Orthopaedics Flashcards Preview

Surgery > Orthopaedics > Flashcards

Flashcards in Orthopaedics Deck (153):
1

Fractures - early local complications

Compartment syndrome
Nerve injury
Vascular injury
Infection

2

Non-union - patient factors

Smoking
Alcohol abuse
Increasing age
Steroids
Diabetes
Chronic renal failure

3

Non-union - fracture factors

Higher energy fracture
Open fractures
Infection
Bone loss

4

Anterior shoulder dislocation

Mode:fall on abducted and externally rotated arm
Neurovascular: axillary nerve, brachial plexus

5

Humoral shaft fracture

Neurovascular: radial nerve

6

Supracondylar fracture

Neurovascular: anterior interossus, median nerve

7

Monteggia fracture-dislocation

Ulnar shaft fracture, radial head dislocation
Neurovascular: posterior interossus, radial nerve

8

Distal radial fracture

Neurovascular: median nerve

9

Posterior hip dislocation

Neurovascular: sciatic nerve

10

Knee dislocation

Neurovascular: common peroneal nerve

11

Volkmann's ischaemic contracture

Permanent flexion contracture of the hand at the wrist, claw-like deformity of the hand and fingers.
Passive extension of fingers is restricted and painful.
Result from undiagnosed compartment syndrome.

12

Neer's classification

Proximal humeral fracture
Parts: humeral head, greater tuberosity, lesser tuberosity, shaft.
Displacement: >45 angulation, >1cm displacement

1 part: fracture lines 1-4 parts, non-displaced
2 part: fracture lines 2-4 parts, 1 displaced
3 part: fracture lines 3-4 parts, 2 displaced
4 part: fracture lines >4 parts, 3 displaced

13

Gartland classification

Supra-condylar fractures
Type I: undisplaced fracture
Type II: angulated fracture with intact posterior cortex
Type III: posteriorly displaced distal fragment, no cortical contact

14

Galeazzi fracture-dislocation

Distal radial fracture, distal radioulnar joint dislocation

15

Colles' fracture

Distal radial fracture with dorsal angulation "dinner fork"
Mode: fall onto extended wrist

16

Smith's fracture

Distal radial fracture with volar displacement
Mode: fall onto flexed wrist

17

Barton's fracture

Distal radial fracture with partial fracture of radial head involving articular surface

18

Garden classification

Intracapsular femoral neck fracture

Stage 1: undisplaced, incomplete (incl valgus impacted fractures)
Stage 2: undisplaced, complete
Stage 3: complete fracture, incompletely displaced
Stage 4: complete fracture, completely displaced

Stage 3&4 higher risk of AVN

19

Schatzer classification

Tibial plateau fracture

Type I: wedge shape, pure cleavage of lateral plateau, 4mm depression
Type IIIa: lateral depression of lateral plateau
Type IIIb: central depression of lateral plateau
Type IV: depression of medial plateau, no fracture
Type V: involving both plateau regions
Type VI: fracture through metadiaphysis of tibia

20

Fractures - systemic complications

Fat embolism
DVT/PE
Sepsis
Complications of immobility

21

Complications of immobility

Respiratory tract infection - basal atelectasis
UTI
Pressure sores
Disuse osteoporosis and joint stiffness

22

Fat embolism - risk factors

Lower limb diaphysis fractures
Multiple fractures
Closed fractures
Young patients

23

Fat embolism - clinical features

Tachypnoea - inflammatory response of lung parenchyma
Dyspnoea
Confusion/agitation
Petechial rash
Tachycardia
Fat in urine, retina, sputum

Low O2, low CO2, low platelets, diffuse bilateral lung infiltrates

24

Gustilo and Anderson classification

Open fractures, for prophylactic antibiotic regime

Types 1: wound 1cm, minimal soft tissue injury, minimal comminution
Type 2: wound 1-10cm, moderate contamination and soft tissue injury
Type 3a: extensive soft tissue damage, massive contamination, soft tissue coverage adequate
Type 3b: extensive soft tissue damage with periosteal stripping and bone exposure, massive contamination, soft tissue coverage inadequate
Type 3c: associated with arterial injury requiring limb salvage

25

Perthe's disease

Idiopathic AVN of the femoral head in children

26

Ankylosing spondylitis

Chronic inflammatory autoimmune disease affecting spine and sacroiliac joints in young males. Features: seronegative spondyloarthropathy, "bamboo" spine

27

Paget's disease

Abnormal bone architecture from abnormal osteoclastic and osteoblastic activity. Bone pain with raised ALP

28

Osteopenia

Decreased bone mass.
Unaffected Ca, PO, PTH. Normal ALP

29

Osteopetrosis

Thick dense "marbled" bone.
Unaffected Ca, PO, PTH. Elevated ALP

30

Osteoporosis

Brittle and fragile bone. Risk factors: postmenopause, steroids.
Treatment: bisphosphenates

31

Ewing's sarcoma

Malignant round cell tumour in diaphysis of long bone or pelvis in children. X-ray: large soft tissue mass with onion-peel sign

32

Osteosarcoma

Cancerous bone tumour, can arise secondary from Paget's disease.

