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849 Cards in this Set
- Front
- Back
Why is hip dislocation an emergency?
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The potential for AVN of the hip, the hip must be reduced ASAP
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What is myositis ossificans?
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hetertrophic ossification. Pathologic bone formation where it is not normally formed. Usually occurs after trauma or surgery in the thigh or hip area. Causes pain and limited ROM.
Ttx:RICE immobilization for no more than 48 hours, then ROM exercises should be begun -mature lesions can be considered for operative removal |
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What is the etiology of referred hip or groin pain?
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-nephrolithiasis
-pelvic infection/inflammation/tumor -hernias -inguinal adenopathy -radiculopathy |
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What is the epidemiology of femoral neck fractures and intertrochanteric hip fractures?
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80% of femoral neck fractures occur in men around 72-77. Intertrochanteric hip fractures occur 8:1 times more commonly in women and about 10 years later.
Overall 3/4 of all hip fractures occur in post-menopausal women. |
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Discuss AVN of the femoral head
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AVN = ischemic necrosis = osteonecrosis.
It presents as increasingly painful hip, buttocks, thigh or knee without history of trauma atraumatic DDx chronic corticosteroid therapy alcoholism sickle cell disease dysbarism chronic pancreaticis protease therapy of HIV traumatic ddx hip dislocation femoral neck fracture AVN does not complicate intertrochanteric fractures because of improved blood supply |
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What findings on the AP pelvic xray predict the need for transfusion?
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-open book pelvis
-any displacement of 0.5cm or more at any fracture site in the pelvic ring -displaced symphysis pubis -displaced obturator ring fracture |
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What are the indications for venous and/or arterial angiographic embolizations in pelvic fractures?
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-venous embolization is ineffective (due to the presence of anastomoses and valveless collateral flow)
-Arterial embolization can be highly effective particularly with the following -inadequate response to initial resuscitation (failure to maintain an SBP >90mmHg after the administration of 2U of prbc (persistent hypovolemia in a patient with a major pelvic fracture despite control from other sources) -presence of contrast extravasation on admission CT -large expanding hematoma on CT POsterior arch disruptions are associated with the most severe hemorrhage and angiography should be considered at an early stage. |
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What are radiographic clues to the presence of pelvic posterior arch fractures?
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-Avulsion of L5 transverse process
-Avulsion of ischial spine -Avulsion of the lower lateral lip of the sacrum (sacrotuberous ligament) -Displacement at the site of pubic ramus fracture -Asymmetry or lack of definition of bone cortex at the superior aspect of the sacral foramina |
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What are 2 mechanisms for acetabular fractures?
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1) forceful impact to a flexed knee (dashboard injury)
2) lateral impact |
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What are signs and symptoms of acetabular fracture?
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Pain and inability to bear weight
Percussion of the sole of the foot or greater trochanter may reproduce the pain. |
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What xray views should you obtain to evaluate acetabular fractures?
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Judet views
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What nerve is commonly injured in acetabular fractures and how do you test it?
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The sciatic nerve
Sensory - lateral aspect of the lower leg and sole of the foot Motor - Hamstrings |
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What is the classification of acetabular fractures?
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Type A - Single column fractures
Type B - Two column fractures, T-type, portion of the acetabulum remains attached to the ileum Type C - Two column fractures, T-type, no portion of the acetabulum remains attached to the axial skeleton |
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What are the two common mechanisms for coccyx fractures?
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-fall in the sitting position
-kick xrays are not usually required |
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What is the usual mechanism for open-book pelvic fractures and what are the hallmark findings on xray
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-AP compression
-Widening at the pubic symphysis >2.5cm and SI joint widening |
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Describe the 2 types of sacral fracture
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Transverse fractures - not considered pelvic ring fractures
Vertical fractures - involve the pelvic ring, result from high-energy injuries. Classified as being lateral to the sacral foramina, through the sacral foramina or medial to the sacral foramina. (high risk of neurological function, increases as the fracture line moves more medially) |
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What are the priorities in managing high-energy pelvic ring fractures in the ED
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-identify the patients who are in hemorrhagic shock and resuscitate them with IVF and blood (resuscitate)
-recognize that patients with posterior arch fractures are at higher risk (recognize) -identify associated injuries and notify trauma surgeon (evaluate) -stabilize the pelvis with a pelvic wrap, alert ortho for possible ex-fix or c-clamp (stabilize) -control bleeding - consider angiography early. Pelvic packing during laparotomy is also an option (control pelvic bleeding) |
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Who gets pelvic avulsion fractures and what are the 4 main types
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Commonly occur in older children and teenagers involved in athletic activities.
1) ischial tuberosity avulsion during strenuous contraction of the hamstrings 2)iliac crest epiphyseal avulsion by contraction of the abdominal muscles 3)ASIS avulsion by forceful contraction of the sartorius 4)AIIS avulsion with forceful contraction of the rectus femoris (kicking a ball) |
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What is a straddle fracture and what is an associated injury
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Four pillar injuries with fractures of both pubic rami on both sides of the pubic symphysis. Also called a butterfly segment
May have concomitant injury to the posterior arch as well as genitourinary tract. |
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What is Tile's Classification
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Classification of Pelvic Fractures
Type A - Stable, posterior arch intact A1 avulsion fractures of the innominate bone A2 Iliac wing fracture (Duverney), minimally displaced pelvic ring fractures, transverse fractures of the sacrum or coccyx Type B - partially stable, incomplete disruption of the posterior arch (rotationally unstable, vertically stable) B1 open book # B2 lateral compression injury Type C - unstable, complete disruption of the posterior arch (vertically and rotationally unstable) includes iliac, sacroiliam and vertical sacral injuries C1- Unilateral C C2 - Unilateral C/ Unilateral B C3 - bilateral C |
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Describe the Young-Burgess Classification of Pelvic Fractures
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1. AP Compression
I. Symphysis diastasis < 2.5cm II. Symphysis diastasis >2.5cm, sacrospinus, anterior sacroiliam ligament disruption, results in rotational instability III. Symphysis diastasis >2.5cm, with complete disruption of the anterior and posterior SI ligament, results in complete rotation and vertical instability 2. Lateral Compression I. Sacral crus injury on ipsilateral side II. Sacral crush injury with disruption of the posterior SI ligaments, iliac wing fracture may be present, rotationally unstable III. Severe internal rotation of the ipsilateral hemipelvis with external rotation of contralateral side, roatationally unstable 3. Vertical shear Vertical displacement of the symphysis and sacroiliac joints resulting in compete rotational and vertical instability Combined mechanisms - any combination of the above mechanisms. |
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What is the value of inlet/outlet radiographs of the pelvis
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Allows better visualization of sacral # and SI joint disruptions.
(AP + inlet + outlet will show all clinically impt #s) so will CT. |
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What is the normal width of the pubic symphysis and the SI joints?
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-Normal width of the pubic symphysis is </=5mm and may have a small 1-2 mm vertical offset.
-The SI join is normally 2-4mm wide |
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Why should you use a fully open technique when performing a DPL in the presence of a pelvic fracture?
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A fully open technique makes it less likely that you will accidentally aspirate a retroperitoneal hematoma that has dissected up the anterior abdominal wall
One should also use the supra-umbilical approach |
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Unstable blunt trauma patient with pelvic fracture and DPL positive by cell count only - Lap or Angio
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Embolization before Lap
|
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Pelvic trauma + blood at the urethral meatus
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Retrograde urethrogram and cystogram
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Gross hematuria = what?
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Urethrography
IVP Cystography CT (some combination of these tests) |
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What are signs and symptoms of S2-S5 injury?
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Bowel and bladder dysfunction
Perineal sensory deficits Sexual Dysfunction |
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AP compression fractures of the pelvis are strongly associated with what thoracic injury?
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Thoracic aorta rupture is 5-8x more likely
|
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What are the sources of pelvic bleeding in trauma?
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Arterial
Venous Marrow +/- coagulopathy |
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What are the possible fates of an enlarging pelvic hematoma
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-May stay retroperitoneal
-May dissect up anterior abdominal wall -May rupture through the peritoneum causing loss of tamponade |
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What physical exam maneuvers should you perform in positive pelvic fracture?
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-inspect urethral meatus for blood
-careful rectal and vaginal exam to r/o open # (if there is rectal violation, the patient may require a diverting colostomy) |
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What is the definition of acute low back pain?
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pain lasting less than 6 weeks duration
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Why do 95% of disk herniations occur at L4/L5 and L5/S1 levels?
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Because the posterior longitudinal ligament (which forms the border between the intervertebral disks and vertebral canal, thins as it run inferiorly
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At what level does the spinal cord end in adults?
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L1-L2 interspace
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What is the definition of spondylolisthesis?
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Slippage of one vertebral body on the other
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What is spondylolysis?
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bilateral pars interarticularis defects in an affected vertebrae (this may be a cause of spondylolisthesis.)
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What are the 4 cannot miss diagnoses that cause low back pain?
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-spinal fracture
-cauda equina -spinal infection -metastatic disease |
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What is sciatica?
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It is an L5 or S1 radiculopathy described as a pain radiating from the low back to the leg (distal to the knees)
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What is a positive straight leg raise?
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The presence of back pain which radiates past the knee when the leg is elevated 30-70 degrees.
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What is the reverse SLR test?
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Have the patient lying prone and extend the hip. Pain will be elicited if there is irritation at L3 or L4.
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What physical exam maneuvers can be used to detect functional back pain?
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-SLR test sitting instead of supine. (if it is positive when supine but negative when sitting this suggests non-physiologic back pain)
-apparent superficial tenderness or non dermatomal sensory loss or widespread non dermatomal pain. -back pain elicited by pushing down on the patient's scalp against the c-spine -> this maneuver axially loads only the cervical and not the lumbar spine. -patients overreact during the examination |
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What diagnoses should be considered in elderly patients with low back pain?
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-worrisome diagnoses
-degenerative spondylolithesis -spinal stenosis |
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Should you perform a lumbar puncture to evaluate for CSF infection when you suspect a spinal infection?
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No, because there is a risk of seeding the cerebrospinal fluid with bacteria
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Wht are indications for LS spine X-rays in patients with lower back pain?
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-age <18, >50
-history of malignancy or unexplained weight loss -any history of fever, immunocompromise or IVDU -recent trauma other than simple lifting -progressive neuro deficits or other findings suggesting of caudal equine syndrome -prolonged duration of symptoms (>4-6 weeks) |
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What is the grading system for spondylolisthesis?
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Grade 1 - less than 25% slippage
Grade 2 - 25-50% slippage Grade 3 - 50-75% slippage Grade 4 - greater than 75% slippage |
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What is spondylitis?
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Osteomyelitis of the vertebral bone which on x-ray appears as erosion of contiguous vertebral endplates and a shortened disk space height.
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What is the most common organism that causes spinal infections? What organism is seen in IVDU?
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Staph aureus
Pseudomonas |
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What are the branch points in the algorithm for management of back pain that is worrisome for malignancy?
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-is there a history of previous cancer?
-is there evidence of radiculopathy? |
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What is the management of patients who have back pain, no history of cancer, no radiculopathy but a history suggestive of malignancy (i.e. weight loss or back pain worse at night)
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-plain radiography
-cbc and ESR (If positive X-ray or elevated ESR >100mm/hr) an urgent CT or MRI should be done within 3-7 days. |
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What emergency causes of thoracic pain must be considered before musculoskeletal pain?
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-PE
-AD -esophageal disease |
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What is different about the anatomy of the spinal cord in the thoracic area?
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At the thoracic level, the space around the spinal cord is smaller than at the lumbar level - the thoracic cord is thicker and significant neurologic abnormalities may result from minimal spinal canal impingement
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What factors should prompt basic radiologic studies for the presence of other conditions in patients with thoracic pain?
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-clinical suspicion
-unexplained symptoms -extremes of age -concern for trauma, tumor, infection, GI or vascular pathology -prolonged symptoms |
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What is the definition of chronic back pain?
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-lasting greater than 3 months
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What cancers typically metastasize to bone?
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-prostate
-breast -lung -thyroid -kidney |
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What is the presentation of an L5 radiculopathy?
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-decreased sensation in the great toe webspace
-weakness in great toe dorsiflexion -normal reflexes |
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What is the presentation of a S1 radiculopathy?
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-decreased sensation on the lateral foot
-weakness in plantar flexion of the foot -diminished/absent ankle reflex |
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Is SLR sensitive or specific for sciatica?
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SLR is sensitive but not specific
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Is reverse SLR sensitive or specific for sciatica?
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rSLR is specific but not sensitive
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Where is vertebral osteomyelitis (aka spondylitis) usually found?
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anterior subchondral vertebral bone (this is the most vascular area, most osteomyelitis is spread hematogenously)
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What is the approach to low back pain and suspicion of cancer?
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-known CA + radiculopathy -> emergency MRI
-known CA + no radiopathy -> xrya and labs (probably urgent[3-7 days] MRI) -no known CA + radiculopathy (ESR and X-ray, if positive MRI, if negative outpatient f/u) -no known CA + no radiculopathy (ESR and X-ray and then outpatient workup vs MRI) |
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What are signs and symptoms of spinal infection?
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-fever
-back pain at rest -midline spinal tenderness |
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What are characteristics of back pain from neoplasm?
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-pain at rest
-pain worse at night -unexplained weight loss -history of malignancy -pain > 1month in duration |
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What is a blood test of interest in back pain?
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ESR
>100 mm/hr is predictive of infection or neoplasm |
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What are classic signs of ankylosing spondylitis?
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-Morning back stiffness
-Relieved by Exercise |
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What are the causes of caudal equine syndrome?
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-massive central disc herniation
-epidural abscess -malignancy -hematoma -trauma |
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What is the most sensitive sign for cauda equine syndrome?
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Urinary retention
(this has a sensitivity of 90%) Cauda equina is unlikely if PVR is 100-200cc |
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Which patients are at risk of spinal infections (epidural abscess or vertebral osteomyelitis)?
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-IVDU
-immunocompromised (DM, HIV, CRF, long term corticosteroids) -alcoholics -elderly with recent blunt trauma to the back -pts with indwelling catheter -pts with recent bacterial infection |
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What are referred cases of acute low back pain?
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cholecystitis
pancreatitis PE AAA nephrolitiasis pneumonia ovarian torsion pyelonephritis retroperitoneal mass or hematoma AD |
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Most metastatic spine disease occur at what part of the spine?
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T-spine
|
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What are indications for surgery in spinal stenosis?
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progressive neurologic deficits
progressive pseudoclaudication intractable pain |
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What are the role of X-rays in detecting vertebral mets?
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-xrays miss 10-17% of vertebral mets. (Cancer needs to erode at least 50% of the bone before becoming radiographically apparent)
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Where do the majority of lumbar disk herniations occur?
In which direction do the herniations mostly occur? |
-L4/L5 (L5 nerve root)
L5/S1 (S1 nerve root) Mostly posterolateral bulge |
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What is sciatica?
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L4/L5 or L5/S1 radiculopathy
pain radiating down the posterior aspect of the leg from sciatic nerve root irritation |
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Within what time frame should a dislocated hip be reduced and why?
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6-12 hours after dislocation because it significantly decreases the incidence of AVN
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What is the classic position of a leg with a femoral neck fracture?
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-external rotation
-abduction -slight shortening |
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What is the classic position of a leg with an intertrochanteric hip fracture?
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-internal rotation
-mild shortening |
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What neuromuscular structures can be injured with subtrochanteric femur fractures?
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-femoral nerve
-arterial injury |
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What injuries can result in sciatic nerve injury?
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posterior hip dislocaiton
hip fracture |
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What are 3 methods to identify inconspicuous femoral neck fractures?
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-examine Shenton's line
-evaluate the medial and lateral cortical lines for S and reverse S curvatures (Lowell's smooth S and reverse S) -look for disruption of the trabecular lines as they pass from the femoral shaft to the femoral head |
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What percentage of hip fractures are radiographically occult?
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2-10%
|
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Why should MRI be used to diagnose occult hip fractures?
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Because CT has a 66% misdiagnosis rate, while MRI has 100% accuracy. Bone scan is also an option but must be delayed 72 hours after the injury
|
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In which injuries is the use of a traction splint contraindicated?
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pelvic injuries
patellar fractures ligamentous knee injuries tibia fracture fibula fracture open fracture |
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Define Open Fracture
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Any fracture in which a break in the integrity of the skin or soft tissue allows communication with the fracture and its hematoma
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What are potential complications of total hip replacement?
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-Loosening of the prosthesis
-component wear -infection -surrounding femoral fracture -DVT -post operative dislocation |
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What position has the most risk of resulting in prosthesis dislocation?
