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Orthopedics > Exam > Flashcards

Exam Flashcards

1
Q

Genu varum

A

“Bow-legged”
Shortening/hardening medial collateral ligament
Varus stress: rupture of LCL

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2
Q

Genu valgum

A

“Knock-kneed”
Collapsing of lateral compartment
valgus stress: rupture of MCL

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3
Q

Sprain

A

Stretching and/or tearing of the ligaments supporting an articulation (joint)

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4
Q

Strain

A

Stretching and/or tearing of the musculotendinous unit

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5
Q

Tendonitis/Tendinitis

A

Inflammation/irritation of a tendon

Commonly due to overuse

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6
Q

Tendinosis

A

AKA “chronic tendonitis”
Degenerative condition affecting a tendon
Commonly associated with “micro tears” of chronically inflamed tendon
Cant see on XRay, Seen on MRI

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7
Q

Shoulder dislocation

A

Glenohumeral joint

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8
Q

Shoulder separation

A

AC joint

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9
Q

OA (osteoarthritis) = DJD (Degenerative Joint Disease)

A

Mechanical wearing of articular surfaces with loss of articular cartilage and new bone growth (osteophytes) and hardening (sclerosis) of bone

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10
Q

Most common location of shoulder dislocation*

A

95%+ are anterior dislocations

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11
Q

Angulation

A

direction based on the direction that apex is pointing relative to the long axis of the bone in anatomical position

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12
Q

Displacement (aka Translation)

A

based on direction of the distal fragment relative to the proximal

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13
Q

physis

A

Epiphyseal plate

Growth plate

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14
Q

Majority of shoulder dislocations are

A

95% anterior dislocations

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15
Q

Colles fracture

A 
transverse fracture of distal radius
volar (toward palm) angulation or distal tilt
from FOOSH
no involvement of articular surface
falling on extended wrist*
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16
Q

Tibia fracture

A

varus angulation

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17
Q

rotation

A

Described according to the direction in which the distal fragment is rotated relative to the proximal portion

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18
Q

Reduce/reduction

A

To restore a fracture or dislocation to the correct position/alignment
Closed vs. Open

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19
Q

What should you pay particular attention to an Ortho history?*

A

Pay attention to the described onset:
Mechanism of injury (MOI) (sudden vs gradual, etc.)
Trauma vs. overuse
Similar previous injury (i.e. repeat shoulder dislocation)

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20
Q

When should you recheck neurovascular status?*

A

following any and all procedures/treatments (i.e. reductions, casting)

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21
Q

What nerve innervates patellar reflex*

A

L4

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22
Q

What nerve innervates Achilles reflex*

A

S1

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23
Q

Anterior thigh sensation innervated by*

A

L3

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24
Q

Anterior medial knee, leg, foot sensation innervated by*

A

L4

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25
Q

Lateral knee, leg innervated by*

A

L5

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26
Q

Posterior midline, LE innervated by*

A

S3

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27
Q

What X ray view of the knee is essential?

A

AP STANDING view, see what knee looks like weight bearing

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28
Q

What is unique about sunrise view and when should it be ordered?

A

only view to see patellofemoral joint

should be ordered on any pt >45yo

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29
Q

What X ray films should you order in DJD of knee

A

Standing AP, standing flexion, lateral, and always sunrise

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30
Q

Tunnel notch view is used in

A

younger pts, suspect ACL injury

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31
Q

What knee meniscal tear is most common, medial or lateral?

A

medial, see gradual effusion

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32
Q

Classic tear for meniscal tears*

A

McMurray’s test

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33
Q

3 main DDx of acute knee pain to evaluate for*

A

Fx
ACL tear
Meniscal tear

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34
Q

Baker’s cyst

A

Normal variant enlargement of semimembranous bursae in medial popliteal space
outpouching of fluid
NOT SURGICALLY EXCISED unless signif problematic

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35
Q

Classic test for PCL instability*

A

Posterior drawer test

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36
Q

Usual cause of ACL tears

A

twisting of hyperextended knee, eg landing after basketball shot

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37
Q

Classic test for ACL

A

Lachman’s

Anterior drawer test

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38
Q

“Housemaid’s Knee”

A

Prepatellar Bursitis
pain anterior and inferior to patella
can be infectious if puncture, trauma

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39
Q

Pes Anserine Bursitis

A

deep to tendon insertion on medial tibial plateau - overuse irritation

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40
Q

What should you not do with patellar tendonitis*

A

do not do injections in tendon!!

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41
Q

What XRay film should you get with patellar fractures?*

A

Sunrise view

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42
Q

What XRay film should you get with tibial plateau fractures?

A

Oblique view

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43
Q

AP XRay of knee shows

A

Femur and Condyles, Tibial Plateau and intracondylar emminence

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44
Q

Lateral XRay of knee shows

A

Femur, Plateau, and Patella

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45
Q

Sunrise XRay of knee shows

A

Patellofemoral joint

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46
Q

Tunnel XRay of knee shows

A

notch

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47
Q

Oblique XRay of knee shows

A

Tibial Plateau Fxs

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48
Q

why do muscles heal faster than tendons and ligaments?

A

more blood flow and metabolic activity

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49
Q

What should you always do with hand lacerations?

A

Always check tendon function or injury:
Active ROM
Explore wound for tendon involvement

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50
Q

Gamekeeper’s Thumb

A

“skier’s” thumb
Injury to the ulnar collateral ligament of the thumb (UCL) resulting from hyperabduction of MCP joint
(inside of thumb)

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51
Q

arthrocentesis of rupture of cruciate ligament**

A

bloody effusion

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52
Q

arthrocentesis of intra-articular fracture**

A

effusion with fat droplets and blood

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53
Q

arthrocentesis of meniscal tears**

A

clear, yellowish joint fluid

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54
Q

Most commonly fractured carpal bone**

A

Scaphoid

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55
Q

Boxer’s fracture

A

4th or 5th metacarpal
from hitting immovable object with closed fist
splint

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56
Q

Thenar atrophy is seen in which nerve compression?

