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CD III > Lecture 7- Ortho > Flashcards

Lecture 7- Ortho Flashcards

1
Q

first line for bones?

A

Xray

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2
Q

when to use CT

A
  • bone detail: extent and severity of fracture
  • fracture fragment evaluation
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3
Q

when to use MRI?

A
  • occult (hidden) fracture evaluation
  • tumor eval
  • soft tissue injuries (ligaments, meniscus, rotator cuff)
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4
Q

Describe use of bone scans

A
  • involves IV injection of radioactive tracer that accumulates in bone that is undergoing rapid turnover/growth
  • imaging of choice for detecting skeletal metastases
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5
Q

describe use of US in ortho

A

newer applications- include evaluating superficial structures (tendons), guiding injections, screening long bone fractures

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6
Q

Xray Views

comparison views

A
  • esp use in kids
  • compare R & L respectively
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7
Q

how to systematically read xray

A
  • adequacy
  • alignment
  • bones (sometimes nutrient vessels look like fractures)
  • cartilage (is there space where cartilage would be? can’t actually see cartilage)
  • soft tissue
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8
Q

how to view xray

A
  1. look at each bone (smooth contours, lucencies/opacities)
  2. look at each joint
  3. look at soft tissue
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9
Q

what color usually are fracture lines?

A

lucent (black)

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10
Q

Shoulder

tips for shoulder view

A
  • don’t forget to view clavicle (separate image)
  • need to know view to read image
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11
Q

Shoulder

Grashey vs AP

A
  • Grashey: glenohumeral joint, humeral tuberous
  • AP: better for acromialclavicular joint, some parts of humerus
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12
Q

Humeral View

when/what views to order? what should be visible for good image?

A
  • only order if concern for shaft fracture or tumor
  • joint above & below
  • always do IR & ER unless fracture or dislocation
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13
Q

Elbow Imaging

what is soft tissue issue

A
  • pos fat pad sign (sail sign)
  • dark area displacing the fat pad indicating blood/injury
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14
Q

Elbow Imaging

how to get proper AP view

A

lay arm as flat as possible

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15
Q

Elbow Imaging

purpose of the radiocapitellar line?

A
  • helps us know if it is dislocated
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16
Q

Forearm Imaging

components

A
  • just changing from pronation to supination does not give 2 proper views of radius/ulna
  • make sure entire unit moves together
  • bones should mostly overlap on lat view
  • must include wrist + elbow
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17
Q

Wrist Imaging

components

A
  • does not have to include fingers
  • does not have to include radius/ulna shaft
  • too much radius/ulna are sometimes signs of bad images
  • scaphoid view ordered here
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18
Q

Hand Imaging

components

A
  • “ok” sign for lat view
  • finger tips should be visible
  • oblique view to look at metacarpals
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19
Q

Hip Imaging

components

A
  • AP, frog leg, pelvis most common
  • cross table lateral possible not common
  • MAKE SURE TO LOOK AT PUBIC RAMI
  • bilat hip is different from pelvis
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20
Q

Femur Imaging

components

A
  • AP should include knee and hip to be adequate
  • difficult to accomplish lateral because of lead in groin and overlap of pelvis structures
  • ok if not perfect, caution w reshooting
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21
Q

Knee Imaging

components

A
  • several views possible, based on problem
  • look at fibula & tibial tubercule
  • should be WB unless fracture & pt can’t stand
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22
Q

Knee Imaging

when to use tunnel imaging?

A

ligament damage

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23
Q

Tib/Fib Imaging

Components

A
  • often anlged on film because leg is too long
  • must include knee/ankle joints
  • only performed for fractures and tumors
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24
Q

Knee Imaging

which views should be wt bearing

A

Ap, Lat, oblique

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25
Q

Ankle Imaging

components

A
  • AP + Lat: arthritis
  • AP + Lat + Mortise: injuries
  • mortise “straightens” things out
  • don’t ignore post ankle
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26
Q

Fracture Terminology

Simple Closed fracure

A

2 fracture fragments, skin intact
may take 7-10d to be visible on xray

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27
Q

Fracture Terminology

compound (open) fracture

A

2 fracture fragments, skin is penetrated

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28
Q

Fracture Terminology

comminuted (complex) fracture

A

2+ bone fragments

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29
Q

Fracture Terminology

transverse

A

fracure like — across bone

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30
Q

Fracture Terminology

Spiral fracture

A
  • “spiral” break in bone (curling)
  • caused by rotational forces
  • common in children (femur), aging females (humerus)
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30
Q

