Block 4 Ortho Flashcards
(181 cards)
1
Q
Define Achilles Tendon Tear
A
Disruption of the tendon 5-7 cm proximal to insertion of the tendon on the calcaneus
2
Q
A pt present with “gun shot pain” at the distal posterior leg
Sudden and severe pain from playing sports
+positive Thompson test
Think ? Tx?
A
Achilles’ tendon tear
Tx:
Cam boot with heel lift until foot reaches neutral
Rehab consult, RICE, Crutches x5-6 days
Operative: if high level athlete/ active duty
3
Q
When is a Thompson test most reliable for Dx a tendon rupture
A
Within 48 hrs
4
Q
When is rereputure of the Achilles after Tx most common
A
Re-rupture with non-op management more common
5
Q
When should all Achilles tears be referred
A
All complete ruptures within 24 hrs.
6
Q
What are the common injuries for an inversion ankle sprain
A
Inversion injury- ATFL and CFL
7
Q
What is the common injury in a high ankle sprain
A
High ankle sprain= AITFL
Requires Increased recovery time
8
Q
What are the long term ADE of Ankle Sprain
A
Chronic instability
Chronic Pain
Development of Ankle OA
9
Q
What are the two most commonly torn ligaments in an ankle Sprain
A
ATFL and CFL
10
Q
How do you screen for a fx in an ankle injury
A
Palpate lateral/medial malleoli, base of 5th metatarsal
Pain at the navicular
(Ottawas Criteria)
(+inability to bear wt x 4 steps)
Get an X-ray
11
Q
Syndesmosis squeeze test evals what tendon tear
A
AITFL (high ankle sprain)
12
Q
What are the 3 phases of non op treatment of ankle sprains
A
- NSAIDs + rest, brace/air stirrup (2-3wks)
- ROM + strength (2-4 wks after injury and patient can bear weight without pain)
- Proprioception, agility, endurance (4-6 wks after injury)
13
Q
What is the most important part of rehab in an ankle injury
A
To control inflammation in phase 1!
14
Q
What is the most common cause of chronic instability in ankle sprains
A
Incomplete rehab
15
Q
Define bunionette
A
AKA Tailor’s bunion
Deformity of the 5th MTP joint that is analogous to a bunion deformity of the great toe
Characterized by prominence of the lateral aspect of the 5th MT head and medial deviation of small toe
16
Q
What does a bunionette look like on XR
A
Medial deviation of 5th proximal phalanx
lateral deviation of 5th MT shaft and/or prominence on the lateral aspect of the 5th MT head
Normal joint space
17
Q
What is the Tx appraoch to Bunionettes
A
Non-operative-
Advised patients to select roomy toe box shoe
Orthotics- modified metatarsal pads, arch support for flatfoot
Operative-
Osteotomy if continued symptoms despite non-operative treatment
18
Q
A pt presents with skin ulcerations, infections, and Charcot arthropathy
Think?
A
Diabetic Foot
19
Q
What is the progression of Charcot arthropathy
A
results from repetitive stress in a patient who doesn’t perceive pain and proprioception normally
20
Q
Autonomic dysfunction in the feet of DM pts leads to what…
A
Autonomic dysfunction- dry, scaly, and cracking skin predisposes to ulceration
21
Q
What are the ADE of Diabetic Foot
A
Skin Ulcers,
Charcot Joint
Osteomyelitis
Gangrene
22
Q
How can you Dx Charcot vs Cellulitis
A
Charcot: 1 minute elevation above heart= loses redness
infection stays red despite elevation
23
Q
A red hot swollen foot with mild or absent pain
Think
A
Charcot Foot
24
Q
What is the imaging W/u for Diabetic Foot
A
Plain films to help r/o osteomyelitis and Charcot
Vascular studies appropriate- absent pulses or non-healing ulcer
Nuclear medicine to differentiate (tagged WBC)
—cold for Charcot
—hot for osteomyelitis
MRI for osteomyelitis, confirm deep abscess
25
What is the Tx approach to Diabetic foot
Non-operative-
Education and prevention
Serum glucose control
Once neuropathy occurs, its irreversible
Accommodative footwear, orthotics
Total contact casting
Treatment of deep infection
Operative-
Debridement of osteomyelitis
Amputation
26
Most diabetic feet are painless, so a pt with diabetic foot that presents with pain should prompt…
Referral!