33

Osteoclastoma

Giant cell tumour, common in young adults and affects epiphysis of long bones. Osteolytic, slow growing tumour, pathological fractures, soap bubble appearence.

34

Musculocutaneous nerve
C5-6

Motor:
Coracobrachialis
Biceps brachii

Sensory:
Lateral cutaneous nerve (lateral forearm)

35

Median nerve
C6-7

Motor:
Brachialis
Pronator teres
Flexor carpi radilalis
Palmaris longus
Flexor digitorium superficialis
Thenar muscles
Lumbricals (2&3)

Sensory:
Lateral 3.5 fingers

36

Medial cutaneous nerve
T1

Sensory:
Medial aspect of arm

37

Ulnar nerve
C8-T1

Motor:
Flexor carpi ulnaris
Flexor digitorium profundus (4&5)
Palmar interossei
Dorsal interossei
Palmar brevis
Hypothenar
Lumbricals (4&5)
Adductor pollicis

Sensory:
Medial aspect of forearm
Medial 1.5 fingers

38

Axillary nerve
C5-6

Motor:
Deltoids

Sensory:
Lateral upper arm

39

Radial nerve
C5-C8

Motor:
Triceps brachii
Brachioradialis
Extensor carpi radialis longus

Sensory:
Medial upper forearm (superficial radial nerve)
Lateral dorsum of hand

40

Posterior interosseous nerve (radial)
C7-8

Motor:
Extensor carpi radialis brevis
Extensor carpi ulnaris
Extensor digiti minimi
Extensor digitorium

Supinator
Extensor indicis
Abductor pollicis longus
Extensor pollicis longus
Extensor pollicis brevis

41

Anterior interosseous nerve (median)
C5-T1

Motor:
Flexor policis longus
Pronator quadratus
Flexor digitorium profundus (2&3)

42

Tibial nerve
L5-S1

Motor:
Ankle plantar flexion
Knee flexion
Great toe flexion

Sensory:
Sole of foot

43

Superficial peroneal
L5-S1

Motor:
Ankle eversion

Sensory:
Dorsum of foot

44

Deep peroneal
L5-S1

Motor:
Ankle dorsiflexion and inversion
Great toe extension

Sensory:
1st web space

45

Sural nerve
S1-2

Sensory:
Lateral foot

46

Saphenous nerve
L3-4

Sensory:
Anteromedial ankle

47

UL Neuro Screen

"Thumbs up" = PIN/radial (abductor pollicis longus)
"OK sign" = AIN/median (flexor digitorium profundus)
"Spread fingers" = ulnar (dorsal interosseus)

48

Open reduction - indications (NO CAST)

Non-union
Open fracture
Neurovascular compromise
intra-Articular fracture
Salter-harris 3,4,5
polyTrauma

49

Fractures - late local complications

Non-union
Malunion
Osteomyelitis
Post-traumatic OA
Avascular necrosis
Joint stiffness/adhesive capsulitis

50

Orthopaedic emergencies (VON CHOP)

Vascular compromise
Open fracture
Neurological compromise
Compartment syndrome
Hip dislocation
Osteomyelitis/septic arthritis
Pelvic fracture (unstable)

51

Compartment syndrome - features

Pain with passive stretch
Pain with active contraction of compartment
Swollen, tense compartment
Suspicious history (tibial shaft, pediatric supracondylar, forearm)

52

Compartment syndrome
(5 P's)

Pain: out of proportion for injury, not relieved by analgesics, increased with passive stretch
Pallor
Paresthesia
Paralysis
Pulselessness

53

Anterior hip dislocation

Mechanism: posteriorly directed blow to knee with hip abducted
Features: shortened, abducted, externally rotated

54

Posterior hip dislocation (more common)

Mechanism: force to knee while hip flexed and adducted
Feature: shortened, adducted, internally rotated

55

Osteomyelitis x-ray

Soft tissue swelling
Lytic bone destruction
Periosteal reaction (seen 10 days post infection)

56

Septic joint

Organisms: Staph species, N. gonorrhoea

Factors: previous surgery/injury to joint, joint disease, IVDU, IA steroids

57

Anterior shoulder dislocation (more common)

Mechanism: abducted arm, external rotation, blow to posterior shoulder
Features: slight abduction, externally rotated, unable to internally rotate, "squared off" shoulder.

58

Anterior shoulder apprehension test + relocation

Gentle shoulder abduction and external rotation to 90, humeral head pushed anteriorly
Posteriorly directed pressure relieves apprehension

59

Hill-Sach lesion

Compression fracture of posterior humeral head against glenoid rim.
Reverse Hill-Sachs in posterior dislocation.