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Flexion at 90 degrees, adduction, internal rotation (eg. standing up from the toilet)
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Which muscles are involved in the following avulsions of the femur/hip: ASIS, AIIS, ischial tuberosity. How are these injuries managed.
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ASIS - Sartorius
AIIS - rectus femoris (both are managed conservatively) Ischial Tuberosity - Hamstrings (managed conservatively if <2cm displacement. If displaced >2cm may benefit from operative fixation |
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What is the most important etiologic factor in femoral neck fractures?
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Age-related bone loss
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What are the most common complications of femoral neck #s?
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AVN (20% of patients)
nonunion |
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How are intertrochanteric hip fractures classified?
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By the number of parts that the fracture produces:
two part - one part connected to the femoral head and the other attached to the shaft three part - a two part plus either greater or less trochanter fracture Four part - as above, but involves both trochaters |
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What are EM pitfalls related to intertrochanteric hip fractures?
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-70% of patients are under-resuscitated (they may be severely dehydrated or have up to 3U of blood loss)
-Associated fractures may be present -distal radius -proximal humerus -rib fractures -compression fractures of the T and L spine (typically T12 or L1) |
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Where do subtrochanteric fractures occur?
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Between the lesser trochanter and the proximal 5cm of the femur
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What 2 groups of patients get subtrochanteric fractures?
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1.Elderly patients (fall, pathological fracture through metastatic lesions, Pagets, osteogenesis imperfect, osteomalacia)
-victims of extreme high trauma |
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What is the mechanism and epidemiology of femoral shaft fractures?
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-young adults
-high-energy trauma |
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What injuries are associated with femoral shaft fractures?
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ligamentous damage to the knee (though proper evaluation of the knee in the ED is not possible in most cases)
|
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Describe how stress fractures occur?
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-Normal bone is repeatedly subjected to sub maximal forces
-this stimulates the bone to remodel and strengthen -Osteoblasts are unable to lay down new bone and remodel fast enough so bone fails |
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What X-ray views should be obtained if stress fracture of the femoral neck is suspected?
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AP, lateral and oblique views
|
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If X-rays are negative, but femoral neck stress fracture is strongly suspected?
|
-Obtain MRI
-If positive for stress fracture image the other side |
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Where are tensile trabecular fibers located in the femoral neck?
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Lateral aspect of the femoral neck
|
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Where are compressive trabecular fibers located in the femoral neck?
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Medial aspect of the femoral neck
|
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What is the pattern of injury associated with pedestrian vs car?
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Head
Chest Pelvis Arm Femur |
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What is the pattern of injury associated with motorcyclist vs car?
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Pelvis and ipsilateral leg
|
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In what percentage of hip dislocations are serious associated injuries found?
|
Up to 95% of patients
|
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How are hip dislocations classified?
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Anterior
Posterior Central Inferior (rare, mostly found in children) |
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What defines a fracture-dislocation of the hip?
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An associated ace tabular or femoral head fracture
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What is the position of the injured extremity in posterior hip dislocation?
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adducted, internally rotated, and flexed
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What is the position of the injured extremity in anterior hip dislocation?
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Abduction, slight flexion and external rotation
|
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What are the most sensitive signs of sciatic palsy?
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Weakness of extensor hallucis longus (big toe extension ?dorsiflexion)
|
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What are subtle radiographic signs that may assist physicians in making the diagnosis of hip dislocation?
|
-position of the lesser trochanter (post disloc is internally rotated therefore lesser trochanter not seen, ant disloc is externally rotated therefore lesser trochanter more visible)
-size of the femoral head (post = head appears smaller, ant = head larger) -Inegrity of Shenton's line |
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What is Shenton's line?
|
A smooth curved line drawn on a hip radiograph along the superior border of the obturator foramen and medial aspect of the femoral metaphysics (disruption of this line should raise suspicion of a femoral neck fracture or hip dislocation)
|
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Is an acetabular fracture a contraindication to hip reduction?
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No, it may make the reduction more difficult
|
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What are contraindications to closed reduction of hip dislocation
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-Femoral neck fracture
-The presence of other fractures in the dislocated limb (relative contraindication) |
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What are 2 methods of hip relocation?
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-Allis maneuver
-Stimson technique |
|
Can closed reduction of a hip dislocation and femoral head fracture be attempted?
|
Yes, only if it cannot be reduced of is unsatisfactorily reduced will open reduction be required
|
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What are the reduction techniques for prosthetic hips?
|
The same as those for native hip dislocations
|
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What should be done with a dislocated prosthetic hip?
|
Consultation with an orthopaedic surgeon (this diagnosis does not carry the same urgency because there is no risk of AVN)
-Traction on the sciatic nerve is the compelling reason for early reduction |
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What are hard signs of vascular injury?
|
-active or pulsatile hemorrhage
-expanding or pulsatile hematoma -diminished or absent pulse -auscultated bruit -palpable thrill -evidence of limb ischemia |
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What injuries are commonly associated with femoral nerve injury
|
Femoral and iliac arteries
|
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What are the motor, sensory and reflex deficits associated with femoral nerve injury?
|
Motor - problem with knee extension (rising from sitting, walking upstairs)
Sensory - anterior thigh, medial lower leg (reliable - superior and medial to patella) Diminished/absent DTR of knee |
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What injuries typically affect the femoral nerve?
|
-Penetrating trauma to pelvis, groin, or thigh
-Hematoma within abdominal wall or iliopsoas muscle |
|
What injuries typically injure the sciatic nerve?
|
-Penetrating injury to the hip, thigh, or buttock
-Posterior hip dislocations and fracture dislocations |
|
What are the deficits associated with sciatic neuropathy?
|
-Paralysis of hamstrings and all muscles below the knee (complete)
-Weakness of extensor hallucis longus(partial) Sensory loss below the knee and posterior thigh, plantar aspect of foot -Diminished absent ankle reflexes |
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What is different about the paediatric hip?
|
Large portions of the paediatric hip are radiolucent?
|
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What is the Delbert classification system?
|
This is the classification system used for paediatric proximal femur fractures
Type 1 - physis Type 2 - transcervical Type 3 - cervicotrochanteric Type 4 - intertrochanteric |
|
What are the categories of abnormalities associated with a limb?
|
-pain
-muscle weakness -structural alteration -sensory deficit -cerebellar or vestibular imbalance |
|
What are 4 key predictors of septic arthritis?
|
T >38.5
non-weight bearing (refusal or inability) ESR >40mm/hr wbc >12,000 |
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What is the most common region of bone for osteomyelitis to develop in adults? in children?
|
Adults - metaphysis
Children - physis |
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What are the most affected joints in septic arthritis?
|
Knee and hip
|
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In what patient population is SCFE most commonly seen?
|
Boys 10-17 years of age - during the period of rapid growth
|
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What is Perthes disease?
|
AVN of the paediatric femoral head
|
|
When does Perthes disease occur?
|
Between the ages of 4 and 8, 5x more common in boys than girls.
|
|
What is Klein's line?
|
If a line is drawn along the superior margin of the femoral neck, part of the femoral head should lie above the line, if not, then the clinician should consider SCFE.
|
|
What are signs and symptoms of a complete muscle tear?
|
-palpable depression
-severe spasm, swelling, ecchymosis, tenderness -loss of muscle function |
|
What are features of iliopsoas strain?
|
-it may cause severe abdo pain
-you should X-ray the femur to r/o avulsion fracture of the lesser trochanter |
|
Describe the Allis maneuver
|
-Pt supine
-Have assistant stabilize the pelvis -bring hip to 90 degrees -provide anterior traction with internal/external rotation -bring leg out in traction when reduced |
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What is the orthopaedic management of a femoral shaft fracture?
|
-ORIF with intramedullary rods
|
|
When is postoperative re-fracture of the femur most likely?
|
-early, during callus formation
-after hardware removal |
|
What is the orthopaedic management of femoral neck fractures?
|
-non-displaced -> non operative if impacted
-displaced or non-impacted -> ORIF vs arthroplasty |
|
What are complications of subtrochanteric hip fractures?
|
-poor healing
-may be associated with fat embolism |
|
What is the Gustilo classification of open fractures? What are the implications?
|
Type I - <1cm
Type II - 1-10cm (some soft tissue damage) Type III - >10cm with extensive soft tissue damage IIIa - adequate soft tissue coverage IIIb - inadequate soft tissue coverage IIIc - associated with arterial injury requiring repair for limb salvage The implication is that Type II and III require gram-negative coverage (amino glycosides) |
|
What are indications for further testing to r/o occult hip fractures?
|
-painful hip, can't ambulate, x-ray negative
-elderly with hip pain, >3 weeks, even if they can ambulate |
|
Should traction be used for femoral fractures?
|
-Traction can cause potentially damaging tension on the nerve and artery and increases the potential for AVN
-If a patient arrives in traction, it should be removed |
|
What attaches to the small concavity in the centre of the femoral head?
|
-ligamentum teres
|
|
What are occult management issues in hip fractures?
|
Dehydration
Electrolyte issues Rhabdomyolysis/hyperkalemia Syncope vs seizure Other injuries |
|
How much blood can be lost into a femur fracture?
|
3 units
|
|
What is the management of SCFE?
|
-No weight bearing
-immediate orthopedic consultation |
|
What are the complications of SCFE?
|
AVN
Chondrolysis (loss of cartilage) |
|
What is an apophysis?
|
The apophysis is a cartilaginous structure that serves as a site for tendons to insert on growing bone
|
|
Name 3 apophyseal injuries
|
-Osgood Schlatter
-Sever's disease (posterior heel calcaneus mass) -Medial epicondylitis (little leaguers elbow) |
|
What is the blanch sign of steele?
|
A crescent shaped area of increased density in the proximal femoral neck (superimposition of posteriorly displaced epiphysis on femoral neck)
|
|
What are the 3 compartments of the knee joint?
|
Patellofemoral
Medial tibiofemoral Lateral tibiofemoral |
|
What are the 4 components of the quadriceps femoris muscle?
|
rectus femoris
vastus medialis vastus lateralis vastus intermedius |
|
What is per anserinus?
|
The three pronged tendinous structure that is the conjoined insertion of sartorius, semi-tendinosus and gracilis
|
|
What are the boundaries of the popliteal fossa?
|
Biceps femoris (laterally)
semi-membranosus and semi-tendinosus (medially) gastrocnemius (inferiorly) |
|
What is found within the popliteal space?
|
-popliteal vein and artery
-peroneal nerve -tibial nerve |
|
Why is there a high incidence of artery injury with knee dislocation?
|
Because the popliteal artery is firmly anchored at the proximal and distal ends of the popliteal fossa
|
|
What injuries result in common peroneal nerve injury?
|
-injury to the fibular head
-prolonged compression |
|
What are signs and symptoms of peri-patellar tendinitis
|
Localized pain at the quadriceps or patellar tendon (aka jumper's knee)
|
|
What is plica syndrome?
|
Non-specific medial femoral condyle symptoms (brought on by activity or prolonged sitting)
|
|
What is the orthopaedic management of knee ligament injuries?
|
Partial tears -> conservative
Collateral ligaments (isolated) -> conservative ACL -> depends on activity level PCL ->typically non-operative combo -> usually operative |
|
Which meniscus is more vulnerable?
|
Medial (lateral meniscus is more mobile)
|
|
Which part of the meniscus heals?
|
Peripheral 1/3 (vascular part)
|
|
Who gets IT band syndrome?
|
High mileage runners
|
|
What are signs and symptoms of IT band syndrome?
|
Pain at the lateral femoral condyle
-aggravated by repetitive knee movement -appears after consistent mileage |
|
What is the treatment patellofemoral pain syndrome?
|
-Quad strengthening exercises
-brace support -activity modification - NSAIDs |
|
What are alternatives to arteriography in evaluation of kneed dislocation. How do you immobilize patients following knee dislocation?
|
-ABIs (serially)
-color flow doppler (immobilize in long leg posterior slab in 20 degrees flexion) |
|
What are complications of knee dislocation?
|
-neurovascular injury
-DVT -compartment syndrome -pseudoaneurysm -arterial thrombosis |
|
What are pitfalls in the diagnosis of patellar fractures?
|
-bipartitie/multipartite patellas (common variant)
-get comparison view |
|
What are RF for patellar dislocation
|
-Patellofemoral joint laxity
-Genu valgum -decreased quad strength -previous dislocation -extensor mechanism rupture -Large Q angle |
|
What is the Q angle?
|
The Q angle is measured with quads contracted - angle formed by lines drawn on an anterior posterior radiograph from the tibial tubercle to the centre of the patella and from the centre of the patella to the ASIS
|
|
Where does AVN occur in the knee?
|
-At the medial femoral condyle
|
|
Describe the pivot shift test?
|
-Grab foot, internally rotate tibia, apply valgus stress, then flex
- amount of pivot determines severity of ACL injury |
|
What are the aetiologies of palpation tenderness @ the following locations
Above patella Patella Inferior to the Patella Joint line tenderness Inferomedial Patella Tibial tubercle |
Above patella -quadriceps tendon
Patella - prepatellar bursitis Inferior to the Patella - Patella tendinitis JLT - meniscus Inferomedial patella - pes anserine bursitis Tibial tubercle - Osgood Schlatter |
|
What knee injuries predispose to osteoarthritis
|
May occur after
-ACL tears -Meniscal damage/meniscectomy -cartilage injury |
|
What is the most effective intra-articular knee analgesia?
|
5mg morphine in 25cc NS
|
|
What is the difference between laxity in the collateral ligament stress test at 0 degrees and at 30 degrees
|
If lax in full extension, the injury is more severe (secondary restraints are disrupted - ACL, PCL etc.)
|
|
What steps are involved in fracture healing?
|
-hematoma formation
-infammatory phase -resorption of the hematoma -procallus -callus -bony union |
|
What is delayed union?
|
-union that takes longer than usual
|
|
What is malunion?
|
When a residual deformity exists
|
|
What is nonunion
|
Failure of a fracture to unite
|
|
What is the triangular metaphyseal fragment in a SH II referred to?
|
Thurston Holland Sign
|
|
In what joints do SH type V fractures occur most commonly?
|
Knee and ankle
|
|
Describe the 5 types of SH injuries
|
Type I - slip in the zone of proximal calcification
Type II - fracture of the physis extending into the metaphysis Type III - fracture of the physis extending into the epiphysis Type IV - fracture of the physis extending into the metaphysis and physis Type V - crush injury of the epiphyseal plate |
|
Why are some #s only visible 7-10d after injury?
|
Absorption widens the radiolucent line, allowing the defect to be visualized
|
|
What is the most commonly missed fracture?
|
The 2nd fracture
|
|
What are antibiotic recommendations for open #s?
|
Grade 1 - Cefazolin
Grade 2 and 2 cefazolin and gentamycin |
|
What is the exception to the antibiotic for open # rule?
|
Open phalangeal #s in fingers with intact digital arteries probably do not require antibiotics
|
|
What are late complications of undiagnosed vascular injuries?
|
-thrombosis
-AV fistulae -Aneurysm -False Aneurysm -tissue schema with limb dysfunction |
|
What is neuropraxia?
|
Contusion of a nerve with disruption of the ability to transmit impulses (paralysis is transient and sensory loss is slight)
|
|
What is axonotmesis?
|
Injury to nerve fibers within their sheaths - spontaneous healing is still possible
|
|
What is neurotmesis?
|
Severing of a nerve, usually requiring surgical repair
|
|
What is the O-Riain wrinkle test?
|
Soaking a normally innervated digit in warm saline for 20 min causes the digit pulps to wrinkle. THe presence of wrinkling probably indicates the nerve is intact, absence of wrinkling may be more difficult to interpret.
|
|
With what injury is compartment syndrome most commonly associated with?
|
Long bone fractures of the tibia
|
|
With what other injuries/in what other situations has compartment syndrome been described?
|
-thigh, forearm, arm, hand, foot fractures
-soft tissue injury -surgical positions -IV injections |
|
At what compartment pressure does inadequate perfusion and relative schema occur?
|
Within 20 mmHg of the patient's diastolic pressure (w/in 30 mmHg of the MAP)
|
|
What is the hallmark finding in compartment syndrome?
|
Pain out of proportion to the injury
|
|
What are other reliable signs of compartment syndrome?
|
-pain on passive stretching
-pain on active flexion of muscles -hypoesthesia or paresthesia in nerves crossing the compartment |
|
What is the indication for fasciotomy in compartment syndrome?
|
Compartment Pressure >30mmHg or pressures w/in 30mmHg of the patient's MAP
|
|
Should the limb with compartment syndrome be elevated?
|
No, elevation does not improve venous outflow and it reduces arterial inflow.
|
|
What can occur with compartment syndrome?
|
-rhabdomyolysis
-hyperkalemia -myogobinuria |
|
Which bones are particularly prone to AVN?
|
-Femoral head
-talus -scaphoid -lunate -capitate (and navicular) |
|
What nerve injury may accompany:
scapular neck, body, or spine injury? supracondylar fracture? elbow dislocation? -olecranon fracture? shoulder dislocation or proximal humerus? sacral fracture? acetabular fracture? hip dislocation? knee dislocation? lateral tibial plateau fracture? Colle's? Pisiform? Monteggia? Femoral shaft? Fibular head? |
-suprascapular nerve
-radial, median, ulnar -posterior: median or anterior: ulnar -ulnar -axillary nerve -cauda equina -sciatic nerve -femoral nerve -tibial or peroneal nerve -peroneal nerve -median -ulnar -peroneal -peroneal |
|
What is the definition of complex regional pain syndrome Type 1?
|
-A pain syndrome that develops after an initiating noxious event
-Extends beyond the distribution of a single nerve -Disproportionate to the inciting event (Often in distal areas, assc with edema or changes in blood flow) |
|
What is the definition of complex regional pain syndrome Type II?
|
A pain syndrome that develops after an initiating noxious event where there is demonstrable peripheral nerve injury.