A

median nerve compression from carpal tunnel syndrome

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57
Q

Dupuytren’s contracture

A

Thickened plaque overlying the flexor tendon of the ring finger and possibly the little finger at the level of the distal palmar crease
Skin puckers
Thickened fibrotic cord between palm and finger
Flexion contracture of the fingers
exercises, injections, surgery

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58
Q

Smith’s fracture

A

falling on flexed wrist

fracture of distal radius

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59
Q

snuffbox bone

A

scaphoid/navicular

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60
Q

De Quervain’s tenosynovitis

A

swelling extensor and abductor tendons at the radial styloid, inflammation of sheath
pain and tenderness of wrist at base of thumb
from repetitive hand or wrist mvmts
Wrist pain and grip weakness in PE*
Pos Finkelstein’s test**

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61
Q

Decreased grip strength is seen in

A

De Quervain’s tenosynovitis

arthritis, carpal tunnel syndrome, epicondylitis, and cervical radiculopathy

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62
Q

Finkelstein’s test

A

patient grasp the thumb against the palm and then move the wrist toward the midline in ulnar deviation
identifies De Quervain’s tenosynovitis

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63
Q

When should you consider carpal tunnel syndrome

A

Complaints of dropping objects
Inability to twist lids of jars
Aching at the wrist/ forearm
Numbness of the first three digits

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64
Q

Abductor pollicus is innervated only by which nerve

A

median nerve

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65
Q

Tinel’s sign

A

Test for median nerve compression by tapping lightly over the course of the median nerve in the carpal tunnel
Aching and numbness in the median nerve distribution is a positive test

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66
Q

Phalen’s sign

A

Test for median nerve compression by asking the patient to hold the wrists in flexion for 60 seconds or press backs of both hands together
Numbness and tingling in the median nerve distribution within 60 seconds is a positive test

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67
Q

Kienbock’s Disease

A

Avascular necrosis of lunate bone
Unknown etiology
excruciating pain, hand crippling

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68
Q

Trigger Finger

A

Painless nodule in a flexor tendon in the palm near metacarpal head
steroid, injection, surgery

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69
Q

hypothenar atrophy suggests

A

ulnar nerve disorder

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70
Q

Ganglion

A

Cystic, round, nontender swellings along tendon sheaths or joint capusles
Frequently found on the dorsum of the wrist
common

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71
Q

avulsion fracture

A

tendon or ligament pulls off a piece of the bone

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72
Q

Mallet Finger

A

Pain and inability to straighten fingertip**
Injury of extensor digitorum tendon of the finger at the distal interphalangeal joint
Results from hyperflexion of the extensor digitorum tendon
Result of sports injury (basketball, volleyball hits an outstretched finger)
splint or sugery

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73
Q

nerve root exits where from the corresponding vertebral body in Cervical spine

A

above*

as compared to lumbar and thoracic spine where they exit below

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74
Q

kyphosis

A

hunch back

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75
Q

lordosis

A

inward curving of lower back

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76
Q

spondylosis

A

secondary degenerative changes: age related wear/tear

1: Disc degeneration: dessication; height loss; herniation
2: Joint degradation: uncinate spurring and facet arthrosis
3: Ligamentous thickening and infolding
4: Deformity: kyphosis with transfer of load to posterior facet joint

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77
Q

Cervical Radiculopathy Sx**

A

Occipital headache/Axial neck pain: Discogenic vs mechanical (arthrosis)
Periscapular pain
Unilateral arm pain/sensory changes/weakness: Usually dermatomal (crossover can occur)

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78
Q

C5 Radiculopathy** Motor/Reflex Exams

A

Motor: Deltoid/Biceps
Reflex: Biceps

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79
Q

C6 Radiculopathy** Motor/Reflex Exams

A

Motor: Biceps/Wrist extension
Reflex: Brachioradialis

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80
Q

C7 Radiculopathy** Motor/Reflex Exams

A

Motor: Triceps/Wrist flexion
Reflex: Triceps

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81
Q

C8 Radiculopathy** Motor/Reflex Exams

A

Motor: Finger flexion
Reflex: None

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82
Q

T1 Radiculopathy** Motor/Reflex Exams

A

Motor: Finger Abduction
Reflex: None

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83
Q

C2 Radiculopathy Sx*

A

posterior occipital HA

Temporal pain

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84
Q

C3 Radiculopathy Sx*

A

Occipital HA, retro-orbital or retroauricular pain

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85
Q

C4 Radiculopathy Sx*

A

Base of neck

trapezial pain

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86
Q

C5 Radiculopathy Sx*

A

Lateral arm

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87
Q

C6 Radiculopathy Sx*

A

Radial forearm, thumb, and index fingers

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88
Q

C7 Radiculopathy Sx*

A

Long finger

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89
Q

C8 Radiculopathy Sx*

A

Ring and little fingers

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90
Q

T1 Radiculopathy Sx*

A

Ulnar forearm

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91
Q

Spurling maneuver

A

provocative test to reproduce the radicular pain pattern

Maximally extend & rotate the neck to the involved side, then apply vertical force downward

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92
Q

Shoulder abduction Test

A

Shoulder abduction should relieve symptoms

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93
Q

Tx of cervical radiculopathy

A

75% improve with non-operative management

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94
Q

Gold Standard for surgical treatment of cervical radiculopathy

A

Anterior cervical decompression & fusion (ACDF)

can choose cervical disc replacement instead to Decrease adjacent level disease

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95
Q

Cervical Myelopathy cause*

A

spinal cord compression rather than root:
Ossification of the Posterior Longitudinal Ligament (OPLL)
Congenital stenosis
Tumor/abscess
Spondylosis
trauma

