Trauma and Orthopedic Surgery: PART III Flashcards
What are some conditions that weaken bone?
Osteoporosis, hyperparathyroidism, bone tumors, metastasis, Paget’s disease
What do we mean by an oblique fracture?
Angle is greater or equal to 30 degrees
What do we mean by transverse fracture?
Angle less than 30 degrees
What is the salter harris classification?
A classification for fractures in relation to the physis, metaphysis, and epiphysis. Use in the case of pediatric fractures involving the growth plate.
What complications do we always consider when assessing a bone fracture?
limb ischemia, peripheral nerve injury, or compartment syndrome
Where are some common locations of pathologic fracture?
Proximal femur, proximal humerus, spine (spinal compression fracture)
A fracture caused by bone shearing at the insertion point of a tendon or ligament
Avulsion Fracture
Why do we preder splints over casting for initial immobilization of most fractures?
it better accommodates secondary swelling and is therefore associated with a lower risk of compartment syndrome and other pressure-related complications.
A nonsurgical, physical manipulation to realign a displaced fracture and/or dislocation into a proper anatomical position.
Closed reduction
What are indications of fractures that require urgent orthopedic consultation
They include open fractures, potentially operative long bone fractures, displaced intra-articular fractures, fracture-dislocations, unstable pelvic fractures, and any signs of neurovascular compromise or compartment syndrome.
What are the ottawa ankle rules and what are they used for?
The Ottawa ankle and foot rules apply to patients presenting to the emergency department (ED) with traumatic ankle and/or foot injuries.
Ankle x-rays are indicated in the presence of pain in the malleolar zone AND one or both of the following:
- Tenderness along the posterior distal 6 cm of the lateral OR medial malleolus
- Inability to weight-bear both immediately post-injury AND for at least 4 steps in the ED
Foot x-rays are indicated in the presence of pain in the midfoot zone AND one or both of the following:
- Tenderness at the base of the 5th metatarsal OR the navicular bone
- Inability to weight-bear both immediately post-injury AND for at least 4 steps in the ED
Most commonly sprained ankle ligament?
Anterior talofibular ligament (ATFL): most commonly affected
Excessive inversion of the ankle joint often injures…
the ATFL and other lateral ligaments including the CFL PTFL
The most common cause of an ankle sprain is a forceful inversion of the ankle that damages the lateral ligaments
Excessive eversion of the ankle joint often injures…
deltoid ligament
A syndrome of pain behind or around the patella that is aggravated by weight bearing on a flexed knee. One of the most common causes of anterior knee pain
Patellofemoral pain syndrome
Patellofemoral pain syndrome is most often due to…
overuse
23 yo active duty male comes into your practice complaining of knee pain. He endorses pain w/flexion of the knee particuarly when he squats at the gym or is going up or down stairs. On PE he has tenderness of the patellar facets and crepitus during knee flexion. What is at the top of your differential?
Patellofemoral pain syndrome.
Others to consider:
Osteoarthritis
Osgood-Schlatter disease
Patellar stress fracture
Patellar tendinopathy
Exercise-induced pain along the posteromedial border of the tibia that is not the result of ischemia or a stress fracture; also known as shin splints
Medial tibial stress syndrome
High riding patella and inability to actively extend the knee
patellar tendon injury
low riding patella, inability to extend knee
quadriceps tendon injury
Muscles affected in this nerve entrapment include the abductor pollicis brevis, opponens pollicis, and flexor pollicis brevis. Sensation is altered in the primarly in the palmar aspect of digits 1-3.
Median nerve entrapement
(eg carpal tunnel syndrome and pronator syndrome).
A condition caused by nerve compression. Compression typically occurs at the level of the elbow (cubital tunnel syndrome) or the wrist (Guyon canal syndrome). Manifests with paresthesias, numbness, weakness, and/or pain in the 4th and 5th digits.
Ulnar nerve entraprement
Radial nerve palsy
Impairment of the radial nerve function due to damage or repeated/prolonged compression. Separated into “high” and “low” lesions. High lesions usually occur where the radial nerve is most vulnerable – at the level of the mid-humerus where it travels in the spiral groove (e.g., associated with wrist drop and sensory impairment). Low lesions occur from damage to the posterior interosseous nerve (PIN), a branch of the radial nerve (e.g., associated with paralysis of the finger extensors).
Primarily affects the sensation of the dorsal aspect of digits 1-3
Radial nerve entrapement
Nerve entrapement that presents with wrist drop
radial nerve palsy
A syndrome characterized by weakness of muscles in the extensor compartment of the forearm as a result of compression of the posterior interosseous nerve. The most common site of compression is within the at the proximal border of the superficial head of the supinator (arcade of Frohse).
