Ortho

Question 0

Leg-Calve-Perthes Disease

Answer 0

Aka avascukar necrosis of capital femoral epiphysis
Age 6
Features: insidious, limping, decreased hip motion, hip/knee pain, antalgic gait, guarded passive motion of hip.
Dx: AP and lateral hip X-rays.
Tx: cast and crutches to keep acetabulum in femoral head.

Question 1

Developmental dysphasia of hip

Answer 1

Feature: uneven gluteal folds, hip easily dislocated posteriorly with jerk and click, snaps to return.
Dx: US
Tx: abduction splinting with pavlik harness 6 months.

Question 2

Slipped capital femoral epiphysis

Answer 2

Ortho emergency
Chubby boy, age 13.
Features: groin or knee pain, limping, sole of foot on affected side points toward other foot, limited hip motion, thigh externally rotates as hip is flexed
Dx: X-ray
Tx: pin femoral head in place

Question 3

Septic hip

Answer 3

Ortho emergency
Toddler who had febrile illness, won’t move hip.
Features: hold leg with hip flexed, slight abduction and external rotation, refuse to let you move it.
Dx: ⬆️ ESR, aspiration of hip.
Tx: drain if find pus.

Question 4

Acute hematogenous osteomyelitis

Answer 4

Little kids, had febrile illness.
Features: severe localized pain in bone.
Dx: MRI
Tx: abx

Question 5

Genu varum

Answer 5

Aka bow legged
Normal until age 3
Persists past 3yr usually Blount disease = disturbance of medial proximal tibial growth plate
Tx: surgery

Question 6

Genu valgus

Answer 6

Aka knock-knee
Normal between 4-8
No tx

Question 7

Osgood-Schlatter disease

Answer 7

Aka osteochondrosis of tibial tubercle
Teens with persistent pain over tibial tubercle, aggravated by contraction of quads.
Features: localized pain over tibial tubercle, no knee swelling
Tx: RICE, if not better then extension or cylinder cast 4-6wk

Question 8

Club foot

Answer 8

Aka talipes equinovarus
At birth
Features: feet turned inward, plantar flexion of ankle, inversion of foot, addiction of forefoot, internal rotation of tibia.
Tx: serial casting, Achilles tenotomy, long term braces, surgery btw 9-12 months.

Question 9

Scoliosis

Answer 9

Adolescent girls
Thoracic spine turned to right. Progresses until skeletal maturity.
Dx: bend forward, see hump on right thorax.
Tx: bracing, if severe then surgery.
Can cause ⬇️ pulmonary function.

Question 10

Issues with bone remodeling in kids

Answer 10

Areas: suprachondylar fractures of humerus, fractures of growth plate.

Question 11

Suprachondylar fractures of humerus

Answer 11

Cause: hyperextension of elbow in kid who falls on hand with arm extended
Can injure vasculature and nerves ➡️ Volkmann contracture
Tx: casting or traction
Watch out for problems with nerves/vasculature, compartment syndrome.

Question 12

Growth plate fracture

Answer 12

Tx: if epiphysis and growth plate laterally deviated but in one piece = closed reduction.
Two pieces = open reduction for alignment and internal fixation.

Question 13

Osteogenic sarcoma

Answer 13

Most common primary bone malignancy.
Ages 10-25, persistent low grade pain
Around knee ( lower femur or upper tibia)
Dx: sunburst on X-ray

Question 14

Ewing sarcoma

Answer 14

Second most common primary bone malignancy
Ages 5-15
Grows in diaphysis of long bones
Dx: onion-skinning on X-ray

Question 15

Malignant bone tumors adults

Answer 15

Women = breast metastasis, lytic, present with pathological fracture
Men = prostate metastasis, blastic.
Feature: localized pain
Dx: X-ray, CT, MRI

Question 16

Multiple myeloma

Answer 16

Old men with fatigue, anemia, localized pain at specific places along multiple bones.
Dx: X-ray with punched out lytic lesions, bence-jones protein in urine, abnormal Ig in blood on immunoelectrophoresis.
Tx: chemotherapy, thalidomide if fails.

