Exam Flashcards
(297 cards)
1
Q
Genu varum
A
“Bow-legged”
Shortening/hardening medial collateral ligament
Varus stress: rupture of LCL
2
Q
Genu valgum
A
“Knock-kneed”
Collapsing of lateral compartment
valgus stress: rupture of MCL
3
Q
Sprain
A
Stretching and/or tearing of the ligaments supporting an articulation (joint)
4
Q
Strain
A
Stretching and/or tearing of the musculotendinous unit
5
Q
Tendonitis/Tendinitis
A
Inflammation/irritation of a tendon
Commonly due to overuse
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
7
Q
Shoulder dislocation
A
Glenohumeral joint
8
Q
Shoulder separation
A
AC joint
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
10
Q
Most common location of shoulder dislocation*
A
95%+ are anterior dislocations
11
Q
Angulation
A
direction based on the direction that apex is pointing relative to the long axis of the bone in anatomical position
12
Q
Displacement (aka Translation)
A
based on direction of the distal fragment relative to the proximal
13
Q
physis
A
Epiphyseal plate
Growth plate
14
Q
Majority of shoulder dislocations are
A
95% anterior dislocations
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*
16
Q
Tibia fracture
A
varus angulation
17
Q
rotation
A
Described according to the direction in which the distal fragment is rotated relative to the proximal portion
18
Q
Reduce/reduction
A
To restore a fracture or dislocation to the correct position/alignment
Closed vs. Open
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)
20
Q
When should you recheck neurovascular status?*
A
following any and all procedures/treatments (i.e. reductions, casting)
21
Q
What nerve innervates patellar reflex*
A
L4
22
Q
What nerve innervates Achilles reflex*
A
S1
23
Q
Anterior thigh sensation innervated by*
A
L3
24
Q
Anterior medial knee, leg, foot sensation innervated by*
A
L4
25
Lateral knee, leg innervated by*
L5
26
Posterior midline, LE innervated by*
S3
27
What X ray view of the knee is essential?
AP STANDING view, see what knee looks like weight bearing
28
What is unique about sunrise view and when should it be ordered?
only view to see patellofemoral joint
| should be ordered on any pt >45yo
29
What X ray films should you order in DJD of knee
Standing AP, standing flexion, lateral, and always sunrise
30
Tunnel notch view is used in
younger pts, suspect ACL injury
31
What knee meniscal tear is most common, medial or lateral?
medial, see gradual effusion
32
Classic tear for meniscal tears*
McMurray's test
33
3 main DDx of acute knee pain to evaluate for*
Fx
ACL tear
Meniscal tear
34
Baker's cyst
Normal variant enlargement of semimembranous bursae in medial popliteal space
outpouching of fluid
NOT SURGICALLY EXCISED unless signif problematic
35
Classic test for PCL instability*
Posterior drawer test
36
Usual cause of ACL tears
twisting of hyperextended knee, eg landing after basketball shot
37
Classic test for ACL
Lachman's
| Anterior drawer test
38
“Housemaid’s Knee”
Prepatellar Bursitis
pain anterior and inferior to patella
can be infectious if puncture, trauma
39
Pes Anserine Bursitis
deep to tendon insertion on medial tibial plateau - overuse irritation
40
What should you not do with patellar tendonitis*
do not do injections in tendon!!
41
What XRay film should you get with patellar fractures?*
Sunrise view
42
What XRay film should you get with tibial plateau fractures?
Oblique view
43
AP XRay of knee shows
Femur and Condyles, Tibial Plateau and intracondylar emminence
44
Lateral XRay of knee shows
Femur, Plateau, and Patella
45
Sunrise XRay of knee shows
Patellofemoral joint
46
Tunnel XRay of knee shows
notch
47
Oblique XRay of knee shows
Tibial Plateau Fxs
48
why do muscles heal faster than tendons and ligaments?
more blood flow and metabolic activity
49
What should you always do with hand lacerations?