-Extends beyond the distribution of a single nerve -disproportionate to the inciting event |
|
What are the 9 criteria to diagnose RSD/CRPS I?
|
-allodynia
-burning pain -edema -color or hair growth changes -sweating changes -temperature changes -radiographic changes -quantitative vasomotor distribution -triple-phase bone scan consistent with RSD 1 point per positive criterion and half a point if equivocal (>5 criteria means probably RSD) |
|
What is a fracture blister?
|
Tense blisters or bullae that accompany high-energy injuries in areas of relatively little skin coverage
|
|
Where do fracture blisters typically occur?
|
Ankle>elbow>foot>knee
|
|
What do fracture blisters indicate?
|
-increased underlying tissue pressure
|
|
What is the difference between subluxation and dislocation?
|
Subluxation is partial loss of continuity between two articulating surfaces while dislocation is complete loss of continuity between two articulating surfaces
|
|
How are dislocations described?
|
According to the direction of the distal segment relative to the proximal segment
|
|
What is the definition of a sprain?
|
-ligamentous injury resulting from an abnormal motion of a joint
|
|
What are the degrees of sprain (ligamentous injury)?
|
I- ligament stretching without tear
II partial tear of a ligament, mild or moderate instability III - complete tearing of a ligament - gross instability |
|
What is the treatment for complete/nearly complete ligamentous disruption?
|
Urgent orthopedic consultation
|
|
What is a strain?
|
An injury to the musculotendinous unit
|
|
What are the 3 joints in the shoulder and what is the pseudo articulation?
|
-acromioclavicular
-glenohumeral -sternoclavicular pseudoarticulation : scapulothoracic |
|
What is the most moved joint in the body?
|
the SCJ (sternoclavicular joint)
|
|
What 5 structures are immediately posterior to the SCJ?
|
-great vessels
-trachea -esophagus -thoracic duct -lung apices |
|
What is the most important stabilizer of the SCJ?
|
-costoclavicular ligament
|
|
What are the most important stabilizers of the ACJ?
|
-the coracoclavicular ligaments (conoid and trapezoid)
|
|
What is the most impt restraint to anterior glenohumeral dislocation?
|
The anterior band of the inferior glenohumeral ligament
|
|
What muscles insert on the greater tuberosity of the humerus?
|
-supraspinatus
-infraspinatus -teres minor |
|
What muscle inserts onto the lesser tuberosity of the humerus?
|
-subscapularis
|
|
What muscles cross the glenohumeral articulations and are involved in humeral fracture dislocations
|
-pectoralis major
-latissmus dorsi -teres major |
|
What are extrinsic sources of shoulder pain?
|
-cervical spine disorders
-thoracic outlet obstruction -pancoast tumor -referred pain (cardiac, diaphragm, LL pneumonia, spleen, ectopic, GB disease, gastric and pancreatic disease) |
|
What are the sensory and motor components of C5?
|
-lateral arm
-deltoid |
|
What are the sensory and motor components of C6?
|
-lateral forearm and thumb
-biceps |
|
What are the sensory and motor components of C7?
|
-tip of the long finger
-thumb extensors |
|
What are the sensory and motor components of C8?
|
-tip of the little finger and medial forearm
-finger flexors |
|
What are the sensory and motor components of T1?
|
-medial arm
-hand interossei |
|
What is the three view series for shoulder radiographs?
|
-true AP
-trans-scapular lateral (Y) -axillary lateral |
|
Which type of clavicular # is the most common?
|
-middle 1/3
|
|
What are the subtypes of distal 1/3 clavicular #s?
|
Type I - minimal displacement, coracoclavicular ligament intact
Type II - torn coracoclavicular ligament associated with displacement (these are unstable) Type III - involves the articular surface (the acromioclavicular joint) |
|
Which clavicular #s require immediate Orthopedic consultation?
|
-open #s
-#s associated with neurovascular compromise |
|
Which clavicular #s require urgent orthopaedic referral?
|
-type II lateral clavicular #s
-severely comminuted or displaced fracture of the middle third ->20mm shortening |
|
What is atlantoaxial rotatory displacement?
|
It is an injury in children that is associated with clavicle #s. Patients present with a clavicle fracture, head bent towards the fracture but turned away. These patients should have their C-spines CT'd
|
|
What is the most important aspect of scapular fractures?
|
The fact that there is a high incidence of associated injuries: ipsilateral lung, chest wall and shoulder girdle components
|
|
What is the therapy for a scapular fracture?
|
-analgesia
-immobilization in a sling |
|
Which scapular #s may require operative intervention?
|
-displaced acromial fractures
-severely displaced coracoid#s -scapular neck #s -glenoid fossa #s |
|
What are the 4 segments involved in proximal humerus #s?
|
-anatomic neck
-surgical neck (humeral shaft) -greater tuberosity -lesser tuberosity |
|
What is the definition of displacement in the Neer classification of proximal humeral #s?
|
-a segment is considered displaced if it is angled >45 degrees or separated >1cm from a neighbouring segment
|
|
What are the 4 major categories of fracture in the Neer classification of proximal humerus #s?
|
-minimal displacement
-2 part -3 part -4 part (anterior and posterior dislocations are included) |
|
What is the treatment for a minimally displaced proximal humerus fracture?
|
Sling or sling and swath
|
|
When should an orthopaedic surgeon be consulted in the presence of a proximal humerus #?
|
-any 2,3 or 4 part fractures
-any fracture-dislocation |
|
What are impression #s? What is the management?
|
Impression fractures are fractures resulting from shoulder dislocation
-posterior dislocations may cause anteromedial impression fractures -anterior dislocation may cause posterolateral impression fractures aka Hill Sachs deformity. If they involve <20% of the articular surface they are usually stable, if they involve >20% of the articular surface they may require surgery) |
|
What are potential complications of proximal humerus fractures?
|
-adnesive capsulitis
-AVN -myositis ossificans -neurovascular injuries (brachial plexus, axillary artery, axillary nerve) |
|
What is particular about epiphyseal proximal humerus fractures?
|
They need to be followed closely and referred early to orthopaedics because of the potential for growth disturbance.
|
|
What is the grading and management of SCJ injuries?
|
Type I - mild sprain with stretching of the sternoclavicular and costoclavicular ligaments -> sling
Type II - subluxation of the joint (rupture of the SCL) ->sling and refer Type III - complete rupture of the SCL and CCL -> closed reduction |
|
What is the best radiologic study for SCJ dislocation?
|
CT
|
|
How do you reduce anterior SCJ dislocations?
|
- elevate shoulders by placing a roll between the shoulders
-downward traction of 90degrees abducted/extended arm +/- inward pressure on medial clavicle |
|
What is the modified Rockwood classification of ACJ dislocations?
|
Type I - AC ligament sprain
Type II - disruption of the AC ligament Type III - disruption of the AC ligament, the coracoclavicular ligament and muscle attachments IV - same as III but clavicle in trapezius V - same as III but exaggerated distance VI - same as III but clavicle inferior |
|
Are there special X-ray view for the ACJ?
|
Yes, view that use 1/3 to 2/3 less intensity
|
|
What is the normal coracoclavicular distance?
|
11-13 mm
|
|
Should stress views of the ACJ be ordered?
|
No, they lack efficacy in distinguishing type II from type III injuries
|
|
What is the management of ACJ dislocation?
|
I + II - conservative with a sling
III - unclear, evidence that OR not better (early ortho referral) IV/V/VI - surgical |
|
What is a Bankart lesion?
|
Avulsion of the anteroinferior glenohumeral ligament with capsulolateral detachment
|
|
In what directions can the glenohumeral joint dislocate?
|
-Anterior (most common)
-Posterior -Superior (rare) -Inferior (rare) |
|
What positions can the humeral head assume post anterior shoulder dislocation?
|
Subcoracoid
Subglenoid Subclavicular Intrathoracic |
|
How do you assess axillar nerve motor and sensory?
|
motor - deltoid and teres minor (shoulder abduction)
sensation - over lateral aspect of the shoulder |
|
What fractures may be associated with shoulder dislocation?
|
-Hill-sachs deformity
-Bankart lesion -avulsion of greater tuberosity |
|
What is the landmark for intra-articular anesthetic shoulder injection? What is injected?
|
2cm inferior to the lateral edge of the acromion. 20cc of 1% lidocaine over 30s
|
|
What are possible techniques for reduction of an anterior shoulder dislocation?
|
-Stimson
-Traction-countertraction -Forward elevation -Snowbird Technique -External rotation of Liedelmeyer -Scapular manipulation |
|
Which methods of shoulder relocation are no longer recommended?
|
-Kocher maneuver
-Hippocratic method |
|
What did Itoi and coworkers find regarding shoulder immobilization?
|
Improved outcomes with immobilization in external rotation. (These findings have not been duplicated)
|
|
What are the possible complications of shoulder dislocations?
|
-fractures
-neurovascular injuries -rotator cuff tears -recurrence |
|
What is transient anterior subluxation (dead arm syndrome)?
|
Sudden sharp shoulder pain and weakness while performing an abduction and external rotation
|
|
What is the most common misdiagnosis of posterior dislocation?
|
Adhesive capsulitis
|
|
What are radiologic findings in posterior shoulder dislocation?
|
AP shows loss of the half-moon elliptical overlap of the humeral head and glenoid fossa
-distance between the anterior glenoid rim and articular surface of the humeral head increased ('rim' sign) -humeral head has a 'light bulb' or 'drumstick' appearance -true AP shows overlap between glenoid fossa and humeral head -reverse Hill sachs deformity |
|
How is the diagnosis of posterior shoulder dislocation confirmed?
|
Using an orthogonal view (axillary, transscapular or apical oblique)
|
|
How is closed reduction of a shoulder posterior dislocation done?
|
Under concious sedation
-Axial traction in line with humerus -gentle pressure on posterior displaced head -external rotation |
|
How do you immobilize a reduced posterior shoulder dislocation?
|
External rotation with slight abduction
|
|
What is luxatio erecta?
|
Interior glenohumeral dislocation
|
|
How does luxatio erecta present?
|
Pt has arm locked overhead in 110-160 degrades abduction
|
|
What radiographic features can be used to distinguish luxatio erecta from subglenoid anterior dislocation?
|
-humeral shaft lies parallel to the spine of the scapula on AP view in luxatio erecta (in subglenoid anterior dislocation the humeral shaft lies parallel to the chest wall.
|
|
How is closed reduction of luxatio erecta achieved?
|
Traction-countertraction
|
|
What are potential complications associated with luxatio erecta
|
-neuropraxic brachial plexus lesions
-axillary artery thrombosis |
|
What are pathognomic findings of scapulothoracic dislocation?
|
-massive soft tissue swelling of the shoulder
->1cm displacement of the scapula on AP chest radiograph |
|
Injuries to what structures are associated with scapulothoracic dislocations?
|
-Vascular lesions
-Severe neurologic injuries |
|
What is contained in the subacromial space?
|
-Long head of the biceps
-rotator cuff -subacromial bursa |
|
What is the subacromial painful arc?
|
60-120 degrees abduction
|
|
What is the acromioclavicular painful arc?
|
120-180 degrees
|
|
What are the 3 stages of Neer impingement syndromes
|
Stage 1 - dull ache around deltoid after strenuous exercise
Stage 2 - more severe pain, particularly at night Stage 3 - significant tendon degeneration after a prolonged history of tendinitis and bursitis |
|
What is the function of the rotator cuff?
|
Dynamic stabilizer of the glenohumeral joint
|
|
What are the functions of infraspinatus and trees minor?
|
-external rotators
|
|
What is the function of supraspinatus?
|
First 30 degrees of shoulder abduction
|
|
What is the function of subscapularis
|
Internal rotators
|
|
What is the presentation of an acute rotator cuff tear?
|
-Usually associated with a specific traumatic event
-point tenderness over the site of rupture (greater tuberosity) -palpable defect -discrepancy between active and passive ROM (no active mvmt possible) -Cannot initiate shoulder abduction (large tear) |
|
What is the hallmark radiographic sign of complete rotator cuff tear?
|
Superior displacement of the humeral head. The space between the humeral head and the undersurface of the acromion is <6mm
|
|
What is the treatment for acute rotator cuff tear?
|
-Sling
-Prompt ortho referral (OR within 3 weeks) |
|
What is the treatment for chronic rotator cuff tear?
|
-pain control
-shoulder rehab program |
|
What are treatment options for painful arc symptoms?
|
-NSAIDs
-modification of activities -physiotherapy and strengthening -subacromial steroid injection -decompression surgery |
|
What are the functions of the biceps?
|
-flexion at the elbow
-supination at the elbow -stabilizes glenohumeral joint |
|
What is Yergason's test and what does it test for?
|
Supination against resistance with the arm adducted and elbow flexed.
+ test reproduces the pain of bicipital tendinitis |
|
What are the two types of biceps tendon rupture and which is more common?
|
Distal and proximal
Proximal ruptures are more common |
|
What are signs and symptoms of proximal biceps rupture
|
-popeye appearance (distal retraction of muscle)
-+ Luddington sign (difference in muscle contour when the arms are behind the head -arm supination weakened -strong elbow flexion (intact coracobrachialis and short head of the biceps) |
|
What is the management of biceps rupture?
|
-immobilization of elbow at 90degrees
-ortho referral within 72 hours |
|
What are the 3 clinical presentations of calcific tendonitis?
|
-silent
-subacute -acute |
|
What are management options for acute calcific tendinitis?
|
-sling
-NSAIDs -analgesia -+/- subacromial local anesthetic injection -subacromial corticosteroids (controversial because this may delay calcium reabsorption) -early shoulder ROM |
|
What is a distinguishing feature of adhesive capsulitis?
|
A sense of mechanical restriction on passive testing
|
|
What are the 3 articulations of the ankle?
|
-inner surface of the medial malleolus with medial surface of the talus
-distal tibial plafond with talar dome -lateral malleolus with lateral process of the talus |
|
What are the talocrural joints?
|
the 3 articulations of the ankle and the tibiofibular joint
|
|
Which ligaments support the ankle joint?
|
-syndesmotic ligaments
-lateral collateral ligaments -medial collateral ligaments |
|
What views make up the ankle radiographic series?
|
-AP
-lateral -mortise |
|
What is the appearance of an ankle effusion on x-ray?
|
-tear drop shaped density displacing the normal fat adjacent to the anterior or posterior margin of the joint capsule
|
|
What does an ankle effusion suggest?
|
the possibility of a subtle intraarticular injury (i.e. osteochondral # of the talar dome)
|
|
How is the mortise view taken?
|
With the ankle in 15-25 degrees of internal rotation
|
|
What is the mortise view important for?
|
Evaluating the congruity of the articular surface between the dome of the talus and the mortise
|
|
What is the maximum distance for the medial clear space?
|
4mm
|
|
According to the Ottawa Ankle Rules, when are ankle radiographs required?
|
-bone tenderness at the posterior edge of the distal 6cm or the tip of the lateral malleolus
-bone tenderness at the posterior edge of the proximal 6cm of the tip of the medial malleolus -Inability to WB for at least 4 steps immediately after injury and at the time of evaluation |
|
According to the Ottawa Foot rules when are foot radiographs required?