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96
Q

Cervical myelopathy is associated with lumbar stenosis in ? %

A

20%

Hence recommendation to image both in symptomatic patients

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97
Q

Cervical myelopathy presentation*

A 
subtle in early manifestations
Clumsiness of hands and gait imbalance
Stable periods punctuated by unpredictable stepwise progression
Usually fails non-op treatment
Early recognition and treatment is key
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98
Q

What exam should you always go in Cervical Myelopathy*

A

RECTAL

Can have problems late dz

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99
Q

Lhermitte’s sign

A

Electric shock like sensations down spine or legs with certain positions of the neck

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100
Q

Cervical Radiculopathy

A

Clinical symptom of nerve root compression resulting in sensory/motor symptoms of the UE

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101
Q

Cervical Radiculopathy causes

A

Cervical spondylosis
Disc herniation
Stimulation of the nerve root by chemical pain mediators

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102
Q

Tx goal of Cervical Myelopathy*

A

STOP PROGRESSION
NOT symptom improvement
most get surgery: Decompression, lordosis restoration, and stabilization

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103
Q

Ossification of the posterior Longitudinal ligament (cervical myelopathy) MC in what population?

A

asian

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104
Q

lower back pain prognosis

A

90% resolves in 1 yr

occurs up to 95% in life time

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105
Q

Causes of Lower back pain

A 
Muscle strain/ligament sprain
Facet joint arthropathy 
Discogenic pain/annular tears
Spondylolisthesis
Spinal stenosis
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106
Q

Waddell Signs

A

Signs of non-organic back pain

basically fake back pain

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107
Q

Grocery cart sign* (unofficial name?)

A

is it easier to lean over your cart? can be lumbar stenosis

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108
Q

Tx of lower back pain

A

In the absence of progressive neurologic deficit, a 6 wk trial of non surgical treatment must occur
be active, acetaminophen, NSAIDS, muscle relaxants
Rule out serious pathology if >3mon

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109
Q

MC level for Lumbar Disc Stenosis

A

L5-S1 > L4-5

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110
Q

L1-3 Motor/Reflex Exam*

A

Motor: Hip Flexion (Iliopsoas)
Reflex: None

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111
Q

L4 Motor/Reflex Exam*

A

Motor: Knee extension/Foot dorsiflexion
Reflex: Patellar

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112
Q

L5 Motor/Reflex Exam*

A

Motor: Great toe extension
Reflex: None
Gait? Trendelenburg (Glut medius innervated by L5)

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113
Q

S1 Motor/Reflex Exam*

A

Motor: Foot Plantarflexion/Eversion
Reflex: Achilles

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114
Q

for both cervical and lumbar disc herniations, the nerve root involved is usu

A

usu corresponds to lower of the adjacent 2 vertebra

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115
Q

Lumbar disc herniation (LDH) Tx

A

Partial discectomy is the standard of care
should not be delayed >3-4mon
improves leg pain almost always

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116
Q

Degenerative spondylolisthesis

A

anterior translation of cephalad vertebral body relative to its adjacent caudal vertebra without a pars defect
MC symptom is mechanical back pain relieved with rest
Leg pain is the 2nd mc symptom

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117
Q

Posterior fat pad in elbow in pediatrics suggests

A

Supracondylar fracture of distal Humerus

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118
Q

Posterior fat pad in elbow in adult suggests

A

Radial head fracture

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119
Q

What films do you always need for tibia and fibula?*

A

full length views (AP and lateral)

120
Q

What films should you order regarding joints in an injury?*

A

image joints above and below the suspected site of injury

121
Q

What to order w/suspected injury: Proximal Humerus*

A

Shoulder (AP, Scapular Y, Axillary vs. Velpeau***), full-length Humerus

122
Q

What to order w/suspected injury: Elbow fx*

A

Humerus (AP and lateral), Shoulder, (AP, Scapular Y, Axillary vs. Velpeau), and Forearm (AP and lateral)

123
Q

What to order w/suspected injury: Distal Radius fx*

A

Forearm (AP and lateral), Wrist (AP and lateral)

124
Q

What to order w/suspected injury: Hand/Finger Fx*

A

Hand (AP, lateral, oblique), special views as needed for specific injuries

125
Q

What to order w/suspected injury: Ankle fx*

A

Ankle Films (3 views - AP, Lateral, Mortise), possible Stress View (Gravity vs. Manual External Rotation view), and full-length Tibia/Fibula X-Rays (AP and lateral)

126
Q

What to order w/suspected injury: Tibia fx*

A

Full-length Tibia/Fibula (AP and lateral), Knee (AP and lateral)

127
Q

What to order w/suspected injury: Femur fx*

A

Full-length Femur (AP and lateral), Hip (AP, Lat, Cross-Table Lateral), and Knee (AP, Lateral)

128
Q

What to order w/suspected injury: Hip fx*

A

Hip, Full-length Femur, AP Pelvis

129
Q

What is the first thing you should assess with any suspected injury due to its urgency?**

A

neurovascular status!

