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Ortho Flashcards

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1
Q

Carpal Bones

A

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2
Q

Ankle Xray Views & Metrics

A
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3
Q

Nomenclature of hip #’s

A
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4
Q

Distal phalanx #

A
  • repair nailbed injury if present
  • hairpin splint not involving PIP
  • plastics within 2 weeks
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5
Q

Middle/Proximal Phalanx #

A
  • correct any rotational deformity
  • buddy tape (dynamic splint) if stable (transverse, non-displaced)
  • radial or ulnar gutter splint if unstable
  • plastics within 1 week
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6
Q

Bennett’s #

A
  • intraarticular base of thumb MC # with dislocation/subluxation of CMC
  • reduce, thumb spica
  • plastics within 2-3 days
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7
Q

Rolando’s #

A
  • comminuted # of base of thumb MC
  • worse prognosis than Bennett’s
  • thumb spica
  • plastics within 2-3 days
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8
Q

DIP Dislocation

A
  • reduce
  • dorsal splint in full extension
    • or buddy tape if stable post-reduction
  • plastics within 1 week
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9
Q

PIP Dislocation

A
  • reduce
  • dorsal splint in 30 deg flexion at PIP
    • or buddy tape if stable post-reduction
  • plastics within 1 week (2-3 d if unstable)
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10
Q

Extensor zones of the hand

A

see Evernote “Hand Injuries”

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11
Q

Management of extensor tendon injuries of the hand

A
  • Zone I, II open injuries: repair 5-0 sutures, splint in extension.
  • Zone III injuries: modified Elson’s test to check for central slip damage. If open & have Boutonniere deformity, call plastics on call. If closed, place PIP in extension and f/u plastics (may leave DIP free).
  • Zone IV injuries: primary repair with 5-0 sutures, splint MCP in 15 deg flexion.
  • Zone V, VI injuries: primary repair with 4-0 sutures if clean laceration, splint.
  • Zone VII, VIII injuries: splint, refer to plastics.
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12
Q

Management of Flexor Tendon Injuries of the Hand

A
  • Splint in position of function
  • Plastics within 1 week
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13
Q

Fingertip Amputation Zones

A

See Hand Injuries on Evernote

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14
Q

Describing Angulation in a #

A
  • for midshaft #’s, angulation is direction of apex
  • for distal fractures (e.g. Colles), angulation is direction of distal fragment
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15
Q

MCP Dislocation

A
  • do not hyperextend during reduction
    • reduce with wrist flexed to relax flexor tendon
    • pressure and traction on base of prox phalanx
  • splint in flexion
  • volar dislocations usually need operative reduction
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16
Q

Scapholunate Ligament Injury

A
  • FOOSH on thenar eminence
  • clicking with wrist movement
  • tender on dorsum of wrist just distal to Lister’s tubercle
  • pain with ballottement of the scaphoid
  • scaphoid shift/Watson shift test
    • wrist in ulnar deviation, thumb on scapohid prominence volarly –> move wrist into ulnar deviation
    • test positive if scaphoid ‘clunks’ dorsally/gives or patient’s pain reproduced
  • XRay
    • 3 mm widening on PA view
    • clenched fist view may help
    • scaphoid shortening with dense ring (cortical ring sign)
  • dorsal intercalated segment instability of lateral view (zig-zag pattern instead of 3 C’s)
  • Tx: radial gutter splint
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17
Q

Triquetrolunate Ligament Injury

A
  • ulnar equivalent to scapholunate injury
  • FOOSH on hypothenar eminence
  • volar intercalated segment instability on lateral xray
  • ulnar gutter splint
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18
Q

Perilunate Dislocation

A
  • FOOSH with great force
  • posterior dislocation of carpal bones, lunate remains in place
  • call ortho/plastics
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19
Q

Lunate Dislocation

A
  • posterior dislocation of carpal bones with lunate facing anteriorly
  • XRay
    • piece of pie sign (lunate triangular on PA)
    • spilled teacup sign (lunate displaced and angled palmar)
    • if fracture associated, then add trans- to the name (e.g. transscaphoid lunate disclocation)
  • call ortho/plastics
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20
Q

Scaphoid Fracture

A
  • tender in snuffbox with ulnar deviation
  • pain with resisted pronation/supination
  • pain with axial load to thumb
  • 10% initial xrays -ve
  • may get dedicated scaphoid view
  • thumb spica with mild wrist dorsiflexion and radial deviation (to compress # fragments)
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21
Q