|
-bone tenderness at the navicular bone
-bone tenderness at the base of the 5th -inability to WB for at least 4 steps immediately after injury and at the time of evaluation |
|
What fractures do the Ottawa ankle and Ottawa foot rules detect?
|
-malleolar zone fractures and midfoot zone fractures
|
|
What are the 2 classification systems for ankle fractures?
|
-Lauge Hansen
-Danis Weber |
|
Which ankle #s require ortho ED consultation?
|
Unimalleolar fractures
displaced medial malleolar fracture medial malleolar fracture with lateral collateral ligament rupture displaced lateral malleolar fracture lateral malleolar fracture with deltoid ligament rupture lateral malleolar fracture with widened medial clear space unimalleolar fracture with syndesmotic diastasis fibula fracture at or proximal to the tibiotalar joint line displaced posterior malleolar fracture posterior malleolar fracture involveing more than 25% of the joint surface all bimalleolar fractures all trimalleolar fractures all intraarticular fractures with step deformity all open fractures all pilon fractures |
|
What is the treatment for chip avulsion #s of the ankle?
|
-Avulsed fragments of <3mm and minimally displaced can be treated as an ankle sprain
->3mm or significantly displaced -> splinting and outpatient orthopedics referral |
|
What is the focus of the Danis-Weber classification?
|
It focuses on the location of the fibular fracture in relation to the tibiotalar joint
|
|
Describe Danis-Weber A, B and C and management of each
|
A- fibular # below the tibiotalar joint
1 - isolated fibular fracture: NWB >/=3 weeks 2: concomitant deltoid ligament injury -> ortho consult 3: concomitant posterior malleolus fracture-> ortho consult B-fibular # at the level of the tibiotalar joint ortho consultation C - fibular # proximal to the tibiotalar joint line (frequently disrupts the distal tibiotalar syndesmosis) ortho consultation |
|
What is the usual mechanism for medial malleolar #s?
|
Eversion and external rotation (abducting force)
|
|
What antibiotic should be added as a 3rd antibiotic for farm or soil related crush injuries? why?
|
Penicillin G
Because of clostridium perfringens |
|
What are delayed complications of ankle fractures?
|
Malunion
Nonunion Osteopenia Traumatic arthritis Chronic Instability Ossification of the Interosseous membrane CRPS |
|
What is a pilon fracture? What it the primary deforming force?
|
-fracture of the distal tibial metaphysis
-axial compression |
|
Which ligament is most commonly injured in ankle sprains? which is the 2nd most common?
|
anterior talofibular ligament
calcaneofibular ligament |
|
Which population of patients are more likely to have distal tibiofibular syndesmotic ligaments injuries?
|
athletes
|
|
Descrive the grading system for ligamentous injuries?
|
Grade I - stretching without grossly evidence tearing or instability
Grade II - partial tear with moderate joint instability Grade III - complete tear of the ligament with marked instability |
|
What is the fibular compression test? how do you perform it?
|
-a test that reveals fibular and syndesmotic injuries
-examiner places fingers over the fibula and the thumb over the tibia at the mid calf and squeezes the 2 bones. Pain along the fibula suggests a fibular fracture ro an intraossesous membrane or syndesmotic ligament disruption |
|
What are indications for stress testing in ankle injuries?
|
-rupture of 2 or more ligaments is suspected
-a suspected isolated ankle fracture in which the presence of an additional ligament rupture would influence management -possibility of concomitant syndesmotic injury -follow up evaluation of acute ankle injury once pain and swelling have subsided -chronically symptomatic ankle |
|
What are common ankle stress tests?
|
Anterior drawer test (ATFL)
Inversion stress test (ATFL and CFL) External rotation stress test (distal tibiofibular syndesmotic ligament injury) |
|
Should stress radiographs of the ankle be done?
|
No, they generally do not influence emergency management
|
|
What is the differential diagnosis for presumed ankle sprain?
|
-lateral collateral ligament sprain
-peroneal tendon dislocation -osteochondral # of the talar dome -# of the posterior process of the talus -# of the lateral process of the talus -# of the anterior process of the calcaneus -midtarsal joint injury -# of the base of the 5th |
|
what analgesics can be used in ankle sprain?
|
-NSAIDs
-acetaminophen -oral opioids -topical diclofenac gel |
|
What is functional instability?
|
Patient's subjective sensation that the ankle gives way during activity
|
|
What is mechanical instability?
|
Ligamentous laxity which allows ankle joint movements beyond the physiologic range
|
|
What soft tissue abnormalities cause chronic ankle pain?
|
-synovial impingement
-peroneal tendon subluxation or dislocation -loose bodies -ATF syndesmotic ligament injury -degenerative arthritis |
|
What are bone related causes of chronic pain?
|
osteochodral fragment
anterior calcaneal process # lateral talus process # anterior and posterior impingement |
|
Why is weak plantar flexion still possible in complete Achilles tendon ruptures?
|
-tibialis posterior
-toe flexors -peroneal muscles |
|
What is the Thompson test?
|
-a maneuver to assess the integrity of the achilles tendon.
-squeezing the calf muscles should cause passive plantar flexion of the foot |
|
When should an MRI or US be performed for suspected Achilles rupture?
|
Diagnostic uncertainty (otherwise it is a clinical diagnosis)
|
|
Where do the peroneal tendons run?
|
They use the fibular groove (posterior peroneal sulcus) as a pulley for midfoot insertions
|
|
Where do the peroneal tendons insert?
|
peroneus brevis -> tuberosity of the 5th metatarsal
peroneus longus -> medial cuneiform and base of the 1st metatarsal |
|
What structure maintains the peroneal tendons against the fibular groove?
|
Superior peroneal retinaculum (attaches to the distal fibular and the calcaneus)
|
|
What are signs and symptoms of peroneal dislocation?
|
-pain and snapping sensation over the posterolateral ankle
-weakened eversion -tender over the retromalleolar area -inability to actively evert the foot when held in dorsiflexion |
|
What is the function of the tibialis posterior tendon?
|
plantar flexion and inversion
|
|
What is the course of tibialis posterior?
|
uses medial malleolus as a pulley and inserts onto the navicular, medial cuneiform and bases of the 2nd through 5th metatarsals
|
|
What is a cause of unilateral flat foot?
|
Tibialis posterior rupture (resulting in unopposed peroneus brevis)
|
|
What tendon is the primary dorsiflexor of the foot?
|
tibialis anterior
|
|
What is the common misdiagnosis of tibialis anterior rupture?
|
-lumbosacral radiculopathy or peroneal palsy (because of foot drop)
|
|
What is dancer's tendinitis?
|
Flexor hallucis longus tendinitis (great toe flexor)
Symptoms include medial malleolus edema and pain on passive extension of the 1st MTP in neutral position |
|
What is the ED management of ankle dislocation?
|
-neurovascular assessment
-tendon function assessment -reduction (should not be delayed if obvious or neuromuscular compromise or tenting) |
|
How is reduction of a dislocated ankle achieved?
|
-knee flexed at 90 degrees
-distraction followed by gentle force to reverse the direction of the dislocation -reverse the direction of the dislocation |
|
What are 3 anatomic/functional regions of the foot?
|
Hindfoot (calcaneus/talus)
Midfoot (navicular/cuboid/cuneiform) Forefoot (metatarsals/phalanges/sesamoids) |
|
What are the articulations of the talus/calcaneus called and how many articulations are there?
|
The subtalar joint
There are 3 articulations |
|
What are the nerves that provide innervation to the foot?
|
-deep peroneal
-superficial peroneal -posterior tibial -saphenous -sural |
|
What joints are primarily involved in inversion and eversion of the foot?
|
the subtalar joints
|
|
What are the 3 standard views of the foot and what structures are they useful in evaluating?
|
-AP midfoot and forefoot
-lateral hindfoot -oblique midfoot and forefoot |
|
What are additional radiographic views?
|
Coned views
WB views 45 degree external oblique Harris (axial) views - to visualize the calcaneus and subtalar joints |
|
What percent of the population has sesamoid bones/accessory ossicle centres in the foot?
|
30%
|
|
What are the most common accessory ossification centres?
|
os trigonum
os tibiale externum os peroneum os vesalinum |
|
What joints of the foot in particular can be visualized on CT?
|
subtalar
calcaneus tarsometatarsal (lisfranc) |
|
What is specific about the talus
|
It is the only bone in the lower extremity with no muscular attachments and is held in place by the malleoli and ligamentous attachments
|
|
Is there a risk of AVN with talar fractures?
|
Yes
|
|
What is the most common tarsal fracture? what is the 2nd most common tarsal fracture?
|
-calcaneus (most common)
-talus (2nd most common) |
|
What is the mechanism for talar chip and avulsion fractures?
|
The same as ankle sprains
|
|
What # has been associated with snowboarding? What is it's management
|
lateral talar process #s
Large displace if >2mm comminuted: excision chip: below the knee cast for 6 weeks |
|
What are minor talar #s?
|
chilp/avulsion #s of the superior neck and head
lateral, medial and posterior aspects of the body lateral process fractures osteochondral fractures |
|
What is the most common major talar # and what is the mechanism?
|
Talar neck #
extreme dorsiflexion of the foot |
|
What #s are commonly associated with talar neck #s?
|
oblique/vertical medial malleolus fracture
calcaneal fracture vertebral compression fracture |
|
What is the Hawkins classification of talar neck #s?
|
Type I - no displacement
Type 2 -subtalar subluxation Type 3 - dislocation of the talar body from the ankle and subtler joint |
|
What is often the treatment for major talus #?
|
open reduction/internal fixation
All of them require orthopedic consultation in the ED |
|
what is the treatment of minor talar 3s?
|
NonWB below the knee case or posterior plaster slab
# fragments >5mm may require excision |
|
What is the differential diagnosis for presumed ankle sprain?
|
Lateral collateral ligament sprain
Peroneal tendon dislocation Osteochondral fracture of the talar dome # of the posterior/lateral process of the talus # of the anterior process of the calcaneus Midtarsal joint injury # of the base of the 5th |
|
How are major talar fractures reduced?
|
Grasp the hind/mid foot ->longitudinal traction and plantar flexion
|
|
What is the most significant complication of major talar #?
|
AVN
|
|
What are other potential complications of talar #?
|
-skin infection
-skin necrosis -post traumatic arthritis -malunion -delayed union -nonunion -predisposition to peroneal tendon dislocation |
|
What is the difference between osteochondral fracture and OCD?
|
Osteochondral #s are injuries that involve cartilage and subchondral bone while OCD is a subacute or chronic talar dome defect that may be caused by an osteochondral fracture
|
|
When should you think of osteochondral fracture and what should be done?
|
Persistent unexplained ankle pain after "sprain" -> this requires orthopaedic evaluation
|
|
What is subtalar dislocation?
|
simultaneous disruption of the talocalcaneal and talonavicular joints (without tibiotalar disruption)
|
|
What is the most common mechanism for calcaneus #?
|
Fall without direct axial compression
|
|
What associated injuries should be should be considered in calcaneal fractures?
|
compartment syndrome
vertebral compression |
|
What is a Harris view and what is it used for?
|
-axial view of the foot
-calcaneal tuberosity, subtalar joint, sustentaculotalar joint |
|
What assessments are critical in the management of calcaneal #s?
|
Whether the # involves the subtaler joint
the degree of depression of the posterior facet |
|
What measurement can be used to determine compression # of the calcaneus?
|
Boehler's angle
|
|
How is Boehler's angle measured? What is the interpretation?
|
-Lateral foot view
it is the angle between the posterior tuberosity and apex of the posterior facet and the apex of the posterior facet and apex of the anterior process An angle of <20 degrees is suggestive of a compression # |
|
What is Chopart's joint?
|
The mid tarsal joint composed of talonavicular and calcaneocuboid joints
|
|
How do midtarsal joint injuries occur?
|
Forced dorsiflexion
|
|
Why are mid foot injuries difficult to identify?
|
-difficult to see on X-ray because of under penetrated and oblique orientation
-pain is often ill-defined and poorly localized |
|
What is a significant risk associated with navicular fractures?
|
AVN (much like scaphoid in the hand)
|
|
What is the most common mid foot #?
|
navicular #
|
|
What is the ED management of navicular fractures?
|
-outpatient ortho f/u - usually treated with a walking cast for 4-6 weeks
-if intra-articular then ortho consult should be in the ED |
|
What is another name for cuboid fracture?
|
nutcracker fracture because the cuboid is crushed between the bases of the 4th and 5th metatarsals and the anterior calcaneus
|
|
What are cuboid fractures associated with?
|
they are associated with fractures of the posterior malleolus
|
|
What is the best radiographic view for the evaluation of the cuboid?
|
Oblique view of the standard foot radiographic series
|
|
What should be considered in any cuboid or cuneiform #
|
A Lisfranc injury
|
|
What is the management of cuboid #s?
|
All warrant ortho assessment
|
|
What is Lisfranc's joint?
|
The tarsometatarsal joints collectively (bases of the 1st 3 metatarsals with their respective cuneiform and the 4th and 5th metatarsals with the cuboid)
|
|
What si the function of the tarsometatarsal joints?
|
They act to allow supination and pronation of the forefoot
|
|
What are the 3 mechanisms associated with Lisfranc injuries?
|
-rotational forces
-axial loads -crush injuries |
|
What are 3 classifications of Lisfranc injuries?
|
isolated - one or more metatarsals displaced away from the others
homolateral - all 5 metatarsals displaced in the same direction divergent - metatarsals splayed outward in both medial and lateral directions |
|
What injuries may be associated with Lisfranc injuries?
|
-associated metatarsal #s
-fractures of the cuboid, cuneiform, or navicular -vascular injury (dorsalis pedis branch dives between the 1st and 2nd metatarsal) |
|
What is the normal radiographic anatomy of the midfoot?
|
The 1st 4 metatarsals should each line up with their respective tarsal articulation along their medial edge on AP and oblique radiographic views
-the tarsals should also line up dorsally with the metatarsals on the lateral view |
|
What are findings suggestive of a Lisfranc injury?
|
-widening between the 1st and 2nd or 2nd and 3rd metatarsal bases
-any fracture around the Lisfranc joint |
|
What fractures are particularly common indicators of Lisfranc injury?
|
-# of the 2nd metatarsal bone (fleck sign - virtually pathognomic of a tarsometatarsal joint disruption)
-cuboid # -cuneiform #s |
|
What is the ED management of a Lisfranc injury?
|
-obvious injury -> ortho consult in the ED
-suspected lisfranc sprain -> casting and ortho referral |
|
What are complications associated with Lisfranc injuries?
|
-degenerative arthritis
-compartment syndrome -residual pain -unequal metatarsal pressure -loss of metatarsal arch -CRPS |
|
How can you determine whether a fracture has entered the knee joint?
|
The methylene blue test: inject MC into the tibiofemoral joint (at a site distant from the skin injury), emergence of methylene blue from the skin lesion confirms an open joint
|
|
What are complications of distal femur fractures?
|
-Thrombophlebitis
-Fat embolus syndrome -delayed union -malunion |
|
What is the most common mechanism for tibial plateau injury?
|
strong valgus force with axial loading
|
|
How common are lateral plateau #'s? medial plateau #'s?
|
Lateral 55-70%
Medial 10-23% |
|
What is a Segond fracture?
|
-Bone avulsion of the lateral tibial plateau (site of lateral capsular ligament attachment)
-it is an important marker of ACL disruption and anterolateral rotatory instability |
|
What is the most important aspect of the initial exam in a patient with suspected tibial plateau fracture?
|
-the neuromuscular exam
(especially for popliteal artery injury or peroneal nerve palsy) |
|
Which ligaments are most commonly injury in tibial plateau fractures?
|
ACL and MCL
|
|
What 4 factors determine the prognosis of tibial plateau fractures?
|
-degree of articular depression
-extent and separation of the condylar fracture lines -diaphyseal-metaphyseal comminution and dissociation -integrity of the soft tissue envelope |
|
What is the revised Hohl classification?
|
A classification system for tibial plateau #s
1- Minimally displaced (<4mm depression or displacement) 2- Displaced -local compression -split compression -total depression -splint -rim -bicondylar |
|
How should a patient with a tibial plateau fracture be immobilized?
|
-non-circumferential splint
-pt should not bear weight on the limb until seen by an Orthopedist |
|
What are early complications of tibial plateau #s
|
-wound infection
-loss of reduction -compartment syndrome |
|
In what patient population are tibial spine fractures commonly seen
|
-children and adolescents (because ligaments are stronger than the adjacent physeal plates)
|
|
How do fractures of the intercondylar eminence occur?
