trauma and degnerative Flashcards
1
Q
How are spondylolisthesis graded?
A
Grade 1: 25% slippage of disc on disc
Grade 2: 50%
grade 3: 75%
Grade 4 and 5: completely seperated
2
Q
How is a herniated disc treated?
A
conservative if no motor signs
-NSAIDS, rest, follow up MRI 3 weeks
If motor signs or worsening sensory then surgery to retract nucleous pulposis
3
Q
How does age affect the spine?
A
disc degeneration leads to smaller disc space and can impinge roots
Fibrocartilage dehydration happens 10 years earlier in men than women. So Annulus fibrosis can’t hold nucleus pulposus
spinal stenosis due to laxity of ligaments
4
Q
How does neurogenic claudication present?
A
numb and paresthesia when walking long distances
5
Q
How does arterial claudication present?
A
cramps in muscles when walking and when rest it gets better
6
Q
What joints does Osteoarthritis affect?
A
synovial. DIP, PIP, 1st MC of hand, 1st MT of foot, facet joint of vertebrae, Ac joint
7
Q
How does OA present on x-ray?
A
abnorm alignment -joint space narrowing, boney ----------subchondral cysts. Boney sclerosis Cartilage---- ----not calcified deformities -----osteophytes no erosions slow progression asymmetrical
8
Q
How does spondylolisthesis present clinically?
A
minor: pain with activity
major: pain with flex and extend. Radicular signs (sensory and motor because impingement)
9
Q
Spinal stenosis is caused by…
A
hypertrophy of the ligaments-flava ligament compresses spinal cord from anterior
disc bulge and osteophytes also compress
10
Q
What are 2 types of spinal stenosis?
A
central and lateral recess.
central is the central canal
lateral recess is area where spinal nerve exits through vertebral foramen
-most common areas are lumbar(can compress caudal equina) and cervical
11
Q
How does lumbar stenosis present?
A
- feel better in flexion
2. weakness and paresthesia when extend
12
Q
What is the treatment for spinal stenosis?
A
antiinflammatory
surgery-laminectomy then allograft and fusion of segments
13
Q
What population would present with an anterior femoral neck and posterior femoral epiphysis?
A
children SCFE boys: 12-15 girls: 10-12 going through growth spurt tend to be overweight and active
14
Q
What does legg calve perches look like on x-ray?
A
initially no change but after 2-3 weeks see epiphysis get smaller because lack of blood supply so just thin line on top of growth plate
15
Q
what population is affected by legg calve perthes?
A
younger children
16
Q
what is the most common hip disorder in adolescents?
A
SCFE
BL in 50%
17
Q
what are some risk factors for SCFE?
A
endocrine disorder(hyperthyroid, hypogonadal endocrinopathy, panhypopituitarism, renal osteodystrophy
obese
delayed skeletal maturation
wide epiphysis
tall and thin with recent growth spurt wide
18
Q
How does a SCFE patient present?
A
adolescent
external rotated hip-waddle gait or limp
-affected foot turned out
pain with internal rotation
knee pain can be only sign
sometimes hip pain
can have groin pain
19
Q
what is the treatment for SCFE?
A
epiphysiodesis-surgical closure of epiphysis (pin)
20
Q
how is SCFE diagnosed?
A
frog leg (Lauenstein) view x-ray lateral x-ray classify by degree of slip all are salter fracture type 1
21
Q
what x-ray view is best for fracture or arthritis of knee?
A
sunrise view-lateral patella is more elongated so can use to orient
22
Q
How are the ligaments and joints of the ankle named?
A
talofibular (fibula always last)
tibiotalar(tibia always first)
talocrural joint is fib and tib on talus subtalar joint is talus on calcaneus inferior tib fib joint is the syndesmosis between the two talonavicular is medial calcaneal cuboid is lateral cuneonavicular is centered
23
Q
if you want to view the talus, what x-ray view is best?
A
mortise view (dorsiflex foot and can see more joint space)
24
Q
what is the fracture called that separates metatarsals from tarsals?
A
lisfranc
can be subtle or dislocated
25
what is a fracture of the 5th Metatarsal called?
jones fracture. if avulse the tuberosity then can also call avulsion. poorest vascular supply here because watershed zone.
