated or that can be aligned by external manipulation
open with internal fixation: broken bones that are severely displaced or angulated or that cannot be aligned easily
How are clavicular fractures managed?
SLING
patient presents with his arm close to his body and rotated outward.
What should you be worried about?
What is another physical finding that is pathognomonic of this and why?
What imaging would you order to cinch the diagnosis?
Anterior dislocation of the shoulder
also presents wtih numbness over a small area of the deltoid, secondary to stretching of the axillary nerve
AP + Lateral XRays are diagnostic
patient with an epileptic seizure disorder presents with his arm held close to the body and internally rotated.
What should you be worried about?
What imaging would you order to cinch the diagnosis?
Posterior shoulder dislocation
Axillary or Scapular Lateral X-rays
little old lady falls on an outstretched hand
X-ray is as shown
Diagnosis? Treatment?
Colle’s fractures - fracture of the distal radius
Note the dorsally displaced and dorsally angulated fracture of the distal radius seen on the X-ray
Trmt: closed reduction + long-arm cast
All time champion boxer comes in excrucating pain in his L arm
X ray is as follows
Diagnosis? treatment?
Monteggia Fracture - usually caused by direct blow to the ulna.
Note Xray shows a diaphyseal fracture of the proximal 1/3rd of ulna with dislocation of the head of the radius
given the extent of the displacement, open reduction with internal fixation is preferred over cosed reduction
Patient falls on an outstretched arm and complains of significant pain and swelling at the distal-third of his arm and hand.
Diagnsois? Treatment? 2
Galeazzi fracture - typically caused by direct blow to the distal third of the radius
Note Xray has an isolated fracture of the distal and middle 1/3rd of the radius with associated subluxation/dislocation of the distal radio-ulnar joint
open reduction and internal fixation of the broken and dislocated bones
Young adult falls on an outstretched hand and immediately complains of pain and swelling at the base of the thumb. Xray is as shown
Diagnosis? Treatment options?
Scaphoid fracture (carpal navicular)
in undisplaced fractures - thumb spica cast
in displaced and angulated fractures - open reduction and internal fixation
drunk person becomes belligerant and punches a wall and his hand becomes swollen and tender.
X-rays are as shown.
daignosis? treatment?
metacarpal neck fracture
closed reduction with ulnar gutter split
old lady sustains a fall; paramedics is called and she is transported to the hospital in a stretcher and you notice her presentation.
diagnosis? management? treatment?
hip fracture
note her affected leg is shortened and externally rotated
treatment depends on the location, so get an x-ray!
treatment - open reduction and internal fixation with screws/plates
Patient presents with femoral neck fracture of the hip. What are you most concerned about? Treatment?
avascular necrosis of the femoral head, resulting in collapse of the necrotic segment
Treatment: replace femoral head with prosthesis
Patient presents an intertrochanteric fracture of the hip. What are you most concerned about? Treatment?
open reduction and internal fixation
requires post-op anticoagulation due to high risk of DVT/PE secondary to prolonged immobilzation
Patient presents a femoral shaft fracture of the hip. What are you most concerned about? Treatment?
cleaning and closure wtihin 6 hours because if the fractures are bilateral and shattered/multiple fractures -> there is a higher risk of internal blood loss and shock +/- fat embolism
how do you diagnose (2) and treat a ACL tear (2)?
MRI + anteiror drawer test
if patients are sedentary -> immoblization + rehab
if patients are very active (ie athletes) -> surgical reconstruction
patient describes a “catch & lock” feeling that limits their knee ROM after a painful knee injury; when they forcefully extend their knee, they feel a “click”
Diagnosis? Best diagnostic test? Treatment?
Meniscal tear
Diagnose with an MRI
open repair - to save as much meniscus as possible, as complete meniscectomy can often lead to late development of degenerative arthritis
long distance runner presents with tenderness to palpation over a very specific point on the bone; initial x-rays are negative for any abnormal processes
Diagnosis? Treatment? 2
Tibial stress fracture - due to repetitive application of force, often by overuse (repeatedly jumping up and down or running long distances)
Cast + non-weight bearing measures (crutches)
pedestrian is hit by a car while crossing the street. physical exam shows angulation of lower leg.