Always check tendon function or injury:
Active ROM
Explore wound for tendon involvement
50
Gamekeeper's Thumb
“skier’s” thumb
Injury to the ulnar collateral ligament of the thumb (UCL) resulting from hyperabduction of MCP joint
(inside of thumb)
51
arthrocentesis of rupture of cruciate ligament**
bloody effusion
52
arthrocentesis of intra-articular fracture**
effusion with fat droplets and blood
53
arthrocentesis of meniscal tears**
clear, yellowish joint fluid
54
Most commonly fractured carpal bone**
Scaphoid
55
Boxer's fracture
4th or 5th metacarpal
from hitting immovable object with closed fist
splint
56
Thenar atrophy is seen in which nerve compression?
median nerve compression from carpal tunnel syndrome
57
Dupuytren's contracture
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
58
Smith's fracture
falling on flexed wrist
| fracture of distal radius
59
snuffbox bone
scaphoid/navicular
60
De Quervain’s tenosynovitis
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**
61
Decreased grip strength is seen in
De Quervain’s tenosynovitis
| arthritis, carpal tunnel syndrome, epicondylitis, and cervical radiculopathy
62
Finkelstein's test
patient grasp the thumb against the palm and then move the wrist toward the midline in ulnar deviation
identifies De Quervain’s tenosynovitis
63
When should you consider carpal tunnel syndrome
Complaints of dropping objects
Inability to twist lids of jars
Aching at the wrist/ forearm
Numbness of the first three digits
64
Abductor pollicus is innervated only by which nerve
median nerve
65
Tinel’s sign
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
66
Phalen’s sign
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
67
Kienbock’s Disease
Avascular necrosis of lunate bone
Unknown etiology
excruciating pain, hand crippling
68
Trigger Finger
Painless nodule in a flexor tendon in the palm near metacarpal head
steroid, injection, surgery
69
hypothenar atrophy suggests
ulnar nerve disorder
70
Ganglion
Cystic, round, nontender swellings along tendon sheaths or joint capusles
Frequently found on the dorsum of the wrist
common
71
avulsion fracture
tendon or ligament pulls off a piece of the bone
72
Mallet Finger
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
73
nerve root exits where from the corresponding vertebral body in Cervical spine
above*
| as compared to lumbar and thoracic spine where they exit below
74
kyphosis
hunch back
75
lordosis
inward curving of lower back
76
spondylosis
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
77
Cervical Radiculopathy Sx**
Occipital headache/Axial neck pain: Discogenic vs mechanical (arthrosis)
Periscapular pain
Unilateral arm pain/sensory changes/weakness: Usually dermatomal (crossover can occur)
78
C5 Radiculopathy** Motor/Reflex Exams
Motor: Deltoid/Biceps
Reflex: Biceps
79
C6 Radiculopathy** Motor/Reflex Exams
Motor: Biceps/Wrist extension
Reflex: Brachioradialis
80
C7 Radiculopathy** Motor/Reflex Exams
Motor: Triceps/Wrist flexion
Reflex: Triceps
81
C8 Radiculopathy** Motor/Reflex Exams
Motor: Finger flexion
Reflex: None
82
T1 Radiculopathy** Motor/Reflex Exams
Motor: Finger Abduction
Reflex: None
83
C2 Radiculopathy Sx*
posterior occipital HA
| Temporal pain
84
C3 Radiculopathy Sx*
Occipital HA, retro-orbital or retroauricular pain
85
C4 Radiculopathy Sx*
Base of neck
| trapezial pain
86
C5 Radiculopathy Sx*
Lateral arm
87
C6 Radiculopathy Sx*
Radial forearm, thumb, and index fingers
88
C7 Radiculopathy Sx*
Long finger
89
C8 Radiculopathy Sx*
Ring and little fingers
90
T1 Radiculopathy Sx*
Ulnar forearm
91
Spurling maneuver
provocative test to reproduce the radicular pain pattern
| Maximally extend & rotate the neck to the involved side, then apply vertical force downward
92
Shoulder abduction Test
Shoulder abduction should relieve symptoms
93
Tx of cervical radiculopathy
75% improve with non-operative management
94
Gold Standard for surgical treatment of cervical radiculopathy
Anterior cervical decompression & fusion (ACDF)
| can choose cervical disc replacement instead to Decrease adjacent level disease
95
Cervical Myelopathy cause*
spinal cord compression rather than root:
Ossification of the Posterior Longitudinal Ligament (OPLL)
Congenital stenosis
Tumor/abscess
Spondylosis
trauma
96
Cervical myelopathy is associated with lumbar stenosis in ? %
20%
| Hence recommendation to image both in symptomatic patients
97
Cervical myelopathy presentation*
```
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
```
98
What exam should you always go in Cervical Myelopathy*
RECTAL
| Can have problems late dz
99
Lhermitte’s sign
Electric shock like sensations down spine or legs with certain positions of the neck
100
Cervical Radiculopathy
Clinical symptom of nerve root compression resulting in sensory/motor symptoms of the UE
101
Cervical Radiculopathy causes
Cervical spondylosis
Disc herniation
Stimulation of the nerve root by chemical pain mediators
102
Tx goal of Cervical Myelopathy*
STOP PROGRESSION
NOT symptom improvement
most get surgery: Decompression, lordosis restoration, and stabilization
103
Ossification of the posterior Longitudinal ligament (cervical myelopathy) MC in what population?