130
Q

Tumors that metastasize to bone?**

A

“BLT with Kosher Pickle”

Breast, Lung, Thyroid, Kidney (Renal Cell Carcinoma), and Prostate

131
Q

Which tumors are blastic and which are lytic?**

A

“PB-KTL” (Lead Kettle)
Prostate and Breast are Blastic
Kidney, Thyroid, and Lung are Lytic

132
Q

Comminuted fracture

A

≥3 pieces

v simple: 2 pieces

133
Q

greenstick fracture

A

periosteum (nutrition for bones) very strong in kids and usu doesn’t break in kids, so stays intact in fractures
bone bends and breaks

134
Q

impacted fracture

A

fracture where a bone fragment is driven into another bone fragment

135
Q

Velpeau view

A

modified trauma axial view

need to order in shoulder injuries (OR axillary view), looks for dislocations

136
Q

Mortise view

A

3 view series of the distal tibia, distal fibula, talus and proximal metatarsals. most pertinent projection for assessing articulation of tibial plafond and two malleoli with the talar dome, otherwise known as the mortise joint of the ankle

137
Q

Stress view*

A

TESTS INTEGRITY OF LIGAMENT –> Ankle (IMPORTANT TO GET STRESS VIEW ON ANKLES***

138
Q

Scapular Y view

A

lateral scapula shoulder
Pertinent projection to assess suspected dislocations, scapula fractures, and degenerative changes.
Excellent projection to see both the coracoid and acromion process in profile

139
Q

Salter-Harris Type II (Growth plate injuries)*

A

Above Physis (in Metaphysis)

140
Q

Salter-Harris Type III (Growth plate injuries)*

A

Lower than Physis (in Epiphysis)

141
Q

MC of Salter-Harris fracture types*

A

Type II

142
Q

Thurston-Holland fragment

A

Name of Metaphyseal fragment in Salter Harris fractures

143
Q

What must you do/order for a patient with a knee dislocation?*

A

Must order ABI vs. CT Angiogram to document blood flow to remainder of lower extremity

144
Q

must be checked on each and every patient with proximal humerus fracture*

A

axillary nerve (test sensation of deltoid)

145
Q

Treatment of Prox Humerus Fxs

A

85% treated with sling immobilization followed by rehab

146
Q

Presentation of Compartment Syndrome**

A

PAIN OUT OF PROPORTION to clinical situation**
Pain w/ passive stretch of fingers (most sensitive finding)
Paresthesia and hypesthesia
Paralysis
Palpable Swelling
Peripheral pulses absent

147
Q

Treatment of Distal Radius Fxs

A

Don’t immobilize in adult with cast –> doesn’t allow room for swelling

148
Q

One of biggest predictors for increased mortality in pelvic ring fx**

A

need for transfusion of >4 units of packed RBCs*

hemorrhage is the leading cause of death

149
Q

Mortality rate for open pelvic ring fx*

A

as high as 50%

150
Q

What should only be done once in Physical Exam for Pelvic Ring Injuries*

A

palpating pelvis

151
Q

strongest ligament in the body

A

posterior sacroiliac ligament

152
Q

What must be imaged in a Trauma Series? (pelvis)***

A

AP Pelvis, CXR, Lateral C-Spine***

153
Q

Treatment of pelvic ring injuries*** (trauma)

A

Resuscitate patient first; ideally 1:1: 1 (pRBC:FFP:Platelets)

154
Q

What scan is not utilized in a femoral neck fx

A

NOT CT SCAN! Within 48hrs, a lot of bony edema  can’t see on CT scan

155
Q

Which population of people more commonly have avascular necrosis?*

A

Commonly see in people who are long-term alcoholics

156
Q

How does the leg appear in leg fractures*

A

Leg may appear in external rotation and abduction, will appear shortened

157
Q

What do all patients with hip fractures get?**

A

Foley catheter: BC CANT GET UP AND PEE
IV fluids: OFTEN OLDER PEOPLE, DEHYDRATED TO BEGIN WITH
Pain Control: SMALL DOSE VALIUM, OR BENZO, AVOID OPIIOID
AP Pelvis, Full Length Femur XRs, Hip XRs, CXR
EKG
NWB (non-weight bearing) to affected extremity
NPO (talk with surgeon or Orthopedic team first)

158
Q

Ideal time to perform hip fracture surgery

A

within 48hrs of injury

elderly should be brought to surgery as soon as medically optimal

159
Q

Mortality rates of geriatrics at 1yr post surgery

A

as high as 14-36%

In patients with chronic renal failure, rates of mortality at 2 years postoperatively are ~45%

160
Q

Mortality rates for Intertrochanteric fractures v Femoral neck

A

Mortality rates HIGHER for than Femoral Neck fractures

161
Q

3 potential spaces for major blood loss in femoral shaft fractures**

A

Thorax, Pelvis, Thigh

162
Q

Schatzker Type IV injuries are associated with

A

knee dislocation and vascular injury

isolated medial tibia plateau fracture

163
Q

What can you still have with an open fracture?*

A

compartment syndrome!

164
Q

Ankle fractures require

A

urgent reduction in ED to prevent soft tissue compromise

ice and elevate injuries ASAP after reduction

165
Q

What must you also image in Calcaneus Fractures?

A

must image L-Spine, and contralateral Calcaneus

Prognosis is poor with ~40% complication rate

166
Q

What must you assess in calcaneus fractures?

A

Must assess for posterior skin necrosis —> If present, surgical emergency

167
Q

What imaging do all trauma patients get?**

A

Chest XR, AP Pelvis XR, Lateral C-Spine XR

168
Q

How do you determine if you get an adequate XR of the C-Spine?

A

Must be able to visualize C7 on T1

169
Q

Potential spaces for life threatening blood loss***

A

Abdomen, Thorax, Thigh

170
Q

Most important thing in managing open fractures**

A

Early IV antibiotics

171
Q

How do you never treat an ACL tear?

A

repairs! Always reconstruct!

