Ch. 4 Ortho Flashcards
(192 cards)
1
Q
Which antibiotic is preferred in open fractures?
A
first generation cephalosporin
2
Q
What antibiotic should be given in addition to ancef if it is a crush injury, contaminated, or wound >5 cm?
A
aminoglycoside
3
Q
Which two nerves/vessels are commonly injured with anterior shoulder dislocations?
A
Axillary N.
Axillary A.
4
Q
Which nerves/vessels are commonly injured with humeral shaft injuries?
A
Radial N.
5
Q
Which nerves/vessels are commonly injured with medial epicondylar fractures?
A
Ulnar N.
6
Q
Which nerves/vessels are commonly injured with Supracondylar fractures and/or elbow dislocations?
A
Brachial A.
Radial, ulnar, and median N.
7
Q
Which nerves/vessels are commonly injured with hip dislocations?
A
Femoral N.
8
Q
Which nerves/vessels are commonly injured with knee dislocations?
A
Popliteal A.
Peroneal (fibular) and Tibial N.
9
Q
Which two nerves/vessels are commonly injured with lateral tibial plateau fractures?
A
Peroneal (Fibular) N.
10
Q
If axillary N. was injured, what would you find on exam?
A
Deltoid muscle paralysis—check by asking patient to abduct shoulder against resistance
11
Q
If Radial N. was injured, what would you find on exam?
A
Loss of wrist extension, inability to give “thumb’s up”
Numbness of dorsal web space
12
Q
If Ulnar N. was injured, what would you find on exam?
A
Inability to spread fingers against resistance
Numbness over dorsal and palmar surfaces of fourth/fifth digits
13
Q
If Median N. was injured, what would you find on exam?
A
Inability to make “ok sign”
Numbness over palmar aspect of index finger
14
Q
If Femoral N. was injured, what would you find on exam?
A
Weakened extension at knee
Numbness over anterior/medial thigh, medial shin, arch of foot
15
Q
If Peroneal N. was injured, what would you find on exam?
A
Weakened dorsiflexion at ankle (“foot drop”)
Numbness over anterior shin, dorsal foot
16
Q
If Tibial N. was injured, what would you find on exam?
A
Weakened plantarflexion, dorsiflexion, and eversion of foot at ankle
Numbness over lateral aspect of calf and foot
17
Q
Which 4 bones are most commonly implicated in avascular necrosis?
A
femoral head, proximal scaphoid, capitate, and talus fractures
18
Q
Where is compartment syndrome most commonly seen?
A
tibia fractures; in anterior compartment
19
Q
In compartment syndrome, when is fasciotomy indicated?
A
Surgical fasciotomy indicated for compartment pressure > 30 or within 30 mm Hg of mean arterial pressure (MAP)
20
Q
How is compartment syndrome diagnosed?
A
Clinical diagnosis: Excessive or increasing pain, pain on passive stretch, paresthesias, tender/tight compartment
21
Q
When does Fat Embolism Syndrome most commonly occur?
A
Most common 1-2 days after LONG bone and PELVIC fractures or surgical repair
22
Q
What is the triad of Fat Embolism Syndrome?
A
- Respiratory distress/hypoxemia
- Petechiae
- Altered mental status
23
Q
What is the treatment for Fat Embolism Syndrome?
A
supportive
24
Q
What is a Volkman ischemic contracture?
A
Flexion contracture of hand/wrist due to untreated forearm compartment syndrome or brachial artery injury and resultant muscle ischemia
25
Where does an anterior shoulder dislocation most commonly occur?
Subcoracoid
26
What is the mechanism of injury that causes anterior shoulder dislocation?
Blow to abducted, externally rotated arm, or less commonly fall on the outstretched hand (FOOSH)
27
What imaging view is most helpful for looking at anterior shoulder dislocations?