asian
104
lower back pain prognosis
90% resolves in 1 yr
| occurs up to 95% in life time
105
Causes of Lower back pain
```
Muscle strain/ligament sprain
Facet joint arthropathy
Discogenic pain/annular tears
Spondylolisthesis
Spinal stenosis
```
106
Waddell Signs
Signs of non-organic back pain
| basically fake back pain
107
Grocery cart sign* (unofficial name?)
is it easier to lean over your cart? can be lumbar stenosis
108
Tx of lower back pain
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
109
MC level for Lumbar Disc Stenosis
L5-S1 > L4-5
110
L1-3 Motor/Reflex Exam*
Motor: Hip Flexion (Iliopsoas)
Reflex: None
111
L4 Motor/Reflex Exam*
Motor: Knee extension/Foot dorsiflexion
Reflex: Patellar
112
L5 Motor/Reflex Exam*
Motor: Great toe extension
Reflex: None
Gait? Trendelenburg (Glut medius innervated by L5)
113
S1 Motor/Reflex Exam*
Motor: Foot Plantarflexion/Eversion
Reflex: Achilles
114
for both cervical and lumbar disc herniations, the nerve root involved is usu
usu corresponds to lower of the adjacent 2 vertebra
115
Lumbar disc herniation (LDH) Tx
Partial discectomy is the standard of care
should not be delayed >3-4mon
improves leg pain almost always
116
Degenerative spondylolisthesis
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
117
Posterior fat pad in elbow in pediatrics suggests
Supracondylar fracture of distal Humerus
118
Posterior fat pad in elbow in adult suggests
Radial head fracture
119
What films do you always need for tibia and fibula?*
full length views (AP and lateral)
120
What films should you order regarding joints in an injury?*
image joints above and below the suspected site of injury
121
What to order w/suspected injury: Proximal Humerus*
Shoulder (AP, Scapular Y, Axillary vs. Velpeau***), full-length Humerus
122
What to order w/suspected injury: Elbow fx*
Humerus (AP and lateral), Shoulder, (AP, Scapular Y, Axillary vs. Velpeau), and Forearm (AP and lateral)
123
What to order w/suspected injury: Distal Radius fx*
Forearm (AP and lateral), Wrist (AP and lateral)
124
What to order w/suspected injury: Hand/Finger Fx*
Hand (AP, lateral, oblique), special views as needed for specific injuries
125
What to order w/suspected injury: Ankle fx*
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
What to order w/suspected injury: Tibia fx*
Full-length Tibia/Fibula (AP and lateral), Knee (AP and lateral)
127
What to order w/suspected injury: Femur fx*
Full-length Femur (AP and lateral), Hip (AP, Lat, Cross-Table Lateral), and Knee (AP, Lateral)
128
What to order w/suspected injury: Hip fx*
Hip, Full-length Femur, AP Pelvis
129
What is the first thing you should assess with any suspected injury due to its urgency?**
neurovascular status!