|
Tibial spine -> knee twisting
Intercondylar eminence -> hyperflexion, hyperextension |
|
Which radiographic view provides a clearer look at the intercondylar area?
|
-tunnel view
|
|
What is the fabella?
|
A sesamoid bone located in the lateral head of the gastrocnemius muscle. In some people it may be mistaken for an intraarticular loose body or fracture fragment
|
|
What is the classification of tibial spine fractures?
|
Type I - incomplete avulsion with no displacement (minimal elevation)
Type II - incomplete avulsion, minimal displacement of the anterior 1/3 of the fracture fragment, posterior portion adherent Type III - complete separation of fracture from fracture bed IIIA - complete displacement IIIB displacement and rotation |
|
When should a growth plate injury (SH-1) be assumed?
|
-juxta-articular tenderness
-negative radiographs |
|
What is osteochondritis dessicans?
|
Partial or total separation of a segment of articular cartilage and subchondral bone from underlying bone
|
|
Where is OCD commonly seen?
|
Lateral aspect of the medial femoral condyle
|
|
What is the fabella?
|
A sesamoid bone located in the lateral head of the gastrocnemius muscle. In some people it may be mistaken for an intraarticular loose body or fracture fragment
|
|
What is the classification of tibial spine fractures?
|
Type I - incomplete avulsion with no displacement (minimal elevation)
Type II - incomplete avulsion, minimal displacement of the anterior 1/3 of the fracture fragment, posterior portion adherent Type III - complete separation of fracture from fracture bed IIIA - complete displacement IIIB displacement and rotation |
|
What is the fabella?
|
A sesamoid bone located in the lateral head of the gastrocnemius muscle. In some people it may be mistaken for an intraarticular loose body or fracture fragment
|
|
When should a growth plate injury (SH-1) be assumed?
|
-juxta-articular tenderness
-negative radiographs |
|
What is osteochondritis dessicans?
|
Partial or total separation of a segment of articular cartilage and subchondral bone from underlying bone
|
|
What is the classification of tibial spine fractures?
|
Type I - incomplete avulsion with no displacement (minimal elevation)
Type II - incomplete avulsion, minimal displacement of the anterior 1/3 of the fracture fragment, posterior portion adherent Type III - complete separation of fracture from fracture bed IIIA - complete displacement IIIB displacement and rotation |
|
When should a growth plate injury (SH-1) be assumed?
|
-juxta-articular tenderness
-negative radiographs |
|
Where is OCD commonly seen?
|
Lateral aspect of the medial femoral condyle
|
|
What is osteochondritis dessicans?
|
Partial or total separation of a segment of articular cartilage and subchondral bone from underlying bone
|
|
What is the fabella?
|
A sesamoid bone located in the lateral head of the gastrocnemius muscle. In some people it may be mistaken for an intraarticular loose body or fracture fragment
|
|
What is the classification of tibial spine fractures?
|
Type I - incomplete avulsion with no displacement (minimal elevation)
Type II - incomplete avulsion, minimal displacement of the anterior 1/3 of the fracture fragment, posterior portion adherent Type III - complete separation of fracture from fracture bed IIIA - complete displacement IIIB displacement and rotation |
|
Where is OCD commonly seen?
|
Lateral aspect of the medial femoral condyle
|
|
What is the fabella?
|
A sesamoid bone located in the lateral head of the gastrocnemius muscle. In some people it may be mistaken for an intraarticular loose body or fracture fragment
|
|
When should a growth plate injury (SH-1) be assumed?
|
-juxta-articular tenderness
-negative radiographs |
|
What is osteochondritis dessicans?
|
Partial or total separation of a segment of articular cartilage and subchondral bone from underlying bone
|
|
What is the classification of tibial spine fractures?
|
Type I - incomplete avulsion with no displacement (minimal elevation)
Type II - incomplete avulsion, minimal displacement of the anterior 1/3 of the fracture fragment, posterior portion adherent Type III - complete separation of fracture from fracture bed IIIA - complete displacement IIIB displacement and rotation |
|
When should a growth plate injury (SH-1) be assumed?
|
-juxta-articular tenderness
-negative radiographs |
|
Where is OCD commonly seen?
|
Lateral aspect of the medial femoral condyle
|
|
What is osteochondritis dessicans?
|
Partial or total separation of a segment of articular cartilage and subchondral bone from underlying bone
|
|
What is the fabella?
|
A sesamoid bone located in the lateral head of the gastrocnemius muscle. In some people it may be mistaken for an intraarticular loose body or fracture fragment
|
|
What is the fabella?
|
A sesamoid bone located in the lateral head of the gastrocnemius muscle. In some people it may be mistaken for an intraarticular loose body or fracture fragment
|
|
Where is OCD commonly seen?
|
Lateral aspect of the medial femoral condyle
|
|
What is the classification of tibial spine fractures?
|
Type I - incomplete avulsion with no displacement (minimal elevation)
Type II - incomplete avulsion, minimal displacement of the anterior 1/3 of the fracture fragment, posterior portion adherent Type III - complete separation of fracture from fracture bed IIIA - complete displacement IIIB displacement and rotation |
|
When should a growth plate injury (SH-1) be assumed?
|
-juxta-articular tenderness
-negative radiographs |
|
What is osteochondritis dessicans?
|
Partial or total separation of a segment of articular cartilage and subchondral bone from underlying bone
|
|
Where is OCD commonly seen?
|
Lateral aspect of the medial femoral condyle
|
|
What is osteonecrosis? What is a common site for it?
|
Disruption of the blood supply to bone causing infarction.
-May occur in the knee |
|
What are the components of the extensor mechanism?
|
-quadriceps muscles
-quadriceps tendon -medial and lateral retinacula -patella -patellar tendon -tibial tubercle |
|
What are 4 signs and symptoms of extensor mechanism disruption?
|
-acute onset pain/swelling/ecchymosis with palpable defect
-loss or limitation in ability to actively extend knee (usually seen in last 10 degrees of extension) -patella alta (patellar tendon rupture) -patella baja (quadriceps tendon rupture) |
|
How soon should treatment for acute extensor mechanism injury be instituted?
|
-within 2-6 weeks
|
|
What is the function of the patella?
|
It increases the effective lever arm of the quadriceps by providing anterior displacement of the quadriceps tendon
|
|
Are patellar fractures intra-articular?
|
-all except small avulsion fractures of the rim
|
|
What is the most common patellar fracture pattern?
|
Transverse
|
|
Why do patients with non-displaced transverse patellar fractures retain limited functional ability for active extension?
|
Because the retinaculum and extensor mechanism remain intact
|
|
What radiologic views are obtained to evaluate the patellar for #?
|
AP, lateral and sunrise
|
|
What is the management of patellar fractures with preserved knee extension?
|
Long leg cast/knee immobilizer
partial weight bearing |
|
What is the most common type of patellar dislocation?
|
Lateral extra-articular dislocation
|
|
What is the patellar apprehension sign?
|
The manifestation of anxiety and anticipatory reactions observed in a patient when the examiner attempts to slide the non-displaced patella laterally (this test indicates a tendency for patellar subluxation or dislocation)
|
|
What should be done after successful reduction of a patellar dislocation
|
Immobilization in full extension for 3-6 weeks
|
|
What is the treatment for an incomplete rupture of gastrocnemius
|
Cast in plantar flexion for 8 weeks
|
|
What is the treatment for complete gastrocnemius tear?
|
surgical repair
|
|
What are shin splints? signs and symptoms?
|
Anterior tibial pain during or after exercise.
-Typically patients have tenderness at the middle/lower 1/3 of the tibia |
|
What is the treatment for shin splints?
|
-Rest, NSAIDs, ice, supportive footwear
|
|
What is the most common isolated knee injury?
|
-MCL injury
|
|
What is a maisonneuve fracture?
|
Proximal fibular # with medial malleolar# or deltoid ligament tear (also involves complete tear of the syndesmotic ligament joining the tibia and fibula)
|
|
What is the treatment of fibular shaft fractures?
|
Symptomatic non-weight bearing to weight-bearing progressively as tolerated, unless severely displaced or associated with a peroneal nerve deficit
|
|
What is the usual history of stress #s
|
-Recent increase in active
-Training on a hard surface -inadequate footwear Pain with activity alleviated by rest |
|
What are typical sites for stress fractures?
|
-tibia (shaft)
-femur -fibula -tarsals (navicular) -metatarsals |
|
What is the role of plain films in suspected stress fractures?
|
X-ray is diagnostic in only 30% of patients at initial presentation (MRI can diagnose the condition earlier and more accurately then plain films)
|
|
What is the treatment for stress fracture?
|
Decrease activity for 3-6 weeks
|
|
Tibial tubercle fractures: population, mechanism, class and treatment
|
-adolescent boys
-violent flexion of knee against contracted quadriceps Watson-Jones Classificaiton I-incomplete avulsion -> cast II - complete avulsion, extra-articular -> reduce and cast III - complete avulatio, intra-articular -> ORIF |
|
How is Osgood Sclatter distinguished from a tibial tubercle #?
|
-more chronic
-less functional disability -no hemarthrosis -irregular apophysis on xray |
|
What is a toddler's fracture?
|
Non-displaced spiral # of the distal tibia in a child 9mo-3 years
|
|
How is motor/sensory function of the peroneal nerve evaluated?
|
-ankle and big toe dorsiflexion (deep peroneal nerve), sensation in the first web space
-active foot eversion (superficial peroneal nerve) sensation in dorsal lateral foot |
|
What are complications of tibial shaft fractures?
|
-Anterior compartment syndrome
-peroneal nerve injury |
|
How is integrity of the post-tibial nerve assessed?
|
Presence/absence of plantar sensation
|
|
What is the treatment of tibial shaft #s?
|
Long leg posterior splint/slab in 20 degrees flexion
|
|
What is the contents of the 4 lower leg compartments?
|
Anterior:
-tibialis anterior -long toe extensors -deep peroneal nerve -anterior tibial artery Lateral: -foot evertors (peroneus longus and brevis) -superficial peroneal nerve Superficial Posterior -strong ankle plantar flexors (gastrocnemius, soleus, plataris) -sural nerve Deep posterior: -tibialis posterior -long toe flexors -posterior tibial and peroneal arteries -tibial nerve |
|
What are the X-ray findings in osteoarthritis?
|
-Joint space narrowing
-osteophytes -subchondral sclerosis -bony cysts |
|
Define a Baker's cyst. What is the treatment?
|
-herniation of the synovial membrane through the posterior aspect of the knee capsule
-There is no treatment required, they spontaneously disappear |
|
What are the 4 lower leg compartments?
|
Anterior
Lateral Superficial Posterior Deep Posterior |
|
What is the pain in popliteus tendinitis?
|
Tenderness in the posterior/posterolateral aspect of the knee
|
|
What are signs and symptoms of pre-patellar bursitis and what is the differential diagnosis?
|
(aka housemaid's knee)
Swelling/effusion overlying the lower pole of the patella Ddx - septic bursitis |
|
Who gets pes anserine bursitis?
|
Obese women with OA or runners
(tenderness and puffiness at the anteromedial tibia) |
|
What joints make up the wrist?
|
DRUJ
Radiocarpal joint midcarpal joints |
|
What separates the wrist from the carpals?
|
The triangular fibrocartilage
|
|
What is the function of the extrinsic ligaments of the wrist?
|
Link carpals to the DR, DU, and MCs
|
|
Which ligaments are most important to provide stability to the wrist?
|
Proximal and distal arcades on the volar aspect of the wrist
|
|
What is the space of poirier?
|
A space between the ligamentous volar arcades in the wrist which is devoid of ligamentous support
|
|
Which carpal bones are at creates risk of AVN?
|
Scaphoid, lunate and capitate
|
|
Where does the radial nerve cross the wrist?
|
At the dorsum of the wrist near the radial styloid
|
|
Where does the ulnar nerve cross the wrist?
|
Along the dorsum of the wrist near the ulnar styloid
|
|
Where does the median nerve cross the wrist?
|
On the volar aspect of the wrist within the carpal tunnel
|
|
What are the borders of the anatomic snuffbox?
|
Radial abductor pollicis longus and extensor pollicis brevis
Ulnar - EPL |
|
What is the radial length measurement?
|
The distance by which the radial styloid extends post the articular surface of the ulna, normally 9-12mm
|
|
What is the radial inclination?
|
The ulnar slant of the articular surface of the radius - normal 15-25degrees
|
|
What is the normal volar tilt of the radius on a lateral X-ray?
|
10-25 degrees
|
|
What is the normal alignment of bones on the lateral wrist X-ray?
|
radius->lunate->capitate->3rd metacarpal all in line or within 10 degrees
|
|
What is the normal scapholunate angle?
|
30-60 degrees
|
|
What is the normal capitolunate angle
|
0-30 degrees
|
|
What is the pronator quadratus line?
|
A linear fat collection on the volar surface of the wrist just anterior to the radius and ulna, with fractures it is volarly displaced or obliterated
|
|
What is the most commonly fractured carpal bone?
|
the scaphoid
|
|
What are physical exam findings of scaphoid fracture?
|
pain in the anatomic snuffbox
pain on resisted supination pain on axial loading of the thumb MC pain on minimal thumb movement |
|
Which scaphoid #s are most at risk of AVN?
|
Those of the proximal pole
|
|
What are physical exam findings of a lunate #
|
pain on the dorsum of the wrist
pain on axial loading of the D3 metacarpal pain on palpation just distal to lister's tubercle |
|
How are lunate fractures treated?
|
Immobilization in a short arm cast
|
|
Whan is Keinbock's disease?
|
Post traumatic AVN of the lunate
|
|
What is the second most commonly fractured carpal done?
|
the triquetrum
|
|
Why is the pisiform unique?
|
It is a sesamoid bone the lies within the FCU tendon
|
|
What is a possible complication of pisiform #?
|
Ulnar nerve injury from impingement in Guyon's canal
|
|
What is the standard radiographic series of the wrist?
|
PA
Lateral Oblique all in neutral position |
|
What radiological view may be requested if there is concern for a pisiform #?
|
Carpal tunnel view
or supinated oblique view |
|
What should be done for pisiform fracture with ulnar nerve compression?
|
Ortho consult for urgent surgical decompression
|
|
What are the best X-ray views to see #s of the hook of the hamate?
|
Carpal tunnel view
Reverse oblique (supinated) |
|
What views are used to see trapezium fractures?
|
Slightly pronated oblique view
or Roberts view - true AP of the trapezium |
|
What is the treatment for a trapezium #?
|
Immobilization in thumb spica unless displaced or involving the carpometacarpal joint
|
|
Which carpal bone #s are immobilized in a thumb spica?
|
Scaphoid
Trapezium (all others are immobilized in a short arm) |
|
Which #s should alert the physician to a possible occult perilunate instability?
|
Scaphoid #
Radial styloid # Capitate # Triquetrum # |
|
What is stage I carpal instability?
|
Scapholunate dissociation (terry thomas sign, signet ring sign)
Routine xrays may be normal - order a clenched fist AP view with ulnar deviation if clinical suspicion of scapholunate ligament injury |
|
What is stage II carpal instability?
|
Perilunate dislocation, capitate dorsally dislocated
The PA view shows overlap of the distal and proximal carpal row |
|
What is stage III carpal instability?
|
Identical to stage II but with triquetral dislocation on PA view
Overlap of the triquetrum on the lunate or hamate |
|
What is stage IV carpal instability?
|
Lunate dislocation (triangular shaped lunate) on PA
Spilled teacup on lateral |
|
What neuro finding may be associated with lunate or perilunate dislocation?
|
decreased 2 point sensory discrimination in the distribution of the median nerve
|
|
What is the gold standard for identifying and grading scapholunate injury?
|
Arthroscopy
|
|
What is stage II carpal instability?
|
Perilunate dislocation, capitate dorsally dislocated
|
|
What is stage III carpal instability?
|
Identical to stage II but with triquetral dislocation on PA view
|
|
What is stage IV carpal instability?
|
Lunate dislocation (triangular shaped lunate) on PA
Spilled teacup on lateral |
|
What neuro finding may be associated with lunate or perilunate dislocation?
|
decreased 2 point sensory discrimination in the distribution of the median nerve
|
|
What is the gold standard for identifying and grading scapholunate injury?
|
Arthroscopy
|
|
Which colles #s merit close f/u with Ortho?
|
>20% angulation
dorsal comminution intra-articular extension |
|
Which colles # should be immediately referred to Ortho?
|
-open #
-neurovascualr compromise -unable to reduce |
|
What are signs of an incomplete colles # reduction?
|
-intra-articular stepoff >1mm
-radial inclination <15 degrees -volar tilt less than neutral -loss of radial length >2mm |
|
What is a Smith's fracture?