Triquetrum Fracture

A
  • often a dorsal avulsion # on lateral view
  • sugartong splint
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22
Q

Lunate Fracture

A
  • tender in dorsum wrist groove on flexion
  • AVN possible (blood supply enters distally)
  • xrays may be negatve
  • thumb spica
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23
Q

Hamate Fracture

A
  • interrupted bat/golf club swing
  • carpal tunnel view
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24
Q

Colles’ Fracture

A
  • reduction: > 20 deg angulation, intra-articular involvement, > 1 cm shortening, comminution
  • criteria for adequate reduction
    • At least 11 mm radial height
    • At least 22 deg radial inclination
    • At least 11 deg volar angulation
    • practically, neutral is OK for age < 50 and 10 deg dorsal tilt is OK for age > 50
      • Acceptable angulation in kids
      • < 5 yrs = 30 deg
      • 5-10 yrs = 20 deg
      • 10-12 yrs = 10-15 deg
      • +-2 mm ulnar variance
    • < 3 mm impaction
  • ulnar styloid often also fractured
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25
Smith's Fracture
* volar angulation of distal radius
26
Radial Styloid Fracture
* often with dislocation of the lunate * major carpal ligaments insert at styloid so carpal instability * short arm splint
27
Ulnar Styloid Fracture
* ulnar gutter splint
28
DRUJ Injuries
* ulnar deviation on lateral * splint in supination for dorsal and pronation for volar dislocations
29
Compartment Syndrome | (Diagnosis, treatment)
* traditional, tissue pressure \> 30-50 mm Hg * better, delta pressure (diastolic - tissue pressure) \> 30 mm Hg * pain refractory to opioids, pain to passive stretch, firmness/fullness in compartment * normal pulses/cap refill as tissue pressure less than arterial pressure * Stryker kit * pressures highest near injured area, obtain within 5 cm of # site * 2 readings each compartment * place limb at level of heart * reverse anticoag/replace factors for hemophiliacs
30
Biceps Tendon Ruptures
* **proximal** * usually older, chronic tendonitis * pain in anterior shoulder * shoulder xray r/o avulsion # * sling --\> # clinic * **distal** * usually younger, eccentric load * pain in AC fossa * Hook sign * sling --\> # clinic more urgently
31
Elbow Dislocation
* 90% are posterolateral * assess (pre- and post-reduction): * brachial artery (just medial to distal biceps tendon) * ulnar, radial, median nerves * Check for full ROM post-reduction, fragments often trapped * call ortho if unstable on ROM or reduced ROM or NV compromise post-reduction * splint in long-arm posterior splint in slightly less than 90 deg flexion and forearm in mild pronation * NV f/u exam next-day
32
Supracondylar #
* common in 5-10 years of age * common to injure anterior interosseous nerve * motor only branch of median * test OK sign * extension-type (95%, posterior displacement) * FOOSH in extension * posterior fat pad or large anterior fat pad (sail sign), disruption of anterior humeral line * long-arm posterior splint 90 deg, neutral rotation * if only sign is fat pad then ortho f/u in 2-7 days * if any angulation/break through cortex then fasting + ortho in ED * flexion-type (5%, anterior displacement) * rare, direct force, often open
33
Intercondylar #
* assume any supracondylar # in adult is intercondylar * supracondylar + T or Y component separating condyles from each other and going intraarticular * splint in long arm posterior splint at 90 deg in neutral position
34
Epicondyle #
* mostly medial, an apophyseal avulsion fracture * pain, tenderness, swelling * medial from repeat valgus stress such as throwing * posterior splint in pronation
35
Condyle #
* mostly lateral * a fracture through the condyle * usually much larger/unstable than radiograph because mostly cartilaginous
36
Ossification Centres of Elbow
* all usually ossify by 12 years * **C**apitellum * **R**adial head * **I**nternal (medial) epicondyle * **T**rochlear * **O**lecranon * **E**xternal (lateral) epicondyle
37
Monteggia/Galeazzi #
* **F**racture * **U**lna/radius * **M**onteggia/galeazzi * **E**lbow (radius)/wrist (ulna) dislocated * may reduce, but often need operative management
38
Calcaneus #
* Boehler angle: line from highest part of anterior process of calcaneus and highest point of posterior articular surface of calcaneus + line between highest point of posterior articular surface of calcaneus and the most superior part of calcaneal tuberosity * normal 25-40 deg * \< 25 deg suspect # * posterior splint, NWB