Diagnosis and treatment? 2
**Fractures involving tibia and fibula **
Casting (for ones that are easily reduced) vs intramedullary nailing (for ones that cannot be aligned)
most common areas for compartment syndrome
lower leg + forearm
what should you be concerned about if a patient with a cast complains about increasing pain? best step in management?
compartment syndrome (pressure from the cast applies an external pressure that decreases blood supply to the area, leading to permanent muscle/nerve damage and ultimately the loss of function of the limb
management: remove the cast and assess immediately; may require emergent fasciotomy
What is the compartment syndrome?
increased pressure within one of the body’s “compartments”, which contains muscles and nerves; can be
- acute - usually due to traumatic injury that causes severe high pressure in the compartment, resulting in insufficient blood supply to muscles and nerves.
- chronic - casts apply external pressure to the area, which decrease in blood flow to the affected area and cause a deprivation of oxygen to the muscles
Either way, if both are untreated, the lack of blood supply leads to permanent muscle/nerve damage and can result in the loss of function of the limb.
an overweight middle aged man decides to play tennis with his friend, after years of not playing. During the game, he heard a loud popping noise after he had rotated his body after planting his foot
Diagnosis? Best diagnostic test? Treatment?
Achilles Rupture
Casting (longer recover) or Surgery (faster recovery)
Patient comes in after falling on an inverted (or everted) foot.
Diagnosis? Best diagnostic test? Treatment?
Ankle Fracture
AP, lateral, and oblique (or “mortise view”) XRay
Open reduction and internal fixation
Patient comes in with an open fracture (bone sticks out through a wound).
Management?
get the person to an OR stat - the injury requires cleaning and reduction within 6 hours from the time of injury
Patient presents to the ED after undergoing a head-on collison with another car on a stretcher where his legs are shortened, adducted, and internally rotated. He was sitting in the front passenger seat of a car
Diagnosis and treatment?
Posterior hip dislocation - femoral head is driven back into the pelvis/out of the acetabulum
Emergency surgical reduction to avoid avascular necrosis
Patient cuts himself with a knife while preparing dinner. After 3 days, he is extremely ill appearing and the affected site is very tender and swollen with noticeable discoloration and gas crepitation
Diagnosis and treatment? 3
Gas gangrene
Trmt: IV penicillin (treats clostridium perfringens), extensive surgical debridement, and hyperbaric O2
major concern of if one has a posterior dislocation of the knee
popliteal artery injury
prompt reduction, otherwise delayed restoration of blood flow will require prophylactic fasciotomy
treatment for carpal tunnel syndrome
splint + anti-inflammatory agent
Women awakes in the middle of the night with an index finger that is acutely flexed and unable to extend it unless it was pulled with the other hand, though this results in a painful “snap”
Diagnosis? Treatment? 2
Trigger finger
Steroid injection (1st line), Surgery (last resort)
A new mother comes in with pain along the radial side of the wrist; pain reproducible when she holds her thumb inside her closed fist and then forces the wrist into ulnar deviation.
Diagnosis? Treatment?
De Quervain’s Tenosynovitis - swelling and inflammation of the tendons and the tendon sheath on the thumb side of the wrist.
Steroid injection is best OR splint + antiinflammatory agents
Man presents with a fixed flexion of the hand (fingers bend towards the palm and cannot be fully extended); notes that this has been getting progressively worse throughout the last few yeras
Diagnosis and treatment?
Dupuytren’s contracture - inherited proliferative CT d/o resulting in palmar fibromatosis
Trmt: Surgery
Man complains of a throbbing pain in his finger tip and is febrile
Diagnosis and Treatment?
Felon - abscess in the pulp of a fingertip, caused by a neglected penetrating injury
emergent I&D - the pulp is a closed space with multiple fascial trabecula and pressure can build up and lead to tissue necrosis
Skiier comes in with pain, swelling, and ecchymoses around his thumb. PE: instability of the MCP joint of the thumb.
