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Course 2 - Orthopedics > Trauma, Fractures in Elderly, Sports Medicine > Flashcards

Trauma, Fractures in Elderly, Sports Medicine Flashcards

1
Q

Skeletal bone is an _____

A

organ; tissues turn over by osteoclastic and osteoblastic activity

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2
Q

What is the structure of the bone

A

cortical (compact) bone & cancellous (trabecular) bone

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3
Q

Describe the cortical (compact) bone

A

80%; closely packed osteons, 5-30% porosity, diaphyseal (shaft), strong, resistant to bending

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4
Q

Describe the cancellous (trabecular) bone

A

network of plates & rods; trabeculae follow lines of stress ; metaphyseal (near ends); porosity 30-90%, 10% of cortical bone strength

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5
Q

what is an osteoblast

A

cells that form new bone; mesenchymal origin

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6
Q

what is an osteocyte

A

osteoblast embedded within the matrix it secretes; maintain bone and cellular matrix

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7
Q

what is an osteoclast

A

large cells that dissolve bone

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8
Q

what is bone extracellular matrix made of?

A

organic matter (20-25%), flexibility and resilience with type 1 collagen; inorganic matter (60-70%), hardness and rigidity with crystals of calcium, phosphate, hydroxyapatite

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9
Q

what is the function of bone ECM?

A

gene expression, tissue development, scaffold, regulate bone cell behaviour

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10
Q

bone is strongest in _____ and weaker in ______

A

bone is strongest in compression and weaker in tension (pulling bone apart)

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11
Q

where does the inner 2/3 of bone blood supply arise from?

A

endosteal

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12
Q

where does the outer 1/3 of bone blood supply arise from?

A

periosteal

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13
Q

what is the mechanical bone function?

A

load bearing, leverage, protect organs, locomotion

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14
Q

what is the biological bone function?

A

calcium homeostasis –> end organ for hormones (PTH, calcitonin, GH, corticosteroids)

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15
Q

what is the callus a response to?

A

living bone reaction to inter-fragmentary movement

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16
Q

describe the four stages of fracture healing

A

inflammatory
soft callus
hard callus
remodelling

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17
Q

describe primary bone healing

A

DIRECT OSTEONAL REMODELING
absolute stability, anatomic reduction & inter-fragmentary compression, no callus formation, healing via cutting cones & lamellar bone formation

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18
Q

describe secondary bone healing

A

relative stability, less stable fixation or non-surgical management, callus formation

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19
Q

what are the three factors that affect fracture healing?

A

soft tissue –> BLOOD SUPPLY
fracture biology
fracture stability

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20
Q

how is osteomalacia and fracture related

A

vitamin D deficiency –> reduced bone mineralization –> softening of bones

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21
Q

describe metabolic bone abnormalities

A

osteoporosis: quantitative bone loss
gastric bypass: calcium absorption affected
diabetes: affect repair and remodelling of bone
HIV: higher prevalence of fragility fractures, delayed healing
systemic inflammation: rheumatoid arthritis, polytrauma

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22
Q

cost of trauma is

A

4x cancer, 6x heart disease, leading cause of death/disability worldwide

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23
Q

age and sex of drivers involved in casualty collisions (most predominant) is:

A

18-24 males

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24
Q

alcohol role in fatal collisions:

A

16.3% of drivers involved in fatal collisions consumed alcohol prior to crash compared to 3.2% in injury collisions

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25
Q

lifetime risk of fragility fracture

A

50% in women, 22% in men

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26
Q

what is AMPLE history

A 
Allergies
Medications
Past medical history 
Last meal 
Events leading to presentation
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27
Q

examination includes:

A

skin (openings, blisters, abrasions)
deformity (bones, joints)
vascularity (arterial, capillary refill)
neuro (motor, sensory)

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28
Q

imaging x-ray method:

A

multiple planes
joint above and below
immobilize and realign joints if possible before
perform NV exam before & after realigning

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29
Q

further imaging is required for:

A 
intra-articular fractures (CT scan)
ligamentous injury (MRI)
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30
Q

what are the functions of soft tissue

A

protect bone, barrier to infection, provide blood supply to bone, power limb for locomotion –> good tissue envelope crucial to fracture healing & overall limb function

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31
Q

what does it mean for bony injury to be static?