Posterior interosseus nerve syndrome, a radial nerve entrapement
Compression of the axillary nerve and posterior humeral circumflex artery within the quadrangular space, which is located inferior and posterior to the glenohumeral joint. Typically occurs in young athletic males as a result of fibrous bands or degenerative paralabral cysts and presents with paresthesias over the lateral and posterior surface of the shoulder that are worsened by active abduction and external rotation of the arm against resistance.
Quadrilateral space syndrome, an axillary nerve palsy
Deltoid muscle atrophy, impaired/altered sensation of the shoulder, impaired externeal roation and arm abduction. What nerve palsy?
Axillary
Paralysis of the teres minor muscle would impeded what action?
Impaired external rotation of the arm, can be seen in mminjuries or something like an axillary nerve palsy
A peripheral nerve of the upper limb that arises from the brachial plexus (nerve roots C4-C6). Innervates the infraspinatus and supraspinatus muscles.
Suprascapular nerve
A compression neuropathy in which the posterior tibial nerve is compressed.. Manifestations include neuropathic pain, paresthesia, and numbness in the posteromedial ankle, heel, and toes.
Tarsal tunnel syndrome
An injury to the lateral femoral cutaneous nerve that results in pain and paresthesias of the outer thigh.
Meralgia paresthetica also called bernhardt-roth syndrome or a lateral femoral cutaneous nerve injury
Superficial_______________nerve injury affects sensation in the back of the feet and toes as well as the lateral surface of the legs. It also affects pronation of the foot.
Deep _____________nerve injury affects sensation in the area between the first and second toes. It affects movement of the foot and toe extensors as well, causing a foot drop and high-stepping gait.
peroneal
Chronic mechanical stress on the joints and age-related decrease in proteoglycans → cartilage loses elasticity and becomes friable → degeneration and inflammation of cartilage → joint space narrowing and thickening and sclerosis of the subchondral bone [3][4]
pathophys of OA
pain and nodular thickening on the dorsal sides of the distal interphalangeal joints
Heberden nodes
finding in OA
pain and nodular thickening on the dorsal sides of the proximal interphalangeal joints
Bouchard nodes
finding in OA
What limbs are primarily affected in complex regional pain syndrome?
Upper more than lower
Symptoms usually develop within 4–6 weeks following a trauma
Pain excessive in duration or severity given the inciting event
Complex regional pain syndrome
A sensation of pain triggered by a stimulus that is not ordinarily considered painful.
Allodynia
Criteria for Chronic Regional Pain Syndrome
- Persistent pain disproportionate to the original injury
- t least one symptom in three of the following four categories, as reported by the patient: sensory, vasomotor, sudomotor/edema, motor/trophic
- At least one sign in two of the following four categories, as assessed by the physician during examination: sensory, vasomotor, sudomotor/edema, motor/trophic
- Exclusion of other possible etiologies (e.g., infection, radiculopathy, neuropathy, vascular disorder)
Routes of spread in septic arthritis
Hematogenous spread (most common)
–From a distant site (e.g., abscesses, wound infection, septicemia)
–Disseminated infection (e.g., gonorrhea)
Direct contamination
–Iatrogenic (e.g., joint injection, arthrocentesis , arthroscopy ) [1]
–Trauma (e.g., open wounds around the joint , penetrating trauma)
Contiguous spread (e.g., septic bursitis, osteomyelitis)
What patients are at an increased risk of septic arthritis?
Pts w/underlying/preexisiting joint disease (like RA), immunosuppressed pts, DM, those with prosthetic implants, chronic skin infections, IV drug users, pts over 80, pts who have gotten interventions recetnly like a joint injection
Pathogens most associated with septic arthritis
Staphylococcus aureus
Most common in adults and children > 2 years
Frequently found in patients with arthritis following invasive joint procedures [2]
K. kingae: most common in infants and children ≤ 2 years [3]
Streptococci
N. gonorrheae
Gram-negative rods esp. E. coli and P. aeruginosa
S. epidermidis
H. influenzae
M. tuberculosis and atypical mycobacteria
B. burgdorferi (Lyme disease)
Prosthetic joint infection; in what time frame would we expect to see this?
Early onset (< 3 months of placement): most commonly S. aureus
Delayed onset (3–12 months of placement): coagulase-negative staphylococci, particularly S. epidermidis
Late onset (> 12 months of placement): most commonly S. aureus
What pathogen do we seen in late onset prosthetic joint infection?
s. aureus most commonly
what pathogen do we commonly see in delayed onset Prosthetic joint infection?
delayed =3-12 months, coagulase-negative staphylococci, particularly S. epidermidis
What pathogen do we commonly see in early onset prosthetic joint infection?
commonly s. aureus
Patient’s hip is often flexed and externally rotated (this decreases intraarticular pressure and alleviates pain). Joint pain (may be referred to the groin or knee).