26
shoulder dislocation usually occurs in what direction?
anteriorly and inferiorly(physiologic)
see on AP x-ray move out of glenoid fossa
posteriorly is non-physio(seizure or electric shock)
-need Y view to see best on x-ray (see light bulb sign of humerus and humerus is not in middle of the y)
27
What are the 3 points of a y view x ray?
the spine of the scapula is most lateral, coracoid process is most medial and body of the scapula is the stem
28
An open fracture (exposed to atmosphere) is treated how?
surgical emergency within 24 hours because of infection
29
How is an uncomplicated fracture treated?
if no reduction required then immobilize, x-ray and follow up x-rays to make sure hasnt moved and is healing
30
how is a phalangeal tuft created?
its is a subungal(beneath the nail bed) hematoma
techinically open fracture
USUALLY CRUSH INJURY
pain increased because of Pressure
31
How is a phalangeal tuft treated?
antiobiotics short course and protect
32
How is a mallet finger created?
TRAUMA WHEN IN EXTENSION
avulse extensor tendons on dorsal surface-can't extend DIP joint anymore
can pull off bone or epiphyseal plate
can cause palmar sublux
33
How does a mallet finger present?
trauma with extension
dorsal swelling
can't extend DIP
some palmar subluxation
34
How is mallet finger treated?
extension splint the PIP
35
How is volar plate injury created?
HYPEREXTENSION OR DISLOCATION OF PIP
can pull off bone
see dorsal subluxation
tear the flexor tendon(volar)
36
Scaphoid fractures present how?
FOOSH
pain in wrist
snuff box tenderness
x-ray is unreliable
37
What are some complications of a scaphoid fracture?
lose circulation because retrograde circulation in the area
AVN
SLAC (scaphoid lunate advanced collapse)
38
Treatment for AVN and SLAC?
surgery
| treatment for scaphoid fracture is casting
39
What is a possible outcome of a distal radius fracture?
4 pieces of bone
after FOOSH
fracture intraarticular or metaphyseal
40
What is the best view for X-ray of distal radius or colles fracture?
lateral xray
41
How is a distal radius feature treated?
distal radial plate or external fixation
42
How is a fracture of the radial head created?
galleozi is a possiblity (radius fracture and ulna dislocated distally)
FOOSH
43
Where do clavicles usually fracture?
midshaft
see tent of skin(penetration rare)
can use conservative treatment with sling and figure 8
44
With a proximal humerus fracture what is the treatment?
1. make sure vascular supply not compromised(key to healing)
2. check neuro
3. rule out shoulder dislocation X-ray
4. if nondisplaced then sling and immobilize
45
what are possible etiologies of the fat pad sign?
fat pad sign= increased radiolucent compared to muscle of anterior fat pad or presence of radiolucent posterior fat pad(not ever seen unless pathologic)
1. occult fracture 2. hemarthrosis 3. joint effusion 4. neoplasm 5. infection/inflam
46
what is the pathophysiology behind the fat pad sign?
posterior capsule fills up with blood but is still enveloped by fibers of the joint capsule
-extrasynovial and intracapusular
47
what is the carrying angle?
```
angle created by elbow
measure between medial hand and hip
normal is 5-15 degrees
increased in elbow fracture
decreased in gunstock demormity
```
48
how is alignment named?
varus- distal part of extremity is medial to proximal
| valgus- distal is lateral to proximal
49
what does an elbow fracture do to the carrying angle?
created cubitus valgus so increased carrying angle
50
What is the work up for an elbow fracture?
common and troublesome in kids
1. check lateral triangle(radial head, lateral epicondyle and olecranon)
- possible to have bursitis or effusion
2. check medial cubital tunnel with ulnar nerve and medial epicondyle
3. often swell and have eccymosis
51
What is the treatment for an elbow fracture?
closed reduction and pin or open reduction and internal fixation
52
In a hip fracture, how does the hip present?
shortened and externally rotated
53
How should the spin be evaluated for fracture?
3 columns: anterior vert body, posterior vert body and facet joint
AP, Lateral, oblique
AP in lumbar will not tell you about disc space because of lordosis
54
What is a burst fracture?
2 of the 3 columns of the spine are fractured, likely to be unstable
55
What usually causes a lumbar spine fracture?
compression forces
56
If a shoulder dislocated posteriorly (nonphysio) then how is the humerus rotated?
internally
57
The garnder classification of 1 and 2 nondisplaced and 3 and 4 displaced are used to classify which fracture?
```
femoral neck
1- see fracture line
2-see narrow space
3. wide space, displaced but aligned
4. wide space, displaced and slip
```
58
What artery is concerning is femoral neck fracture?
lateral retinacular artery
intracapsular break
high morbidity. increases with age. increases with delay of surgery
59
what is a common extracapsular fracture of the hip
intertrochanteric fracture
x-ray shows medial cortical bone off line
heals better than femoral neck because good blood supply
60
How are intertrochanteric fractures classifed?
undisplaced=stable
displaced and reduce- stable medial cortical apposition
displaced and unreduced=unstable no apposition
minuted= unstable, no apposition
61
How are hip fractures diagnosed?
x-ray view internal rotation, AP and lateral
| can do MRI and bone scan
62
What are some options for tx of hip fracture?
pin(femoral neck but cast in young), sliding screw (intertrochanteric fracture), hemiarthroplasty-replace ball not socket
15 treat as adult and nail
63
Which population is most at risk for hip fracture?
women, white, osteoporosis, elderly, decreased BMI, smoking and alcohol, previous fracture
other: dementia and psychotropic drugs
64
what are some complications of fracture?