A

extent is known as soon as it occurs and does not usually change over time

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32
Q

what are the principles of fracture treatment?

A

reduce deformity (closed reduction, operative intervention), maintain reduction (cast, internal fixation), rehab

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33
Q

what does it mean for soft tissue injury to evolve?

A

management of soft tissue to prevent injury degeneration is important

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34
Q

what are indications for fracture surgery?

A

open fractures, articular fractures (difficult to maintain in cast), poly-trauma, patient mobilization restoration, correction of alignment

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35
Q

what is the most common upper extremity fracture?

A

distal radius fracture

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36
Q

describe a distal radius fracture

A

‘dinner fork’ deformity at wrist

dorsal angulation

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37
Q

how to manage a distal radius fracture?

A

cast (closed reduction) first

surgery if closed reduction fails

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38
Q

how to image hip fractures?

A

AP pelvis, hip AP/lateral, joint above and below (knee)

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39
Q

how are occult hip fractures discovered?

A

not shown on x-ray, MRI shows positive results within 24hr, CT scan shows trabeculae, bone scan (take 2-3 days)

start with CT scan

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40
Q

how soon should surgery be done on hip fractures?

A

within 24hr

look for underlying reasons for hip fracture (UTI, electrolyte abnormality, dehydration)

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41
Q

how should ankle fractures be managed?

A

PHx to discover MOI
Reduce and splint –> reverse MOI, recheck NV status
elevate, ice

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42
Q

how should ankle fractures be imaged?

A

AP, lateral, mortise views

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43
Q

what are the three potential areas for fractures

A

medial, lateral, posterior malleoli

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44
Q

what is a bi-malleolar ankle fracture equivalent?

A

fracture of LM, soft tissue injury on medial side (functionally like a bimalleolar)

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45
Q

what is the hierarchy during orthopedic emergencies?

A
  1. life
  2. limb
  3. function
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46
Q

management for open fractures

A

timely Abx, tetanus, NV exam, irrigation, sterile, moist dressing, splint, repeat NV exam, image joint above and below, secondary survey for other injuries

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47
Q

what Abx to use for open fractures?

A

I-II: 1st gen cephalosporin for 24hr after closure
IIIA-IIIC: 1st gen cephalosporin for gram positive, aminoglycoside (gentamycin) for gram negative, penicillin if anaerobic

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48
Q

how do you define a joint dislocation?

A

joint forced to move beyond its normal range

ligaments are often stretched or torn; soft tissue, NV, bone injury can occur

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49
Q

what is incomplete (subluxation) joint dislocation

A

surface retain partial contact

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50
Q

what is complete joint dislocation

A

no joint surface contact

51
Q

treatment for joint dislocation

A

prompt diagnosis, adequate imaging, NV exam, sedation/numbing, well-planned reduction maneuver

52
Q

describe a closed reduction of joint dislocation

A

NV exam, ‘recreate’ the injury, splint, redo NV exam

53
Q

describe an open reduction of joint dislocation

A

failure of closed reduction, contraindication to closed reduction, displaced fracture, NV injury

54
Q

describe how diminished pulses are managed

A

realign limb and splint – repeat exam; check limb perfusion (pulse, cap refill, bleeding to pinprick)
unequal pulse – vascular consult, angiography

55
Q

what is ankle-brachial index?

A

ABI - P(leg)/P(arm)

if ABI <0.9 = suspect vascular injury

56
Q

what is compartment syndrome?

A

elevated tissue pressure within a closed fascial space, result in ischemia and necrosis

57
Q

what causes compartment syndrome?

A

tight dressing, localized external pressure (lying on limb), closure of fascial defects
bleeding, capillary permeability (ischemia, trauma, burns, snake bite, IV fluid, etc.)
depends on diastolic pressure

58
Q

what are the five P’s for compartment syndrome Dx?