Y view; anterior dislocation: humeral head will appear anterior to the glenoid
28
What is a sign of axillary nerve injury as a complication of anterior shoulder dislocation?
loss of sensation at "badge" area of shoulder, weak abduction due to deltoid paralysis
29
What is a Bankart lesion?
an avulsion of the anteroinferior glenoid labrum (often diagnosed on MRI); If present, high incidence of instability and may require SURGERY
30
What is a Hill-Sachs deformity
an impaction fracture of the posterolateral aspect of the humeral head
(generally not clinically significant enough unless large enough to cause instability)
31
What is the mechanism of injury that causes a posterior shoulder dislocation?
significant direct force to the anterior shoulder classically from a seizure, electrocution, or high speed injury -- fall from height or grabbing dashboard during MVC
32
How does posterior shoulder dislocation appear clinically?
arm is adducted and slightly internally rotated (patient cannot externally rotate the arm); coracoid process in prominent anteriorly
32
How does posterior shoulder dislocation appear clinically?
arm is adducted and slightly internally rotated (patient cannot externally rotate the arm); coracoid process in prominent anteriorly
33
What is another name for inferior shoulder dislocation?
Luxatio Erecta
34
What mechanism of injury causes inferior shoulder dislocations?
hyperabduction of the shoulder
35
How does inferior shoulder dislocation appear clinically
Arm is held in fixed position up over head 180 degrees
36
What is the treatment for inferior shoulder dislocation?
procedural sedation and closed reduction via traction-countertraction
37
What accompanies inferior shoulder dislocations?
rotator cuff disruption and tear though inferior capsule ; often associated with fractures of proximal humerus; also has high incidence of neurovascular compromise, including axillary nerve, brachial plexus, and axillary artery injuries
38
What examination test is positive in rotator cuff tears?
Drop arm test - patient abducts to 90 degrees, then lowers slowly to side; positive if unable to lower slowly
39
What is the treatment for AC joint separation?
Depends on degree of separation
40
When is immediate orthopedic consultation necessary for clavicular fractures?
open fractures, skin tenting, or neurovascular injury; or severely comminuted (>20 mm of shortening or 100% displacement)
41
What is the most common location of clavicular fractures?
middle third (80% of clavicle fractures)
42
Why are 3rd degree posterior sternoclavicular injuries so bad?
25% chance of life-threatening injuries, including esophageal rupture, carotid artery injury, and injury to great vessels
43
What are complications of scapular injury?
Rib fractures, pneumothorax, hemothorax, pulmonary contusion, clavicular
fractures, shoulder dislocation with associated rotator cuff tears, neurovascular
injuries, and vertebral compression fractures.
44
What are the four parts of the proximal humerus?
humeral head
greater tuberosity
lesser tuberosity
humeral shaft
45
What is the treatment for a nondisplaced humeral shaft fracture?
stabilization with coaptation splint with sling or hanging cast
46
What is the most common complication of humeral shaft fractures?
radial nerve injuries; neuropraxia that resolves after weeks to months;
radial nerve injury causes weakness of the extensors of the wrist and digits and numbness of the dorsoradial aspect of the hand
47
How are supracondylar fractures classified?
Gartland classification
48
What is the Gartland classification system for supracondylar elbow fractures?
Type I (nondisplaced) may be immobilized in posterior splint with orthopedic follow-up in 48 hours.
Type II (some displacement but intact posterior cortex) and Type III (completely displaced, no cortical contact) require urgent operative management.
49
What is the treatment for NONdisplaced condylar fractures?
Posterior splint and early orthopedic follow-up; displaced comminuted or otherwise complicated fractures require immediate ortho consultation
50
Medial epicondylar fractures are more common in children; 50% are associated with an associated _____ injury
ulnar nerve
51
How are elbow dislocations classified?
according to position of ulna relative to humerus
52
What is the mechanism of injury that causes posterior elbow dislocations?
FOOSH with elbow hyperextended
53
What is the mechanism of injury that causes anterior elbow dislocations?
Direct posterior blow to flexed elbow
54
How will a posterior elbow dislocation appear clinically?
Posterior prominence of the olecranon with swelling, shortened forearm held in 45° flexion
55
How will an anterior elbow dislocation appear clinically?
Elongated forearm, arm held in full extension
56
What is the most serious complication that can occur with elbow dislocations?
Brachial artery injury
57
How do you treat a NONdisplaced olecranon fracture?
posterior splint
58
How do you treat an olecranon fracture with >2mm displacement
Ortho consult for possible ORIF
59
What is a complication that can occur with olecranon fracture?
ulnar nerve injury; loss of triceps flexion
60
What is the treatment for NONdisplaced radial head fracture?