27
Define Hallux Rigidus
Degenerative OA of the 1st MTP
Most common arthritis of the foot
-Second most common foot malady
Principle symptoms are pain and stiffness, especially with toe dorsiflexion
28
A pt presents with stiff 1st toe with loss of decreased extension at the 1st MTP
Think ?
Tx?
Hallux Rigidus
Rads will show osteophytes
Tx: Non-operative-
- Wearing shoe with soft, roomy toe box
- Stiff soled shoe modified with steel shank or rocker bottom limits dorsiflexion of the great toe and decreases pain
- Avoid wearing high-heeled shoes
- NSAIDS, contrast baths
Operative-
-Dorsal osteophyte excision w/ Cheilectomy
-Arthrodesis
29
Define Hallux Valgus
Aka Bunion
-Most common malady of the great toe
- Lateral deviation of great toe at 1st
- MTP may lead to painful prominence pf the medial aspect of 1st MT head
10x more common in women
30
What are the NML valgus angles in Hallux Valgus
Hallux valgus angle (HVA)
normal = less than 15 degrees
```
Intermetatarsal angle (IMA)
normal = less than 10 degrees
```
31
What is the Tx approach to Hallux Valgus
Non-operative-
No treatment is needed for asymptomatic hallux valgus
Education and shoe wear
modifications
Roomy toe box
Avoid high heels
Operative-
Osteotomy
32
Persistent pain despite shoe modifications should prompt
referral
33
Describe Interdigital neuroma
AKA Morton Neuroma
Due to Tight shoes
Not a true neuroma, but a perineural fibrosis of common digital nerve as it passes between metatarsal heads
Most common is between 3rd and 4th toes (3rd web space)
34
A pt states it feels like they are walking on a marble or a wrinkle sensation in their sock when walking
On the plantar side of their foot
With toe numbness adjacent to the involved web space
+plantar forefoot pain
+metatarsal head compression Test
Think ?
Tx?
Interdigital neuroma
Tx:
Non-operative-
-Low-heeled, well-cushioned shoe with a wide toe box
-Metatarsal/Decompression pad
-Steroid Injection (diagnostic and therapeutic)
Operative-
-Neuroma excision or plantar nerve release
35
Define metatarsalgia
Forefoot pain localized under one or more of the lesser metatarsals
Lesser MT heads (2-5)
Causes
- Abnormal MT length
- Toe deformities- claw toe, hammer toe
- Metatarsal fat pad atrophy
- Callus formation
36
A pt presents with activity related pain to the plantar aspect of the forefoot with TTP over the Metatarasal heads
States it feels like walking on pebbles
Think?
Dx?
Tx?
Metatarsalgia
```
Dx: WB Ap/Lat Rads
Tx:
Non-operative-
-Accommodative, roomy toe box shoes
-Metatarsal pad, orthotic device
-Pare thickened callus
```
Operative-
- Toe/MT head realignment
- Remove condyle (condylectomy)
37
Describe plantar fasciitis
Inflammation of the PF
PF- arises from medial tuberosity of the calcaneus and extends to the proximal phalanges of the toes
Provides support to the foot
38
What is the most common heel pain in adults
Plantar fasciitis followed by tendinosos
39
A pt presents with focal pain over the medial calcanea tuberosity
And distal along the fascia
Most intense during the first steps of the morning
+TTP at plantar calcaneus
+/- Achilles’ tendon tightness
Think?
Dx?
Tx?