Question 17

Soft tissue sarcomas

Answer 17

Relentless growth of soft tissue mass.
Firm, fixed to surroundings.
Metastasize to lung, not to lymph nodes.
Dx: MRI, incisional biopsy.
Tx: wide local excision, radiation, chemotherapy.

Question 18

Closed reduction

Open reduction

Answer 18

Closed = immobilized in cast

Open with internal fixation = surgery

Question 19

Clavicular fractures

Answer 19

At junction of middle and distal thirds

Tx: sling, surgery for cosmetic reasons.

Question 20

Anterior dislocation of shoulder

Answer 20

Most common shoulder dislocation
Feature: hold arm close to body, rotated outward, numbness over small area of deltoid (stretched axillary nerve).
Dx: AP and lateral X-rays.

Question 21

Posterior dislocation of shoulder

Answer 21

Rare, after massive uncoordinated muscle contractions (epileptic seizure or electrical burn)
Feature: held close to body, internally rotated.
Dx: axillary or scapular lateral X-rays.

Question 22

Colles fracture

Answer 22

From fall on outstretched hand
Old osteoporotic women
Deformed, painful wrist, looks like dinner fork.
Dorsally displaced, dorsally angular fracture of distal radius.
Tx: closed reduction, long arm cast

Question 23

Monteggia fracture

Answer 23

Cause: direct blow to ulna (raised protective arm)
Diaphyseal fracture of proximal ulna, anterior dislocation of radial head.
Tx: open reduction with internal fixation, closed reduction of dislocation.

Question 24

Galeazzi fracture

Answer 24

Cause: direct blow to distal third of radius causing fracture and dorsal dislocation of distal radioulnar joint. Tx: open reduction with internal fixation, closed reduction of dislocation.

Question 25

Fracture of scaphoid

Answer 25

Young adult who falls on outstretched hand Feature: wrist pain, localized tenderness over an atomic snuff box. Dx: clinical, X-ray. Tx: thumb spica cast if undisplaced. Displaced and angulated = open reduction and internal fixation.

