Primary Care Ortho Flashcards
Define physis
growth plate at each end of a long bone
Define epiphysis
on joint side of physis
Define metaphysis
on shaft side of physis
Where do kids tend to fracture and why?
through the PHYSIS because it’s generally weaker than the shaft of the bone
Salter Harris fractures involve the…
physis
SH 1 fracture
through the physis only
How should you treat any significant injury around the physis?
splint and re-x-ray in 10 to 21 days
SH 2 fracture
through the physis and metaphysis
SH 3 fracture
through the physis and epiphysis
SH 4 fracture
through the metaphysis, physis and epiphysis
Which SH fractures are the worst?
SH III and IV are worse that I and II because the joint is involved
SH 5 fracture
d/t crush or burn injury of the growth plate - will get closure of growth plate
Greenstick fracture
incomplete fracture- may have to complete the fracture to realign
Torus fracture
bone is bent and fracture can be minimal buckle in cortex
Peds fractures vs. fractures in adults
Children will heal and remodel a fracture much better and faster than an adult
Hip dysplasia can be…
one or both hips dislocated or dislocatable
Hip dysplasia is associated with…
oligohydramnios and large babies (Diabetic Mother?)
Hip dysplasia tests (2)
- Ortolani (out or dislocated)- clunk as hip reduces.
2. Barlow- clunk as hip dislocates
Hip dysplasia tx
Pavlic harness in newborns with frequent follow up exams.
Fracture principles
- open fractures go to the OR (Most)
- always check neurologic status
- always check distal vascular status
What are the 5 P’s of compartment syndrome?
Pain, Pallor, Paresthesias, Pulselessness, and Paralysis
What is the MC site of fractures?
Tibial plateau
**medical emergency
Fat emboli d/t fracture
- Fx of long bones,(femur, tibia and humerus, or pelvis)
- Pt presents with mental confusion, tachypnea, tachycardia and hypoxia.
DVT s/p fracture
-how to dx?
- increased chance of clot with immobilization, bedrest.
- Dx with doppler venous studies or venogram
- CT Angio of chest for suspected PE
Tx of DVT
IV heparin bolus then drip, switch to Coumadin for several months
Tx of DVT or PE in fracture patients
- includes Factor X A inhibitors.
- Finn PA-C prefers apixaban - can use to bridge patients on Coumadin.
- should hold for 48 hours before surgery.
NEVER use in neurosurgery***
Shoulder impingement
-involved anatomy
- tendonitis of rotator cuff muscles
- usually involves the Supraspinatus muscle
S/sx of shoulder impingement
weakness, pain (night), minimum of injury
Exam of shoulder impingement
- (+) impingement test (neer, hawkin’s, empty can)
- get MRI to visualize? -discouraged, you should be able to diagnosis via simple tests
Adhesive capsulitis
AKA frozen shoulder
- decreased ROM
- pain often perceived as severe
Adhesive capsulitis cause
disuse of shoulder because of pain of injury.
Adhesive capsulitis tx
injection, ROM stretching exercises
Other shoulder problems
-posterior dislocation
- associated with seizures and electrical shock
- commonly missed on routine x-rays in OP setting
Epicondylitis of the elbow
-lateral
“tennis elbow”
-extensor tendonitis
Epicondylitis of the elbow
-medial
“golfer’s or pitcher’s elbow”
-flexor tendonitis
Epicondylitis of the elbow
-tx
-both medial and lateral d/t overuse
TX:
-stretching exercises, NSAIDS, brace, steroid injections.
Wrist fractures
-Colles
common with elderly and falls onto outstretched hand (FOOSH)
Wrist fractures
-Scaphoid
fall onto outstretched wrist
-pt c/o pain at snuff box
Tx of wrist fractures
any wrist with hx. of fall and snuff box tenderness is immobilized in splint including the thumb and then re-x-rayed in 10 to 21 days.
Wrist tendonitis
-can occur anywhere in wrist.
-Dequarvain’s- 1st extensor compartment. Extensor Pollicis Brevis and Abductor Pollicis Longus tendons.
(+ Finklestein test)
*EPL tendonitis/rupture common after Colles fracture.
Carpal Tunnel in the wrist
- sx
- causes
SX’s- numbness/tingling of thumb, index, long, and radial half of ring fingers.
Causes- synovitis, tendonitis or acutely with fracture.
**All reduce space in the carpal tunnel causing the compression of Median Nerve.
Carpal Tunnel exam & tx
Exam-
- (+) Tinel’s and Phelan’s, Thenar muscle atrophy.
- Adductor policis weakness
TX:
Rest, brace, NSAIDS, steroid injection, surgical release.