Plantar fasciitis
Dx:
Rads may show a calcaneal heal spur,
Order rads before steroid injection
```
Tx:
Non-operative (95% effective)-
-Orthotic + stretching
-Night splint
Steroid injection
-Shock wave therapy/Botox
```
Rehab consult- control pain and increase ROM
Resolves 6-12 months
40
Describe Plantar warts
Hyperkeratotic lesions on sole of foot
Common from Human papilloma virus
Common in Young athletes, 2nd decade of life
41
When should you order Rads in plantar fasciitis
Should be obtained before steroid injection (lateral)
Symptoms after 6-8 weeks of non-operative treatment
Systemic symptoms or pain at rest
42
What is the Tx approach to plantar warts
Non-operative-
-Most lesions resolve spontaneously in 5-6 months
-Superficial paring then keratolytic (salicylic acid) with occlusion
—Two times a day for 1 month
-Electrocautery, cryotherapy with liquid nitrogen, laser ablation, curettage for resistant warts
43
describe posterior tibial tendon dysfunction
Posterior tibial tendon- one of the main supporting structures of the medial ankle and arch
Primary cause of medial ankle pain in middle-aged patient
Classic presentation- overweight female older than 55 years old
Tendon dysfunction results in flatfoot
Other risk factors include flexible flatfoot, steroid injections, DM, HTN, previous trauma
44
What is the primary cause of medial ankle pain in the middle aged pt
Posterior tibial tendon dysfunction
45
A pt presents with pain and swelling of the medial ankle, with loss of foot arch with a “rolling in “ of the ankle
Think ?
Tx?
Posterior Tibial tendon Dysfunction
```
Tx:
Non-operative-
NSAIDs and activity limitations
-4 weeks short leg cast/cast brace
NOT steroid!
```
-Orthotic with medial longitudinal arch support
Operative-
- Flexible = tendon transfer + osteotomy
- Rigid = arthrodesis
46
What are the long term ADE of Post. Tib. Tendon dys.
Progressive, painful flatfoot with gait disturbance
| Valgus ankle with possible OA
47
What are the prominent risk factors for post. Tibial, tendon dysfunction
Obesity, female, age over 55,
| DM, HTN, steroid injections, Flatfoot, previous trauma
48
what does pes planus mean
Flatfoot
49
Describe sesamoiditis
Embedded in the flexor hallucis brevis tendon beneath first MT head (plantar surface)
Disorders include inflammation, fracture, osteonecrosis, and OA
Occurs due to repeated stress and the subsequent inflammation
50
A pt presents with pain UNDER teh 1st MT head of the foot
+/-swelling
Pt is a long distance runner or dancer
Think?
Tx?
Sesmoiditis of the 1st MT head
```
Tx:
Non-operative-
-Avoid wearing high-heeled shoes
-Sesamoid/decompression pad
-Stiff-soled/rocker bottom shoe
```
Operative-
Sesamoid excision
51
What are the sesamoid s of the 1st mt imbedded in
Flexor Hallucis brevis tendon sheath
52
What are the three main types of toe deformities
Claw toe, Hammer toe, Mallet toe
53
A toe deformity with fixed extension at the MTP, and flexible flexion at the PIP with flexion at the DIP
Think. ?
Claw toe
Most common in Charcot Marie Tooth
Or RA
54
A toe deformity with Flexible extension at the MTP with Fixed flexion at the PIP
Think ?
hammer Toe
55
A toe deformity with Fixed flexion at the DIP
Think
Mallet toe
56
What is the Physical Exam approach to Toe deformities
Evaluate standing and sitting
Note alignment, joint ROM (fixed v flexible)
Neurovascular exam (sensory/motor function)
57
What is the Tx appraoch to Toe deformities
Non-operative-
- Soft, roomy toe box shoe
- Avoid 2 ¼” heels
- Decompression pads for corns
- Toe splints
Rehab consult- Toe strength and flexibility
Operative-
-Proper toe alignment to accommodate for shoe wear (not cosmetic)
58
A pt presents with a claw toe + high arch
Think what condition should you r/o
Neurogenic cause, think Charcot Marie Tooth
59
What is turf toe
1st MTP sprain following hyperextension but can occur with any force ROM
Artificial turf on playing fields
Account for more missed playing time than ankle sprains
60
A pt presents with swelling, tenderness, and limited ROM of the 1st MTP
From playing sports on improved fields
Think ?
Tx?