130
Tumors that metastasize to bone?**
“BLT with Kosher Pickle”
| Breast, Lung, Thyroid, Kidney (Renal Cell Carcinoma), and Prostate
131
Which tumors are blastic and which are lytic?**
“PB-KTL” (Lead Kettle)
Prostate and Breast are Blastic
Kidney, Thyroid, and Lung are Lytic
132
Comminuted fracture
≥3 pieces
| v simple: 2 pieces
133
greenstick fracture
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
impacted fracture
fracture where a bone fragment is driven into another bone fragment
135
Velpeau view
modified trauma axial view
| need to order in shoulder injuries (OR axillary view), looks for dislocations
136
Mortise view
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
Stress view*
TESTS INTEGRITY OF LIGAMENT --> Ankle (IMPORTANT TO GET STRESS VIEW ON ANKLES***
138
Scapular Y view
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
Salter-Harris Type II (Growth plate injuries)*
Above Physis (in Metaphysis)
140
Salter-Harris Type III (Growth plate injuries)*
Lower than Physis (in Epiphysis)
141
MC of Salter-Harris fracture types*
Type II
142
Thurston-Holland fragment
Name of Metaphyseal fragment in Salter Harris fractures
143
What must you do/order for a patient with a knee dislocation?*
Must order ABI vs. CT Angiogram to document blood flow to remainder of lower extremity
144
must be checked on each and every patient with proximal humerus fracture*
axillary nerve (test sensation of deltoid)
145
Treatment of Prox Humerus Fxs
85% treated with sling immobilization followed by rehab
146
Presentation of Compartment Syndrome**
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
Treatment of Distal Radius Fxs
Don’t immobilize in adult with cast --> doesn’t allow room for swelling
148
One of biggest predictors for increased mortality in pelvic ring fx**
need for transfusion of >4 units of packed RBCs*
| hemorrhage is the leading cause of death
149
Mortality rate for open pelvic ring fx*
as high as 50%
150
What should only be done once in Physical Exam for Pelvic Ring Injuries*
palpating pelvis
151
strongest ligament in the body
posterior sacroiliac ligament
152
What must be imaged in a Trauma Series? (pelvis)***
AP Pelvis, CXR, Lateral C-Spine***
153
Treatment of pelvic ring injuries*** (trauma)
Resuscitate patient first; ideally 1:1: 1 (pRBC:FFP:Platelets)
154
What scan is not utilized in a femoral neck fx
NOT CT SCAN! Within 48hrs, a lot of bony edema can’t see on CT scan
155
Which population of people more commonly have avascular necrosis?*
Commonly see in people who are long-term alcoholics
156
How does the leg appear in leg fractures*
Leg may appear in external rotation and abduction, will appear shortened
157
What do all patients with hip fractures get?**
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
Ideal time to perform hip fracture surgery
within 48hrs of injury
| elderly should be brought to surgery as soon as medically optimal
159
Mortality rates of geriatrics at 1yr post surgery
as high as 14-36%
| In patients with chronic renal failure, rates of mortality at 2 years postoperatively are ~45%
160
Mortality rates for Intertrochanteric fractures v Femoral neck
Mortality rates HIGHER for than Femoral Neck fractures
161
3 potential spaces for major blood loss in femoral shaft fractures**
Thorax, Pelvis, Thigh
162
Schatzker Type IV injuries are associated with
knee dislocation and vascular injury
| isolated medial tibia plateau fracture
163
What can you still have with an open fracture?*
compartment syndrome!
164
Ankle fractures require
urgent reduction in ED to prevent soft tissue compromise
| ice and elevate injuries ASAP after reduction
165
What must you also image in Calcaneus Fractures?
must image L-Spine, and contralateral Calcaneus
| Prognosis is poor with ~40% complication rate
166
What must you assess in calcaneus fractures?
Must assess for posterior skin necrosis —> If present, surgical emergency
167
What imaging do all trauma patients get?**
Chest XR, AP Pelvis XR, Lateral C-Spine XR
168
How do you determine if you get an adequate XR of the C-Spine?
Must be able to visualize C7 on T1
169
Potential spaces for life threatening blood loss***
Abdomen, Thorax, Thigh
170
Most important thing in managing open fractures**
Early IV antibiotics
171
How do you never treat an ACL tear?
repairs! Always reconstruct!
