Trauma and Orthopedic Surgery: PART III

Question 1

What are some conditions that weaken bone?

Answer 1

Osteoporosis, hyperparathyroidism, bone tumors, metastasis, Paget’s disease

Question 2

What do we mean by an oblique fracture?

Answer 2

Angle is greater or equal to 30 degrees

Question 3

What do we mean by transverse fracture?

Answer 3

Angle less than 30 degrees

Question 4

What is the salter harris classification?

Answer 4

A classification for fractures in relation to the physis, metaphysis, and epiphysis. Use in the case of pediatric fractures involving the growth plate.

Question 5

What complications do we always consider when assessing a bone fracture?

Answer 5

limb ischemia, peripheral nerve injury, or compartment syndrome

Question 6

Where are some common locations of pathologic fracture?

Answer 6

Proximal femur, proximal humerus, spine (spinal compression fracture)

Question 7

A fracture caused by bone shearing at the insertion point of a tendon or ligament

Answer 7

Avulsion Fracture

Question 8

Why do we preder splints over casting for initial immobilization of most fractures?

Answer 8

it better accommodates secondary swelling and is therefore associated with a lower risk of compartment syndrome and other pressure-related complications.

Question 9

A nonsurgical, physical manipulation to realign a displaced fracture and/or dislocation into a proper anatomical position.

Answer 9

Closed reduction

Question 10

What are indications of fractures that require urgent orthopedic consultation

Answer 10

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.

Question 11

What are the ottawa ankle rules and what are they used for?

Answer 11

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

Question 12

Most commonly sprained ankle ligament?

Answer 12

Anterior talofibular ligament (ATFL): most commonly affected

Question 13

Excessive inversion of the ankle joint often injures…

Answer 13

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

Question 14

Excessive eversion of the ankle joint often injures…

Answer 14

deltoid ligament

Question 15

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

Answer 15

Patellofemoral pain syndrome

Question 16

Patellofemoral pain syndrome is most often due to…

Answer 16

overuse

Question 17

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?

Answer 17

Patellofemoral pain syndrome.

Others to consider:
Osteoarthritis
Osgood-Schlatter disease
Patellar stress fracture
Patellar tendinopathy

Question 18

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

Answer 18

Medial tibial stress syndrome

Question 19

High riding patella and inability to actively extend the knee

Answer 19

patellar tendon injury

Question 20

low riding patella, inability to extend knee

Answer 20

quadriceps tendon injury

Question 21

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.

Answer 21

Median nerve entrapement
(eg carpal tunnel syndrome and pronator syndrome).

Question 22

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.

Answer 22

Ulnar nerve entraprement

Question 23

Radial nerve palsy

Answer 23

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).

Question 24

Primarily affects the sensation of the dorsal aspect of digits 1-3

Answer 24

Radial nerve entrapement

Question 25

Nerve entrapement that presents with wrist drop

Answer 25

radial nerve palsy

Question 26

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).

Answer 26

Posterior interosseus nerve syndrome, a radial nerve entrapement

Question 27

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.

Answer 27

Quadrilateral space syndrome, an axillary nerve palsy

Question 28

Deltoid muscle atrophy, impaired/altered sensation of the shoulder, impaired externeal roation and arm abduction. What nerve palsy?

Answer 28

Axillary

Question 29

Paralysis of the teres minor muscle would impeded what action?

Answer 29

Impaired external rotation of the arm, can be seen in mminjuries or something like an axillary nerve palsy

Question 30

A peripheral nerve of the upper limb that arises from the brachial plexus (nerve roots C4-C6). Innervates the infraspinatus and supraspinatus muscles.

Answer 30

Suprascapular nerve

Question 31

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.

Answer 31

Tarsal tunnel syndrome

Question 32

An injury to the lateral femoral cutaneous nerve that results in pain and paresthesias of the outer thigh.

Answer 32

Meralgia paresthetica also called bernhardt-roth syndrome or a lateral femoral cutaneous nerve injury

Question 33

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.

Answer 33

peroneal

Question 34

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]

Answer 34

pathophys of OA

Question 35

pain and nodular thickening on the dorsal sides of the distal interphalangeal joints

Answer 35

Heberden nodes

finding in OA

Question 36

pain and nodular thickening on the dorsal sides of the proximal interphalangeal joints

Answer 36

Bouchard nodes

finding in OA

Question 37

What limbs are primarily affected in complex regional pain syndrome?

Answer 37

Upper more than lower

Question 38

Symptoms usually develop within 4–6 weeks following a trauma
Pain excessive in duration or severity given the inciting event

Answer 38

Complex regional pain syndrome

Question 39

A sensation of pain triggered by a stimulus that is not ordinarily considered painful.

Answer 39

Allodynia

Question 40

Criteria for Chronic Regional Pain Syndrome

Answer 40

1. Persistent pain disproportionate to the original injury
2. t least one symptom in three of the following four categories, as reported by the patient: sensory, vasomotor, sudomotor/edema, motor/trophic
3. At least one sign in two of the following four categories, as assessed by the physician during examination: sensory, vasomotor, sudomotor/edema, motor/trophic
4. Exclusion of other possible etiologies (e.g., infection, radiculopathy, neuropathy, vascular disorder)

Question 41

Routes of spread in septic arthritis

Answer 41

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)

Question 42

What patients are at an increased risk of septic arthritis?

Answer 42

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

Question 43

Pathogens most associated with septic arthritis

Answer 43

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)

Question 44

Prosthetic joint infection; in what time frame would we expect to see this?

Answer 44

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

Question 45

What pathogen do we seen in late onset prosthetic joint infection?

Answer 45

s. aureus most commonly

Question 46

what pathogen do we commonly see in delayed onset Prosthetic joint infection?