Turf Toe
Graded:
1= stretch injury or capsule, continue playing with mild symptoms
2= partial plantar tear
3= complete tear, can’t play or walk normally
```
Tx:
Non-operative-
-RICE
-Early ROM when symptoms allow
-Stiff soled/rocker bottom shoe (Grade 1 & 2)
```
Grade 3=
Protected weight bearing or immobilization x 1-2 weeks
-4-6 weeks no play
61
What are the ADE of Dz for turf toe
OA, Hallux Rigidus
62
Define os trigonum
Accessory ossicle of the posterior talus that usually is a normal anatomic variant
Causes boney ankle impingement
63
A pt presents with pain on plantar flexion between the tibia and the talus
Think
Os trigonium
64
A pt presents with Tenderness, swelling at medial aspect of the navicular (insertion of tibialis posterior)
Think
Accessory navicular
+/- pes planus
65
What is the best view to see os trigonum
Lateral view
66
What is the best view to see accessory navicular
Ap is the best view
67
Describe Calcaneal apophysits
Aka Sever disease
Affects active, prepubertal children
Pain posterior aspect of heel that occurs after activity
Typically will resolve once fusion occurs (9-year-old girls or 11-year-old boys)
68
What is the NML age for calcaneal epiphysis closure
(9-year-old girls or 11-year-old boys)
69
What is the Tx approach to calcaneal apophysitis
Non-operative-
-Short term activity modification
¼ in heel lifts/cushion
-Rarely casting, but can be used for 4-6 weeks if pain and limp do not improve with activity modifications, heel lifts.
Operative-
-Almost never surgery
70
Define pes cavus
abnormally high arch resulting from plantar flexion (equinus) of the forefoot or midfoot in relation to the hindfoot
71
A pt comes in with frequent ankle stairs, lots of callous on the foot with a high ankle arch
Think?
Tx
Cavus deformity
Non-operative-
Based on the underlying disorder
Mild & flexible deformities- shoe modifications, arch supports, rehabilitation
Operative-
Most will need – will likely recur due to neuromuscular disease
72
Define Clubfoot
Congential clubfoot or talipes equinovarus
```
Characterized by four clinical components
CAVE-
-midfoot Cavus (high arch)
-forefoot Adduction
-heel Varus (adduction of calcaneus)
-ankle Equinus (plantar flexion)
```
73
What is the W/u for pes clavus
WB ap/lat foot or the meary angle
74
What is the Tx for CLub foot ?
Non-operative-
Ponseti method
(treatment of choice) = serial casting + Achilles release
After casting- Foot abduction brace full time for 3 months then at night for 3 years
Operative-
Most older and those with persistent or recurrent deformities
Soft-tissue release, osteotomies, arthrodesis
Adverse outcomes of treatment-
Recurrence
75
Define flatfoot
Abnormally low or absent loss in the ankle or foot
Most kids is a normal variant
76
When deos the foot arch develop and mature
Arch develops at age 4 and develops to age 10
77
What is the MC type of flat foot
Flexible is most common
Flat foot means its congenital, tarsal coalition, or vertical talus, NMD, or inflammatory dz like RA
78
What type of flat foot is seen in obesity
Idiopathic rigid flat foot
79
A pt presents with loss of arch on WB, with valgus alignment of the hind fort with a medial mall prominence
With abduction of the forefoot
Think
Flat form classic findings (may look like a posterior tendon dysfunction without too many toes sign)
80
What is the special test to assess flatfoot
Jack test to assess arch formation
81
What is the Tx appraoch to Flatfoot
If young just observe to age 10
Can use inserts in the shoe
If Rigid, evaluate for other etiology then SRGRY
If untreated may lead to Achilles’ tendon contracture
82
define metatarsus adductus
Most common foot deformity in infancy characterized by medial deviation of the forefoot
Most often due to intrauterine positioning
83
A newborn presents with adduction of the forefoot relative to the hind foot with a convex lateral foot border
Think
Metatarsus adductus
Graded on the heel bisector line
84
Bisector line of the heel that goes through the middle toe
What severerty metatarsus adductus
Middle for mild
85
A Bisector line of the heel goes through between the 3rd and 4th toe
Think what level severity metatarsus adductus ?
Moderate
86
Define severe metatarsus adductus
A bisector heel line that goes through the last toe or between the last two toes
87
how do you track the progression of metatarsus adductus
Photocopy machine
88
When should you get radiographs for metatarsus adductus
Radiographs rarely needed but indicated when deformity cannot be passively corrected or fails non-operative treatment
89
What are the treatment options for metatarsus adductus
Most newborns do not require active treatment due to spontaneous resolution (flexible)
Rigid
casting v surgery (very few cases)
90
A pt with metatarsus adductus that persist for 3-6 months
What is the approach
Referral, and also for rigid
91
Define Osteochondral Lesions of the talus
Osteochondral lesions of the hyaline cartilage and underlying subchondral bone of the WB surface of the talus can occur after trauma or due to idiopathic avascularity
Cause collapse of the joint surface, delamination of cartilage, loos fragment formation
92
A pt presents with ankle pain, recurrent effusions in the ankle joint space
With a sensation of popping, catching, or giving away of the ankle
With anterior joint line pain
With painful ROM in every direction
and started to occur acutely after injury or intermittently with vigorous activity over weeks to months
Neg ligamentous stress tests
Think ? Tx?