172
Q

Ottawa ankle rule

A

when pt should receive an x ray

173
Q

Lisfranc injury

A

fracture at distal end of MTP, proximal end dislocated, some type of twisting location; needs surgery

174
Q

Legg calve perthes: age group**

A

USUALLY 4-10 Y/O MALES

younger the kid, better the outcome

175
Q

Legg calve perthes: Sx**

A 
PAIN (GROIN/THIGH) 
POSSIBLE KNEE PAIN
EFFUSION
LIMP/ANTALGIC GAIT
LIMITED ABDUCTION AND INTERNAL ROTATION
Can lead to OA later on
176
Q

Legg calve perthes: Tx**

A

VERY YOUNG CHILD (2-6), W/ FEW XRAY CHANGES, USUALLY OBSERVATION
NSAIDS
CRUTCHES (HELPS LIMIT WB)
PT (IMPROVE ROM)
CASTING/BRACING OF PROGRESSIVE DEFORMITY
SURGERY (FEMORAL VS ACETABULAR OSTEOTOMY)

177
Q

Slipped capital femoral epiphysis: age group**

A

MORE COMMON IN MALES (AGES 11-15)

Older than Perthes

178
Q

Legg calve perthes: Dx**

A

X Ray ASAP

immediate referral

179
Q

Legg calve perthes**

A

ISCHEMIA WITH SUBSEQUENT NECROSIS OF FEMORAL HEAD

180
Q

Legg calve perthes: Dx**

A

X Ray ASAP
immediate referral
Late Dz on XR: signif bone remodeling and bone resorption

181
Q

Slipped capital femoral epiphysis**

A

POSTERIOR INFERIOR DISPLACEMENT OF THE FEMORAL EPIPHYSIS THROUGH THE GROWTH PLATE
DON’T MISS!!!!

182
Q

Slipped capital femoral epiphysis: Dx**

A

PAINFUL, LIMITED ROM
XRAYS: quality films
AP PELVIS AND BILATERAL FROG LEG LATERAL VIEWS TO R/O OPPOSITE HIP INVOLVEMENT

183
Q

Slipped capital femoral epiphysis: Tx**

A

SURGERY: stabilize –> good outcome usually
BUT ALWAYS WATCH PT CAREFULLY ABOUT WHAT COMES ON THE OTHER SIDE, CAN COME ON DAYS, WKS, MONTHS, OR YRS LATER

COMPLICATIONS: AVN
OA LATER IN LIFE

184
Q

Complex Regional Pain Syndrome Type I

A

without a definable nerve lesion
Includes Reflex Sympathetic Dystrophy
Represents 90%

185
Q

Complex Regional Pain Syndrome Type II

A

with a nerve lesion, Causalgia

Involves the Peripheral, Central & Autonomic Nervous systems

186
Q

Complex Regional Pain Syndrome Type II

A

with a nerve lesion, Causalgia

Involves the Peripheral, Central & Autonomic Nervous systems

187
Q

Complex Regional Pain Syndrome

A

pain disproportionate in time or degree to the usual course of any known trauma or other lesion
not in a specific nerve territory or dermatome
distal predominance

188
Q

Dx complex regional pain syndrome

A

Continuing pain, which is disproportionate to any inciting event
exclude all other causes
For the clinical diagnosis of CRPS, the patient must REPORT and DISPLAY at least one symptom in three of the following four categories:
SENSORY: Hyperesthesia (amplified reaction to normal pain stimulus), Allodynia (painful response to a normally harmless/nonpainful stimulus)
VASOMOTOR: Cyanosis, asymmetric skin temp (coolness)
SUDOMOTOR/EDEMA: Brawny (thick, leathery, red, non-pitting), Hyperhidrosis (excessive sweating)
MOTOR/TROPHIC: Changes in hair/nail growth –> growth; Skin Atrophy (shiny), ulcerations; Decreased ROM, weakness, tremor, dystonia, Bone loss

189
Q

Dx complex regional pain syndrome

A

Continuing pain, which is disproportionate to any inciting event
exclude all other causes
For the clinical diagnosis of CRPS, the patient must REPORT and DISPLAY at least one symptom in three of the following four categories:
•Sensory: Reports of hyperesthesia and/or allodynia
•Vasomotor: Reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry
•Sudomotor/edema: Reports of edema and/or sweating changes and/or sweating asymmetry
•Motor/trophic: Reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)

190
Q

complex regional pain syndrome Tx

A

First line treatments: Physical therapy (PT) and Occupation therapy (OT)

191
Q

5 P’s of Compartment Syndrome**

A 
pain: early, universal
paresthesia
paralysis: late finding
pallor
pulseless: rare
192
Q

Stryker Stic Device

A

measures compartment pressure
Continuous/Serial Monitoring: > 30 mmHg
OR
Difference between Diastolic Pressure and Compartment Pressure (Delta Pressure): < 30 mmHg

193
Q

acute compartment syndrome tx

A

Fasciotomy

194
Q

If acute compartment syndrome not treated within a few hours,

A

muscle loss, amputation, infection, nerve damage, and kidney failure (following rhabdomyolysis)

195
Q

Pre Hospital Management of acute compartment syndrome

A

Oxygen; high flow
Do NOT ice; ice increases vasoconstriction
Do NOT elevate; keep in position where found or position of comfort
Splint for comfort and protection only when necessary (i.e. long transport)
Transport to appropriate medical facility (trauma?); heads up to receiving medical facility
IV’s established
Fentanyl (Fentanyl preferred because it provides pain control without vasodilation)

196
Q

Osteomyelitis

A

Infection of bone caused by an organism

acute: 2wks after initiating event
subacute: 1-3mon
chronic: +3mon

197
Q

Most common cause of osteomyelitis from open fractures**

A

multiple organisms

198
Q

Most common site for osteomyelitis in children

A

Long bones – Metaphysis

199
Q

Most common site for osteomyelitis in adult

A

Vertebral

200
Q

GOLD STANDARD for Dx of osteomyelitis

A

Bone biopsy for culture

201
Q

Imaging test of choice for osteomyelitis if <2wks of Sx

A

MRI

X ray if >2wks

202
Q

To Dx osteomyelitis in absence of positive bone biopsy…must have

A 
must have 2 of the following: 
Pus on aspiration
Positive blood culture
Classic s/s of osteomyelitis
Radiographic findings: periosteal elevation, cortical disruption, medullary involvement
203
Q