|
A transverse # of the radial metaphysis with volar displacement and volar angulation
|
|
What is a complication of cast holding for Smiths#?
|
median nerve compression
|
|
What is a Barton's #?
|
An oblique intraarticular # of the rim of the distal radius with displacement of the carpus along with the # fragment
|
|
What is the management of a Barton's #?
|
Orthopedic consultation for reduction and stabilization
|
|
What is a Hutchinson's #?
|
A chaffeurs or radial styloid #
|
|
What is the management of a Hutchinson #?
|
non-displaced-> short arm cast
displaced - reduction (many ligaments attach to the DR therefore accurate # reduction is critical) |
|
What is a possible complication of radial styloid #s?
|
Scapholunate dissociation
|
|
What are clinical findings of DRUJ injury?
|
-MOI with hyperpronation or supination
-sudden onset of pain with 'snapping' sensation in the wrist, limited ROM and swelling -tenderness on ulnar aspect -crepitus with supination and pronation -prominence or loss of normal prominence of ulnar styloid (compared with normal side) |
|
Why are the clinical findings of DRUJ important?
|
Because X-rays are often read as normal
|
|
What # is commonly associated with DRUJ dislocation?
|
Radial head #
|
|
What is the treatment of DRUJ injuries?
|
Ortho consult for ORIF
Closed reduction with forearm supinated and long arm cast x 6 weeks can often be successful |
|
What forms the carpal tunnel?
|
The transverse carpal ligament and the volar aspect of the carpals
|
|
What is the contents of the carpal tunnel?
|
FPL
4x FDS 4x FDP median nerve |
|
Which conditions may mimic carpal tunnel syndrome?
|
Cervical radiculopathy
Thoracic outlet obstruction |
|
What is the most sensitive provocative test for CTS?
|
Wrist flexion (Phalen's) test
|
|
What is the confirmatory test for CTS?
|
Nerve conduction studies
|
|
What is nonoperative treatment for CTS?
|
Splinting the wrist in neutral position
|
|
What is the Essex Lopresti lesion?
|
Longitudinal rupture of the interosseous membrane that joins the diaphyseal shafts of the radius and ulna and radial head fracture. This lesion renders the forearm unstable, painful and weak
MRI is the diagnostic test of choice |
|
What is the main stabilizer of the DRUJ?
|
TFC
|
|
What is the radial line used to assess?
|
For radial head dislocation
|
|
What is the treatment for undisplaced forearm #s in adults?
|
-long arm cast
-f/u in 1 week to assess for displacement |
|
What is the treatment for displaced ulnar or radial shaft #s?
|
Splint and ortho for OR
|
|
What is the most significant complication of either radial or ulnar shaft fractures?
|
Compartment syndrome
|
|
What is a nightstick #?
|
An ulnar shaft #
|
|
What is the treatment for undisplaced ulnar shaft fractures?
|
Distal 1/3 fo ulna -> short arm
Proximal 2/3 of ulna -> long arm cast |
|
What is the definition of a displaced ulnar fracture?
|
->10 degrees of angulation
-displacement of >50% the diameter of the ulna |
|
What is associated with ulnar shaft #?
|
Radial head dislocation (Monteggia)
|
|
What nerve injury may be present with Monteggia #?
|
Radial
|
|
What is a Monteggia #?
|
Proximal/mid ulnar shaft # and radial head dislocation
|
|
What is a Galleazi #?
|
# of the middle/distal 1/3 of the radius and DRUJ dislocation/subluxation
|
|
What is the management of a Galleazi fracture?
|
OR
|
|
What is plastic deformation?
|
Bending of the bone without overt #
|
|
What are the standard radiographic views of the hand?
|
AP
Lateral Oblique |
|
What inserts onto the proximal phalanx of the digits of the hand?
|
Nothing
|
|
What inserts onto the middle phalanx of the hand digits?
|
FDS
extensor tendons |
|
How is rotational deformity assessed?
|
It is judged clinically by the relationship of the finger to the adjacent normal fingers
|
|
What is the management of an undisplaced stable phalangeal #?
|
Dynamic splinting (buddy taping)
|
|
If a phalangeal # is successfully reduced, how should it be casted?
|
The finger and wrist should be immobilized
|
|
How are metacarpal #s divided?
|
Those involving D1
Those involving D2-D5 |
|
How much lateral angulation, dorsal angulation and shortening can finger metacarpals accommodate?
|
Lateral angulation
D2-D5 10-15 degrees lateral angulation Dorsal angulation D2-D3 - 10-15 degrees D4 - 40-45 degrees D5 - 50-70 degrees 3-4mm shortening |
|
What can you do if you strongly suspect a metacarpal head # but the initial X-ray is negative?
|
Brewerton or Ball catcher's view
|
|
What is the safe or functional position for hand immobilization?
|
20-30 degree wrist extension
90 degree metacarpal flexion DIP and PIP extension |
|
Why are metacarpal neck #s difficult to manage?
|
They are inherently unstable
|
|
How much angulation is allowed for metacarpal neck #s?
|
2 and 3 - 15 degrees
4 - 35 degrees 5 - 45 degrees |
|
What are the landmarks for a metacarpal neck # splint?
|
Just below the elbow to just proximal to the PIP
|
|
What is the reduction technique for metacarpal neck #s?
|
Volar pressure over the metacarpal shaft
Dorsal pressure over the metacarpal head |
|
What are the 3 types of metacarpal shaft #s?
|
Transverse
Oblique Comminuted |
|
How should metacarpal shaft #s be immobilized?
|
A gutter splint including the wrist and the entire metacarpal shaft but not the MCP if the # is proximal to the metacarpal neck
|
|
What is the management of metacarpal base #s?
|
immobilization
referral to a hand surgeon |
|
What are intra articular #s involving D1 metacarpal?
|
Bennetts
Rolando |
|
What is the management of a Bennett's fracture?
|
Immobilization in a thumb spica
referral to a hand surgeon |
|
What is a Bennett's fracture?
|
Intra-articular # of the base of the thumb metacarpal with sublimation of the CMC joint
|
|
What is a Rolando's fracture?
|
comminuted # of the base of the thumb metacarpal
|
|
What is the purpose of the S-H classification?
|
To direct treatment and predict outcomes
|
|
What is the most common ligament injury in the hand?
|
PIP dislocation
|
|
What is skier's thumb?
|
UCL injury of D1 from forced abduction
|
|
What testing should be done to diagnose UCLinjury?
|
Valgus stress in extension and 30 degrees of flexion
|
|
What criteria are used to diagnose UCL injury?
|
>35 degrees of laxity or >15 degrees of laxity compared to the uninjured side
|
|
How many extensor tendon zones are there?
|
8
|
|
What is mallet finger?
|
A closed disruption of the distal extensor tendon
|
|
What is the MOI in mallet finger?
|
Forceful flexion of the DIP
|
|
What are the 3 types of mallet finger?
|
Type 1 - tendon rupture
II - tendon rupture and small avulsion III - tendon rupture and avulasion 25-33% articular surface |
|
What is the treatment for mallet finger?
|
DIP immobilization in hyperextension for 6-8 weeks
|
|
How do you repair extensor tendon lacerations?
|
5-0 or 4-0 non-absorbable sutures
figure of 8 stitch |
|
What is a Boutonniere deformity?
|
Flexion at the PIP
Hyperextension of MP and DIP |
|
What is the injury if a Boutonniere injury develops?
|
Disruption of the central extensor tendon
|
|
What is necessary in human bite wounds?
|
Operative exploration, irrigation, debridement
|
|
What is empiric antibiotic treatment for human bite?
|
Amox-clav
pen allergy clinda and fluoroquinolone |
|
What is associated with palmaris longus laceration?
|
Median nerve laceration
|
|
What is the management of a flexor tendon injury in the absence of a hand surgeon?
|
Irrigation, close the wound, splint wrist at 30 degrees flexion, MCP 70 degrees of flexion, IP 15 degrees flexion
|
|
How do you classify amputations?
|
As open #s administer
Initial IV cephalosporin dose and then PO antibiotics |
|
What is the management of a clenched fist wound?
|
-debride/irrigate
-tetanus -xray to exclude FB -splint/elevate -IV abx -hand surgeon |
|
What is contraindicated in high pressure injection injuries?
|
Digital block (may increase pressure in the compartment)
|
|
What defines a partial amputation?
|
The presence of interconnecting tissue between the proximal and distal portion
|
|
What should be done with an amputated part?
|
Cover with saline soaked gauze, place in a dry plastic bag and put on ice
|
|
What are classic indications for re-implantation?
|
-multiple digits
-thumb -wrist and forearm -sharp amputation with minimal to moderate avulsion proximal to the elbow -single digits amputated between PIP and DIP -all pediatric amputations |
|
What are classic contraindications to re-implantation?
|
-unstable patients with other life-threatening injuries
-multilevel -self-inflicted -single digit proximal to FDS -serious underlying disease vascular, CHF, DM -extremes of age |
|
How many compartments exist in the hand?
|
10
|
|
What is neuropraxia?
|
Loss of nerve function but axon intact
|
|
Which nerve injury in the hand should be considered for re-approximation?
|
-motor median and ulnar
-digit injury proximal to DIP crease on radial aspect of index and ulnar aspic of little finger and both sides of the thumb |
|
What is a felon?
|
An infection of the pulp of the finger
|
|
What is the treatment of a felon?
|
Lateral incision of the finger, ulnar of II-IV radial of I and V
|
|
What is the treatment of a herpetic whitlow?
|
-prevent transmission
-cover with a dry dressing -oral acyclovir for those that are immunocompromised or frequent recurrences -resolves spontaneously in 3-4 weeks |
|
What are the cardinal signs of flexor tenosynovitis?
|
Tenderness along the flexor sheath
-symmetrical swelling -pain on passive extension -flexed posture of the fingers |
|
What is the treatment for flexor tenosynovitis?
|
-IV abx (ancef or ceftriaxone if GC is suspected)
-early -> anti staphylococcal penicillinase or cephalosporin -splint -consult |
|
What is contained in the anterior compartment of the upper arm?
|
biceps brachii
brachialis coracobrachialis median, ulnar and musculocutaneous nerve brachial artery |
|
What is contained in the posterior compartment of the upper arm?
|
-radial nerve
-triceps |
|
In what injuries is the radial nerve particularly susceptible?
|
midshaft # of the humerus
|
|
Which fractures pose a risk to the ulnar nerve?
|
those of the medial condyle
|
|
Which elbow bursae are clinically important?
|
-olecranon bursa
-radiohumeral bursa -bursa that cushions the biceps tendon from the radial head |
|
What is the only dependable early sign of compartment syndrome?
|
pain
|
|
What is the most likely cause of a posterior fat pad sign on elbow X-ray?
|
adults - radial head #
child - supracondylar fracture |
|
How do you determine Baumann's angle?
|
The angle between one line drawn through the midshaft of the humerus and another drawn through the capitellum growth plate
|
|
What is the order of appearance and fusion of ossification centres?
|
Capitellum 1-2
Radius 4-5 Internal epicondyle 4-5 Trochlea 8-10 Olecranon 8-9 Externa epicondyle 10-11 |
|
What features suggest a pathologic #?
|
Thinning of the cortex
Abnormal osteoblastic or osteoclastic activity |
|
What is the management of isolated radial nerve palsy in humeral fractures?
|
Treat conservatively - assumed to be neuropraxia
|
|
What is the management of radial nerve palsy post reduction?
|
Assumed to be entrapment therefore go to OR
|
|
Which patients with humeral shaft #s require emergent orthopaedics?
|
-open
-comminuted -concomitant # in the forearm -radial nerve injury -severely displaced injuries |
|
What is the classification of supracondylar fractures?
|
Type I - minimal to no displacement
Type II - at least one cortex intact Type III - completely displaced, no cortex intact |
|
When should a supracondylar fracture be reduced in the ED?
|
Vascular compromise which threatens the viability of the limb
|
|
What is important about supracondylar # reduction?
|
Only one attempt should be made, multiple attempts increase the likelihood of neuromuscular injury
|
|
What is the most common reason for losing a radial pulse in supracondylar #s, what is the management?
|
-Swelling
Mgmt -reduce # -avoid flexing to 90 degrees -elevate the arm |
|
What is the most common complication of a flexion supracondylar #?
|
injury to the ulnar nerve by the proximal fragment
|
|
What is a transcondylar #?
|
Fracture that passes through both condyles within the joint capsule (it is most commonly seem in elderly)
|
|
What is the intercondylar #?
|
T or Y shaped # with separation of condyles from each other and from the proximal humerus
|
|
What is the 2nd most common elbow # in children?
|
Lateral condyle #
|
|
What is the treatment for lateral condyle #?
|
non-displaced -> cast
displaced -> closed or open reduction |
|
What type of SH# are medial condyle #s in kids?
|
SH-IV
|
|
What is particular about medial condyle #s in kids?
|
xray will not show a # in those <9 because the trochlea does not ossify until the age of 9
|
|
When is operative treatment recommended for medial condyle #s in children?
|
Displacement >2mm
|
|
What is key to analyzing humeral condyle #s?
|
The lateral trochlear ridge, it's involvement is likely to result in instability
|
|
How should you immobilize lateral condylar #s in adults?
|
Posterior plaster splint in supination and wrist extension
|
|
How should you immobilize a medial condyle # in an adult?
|
Posterior plaster splint with wrist in flexion and forearm in pronation
|
|
How do injuries to the capitellum occur?
|
FOOSH where the radial head jams up
|
|
When do #s of the trochlea and capitellum most often occur?
|
Posterior elbow dislocation
|
|
Which humeral epicondyle ismore commonly #d?
|
medial
|
|
What are the mechanisms of injury for medial epicondyle #s?
|
-posterior elbow dislocation
-little league elbow -arm wrestling |
|
What is little league's elbow?
|
Avulsion of the medial epicondyle or compression # of the radial head/lateral condyle
|
|
What are the mechanisms for olecranon #?
|
-direct blow
-forceful contraction of the triceps |
|
Which neuromuscular structure is most vulnerable in olecranon #?
|
ulnar nerve
|
|
What are physical findings of an olecranon #?
|
-pain
-palpable deformity -inability to extend the elbow against force |
|
What is the treatment for an olecranon #?
|
undisplaced ->immobilize with frequent RA to ensure there is no displacement
displaced-> immediate ortho Document the presence of ulnar nerve involvement |
|
What is the typical mechanism for radial head and neck #s?
|
indirect mechanism typically FOOSH
|
|
In addition to # of the radial head what other structures are typically damaged?
|
-articular surface of capitellum
-collateral ligament injury |
|
What are the classifications of radial head #s?
|
I- undisplaced
II - marginal # (<30% articular surface) with displacement III - comminuted # of the entire radial head IV - any of the above and elbow dislocation |
|
What is the management of radial head #s?
|
Type I - sling
Type II - immobilize with trail of ROM, excision of the radial head if failed III-IV - usually radial head excision IV - reduce elbow dislocation |
|
What does elbow dislocation mean?
|
Disruption of the relationship between the humerus and olecranon
|
|
In what directions can elbows dislocate?
|
post - most commonly
ant/medial/lateral |
|
What is the ideal position for reduction of a posterior elbow dislocation?
|
flexed @ 30 degrees and supinated distal traction applied
|
|
What is the most serious complication of elbow dislocation?
|
Vascular compromise
|
|
Which vessel is injured in posterior elbow dislocation?
|
Brachial
|
|
Where does biceps tendon rupture most commonly occur?
|
Proximal portion of the long head
|
|
What can fractures be confused with on X-ray?
|
nutrient arteries
soft tissue folds bandages or overlying materials anomalous bones calcified soft tissue accessory ossicles and sesamoids |
|
What are the complications of fractures (10)?
|
Hemorrhage
Vascular injuries Nerve injuries Osteomyelitis Fat emboli syndrome Complex regional pain syndromes (reflex sympathetic dystrophy and causalgia) Compartment syndrome Avascular necrosis Fracture blisters Complications of immobilization |
|
What are the complications of immobilization?
|
Pneumonia
UTI Wound infection DVT PE Decubitus ulcers Muscle atrophy Stress ulcers |
|
What is fat embolism syndrome?
|
The presence of fat globules in the lung parenchyma and peripheral circulation after a long bone fracture or major trauma
|
|
What is the presentation of fat embolism syndrome?
|
Surgery 1-2 days post injury or intramedullary nailing
Fever, tachycardia Dyspnea, respiratory distress, hypoxemia Confusion and deteriorating mental status Petechial rash Retinal changes Thrombocytopenia |
|
What is the treatment for fat embolism syndrome?