Osteeochondral lesion of the talus
Order a mortise view of the ankle
Non-operative-
Skeletally immature
- Capacity to heal and only require immobilization
Operative-
Older, adolescent approaching skeletal maturity= surgery
Refer all
93
define Tarsal coalition
Abnormal connection between two tarsal bones (fibrous, cartilaginous, osseous)
Most commonly- Calcaneus and navicular or Talus and calcaneus
More than one coalition is rare
94
What are the most common tarsal coalitions
Most commonly
| - Calcaneus and navicular or Talus and calcaneus
95
A pt presents in late childhood or teen years with onset of insidious pain associated with activity/ injury
Has frequent ankle sprains and a limp
+rigid flat foot
+hindoot motion is markedly restricted
(Decreased inversion and eversion)
Think ?
Tx?
Tarsal coalition
Order a Harris Heel view
Ap/lat/oblique
Ct more helpful than mri
Tx:
Observation- asymptomatic or have minimal symptoms
Short leg cast immobilization- severe symptoms or for milder symptoms that persist
(4-6 weeks in cast)
Resection of the coalition- persistent symptoms that do not respond to non-surgical treatment
Arthrodesis- no response to resection or not candidates for resection due to size
96
Define toe walking
Habitual toe walking
Idiopathic = otherwise healthy and no neurologic problems
Normal variation when they begin to walk
Persistent or toe walking that develops after child has been walking with feet flat can indicated underlying disease process
97
Toe walking is typically benign
When is it not
Persistent beyond young age
Or acute onset
Look for Abnormal physical exam
Persistent toe walking despite stretching and rehab
Tight Achilles- may need heel cord lengthening
Unilateral- not normal
Other mental or developmental concerns
98
What are the tx options for Toe walking
Depends on age of child and severity of the problem
Non-operative-
Occasional or toddler just beginning to walk =observation (resolves 3-6 months)
Serial casting
Especially if Achilles tendon contracture
99
Where is the direction of a dislocation determined by
Direction of dislocation is described based on the distal (mobile) fragment
100
Define a segmental fractures
3 distinct pieces of fracture
101
Discribe the difference between butterfly and segmental Fx
Both are comminuted Fxs
Butterfly has an angular butterfly segment
Segmental has three distinct pieces
102
How do you describe angular malalignment in fx
In relation to the apex (where does the arrow point)
103
A fx through only the growth Plate is what type of fracture
Salter Harris 1
104
Describe Salter Harris 2
105
What does OTL RADS mean
```
Open/ Closed
Type (simple, comminuted ect)
Location
Rotation
Angulation
Displacement
Shortening
```
106
Outline salter Harris Type 1-6
107
What are the ADE of growth plates (Fx)
Premature growth arrest leading to limb length discrepancy or angular deformity
Physeal bars
108
When should you order CT for (fx)
When the fx is in a joint line
109
What are the tx options for growth plate fx
Goals: anatomic reduction, maintenance of reduction, avoid growth arrest
Most fractures heal rapidly (4-6 weeks)
S-H 1 & 2-
Injury less than 7 days old= closed reduction and cast immobilization
Displaced and older than 7 days= refer (risk of growth plate reinjury causing arrest
Follow-up at one year (skeletally immature)
Operative-
S-H 3 & 4 (articular)- Open reduction internal fixation
110
What should you suspect in all high energy trauma
Cervical Spine Fracture
111
What must be done before you can ‘clear’ a pt
No clearance until you have examined a coherent patient
Most missed spinal injuries occur in patients who are obtunded, unconscious, and/or intoxicated
112
What is a physical exam for cervical spine
Inspect for swelling, contusions
Step-off or gap = unstable
```
Neurologic exam
—Upper and lower extremities
—perianal sensation
—sphincter tone
—bulbocavernosus reflex
```
113
What are the imaging for cervical spine fx
Initial X-ray
(cross table lateral view)
(Odontoid, or swimmers)
CT is mainstay!