Fracture Terminology

oblique fracture

A

diagonal fracture ( / )

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31
Q

Fracture Terminology

angulation

A
  • to describe direction of fracture
  • dorsal, radial, ulnar, valgus, varus, lateral, medial
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32
Q

Fracture Terminology

displacement

A
  • describe the DISTAL fragment when looking as displacement (proximal part of bone is the “anchor”)
  • can be full displacement or side to side movement of the fragments
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33
Q

Fracture Terminology

Distraction vs Overriding

A
  • distraction: fragments have been pulled apart
  • overriding: overlap of fragments/shortening
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34
Q

Fracture Terminology

impaction

A

fragments have been driven together

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35
Q

Fracture Terminology

stress fracture

A
  • opaque on imaging NOT lucent
  • summation of microfractures caused by unusal or excess stress (athletes)
  • tibia is common site of stress fx in all ages
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36
Q

Fracture Terminology

Pathologic Fractures

A
  • fracture through bone abnormality (benign or malignant leading to bone weakness)
  • minimal or no trauma
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37
Q

Fracture Terminology

Avulsion fracture

A
  • fracture of bony fragment that is produced by the pull of a ligamentous or tendinous attachment
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38
Q

Fracture Terminology

describe avulsion fracture of the knee

A
  • Segond fracture
  • highly associated with ACL tear, get an MRI
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39
Q

Pediatric Fracture Terminology

  • physis
  • diaphysis
A
  • physis: grwoth plate, bone formation here, weakest part of bone
  • diaphysis: shaft
40
Q

Pediatric Fracture Terminology

Salter-Harris Fracture types for physis fractures

SALTER

A

Type 1: straight across physis
Type 2: above physis (meta)
Type 3: below physis (epi)
Type 4: through everything
Type 5: crushed

41
Q

Pediatric Fracture Terminology

greenstick fracture

A
  • incomplete fractures where the bone “bends like a twig” and the cortex cracks
42
Q

Pediatric Fracture Terminology

torus fractures

A
  • buckle fracture, type of incomplete
  • creates a “bump” without an obvious fracture line
  • very common- seen w/ falls on outstretched hands (FOOSH)
43
Q

Fracture Healing Terminology

callus formation

A

fracture line is no longer clean + lucent
bony bridging of fracture line

44
Q

Fracture Healing Terminology

nonunion

A
  • causes: infection, inadequate immbolization, inadequate blood supply, inadequate nutrition
  • non healing fracture
45
Q

Fracture Healing Terminology

rate of fracture healing depends on?

A

age, type of fracture, nutritional/hormonal status, adequacy of tx

46
Q

Fracture Healing Terminology

malunion

A

healed in bad positioning

47
Q

Common Fractures

Scaphoid- overview

A
  • 5% have complications (nonunion, osteoarthritis, avascular necrosis)
  • surgically repair, refer to ortho if you see it
48
Q

Common Fractures

colles fracture overview

A
  • fracture of the distal radius with dorsal angulation of the distal fragment
  • +/- ulnar styloid fracture
  • FOOSH (hyperextension injury)
49
Q

Common Fractures

Smith Fracture

A
  • fracture of distal radius with palmar angulation of the distal fragment
  • fall on back of flexed hand
50
Q

Common Fractures

Radial head fracture

A
  • easily missed- look for posterior fat pad sign
  • most common elbow fracture in adults
  • caused by fall on outstretched arm or direct blow to elbow
51
Q

Common Fractures

boxer fracture

A
  • fracture of head of 5th metacarpal
  • usually result of punching solid object
  • usually closed
  • prescribe abx; if they punched someone in mouth give abx
52
Q

Common Fractures

hip fracture risk factors

A
  • old people more common due to brittle bones
  • risk factors: osteoporosis, age, high energy trauma, pathologies that weaken bone
53
Q

Common Fractures

Hip fracture- what part of bone most common

A

femoral neck or intertrochanteric region

54
Q

Common Fractures

which view is best initial view to look for hip fractures? which is best for occult fractures?

A
  • initial: AP pelvis
  • occult: MRI
55
Q

Common Fractures

hip fx lines may be difficult to see in who?

A

pts w/ osteoporosis

56
Q

Joint Injury Terminology

define subluxation

A

incomplete loss of contact between articular surfacces

57
Q

Joint Injury Terminology

define dislocation

A

complete loss of contact between articular surfaces

58
Q

Joint Injury Terminology

which is most common site of dislocation?