172
Ottawa ankle rule
when pt should receive an x ray
173
Lisfranc injury
fracture at distal end of MTP, proximal end dislocated, some type of twisting location; needs surgery
174
Legg calve perthes: age group**
USUALLY 4-10 Y/O MALES
| younger the kid, better the outcome
175
Legg calve perthes: Sx**
```
PAIN (GROIN/THIGH)
POSSIBLE KNEE PAIN
EFFUSION
LIMP/ANTALGIC GAIT
LIMITED ABDUCTION AND INTERNAL ROTATION
Can lead to OA later on
```
176
Legg calve perthes: Tx**
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
Slipped capital femoral epiphysis: age group**
MORE COMMON IN MALES (AGES 11-15)
| Older than Perthes
178
Legg calve perthes: Dx**
X Ray ASAP
| immediate referral
179
Legg calve perthes**
ISCHEMIA WITH SUBSEQUENT NECROSIS OF FEMORAL HEAD
180
Legg calve perthes: Dx**
X Ray ASAP
immediate referral
Late Dz on XR: signif bone remodeling and bone resorption
181
Slipped capital femoral epiphysis**
POSTERIOR INFERIOR DISPLACEMENT OF THE FEMORAL EPIPHYSIS THROUGH THE GROWTH PLATE
DON'T MISS!!!!
182
Slipped capital femoral epiphysis: Dx**
PAINFUL, LIMITED ROM
XRAYS: quality films
AP PELVIS AND BILATERAL FROG LEG LATERAL VIEWS TO R/O OPPOSITE HIP INVOLVEMENT
183
Slipped capital femoral epiphysis: Tx**
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
Complex Regional Pain Syndrome Type I
without a definable nerve lesion
Includes Reflex Sympathetic Dystrophy
Represents 90%
185
Complex Regional Pain Syndrome Type II
with a nerve lesion, Causalgia
| Involves the Peripheral, Central & Autonomic Nervous systems
186
Complex Regional Pain Syndrome Type II
with a nerve lesion, Causalgia
| Involves the Peripheral, Central & Autonomic Nervous systems
187
Complex Regional Pain Syndrome
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
Dx complex regional pain syndrome
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
Dx complex regional pain syndrome
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
complex regional pain syndrome Tx
First line treatments: Physical therapy (PT) and Occupation therapy (OT)
191
5 P’s of Compartment Syndrome**
```
pain: early, universal
paresthesia
paralysis: late finding
pallor
pulseless: rare
```
192
Stryker Stic Device
measures compartment pressure
Continuous/Serial Monitoring: > 30 mmHg
OR
Difference between Diastolic Pressure and Compartment Pressure (Delta Pressure): < 30 mmHg
193
acute compartment syndrome tx
Fasciotomy
194
If acute compartment syndrome not treated within a few hours,
muscle loss, amputation, infection, nerve damage, and kidney failure (following rhabdomyolysis)
195
Pre Hospital Management of acute compartment syndrome
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
Osteomyelitis
Infection of bone caused by an organism
acute: 2wks after initiating event
subacute: 1-3mon
chronic: +3mon
197
Most common cause of osteomyelitis from open fractures**
multiple organisms
198
Most common site for osteomyelitis in children
Long bones – Metaphysis
199
Most common site for osteomyelitis in adult
Vertebral
200
GOLD STANDARD for Dx of osteomyelitis
Bone biopsy for culture
201
Imaging test of choice for osteomyelitis if <2wks of Sx
MRI
| X ray if >2wks
202
To Dx osteomyelitis in absence of positive bone biopsy…must have
```
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
Fractures with highest potential for blood loss*
Pelvic fx 1st
| femur 2nd
204
What vascular injury can occur w/Anterior shoulder dislocation
axillary artery injury
205
What vascular injury can occur w/Extension supracondylar fracture
brachial artery injury
206
What vascular injury can occur w/Posterior elbow dislocation
brachial artery injury
207
What vascular injury can occur w/Knee dislocation
popliteal artery injury
208
Volkmann Ischemic Contracture
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
What nerve injury can occur w/Shoulder dislocation
axillary* and musculocutaneous nerve injury
