Trauma, Fractures in Elderly, Sports Medicine Flashcards
Skeletal bone is an _____
organ; tissues turn over by osteoclastic and osteoblastic activity
What is the structure of the bone
cortical (compact) bone & cancellous (trabecular) bone
Describe the cortical (compact) bone
80%; closely packed osteons, 5-30% porosity, diaphyseal (shaft), strong, resistant to bending
Describe the cancellous (trabecular) bone
network of plates & rods; trabeculae follow lines of stress ; metaphyseal (near ends); porosity 30-90%, 10% of cortical bone strength
what is an osteoblast
cells that form new bone; mesenchymal origin
what is an osteocyte
osteoblast embedded within the matrix it secretes; maintain bone and cellular matrix
what is an osteoclast
large cells that dissolve bone
what is bone extracellular matrix made of?
organic matter (20-25%), flexibility and resilience with type 1 collagen; inorganic matter (60-70%), hardness and rigidity with crystals of calcium, phosphate, hydroxyapatite
what is the function of bone ECM?
gene expression, tissue development, scaffold, regulate bone cell behaviour
bone is strongest in _____ and weaker in ______
bone is strongest in compression and weaker in tension (pulling bone apart)
where does the inner 2/3 of bone blood supply arise from?
endosteal
where does the outer 1/3 of bone blood supply arise from?
periosteal
what is the mechanical bone function?
load bearing, leverage, protect organs, locomotion
what is the biological bone function?
calcium homeostasis –> end organ for hormones (PTH, calcitonin, GH, corticosteroids)
what is the callus a response to?
living bone reaction to inter-fragmentary movement
describe the four stages of fracture healing
inflammatory
soft callus
hard callus
remodelling
describe primary bone healing
DIRECT OSTEONAL REMODELING
absolute stability, anatomic reduction & inter-fragmentary compression, no callus formation, healing via cutting cones & lamellar bone formation
describe secondary bone healing
relative stability, less stable fixation or non-surgical management, callus formation
what are the three factors that affect fracture healing?
soft tissue –> BLOOD SUPPLY
fracture biology
fracture stability
how is osteomalacia and fracture related
vitamin D deficiency –> reduced bone mineralization –> softening of bones
describe metabolic bone abnormalities
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
cost of trauma is
4x cancer, 6x heart disease, leading cause of death/disability worldwide
age and sex of drivers involved in casualty collisions (most predominant) is:
18-24 males
alcohol role in fatal collisions:
16.3% of drivers involved in fatal collisions consumed alcohol prior to crash compared to 3.2% in injury collisions
lifetime risk of fragility fracture
50% in women, 22% in men
what is AMPLE history
Allergies Medications Past medical history Last meal Events leading to presentation
examination includes:
skin (openings, blisters, abrasions)
deformity (bones, joints)
vascularity (arterial, capillary refill)
neuro (motor, sensory)
imaging x-ray method:
multiple planes
joint above and below
immobilize and realign joints if possible before
perform NV exam before & after realigning
further imaging is required for:
intra-articular fractures (CT scan) ligamentous injury (MRI)
what are the functions of soft tissue
protect bone, barrier to infection, provide blood supply to bone, power limb for locomotion –> good tissue envelope crucial to fracture healing & overall limb function
what does it mean for bony injury to be static?
extent is known as soon as it occurs and does not usually change over time
what are the principles of fracture treatment?
reduce deformity (closed reduction, operative intervention), maintain reduction (cast, internal fixation), rehab
what does it mean for soft tissue injury to evolve?
management of soft tissue to prevent injury degeneration is important
what are indications for fracture surgery?
open fractures, articular fractures (difficult to maintain in cast), poly-trauma, patient mobilization restoration, correction of alignment
what is the most common upper extremity fracture?
distal radius fracture
describe a distal radius fracture
‘dinner fork’ deformity at wrist
dorsal angulation
how to manage a distal radius fracture?
cast (closed reduction) first
surgery if closed reduction fails
how to image hip fractures?
AP pelvis, hip AP/lateral, joint above and below (knee)
how are occult hip fractures discovered?
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
how soon should surgery be done on hip fractures?
within 24hr
look for underlying reasons for hip fracture (UTI, electrolyte abnormality, dehydration)
how should ankle fractures be managed?
PHx to discover MOI
Reduce and splint –> reverse MOI, recheck NV status
elevate, ice
how should ankle fractures be imaged?
AP, lateral, mortise views
what are the three potential areas for fractures
medial, lateral, posterior malleoli
what is a bi-malleolar ankle fracture equivalent?
fracture of LM, soft tissue injury on medial side (functionally like a bimalleolar)
what is the hierarchy during orthopedic emergencies?