Septic arthritis of the hip (bacterial coxitis) Bacterial coxitis is an orthopedic emergency that requires urgent management to avoid joint destruction.
What WBC count would we expect in a needle aspiration of a septic joint?
> 50,000/mm3 for an acutely infected joint, Synovial fluid WBC count may be much lower in PJI than septic arthritis in a native joint. WBC count > 1100/mm3 (≥ 64%) should raise suspicion for PJI.
In a gram NEGATIVE stain with concern for gononnococcal arthritis where chlamydia has NOT been ruled out, what abx should you consider?
Ceftriaxone and doxycycline
In a gram NEGATIVE joint aspiration with no concern for gononnococcal arthritis, what empiric antibiotics should we use?
vancomycin
Who is at increased risk for osteomyelitis?
Individuals are at increased risk of osteomyelitis following trauma, placement of surgical implants or hardware, or if they are immunosuppressed or have poor tissue perfusion.
What are the major routes of infection in osteomyelitis?
Hematogenous osteomyelitis (endogenous osteomyelitis): caused by hematogenous dissemination of a pathogen
Exogenous osteomyelitis: caused by a spread of bacteria (typically multiple pathogens) from the surrounding environment [4]
What special pt group must you maintain a high index of suspicion for osteomyelitis?
CHILDREN!
overuse injury of the hand, esp. finger extensor tendons which originate in the lateral humeral epicondyle
Lateral epicondylitis (tennis elbow)
extensor tendons which originate in the (medial or lateral) humeral epicondyle
extensor tendons which originate in the lateral humeral epicondyle
extensor tendons which originate in the lateral humeral epicondyle
Medial epicondylitis (golfer’s elbow)
finger flexor tendons which originate in the (medial or lateral) humoral epicondyle
medial
insertional tendinopathy that arises from repetitive flexion and extension of the knee (e.g., from running, cycling)
Iliotibial band syndrome
What test: patient lies on their side and the examiner passively flexes the patient’s leg while exerting constant pressure on the lateral femoral epicondyle with their thumb; test is positive if pain is elicited
Noble test
The formation of bone in soft tissue and/or muscle that can occur after tissue injury. Typically results in muscle stiffness and restriction of movement.
Myositis ossificans (heterotopic ossification)
What does noble test indicate?
Ilitibial band syndrome
lateral hip pain caused by tendinopathy of the gluteus medius or minimus
greater trochanteric pain syndrome
a condition characterized by pain and tenderness at the anteromedial aspect of the knee
pes anserinus pain syndrome
a collection of synovial fluid in or around the meniscus ususally associated with Chronic meniscal tears
meniscal cyst
valgus (lateral) misalignment of the knee, resulting in a knocked knee deformity
genu valgum
varus (medial) misalignment of the knee, resulting in a bowleg deformity
genu varum
a condition characterized by damage to the fatty and fibrous tissue in the heel. haracterized by Deep, mid-heel pain that increases with activity and when walking on hard surfaces
heel pad syndrome
In a patient with suspected vertebral osteomyelitis supported by x-ray and MRI findings, the next most appropriate step after negative blood cultures is ___________________
In a patient with suspected vertebral osteomyelitis supported by x-ray and MRI findings, the next most appropriate step after negative blood cultures is a CT-guided bone biopsy with Gram staining, culture, and histology to identify the causal organism.
A _________________ followed by gram staining, culture, and histology is the diagnostic test of choice for confirming acute osteomyelitis and provides guidance for targeted antibiotic therapy.
bone biopsy
The most common pathogens in IV drug users-osteomyelitis are __________________- and -__________________
Pseudomonas and Staphylococcus species.
The most common pathogens in IV drug users-osteomyelitis are __________________- and -__________________ which means we start empriric therapy of ______________________
The most common pathogens in IV drug users-osteomyelitis are Pseudomonas and Staphylococcus species which means we start empiric therapy of IV cefepime and vanc.
When do we give empiric abx therapy in suspected osteomyelitis pts and when do we hold until after bone bx?
Patients with vertebral osteomyelitis who present with new or progressive neurologic symptoms, hemodynamic instability, or impending sepsis should receive empiric antibiotics. If none of the criteria are fulfilled, antibiotic therapy can be delayed until the causative organism is identified (via blood culture and/or bone biopsy).
A child presenting w/septic arthritis with no hx of complication/hospitalization should be started on what empiric abx?
Cefazolin
Initial antibiotic therapy should cover Staphylococcus aureus, the most common cause of septic arthritis. Patients are often given vancomycin if they have a high risk of MRSA infection and/or signs of sepsis are present. However, an appropriate antibiotic for this child, who has no history of hospitalization and therefore is unlikely to have an MRSA infection, would be parenteral cefazolin
A 6-year-old girl is brought to the emergency department because of right knee pain for the past 3 days. During this period, the girl has refused to walk. Her mother reports that her symptoms began after she fell down while playing. Three weeks ago, the patient had a sore throat and was treated with penicillin V. She is febrile and the right knee joint is warm and erythematous.