Sling and early ROM; more complicated fractures require operative intervention
61
What do you call a distal radius fracture with dorsal displacement?
Colles fracture
62
What do you call a distal radius fracture with volar displacement?
Smith fracture
63
What do you call a distal radius rim fracture with intra-articular involvement?
Barton fracture
64
What do you call a radial head fracture and dislocation of the distal radioulnar joint?
Essex-Lopreseti fracture
65
What do you call a radial shaft fracture with dislocation of distal radioulnar joint?
Galeazzi fracture
66
What do you call a midshaft ulnar fracture?
Nightstick fracture
67
What do you call an ulnar shaft fracture with radial head dislocation
Monteggia fracture
68
What is the treatment for a Colles fracture?
reduction,
sugar tong splint,
orthopedic follow-up
69
What are the goals of reduction for Colles fractures?
Neutral volar tilt, <5 degrees loss of volar inclination, <2-3 mm loss of length, step off <2mm
70
What is the treatment for Smith fractures?
closed reduction,
long arm or sugar tong splint
ortho follow up
71
What is the treatment for Barton fractures?
ORIF for joint stabilization
Barton fracture -- Dorsal or volar rim fracture of the distal radius, intra-articular, disrupts
radiocarpal joint
72
What is the difference between Essex-Lopreseti and Galeazzi fractures?
Essex-Lopreseti --
A radial head fracture with dislocation of the distal radioulnar joint and disruption of the interosseous membrane (similar to Galeazzi, but radial head is fractured instead of shaft).
73
What is the treatment for Essex-Lopreseti fractures?
sugar tong splint & ortho referral
74
What is the treatment for Galeazzi fractures?
Sugar tong splint and referral to ortho for ORIF;
this is an UNSTABLE fracture
75
What is the treatment for Monteggia fracture?
reduction, long arm splint, ORIF
76
What is a frequent complication of Monteggia fractures?
Radial Nerve injury
77
What is the treatment for simple nightstick fractures?
Long arm splint
78
What is the most common carpal fracture?
Scaphoid fracture
79
What mechanism of injury causes scaphoid fractures?
FOOSH
80
What is the treatment for scaphoid fractures?
thumb spica and ortho follow up in 7-10 days
81
What is the second most common carpal fracture?
Triquetral fracture
82
What is the treatment for triquetral fracture?
Volar splint
83
What is a boxer's fracture?
a fracture of the fifth metacarpal neck
84
What degree of angulation of a fifth metacarpal fracture is unacceptable and warrants reduction?
>40 degrees of volar angulation is unacceptable
85
What is a Bennett fracture?
Intra-articular fracture of thumb at the base of the metacarpal with associated subluxation or dislocation at the carpometacarpal joint
86
What is a Rolando's fracture?
Comminuted intra-articular fracture of the thumb at the base of the metacarpal.
87
How are fractures of first metacarpal treated?
thumb spica, ortho consult
88
How do you treat fractures of digits that are stable and nondisplcaed?
buddy taping
89
What is gamekeepers thumb?
Rupture of the ulnar collateral ligament (UCL), also known as skier’s thumb.
90
What is the mechanism of injury for gamekeepers thumb?
Hyperabduction of the thumb (eg, fall on the hand while holding a ski pole) leads to a tear of this ligament or avulsion from its insertion site on the base of the proximal phalanx.
91
Where does the Flexor Digitorum Superficialis insert?
FDS divides into two slips that insert on
either side of the middle phalanx
92
Where does the Flexor Digitorum Profundus insert?
passes through these slips to insert on the base of the distal phalanx
93
What is the treatment for injuries to Flexor Digitorum Profundus and/or Superficialis?
Surgical repair
94
What is Mallet finger?
extensor tendon rupture at its insertion site on the base of distal phalanx
95
What is a Boutonniere deformity?
Disruption of the extensor tendon at the central slip over the PIP
96
What is the gold standard for diagnosing femoral neck fractures?
MRI (CT has an unacceptably high misdiagnosis rate)
97
What is a complication of femoral trochanteric and shaft fractures?
Hypovolemia -- can have up to 3L blood loss into fracture site and thigh compartment
98
What is the treatment for nondisplaced patella fractures?
immobilization in full extension
with weight bearing as tolerated and orthopedic referral
99
What is the treatment for patella fractures with >3 mm displacement or loss of extensor function?