- life
- limb
- function
management for open fractures
timely Abx, tetanus, NV exam, irrigation, sterile, moist dressing, splint, repeat NV exam, image joint above and below, secondary survey for other injuries
what Abx to use for open fractures?
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
how do you define a joint dislocation?
joint forced to move beyond its normal range
ligaments are often stretched or torn; soft tissue, NV, bone injury can occur
what is incomplete (subluxation) joint dislocation
surface retain partial contact
what is complete joint dislocation
no joint surface contact
treatment for joint dislocation
prompt diagnosis, adequate imaging, NV exam, sedation/numbing, well-planned reduction maneuver
describe a closed reduction of joint dislocation
NV exam, ‘recreate’ the injury, splint, redo NV exam
describe an open reduction of joint dislocation
failure of closed reduction, contraindication to closed reduction, displaced fracture, NV injury
describe how diminished pulses are managed
realign limb and splint – repeat exam; check limb perfusion (pulse, cap refill, bleeding to pinprick)
unequal pulse – vascular consult, angiography
what is ankle-brachial index?
ABI - P(leg)/P(arm)
if ABI <0.9 = suspect vascular injury
what is compartment syndrome?
elevated tissue pressure within a closed fascial space, result in ischemia and necrosis
what causes compartment syndrome?
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
what are the five P’s for compartment syndrome Dx?
pain on passive stretch pain out of proportion to injury poikilothermia paresthesia pallor, pulselessness, and paralysis
management of compartment syndrome
prompt eval.
remove cast/dressing
place @ heart level (do not elevate)
need urgent surgical management with fasciotomies
how to use compartment pressure for diagnosing compartment syndrome?
diastolic BP - compartment pressure (should be >30mmHg for Dx)
lower leg has 4 compartments
indication for pelvic binder
open-book pelvis injury (opened up anteriorly), disrupt vasculature running by pelvis, life threatening
closing pelvis anteriorly and closing volume can save life
what is intimate partner violence
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
IPV is the #1 cause of _____ to women
musculoskeletal injuries are the ____ common manifestation of IPV
IPV is the #1 cause of non-fatal to women
musculoskeletal injuries are the second-most common manifestation of IPV
_____ 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
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
_____ is the #1 predictor of intimate partner homicide
escalating violence is the #1 predictor of intimate partner homicide
____ of women murdered by their intimate partner presented to HCP in the 2 years before their death for treatment of IPV injury
45% of women murdered by their intimate partner presented to HCP in the 2 years before their death for treatment of IPV injury
what are signs of IPV perpetrators
speaks for partner/belittles, over-solicitous, reluctance to leave partner, disrespectful, manipulative, charming
presentation of IPV
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
when to ask about IPV
all women, anytime during fracture clinic appt
mid-appt, each appt, repetition and consistency
don’t use trigger words (abused, battered)
define fragility fractures
fracture that occurs spontaneously or after minor trauma, such as a fall from standing height or less or walking speed or less
___ 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
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
___ 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
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
three types of hip fractures & description
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)
what are sequelae of immobilization?
pulmonary complications, DVT, PE, cardiac complications, pressure ulcers, muscle atrophy
goals of surgical treatment of hip fracture
safe, early mobilization without restriction, prevention of sequelae of immobilization, perform surgery within 24hr, multi-disciplinary (orthogeriatrician)
what are correctable comorbidities for hip surgery?
anemia, anticoagulation, volume depletion, electrolyte imbalance, uncontrolled diabetes, uncontrolled heart failure, correctable cardiac arrhythmia or ischemia
post-operative management for hip fracture surgery:
acute multidisciplinary care, rapid secondary prevention, rehab
define osteoporosis
disease characterized by low bone mass and deterioration
bone density 2.5SD below young adult measured by dual-energy x-ray absorptiometry
calcium/vitamin D intake rec (Toward Optimized Practice)
calcium 1200mg/day and vitamin D 1000IU/day
risk factors for osteoporosis
long term steroid use, fragility fracture, vertebral fracture/osteopenia on x-ray, RA, malabsorption, hyperparathyroidism, hypogonadism
using OST to determine risk of osteoporosis
weight (kg) - age (years)
ost 10+: low risk of osteoporosis
ost <10: moderate-high risk of osteoporosis
WHO fracture assessment tool (FRAX) components
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.
describe pharmacotherapy for osteoporosis
anti-resorptive agents (bisphosphonates, hormonal, biological agents), promotion of bone formation (peptide hormones)
screening questions for fall risk
- feel unsteady
- worry about falls
- have fallen in last year
tests for fall risk
gait (TUG; timed up-and-go test), strength (30 second chair stand), balance (4 stage balance test)
what is fascia?