What is the most likely causal organism and what would you see in the synovial fluid?
strep is the likely causal organism and you would see gram positive cocci
A 6-year-old girl is brought to the emergency department because of right knee pain for the past 3 days. During this period, the girl has refused to walk. Her mother reports that her symptoms began after she fell down while playing. Three weeks ago, the patient had a sore throat and was treated with penicillin V. She is febrile and the right knee joint is warm and erythematous. Why is it more likely to be a gram positive cocci than a gram negative bacilli as the causitive agent?
Gram-negative bacilli in the synovial fluid would be concerning for septic arthritis. In the past, infections with gram-negative bacilli (particularly Haemophilus influenzae) were very common, especially in children. Since the introduction of the HiB vaccine, infection with this bacterial species has become much less common.
In septic arthritis, how does the flucose levels of the synovial flid compare to blood glucose?
Its LOWER
Cultures are usually positive, glucose levels are much lower than serum levels due to the glycolytic activity of bacteria, and crystals are not present.
S aureus is coagulase positive or negative?
Positive
Septic arthritis following a UTI yields gram negative rods on stain. Empiric antibiotics consists of….
The empiric antibiotics of choice for gram-negative bacilli are third-generation cephalosporins (e.g., ceftazidime) or fourth-generation cephalosporins (e.g., cefepime). Alternative empiric antibiotics for gram-negative bacilli include piperacillin/tazobactam, carbapenems, and, in patients with a known allergy to beta-lactam antibiotics, fluoroquinolones or aztreonam.
Pseudomonas septic arthritis is seen in what patient population (what risk factors)?
no risk factors for Pseudomonas infection, such as IV drug use, diabetes mellitus, or recent nosocomial infection (hospital acquired infection).
What is the empiric abx regimen for someone with suspected pseudomonas septic arthritis?
A combination of ceftazidime and an aminoglycoside (gentamicin) is an empiric antibiotic regimen in patients with suspected Pseudomonas aeruginosa septic arthritis.
Examination of the right knee shows swelling and erythema; there is fluctuant edema over the lower part of the patella. The range of flexion is limited because of the pain. The skin over the site of his pain is not warm. There is tenderness on palpation of the patella; there is no joint line tenderness. The remainder of the examination shows no abnormalities (afebrile, 37 otherwise healthy dude)
Prepatellar bursitis
Prepatellar bursitis is an inflammation of the synovial bursa located between the skin and patella. It is often caused by overuse injuries (such as excessive kneeling, as seen in this case) or repeated trauma to the knee. Professions which require frequent kneeling (e.g., carpet installers, masons, plumbers, mechanics) are especially prone to developing prepatellar bursitis. In acute bursitis, bursal fluid aspiration is indicated to rule out infection or gout. Treatment is conservative and involves rest, ice or heat, elevation, NSAIDs, and, in case of infection, antibiotics. Surgery may be indicated (e.g., drainage of pus, bursectomy) for recurrent bursitis if conservative management fails.
How can you tell the difference between greater trochanteric hip pain and ITB syndrome?
For IT band syndrome, use nobles test. Pain will be closer to the knee where it inserts, not with hip pain. For GTPS, Typical findings include tenderness to palpation over the greater trochanter, exacerbation of pain by lying on the affected side, and triggering of pain by resisted abduction.
First line tx for osteoarthritis is ____________________, second line is ____________________-
First line NSAIDs like ibuprofen, second line Second-line treatment consists of acetaminophen or intraarticular glucocorticoid injections.
joint space narrowing, subchondral sclerosis, osteophytes, and subchondral cysts.
OA
Joint effusion and pannus formation are classic findings of
rheumatoid arthritis (RA)
Calcium pyrophosphate dihydrate crystal precipitation in the joints
pseudogout
Monosodium urate crystal precipitation in the joints
gout
DM type I w/ positive psoas sign, increased urinary frequency and 3+ glucose on urinalysis, flank pain is concerning for…
This patient’s combination of subacute flank pain, positive psoas sign, fever, and leukocytosis suggests a psoas abscess. A psoas abscess can either be classified as a primary abscess, caused by hematogenous spread of infection (e.g., bacteremia, endocarditis), or a secondary abscess, which is due to local spread of infection (e.g., osteomyelitis, pyelonephritis, trauma). Primary abscesses are most common, and diabetes is an important risk factor for primary abscess formation. Definitive diagnosis requires imaging with MRI or CT; ultrasound may allow for identification of a large abscess.
What muscles should you strengthen if you have patellofemoral pain syndrome?
Treatment includes exercises to strengthen the quadriceps muscle.