Diagnosis? Treatment?
Gamekeeper’s thumb (aka skier’s thumb) - UCL is torn at its insertion site into the proximal phalanx of the thumb due to forced hyperextension of the thumb.
Casting
This action can result in this injury
Diagnosis and Treatment?
Jersey finger - injury to the flexor tendon that occurs when a flexed finger is forcefully extendd; when making a fist, the distal phalanx of the injured finger does not flex with the others
Splinting
Volleyball player comes in with a finger that remains flexed when the hand is extended.
Diagnosis and Treatment?
Mallet Finger - occurs when the extended finger is forcefully flexed, which rips the extensor tendon; tip of the finger remains flexed when the hand is extended
Splinting
Lumbar disk herniation usually occurs at what spine level?
What physical findings can be elicited after a forced movement to determine exactly where the herniation is located?
L4/L5 - pain shoots down leg and exists at the side of the big toe
L5/S1 - pain shoots down leg and exists at the side of the little toe
exacerbated by coughing, sneezing, or defecating
Treatment of lumbar disk herniation?
bed rest + nerve blocks (pain control)
under what condition does lumbar disk herniation require surgery? 2
surgery indicated when:
- neurologic deficits are progressing (increasing muscle weakness)
- if there is cauda equina syndrome (distended bladder, flaccid rectal sphincter, or saddle anestheia)
Patient presents with an inability to void, flaccid rectal sphincter, and saddle anestheia
diagnosis and treatment?
this triad should make you think of cauda equina syndrome
emergency surgery to decompress the area
management of men/women in their 30s/40s who complain of chronic back pain and morning stiffness; pain is worst with rest and improves with activity.
Diagnosis? Diagnostic test? 2 Treatment? 2
Ank Spondylitis
Tests: X-ray (bamboo spine) + HLA-B27
Trmt: anti-inflammatory agents and PT
What should you suspect in an eledrly patient who complains of weight loss and progressive back pain that is worst at night and unrelieved by rest or positional changes?
How would you go about making the diagnosis?
metastatic cancer
MRI
Management of diabetic ulcers 3
good diabetic control
keep ulcers clean
keep leg elevated for many weeks/months
management and treatment of ulcers secondary to arterial insufficiency
W/U with doppler studies to determine if there is a pressure gradient (if there isn’t one, then the microvascular disease is NOT amenable to surgical therapy)
If there is, then get angiogram (MRI/CT) or arteriogram to determnie the site of occlusion
Surgical revascularization, angioplasty, and stents
management and treatment of venous stasis ulcers
W/U with duplex scan
Treatments:
- physical support to keep veins empty (compression stockings, ACE bandages, Unna boot)
- surgery (vein stripping, grafting of ulcer, endovascular ablation of the vein)
elderly with chronic leg ulcer presents with this skin finding.
Diagnosis? Best diagnostic test? Treatment?
marjolin ulcer - squamous cell carcinoma of the skin that develops in a chronic leg ulcer; ulcer appears dirty and deep with heaped up growth around edges
diagnsois: biopsy
trmt: wide local excision and skin grafting
Overweight patient complains of sharp, localizable heel pain whenever they go for a jog; pain elicited reproducibly with palpation. X-ray is as shown
Diagnosis? Management?
Plantar Fasciitis
Trmt: symptomatic treatment OR removal of spur (though it is NOT the cause of the problem)
business woman comes in with complaints of a palpable and very tender spot at the ball of her foot, between her third and fourth toes.
Diagnosis? Treatment? 3
Morton Neuroma - inflammation of the common digital nerve at the third interspace, btwn third and fourth toes; typically caused by the use of pointed, high-heeled shoes
trmt: analgesics, more sensible shoes, and surgical excision if necessary
Treatment of a Gout Attack 2
Indomethacin and Colchicine
Chronic control of Gout 2
allopurinol and probenecid