Fractures with highest potential for blood loss*

A

Pelvic fx 1st

femur 2nd

204
Q

What vascular injury can occur w/Anterior shoulder dislocation

A

axillary artery injury

205
Q

What vascular injury can occur w/Extension supracondylar fracture

A

brachial artery injury

206
Q

What vascular injury can occur w/Posterior elbow dislocation

A

brachial artery injury

207
Q

What vascular injury can occur w/Knee dislocation

A

popliteal artery injury

208
Q

Volkmann Ischemic Contracture

A

when there is ischemia to the forearm, eg compartment syndrome
the muscles of the forearm are severely injured, leading to contracture deformities of the fingers, hand, and wrist.

209
Q

What nerve injury can occur w/Shoulder dislocation

A

axillary* and musculocutaneous nerve injury

210
Q

What nerve injury can occur w/Humeral shaft injury

A

radial nerve injury

211
Q

What nerve injury can occur w/Supracondylar fracture

A

median, radial and ulnar nerve injury

212
Q

What nerve injury can occur w/Medial epicondylar fracture

A

ulnar nerve injury

213
Q

What nerve injury can occur w/Elbow dislocation

A

ulnar and median nerve injury

214
Q

What nerve injury can occur w/Olecranon fracture

A

ulnar nerve injury

215
Q

What nerve injury can occur w/Acetabular fracture

A

sciatic nerve injury

216
Q

What nerve injury can occur w/Posterior hip dislocation

A

sciatic nerve injury

217
Q

What nerve injury can occur w/Anterior hip dislocation

A

femoral nerve injury

218
Q

What nerve injury can occur w/Knee dislocation

A

peroneal and tibial nerve injury

219
Q

What nerve injury can occur w/Lateral tibial plateau or fibular head fracture

A

peroneal nerve injury
People tackled on side
Can’t dorsiflex, get foot drop

220
Q

Fat Embolism

A

Fx long bones or surgery (femoral rods and hips), can shower fat emboli into circulation
Sx to lungs similar to PE  sudden drop in stats with no blood clots on CT

221
Q

most common pathogens mediating necrotizing skin and soft tissue infections*

A

Group A β-hemolytic Streptococcus (GAS), especially in the case of necrotizing fasciitis

222
Q

most common pathogens mediating gangrenous cellulitis and myonecrosis*

A

clostridial species
arise either from deep traumatic or surgical inoculation
Many don’t survive
Will need skin grafts

223
Q

Primary Survey for orthopedists in trauma

A

Airway/C-spine protection: fractures?
Breathing: fractures?
Circulation:
Adequate perfusion of musculoskeletal system? Hemorrhage from pelvic or femur fractures?
Disability: AVPU
Alert, Verbal stimuli response, Painful stimuli response, or Unresponsive
Exposure: remove all clothing!

224
Q

common bleeding site in pelvic ring fx

A

Sacral Venous Plexus and Internal Iliac Arteries

225
Q

What to do 1st in pelvic fractures

A

ATLS: stop the bleed
Resuscitate: IV fluid, blood transfusion
Binder/Sheet: stabilize

226
Q

Dislocated Joints that are considered

A

emergencies!
The longer dislocated, harder to put back in bc muscle tense around it
worry about vessels, nerves, ligaments

227
Q

Hill–Sachsfracture

A

cortical depression in the posterolateral head of the humerus. It results from forceful impaction of the humeral head against the anteroinferior glenoid rim when the shoulder is dislocated anteriorly.

228
Q

How to test axillary nerve?

A

deltoid sensation

touch pt’s deltoid and ask if they can feel

229
Q

Prehospital personnel should what in an elbow dislocation?*

A

splint the limb in the position found. Because of the risk of neurovascular injury, field reduction is not recommended
1/3 assoc w/fx*
very stable joint, takes large force to dislocate

230
Q

Neuropraxia

A

(transient episode of motor paralysis)

involving median or ulnar nerve in 20% of elbow dislocations

231
Q

Anterior hip dislocation

A

hip in external rotation

232
Q

Posterior hip dislocation

A

hip in internal rotation
4/5 from trauma
more common
can have sciatic n injury

233
Q

Knee dislocation

A

Can be devastating, painful
Usu reduced on site by trainers or sports medicine providers
high energy: usu from dashboard injury
low energy: athletes
signif soft tissue disruption, usu 3/4 ligaments disrupted

234
Q

What urgent thing to check w/Knee Dislocation

A

High index of suspicion for multi-ligamentous knee injuries
Check pulse!!
Check Ankle Brachial Index !!
Check post-reduction xray!!
Check post-reduction vascular exam!!
If unstable: Needs external fixation
outside hospital: splint and transport to hospital; field reduction only if vascular compromise

235
Q

What to give in the ER with open fx

A

irrigate w/saline and cover with saline soaked sponge
a first-generation cephalosporin with or without an aminoglycoside; early administration
tetanus prophylaxis for large crush wounds
larger wounds might need OR wound irrigation and debridement
splint before sending to XR

236
Q

MC Elbow Dislocation

A

80% Posterior
may have neurovascular injury
MC childhood dislocation

237
Q

PIN (POSTERIOR INTEROSSEUS N) compression (Radial tunnel syndrome)

A

Pain 4 - 5 cm distal to lateral epicondyle.
No paresthesias
Middle finger test: Extend against resistance = pain

238
Q

Most important components of fx of distal humor**

A

displacement, neurovascular status, joint surface involvement or skin injury
ulnar n most commonly injured