Ortho referral for surgical intervention
100
What is the treatment for Patella dislocation?
Reduction by placing knee in full extension, hip in some flexion and pushing on patella medially up and over lateral condyle;
Once reduced, immobilize in full extension for Ortho follow-up
101
What is the most common fracture of the knee?
tibial plateau fracture (usually lateral plateau)
102
How are tibial plateau fractures treated?
Nondisplaced fractures can be treated with knee-immobilizer and non–weight bearing. Displaced fractures require ORIF.
103
What is the most common knee ligamentous injury?
ACL injury
104
What is the "terrible triad" of knee injuries?
ACL, MCL, medial meniscus injury
105
What is the most sensitive physical exam test for ACL tear?
Lachman test -- Instability with anterior stress in 15°-30° of flexion (anterior drawer test is in 90 degrees of flexion)
106
What is the McMurray test?
Pain as the knee is brought from full flexion to 90° flexion while the leg is externally rotated with compression over the medial joint
line and/or when the leg is internally rotated with compression over the lateral joint line;
Medial joint line pain = medial meniscus injury
107
What is the Apley test?
In prone position with knee flexed 90º, pain as knee is internally/externally rotated with downward pressure to heel;
Indicated Meniscal injury
108
What is the Ege test?
In squatting position, pain, and/or click on maximum rotation of knee;
External rotation = medial meniscus tear
Internal rotation = lateral meniscus tear
109
Describe a Grade I (first degree) sprain.
Ligamentous stretching without tear or rupture.
No joint instability.
Able to bear weight.
110
Describe a Grade II (second-degree) sprain.
More significant ligament damage (partially torn), but no joint instability.
Limp with walking.
111
Describe a Grade III (third-degree) sprain.
Torn ligament with joint instability. Unable to bear weight, severe swelling.
112
What is the treatment for ankle sprain?
■ If ankle is unstable, consider posterior splint and urgent orthopedic referral.
■ If ankle is stable but patient is unable to bear weight, rest, ice, compression, elevation, crutches, apply ankle brace, and follow-up in one week with orthopedics.
113
What is the most commonly injured ligament in the ankle?
ATL -- anterior talofibular ligament
114
What is the mechanism of injury for the ATL?
Inversion with internal rotation of a plantar-flexed foot
115
What is the mechanism of injury for the medial deltoid ligament?
Eversion and external rotation of foot
116
What is it called when a medial deltoid ligament injury is associated with proximal fibula fracture?
Maisonneuve fracture
117
What test can be used to evaluate for syndesmosis sprains?
positive Squeeze test -- examiner firmly grasps the patient's lower leg and "squeezes" the distal tibia and fibula together, causing pain if the injury is present
118
What exam finding would be present in peroneal / fibular tendon subluxation/dislocation/injury?
- swelling posteriorly/inferiorly to lateral malleolus in abscess of tenderness over anterior ATL
- when held in dorsiflexion, unable to evert the foot
119
What is the treatment for peroneal tendon injury?
Splint in midplantar flexion; ortho referral for possible surgical repair
120
What are 4 risk factors for achilles tendon rupture?
1. older age
2. rheumatoid arthritis
3. Lupus
4. Recent fluoroquinolone use
121
What is the typical mechanism of injury for achilles tendon rupture?
forceful plantar flexion against resistance
122
How is achilles tendon rupture diagnosed on physical exam?
Abnormal Thompson test -- position patient prone with knee bent to 90 degrees. Squeeze the calf. If tendon is intact, the foot should plantarflex.
123
What is the treatment for achilles tendon rupture?
Posterior splint in plantar flexion
aka "Equinus splint"; Ortho consult -- early surgical repair leads to better outcomes.
124
What are 4 types of ankle fractures that require ortho consult in ED?
1. Any unstable joint, including bimalleolar fractures
2. Intra-articular fractures
3. Open fractures
4. Fracture dislocation
125
What is a Maisonneuve Fractures?
Ankle-eversion injury with forces transmitted along interosseous membrane
causing proximal fibula fracture.
May also be associated with avulsion fracture of the medial malleolus, rupture of the deltoid ligament, or distal tibiofibular syndesmosis.