Question 26

Metacarpal neck fracture

Answer 26

``` Usually 4th, 5th, or both. Closed fist hits hard surface. Feature: hand swollen and tender. Tx: mild = closed reduction and ulnar gutter splint. Bad = kirschner wire or plate fixation. ```

Question 27

Hip fractures

Answer 27

Elderly who fall Features: hip hurts, affected leg is shorter and externally rotated. Dx: X-ray

Question 28

Femoral neck fracture

Answer 28

Displaced = compromise blood to femoral head. | Tx: femoral head replaced with prosthesis.

Question 29

Intertrochanteric fractures

Answer 29

Less likely to cause avascular necrosis than femoral neck fracture. Tx: open reduction with internal fixation. Post-op anticoagulation. Risk of DVT, PE.

Question 30

Femoral shaft fracture

Answer 30

Tx: intermedullary rod fixation. Open = ortho emergency, ORA cleaning and closure within 6 hr. Can cause fat emboli.

Question 31

Collateral ligament injuries

Answer 31

Cause: sideways blow to knee, sports Features: swollen knee, localized pain by direct palpation, pain with passive abduction or adduction when knee flexed at 30 degrees. Abduction shows medial injuries, adduction shows lateral injuries. Dx: MRI Tx: only 1 affected = hinged cast. More than 1 affected = surgery.

Question 32

Anterior cruciate ligament injury

Answer 32

Features: severe swelling and pain of knee, positive anterior drawer test, pain when knee flexed at 20 degrees by grasping thigh and pulling leg with other hand (Lachman test). Dx: MRI Tx: immobilization and rehab, or surgery for athletes. Opposite signs for PCL injury.

Question 33

Meniscal tears

Answer 33

Features: protracted pain and swelling in knee, knee catches and locks with click to release. Dx: MRI Tx: open repair. Complete meniscectomy ➡️ degenerative arthritis

Question 34

Terrible triad

Answer 34

Medial meniscal tear, medial collateral tear, anterior cruciate tear

Question 35

Tibial stress fracture

Answer 35

Young men on long marches Features: tenderness to palpation over specific part of bone, normal X-ray. Tx: cast, repeat X-ray in 2 weeks, crutches.

Question 36

Leg fractures of tibia and fibula

Answer 36

Pedestrian hit by car. Dx: angulation, X-ray. Tx: casting, intramedullary nailing. Be ware of compartment syndrome

Question 37

Rupture of Achilles' tendon

Answer 37

Out of shape middle aged men under severe stress (tennis). They plant foot, change direction, hear pop like a gunshot, fall clutching ankle. Features: limited plantar flexion, pain, swelling, limping. Dx: gap on tendon palpation. Tx: casting in equinus position for months, surgery

Question 38

Ankle fracture

Answer 38

Falling on inverted or exerted foot. Features: both malleoli break. Dx: AP, lateral, and mortise X-rays Tx: open reduction and internal fixation.

Question 39

Compartment syndrome

Answer 39

Mostly in forearm or lower leg. Causes: prolonged ischemia with repercussion, crushing injury, trauma, closed reduction of lower leg. Features: excruciating pain with passive extension, limited use of extremity. Tx: fasciotomy

Question 40

Posterior dislocation of hip

Answer 40

Cause: femur driven backward, head in collision. Features: hip pain, leg shortened, addicted, internally rotated. Tx: emergency reduction to prevent avascular necrosis.

Question 41

Gas gangrene

Answer 41

Cause: deep penetrating, dirty wounds. Features: 3 days later extremely sick, toxic, moribund. Site is tender, swollen, discolored, gas crepitation. Tx: IV penicillin, debridement, hyperbaric oxygen

Question 42

Radial nerve injury

Answer 42

Cause: oblique fracture of middle to distal third of humerus. Surgery if reduction does not relieve nerve involvement.

Question 43

Popliteal artery injury

Answer 43

Cause: posterior dislocation of knee Dx: integrity of pulses, Doppler, CT angio. Tx: reduction. Delayed restoration of flow requires fasciotomy.

Question 44

Falls from height

Answer 44

Fractures of foot or leg | Fractures of lumbar or thoracic spine

Question 45

Head on collision

Answer 45

Facial, head, torso injury | Femoral or pelvic injury

Question 46

Facial fracture or closed head injury

Answer 46

Look at cervical spine as well

Question 47

Carpal tunnel syndrome

Answer 47

Women doing repetitive hand work. Features: numbness and tingling in hands, particularly at night, along median nerve (radial 3 1/2 fingers). Dx: reproduced by hanging hands limply a few minutes or tapping median nerve in carpal tunnel, X-ray Tx: splints, anti-inflammatory agents, electromyography then surgery

Question 48

Trigger finger

Answer 48

Women Features: wake up with flexed finger, can't extend it unless pull on it causing snap. Tx: steroid injection, surgery as last resort

Question 49

De Quervain tenosynovitis

Answer 49

Young mothers carrying kids, force hand into wrist flexion and thumb extension. Features: pain along radial side wrist and first dorsal compartment. Dx: reproduced by holding thumb inside closed fist then forcing ulnar deviation of wrist. Tx: splint, anti-inflammatory agents, steroid injection***

Question 50

Dupuytren contracture

Answer 50

