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Flashcards in chapter 42: orthopedics Deck (155):
1

synthesize non mineralized bone cortex

osteoblasts

2

reabsorb bone

osteoclasts

3

stages of healing

1) inflammation
2) soft callus formation
3) mineralization of the callus
4) remodeling of the callus

4

receives nutrients from synovial fluid (osmotic)

cartilage

5

fractures: cross the epiphyseal plate and can affect the growth plate of the bone; need ORIF

Salter-Harris fractures 3, 4, and 5

6

fractures: closed reduction

Salter-Harris fractures 1 and 2

7

epiphysiolysis of the involved growth plate without associated fracture

salter-harris type 1 fracture

8

epiphysiolysis of the involved growth plate without associated fracture; additional metaphysical fracture fragment

salter-harris type 2 fracture

9

salter harris fracture: good prognosis and are usually treated with closed reduction and casting

type 1 and 2 fractures

10

injury results in a fracture through the growth plate and epiphysis

type 3 fracture

11

fracture cross the epiphysis, growth plate (physis), and metaphysis

type 4 fracture

12

injuries require careful ORIF if displaced

type 3 and 4 fractures

13

involves a crush of the growth plate without a fracture and is usually detected late by asymmetric or premature closure of the growth plate

type 5 injury

14

fractures associated with avascular necrosis (AVN)

scaphoid, femoral neck, talus

15

fractures associated with nonunion

clavicle, 5th metatarsal fracture (Jones' fracture)

16

fractures associated with compartment syndrome

supracondylar humerus, tibia

17

biggest risk factor for nonunion

smoking

18

LE nerve: hip adduction

obturator nerve

19

LE nerve: hip abduction

superior gluteal nerve

20

LE nerve: hip extension

inferior gluteal nerve

21

LE nerve: knee extension

femoral nerve

22

presents with back pain, sciatica
herniated nucleous pulposus
nerve root compression affects 1 nerve root below disc

lumbar disc herniation

23

Lumbar disc herniation: weak hip flexion

L3 nerve compression (L2-3 disc)

24

Lumbar disc herniation: weak knee extension (quadriceps), weak patellar reflex

L4 nerve compression (L3-4 disc)

25

Lumbar disc herniation: weak dorsiflexion (foot drop), decreased sensation in big toe web space

L5 nerve compression (L4-5 disc)

26

Lumbar disc herniation: weak plantar flexion, weak Achilles reflex, decreased sensation in lateral foot

S1 nerve compression (L5-S1 disc)

27

dx: lumbar disc herniation

patients with neurologic findings need MRI

28

tx: lumbar disc herniation

NSAIDs, heat, and rest; surgery for substantial / progressive neurologic deficit, refractory cases, severe sciatica, or disc fragments that have herniated into the cord

29

motor: intrinsic musculature of hand (palmar interpose, palmar brevis, adductor pollicis, and hypothenar eminence); finger abduction (spread fingers); wrist flexion

sensory: all of 5th and 1/2 4th fingers, back of hand

ulnar nerve

30

injury results in claw hand

ulnar nerve

31

- motor: thumb apposition (anterior interosseous muscle, OK sign); finger flexors

- sensory: most of palm and 1st 3 and 1/2 4th fingers on palmar side

median nerve

32

nerve involved in carpal tunnel syndrome

median nerve

33

- motor: wrist extension, finger extension, thumb extension, and triceps; no hand muscles

- sensory: 1st 3 and 1/2 4th fingers on dorsal side

radial nerve

34

motor to deltoid (abduction)

axillary enrve

35

motor to biceps, brachialis, and coracobrachialis

musculocutaneous nerve

36

cervical radiculopathy: neck and scalp pain

C1, C2, C3 and C4 nerve compression (C1-2, C2-3, C3-4 discs)

37

cervical radiculopathy: weak deltoid and biceps
- weak biceps reflex

C5 nerve compression (C4-5 disc)

38

cervical radiculopathy: weak deltoid and biceps, weak wrist extensors
- weak biceps reflex and brachioradialis reflex