239
Q

Fat pad sign

A

anterior fat pad of elbow becomes elevated, and the posterior fat pad becomes visible

240
Q

Type 4 Mason classification of radial head fx

A

Radial head fracture with associated elbow dislocation

241
Q

What should you avoid doing in olecranon bursitis*

A

I&D

242
Q

Froment’s sign

A

Ask patient to hold a piece of paper between the thumb and fist as you pull the paper away. Normally they can. With an ulnar nerve palsy the thumb is flexed as the patient tries to hold on to the paper

243
Q

Stages of Cervical Disc Syndromes

A

protrusion/prolapse: bulging
herniation/extrusion: AF tear, NP leak, entrapment
sequestration: leaks completely out of disc

244
Q

Tx of cervical disc syndromes

A

rest = cornerstone
acute tx: Moist heat, soft collar, PT, cervical pillow
simple analgesics

245
Q

cervical sprain (whiplash)

A 
Extension-flexion mechanism
Ligamentous injury
Delayed onset (few hours) common.
Increasing neck stiffness -> generalized and diffuse pain -> decreased range of neck motion.
246
Q

Discitis

A

Inflammation of vertebral disc space
Consider co-infection: vertebral osteomyelitis
Infection usually spread from other sites
Present with neck pain and stiffness.
Lumbar most common
IV antibiotics req, 6-8wks; symptomatic tx if viral

247
Q

Spondylolysis

A 
Defect in pars interarticularis
Nondisplaced stress fracture
Overuse injury:  hyperextension
Stork Test
Oblique XRay
248
Q

spondylolisthesis

A

Bilateral spondylolysis with lithesis (slippage) of vertebral body
Anterior displacement of vertebral body inferior to the defect
Lateral XRay
surgery only if severe

249
Q

Congenital muscular torticollis

A

1%
sclerosis of SCM, shortening of muscle resulting in tilt
often assoc w/difficult delivery
most resolve spontaneous; treat w/stretching
if doesn’t resolve by 1yo, seek consult

250
Q

Acquired torticollis

A

spasm of neck muscles, trauma, infection, idiopathic

251
Q

partial dislocation of vertebrae

A

flexion injury, less traumatic
usu PLL Disruption
lateral c spine x ray
STABLE

252
Q

Bilateral facet dislocation

A 
UNSTABLE
Flexion injury
Disruption of ALL and PLL
Complete anterior dislocation of vertebral body
Very high risk of cord injury
Lateral x ray
Tx: closed reduction and traction
253
Q

Compression fractures

A

common in osteoporosis*
trauma, malignancy, infection
may affect one or more vertebrae

254
Q

Compression fracture types

A

Type I: Wedge fracture: stable; associated with osteoporosis or malignancy from axial force; Heal on own in 8-10 weeks with cervical collar; MC

Type III: Burst Fracture: high energy axial load, less stable, more likely surgery
Posterior ligaments intact but bone fragments can get displaced in spinal cord
Serious neurological injury
Treatment surgery

Type IV-V: complex, Involve posterior ligaments
Poor prognosisoften quadriplegia

255
Q

MOST UNSTABLE and dangerous C-spine injury***

A

Flexion teardrop fracture

256
Q

Flexion teardrop fracture

A

Considered MOST UNSTABLE and dangerous C-spine injury
Variant of burst compression fracture
displace anterior-inferior edge of vertebral body usually causes comminution of vertebral body and displacement of fragments into spinal cord.
Diving head first
Usually associated with spinal cord injury (anterior cord syndrome): Acute and severe neurologic deficits. (quadriplegia) Loss of sensation of pain, temperature, touch distal to lesion , usu C5-6
lateral C spine to Dx
tx: usually require anterior decompression, skeletal traction and stabilization

257
Q

Clay-shoveler’s fracture

A

STABLE, affects only posterior
Usually an avulsion of spinous process of C7 or T1, due to heavy lifting (or shoveling clay)
Or direct trauma to spinous process
Tx: soft collar, activity modification

258
Q

Hangman’s fracture (fracture of C2)

A

Traumatic spondylolisthesis
Bilateral fracture of pars interarticularis
Usually the result of hyperextension + axial compression: MVA most common cause
Type I: rigid collar 4-6 weeks
Type II, III: usually surgery

259
Q

Jefferson fracture

A

Fracture of anterior and posterior arches of C1
“burst fracture of C1”
40% are associated with fractures of axis (C2).
Can be associated with vertebral artery injury: 50%
Disruption of transverse ligament determines instability
Best seen CT scan
Most will be managed with skeletal traction/immobilization (halo)

260
Q

Anterior Talofibular Ligament

A

stabilizes forward from sliding anteriorly (similar to ACL that keeps sliding anteriorly)

261
Q

Calcaneofibular ligament

A

keep foot from INVERSION and stabilize foot; commonly injured foot esp people who roll their foot a lot (sudden changes in direction, basketball players)

262
Q

Deltoid ligaments

A

a number of components; less likely injured in isolated sprain but more dislocations/fx
keep foot from eversion

263
Q

Sprains: Grade I*

A

I: Stretching and/or partial tear of a ligament
Mild tenderness and swelling*
Minimal or no functional loss (i.e. patient is able to bear weight and ambulate with minimal pain)
No mechanical instability (negative clinical stress examination)*

264
Q

Sprains: Grade II

A 
Incomplete tear of a ligament
Tenderness over the involved structures
Some loss of motion and function (i.e., patient                         has pain with weight-bearing and ambulation)
Mild to moderate instability - laxity
Severe swelling and ecchymosis
265
Q

Sprains: Grade III

A

Complete tear and loss of integrity of a ligament
Loss of function and motion (unable to bear weight or ambulate)
Mechanical instability
Moderate to severe positivity of clinical stress exam
Laxity , no defined end point in stress test