MRI for radicular or ligamentous injury
114
What is the Tx approach to cervical spine injury
Non-operative-
Trauma =
—immobilization until cleared
—C-collar and spine board
Normal rads but pain persists
-C-collar for 7-10 days then follow-up imaging
Operative-
Unstable patterns
-Soft tissue OR fracture
115
What are the likely high energy thoracic spine fx
MVA, fall from height
Flexion-distraction = unstable and associated with abdominal injury
116
A finding of hematoma +step off/gap in the thoracic spin indicates
Unstable flex/ distraction fx or burst fx
117
What is often the initial modality of choice to image a thoracic or lumbar fx
Often CT in the ER
118
What is the Tx approach to Thoracic or lumbar spine Fx
restoring normal function
Compression-
Less than 20 degrees of wedging and no posterior involvement
—brace 8-10 weeks
Treat osteoporosis
Operative-
Unstable burst fractures, flexion-distraction, fracture-dislocations
119
What is the gen appraoch for any type of fracture
Before you do ANYTHING do a neurovascular exam distally
Always get x rays
Be kind, anesthetize
Make it anatomic= “reduce”
Repeat the neurovascular exam
Repeat x rays
120
What are the ADE of Fx at the joint
Secondary Osteoarthritis
121
What are the ADE of Fx at the proximal humerus
Osteonecrosis
| Also in femoral head
122
When should you always get a CT for a Fx
Always at a joint
123
Define high e energy vs low energy lower extremity Fx
Low energy usually stable
| high energy poly trauma usually unstable
124
What are the ADE of LE (Fx)
At a Joint = Secondary Osteoarthritis
Proximal femur= Osteonecrosis of the femoral head
Joint instability
125
What is the approach to Fractures
Always 1st do a neuro vasc exam
Then get X-rays
Sedation then reduction
Then post reduction neuro vasc exam
Then repeat X-ray + CT
126
What nerve should be checked in a pos hip dislocation
Sciatic nerve
127
What nerve should be checked in an ant hip dislocation
femoral nerve
128
What nerve should be checked in all knee injuries
Tibial nerve
129
What special imaging should be ordered for pelvic ring fx
Inlet and outlet views
130
Special imaging for mid foot fx
Midfoot fracture/dislocations- bilateral weight bearing
131
Special imaging for a ankle injury
Ankle- Mortise view
132
Special imaging for a calcaneus fx
Calcaneus- Harris heel view
133
Special imaging for a great toe sesamoid fx
Great toe sesamoids- Sesamoid view
134
Should you order a frog lateral view for a hip Fx
NO! Will cause displacement
135
Every fx at the acetabulum should get what imaging
CT
136
When should you order a MRI for a lower leg injury
MRI can be used on non displaced knee fractures to eval soft tissue concern
137
When would you likely see changed on plain films, bone scan, or MRI for a Fx
plain Film : 2-4 wks
Bone scan: 24-28 hrs
MRI: 72 hrs
138
WHen is non operative tx appropriate for Lower Exteremit Fx
Stable, non-displaced
-Stress fractures non-weight bearing for 6 weeks
Stable, minimally displaced
-Pelvis weight bearing as tolerated for 4-6 weeks
Incomplete (torus or greenstick)
139
What is the major ADE of lower extremity FX
DVT!
140
Describe Posterior Vs anterior Dislocation of the hip
High energy MVA is most common
Fall from great ht
Posterior-
Affected limb is short, flexed, aDducted and internally rotated
Anterior-
flexed, aBducted and externally rotated
141
What is the Tx appraoch to Dislocation of the Hip
Emergency!