C6 nerve compression (C5-6 disc)

39

cervical radiculopathy: weak triceps
- weak triceps reflex

C7 nerve compression (most common, C6-7 disc)

40

cervical radiculopathy: weak triceps, weak intrinsic muscles of hand and wrist flexion
- weak triceps reflex

C8 nerve compression (C7-T1 disc)

41

radial nerve

C5-8

42

median nerve

C6-T1

43

ulnar nerve

C8-T1

44

musculocutaneous nerve

C5-7

45

axillary nerve

C5-6

46

on the superior portion of the brachial plexus

radial nerve roots

47

on the inferior portion of the brachial plexus

ulnar nerve roots

48

tx: clavicle fracture

usually just treated with sling (risk of vascular impingement)

49

shoulder dislocation: risk of axillary nerve injury
- tx?

anterior (90%) - tx: closed reduction

50

should dislocation: risk of axillary artery injury
- tx?

posterior (seizures, electrocution)
- tx: closed reduction

51

tx: acromioclavicular separation

sling (risk of brachial plexus and subclavian vessel injury)

52

tx: scapula fracture

sling unless gleaned fossa involved, then need internal fixation

53

tx: midshaft humeral fracture

sling for almost all

54

tx: adults - supracondylar humeral fracture

ORIF

55

tx: children - supracondylar humeral fracture

nondisplaced -> closed reduction; displaced -> ORIF

56

proximal ulnar fracture and radial head dislocation
- tx: ORIF

monteggia fracture

57

fall on outstretched hand, distal radius
- tx: closed reduction

colles fracture

58

subluxation of the radius at the elbow caused by pulling on an extended, pronated arm
- tx: closed reduction

nursemaid's elbow

59

adults: combined radial and ulnar fracture

ORIF

60

children: combined radial and ulnar fracture

closed reduction

61

snuffbox tenderness; can have negative XR

scaphoid fracture

62

tx: scaphoid fracture

all patients require cast to elbow, may need fixation; risk of avascular necrosis

63

supracondylar humerus fracture -> occluded anterior interosseous artery -> closed reduction of humerus -> artery opens up -> reperfusion injury, edema, and forearm compartment syndrome (flexor compartment most affected)

volkmann's contracture

64

symptoms: forearm pain with passive extension; weakness, tense forearm, hypesthesia

volkmann's contracture

65

what nerve is most affect by swelling in volkmann's contracture?

median nerve

66

tx: volkmann's contracture

forearm fasciotomies

67

management: forearm fasciotomies

need to open volar and dorsal compartments

68

- associated with diabetes, ETOH
- progressive proliferation of the palmar fascia of hand results in contractures that usually affect the 4th and 5th digits (cannot extend fingers)

dupuytren's contracture

69

tx: dupuytren's contracture

NSAIDs, steroid injections; excision of involved fascia for significant contraction

70

median nerve compression by transverse carpal ligament

carpal tunnel syndrome

71

tx: carpal tunnel syndrome

splint, NSAIDs, and steroid injection; transverse carpal ligament release if that fails

72

tenosynovitis of the flexor tendon that catches at the MCP joint when trying to extend finger

trigger finger

73

tx: trigger finger

splint, tendon sheath steroid injections (not the tendon itself); if that fails, can release the pulley system at the MCP joint

74

infection that spreads along flexor tendon sheaths of digits (can destroy sheath)

suppurative tenosynovitis

75

tendon sheath tenderness
pain with passive motion
swelling along sheet
semi-flexed posture of the involved digit

4 classic signs of suppurative tenosynovitis

76

tx: suppurative tenosynovitis

midaxial longitudinal incision and drainage

77

rotator cuff tears: what are the muscles?

supraspinatus
infraspinatus
teres minor
subscapularis

78

tx: acutely for rotator cuff tears

sling and conservative treatment

79

when do you consider surgical repair for rotator cuff tears?

surgical repair if the patient needs to retain a high level of activity or if ADL affected