126
What is the treatment for Maisonneuve fracture?
Often requires ORIF to stabilize the tibiofibular syndesmosis
127
What is the most commonly fractured tarsal bone?
Calcaneus
128
What is Bohler's angle and what is it used for?
angle between a line formed from the posterior tuberosity of the calcaneus and the apex of the posterior facet and a line between the apex of the posterior facet and anterior process of the calcaneus
Used to detect calcaneus compression fracture
129
What is a normal Bohlers angle? What is abnormal?
Bohler’s angle of 20°-40° is normal
<20° is abnormal --> compression fracture
130
What is the treatment for calcaneal fractures?
Bulky Jones dressing, posterior splint, non–weight bearing; orthopedic consult.
■■ Surgical repair (when needed) is delayed up to three weeks until swelling is improved.
131
What is a complication that can occur in comminuted calcaneal fractures?
Comminuted fractures have a high rate of compartment syndrome.
132
What is the treatment for minor talar avulsion fractures?
posterior splint and crutches
133
What is the treatment for major fractures of the neck and body of talus?
Ortho consult, often requires ORIF
134
What is a common complication of talus fracture?
High rates of AVN
135
What do you call a tarsometatarsal fracture?
Lisfranc fracture
136
What is the Lisfranc joint?
the tarsometatarsal complex made up of the 5 metatarsals and their adjoining tarsal bones (3 medial cuneiforms and 2 lateral cuboids).
Lisfranc injuries are Ortho emergencies
137
When should you suspect a Lisfranc fracture?
if there is gap > 1 mm between the base of the first and second or second and third metatarsals or any fractures around the Lisfranc joint.
138
What is Fleck sign and what does it represent?
an avulsion fracture of the base of the SECOND metatarsal on the medial side
it is pathognomonic of a Lisfranc fracture
139
Lisfranc injuries are commonly associated with injury to which vessel?
Dorsalis Pedis artery
140
What is a Jones fracture?
a transverse fracture through the metaphyseal-diaphyseal junction of the FIFTH metatarsal;
the fracture will be at least 1.5 cm distal to the base of the 5th metatarsal
141
What is the treatment for a Jones fracture?
splint, NWB, ortho referral for possible ORIF
142
What is a Pseudo-Jones Fracture?
Avulsion of the base of the fifth metatarsal
(more common than Jones frcatures)
143
What is the treatment for a Pseudo-Jones fracture?
Ankle stirrup splint, hard post-op shoe, or rocker walker.
144
What type of spread most commonly causes osteomyelitis in adults? in children?
adults -- contiguous spread
children -- hematogenous spread
145
What organism most commonly causes osteomyelitis?
Staph aureus
146
Which antibiotics should be used to treat Osteomyelitis caused by injection drug use?
PRP (nafcillin, dicloxacillin) + antipseudomonal aminoglycoside (tobramycin, amikacin, gentamycin)
147
Which antibiotics should be used to treat Osteomyelitis caused by chronic infection or diabetic foot infection?
PRP (nafcillin, dicloxacillin) + fluoroquinolone + flagyl
148
What indicates a positive straight leg raise?
Positive when back pain is elicited, radiating past the knee, at an elevation <60 degrees
149
What does a positive contralateral straight leg raise indicate?
highly specific for sciatica
150
Which systemic rheumatic diseases cause symmetric joint involvement?
1. rheumatic arthritis
2. SLE
3. viral
4. IBD
5. Spondylitis
151
Which systemic rheumatic diseases cause asymmetric joint involvement?
1. psoriatic arthritis
2. reactive arthritis
152
What organism is most commonly found in septic joints?
staph aureus
153
What medication should not be used in acute gout attacks?
Allopurinol
154
Which medications CAN be used in acute gout attacks?
NSAIDs, steroid injection, colchicine
155
What viruses most commonly cause a polyarthritis?
1. Parvovirus
2. Hepatitis A, B, and C
parvovirus will also have "slapped cheek" and lacey rash
156
What is the triad of Reiter syndrome?
conjunctivitis
urethritis
polyarthritis
seen in males 15-30 years old
157
What is the treatment for Reiter syndrome?