1. acute blood loss
2. fat embolism(long bone fracture or crush)
3. compartment syndrome
4. malunion
5. delayed union(takes longer to heal)
6. avascular necrosis(talus, scaphoid, femoral neck)
7. Reflex sympathetic dystrophy
8. complex regional pain syndrome
65
How does a fat embolism present?
petechia, hypoxia, confusion
| can be immediate or 48 hours after injury
66
in a compartment syndrome what occurs?
Edema that causes a decreased in the arterial venous pressure difference
- pulse might be palpated but not distally
- high Pressure in an enclosed space causes compartment tamponade (loss of blood to muscles)
- muscle hypoxia
- high pressure compresses nerves
- neural injury and volkmann contracture
67
how can a compartment syndrome be diagnosed?
1. pressure is 30-40mmHg or greater then pressure is too high
2. pain out of proportion to the injury
3. pulses can help but not definite
68
how is malunion treated?
osteotomy
69
what causes delayed union?
blood supply and stability of fracture varies (hypertrophic= too much motion)
70
How should avascular necrosis be treated?
prolonged immobilization
if legg calve perthes then no weight bearing
occassionally it will revascularize
treat immediately otherwise can suffer early OA
71
How does reflex sympathetic dystrophy present?
1. chronic
2. severe, burning pain
3. vasomotor disturbances-sweating
4. pathologic changes in bone and skin
5. delayed healing
72
What is the treatment for reflex sympathetic dystrophy?
sympathetic blockers
| analgesics
73
How does chronic regional pain syndrome present?
after injury(can be fracture)
chronic pain
similar to RSD
74
What is the etiology of frozen shoulder?
fibroblastic proliferation leading to adhesive capsultitis then joint contracture
75
What is the presentation of adhesive capsulititis?
1. decreased ROM passive and active of 50% or greater
2. phases of freezing, frozen, thawing
3. 6-24months duration
76
how is adhesive capusulitis diagnosed?
rule out calcific changes with x-ray
ROM on PE (lose motion 50% in passive and active)
MRI see contracture of capsule
77
What are some conditions associated with adhesive capsulitis?
diabetes, hypothyroid, CVA, Parkinson's, cervical disc, duputren's contracture
78
what is the treatment for adhesive capsulitis?
palliative
| 1. NSAID 2. sleep aid 3.PT-gentle stretch 3. hydro-distention injection
79
Classify an acromioclavicular tear and coracoclavicular sprain.
Type 2 AC seperation
Type 1= sprain AC
Type 2 =tear ac and sprain cc
Type 3= tear ac and tear cc
Type 4-6= irreducible
80
what are the diagnostic criteria for AC seperation?
AC joint feels lax on internal and external rotation
may feel step off at AC
X-ray
MRI
81
what is the work up for a humeral shaft fracture?
1. check radial nerve integrity-dorsal sensation
- C6 extension wrist
2. u splint for 2 weeks and fracture brace
- union likely
- malunion well tolerated bc GH mobility
3. continue nerve checks
82
based on age how would you diagnose shoulder pain?
<30 yo possible instability(shallow socket)
middle age: impingement, rotator cuff pathology, adhesive capsulitis
elderly: OA, RA of GH and AC, rotator tear, malignancy
83
describe the location of the rotator cuff muscles.
all are subacromial (beneath bursa too)
anterior to posterior 1. supraspinatus 2.infraspinatus 3. teres major 4. subscapularis
all depress the humerus
84
How does a shoulder impingement present?
1. night pain when sleeping on that side
2. touch tender to subacromion
3. near's test (empty can motion with pressure on AC) positive
4. lidocaine impinge test
5. supraspinatus and infraspinatus atrophy
6. rotator cuff weakness
85
what are 2 areas in the shoulder that can become impinged?