Older men, Norwegian ancestry Contracture of palm and palmar fascial nodules felt. Tx: surgery if hand can't lay flat on table

Question 51

Felon

Answer 51

Abscess in pulp of fingertip from neglected penetrating injury Features: throbbing pain, abscess features (fever). Can cause tissue necrosis. Tx: surgical drainage.

Question 52

Gamekeeper thumb

Answer 52

Injury of ulnar collateral ligament by forced hyperextension of thumb. Skiing injury. Features: collateral laxity at thumb metacarpophalangeal joint. Can lead to arthritis if untreated. Tx: casting.

Question 53

Jersey finger

Answer 53

Injury to flexor tendon when finger forcefully extended ( grabbing jersey). Dx: making fist, distal phalanx doesn't flex with others Tx: splinting

Question 54

Mallet finger

Answer 54

Extended finger is forcefully flexed. Volleyball. Extensor tendon is ruptured. Dx: tip of finger remains flexed when others are extended. Tx: splinting.

Question 56

Lumbar disc herniation

Answer 56

At L4-L5 or L5-S1. Age 45-46 Features: months of vague aching pain then sudden severe pain that shoots down leg, exacerbated by coughing/sneezing/defecating, cannot walk, hold leg flexed. Dx: straight leg test positive, MRI Tx: pain control via nerve blocks, surgery if progressing neuro deficits, emergency if get cauda equina syndrome.

Question 57

Cauda Equina Syndrome

Answer 57

Distended bladder, flaccid rectal sphincter, perineal saddle anesthesia. Tx: immediate decompression.

Question 58

Ankylosing spondylitis

Answer 58

Young men in 30's and 40's. Many have HKA- B27 antigen, associated with uveitis and IBD. Features: chronic back pain, morning stiffness, worse at rest, improves with activity, progressive. Dx: bamboo spine on X-ray. Tx: anti-inflammatory agents, PT.

Question 59

Metastatic malignancy of back

Answer 59

Elderly with progressive back pain, worse at night, not relieved by rest or positional changes, weight loss. Dx: X-ray shows lesions (lytic breast cancer at pedicles, blastic from prostate), MRI

Question 60

Traumatically amputated digits

Answer 60

Tx: surgically reattach. | Clean with saline, wrap in moist gauze, keep on ice.

Question 61

Lumbar Disk Herniation

Answer 61

usually L4-L5 or L5-S1 peak age 45-46 Features: months of vague aching pain, sudden onset neurogenic pain from a forced movement, pain shoots down leg, exacerbated by coughing, sneezing, defecating. Can't walk, hold leg flexed. Dx: straight leg test +, MRI Tx: bed rest for 3 wks, pain control via nerve blocks, surgery if progressive neuro deficits or cauda equina syndrome.

Question 62

Cauda Equina Syndrome

Answer 62

distended bladder, flaccid rectal sphincter, perineal saddle anesthesia Tx: surgical decompression

Question 63

Ankylosing Spondylitis

Answer 63

young men in 30's or early 40's Features: complain of chronic back pain and morning stiffness, worse at rest, improves with activity, progressive. Dx: 'bamboo spine' on x-ray Tx: antiinflammatory agents, PT HLA B-37 antigen associated with uveitis and IBD.

Question 64

Back pain from Metastatic Malignancy

Answer 64

Features: elderly with progressive back pain, worse at night, unrelieved by rest or positional changes, weight loss. Dx: lytic breast cancer in pedicles, blastic prostate cancer on MRI

Question 65

Diabetic Ulcers

Answer 65

At pressure points (heel, metatarsal head, tip of toes) from neuropathy. Don't heal because of microvascular disease. Tx: keep clean and elevated, amputation.

Question 66

Arterial Insufficiency Ulcers

Answer 66

at tip of toes Features: look dirty, pale base without granulation, features of arteriosclerotic occlusive disease (absent pulses, trophic changes, claudication or rest pain). Dx: Doppler, CT angio, MRI angio, arteriograms. Tx: surgical revascularization, angioplasty, stents

Question 67

Venous Stasis Ulcers

Answer 67

in chronically edematous, indurated, hyperpigmente sin above medial malleolus. Features; painless ulcer with granulating bed, varicose veins, frequent bouts of cellulitis. Dx: duplex scan Tx: support stockings, ace bandages, unna boot, vein stripping, grafting, endovascular ablation, radiofrequency ablation

Question 68

Marjolin Ulcer

Answer 68

squamous cell carcinoma of skin in a chronic leg ulcer. Features: dirty looking, deep ulcer with heaped up tissue growth around edges. Dx: biopsy Tx: wide local excision, skin grafting.

Question 69

Plantar Fasciitis

Answer 69

older, overweight patients with disabling, sharp heel pain when foot strikes ground, worse in morning. Dx: x-ray shows bony spur at location of pain, tenderness to palpation over spur Tx: spontaneous in 12-18 months, treat symptoms, remove spur.

Question 70

Morton Neuroma

Answer 70

inflammation of common digital nerve at third interspace btw 3rd and 4th toes. Features: palpably tender spot, from high heels that are pointed. Tx: analgesics, sensible shoes, surgical excision

Question 71

Gout

Answer 71

Features: swelling, redness, exquisite pain suddenly at first emtatarsal phalangeal joint in middle age obese man, high serum uric acid. Dx: uric acid crystals in joint fluid. Tx: indomethacin and colchicine if acute. chronic = allopurinol and probenicid.