What joint is avascular necrosis commonly seen in?
the hip
Avascular necrosis
- cause
- s/sx
- bone dies d/t loss of blood supply
- pain, antalgic gait, decreased ROM
What is Perthes disease?
- rare childhood condition where blood supply is cut off to the hip
- occurs in kids 3-8 y.o. primarily
- unknown etiology
- the older the child, the worse the prognosis
Avascular necrosis can be seen in patients who…
- have Sickle cell
- use steroids
- drink ETOH
- are scuba divers
**or can be idiopathic
Tx for avascular necrosis
- limit activities
- NSAIDs
- core decompression to bring more blood supply to joint
- total hip replacement
What imaging should you use for avascular necrosis?
MRI
Hip fracture etiology
- typically occur in femoral neck, intertrochanteric or sub-trochanteric
- females > males
- 35% die within a year after hip fracture
- osteoporosis is common
- pts often break their hip before they fall
Hip fracture tx
- stabilize or replace
- mobilize ASAP after surgery
- treat underlying osteoporosis
Slipped capital epiphysis etiology
- young males (10-15 y.o.)
- 25% occur bilateral
- commonly presents as knee pain
- xray shows slip but may need MRI
Slipped capital epiphysis tx
stabilize surgically
Knee - patellofemoral pain is commonly d/t
- chondromalacia (softening of the cartilage)
- patellar tracking problems
Patellofemoral pain
- sx
- tx
Sx:
- pain
- gelling?
- increased pain arising from chair or using stairs
Tx:
- short arc quad sets (to realign the patella)
- arthroscopic debridement of patella
Knee - ACL tear etiology
- frequent injury from sudden deceleration
- effusion: rapid onset, grade III, and bloody
- (+) Lachman test, (+) pivot shift
*MCL and meniscus injury common
ACL tear tx
- immobilizer
- gradual return to normal activities
- 1/3 need reconstruction of ligament
Knee - meniscal tear etiology
- caused by extension and twisting motion of knee during weight bearing
- effusion: mild to moderate + or - blood; occurs slowly (> 1 - 2 hrs)
Meniscal tear sx
-joint margin tenderness
-locking
-popping
(+) or (-) McMurray test
Meniscal tear tx
arthroscopic resection
Foot and ankle sprain
- etiology
- sx
-tear of one or more lateral ankle ligaments
Sx:
-pain, ecchymosis, high amount of swelling
Foot and ankle sprain tx
- air or gel splint until asymptomatic
- RICE: rest, ice, compression, elevation
Foot and ankle infection
- seen in patients who step on a nail with shoes on - the glue contains Pseudomonas
- start on anti-pseudomonal abx
Neck injury
- etiology
- imaging
- car wrecks, diving injuries, etc.
- must get lateral x-ray see all 7 cervical vertebrae to clear accident victim for battery of x-rays and removal of brace
Spine injury
-sx
Clonus signifies upper motor neuron injury.
When do you see increased deep tendon reflexes in spine injuries?
with spinal cord lesion above that level
When do you see decreased deep tendon reflexes in spine injuries?
radiculopathy, lesion below the level
Imaging for spine injuries
CT, MRI, or Myelogram
Sprain of the lumbar spine
- sx
- tx
- back pain, but NO radiculopathy (no pain in the buttocks or legs)
- tx with rest, NSAIDs, non-narcotic analgesics, +/- lumbar support
- long-term tx: aerobic exercises, back strengthening, work hardening, and spine education
Lumbar spine herniated discs MC occur in level…
L4-L5
L3-L4 is 2nd MC
Lumbar spine herniated disc tx
- is the same as sprain early.
- PO or epidural steroids are added
- tx conservatively for at least 6 weeks
When should you consider surgery in lumbar spine herniated disc?
as last resort if it does not get better with conservative tx
Lumbar spinal stenosis
-etiology
compression of nerve roots due to arthritic changes
Lumbar spinal stenosis
-sx
- neurogenic claudication- similar to vascular claudication with pain with ambulation, relieved with rest
- must differentiate between +/- neuro changes
- if minimal neuro. changes - most pt c/o back and leg pain (bilateral)
Lumbar spinal stenosis
-tx
- same as for herniated disc
- epidural steroid injections
- PT for 6 weeks
- decompressive laminectomy
Nerve injuries
-humerus
radial N located just behind the humerus and injured with a fracture
Nerve injuries
-fibula
peroneal N located just behind the head of fibula
Nerve injuries
-radius
median N located volar to distal radius
Nerve injuries
-hip
sciatic N can be injured d/t fracture or dislocation (MC)