210
What nerve injury can occur w/Humeral shaft injury
radial nerve injury
211
What nerve injury can occur w/Supracondylar fracture
median, radial and ulnar nerve injury
212
What nerve injury can occur w/Medial epicondylar fracture
ulnar nerve injury
213
What nerve injury can occur w/Elbow dislocation
ulnar and median nerve injury
214
What nerve injury can occur w/Olecranon fracture
ulnar nerve injury
215
What nerve injury can occur w/Acetabular fracture
sciatic nerve injury
216
What nerve injury can occur w/Posterior hip dislocation
sciatic nerve injury
217
What nerve injury can occur w/Anterior hip dislocation
femoral nerve injury
218
What nerve injury can occur w/Knee dislocation
peroneal and tibial nerve injury
219
What nerve injury can occur w/Lateral tibial plateau or fibular head fracture
peroneal nerve injury
People tackled on side
Can’t dorsiflex, get foot drop
220
Fat Embolism
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
most common pathogens mediating necrotizing skin and soft tissue infections*
Group A β-hemolytic Streptococcus (GAS), especially in the case of necrotizing fasciitis
222
most common pathogens mediating gangrenous cellulitis and myonecrosis*
clostridial species
arise either from deep traumatic or surgical inoculation
Many don’t survive
Will need skin grafts
223
Primary Survey for orthopedists in trauma
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
common bleeding site in pelvic ring fx
Sacral Venous Plexus and Internal Iliac Arteries
225
What to do 1st in pelvic fractures
ATLS: stop the bleed
Resuscitate: IV fluid, blood transfusion
Binder/Sheet: stabilize
226
Dislocated Joints that are considered
emergencies!
The longer dislocated, harder to put back in bc muscle tense around it
worry about vessels, nerves, ligaments
227
Hill–Sachs fracture
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
How to test axillary nerve?
deltoid sensation
| touch pt's deltoid and ask if they can feel
229
Prehospital personnel should what in an elbow dislocation?*
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
Neuropraxia
(transient episode of motor paralysis)
| involving median or ulnar nerve in 20% of elbow dislocations
231
Anterior hip dislocation
hip in external rotation
232
Posterior hip dislocation
hip in internal rotation
4/5 from trauma
more common
can have sciatic n injury
233
Knee dislocation
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
What urgent thing to check w/Knee Dislocation
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
What to give in the ER with open fx
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
MC Elbow Dislocation
80% Posterior
may have neurovascular injury
MC childhood dislocation
237
PIN (POSTERIOR INTEROSSEUS N) compression (Radial tunnel syndrome)
Pain 4 - 5 cm distal to lateral epicondyle.
No paresthesias
Middle finger test: Extend against resistance = pain
238
Most important components of fx of distal humor**
displacement, neurovascular status, joint surface involvement or skin injury
ulnar n most commonly injured
239
Fat pad sign
anterior fat pad of elbow becomes elevated, and the posterior fat pad becomes visible
240
Type 4 Mason classification of radial head fx
Radial head fracture with associated elbow dislocation
241
What should you avoid doing in olecranon bursitis*
I&D
242
Froment's sign
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
Stages of Cervical Disc Syndromes
protrusion/prolapse: bulging
herniation/extrusion: AF tear, NP leak, entrapment
sequestration: leaks completely out of disc
244
Tx of cervical disc syndromes
rest = cornerstone
acute tx: Moist heat, soft collar, PT, cervical pillow
simple analgesics
245
cervical sprain (whiplash)
```
Extension-flexion mechanism
Ligamentous injury
Delayed onset (few hours) common.
Increasing neck stiffness -> generalized and diffuse pain -> decreased range of neck motion.