39
Lisfranc Injury
* plantar flexion + axial load * pain with torsion/dorsi/plantar flexion * weight-bearing AP, lateral, 30 deg oblique * 1 mm displacement base 1st/2nd MT
40
Base of 5th MT #
* Review Evernote "Foot Injuries"
41
Hip #
* Review Evernote
42
Ottawa Knee Rules
* age \>= 2 * Xray if * age \>55 * tender at * fibular head * patella * cannot flex \> 90 deg * cannot WB 4 steps immediately + in ED
43
Additional Knee Xray Views
* sunrise view * patellar #/subluxation * tunnel view * intercondylar region/tibial spine # * oblique view * (internal for lateral, external for medial plateau #)
44
Treatment for Locked Knee
* usually meniscal tear * sedation * supine with knee 90 deg flexed hanging over edge * longitudinal traction, internal + external rotation * ortho if not successful
45
Knee Dislocation
* 50% self-reduce * ++ injured & unstable multiple directions * reduce, splint in 20 deg flexion * if no vascular + ortho in house & NV intact, delay reduction for transfer * CT angio post-reduction
46
Patellar Dislocation
* flex hip, hyperextend knee, posteromedial pressure on lateral border of patella * 1st time dislocation: tensor, knee immobilizer, no flexion allowed, urgent ortho * recurrent: less strict need for immobilization (ligaments already lax), semi-elective ortho
47
Tibial Shaft #, criteria for adequate reduction
* criteria for adequate reduction: * \<10 deg varus or valgus * \<10 deg anterior/posterior angulation - can accept more in the plane of joint motion * \<1 cm shortening * min 50% apposition * long leg splint, elevate * ortho in ED
48
Pilon/Tibial Plafond #
* "mortal pestle" # * axial load grinds tibia into talus * look for L1 # & compartment syndrome
49
Gastrocnemius Tear
* sudden pop, swelling in calf * RICE * may splint in equinus
50
Ankle Syndesmosis Injury
* see Evernote
51
Grading Ankle Sprains
* Grade I: no tear, minimal functional loss, pain and ecchymosis * Grade II: partial tear, some loss of function * Grade III: complete tear, ++ swelling, bruising, usually NWB * Any medial maleolar swelling/tenderness needs to be NWB and have close ortho f/u * lateral mal # with medial mal swelling/tenderness needs posterior slab with medial molding
52
Weber Classification Distal Fibula #'s
* NWB with aircast unless avulsion #
53
Sternoclavicular Joint Dislocation
* CT imaging of choice * US + aspiration if infectious/effusion (common in IVDU) * anterior dislocation * sling, ice, no need to reduce (won't hold anyway) * posterior dislocation * ortho, open reduction * closed reduction if mediastinal compromise
54
Clavicle #
* xray may miss #'s at extreme ends of bone * 45 degree cephalad tilt view +- CT * **distal** * displaced often operated on * sling + early ortho f/u * **middle third/distal #'s** * usually non-op unless athlete/cosmetic * rule of 2's for op mgmt * 2 cm short * 2 cm displaced * 2 pieces * sling, early ROM (in 3-5 days) * **proximal third clavicle #'s** * rare, check with ortho
55
Scapular #
* dedicated views * look for associated rib #'s/lung injury * sling, ice
56
Anterior Shoulder Dislocation
* slight abduction + external rotation * check deltoid sensation (axillary) * **reduction** * 10-20 mL 1% lidocaine subacromial * **Modified Hippocratic** * traction-countertraction * **Snowbird** * belt looped over flexed elbow * use foot to pull down on belt * **Stimson** * prone, weights * **Scapular Manipulation** * Stimson + rotate scapula (distal tip goes medial) * **Kocher's** * elbow 90 deg, slow external rotation * may bring elbow anteriorly * **Milch** * external rotation, arm straight * arm abduction to 180 degrees * push on humeral head upwards with R thumb * **Cunningham** * sitting massage, shrug shoulders back
57
Posterior Shoulder Dislocation
* \<1% * usually held in internal rotation + adduction * unable to external rotate + abduct * reduce with longitudinal traction
58
Inferior Shoulder Dislocation (Luxatio erecta)
* hyperabduction force (levers neck of humerus against acromion) * humerus fully abducted, elbow flexed, hand on or behind head * traction upward + outward in line with humerus
59
Proximal Humerus #