A

shoulder

59
Q

Joint Injury Terminology

differentiate posterior and anterior shoulder dislocation

A
  • posterior: humeral head appears superior to glenoid cavity on AP film
  • anterior: humeral head appears inferior to glenoid cavity on AP film
60
Q

Non-Traumatic Skeletal Pathology

describe osteoarthritis

A
  • most common joint disease
  • clinically: pain, deformity, limited ROM
  • most common cause of disability after age 65 yrs
61
Q

Non-Traumatic Skeletal Pathology

radiographic signs of OA

A
  • asymmetric joint space narrowing
  • sclerotic bone changes (more dense)
  • degenerative cysts (more lucent)
  • osteophyte formation (bone spurs)
62
Q

Non-Traumatic Skeletal Pathology

what joints are most typically affected by OA?

A
  • DIP
  • 1st metacarpal-carpal
  • hips
  • knees
  • spine
63
Q

Non-Traumatic Skeletal Pathology

answer OA question on slide 85

A

ok

64
Q

Non-Traumatic Skeletal Pathology

describe rheumatoid arthritis

A
  • inflammatory arthritis
  • joints become painful, swollen, deformed w/ morning stiffness
  • most commonly affects MCP, carpal, PIP joints (DIP involvement unusual)
65
Q

Non-Traumatic Skeletal Pathology

radiographic signs of rheumatoid arthritis

A
  • symmetric joint space narrowing
  • periarticular osteopenia or osteoporosis
  • osseous erosions
  • MCP subluxation (which causes ulnar deviation clinically)
66
Q

Non-Traumatic Skeletal Pathology

go label OA vs RA slides on pt

A

ok

67
Q

Non-Traumatic Skeletal Pathology

bone tumors

A
  • sharply marginated lesions are usually benign (benign = risk of breaking)
  • fuzzy borders, outside bone margin usually indicates malignancy (cancerous = risk of dying)
68
Q

Non-Traumatic Skeletal Pathology

most common cause of bone tumors?

A

metastatic lesions are more common than primary cancerous lesions

69
Q

Non-Traumatic Skeletal Pathology

describe osteomyelitis

A
  • focal destruction of bone due to infection
  • happens via hematogenous spread, contagious spread, or direct inoculation
70
Q

Non-Traumatic Skeletal Pathology

which radiographic modalities are best for dx osteomyelitis

A
  • bone scan or MRI

if you can see it on x-ray it has been going on for a while

71
Q

Spine/Head Imaging

role of xray? ct? mri?

A
  • xray: initial screening for some conditions or in low-resource areas
  • ct: initial screen ing for pts w/ C-spine trauma (esp if need concurrent brain eval), good for localizing fracture fragments!
  • mri: in trauma to look for spinal cord, disc, or ligament injruy; study of choice for most diseases of spine
72
Q

Spine/Head Imaging

describe c-spine trauma imaging

A
  • 50% of c-spine trauma is due to MVA
  • if imaging is indicated use CT
  • rural places may use x ray but stuff gets missed
73
Q

Spine/Head Imaging

when do not do radiography at all?

A

NEXUS low risk pt- meets ALL conditions:
* no posterior midline cervical tenderness
* normal level of alertness
* no evidence intoxication
* no focal neurologic deficits
* no painful distracting injuries (e.x if broken toe also do c spine)

74
Q

Spine/Head Imaging

ABCS of viewing miages

A
  1. adequacy (all vertebrae seen, no rotation)
  2. Alignment (four smooth curves in correct direction)
  3. Bones (fractures of vertebral bodies, lateral masses, laminae, spnious processes)
  4. Cartilage (intervertebral disc spaces, interspinous process distances)
  5. Soft tissues (preverterbral soft tissues, esp C1-C3)
75
Q

Spine/Head Imaging

what are the four curves of alignment? go to slide & label image too!

A
  • anterior verterbral body line
  • posterior vertebral body line
  • spinolaminar line
  • tips of spinous processes
76
Q

Spine/Head Imaging

what would absent curves mean?