Reduction immediately
(+/- sedation PRN)
If no assoc fx then wt bearing as tolerated and f/u with pt
If there is a fx or neurovasc comp. Then operative for —Associated acetabulum fracture
Or Intraarticular bony fragments (arthroscopically)
142
What are the ADE of Hip Dislocation
Adverse outcomes of treatment-
—Cartilage damage or fracture during reduction
—Osteonecrosis of the femoral head (even despite rapid reduction)
143
Define femoral shaft fx and treatment
2/2 High-energy trauma-MVA
Associated with life-threatening pulmonary, intra-abdominal, and head injuries
Non-operative-
Immediate, temporary splinting for comfort and stabilization prior to surgical intervention
Operative-
Skeletal traction- pins in distal femur or proximal tibia
Usually always- Surgery
144
Define Pelvis Fx
Include pelvic ring and acetabulum
- Stable/low energy-Older patients
- Unstable/high energy-Massive blood loss leads to hemodynamic instability which causes death
145
What is the physical exam approach to Pelvis fractures
Neurovascular exam-Spinal nerve roots
Gentle pelvic compression
Blood in the perineal area= urology consult prior to foley placement!!
—Blood coming out of the urethral meatus
—Blood coming out of the anus
146
What are the ADE of pelvis Fx
GU injury- pain/sexual dysfunction
Thromboembolism
Permanent neurological injuries
147
What are the Tx approaches to pelvis Fx
Non-operative-
Stable/low energy- Analgesics, rest, protected weight bearing
(6 weeks)
Operative-
Unstable/high energy-
Hemodynamic stability then definitive surgical treatment
148
Define proximal femur fx
Risk factors- white women, older than 50 years old, sedentary, smoking, alcoholism, psychotropic use, dementia, osteoporosis, living in urban area
Involve either the femoral neck or intertrochanteric region
1 year mortality = 10-30%
149
What are the PE findings of a proximal femur Fx
Short, Ext Rotated, aBducted leg
With pin in the hip area
Unable to perform a straight leg raise
150
What are the two areas that are involved in a proximal femur fx
Femoral neck or the pertorchanteric line
151
What are the Tx approaches to Proximal femur Fx
Non-operative-
Non-ambulatory and/or have dementia with minimal pain associated with transfers
Operative-
Most treated surgically
Urgent surgical fixation within 48 hrs- increased mortality after 48 hrs
152
What is the time frame for repair a proximal femur Fx
48 HRS!
Increased mortality after 48 hrs
153
Define Stress Fx of the femoral neck
Tension- superior side, older, complete and then displace
(older pts more likely to displace)
Compression- young, active (military)
On the inferior side of the femoral neck
154
What is the most sensitive imaging for a stress fx of the femoral neck
MRI
Sensitive for stress fractures and to differentiate tension vs compression
155
What is the Tx approach to stress fractures of the femoral neck
Non-operative- Compression sided
—Cessation of activity with crutches, no weight bearing until fracture healed (6-8 weeks)
Operative- Tension sided whether displaced or nondisplaced
—High tendency to displace
Internal fixation
156
Define fractures around the knesss
Can either be
Distal femur- supracondylar or intra-articular or periprosthetic (knee replacement)
Tibial plateau- usually valgus force that impacts less dense lateral tibial plateau
157
What is the imaging approach to fractures of the knee
Radiographs- AP/lateral of the knee
CT- further assess fracture configuration and displacement of the joint surface
MRI- helps identify nondisplaced fracture and for concomitant meniscal/ligamentous injury
CT Angiography- if ABI less than 0.9
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When should you order a CT Angiography of knee Fx
When the ABI is less than 0.9
159
What is the Tx approach to Fractures of the knee
Nonoperative
- Nondisplaced or minimally displaced fractures
- Partial weight bearing with crutches (6 weeks)
Operative
- Displaced fractures
- Open reduction internal fixation (ORIF)
- Open fractures
- Vascular injuries
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Define a stress Fx
Hairline/microscopic break in bone
Risk factors- overtraining, incorrect biomechanics, fatigue, hormonal imbalance, poor nutrition, vit D deficiency, osteoporosis
Anterior- tension side
Posterior medial- compression side
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What is the imaging work up for a stress fx
Radiographs- Stress fractures not visible until 3 weeks or longer after injury
Bone scan- increased uptake a the location of the stress fracture
MRI- can confirm but false-negative results can occur
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What is the tx approach to stress fx
Non-operative
- Mild- Activity modifications
- Pain with walking- Cast immobilization and limited weight bearing