|
Supportive
the mortality is 20% |
|
What is compartment syndrome?
|
Increased pressure in a closed nonexpandable compartment
May be caused by 1) increased compartment contents 2) decreased compartment volume 3) external pressure |
|
What is the physiology of compartment syndrome?
|
At compartment pressures above the DBP there is circulatory compromised and tissue hypoxia due to the reduced arteriovenous gradient at the tissue. The body responds by releasing histamine in an attempt to dilate capillaries and increase blood flow. Eventually you have impairment of the venous and arterial flow resulting in ischemic necrosis of muscles and nerves
|
|
What are causes of compartment syndrome that result in increased compartment contents?
|
Bleeding - major vascular injury, coagulation disorder, and anticoagulant therapy
Increased capillary filtration - reperfusion after ischemia (bypass grafting, embolectomy, cardiac catheterization, lying on a limb) trauma - fracture, convulsion intensive use of a muscle - exercise, seizures, eclampsia, tetany burns - thermal or electrical intra-arterial drub injection orthopedic surgery - tibial osteotomy, hauser's procedure, reduction and internal fixation of fractures snakebite |
|
What are causes of compartment syndrome that resulting in increased capillary pressure?
|
Venous obstruction - phlegmasia cerulea dolens, ill-fitting leg brace, venous ligation
diminished serum osmolarity - nephrotic syndrome Miscellaneous - infiltrated infusion, pressure transfusion, leaky dialysis cannula, popliteal cyst |
|
What are causes of compartment syndrome with decreased compartment volume?
|
Closure of fascial defects
excessive traction on fractured limbs |
|
What are causes of compartment syndrome resulting from external pressure on the compartment?
|
Tight cases, dressings or air splints
lying on the limb |
|
What compartment is most often involved in compartment syndrome?
|
anterior compartment of the leg
|
|
What are locations of compartment syndrome?
|
Leg - anterior, lateral, superficial and deep posterior
Thigh - quadriceps Buttock - gluteal Hand - intraosseous Forearm -dorsal and volar arm - deltoid and biceps |
|
What are the reliable indicators of compartment syndrome?
|
Pain disproportionate to the injury
hypoesthesia and paresthesia sensation of tenseness within the compartment |
|
What is the treatment of compartment syndrome?
|
Fasciotomy within 12 hours
|
|
What are complications of compartment syndrome? (9)
|
Rhabdomyolysis
Hyperkalemia Myoglobinuria Renal failure Lactic acidosis infection Tissue loss Loss of nerve and muscle function contracture |
|
What conditions are associated with the development of tendinopathy?
|
Advanced age
smoking obesity steroid use fluoroquinolone use DM CRF RA SLE |
|
What are contraindications to cryotherapy?
|
Absolute:
-severe cold allergy (with hives and joint pain) -Raynaud's phenomenon and disease Relative: Some rheumatoid conditions paroxysmal cold hemoglobinuria with renal dysfunction |
|
What are the interossei muscles (function, innervation, testing)
|
There are 7 interossei
They adduct and abduct the fingers innervated by the ulnar nerve test them by placing the palm flat, extend the finger and move it side to side |
|
What are the lumbricals (function, innervation)
|
muscles that flex the MCP joints and extend the IP joints
the radial two are innervated by the median nerve and the ulnar two are innervated by the ulnar nerve |
|
What are the extensor tendons?
|
They are tendons with origins in the forearm and insertion in the hand
9 tendons with 6 compartments 1 - APL and EPB 2 - radial wrist extensors 3 - EPL 4 - EDC (extensor digitorum communis), EIP (extensor indicis proprius) 5 - extensor digiti quinti proprius (EDQP) 6 - ECU |
|
What is the vascular supply to the hand?
|
Radial artery which terminates in the deep palmar branch
Ulnar artery which terminates as the superficial palmar arch |
|
What deformity occurs with radial nerve palsy?
|
Wrist drop
(fingers in flexion and thumb is adducted) |
|
What deformity occurs with ulnar nerve palsy?
|
claw-hand
Duchenne sign - clawing of D4 and D5 -> hyperextension at the MCP and flexed at the IP |
|
What deformity occurs with median nerve palsy?
|
absence of flexion of the thumb, index DIP and PIP, weakness of thumb abduction and opposition
|
|
What is normal 2-point discrimination?
|
2-5mm at the fingertips
7-10mm at the base of the palm 7-12mm at the dorsum of the hand |
|
What is trigger finger and what is the treatment?
|
Stenosing tenosynovitis - pathologic nodular swelling of a long flexor tendon resulting in intermittent painful blocking of flexion or extension usually at the MCP joint
treatment - injection of local anesthetic and corticosteroid, splint in extension and referral to a hand surgeon |
|
In which position are angular finger deformities best assessed?
|
Fingers in full extension
|
|
In which position are rotational finger deformities best assessed?
|
fingers flexed
|
|
When is surgical intervention indicated for metacarpal fractures?
|
2-3mm shortening
1mm articular surface off >25% articular involvement |
|
What are acceptable angulations for metacarpal shaft fractures?
|
0-0-10-20
D2-D3 - no angulation tolerated D4 - <10 degrees tolerated D5 - <20 degrees tolerated |
|
What associated injury can occur with metacarpal base fractures?
|
Injury to the motor branch of the ulnar nerve resulting in paralysis of intrinsic muscles of the hand
|
|
What is the management of extra-articular thumb metacarpal fracture?
|
Acceptable angulation: 20-30 degrees
Closed reduction immobilize with the thumb IP extended using a thumb spica |
|
What is the difference between a Bennett's and Rolando fracture?
|
Bennett's is a fracture at the base of the thumb metacarpal with dislocation of the CMC joint
Rolando's is a comminuted fracture at the based of the thumb metacarpal with a Y or T shaped pattern |
|
What radiographic finding is pathognomic of a complex MCP dislocation?
|
The presence of a sesamoid bone in the wodened joint space. This requires operative intervention
|
|
How do you reduce MCP dislocations?
|
Flex the wrist to relax the flexor tendons
Apply firm pressure over the dorsum of the proximal phalax in the distal and volar direction |
|
What is the treatment of a UCL (Gamekeeper's thumb)?
|
Partial -> thumb spica cast for 4 weeks
Complete -> surgical repair within 3 weeks |
|
What is a swan neck deformity (cause and anatomic basis)
|
Lateral bands displace proximally and dorsally resulting in extension of the PIP joint and flexion of the DIP joint
-it is the result of an untreated mallet finger |
|
What is the zone classification of extensor tendons?
|
Zone I - distal phalanx and DIP
Zone II - middle phalanx Zone III - PIP joint Zone IV - proximal phalanx Zone V - MCP joint Zone VI - dorsum of the hand Zone VII/VIII - wrist and forearm |
|
What is important about Zone V injuries
|
Any injury over the MCP are assumed to be human bite wounds.
Xrays are mandatory Operative exploration, debridement and irrigation are mandatory Treatment should be with timentin or clinda plus a fluoroquinolone |
|
Why do palmaris longus lacerations have diagnostic significance?
|
Palmaris longus is not a functionally significant wrist flexor but 80-90% of the time it is associated with a concomitant median nerve laceration
|
|
What is no man's land?
|
From the distal palmar crease to the midportion of the middle phalanx
|
|
What are concerns with high-pressure injuries and what is their management?
|
Compartment syndrome and high amputation rate
Mgmt: IV antibiotics tetanus analgesia splinting and elecation urgent plastics consult for surgical decompression and debridement digital blocks are contraindicated |
|
What are the warm and cold ischemia times for amputated parts?
|
warm: 6-8 hours
cold: 12-24 hours the more proximal the amputation the less ischemia time the amputated part can tolerate |
|
What is a paronychia?
|
localized superficial infection or abscess involving the lateral nail fold
|
|
Describe the anatomy of the extensor mechanism of the finger?
|
The extensor mechanism of the PIPI joint is a trifurcation of the extensor tendon into the central slip which attaches to the dorsal base of the middle phalanx and the two lateral bands which continue distally and attach to the distal phalanx
|
|
What is a collar button abscess?
|
A palmar space infection that has spread to the dorsum of the hand
|
|
What ligaments are the most important in maintaining carpal stability?
|
Scapholunate
Lunotriquetral |
|
What are the important landmarks on the wrist exam?
|
Anatomic snuffbox: just distal to the radial styloid
Scaphoid tubercle: just distal and palmar to the radial styloid Lister's tubercle: on the dorsum of the wrist just ulnar to the radial styloid, scapholunate ligament is just distal to it triquetrum: just distal to the ulnar styloid in the proximal carpal row Pisiform: at the base of the hypothenar muscles just distal to the distal wrist crease Hook of the hamate: 1cm distal and radial to pisiform |
|
What is proper positioning on a PA wrist view?
|
The distal radius and ulna should not overlap at their distal articulation and the axis of the 3rd metacarpal should parallel that of the radius
|
|
What is proper positioning on a lateral wrist view?
|
the radius and ulna should overlap one another and the radial styloid should be centered over the distal radial articular surface
|
|
What is the purpose of a wrist PA view in ulnar or radial deviation?
|
to better identify carpal ligament injuries
|
|
What is the purpose of a lateral view in max flexion or extension?
|
to better identify carpal ligament injuries
|
|
What is the purpose of a clenched-fist wrist AP view?
|
exposes the scapholunate ligament injury, it pushes the capitate into the proximal carpal row
|
|
Who typically gets scaphoid fractures and what is the mechanism of injury?
|
Young adults 15-30
post FOOSH |
|
Where is the scaphoid most commonly fractured?
|
Through the waist
|
|
What % of scaphoid fractures are not detected on xrays taken soon after injury?
|
14%
|
|
What should be done when a patient has clinical findings of a scaphoid fracture but no fracture on xray
|
Below elbow thumb spica and repeat xray in 10-14d
MRI CT Below elbow thumb spica and bone scan in 3-4d |
|
What is the sensitivity of MRI for detecting acute scaphoid fractures?
|
100%
|
|
What is the duration of cast immobilization for scaphoid fracture?
|
12weeks
(longer for more proximal fractures) |
|
Which scaphoid fractures require operative repair?
|
Displaced >1mm
Scapholunate angle > 30-60 degrees capitolunate angle >0-30 degrees |
|
Which patients fracture their lunate more commonly?
|
Those with congenitally short ulna's because of compromised triangular fibrocartilage
|
|
What are physical findings in patients with a lunate fracture?
|
Pain over the dorsum of the wrist exacerbated by axial loading of the long metacarpal
tenderness to palpation of the depression just distal to Lister's tubercle |
|
What are complications of a lunate fracture?
|
Non-union
AVN Carpal instability |
|
What should be done when a patient has clinical findings of lunate fracture but no fracture is seen on X-ray?
|
Immobilize in a short arm cast until fracture can be excluded by CT or MRI
|
|
What is the mechanism of injury leading to triquetral fracture?
|
Direct blow to the bone
FOOSH -> dorsal chip fracture |
|
What radiographic view allow for better visualization of a triquetral fracture?
|
Standard lateral view of the wrist
|
|
What is the management of a triquetral fracture?
|
Short arm cast or splint for 4-6 weeks
|
|
What are clinical findings of pisiform fracture?
|
Tenderness over the ulnar aspect of the volar wrist crease exacerbated by wrist flexion and ulnar deviation
Paresthesias in the ulnar nerve distribution Hand clumsiness rom intrinsic muscle dysfunction |
|
What is the treatment of a pisiform fracture?
|
Short arm cast or splint for 3-4 weeks
If there is evidence of ulnar nerve compromise you should consult ortho for possible urgent surgical decompression |
|
What are the mechanisms of injury leading to hamate fracture?
|
Direct blow to the palm
FOOSH the use of hammers vibration from equipment |
|
What are the clinical findings in patients with a hamate fracture?
|
Pain over the hypothenar eminence with decreased grip strength
Pain on palpation of the hamate |
|
What is the treatment for hamate fractures?
|
Immobilization in a short arm cast
|
|
What is the treatment for a trapezium fracture?
|
immobilization in a thumb spica for 6 weeks
|
|
When should a patient with a trapezium fracture be referred to ortho for ORIF?
|
Displaced fracture
Fracture involving the carpometacarpal joint |
|
What carpal bone fractures are rare and uncommon?
|
Rare: hamate, capitate, trapezoid
Uncommon: lunate, trapezium |
|
What are the complications of carpal dislocation injuries
|
Median nerve injury
Chronic carpal instability with resultant degenerative joint disease |
|
What is the gold standard for identifying and grading scapholunate injuries?
|
Arthroscopy
|
|
What is DISI?
|
Dorsal intercalated segment instability
dorsiflexion of the lunate relative to the capitate, increased scapholunate angle and increased capitolunate angle. Most common pattern of carpal instability |
|
What is VISI?
|
volar intercalated segment instability
volar flexion of the lunate relative to the capitate resulting in decreased scapholunate angle and increased capitolunate angle |
|
What is the definition of a Colle's fracture?
|
Transverse fracture of the radial metaphysis
Dorsally displaced and angulated Located within 2 cm of the radial articular surface possible intra-articular extension associated fracture of the ulnar styloid is common |
|
Which patients with Colles fracture require an ortho consult in the ED?
|
Unsuccessful closed reduction
Open fracture Neurovascular compromise |
|
Which patients with Colles fracture require close ortho follow-up?
|
Significant displacement (>20degrees)
Marked comminution Intra-articular extension |
|
What is the definition of a Barton's fracture?
|
oblique intraarticular fracture of the rim of the distal radius
displacement of the carpus and the fracture fragment classic bartons -> dorsal volar bartons -> volar |
|
What is a Hutchison's fracture?
|
intra-articular fracture of the radial styloid
|
|
What is the management of a Hutchison/Chauffeur's fracture?
|
Non displaced: short arm cast immobilization for 4-6 weeks
Displaced: ortho consult for ORIF |
|
What is carpal tunnel syndrome?
|
Neuropathy of the median nerve at the wrist resulting from compression of the median nerve within the carpal tunnel
|
|
What are 5 factors that determine the success of non-operative management for CTS?
|
Age >50
Duration > 10months constant paresthesia Stenosing flexor tenosynovitis Positive Phalen's test at less than 30s (0/5 67% of patients were cured by medical therapy, 4-5/5 no patient was cured by medical management |
|
What nerve may be injured in medial epicondyle fractures?
|
ulnar nerve
|
|
what nerve may be injured in olecranon fracture?
|
ulnar nerve
|
|
What are the different positions of humeral shaft fractures
|
if the fracture is proximal to the pectoralis major attachement the proximal fragment abducts and internally rotates and the distal fragment is displaced medially
if the fracture is between the insertion of the pectoralis major and deltoid insertion proximal fragment displaced medially and distal fragment displaced laterally if the fracture is distal to the deltoid insertion the distal fragment is proximally displaced because of the triceps and coracobrachialis |
|
What population of patients get intercondylar fractures?
|
Adults 50-60 with direct trauma to elbow
This requires an emergent ortho consult for ORIF |
|
What is the management of a capitellum fracture?
|
ORIF
|
|
What is the management of a trochlear fracture
|
If non-displaced -> posterior splint x 3 weeks
If displaced -> ORIF |
|
What is the technique for reduction of medial, lateral and anterior elbow dislocations?
|
medial and lateral -> same technique as posterior except that the patient's arm should be in slight extension
anterior -> distal traction of the wrist and a backward pressure on the forearm, while grasping the distal humerus (more common vascular impairment with emergency ortho referral) |
|
What are the risk factors for proximal biceps rupture?
|
It is often associated with impingement
Middle aged athletes or physical laborers with repetitive microtrauma to the tendon |
|
What is the pathophysiology of distal biceps rupture?
|
Avulsion from the insertion on the radial tuberosity
|
|
What is the MOI of distal biceps rupture?
|
unexpected extension force applied to the arm flexed at 90 degrees
|
|
What are the physical findings in distal biceps rupture
|
weakness of elbow flexion and supination
visible deformity and palpable defect of the biceps muscle belly |
|
What is the differential diagnosis for shoulder pain?
|
Referred pain from the neck
-OA of c-spine -disk herniation -muscular spasm or strain Referred pain from the chest/abdomen -ACS, PE, pneumonia, ruptured ectopic, splenic injury, BTD, perforated viscus, any condition causing irritation of the diaphragm Vascular injury -acute thrombosis of the axillary artery Neurologic injury -brachial plexus injury -thoracic outlet obstruction MSK pain -fracture -AC joint separation -shoulder dislocation -rotator cuff tendinitis -subacromial bursitis -long head of biceps tendinitis -rotator cuff tear -biceps tendon rupture -labrum tear/SLAP lesion -adhesive capsulitis -scapulothoracic dysfunction -OA |
|
What is the motor evaluation for the brachial plexus?
|
C2-4 trapezius
C5 deltoid C6 biceps C7 thumb extensors C8 finger flexors T1 hand interossei |
|
What is the sensory evaluation of the brachial plexus?
|
C5 lateral arm
C6 lateral forearm and thumb C7 tip of the long finger C8 tip of the little finger and medial forearm T1 medial arm |
|
What are the standard radiographic views required to assess the shoulder?
|
True AP (35 degrees oblique) because there is no bony overlap
Transscapular lateral (Y view) Axial lateral (projects the glenohumeral join in cephalocaudal plain, useful to define the relationship of the humeral head with the glenoid fossa) |
|
What neurovascular injuries are associated with acromion process injuries?
|
brachial plexus
|
|
What neurovascular injuries are associated with coracoid process injuries?
|
brachial plexus and axillary artery
|
|
What neurovascular injuries are associated with scapular neck, body or spine injuries?
|
suprascapular nerve
|
|
What neurovascular injuries are associated with proximal humerus injuries?
|
brachial plexus, axillary nerve and artery
|
|
What neurovascular injuries are associated with anterior shoulder dislocation?
|
axillary nerve
|
|
What is the classification of scapular fractures?
|
Type 1 - acromion process, scapular spine, coracoid process
Type 2 - scapular neck Type 3 - intra-articular Type 4 - body fractures (most common) |
|
What can be confused with an acromial fracture?
|
Os acromiale (unfused acromial process epiphysis
this is present in 3% of the population and bilateral in 60% |
|
What is the management of scapular fractures?
|
Search for associated injuries
body, spine and non-displaced acromial fractures-> conservative treatment with analgesia, immobilization and passive shoulder exercises displaced acromial fracture with impingement on the glenohumeral joint,scapular neck and glenoid fossa -> surgical treatment |
|
Compare the presentation of anterior and posterior sternoclavicular dislocations?
|
Anterior- due to indirect anterolateral force to the shoulder, then backward roll of the shoulder. Reduction by the EP in the ED.
