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Flashcards in Ortho Deck (86):
1

What is the presentation of fat embolism syndrome?

Resp symptoms
Neuro changes
Reddish brown petechial rash

2

How long after injury does fat embolism present?

24-72 hours

3

What are the 4 functional components of the extremity exam after trauma?

Nerves
Vessels
Bones
Soft tissues

4

What is the pathophysiology of fat embolism syndrome?

Embolization of fat and marrow content from fractured long bones, especially femur - affects brain and lungs most

5

What are the 3 nerve injury types?

Neuropraxia
Axonotmesis
Neurotmesis

6

What sign is a humeral shaft fracture associated with?

Radial n injury --> wrist drop

7

Why does open fracture require special treatment?

Communication with environment disrupts soft tissue/skin and requires special treatment due to infection risk

8

Why is it important to do a thorough secondary survey after trauma?

To avoid missing additional fractures

9

What must the XR show in any bone fracture?

Joint above and below

10

What constitutes an open fracture?

Soft tissue wound + fracture

11

In patients with femoral neck fracture, what else must we look for?

Femoral neck fracture

12

What antibiotics are appropriate for open fracture?

First gen cephalosporin +/- aminoglycoside

13

Within what time frame should open fractures be managed?

W/in 6 hour

14

What is the protocol for treating an open fracture?

- Antibiotics
- Irrigation and surgical debridement
- External fixation immediately if unstable
- Internal fixation is definitive

15

Within how long should a closed fracture be managed?

Within 2-12 hours: intramedually nailing

16

Why is prompt management important for closed fracture?

Reduces risk of fat embolism syndrome

17

What are the main surgical risks of fracture repair?

Infection
Nonunion
Nerve or vessel injury
Amputation

18

What is a dangerous sequela of a tibia fracture?

Compartment syndrome

19

What is neuropraxia?

Minimal injury to myelin, but not axon or nerve sheath

20

What is axonotmesis?

Myelin + axon disrupted, nerve sheath intact. Wallerian degeneration

21

What is neurotmesis?

Myelon + axon + nerve sheath damaged. Wallerian degeneration

22

What is the most important determinant of severity for open fractures?

Energy imparted to the limb

23

Which grades of open fractures need additional antibiotic coverage with aminoglycoside?

Grade IIIA, B, C

24

Why is it important to have early stabilization of open fractures?

Protect soft tissues around the injury and prevent further damage secondary to mobile fracture fragments

25

What is reduction?

Putting displaced bones back to normal anatomic position
Open: through surgical incision
Closed: External manipulation of limb

26

What are 2 main concerns with femur fracture?

- Fat embolism
- Blood loss: highly vascular: monitor for shock

27

What type of orthopedic fracture is at greatest risk for hemorrhagic shock?

Pelvic fractures

28

What is management for fat embolism syndrome?

- Ventilatory support w/ high PEEP
- Early stabilization of fractures
- Possibly steroids

29

What is most important step to prevent fat embolism in poly trauma patient?

Early stabilization of long bone fractures w/in first 24 hours

30

What to watch out for in crush injuries?

Compartment syndrome
Rhabdo leading to kidney failure

31

What does acute trauma to the knee with anterior knee laxity suggest?

ACL injury

32

If a patient can bear weight, what can we assume?

Fracture less likely

33

What are the key components of the knee exam?

Gait
Observation
Palpation
ROM
Joint line tenderness
Neurovascular
Knee maneuvers

34

What is the major concern with a knee dislocation?

Vasculature damage: dysvascular limb risking amputation

35

How do ligament and meniscal injuries differ with regard to swelling?

Ligament: immediate swelling
Meniscal: delayed swelling

36

What are the 2 causes of ACL injury?

Contact
Non contact: pivoting injuries

37

What is the unhappy triad of the knee?

MCL
ACL
Medial meniscus

38

What is the imaging workup for a suspected ACL injury?

1. Radiograph: look for fracture, alignment/deformity, infection and tumor
2. MRI to confirm

39

What is the treatment for ACL tear?

Individualized: conservative or surgery

40

What conservative management principles should every ACL patient get?

RICE: Rest Ice Compression Elevation

41

Which patients with ACL tear are better candidates for non-op management?

Elderly, low-demand patients

42

Which patients with ACL tear are better candidates for surgery?

Young, healthy people who want to return to athletics

43

What type of surgery is ACL surgery?

Reconstruction, NOT repair

44

What are the concerns after ACL surgery?

Infection
Knee stiffness
Graft failure

45

If a complication is present after ACL surgery, what is the principle guiding management?

Exhaust all conservative options before re-operating

46

What to consider in patients with recurrent fractures?

Neoplastic lesion e.g. osteosarcoma weakening the bone

47

What is the distribution of blood supply to the meniscus, and why is it important?

Outside-in: only 25-30% of diameter gets blood:
Red zone: gets blood
White zone: less blood flow: not repaired but debrided if necessary

48

What is the significance of being unwilling (vs. unable) to range the knee?

Unwilling: suspect fracture or septic arthritis

49

What radiographic sign is pathognomonic for ACL injury?

Segond fracture or small fleck of bone avulsed from lateral tibial plateau

50

What is classic presentation of SCFE?