widespread connective tissue, superficial lies under skin, deep envelops muscles and organs
4 broad phases of healing are:
Bleeding, Inflammatory Phase, Proliferation Phase, Remodeling Phase
healing depends on _______, so poor healing occurs in _______, whereas good healing occurs in _______
healing depends on vascularization, so poor healing occurs in knee menisci and tendon, whereas good healing occurs in muscle and skin
define stress fractures
accumulation of microtrauma from repetitive bond loading, imbalance of bone remodelling and breakdown
tibia and metatarsal stress fractures are most common. what are symptoms?
gradual onset, localized pain, often due to sudden increase in training, night pain
how to diagnose stress fractures?
localized bony tenderness, pain with resisted and LE motion
Triple phase Bone scan
XR not helpful
Tx for stress fractures
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)
what is significant about ant tib fracture
higher rate of delayed/non-union
XR will show non union ‘dreaded black line’
Tx: IM nail, drilling, excision and bone grafting
define periostitis
Medial Tibial Stress Syndrome
Chronic inflammation of periosteum and fascia thickening (not bone injury, just the covering)
diffuse pain, gradual onset
generalized tenderness, pain
describe what you would see on bone scan of periostitis
linear uptake of dye vs. focal points on stress fracture
Tx for periostitis
no need for activity modification
RICE, NSAID
op: surgical periosteal stripping
extracorporeal shock wave therapy
muscle strain/tear occurs during _______
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
complications of contusion
myositis ossificans
calcification secondary to intra-muscular bleeding
define the following terms: Tendinopathy Tendinitis Tendinosis Tenosynovitis Enthesopathy
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
what is high ankle sprain
MOI: external rotation and dorsiflexion
anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) torn, inferior tib-fib also torn, interosseous membrane
TX for sprains
NSAID
protective bracing
PT
surgical reconstruction for high grade
define plantar fasciitis
inflammation of thick connective tissue that support arch of foot focal pain (medial calcaneal tubercle), morning pain/stiffness walking on heels
Chronic vs. Acute injury
Acute - traumatic
Chronic - overuse
Intrinsic and extrinsic risk factors for ACL tear
Intrinsic: young age, poor quads strength and proprioception
Extrinsic: running cleats that are too grippy, poorly maintained turf
inciting event for ACL tear
valgus/ER twist of the knee while cutting to the left
what is ACL injury prevention neuromuscular program
exercise to strengthen, etc. to
reduce risk of injury
urgent surgery for tendon rupture if
young, distal biceps tendon, quads and patellar tendons, achilles, peroneal and posterior tib
muscle strain/tear grading
grade 1 - microtearing
grade 2 - partial tear
grade 3 - complete tear
Management of muscle injuries
RICE, immobilize (short), analgesic
avoid NSAID/ASA to avoid bleeding
aspiration of hematoma
quadriceps contusion: immobilize in flexion to prevent stiffness
symptoms of tendon injury
progressively worsening
pain during and after physical activity
focal tenderness, swelling
weakness secondary to pain
management of tendonopathy
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
ligament injury grading
grade 1: ligament stretched
grade 2: partially torn
grade 3: completely torn
ligament injury management
RIC, Activity modification, analgesic & NSAID
grade 2&3: protective bracing
Tx for plantar fasciitis
rest, ice, compression, activity modification analgesic PT Injection ESWT surgical debridement
what is iliotibial band syndrome (ITBS)
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
Dx & Tx of ITBS
focal tenderness
normal knee exam
weak hip ER and ABD
symptomatic management, PT
what is CECS (chronic exertion compartment syndrome)
compression of intra-compartment NV structures within fascia
present as pressure/tightness
predictable onset
xr/us normal
diagnostic criteria for CECS
post extertional compartment pressure testing
opening pressure >30mmHg
pressure at 5 min >20mmHg
treat with conservative, then fasciotomy
bursa can involve _____ of adjacent ____ structures
bursa can involve tendinopathy of adjacent tendon structures
e.g. greater trochanteric pain syndrome
RC impingement syndrome
diagnostic criteria of frozen shoulder/adhesive capsulitis
functional restriction of BOTH active and passive shoulder motion
normal x rays except osteopenia or calcific tendonitis
new classification of primary stiff shoulder
idiopathic cause, predisposing factors include diabetes (type I), Dupuytren contracture, thyroid, cardiac and pulmonary disorders, neoplasms
secondary stiff shoulder causes
intra-articular, capsular, extra-articular, neurologic causes
Tx for stiff shoulder
NSAID, corticosteroid injection, suprascapular nerve block, arthrographic distention (expand joint hole)