* Neer classification of shoulder #'s * a "part" is a fragment displaced \> 1cm or angulated \> 45 deg * i.e. even if many fragments, if none angulated/displaced then it is a "one-part" # * one part # * sling + swathe, ice, early ROM * more than one part # or #-dislocation * ortho in ED
60
Humeral Shaft #
* **proximal** * accept up to 45 deg angulation, 1 cm displacement * minimal displacement * shoulder immobilizer, close f/u * displacement/comminution * d/w ortho * **middle third #'s** * most common * usually non-op * radial nerve * not comminuted * sugar-tong, close follow-up * comminuted * call ortho * **distal humerus #** * ED consultation re: NV structures
61
Jersey Finger
* FDP rupture from grabbing jersey * splint in slight flexion * hand clinic
62
Compression #'s
* Discuss all spine #'s with a surgeon * if \<40% loss of height, generally stable * if \>= 50% loss of height, or angle between damaged vertebra and spinal column is \>25-30 deg usually unstable * can often misdiagnose Chance (transverse) + burst #'s as compression #'s * consider CT in all compression #'s found on plain films * if truly stable, non-pathologic --\> heat, massage, rest, f/u
63
Coccyx #
* pain meds, doughnut pillow
64
Prevertebral soft tissue spaces in cervical trauma
* 6 mm at C3 * 22 mm at C6
65
C-Spine Trauma Approach
* NEXUS * CCSR * Xray * CT if inadequate * If CT -ve but suspcious and MRI not available, may DC in firm foam collar and f/u in 3-5 days. If pain resolved, may DC collar
66
Neurogenic Shock vs. Spinal Shock
**Neurogenic Shock** * loss of peripheral sympathetic innervation * if T1-T4 then unopposed vagal to heart, bradycardia **Spinal Shock** * temporary loss of spinal reflex activity below injury that may recover
67
Thoracolumbar Spine Trauma Xray vs. CT
* EAST recommends CT over xray (Level 1) although no studies in mildly injured patients
68
How Long to Immobilize a Shoulder Dislocation For?
* "8 minus decade of life" * means if 75 years old then simple sling + ROM immediately * max 3 weeks * longer for first-time dislocators
69
Radial Head #
* **undisplaced, radial neck** * sling, f/u 1 week * **undisplaced, intra-articular** * posterior slab, f/u 1 week * **displaced** * call ortho to discuss
70
Coronoid Process #
* displaced, large fragment * call ortho to discuss * undisplaced * posterior slab, 1 week
71
Olecranon #
* check triceps with arm horizontal (gravity eliminated) * displaced * call ortho to discuss * undisplaced * posterior slab, 1 week
72
Ulnar Collateral Ligament Injury
* 25% have Stener's lesion (interposition of adductur pollicis between ends of ligament tear resulting in poor healing + chronic thumb pain) * **Grade 1/2** * thumb spica * plastics 1-2 weeks * **Grade 3** * plastics within 2-3 days (operate within 1 week)
73
Toe Fracture
* Indications for referral (Great Toe) * Fracture with dislocation * Displaced intraarticular fractures * Unstable, displaced fractures (ie, fractures initially reduced that immediately displace once traction is released unstable displaced fractures * Indications for referral (lesser toes) * Displaced intraarticular fractures * Irreducible fractures * Open fractures of non-distal phalanges * Fractures that do not maintain acceptable position with buddy taping
74
Toddler's #
* 9 mo to 5 yrs * twisting of foot --\> oblique tibial # * often minor mechanism, subtle tenderness * additional oblique views increase sensitivity * above knee splint --\> ortho 1 wk
75
Tillaux #
* girls age 11-13, boys age 12-15 * distal tibial growth plate closes from medial to lateral * external rotation results in SH III # of the distal tibia * ortho in ED
76
Patella #
* if has active knee extension: knee immobilizer, ortho 1 wk * if no active knee extension: ortho in ED
77
Segond #
* vertically oriented avulsion # from lateral tibial plateau at the attachment of the lateral capsular ligament * 75% association with ACL tear * tensor, crutches, WBAT * early ROM as tolerated * early sports med f/u
78
Tibial Plateu #
* suspected/undisplaced * long-leg splint, NWB, urgent ortho * displaced * ortho in ED
79
How to examine extensor tendons of fingers
* Test extension PIP/DIP with MCP in extension to remove lumbricals * Modified Elson's Test for zone III injuries
80
How to test SLR in knee exam
* test SLR seated to remove IT band
81
Mandible Dislocation
See Evernote "Dental"
82
How to Apply a Thomas Splint
See Evernote "Procedures"
83
Snowboarder's #
See evernote "Leg + Ankle Injuries"

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