80

infection under nail bed; painful
- tx: antibiotics; remove nail if purulent

paronychia

81

infection in the terminal joint space of the finger
- tx: incision over the tip of the finger and along the medial and lateral aspects to prevent necrosis of the tip of the finger

felon

82

patients have internal rotation and adduction of leg;
- risk of sciatic nerve injury
- tx?

posterior hip dislocation (90%)
- tx: closed reduction

83

patients have external rotation and abduction of leg; risk of injury to femoral artery
- tx?

anterior hip dislocation
- tx: closed reduction

84

tx: isolated anterior ring with minimal ischial displacement

weight bearing as tolerated

85

tx: femoral shaft fracture

ORIF with intramedullary rod

86

tx: femoral neck fracture

ORIF -> risk of avascular necrosis if open reduction delayed

87

what structures are at risk in lateral knee trauma?

can result in injury to ACL, PCL, and medial meniscus

88

positive anterior drawer test
- present with knee effusion and pain with pivoting action; MRI confirms diagnosis

anterior cruciate ligament injury

89

tx: anterior cruciate ligament injury

surgery with knee instability (reconstruction with patellar tendon or hamstring tendon); otherwise physical therapy with leg-strengthening exercise

90

positive posterior drawer test
- much less common than ACL injury; present with knee pain and joint effusion

posterior cruciate ligament injury

91

tx: posterior cruciate ligament injury

conservative therapy initially; surgery for failure of medical management

92

collateral ligament: lateral blow to knee

medical collateral ligament injury

93

collateral ligament: medial blow to knee

lateral collateral ligament injury

94

tx: collateral ligament

tx -
small tear: brace
large tear: surgery

95

what are collateral ligaments associated with?

these injuries are associated with injuries to the corresponding meniscus

96

joint line tenderness; can treat with arthroscopic repair or debridement

meniscus tears

97

what do you need to rule out in posterior knee dislocation?

all patients need angiogram to rule out popliteal artery injury

98

tx: patellar fracture

long leg cast unless comminuted, then need internal fixation

99

tx: tibial plateau fracture and tibia-fibula fracture

ORIF fixation unless open, then need external fixator until tissue heals

100

pain and mass below popliteal fossa (contracted planters) and ankle ecchymosis

plantaris muscle rupture

101

tx: ankle fracture

most treated with cast and immobilization; bimalleolar or trimalleolar fractures need ORGI

102

tx: metatarsal fracture

cast immobilization or brace for 6 weeks

103

tx: calcaneus fracture

cast and immobilization if non displaced; ORIF for displacement

104

tx: talus fracture

closed reduction for most; ORIF for severe displacement

105

nerve most commonly injured with lower extremity fasciotomy

superficial peroneal nerve (foot eversion)

106

nerve: foot drop after lithotomy position or after crossing legs for long periods or fibula head fracture

common perennial nerve (foot-drop)

107

components of anterior leg compartment

anterior tibilal artery, deep peroneal nerve
- muscles: anterior tibialis, extensor hallucis longus, extensor digitorum longus, and communis

108

components of lateral leg compartment

superficial peroneal nerve
- muscles: peroneal muscles

109

components of deep posterior leg compartment

posterior tibial artery, peroneal artery, and tibial nerve
- muscles: flexor hallucis longus, flexor digitorum longus, posterior tibilais

110

components of superficial leg compartment

sural nerve
- muscles: gastrocnemius, soleus, plantaris

111

what are the four compartments of the leg?

anterior, lateral, deep posterior, superficial posterior

112

most likely to occur in the anterior compartment of the leg (get foot drop) after vascular compromise, restoration of blood flow, and subsequent repercussion injury with swelling of the leg compartment

compartment syndrome

113

can occur from crush injuries
- symptoms: pain with passive motion; swollen extremity

compartment syndrome

114

what is the last thing to go in compartment syndrome

distal pusles can be present with compartment syndrome -> last thing to go

115

abnormal pressures in compartment syndrome

pressure > 20-30mmHg

116

dx: compartment syndrome

based on clinical suspicion

117

tx: compartment syndrome

fasciotomy

118

can occur in metaphysis of long bones in children; most commonly staph
- symptoms: pain, decreased use of extremity