- Resume normal activities once pain has resolved
Operative
-Anterior tibial stress fracture may require surgical treatment
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What are the Tx options for pediatric femur Fx
Non-operative-
6 months to 5 years old= casting for non-displaced femoral neck, intertrochanteric, and shaft fractures
Operative-
- Displaced femoral neck and trochanteric
- Older than 6 years old
- Distal femur
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What is the approach to pediatric Tibia
Conduct a NeuroVasc exam to assess compartment syndrome
CT at the joint
165
Describe a Lis-Franc Fx
Lisfranc fracture-dislocation
Disruption of the tarsometatarsal joints
Critical injury is the 2nd tarsometatarsal joint
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What are the imaging for Lis Fanc Fx
Bilateral weight bearing
Widening between middle cuneiform and second metatarsal
Avulsion fracture
—CT or MRI if radiographs inconclusive
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What is Tx for a lis Franc Fx
Non-operative-
Non-displaced fractures
-6-8 weeks NWB in cast
-Rigid arch supports x 3 months after casting
Operative-
Displaced
-Open reduction internal fixation vs arthrodesis
168
Define Ankle Fx
Injuries to lateral malleolus, medial malleolus, posterior malleolus, collateral ligaments, and/or talar dome
Stable v unstable
1 side vs. both sides of joint
-Maisonneuve- medial malleolus (deltoid ligament and syndesmosis) + proximal fibula fracture
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A fr to the medial mal, with a tear at the deltoid ligament, and the syndesmosis, + a proximal fibula fracture is called
maisonneuve Fx
170
What is the imaging and tx for ankle Fx
XRay:
Ankle- AP, lateral and mortise
-Proximal tibia/fibula- for Maisonneuve fracture
Tx:
Stable distal fibula- WB cast for 4-6 weeks
Unstable but nondisplaced-NWB cast
Unstable and displaced-ORIF
171
Describe Fxs to the calcaneus and talus
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Severe trauma (MVA, fall from height)
One or the other (seldom both)
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Most are intra-articular
Calcaneus and spine fractures
Associated with compression fractures
(review spine compression fx)
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What is the tx option for calcaneus or talus fx
Splint then elevate then send to ortho with surgery
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What is the tx appraoch to metatarsal fxs
Most heal with nonsurgical treatment
Except proximal 5th MT Zone 2 (Jones Fracture)
-Acute zone 2= Non-weight bearing in a cast x 6-8 weeks
Zone 3- Stress fracture (nonunion or delayed union)
-operative
more than 4mm displacement or more than 10 deg angulation= formal closed or open reduction
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What is the Tx appraoch to zone 2 metatarsal fxs
Acute zone 2= Non-weight bearing in a cast x 6-8 weeks
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What are the referral criteria for metatarsal Fxs
Compartment syndrome
Multiple MT fractures
5th MT zones 2 and 3
Open fractures
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What is the Tx approach to Fxs of the phalanges
Non-operative-
-Buddy taping to adjacent toe
(padding between to avoid maceration)
Rotational deformity or angulation= reduction
Operative-
- Great toe MTP intra-articular fractures
- Open reduction and pinning
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Define sesamoid Fx
1st MTP joint-2 sesamoids
Surrounded by flexor hallucis brevis
Bipartite sesamoids normal variant
Fx Most common to medial
178
What is the imaging approach to a sesamoid fx
AP, lateral, axial foot
Bone scan or MRI
- Cold bone scan = bipartite
- MRI= bone marrow edema
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What is the tx appraoch to a Sesmoid Fx
Non-operative-
Weight bearing as tolerated in boot/stiff- soled shoe x 4 weeks, then stiff-soled shoe with high toe box
-Then MT pad for up to 6 months after fracture clinically healed
Operative-
-Fracture with plantar plate rupture
Adverse outcomes of treatment-
-Hallux rigidus due to extended healing time
180
Define Stress Fx of the Foot/ Ankle
Insufficiency or March fracture
Increase in activity, repetitive overloading
Young women at risk due to Female athlete triad-
- Amenorrhea
- Osteopenia
- Disordered eating
Most common is 2nd MT
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What is the Tx approach to stress Fx of the foot and ankle
Non-operative-
-Most MT stress fractures- Weight bearing as tolerated CAM boot x 4 weeks
Calcaneus or fibula = Weight bearing as tolerated cast x 2-4 weeks
Navicular or 5th MT= Non-weight bearing cast x 4 weeks
Operative-
5th MT stress fracture