A

whiplash, muscle spasms

77
Q

Spine/Head Imaging

describe components of distractive-flexion injuries

A
  • posterior ligament tear
  • occurs due to hyperflexion sprain; bilateral “perched” facets
  • bilat facet dislocation = bilat interfacetal dislocation
  • unilateral facet dislocation (w/ rotational component) causes nerve root injury
  • big spaces, slanted forward
78
Q

Spine/Head Imaging

describe compressive flexion c spine injury

A
  • anterior fracture of vertebral body
  • wedge compression fracture
  • flexion teardrop (causes anterior cord syndrome due to retrolisthesis of vertebral body into ant portion of spinal canal)
79
Q

Spine/Head Imaging

describe distractive extension injury

A
  • anterior ligament tear
  • causes central cord syndrome due to compression of the spinal cord w/in spinal canal
  • hyperextension spain, hyperextension teardrop
80
Q

Spine/Head Imaging

describe compressive-extension injury

A
  • posterior fracture
  • unilat or bilat fractures of lamina, lateral masses (pillars), or spinous processes
  • pedicolaminar fractures result in separation of lateral mass from vertrab (hyperextension fracture dislocation)
81
Q

Spine/Head Imaging

describe axial compression

A

vertebral body burst fracture

82
Q

Spine/Head Imaging

describe lateral bending injuries

A
  • uncinate process fracture
  • unilat vertebral body or posterior element fracture
83
Q

Spine/Head Imaging

describe clay shoveler’s fracture

A

isolated spinous process fracture of C7 (or C6, T1)

84
Q

Spine/Head Imaging

describe spinous process by shoulder muscle injuries

A
  • pull by shoulder muscles (Scapular rhomboid muscle) or direct impact to spinous process
85
Q

Spine/Head Imaging

describe:
* anterior column
* middle column
* posterior column

A
  • anterior: ant longit ligaments, anterior annulus, anterior 2/3 vertebral body
  • middle: posterior 1/3 of verterbral body, post annulus, posterior longit lig
  • posteior: posterior elements (pedicles, facets, lamina, spinous process), posterior ligaments
86
Q

Spine/Head Imaging

how to tell if spinous fracture is stable?

A

if only one column is disrupted then the injury is stable. If multiple columns are disrupted, then the injury is not stable

87
Q

Spine/Head Imaging

what is a burst fracture?

A

unstable- involves anterior and middle columns

88
Q

Spine/Head Imaging

when could a two column injury be managed conservatively?

A

with a middle coluumn injury and an intact posterior ligmament complex (PLC)- get MRI to evaluate

89
Q

Spine/Head Imaging

steps to viewing thoracic spine

A
  • go through the same steps as c spine but also look at ribs/costovertebral joints
  • look at vertebral bodies (origin of compression fractures)
  • check for kyphosis
90
Q

Spine/Head Imaging

steps/tips for viewing lumbar spine

A
  • go through same steps as C-spine
  • also look at Si joints, vertebral bodies (compression fractures)
  • check “scotty dogs” for spondylolysis and spondylolistheses
  • check for severity of lordosis
91
Q

Spine/Head Imaging

describe scotty dog sign

A
  • seen on oblique view
92
Q

Spine/Head Imaging

differentiate:
* jefferson fracture
* hangman fracture
* odontoid process fracture

A
  • jefferson: axial loading injury, fracture of C1
  • hangman: extension injury; fracutre of posterior elements of C2
  • odontoid: flexion/extension injury, more common in elderly
93
Q

Spine/Head Imaging

which cervical vertebrae are most commonly fractured?

A
  • C5-C7
  • C1/C2
94
Q

Spine Imaging

imaging for bain pain

A
  • acute back pain top 5 PCP complaint
  • 90% will resolve w/out imaging or intervention
  • problem: most adults 40+ will have degeneratvie lumbar spine changes on conventional radiograph + degenerative disc changes on MRI which is normal finding for age
  • should wait for sx to persist for 4-6 wks prior to imaging unless red flags
95
Q

Spine Imaging

red flags that indicate need for imaging

7

A
  • severe, progressive neurologic deficit
  • minor trauma in OA pts
  • major trauma in all other pts
  • prolonged use of corticosteroids
  • hx of cancer/unintentional wt loss
  • recent bact infection/fever
  • immunesuppression
96
Q

Spine Imaging

compression fractures

A
  • may occur w/ minimal stress in pt w/ osteoporosis
  • most frequently involves middle lower thoracics & upper lumbar
  • major cause of morbidity in geriatric population
97
Q

Head/Spine Imaging

when to use CT for head?

A
  • complicated sinusitis (can see fluid, mucosal thickening, sinus wall erosion)
  • evaluating facial/skull fractures
  • acute head/neck trauma
  • detecting hemorrhage
98
Q

Spine Imaging

when to use MRI for head/spine?

A
  • modailty of choice for evaluating most other spinal cord & intracranial abnormalities
  • better tissue constrast than CT

CD III (12 decks)

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