A 
pain on passive stretch 
pain out of proportion to injury
poikilothermia
paresthesia
pallor, pulselessness, and paralysis
59
Q

management of compartment syndrome

A

prompt eval.
remove cast/dressing
place @ heart level (do not elevate)
need urgent surgical management with fasciotomies

60
Q

how to use compartment pressure for diagnosing compartment syndrome?

A

diastolic BP - compartment pressure (should be >30mmHg for Dx)

lower leg has 4 compartments

61
Q

indication for pelvic binder

A

open-book pelvis injury (opened up anteriorly), disrupt vasculature running by pelvis, life threatening
closing pelvis anteriorly and closing volume can save life

62
Q

what is intimate partner violence

A

any behavior within an intimate relationship that is used to exert power and control that causes physical, psychological, or sexual harm to the other person

63
Q

IPV is the #1 cause of _____ to women

musculoskeletal injuries are the ____ common manifestation of IPV

A

IPV is the #1 cause of non-fatal to women

musculoskeletal injuries are the second-most common manifestation of IPV

64
Q

_____ women who present to fracture clinics have experienced IPV in the past year

____ female patients presents to the fracture clinic as a direct result of IPV

only ___ of clinic patients with an IPV injury had ever previously been asked about IPV

A

1 in 6 women who present to fracture clinics have experienced IPV in the past year

1 in 50 female patients presents to the fracture clinic as a direct result of IPV

only 14% of clinic patients with an IPV injury had ever previously been asked about IPV

65
Q

_____ is the #1 predictor of intimate partner homicide

A

escalating violence is the #1 predictor of intimate partner homicide

66
Q

____ of women murdered by their intimate partner presented to HCP in the 2 years before their death for treatment of IPV injury

A

45% of women murdered by their intimate partner presented to HCP in the 2 years before their death for treatment of IPV injury

67
Q

what are signs of IPV perpetrators

A

speaks for partner/belittles, over-solicitous, reluctance to leave partner, disrespectful, manipulative, charming

68
Q

presentation of IPV

A

medical: chronic unexplained pain, anxiety, substance abuse, frequent injuries, depression, injuries at different stages of recovery, strangulation/ circumferential bruising

behavioural signs: fear, minimize abuse or injuries, heightened startle response, ambivalence, nervous

69
Q

when to ask about IPV

A

all women, anytime during fracture clinic appt
mid-appt, each appt, repetition and consistency

don’t use trigger words (abused, battered)

70
Q

define fragility fractures

A

fracture that occurs spontaneously or after minor trauma, such as a fall from standing height or less or walking speed or less

71
Q

___ of seniors experience one or more falls each year

falls are cause of ___ of seniors’ injury-related hospitalizations

falls are the cause of ___ of all hip-fractures

A

20-30% of seniors experience one or more falls each year

falls are cause of 85% of seniors’ injury-related hospitalizations

falls are the cause of 95% of all hip-fractures

72
Q

___ of nursing home residents fall each year

hip fractures are the most common cause of death in ___ age group

death 1 year after hip fracture:
___ women, ___ men

A

60% of nursing home residents fall each year

hip fractures are the most common cause of death in >75 age group

death 1 year after hip fracture:
28% women, 37% men; only 1/3 return to prior lifestyle

73
Q

three types of hip fractures & description

A

subcapital (across neck of femur)

intertrochanteric (break occurs between the greater trochanter and lesser trochanter)

subtrochanteric (break occurs below the lesser trochanter or further down the femur)

74
Q

what are sequelae of immobilization?

A

pulmonary complications, DVT, PE, cardiac complications, pressure ulcers, muscle atrophy

75
Q

goals of surgical treatment of hip fracture

A

safe, early mobilization without restriction, prevention of sequelae of immobilization, perform surgery within 24hr, multi-disciplinary (orthogeriatrician)

76
Q

what are correctable comorbidities for hip surgery?