osteomyelitis

119

dx: osteomyelitis

MRI, bone biopsy

120

tx: osteomyelitis

incision and drainage; antibiotics

121

prepubertal females, right thoracic curve most common, usually asymptomatic

idiopathic adolescent scoliosis

122

tx: idiopathic adolescent scoliosis - curves 20-45 degrees

need bracing to slow progression, which can occur with growth spurt

123

tx: idiopathic adolescent scoliosis - curves > 45 degrees or those likely to progress

spinal fusion

124

tibial tubercle apophysitis; caused by traction injury from the quadriceps in adolescents aged 13-15; most commonly have pain in front of the knee

Osgood-Schlatter disease

125

xr: osgood-schlatter disease

irregular shape or fragmenting of the tibial tubercle

126

tx: osgood-schlatter disease

mild symptoms -> activity limitation, severe symptoms -> cast 6 weeks followed by activity limitation

127

AVN of the femoral head; children 2 years and older
- can result form a hyper coagulable state; bilateral in 10%
- symptoms: painful gait limp

Legg-Calve-Perthes disease

128

xr: legg-calve-perthes disease

flattening of the femoral head

129

tx: legg-calve-perthes disease

maintain range of motion with limited exercise; femoral head will remodel without sequelae

130

when do you consider surgery for legg-calve-perthes disease?

surgery if femoral head is not covered by the acetabulum

131

males aged 10-13 ; increased risk of AVN of the femoral head; painful gait

slipped capital femoral epiphysis

132

xr: slipped capital femoral epiphysis

widening and irregularity of the epiphyseal plate

133

tx: slipped capital femoral epiphysis

surgical pinning

134

- more common in females
- tx: pavlik harness, which keeps the legs abducted and the femoral head reduced in the acetabulum

congenital dislocation of the hip

135

tx: clubfoot

serial casting

136

MCC bone tumors

most common is metastatic disease
#1 breast
#2 prostate

137

tx: bone tumors secondary to metastatic disease

internal fixation with impending fracture (> 50% cortical involvement); followed by XRT

138

most common primary malignant tumor of bone

multiple myeloma

139

tx: multiple myeloma

chemotherapy for systemic disease; internal fixation for impending fractures

140

tx: pathologic fracture from bone tumors

treat with internal fixation

141

management: pathologic fractures from bone tumors

XRT can be used for pain relief in patients with painful bony metastases

142

most common primary bone sarcoma, usually around the knee

osteogenic sarcoma

143

demographic of osteogenic sarcoma

80% in patients

144

xr: osteogenic sarcoma

codman's triangle -> periosteal reaction

145

tx: osteogenic sarcoma

limb-sparing resection; XRT and doxorubicin-based chemotherapy can be used preoperatively to increase chance of limb-sparing resection

146

benign bone tumors treated with curettage +/- bone graft

osteoid osteoma, endochondroma (may be able to observe), osteochondroma (resection only if cosmetic defect or causing symptoms), chrondoblastoma, non ossifying fibroma (may be observed) and fibrodysplasia

147

tx: giant cell tumor of bone

total resection +/- XRT (Benign but 30% risk of recurrence; also has malignant degeneration risk)

148

formed by subluxation or slip of one vertebral body over another

spondylolisthesis

149

where does spondylolisthesis most commonly occur?

lumbar region

150

most common cause of lumbar pain in adolescents (gymnasts)

spondylolisthesis

151

tx: spondylolisthesis

depends on degree of subluxation and symptoms - ranges from conservative treatment to surgical fusion

152

tx: cervical stenosis

surgical decompression if significant myelopathy present

153

tx: surgical decompression for cases refractory to medical treatment

lumbar stenosis

154

tx: torus fracture

buckling of the metaphyseal cortex seen in children (i.e. distal radius)

155

tx: open fractures

need incision and drainage, antibiotics, fracture stabilization, and soft tissue coverage.