Posterior - less common, more severe pain, possible harseness, dysphagia, dyspnea and paresthesias in the upper extremity. It results from a direct blow to the medial clavicle or posterolateral force to the shoulder and inward roll. Reduction by ortho is preferred though reduction by EP in the ED if airway or vascular compromise |
|
HOw do you reduce SCJ dislocations?
|
Patient supine
Place a rolled sheet between the shoulder blades Apply traction to the arm that is extended at abducted. PUsh (anterior) or Lift (posterior) the claivicle back into place |
|
What is the most common mechanism for inferior shoulder dislocation?
|
hyperabduction
|
|
What is the most common mechanism for posterior shoulder dislocation?
|
Seizures
FOOSH Direct blow to the anterior shoulder |
|
What is the clinical presentation of anterior, posterior and inferior shoulder dislocation?
|
anterior - arm held in slight abduction and external rotation, squared off, appearance, indistinct coracoid, anterior fullness
posterior- arm held in adduction and internal rotation, squared off, prominant coracoid, humeral head may be palpable inferior - arm locked overhead,humeral head may be palpable along the lateral chest wall, elbow flexed and forearm rests on head |
|
What are the xray findings for anterior, posterior and inferior shoulder dislocation?
|
anterior - hill-sachs lesion, bankart lesion
posterior - loss of elliptical ovelap of the humeral head and glenoid fossa, humeral shaft parallel to the chest wall, rim sign: increased distance between the anterior glenoid rim and the articular surface of the humeral head,light bulb appearance inferior - the superior articular surface of the humeral head appears inferior to the glenoid fossa, humeral shaft parallel to the spine of the scapula |
|
What are the physical findings in the 3 stages of shoulder impingement?
|
Stage 1 - tenderness over the supraspinatus and anterior acromion, painful arc 60-120, positive Neers and Hawkins
Stage 2 - crepitus in the joint and as above Stage 3 - findings of rotator cuff tear |
|
What is the pathophysiology of adhesive capsulitis?
|
inflammatory reaction resulting in the formation of adhesion within the capsule
|
|
What is the presentation of adhesive capsulitis?
|
Typically diabetic women between 40 and 60
Limitation of all shoulder movements pain severe at night and localized over deltoid sense of mechanical restriction on PROM |
|
What is the treatment for adhesive capsulitis?
|
NSAID
intraarticular steroid injection ortho referral for surgery after 6mo of failed conservative treatment |
|
What is the differential for low back pain?
|
Localized common
Uncomplicated musculoskeletal back pain intervertebral disk herniation spinal stenosis spondylolithesis osteoarthritis fracture Infection spondylitis epidural abscess diskitis herpes zoster malignancy breast/lung/prostate multiple myeloma lymphoma leukemia primary cord/extradural tumors osteoid osteoma Peds spondylolisthesis/spondylolysis severe scoliosis scheurmanns disease Rheumatologic ankylosing spondylitis psoriatic arthritis reiter's PMR VAscular AVM epidural hematoma AAA Biliary pathology pancreatitis PUD Diverticulitis REnal colic Pyelonephritis Prostatis Cystitis Menstrual cramps Spontaneous abortion labor ectopic preg PID endometriosis ovarian cyst ovarian torsion sickle cell crisis Functional Somatization Depression Malingering Fibrositis |
|
What are red flags associated with vertebral fracture?
|
recent significant tauma
recent mild trauma in >50 osteoporosis Age>70 |
|
What are red flags for epidural abscess or vertebral osteomyelitis?
|
fever
IVDU recent bacterial infection immunocompromised alcoholism |
|
What are red flags for cauda equina
|
bilateral lower extremity pain
weakness or paresthesia urinary retention loss of rectal sphincter tone saddle anesthesia |
|
What are red flags for back pain caused by malignancy?
|
history of CA
age >50 unexplained weight loss low back pain worse at rest or night |
|
What are red flags for back pain related to AD?
|
syncope
unequal BP in upper extremities pulse deficit of the lower extremities |
|
What are red flags for back pain related to AAA?
|
syncope
Tachycardia hypotension pulsatile abdominal mass |
|
What does back pain in patients <18 years of age suggest?
|
Spondylolysis +/- spondylolisthesis
malignancy osteomyelitis Sheuermanns disease (kyphosis and uneven growth) |
|
What is the management of spondylolisthesis?
|
The majority can be managed conservatively with analgesia and lifestyle changes (limited contact sports)
For patients with refractory or severe back pain, outpatient MRI and NSx referral for possible operative decompression is recommended |
|
What is the classic history associated with spinal stenosis?
|
Older patient (>55) with subacute or chronic pain and lower extremity radiculopathy that occurs with walking and is relieved with rest and bending forward at the waist.
Patient can walk uphill without pain but experiences pain when walking down hill |
|
What is the typical presentation of disk herniation?
|
Age 30-50
low back pain and radiculopathy exacerbated with coughing, sitting or any movement Positive SLR test Presence of sciatica |
|
What are the indications for surgical treatment of disk herniation?
|
Duration of pain >4-6 weeks
Intractable pain Worsening motor or sensory deficit |
|
What is the differential diagnosis for thoracic back pain?
|
Uncomplicated MSK back pain
Spinal cord and nerve root pathology Vertebral column disease Disk infection Primary neurologic disease Degenerative and autoimmune arthropathy Herpes Zoster Vascular disease (thoracic aortic dissection, ACS, pulmonary embolism) Thoracic cavity pathology (pleuritis, pericarditis, pneumonia, esophageal pathology) Intraperitoneal and retroperitoneal abdominal pathology (PUD, pancreatitis, hepatobiliary disease) |
|
How can you clinically r/o a pelvic open fracture?
|
Rectal and vaginal exam
look for skin wound in the pelvic area |
|
What are clinical signs of a pelvic fracture?
|
Rotation of the iliac crests
Tenderness on palpation of the pelvis leg length discrepancy Cullen's sign and Grey Turner's signs indicating retroperitoneal hemorrhage Blood at the meatus and introits Perineal ecchymosis or hematoma Vaginal and rectal exams leading to identification of a presacral hematoma or bony spicule due to an open pelvic fracture |
|
Are routine AP radiographs of the pelvis always required for patients who sustained blunt trauma?
|
No need for pelvis X-ray if the patient is
asymptomatic alert normal physical exam of the pelvis no distracting injury |
|
What are the radiographic clues to identifying anterior column and posterior column acetabular fractures on AP radiograph of the pelvis?
|
Iliopectineal line -> landmark for the anterior column
Ilioischial line -> landmark for the posterior column Posterior wall -> larger more lateral, visualized more easily than the medial wall Anterior wall -> smaller more medial Acetabular tear drop -> composite shadow of the inferomedial structures of the acetabulum, the ilioischial lind should pass through the teardrop on a true AP view of the pelvis |
|
What is the management of a coccygeal fracture?
|
Xrays are not mandatory
Bedrest Stool softeners Analgesia Sitz baths may relieve the muscle spasm Use an inflatable rubber donut cushion Alternate sitting on the side of each buttock Sitting on a hard chair rather than a soft chair |
|
What are the 3 compartments of the thigh?
|
Anterior
Medial Posterior |
|
What structures are found in the anterior compartment of the thigh?
|
Quadriceps femoris
Sartorius iliacus Psoas Pectineus Lateral femoral cutaneous nerve Femoral artery and vein |
|
What structures are found in the medial compartment of the thigh?
|
Gracilis
Adductor longus Adductor magnus Obturator externus Obturator nerve Profundus femoris artery Obturator artery Obturator vein |
|
What structures are found in the posterior compartment of the thigh?
|
Biceps femoris
Semitendinosus Semimembranosus Adductor magnus Sciatic Posterior femoral cutaneous Profundus femoris artery branches |
|
What are the types of hip fracture?
|
Femoral neck
intertrochanteric trochanteric subtrochanteric femoral shaft |
|
What nerve can be injured in femoral shaft fractures?
|
peroneal nerve
|
|
What is the Garden classification of femoral neck fractures and their treatment?
|
Garden 1 - incomplete or impacted fracture
ttx: controversial between non-surgical vs internal fixation Garden 2 - complete fracture but non displaced ttx: closed reduction and internal fixation Garden 3 - complete fracture with partial displacement ttx: closed reduction and internal fixation Garden 4 complete fracture with total displacement ttx: closed reduction and internal fixation |
|
What are the indications for hemiarthroplasty of the hip in patients with femoral neck fractures?
|
age>70
poor general health that would prevent a second operation neurological disease severe osteoporosis pathologic fracture pre-existing hip disease inadequate closed reduction displaced fracture which is several days old |
|
What are the contraindications to hemiarthroplasty of the hip in patients with femoral neck fractures?
|
preexisting sepsis
young patient failure of internal fixation devices |
|
When is AVN a concern in hip injuries?
|
Hip dislocations
Femoral neck fractures |
|
What is the differential diagnosis for a painful hip without an obvious fracture?
|
Referred pain (lumbar spine, hip or knee)
Herniation of a lumbar disk diskitis occult fracture AVN of the femoral head DJD or OA toxic synovitis septic arthritis osteomyelitis tumor (lymphoma) bursitis tendonitis ligamentous injury of the knee or hip DVT arterial insufficiency iliopsoas abscess retroperitoneal hematoma inguinal hernia inguinal lymphadenopathy sports related hernia GU complaints Peds Occult fracture toxic synovitis SCFE Perthes disease |
|
What are the mechanisms of injury in posterior and anterior hip dislocation?
|
posterior: MVC dashboard injury presenting with hip flexed, adducted and internally rotated
anterior: MVC dashboard injury presenting with hip flexed abducted and externally rotated |
|
Which nerves are injured in posterior and anterior hip dislocations?
|
posterior: sciatic (especially the peroneal branch)
anterior: femoral nerve and vessels |
|
Describe the stimson technique for posterior hip dislocation reductions?
|
-Patient prone with affected leg hanging over the edge of the bed
-knee and hip are flexed at 90 degrees -assistant stabilizes the pelvis -operator applies downward traction in line with femur -femoral head is gently rotated, assistant pushes greater trochanter anteriorly toward the acetabulum |
|
What is the post reduction management of a hip dislocation?
|
Test ROm of the hip
verify neurovascular status of the limb place injured extremity in a knee immobilizer abduction pillow to prevent redislocation post-reduction films ortho consult |
|
When do dislocations of prosthetic hips most commonly occur?
|
within 3 months post surgery
|
|
What clinical tests can be used to diagnose ACL injuries?
|
Anterior drawer
Lachman's test Pivot shift test |
|
What clinical tests can be used to diagnose PCL injuries?
|
Posterior drawer
Posterior sag sign |
|
What clinical tests can be used to diagnose LCL and MCL injuries?
|
Collateral ligament stress tests
|
|
What clinical tests can be used to diagnose meniscus injuries?
|
McMurray test
Apley's test |
|
What injury is frequently associated with tibial spine fractures?
|
ACL rupture
|
|
What causes patella alta?
|
Rupture of the patellar tendon
|
|
What causes patella baja?
|
rupture of the quadriceps tendon
|
|
What is the management of a patellar fracture?
|
Nondisplaced - long leg cast for 4-6 weeks and fu with ortho
Displaced - ORIF |
|
What clinical test can be used to identify patients at risk for patellar subluxation?
|
Apprehension test
Anxiety and anticipatory reactions observed in the patient when the examiner attempts to slide the non-displcaed patella laterally |
|
What knee injury presents in 10-20 year olds and is worse with climbing stairs and prolonged flexion?
|
Patellofemoral syndrome
|
|
What knee injury presents as lateral knee pain in a distance runner?
|
Iliotibial band syndrome
|
|
What knee injury presents with knee pain due to repetitive jumping?
|
Jumper's knee or peripaterlla tendinitis
|
|
What knee injury presents in runners as posterior or posterolateral knee pain
|
popliteus tendinitis
|
|
What knee injury presents as anterior tibial pain during or after exercise?
|
Shin splints or periostitis
|
|
Name all the bursa around the knee
|
Suprapatellar
Prepatellar superficial infrapatellar anserine deep infrapatellar |
|
List the structures (bony and ligamentous) of the ring providing stability around the talus
|
Tibial plafound
Medial Malleolus Deltoid ligament Calcaneus Lateral collateral ligaments Syndesmotic ligaments |
|
List radiographs in the standard ankle series?
|
AP
Lateral Mortise |
|
What are limitations of the Ottawa ankle rues?
|
They do not apply to subacute or chronic injuries
They do not apply to paediatrics (**) They only apply to inversion and "rolled ankle" injuries They do not apply to forefoot and hindfoot injuries They do not apply to multiply injured, intoxicated or otherwise difficult to assess patients |
|
What is the mechanism of lateral malleolar fractures?
|
Inversion and internal rotation (adducting force)
|
|
What is a pilon fracture and what is the mechanism of injury?
|
A comminuted fracture of the distal tibia which results from the head of the talus being driven into the tibial plafond. The MOI is axial compression
|
|
What injuries are commonly associated with pilon fractures?
|
Calcaneal fractures
Tibial plateau fractures femoral neck fractures acetabular fractures lumbar fractures |
|
What are mechanisms of Achilles tendon rupture?
|
Direct trauma
Sudden unexpected dorsiflexion Forced dorsiflexion of the plantar flexed foot Strong push off of the foot with simultaneous knee extension and calf contraction |
|
What are the xray features of achilles tendon rupture?
|
Opacification of Kager's triangle
|
|
What are clinical features of peroneal tendon dislocation?
|
Snapping sensation
Tenderness and swelling over the lateral retromalleolar area Inability to evert the foot when held in dorsiflexion |
|
What is the management of peroneal tendon dislocation?
|
CT/MRI confirmation
Orthopedic referral Well molded cast in plantar flexion |
|
What is the most common midfoot fracture?
|
Navicular fracture
|
|
What differentiation must be made about base of the 5th metatarsal fractures?
|
True Jones - transverse diaphyseal fracture (>15mm distal to the proximal end of the bone)
PseudoJones - fracture of the tuberosity (avulsion by the plantar aponeurosis/peroneus brevis) |
|
What is the management of metatarsal base fractures?
|
Nondisplaced MT 1-4 -> below the knee cast
All other MT 1-4 -> ortho consult ? Lisfranc injury |
|
List 3 general causes of foot pain that must be considered in the differential for nontraumatic foot pain
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Reflex sympathetic dystrophy
Retained FB Stress fractures |