NSAIDs; antibiotics are NOT helpful
158
What gene is commonly associated with Reiter syndrome?
HLA-B27 (80-90%)
159
What joints are most commonly affected by septic arthritis?
Large joints of lower extremity (hip and knee)
160
What is the only way to definitively diagnose a septic joint?
Joint fluid cultures is the only definitive test
161
If endemic to the area, Lyme should be considered in a monoarticular arthritis. How do you test for this?
Serum antibody titers
162
What are risk factors for bursitis?
diabetes, ETOH use, overlying skin disease, trauma (most common), and steroid use
163
What cell counts for aspirate suggest infection in suspected bursitis?
WBC counts >5000/uL
164
What is the treatment for septic bursitis?
oral antistaph abx (eg oxacillin)
165
What is the most common electrolyte abnormality seen in rhabdomyolysis?
hypocalcemia
(however, hyperkalemia is the most lethal)
166
How is rhabdo diagnosed?
CK >5x normal limit (about ~1000U/L)
167
Why must platelets and coags (PT/PTT) be monitored in rhabdo?
rhabdo can cause DIC
168
What urine output should you target is IV hydration for patient's with rhabdo?
3ml/kg/hr
169
What is carpal tunnel syndrome?
A compressive neuropathy of the median nerve (at the level of the carpal tunnel in the volar aspect of the wrist)
170
What is a positive Durkin Compression test?
Reproduction of symptoms with compression of carpal tunnel for 30 seconds.
for carpal tunnel syndrome
171
What is a positive Phalen sign?
Reproduction of symptoms with hyperflexion of wrists at 90° for 1 minute.
for carpal tunnel syndrome
172
What is a positive Tinel sign?
Pins-and-needles sensation in the median nerve distribution with tapping on the carpal tunnel.
for carpal tunnel syndrome
173
What is a positive Flick sign?
Shaking or “flicking” the hands provides relief of symptoms during episodes.
for carpal tunnel syndrome
174
What do you call synovitis of the tendons in the first dorsal wrist compartment?
De Quervain Tenosynovitis
175
What causes de quervain tenosynovitis?
thickening of the extensor retinaculum of the wrist from repetitive trauma or wrist movement
176
What symptoms/exam is present in De Quervain Tenosynovitis?
pain over radial styloid that radiated proximally or down thumb
177
What physical exam test can be used to test for De Quervain tenosynovitis?
Finkelstein test - pain near radial styloid upon ulnar deviation of wrist with hand in fist position
178
What is the treatment for de quervain tenosynovitis?
rest, ice, NSAIDs, thumb spica splint
179
What is the treatment for plantar fasciitis?
conservative management with rest, orthotics, stretches; surgery is rarely needed
180
What is felon?
infection of the fingertip pulp
181
What bacteria most commonly causes felon?
s. aureus
182
What is the treatment for felon?
early --> warm soaks and antibiotics
otherwise I&D may be necessary in addition to abx
183
What is paronychia?
soft tissue infection along the border of the fingernail or paronychium that results from the breakdown of skin (trauma, nail biting) and entry of bacteria or fungi into the nail fold
184
What bacteria most commonly causes acute paronychia?
s. aureus
185
What commonly causes chronic paronychia?
candida albicans
186
What is the treatment for acute paronychia?
early --> warm soaks and antibiotics
possible need for I&D in addition to abx
Do not incise if herpetic whitlow is suspected
187
What is flexor tenosynovitis?
Infection of flexor tendon sheaths of the fingers
true surgical hand emergency
188
What organisms most commonly cause flexor tenosynovitis?
S. aureus and streptococci
189
What symptoms and exam are present in flexor tenosynovitis?
Symptoms/Examination (Kanavel Cardinal Signs)
■■ Flexed posture of the involved digit
■■ Fusiform swelling of the finger (“sausage digit”)
■■ Tenderness over the flexor tendon sheath
■■ Pain with passive extension
190
What is the treatment for flexor tenosynovitis?
1. immobilize and elevate
2. IV abx -- amp/sulbactam, keflex, or vanc
3. consult hand surgery
191
What is the treatment for high pressure injection injuries?
SURGICAL EMERGENCIES
splint and elevate
antibiotics, tdap
analgesia -- NO digital blocks
EMERGENCT ortho consultation