1. coracoacromial arch- fibrosis AC, partial or full tear causes edema which occupies space
- hooked acromion
2. subacromion -physiologically less space <7mm
- tendinopathy or fibrosis
- partial or full tear causes edema and space occupies
- over the head activities so dysfunction of humoral compressors
- age related loss of blood supply
86
How is impingement treated?
rest from overhead activities 90% works
post-capsular stretch 'windlass mechanism"
injection with local anesthetic and corticosteriods
(3 x per year)
surgery if after 6- 12m not better
87
If you suspect an impingement what should you look for on x-ray?
calcification abnomal
- hooked acromion
- measure subacromial space
- AC joint integrity
88
how many shoulder dislocation/rotator cuff tear reoccur in 11-20 year olds?
60%
89
What is the presentation for rotator cuff tear?
trauma
instability of motion
positive aprehension test
positive sulcus sign shows ligament laxity
90
what are possible etiologies of rotator cuff tear?
age
tissue degneration
trauma
91
Who is full thickness tear of rotator cuff most common in?
25% of people over 60 yo
greater than 40 have greater neuro problems but less likely to reoccur
elderly have no significant symptoms and no significant change from treatment
92
If rotator cuff tear reoccurs/shoulder dislocation what could happen?
injure articular cartilage (if athlete at risk then consider surgery for first tear or dislocation)
93
How does a radial head fracture occur?
FOOSH
| can also injure the MCL
94
How are fractures described?
View
Atomosphere: open or closed
Number: comminuted is more than 2 peices
Direction: transverse, oblique, spiral, segemented, impacted, avulsed
Alignment: displacement and angulation(varus/valgus)
-described displacement as where distal is to proximal
Location: cartilage, epiphysis, metaphysis, diaphyiss
95
What happens when the radial head is displaced?
the head come out of hte annular log(helps with kids who don't have full boney radial head)
Need to supinate and extend while pushing on radial head or pronate and flex while pushing on radial head
96
what is the treatment for olecranon bursitis?
compress and decompress, steriods, ABX if aspirate culture is bacterial
97
Who is most likely to get adhesive capsulitis?
women over 40
98
what are other diagnoses for olecranon inflammation?
```
gout, alcohol, RA
inflammation
infection
trauma
COPD
```
99
Who is most likely to be affected by carpal tunnel syndrome?
```
women over 50
pregnancy
hypothyroid
diabetes
rheumatism
obesity
tobacco and alcohol
```
100
How does carpal tunnel present?
aching thenar eminence
shaking out hand in morning...sleep with hand out so won't flex wrist
paresthesias radial 3.5 digits
thenar atrophy
101
How is carpal tunnel DX?
tinels (can be done on cubital tunnel for ulnar too in DTR position)
phalens 90s
nerve compression test (shoulder shrugged down and elbow at 90 and extended
Rule out double crush_impaired axonplasmic flow so easier to compress other location with less pressure
102
what is the treatment for carpal tunnel?
```
nocturnal splint
carpal stretching
NSAIDS
steriod inject
ergonomic adjustment
surg: carpal tunnel release
```
103
What is tenosynovitis of the wrist?
pain from repetitive tasks from elbow to wrist
preciptiates entrapment
flexor and extensor tendons
104
Who is likely to get tenosynovitis of the wrist?
laborers
105
Dequervain's disease affects what?
tenosynovitis of abductor hallucis longus and extensor hallucis brevis(1st dorsal compartment)
106
How does dequervain's present?
acute onset with new repetitive tasks
radial sided pain
swell near styloid process
finkelstein's manuever hurts (thumb in fist and ulnar deviate)
107
Who is at risk for dequerivain's?
hypothyroid, diabetes, gout, pregnant
108
How is dequerivanain's diagnosed?
X-ray to rule out scaphoid fracture, degenerative joint disease
109
How is dequerivan's treated?
```
rest from repetitive tasks
thumb in spica splint
NSAID
PT
inject corticosteriods
surgical release of 1st dorsal compartment
```
110
What is the most common type of elbow tendinosis?
lateral epicondylitis (over use extendors)
111
What is the work up for lateral epicondylitis?
rule out radial tunnel syndrome and check median nerve in extension
112
how does lateral epicondilitis present?
gradual onset of ache and exacerbation in extension(screw driver, jar, hammer)
usually middle age from degeneration of muscles-extensor carpi radials
can follow trauma
113
what is the treatment for lateral or medial epicondylitis
NSAIDS
counterforce brace
rest
surgery after 1 year of failed treatment to excise degenerated tissue and decortication of cortical bone
114
in medial epicondylitis what should be ruled out?
cubital tunnel syndrome-ulnar neuropathy
| can put in DTR position and tap on nerve or test sensation
115
What is the most common joint dislocated in kids?
elbow which is #3 in adults
116
What is the treatment for dislocated elbow?
pronate and extend and distract
reduction urgent to prevent contracture
hinge brace the joint and within 7 days do gentle ROM (avoid Volmann's contracture)
loss of terminal extension is common but full ROM returns in one year usually
117
What is volkmann's contracture?
the ischemia of extensor tendons leading to permanent flexion of wrist and fingers.