A

anemia, anticoagulation, volume depletion, electrolyte imbalance, uncontrolled diabetes, uncontrolled heart failure, correctable cardiac arrhythmia or ischemia

77
Q

post-operative management for hip fracture surgery:

A

acute multidisciplinary care, rapid secondary prevention, rehab

78
Q

define osteoporosis

A

disease characterized by low bone mass and deterioration

bone density 2.5SD below young adult measured by dual-energy x-ray absorptiometry

79
Q

calcium/vitamin D intake rec (Toward Optimized Practice)

A

calcium 1200mg/day and vitamin D 1000IU/day

80
Q

risk factors for osteoporosis

A

long term steroid use, fragility fracture, vertebral fracture/osteopenia on x-ray, RA, malabsorption, hyperparathyroidism, hypogonadism

81
Q

using OST to determine risk of osteoporosis

A

weight (kg) - age (years)
ost 10+: low risk of osteoporosis
ost <10: moderate-high risk of osteoporosis

82
Q

WHO fracture assessment tool (FRAX) components

A

age, sex, weight, height, previous fracture, parent fractured hip, current smoker, ETOH 3+ a day, RA, steroid use, type I diabetes, chronic liver disease, etc.

83
Q

describe pharmacotherapy for osteoporosis

A

anti-resorptive agents (bisphosphonates, hormonal, biological agents), promotion of bone formation (peptide hormones)

84
Q

screening questions for fall risk

A
  1. feel unsteady
  2. worry about falls
  3. have fallen in last year
85
Q

tests for fall risk

A

gait (TUG; timed up-and-go test), strength (30 second chair stand), balance (4 stage balance test)

86
Q

what is fascia?

A

widespread connective tissue, superficial lies under skin, deep envelops muscles and organs

87
Q

4 broad phases of healing are:

A

Bleeding, Inflammatory Phase, Proliferation Phase, Remodeling Phase

88
Q

healing depends on _______, so poor healing occurs in _______, whereas good healing occurs in _______

A

healing depends on vascularization, so poor healing occurs in knee menisci and tendon, whereas good healing occurs in muscle and skin

89
Q

define stress fractures

A

accumulation of microtrauma from repetitive bond loading, imbalance of bone remodelling and breakdown

90
Q

tibia and metatarsal stress fractures are most common. what are symptoms?

A

gradual onset, localized pain, often due to sudden increase in training, night pain

91
Q

how to diagnose stress fractures?

A

localized bony tenderness, pain with resisted and LE motion
Triple phase Bone scan
XR not helpful

92
Q

Tx for stress fractures

A

Rest until pain-free for at least 2 weeks, symptomatic (ice, NSAID, taping), Walk-run program (6 cycles of alternating walking and running), review training program, RED-S (relative energy deficiency in sport; nutrient deficiency)

93
Q

what is significant about ant tib fracture

A

higher rate of delayed/non-union
XR will show non union ‘dreaded black line’
Tx: IM nail, drilling, excision and bone grafting

94
Q

define periostitis

A

Medial Tibial Stress Syndrome
Chronic inflammation of periosteum and fascia thickening (not bone injury, just the covering)
diffuse pain, gradual onset
generalized tenderness, pain

95
Q

describe what you would see on bone scan of periostitis

A

linear uptake of dye vs. focal points on stress fracture

96
Q

Tx for periostitis

A

no need for activity modification
RICE, NSAID
op: surgical periosteal stripping
extracorporeal shock wave therapy

97
Q

muscle strain/tear occurs during _______

A 
eccentric contraction (contraction while lengthening) 
lift a barbell, concentric contractions; lower it, eccentric contractions 
walking down stairs, running downhill, lowering weights, and the downward motion of squats, push-ups or pull-ups
98
Q

complications of contusion

A

myositis ossificans

calcification secondary to intra-muscular bleeding

99
Q 
define the following terms:
Tendinopathy 
Tendinitis
Tendinosis 
Tenosynovitis 
Enthesopathy
A

Tendinopathy – tendon problem/ disease
Tendinitis – acute inflammation
Tendinosis – intra-tendinous degeneration (chronic, 60-70 yo)
Tenosynovitis – inflammation within tendon sheath (pts feels “creaking”)
Enthesopathy – disease at tendon-bone insertion