Obese, adolescent male aged 10-16
Groin pain
Painful limp
Externally rotated hip
Not irritable (allows ROM)

51

What is the thinking re: knee pain in young children?

Hip pathology causing referred knee pain

52

What is the pathophysiology of slipped capital femoral epiphysis?

Excess loading across the physis causes slippage of the head on the neck of the femur (epiphysis on metaphysics)

53

What are predisposing factors for weak physis?

Endocrine disorders
Osteodystrophy
Hypothyroid/ hypopituitarism

54

What is the workup for suspected SCFE?

- XR: AP and/or frog lateral view of the hip: shows displacement of proximal femoral epiphysis on metaphysis
- Rule out septic arthritis

55

What is the management of SCFE?

- Admit to hospital: urgent surgical pinning of the hip w/ a single screw
- Short period of protected weight bearing with crutches

56

What are possible complications of fixing SCFE?

- Screw too short
- Inadequate fixation
- Additional slippage
- Avascular necrosis

57

In a peds patient, complaint of knee pain should prompt what?

Clinical/radiographic exam of the hip

58

Hip pain plus history of steroid use, what to think?

Avascular necrosis of the femoral head (osteonecrosis)

59

What is the significance of leg length discrepancy with hip pain?

mechanical pathology: disruptions in structural integrity of the long bones of the lower limb can lead to leg length discrepancy

60

What to think: inability to bear weight on the hip or range motion?

Septic arthritis or unstable SCFE

61

What is an antaglic gait?

Limping due to pain: short stance phase on the affected limb to minimize time on the painful limb

62

What is Legg-Calve-Perthes disease?

Idiopathic osteonecrosis of the femoral head: ages 4-8

63

What are the 4 Kocher criteria to diagnose pediatric septic arthritis?

Fever > 38.5 C
Inability to bear weight
ESR > 20 mm/h
WBC > 12,000

3% with 1, 40% with 2, 93% with 3, 99% with 4

64

What are the classic x-ray findings of developmental dysplasia of the hip?

Subluxation or dislocation of femoral head from acetabulum

65

What is the classic x-ray finding of Legg-Calve-Perthes disease?

Subchondral collapse of the bone of the femoral head

66

What is the classic x-ray finding of SCFE?

Asymmetry o femoral head on the neck: ice cream appears to slide off of the cone

67

What is the treatment of Legg-Calve-Perthes disease?

Usually none: advanced disease contains the hip: casting/bracing or femoral/pelvic ostomies

68

What other imaging should be done to the hip if diagnosis is unclear?

MRI
Bone scan for bone pathology

69

What are key symptoms of carpal tunnel?

-Sensory dysthesias in median nerve distribution
- Dropping things
- Symptoms worse at night
- Job involving repetitive wrist/hand movements

70

What is Tinel's sign?

Gently percussing over median nerve at carpal tunnel: positive if the patient describes an electrical shock sensation in the median nerve distribution

71

What is Phalen's sign?

Patient places dorsal sides of hands against each other in maximal wrist flexion for 30-60s: positive if the patient reports new or worsening paresthesias in the median nerve distribution of affected hand

72

What is Durkan's test?

Squeezing the patient's wrist w/ direct compression over the median nerve over the carpal tunnel w/ examiner's thumb
Test is positive if patient has new or worsening symptoms

73

How do we diagnose carpal tunnel?

Clinically: history and exam

74

If the diagnosis is unclear clinically for carpal tunnel, what is the next step?

EMG / NCS

75

What must we rule out with suspected carpal tunnel?

Rule out spinal disease / medical neuropathy with:
- MRI
- Labs

76

What are the treatments for carpal tunnel in order of 1st line first?

NSAIDs / Wrist splinting
Carpal tunnel injection
Surgical release

77

When is surgical release the first management option for carpal tunnel?

Thenar wasting is present

78

What are the important complications of carpal tunnel?

- Painful scar / neuroma
- Injury to recurrent motor branch
- Inadequate release (particularly endoscopic technique)
- Recurrence

79

What are important things NOT to overlook in carpal tunnel?

Myelopathy
Pancoast tumor
Treatable peripheral neuropathy

80

What form of carpal tunnel is an emergency?

Acute: after fracture or dislocation

81

What form of carpal tunnel is an emergency?

Acute: after fracture or dislocation

82

Which test is most sensitive for carpal tunnel?

Durkan's Median Nerve Compression Test

83

How to distinguish between proximal vs. carpal tunnel median nerve compression?

Palmar cutaneous branch of median nerve: branches before carpal tunnel to innervate thenar eminence
* Typical carpal tunnel: no sensory dysthesias in thumb

84

What is thoracic outlet syndrome?

Compression of the lower brachial plexus: ulnar symptoms predominate, or compression of subclavian vessels between anterior and middle scalene muscles (associated often with cervical rib)

85

What are risk factors for carpal tunnel syndrome?

Women
Obesity
Pregnancy
Smoking
Repetitive wrist movements
RA
Hypothyroidism
Alcoholism
CKD

86

What are the 3 stages of median nerve compression?

1: Sensory symptoms at night
2: Symptoms also occur by day
3: Motor symptoms of weakness and/or muscle wasting