Ortho part 2

Question 1

Scaphoid fracture

Answer 1

Point of maximal tenderness lies in anatomic snuffbox

Question 2

Lunate fracture

Answer 2

Palpable on dorsal radius

Axial loading of the third metacarpal may increase pain

Question 3

Colles fracture

Answer 3

Dinner fork deformity

Question 4

Smith fracture

Answer 4

Volar displacement of the wrist relative to the forearm

Question 5

Workup of wrist fracture

Answer 5

AP, lateral, and oblique XRs

Question 6

Tx of wrist fx

Answer 6

Reduction and immobilization
Sedation/anesthesia beforehand
Conscious sedation is becoming the method of choice
Colles, Smith, volar and dorsal dislocations, triquetrium: sugar-tong splint
Scaphoid: thumb-spica splint
Lunate: short-arm spica cast or splint with thumb immobilization
Pisiform: volar splint
Hamate: short-arm cast with 4th and 5th MCP joints heald in flexion

Question 7

Hx details to get with hand fx: general

Answer 7

Hand dominance of the pt
Hand that is injured
Occupation and hobbies requiring dexterity

Question 8

Hx details to get with hand fx: MOI

Answer 8

Did injury occur in a clean or dirty environment?
Were crush injuries sustained?
What was the position of the hand at the time of injury?
Was injury the result of high-pressure grease, water, air, or paint injection?
Did a thermal, electric, or chemical injury occur?
Was pt wearing any type of jewelry on fingers?
If so, has it been removed?

Question 9

Hx details to get with hand fx: assault

Answer 9

Was hand open or fist clenched?
Are lacs present?
Did the pt’s fist contact mouth or teeth?

Question 10

Sensory nerves of hand

Answer 10

Ulnar nerve supplies the fifth finger and the medial aspect of the fourth finger
The median nerve supplies the volar aspect of the 1st through 3rd fingers as well as the lateral aspect of the volar surface of the 4th finger
The radial nerve supplies the dorsal surface of the entire hand except for the 5th finger

Question 11

Motor nerve components of the hand

Answer 11

The radial nerve extends the wrist and the fingers
The ulnar nerve allows adduction of the 4th and 5th fingers and adduction of the thumb
The median nerve adducts the 2nd and 3rd fingers and allows opposition of the thumb to the 5th finger

Question 12

Hand fx workup

Answer 12

AP, lateral, and oblique XRs

Question 13

Hand fx tx- general

Answer 13

Most simple hand fxs may be treated with padded aluminum splints or buddy taping
All pts should be referred to hand surgeon except distal phalanx fxs
Treat any subungual hematoma with trephination or nail removal. Tx is controversial
Abx required with nail removal

Question 14

Hand fx tx- mallet finger, transverse fx of distal phalanx, middle and proximal phalangeal fxs

Answer 14

Mallet finger- exploration and open fixation vs splinting alone
Transverse fracture of distal phalanx- splint
Middle and proximal phalangeal fractures- surgery

Question 15

Hand fx tx-middle phalanx, transverse fx of proximal phalanx, oblique and spiral fxs

Answer 15

Middle phalanx- splint, buddy tape if phalanx is stable
Transverse fx of proximal phalanx- Splint, and frequently, open reduction
Oblique and spiral fxs- Splint with either ulner or radial gutter splint

Question 16

Hand fx tx- condylar, metacarpal head, and metacarpal neck fxs

Answer 16

Condylar fx- open fixation
Metacarpal head fx- Splinting with immediate orthopedic referral
Metacarpal neck fx- closed reduction, gutter splint, and prompt orthopedic referral

Question 17

Hand fx tx- metacarpal shaft, metacarpal base, Bennet, and Rolando fxs

Answer 17

Metacarpal shaft- Splint for 4-6 wks, multiple fx and those with shortening, angulation, or rotation usually require fixation
Metacarpal base- Gutter with immediate hand surgeon referral
Bennett- oblique, intraarticular fx at the volar base of the ulnar aspect of the first metacarpal. Thumb spica splint and ortho referral
Rolando- a large dorsal fragment creates a T or Y shaped fx at the base of the first metacarpal

Question 18

Pathophys/etiology of hip dislocation

Answer 18

Posterior dislocation is MCC with a large force required to dislocate the joint
MVCs are common, but falls from height are also a significant cause
With MVCs, the injury can occur with the knees striking the dashboard

Question 19

H/o hip dislocation

Answer 19

Keep a high index of suspicion with major trauma, such as an MVC, significant fall, or an athletic injury
Severe pain, may go to lower extremities, back, or pelvic areas
Difficulty moving the lower extremity on the affected side and may complain of numbness or paresthesias

Question 20

PE of hip dislocation

Answer 20

Assess ABCs
Posterior: hip is flexed, internally rotated, and adducted
Anterior: Hip is minimally flexed, externally rotated, and markedly abducted
In anterior, femoral head can occasionally be palpated
Severely limited ROM
Signs of sciatic nerve injury:
Loss of sensation in posterior leg and foot
Loss of dorsiflexion or plantar flexion
Loss of DTRs at the ankle
Signs of femoral nerve injury:
Loss of sensation over the thigh
Weakness of the quadriceps
Loss of DTRs at knee
Signs of vascular injury:
Hematoma
Loss of pulses
Pallor

Question 21

Workup of hip dislocation

Answer 21

Type and crossmatch
AP pelvis radiograph
CT pelvis
Reduction

Question 22

Tx of hip dislocation

Answer 22

Stabilize life-threatening injuries
Perform proper neurovascular exam
Procedural sedation
Reduction
Fracture-dislocations should be referred to ortho
Confirm reduction with radiograph