100
Q

what is high ankle sprain

A

MOI: external rotation and dorsiflexion
anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) torn, inferior tib-fib also torn, interosseous membrane

101
Q

TX for sprains

A

NSAID
protective bracing
PT
surgical reconstruction for high grade

102
Q

define plantar fasciitis

A 
inflammation of thick connective tissue that support arch of foot 
focal pain (medial calcaneal tubercle), morning pain/stiffness walking on heels
103
Q

Chronic vs. Acute injury

A

Acute - traumatic

Chronic - overuse

104
Q

Intrinsic and extrinsic risk factors for ACL tear

A

Intrinsic: young age, poor quads strength and proprioception
Extrinsic: running cleats that are too grippy, poorly maintained turf

105
Q

inciting event for ACL tear

A

valgus/ER twist of the knee while cutting to the left

106
Q

what is ACL injury prevention neuromuscular program

A

exercise to strengthen, etc. to

reduce risk of injury

107
Q

urgent surgery for tendon rupture if

A

young, distal biceps tendon, quads and patellar tendons, achilles, peroneal and posterior tib

108
Q

muscle strain/tear grading

A

grade 1 - microtearing
grade 2 - partial tear
grade 3 - complete tear

109
Q

Management of muscle injuries

A

RICE, immobilize (short), analgesic
avoid NSAID/ASA to avoid bleeding
aspiration of hematoma
quadriceps contusion: immobilize in flexion to prevent stiffness

110
Q

symptoms of tendon injury

A

progressively worsening
pain during and after physical activity
focal tenderness, swelling
weakness secondary to pain

111
Q

management of tendonopathy

A

RIC, activity modification analgesic and NSAID
bracing, PT, stretching and eccentric strengthening exercises, extra-corporeal shock wave therapy
nitroglycerin patching, injection, surgical debridement
partial tear: immobilization
complete tear: immobilization + surgical repair

112
Q

ligament injury grading

A

grade 1: ligament stretched
grade 2: partially torn
grade 3: completely torn

113
Q

ligament injury management

A

RIC, Activity modification, analgesic & NSAID

grade 2&3: protective bracing

114
Q

Tx for plantar fasciitis

A 
rest, ice, compression, activity modification 
analgesic
PT
Injection
ESWT
surgical debridement
115
Q

what is iliotibial band syndrome (ITBS)

A

lateral fascia from glut. max. to lateral tibia
inflammation of distal ITB as it slides over the lateral femoral condyle with repeated knee flexion and ext.
worse w/ downhill running/walking down stairs

116
Q

Dx & Tx of ITBS

A

focal tenderness
normal knee exam
weak hip ER and ABD
symptomatic management, PT

117
Q

what is CECS (chronic exertion compartment syndrome)

A

compression of intra-compartment NV structures within fascia
present as pressure/tightness
predictable onset
xr/us normal

118
Q

diagnostic criteria for CECS

A

post extertional compartment pressure testing
opening pressure >30mmHg
pressure at 5 min >20mmHg
treat with conservative, then fasciotomy

119
Q

bursa can involve _____ of adjacent ____ structures

A

bursa can involve tendinopathy of adjacent tendon structures

e.g. greater trochanteric pain syndrome
RC impingement syndrome

120
Q

diagnostic criteria of frozen shoulder/adhesive capsulitis

A

functional restriction of BOTH active and passive shoulder motion
normal x rays except osteopenia or calcific tendonitis

121
Q

new classification of primary stiff shoulder

A

idiopathic cause, predisposing factors include diabetes (type I), Dupuytren contracture, thyroid, cardiac and pulmonary disorders, neoplasms

122
Q

secondary stiff shoulder causes

A

intra-articular, capsular, extra-articular, neurologic causes

123
Q

Tx for stiff shoulder

A

NSAID, corticosteroid injection, suprascapular nerve block, arthrographic distention (expand joint hole)

Course 2 - Orthopedics (7 decks)

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