Answer 46

delayed =3-12 months, coagulase-negative staphylococci, particularly S. epidermidis

Question 47

What pathogen do we commonly see in early onset prosthetic joint infection?

Answer 47

commonly s. aureus

Question 48

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).

Answer 48

Septic arthritis of the hip (bacterial coxitis) Bacterial coxitis is an orthopedic emergency that requires urgent management to avoid joint destruction.

Question 49

What WBC count would we expect in a needle aspiration of a septic joint?

Answer 49

> 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.

Question 50

In a gram NEGATIVE stain with concern for gononnococcal arthritis where chlamydia has NOT been ruled out, what abx should you consider?

Answer 50

Ceftriaxone and doxycycline

Question 51

In a gram NEGATIVE joint aspiration with no concern for gononnococcal arthritis, what empiric antibiotics should we use?

Answer 51

vancomycin

Question 52

Who is at increased risk for osteomyelitis?

Answer 52

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.

Question 53

What are the major routes of infection in osteomyelitis?

Answer 53

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]

Question 54

What special pt group must you maintain a high index of suspicion for osteomyelitis?

Answer 54

CHILDREN!

Question 55

overuse injury of the hand, esp. finger extensor tendons which originate in the lateral humeral epicondyle

Answer 55

Lateral epicondylitis (tennis elbow)

Question 56

extensor tendons which originate in the (medial or lateral) humeral epicondyle

Answer 56

extensor tendons which originate in the lateral humeral epicondyle

Question 57

extensor tendons which originate in the lateral humeral epicondyle

Answer 57

Medial epicondylitis (golfer’s elbow)

Question 58

finger flexor tendons which originate in the (medial or lateral) humoral epicondyle

Answer 58

medial

Question 59

insertional tendinopathy that arises from repetitive flexion and extension of the knee (e.g., from running, cycling)

Answer 59

Iliotibial band syndrome

Question 60

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

Answer 60

Noble test

Question 60

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.

Answer 60

Myositis ossificans (heterotopic ossification)

Question 61

What does noble test indicate?

Answer 61

Ilitibial band syndrome

Question 62

lateral hip pain caused by tendinopathy of the gluteus medius or minimus

Answer 62

greater trochanteric pain syndrome

Question 63

a condition characterized by pain and tenderness at the anteromedial aspect of the knee

Answer 63

pes anserinus pain syndrome

Question 64

a collection of synovial fluid in or around the meniscus ususally associated with Chronic meniscal tears

Answer 64

meniscal cyst

Question 65

valgus (lateral) misalignment of the knee, resulting in a knocked knee deformity

Answer 65

genu valgum

Question 66

varus (medial) misalignment of the knee, resulting in a bowleg deformity

Answer 66

genu varum

Question 67

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

Answer 67

heel pad syndrome

Question 68

In a patient with suspected vertebral osteomyelitis supported by x-ray and MRI findings, the next most appropriate step after negative blood cultures is ___________________

Answer 68

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.

Question 69

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.

Answer 69

bone biopsy

Question 70

The most common pathogens in IV drug users-osteomyelitis are __________________- and -__________________

Answer 70

Pseudomonas and Staphylococcus species.

Question 71

The most common pathogens in IV drug users-osteomyelitis are __________________- and -__________________ which means we start empriric therapy of ______________________

Answer 71

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.

Question 72

When do we give empiric abx therapy in suspected osteomyelitis pts and when do we hold until after bone bx?

Answer 72

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).

Question 73

A child presenting w/septic arthritis with no hx of complication/hospitalization should be started on what empiric abx?

Answer 73

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

Question 74

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?

Answer 74

strep is the likely causal organism and you would see gram positive cocci

Question 75

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?

Answer 75

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.

Question 76

In septic arthritis, how does the flucose levels of the synovial flid compare to blood glucose?

Answer 76

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.

Question 77

S aureus is coagulase positive or negative?

Answer 77

Positive

Question 78

Septic arthritis following a UTI yields gram negative rods on stain. Empiric antibiotics consists of….

Answer 78

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.

Question 79

Pseudomonas septic arthritis is seen in what patient population (what risk factors)?

Answer 79

no risk factors for Pseudomonas infection, such as IV drug use, diabetes mellitus, or recent nosocomial infection (hospital acquired infection).

Question 80

What is the empiric abx regimen for someone with suspected pseudomonas septic arthritis?

Answer 80

A combination of ceftazidime and an aminoglycoside (gentamicin) is an empiric antibiotic regimen in patients with suspected Pseudomonas aeruginosa septic arthritis.

Question 81

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)

Answer 81

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.

Question 82

How can you tell the difference between greater trochanteric hip pain and ITB syndrome?

Answer 82

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.

Question 83

First line tx for osteoarthritis is ____________________, second line is ____________________-

Answer 83

First line NSAIDs like ibuprofen, second line Second-line treatment consists of acetaminophen or intraarticular glucocorticoid injections.

Question 84

joint space narrowing, subchondral sclerosis, osteophytes, and subchondral cysts.

Answer 84

OA

Question 85

Joint effusion and pannus formation are classic findings of

Answer 85

rheumatoid arthritis (RA)

Question 86

Calcium pyrophosphate dihydrate crystal precipitation in the joints

Answer 86

pseudogout

Question 87

Monosodium urate crystal precipitation in the joints

Answer 87

gout

Question 88

DM type I w/ positive psoas sign, increased urinary frequency and 3+ glucose on urinalysis, flank pain is concerning for…

Answer 88

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.

Question 89

What muscles should you strengthen if you have patellofemoral pain syndrome?

Answer 89

Treatment includes exercises to strengthen the quadriceps muscle.