118
What is a complication of a distal humerus fracture (elbow fracture)?
gunstock deformity-decreased carrying angle
adults have intra-articular fractures
chidlren usually have suprcondylar fractures
119
how is an olcranon fractured?
blow from behind during eccentric contraction
| check ulnar nerve when assessing
120
A painful palmar nodule at the distal palmar crease that causes the ring, middle or thumb to lock in flexion is...
trigger finger. A1 pulley nodule of flexor tendon(can be proximal or distal to the pulley.
Snap heard at PIP
121
How is trigger finger treated?
MCP extension splint or tendon sheath injection or surgical release of A1.
without tx: patient has flexion contracture at PIP. permanent loss of extension
122
What is the etiology of trigger finger?
congenital or tenosynovitis
123
how is lateral epicondylitis diagnosed?
1. tender over origin of extensor
2. light tap to epicondyle= painful
3. pain on extension of wrist
4. rule out radial tunnel syndrome by checking median nerve in extension for sensory
124
What is tendonopathy?
tendinosis and tendonitis(both degnerative and inflammatory)
1. initial swell of tendinous sheath
2. if chronic then degneration
125
How does tendinosis present?
1. pain on movement
126
What is the treatment of tendinosis?
1. NSAIDS early use when inflam present and late as analgesic
- Doesnt facilitate healing
2. corticosteriods are controversial
3. eccentric training
4. ultrasound-little evidence
127
What are kanavel's signs?
signs describing flexor tenosynovitis
1. intense pain with movement
2. tender to percussion along surface of flexor tendon
3. swelling of digits
4. flexed posture of finger for comfort
128
What can cause pain with flexion of fingers?
tenosynovitis
| midpalmar space abcess(this can present as a horseshoe from pinky to thumb)
129
Who is dequervain's tenosynovitis most common in?
women 30-50
| manual workers
130
what 2 tendons are involved in dequervain's tenosynovitis?
abductor pollicis longis
extensor pollicis brevis
subsequent to inflammation stenosing of compartment can occur
131
What are some possible causes of osteonecrosis?
corticosteriods
radiation exposure
mechanical stress
132
how does osteonecrosis present?
1. dull, achy, throbbing pain (insidious onset)
| 2. mild changes on imaging with onset of pain
133
How should osteonecrosis be diagnosed?
1. x -ray
| 2. MRI gold standard
134
What is a complication of osteonecrosis?
early OA
135
what is the etiology of osteonecrosis?
idiopathic
familial collagen II defect
vascular infarct
136
how is legg calve pethes(cox plans) graded?
Grade 1 s sign)
-metaphyseal rarefication (avasc segment)
grade 3 most of epiphysis is avasc
metaphyseal changes
still viable bone posterior and antioer
grade 4
total collapse of epiphysis and consolidation
diffuse metaphyseal change
-no viable posterior bone
137
how does a legg calve perthes patient presetn?
```
more common in boys pre-puberty age 4-12
pain on internal rotation
limited ROM AB and Int rotation
antalgic limp
hip pain or referred to knee
insidous onset maybe microtruama
```
138
What are some risk factors for legg calve perches?
sickle cell
high dose steroids
trauma
arterial supply reticular and lateral epiphyseal artery at risk
139
What are the stages of Legg Calve perthes?
1. synovitis- 1-3 weeks
inferior aspect of metaphysis is osteopenic
soft tissue swelling
2. avasular stage (head opacitiy increased)(Ant 1/2 or entire head necrosed)
months-1 year
3. fragmentation stage after 1year
-areas of rarefied because ingrowth
-femoral head compressed and fragmented
4. regeneration: replace necrotic with fibrous connective-femoral neck widened though head fragmented (1-3 years)
5. residual stage-no rareifed bone, joint incongruent
140
what should be ruled out when considering diagnosis of Legg Calve perches in synovitis stage?
1. Ra
2. pigmented villonodular synovitis(young adult)
- knee, hip, ankle
3. tuberculous arthritis
141
What shoule be ruled out when considered diagnosis in the avascualr stage of LCP?
juvenile dysplasia
osteoid osteoma
sickle cell
gauchers
142
what is osteochondritis dissicans?
Aseptic necrosis
chronic repetititve microtrauma of bone or growth center
form of osteochondrosis
143
who does osteochondritis dissicans present in?
more common in males
144
What is the most common joint for osteochondritis dissicans to present in?
Talus