266
Q

High Ankle Sprain”Syndesmosis Injury MOI**

A

Dorsiflexion & external rotation
Widens between tibia and fibula and damage syndesmosis
Usu an athlete that foot gets caught on grass or turf causing external rotation and dorsiflexion

267
Q

Syndesmosis

A

interosseous ligament
anterior-inferior tibiofibular ligament
posterior-inferior fibular ligaments, and
inferior transversetibiofibular ligament
provides stability between tibia and fibula above ankle
normally <5mm

268
Q

Tests for syndesmosis injury*

A

“Squeeze Test”
Squeeze distal tib or fib to reproduce pain

Kleiger’s Test
Passively dorsiflex and externally rotate the foot
Aggravation of pain above ankle = positive
Point to push up dome of talus to widen space

269
Q

Achilles Tendonitis

A

Typically from overuse or new activity/gait
May show calcification or “bone spur” (osteophyte) at
pain, swelling, thickening of tendon
insertion on calcaneus
rest, NSAIDs, stretching, PT
AVOID INJECTIONS** Can weaken tendon and risk rupture

270
Q

Acute AchillesTendon Rupture

A

MOI: forceful plantarflexion w/knee extended/pushoff injury, sudden dorsiflexion
Pain, inability to bear weight, swelling
Loss of function – inability to plantar flex (extend) ankle
need surgery
gradually change cast from plantar to neutral/dorsiflex throughout healing

271
Q

Thompson Test

A

CAUSE PLANTARFLEXION WITH SQUEEZING IF ACHILLE INTACT

calf squeeze for achilles tendon rupture

272
Q

Orthotics

A

design, manufacture, fit and/or modify shoes and foot orthoses to alleviate foot problems caused by disease, overuse, or injury.

273
Q

ORIF for trimalleolar fx is recommended if

A

> 25% of posterior articular surface is involved;

  • fracture is displaced more than 2 mm;
  • there is posterior subluxation of talus;
  • if fracture prevents reduction of fibula
274
Q

What should you look for w/ankle fx’s*

A

**Look for a Proximal Fibula Fx!

275
Q

Lisfranc Injury

A

“keystone” wedging of the second metatarsal into the cuneiforms –> prone to dislocation
Dorsal dislocation of the proximal base of the second metatarsal
MOI: Foot is placed in extreme plantar flexion (extension) with an axial load (large arrow); base of 2nd MT extends beyond horizontal axis

276
Q

What to do if Lisfran injury persist?*

A

Obtain a MRI to define soft tissue damage if persists

277
Q

Avulsion fx v Jones fx

A

avulsion fx: on tuberosity
jones: between tendons, from foot inversion, healing takes a long time bc low blood flow
fx of base of 5th metatarsal

278
Q

Tarsal Tunnel Syndrome

A

tibial nerve entrapment
dorsiflexion/eversion test aggravates
Pain and numbness on bottom of foot, weak toe flexion!

279
Q

Plantar Fasciitis

A

Caused by collagen degeneration from repetitive microtears of the plantar fascia, overuse, pes planus/cavus
First few steps of the day and end of day produce excruciating pain – feels like stepping on glass.
Treatment: Splints/orthotics, Massage/stretching

280
Q

corns v callus

A

corns: central core,extends deep into skin and presses on nerve endings → pain; can be soft or hard

281
Q

Cellulitis Tx

A

Quinolone (Cipro, Levo) and 1st generation Cephalosporin [i.e. Cefalexin (Keflex) or Cefazolin if IV]

282
Q

most common tendon injured in rotator cuff tear

A

supraspinatus muscle

283
Q

common place for IMPINGEMENT

A

Space between supraspinatus and AC joint

284
Q

What neurovascular structures can be irritated by backpacks and bra straps?

A

suprascapular nerve and artery

285
Q

Trauma series of shoulders**

A

AP, Lateral, Scapular (outlet- impingement) Y

286
Q

“painful arc”

A

Rotator cuff or subacromial impingement –> tend to have 60 degrees to 120 abduction
also inflammation of subacromial bursa

287
Q

Imaging for rotator cuff tears

A

Plain films may show OA of AC joint, GH joint, or chronic changes of proximal humerus
Ortho may order MRI - provides very detailed imaging of the shoulder and is frequently ordered with an arthrogram (evaluate capsule integrity).

288
Q

Supraspinatus tears usu accompany…*

A

Supraspinatus passes through joint capsule; so if it tears it tends to tear joint capsule as well**

289
Q

Tests for Biceps tenosynovitis

A

Positive Yergason’s test or Speed’s test

290
Q

“Popeye’s Deformity”

A

from forceful contraction of biceps tendon
Sudden snap followed by pain and weakness
retraction of biceps
surgical repair in younger pts

291
Q

Posterior glenohumeral dislocations often seen in

A

seizure or convulsive disorders

292
Q

Anterior/Posterior glenohumeral dislocations have a risk for

A

Neurovascular compromise

293
Q

Hill Sachs lesions

A

indentation of superolateral humeral head in recurrent anterior dislocators – chip of bone taken out head of humerus

294
Q

Bankart lesion

A

lesion of the labrum or glenoid margins – can extend into tear of bone
Anterior (MC) vs Posterior (reverse Bankart)

295
Q

What is humeral shaft fx at risk for

A

radial nerve compromise

296
Q

Medical cause of shoulder pain

A

Be suspicious if shoulder pain not aggravated by neck or shoulder motion and patient has a positive GI history
Pain may be referred to top of shoulder via phrenic nerve with irritation of the diaphragm (“C3, 4,& 5 keep the diaphragm alive!”)

297
Q

Crossover maneuver for shoulders

A

Cross body adduction
Typically arthritic changes
AC or SC disease

Orthopedics (1 decks)

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