```
246
Discitis
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
Spondylolysis
```
Defect in pars interarticularis
Nondisplaced stress fracture
Overuse injury: hyperextension
Stork Test
Oblique XRay
```
248
spondylolisthesis
Bilateral spondylolysis with lithesis (slippage) of vertebral body
Anterior displacement of vertebral body inferior to the defect
Lateral XRay
surgery only if severe
249
Congenital muscular torticollis
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
Acquired torticollis
spasm of neck muscles, trauma, infection, idiopathic
251
partial dislocation of vertebrae
flexion injury, less traumatic
usu PLL Disruption
lateral c spine x ray
STABLE
252
Bilateral facet dislocation
```
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
Compression fractures
common in osteoporosis*
trauma, malignancy, infection
may affect one or more vertebrae
254
Compression fracture types
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 prognosisoften quadriplegia
255
MOST UNSTABLE and dangerous C-spine injury***
Flexion teardrop fracture
256
Flexion teardrop fracture
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
Clay-shoveler’s fracture
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
Hangman’s fracture (fracture of C2)
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
Jefferson fracture
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
Anterior Talofibular Ligament
stabilizes forward from sliding anteriorly (similar to ACL that keeps sliding anteriorly)
261
Calcaneofibular ligament
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
Deltoid ligaments
a number of components; less likely injured in isolated sprain but more dislocations/fx
keep foot from eversion
263
Sprains: Grade I*
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
Sprains: Grade II
```
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
Sprains: Grade III
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
High Ankle Sprain”Syndesmosis Injury MOI**
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
Syndesmosis
interosseous ligament
anterior-inferior tibiofibular ligament
posterior-inferior fibular ligaments, and
inferior transverse tibiofibular ligament
provides stability between tibia and fibula above ankle
normally <5mm
268
Tests for syndesmosis injury*
“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
Achilles Tendonitis
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
Acute AchillesTendon Rupture
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
Thompson Test
CAUSE PLANTARFLEXION WITH SQUEEZING IF ACHILLE INTACT
| calf squeeze for achilles tendon rupture
272
Orthotics
design, manufacture, fit and/or modify shoes and foot orthoses to alleviate foot problems caused by disease, overuse, or injury.
273
ORIF for trimalleolar fx is recommended if
> 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
What should you look for w/ankle fx's*
**Look for a Proximal Fibula Fx!
275
Lisfranc Injury
"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
What to do if Lisfran injury persist?*
**Obtain a MRI to define soft tissue damage if persists**
277
Avulsion fx v Jones fx
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
Tarsal Tunnel Syndrome
tibial nerve entrapment
dorsiflexion/eversion test aggravates
Pain and numbness on bottom of foot, weak toe flexion!
279
Plantar Fasciitis
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
corns v callus
corns: central core,extends deep into skin and presses on nerve endings → pain; can be soft or hard
281
Cellulitis Tx
Quinolone (Cipro, Levo) and 1st generation Cephalosporin [i.e. Cefalexin (Keflex) or Cefazolin if IV]
282
most common tendon injured in rotator cuff tear
supraspinatus muscle
283
common place for IMPINGEMENT
Space between supraspinatus and AC joint
284
What neurovascular structures can be irritated by backpacks and bra straps?
suprascapular nerve and artery
285
Trauma series of shoulders**
AP, Lateral, Scapular (outlet- impingement) Y
286
"painful arc"
Rotator cuff or subacromial impingement --> tend to have 60 degrees to 120 abduction
also inflammation of subacromial bursa
287
Imaging for rotator cuff tears
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
Supraspinatus tears usu accompany...*
Supraspinatus passes through joint capsule; so if it tears it tends to tear joint capsule as well**
289
Tests for Biceps tenosynovitis
Positive Yergason’s test or Speed’s test
290
“Popeye’s Deformity”
from forceful contraction of biceps tendon
Sudden snap followed by pain and weakness
retraction of biceps
surgical repair in younger pts
291
Posterior glenohumeral dislocations often seen in
seizure or convulsive disorders
292
Anterior/Posterior glenohumeral dislocations have a risk for
Neurovascular compromise
293
Hill Sachs lesions
indentation of superolateral humeral head in recurrent anterior dislocators – chip of bone taken out head of humerus
294
Bankart lesion
lesion of the labrum or glenoid margins – can extend into tear of bone
Anterior (MC) vs Posterior (reverse Bankart)
295
What is humeral shaft fx at risk for
radial nerve compromise
296
Medical cause of shoulder pain
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
Crossover maneuver for shoulders
Cross body adduction
Typically arthritic changes
AC or SC disease