Question 23

H/o hip fractures

Answer 23

In elderly pts, hip fx usually occurs from a simple fall
Sometimes, occurs spontaneously
Complaint of pain and inability to move the hip
Stress fxs in young athletes and nondisplaced fxs, pain in hip or knee and may be ambulatory

Question 24

PE of hip fractures

Answer 24

Make sure pt is not in shock
Femoral head fx: posterior dislocation is most common, with adduction and internal rotation
Femoral neck fx: With partial and completely displaced fxs, severe pain and lies with the extremity slightly shortened, abducted, and externally rotated
Trochanteric fx: Greater trochanter fx, pain, esp with abduction and extension. Lesser trochanter, pain with flexion and internal rotation
Intertrochanteric fx: Extremity appears shortened and significantly externally rotated. Pain, hip edema and ecchymosis, and pain with any movement
Subtrochanteric: Proximal femur usually is held in fexion and external rotation

Question 25

Common causes of hip fxs

Answer 25

Young: trauma associated with significant force | Osteoporosis is the leading cause

Question 26

Workup of hip fx

Answer 26

AP and lateral views If findings are equivocal, consider CT scan If not found, MRI

Question 27

Tx of hip fx

Answer 27

Obvious femur fx: immobilize, 2 large-bore IV lines, NPO, perioperative labs Femoral head: Type 1, ortho consult, if single reduction fails, ORIF Type 2: ortho consult for admission, arthroplasty Femoral neck: Type 1, immobilization in selected pts Types 2, 3, and 4: ORIF or arthoplasty Trochanteric: Type 1, ortho consult Type 2: reduction and internal fixation Intertrochanteric: Traction splint, IVF, ORIF with early ortho consult Subtrochanteric: IVF, traction splint, ortho surgery consult

Question 28

Tx of foot fxs: immobilization, toe, first metatarsal

Answer 28

``` Initial immobilization options: Posterior or stirrup splints Reinforced bulky dressing Rigid, flat-bottom orthopedic shoe Cylindrical cast Toe fx: buddy tape First metatarsal: Immobilization without wt bearing for minimally displaced or nondisplaced. Displaced: ORIF ```

Question 29

Tx of foot fxs: internal metatarsal, proximal avulsion, and Jones fxs

Answer 29

Internal metatarsal: Cast or rigid flat-bottom orthopedic shoe. Avoid aggravating activity for 4-6 wks Proximal avulsion: Compression dressing and wt bearing as tolerated Jones: Immobilization without wt bearing

Question 30

Tx of foot fractures: Lisfranc, talar fxs

Answer 30

Lisfranc: immediate ortho consult for reduction and fixation Talar: neck and body, surgical fixation for displaced and non-wt-bearing short leg cast for 6-10 wks Lateral process, immobilization without wt bearing Posterior process, immobilization with either partial or full wt-bearing Transchondral/osteochondral dome: referral to ortho Navicular: immobilization or wt bearing as tolerated, unless displaced; ORIF

Question 31

Tx of calcaneal fxs

Answer 31

Urgent ortho consultation

Question 32

Etiology of ankle fx

Answer 32

Excessive inversion stress is the MCC

Question 33

H/o ankle fx

Answer 33

Take hx of how the trauma occurred Hx of prior trauma Chronic medical conditions and medications

Question 34

PE of ankle fx

Answer 34

Gross deformity Swelling, esp perimalleolar, bony tenderness, discoloration, and ecchymosis Inability to bear wt on the injured foot

Question 35

Indications to take radiographs of an ankle in pts with acute ankle pain

Answer 35

Bony tenderness at the distal 6 cm of the posterior edge of the medial malleolus Bony tenderness at the distal 6 cm of the posterior edge of the lateral malleolus Inability to bear wt both immediately and in the ED (defined as 4 steps)

Question 36

Tx of ankle fx

Answer 36

Compromised neurovascular status: reduction ASAP. Maintain with cast, external fixator, or ORIF Defer reduction of unstable to ortho unless neurovascular compromise Cover open fxs with wet, sterile dressing Tetanus when expired Splinting

Question 37

What is an unstable ankle fx?

Answer 37

Any fx-dislocation Any bimalleolar or trimalleolar Any lateral malleolar fx with significant talar shift

Question 38

Pathophys of gout

Answer 38

A disorder of metabolism that allows uric acid or urate to accumulate in blood and tissues When tissues become supersaturated, the urate salt precipitate, forming crystals

Question 39

Etiology of gout

Answer 39

``` Genetic causes Comorbid conditions: HTN DM Renal insufficiency Hypertriglyceriemia Hypercholesterolemia Obesity Anemia ```

Question 40

Hx of gout

Answer 40

Spontaneous onset of excrutiating pain, edema, and inflammation of the metatarsal-phalangeal joint of the great toe Other common sites are instep, ankle, wrist, finger joints, and knee Attacks begin abruptly and typically reach maximum intensity within 8-12 hrs Can be provoked by consumption of beer or liquor, overconsumption of foods with high purine content, trauma, dehydration, or the use of medications that elevate levels of uric acid

Question 41

PE of gout

Answer 41

Acute attack most often presents with involvement of a single joint Involved joints have all the signs of inflammation: swelling, warmth, erythema, and tenderness Erythema may resemble cellulitis, joint capsule becomes quickly swollen Pts may be febrile Tophi present

Question 42

Workup of gout

Answer 42

``` Synovial fluid analysis Urinary uric acid Calculate GFR WBC Lipid profile Chronic gout- XR U/s ```

Question 43

Tx of gout

Answer 43

Acute attack- NSAIDs, corticosteroids, and ACTH are options | Comorbidities that limit NSAIDs or colchicine- intra-articular steroid injection