60

Bankart lesion

Avulsion of anterior glenoid labrum from glenoid rim.
Reverse Bankart in posterior dislocation.

61

Sulcus sign

Subacromial indentation with distal traction on humerus, inferior shoulder instability

62

Posterior shoulder dislocation

Mechanism: adducted, internally rotated, flexed arm (seizure, alcohol, electrocution)
Features: adducted and internally rotated arm, external rotation blocked, anterior shoulder flattening

63

Posterior shoulder apprehension test

Apply posteriorly force on flexed, adducted, internally rotated arm.
For posterior instability

64

Supraspinatous

Insertion: Greater tuberosity
Nerve: Suprascapular
Function: Abduction

65

Infraspinatous

Insertion: Greater tuberosity
Nerve: Suprascapular
Function: External rotation

66

Teres minor

Insertion: Greater tuberosity
Nerve: Axillary
Function: External rotation

67

Subscapularis

Insertion: Lesser tuberosity
Nerve: Suprascapular
Function: Internal rotation, adduction

68

Corocoid process attachment

Short head of biceps
Coracoid brachialis
Pectoralis minor

69

Painful arc syndrome

Compression of supraspinatous tendon, subacromial bursa.

Pain with abduction >90 degrees

70

Rotator cuff tears

Night pain and difficulty sleeping on affected side
Pain worse with active movement
Weakness and loss of ROM
Tenderness over greater tuberosity

71

Jobe's test

Supraspinatous

90 degree abduction, 30 degree forward flexion, internal rotation so thumb at ground

72

Lift-off test

Subscapularis

Internal rotation so hand on back

73

Posterior-cuff test

Infraspinatous and teres minor

External rotation, elbow at 90 degrees

74

Neer's test

Rotator cuff impingement

Passive shoulder flexion with thumb down, pain between 130-170 degrees

75

Hawkins-Kennedy test

Rotator cuff impingement

Shoulder flexion at 90 degrees, passive internal rotation

76

Frozen shoulder (adhesive capsulitis)

Gradual onset diffuse shoulder pain
Decreased active and passive ROM
Pain worse at night
Increased stiffness as pain subsides (6-12 months)

77

Lateral epicondylitis

"tennis elbow", inflammation of extensor tendon inserts

78

Medial epicondylitis

"golfer's elbow" inflammation of flexor tendon inserts

79

Scaphoid fracture

Mechanism: FOOSH, impaction of scaphoid onto distal radius
Features: pain in wrist movement, tenderness in anatomical snuff box, no displaced.

80

Compression fracture - spine

Anterior column = stable

81

Burst fracture - spine

Anterior, midline = unstable

High energy axial loading + flexion

82

Flexion dislocation - spine

Middle, posterior = unstable

MVA, lap belt only

83

Fracture dislocation - spine

Anterior, middle, posterior = unstable

84

Compression test (C-spine)

Compression on head worsens radicular pain

85

Distraction test (C-spine)

Traction on head relieves radicular symptoms

86

Valsalva test (C-spine)

Increased intrathecal pressure and causes radicular pain

87

C5

Motor: deltoid, biceps, wrist extension
Sensory: axillary nerve, rhomboids
Reflex: biceps

88

C6

Motor: biceps, brachioradialis
Sensory: thumb and index
Reflex: biceps, brachioradialis

89

C7

Motor: triceps, wrist flexion, finger extension
Sensory: middle finger
Reflex: triceps

90

C8

Motor: interossei, digital flexors
Sensory: ring and little fingers
Reflex: finger jerk

91

Swimmer's view

Lateral view with arm abducted 180 degrees to evaluate C7-T1

92

Lateral flexion/extension view

Evaluate subluxation of C-spine

93

Straight leg raise

Radicular pain radiating down posterior/lateral leg to knee

94

Lasegue maneuver

Dorsiflexion of foot during straight leg raise, exacerbates pain

95

Femoral stretch test

Prone, passive flexing of knee and extending of hip exacerbates radicular pain

96

L4

Motor: quadriceps, tibialis anterior
Sensory: medial malleolus
Reflex: knee
Test: femoral stretch

97

L5

Motor: extensor hallucis longus, gluteus medius
Sensory: 1st dorsal web, lateral leg
Test: straight leg raise

98

S1

Motor: peroneus longus + brevis, gastrocnemius + soleus
Sensory: lateral foot
Reflex: ankle
Test: straight leg raise

99

Red flags for BACK PAIN

Bowel/bladder dysfunction
Anesthesia (saddle)
Constitutional symptoms/malignancy
Khronic disease
Paresthesias
Age >50
IV drug use
Neuromotor deficits

100

Mechanical back pain - disc

Back pain
Flexion aggravation
Gradual onset
Weeks-months duration

101

Mechanical back pain - facet

Back pain
Extension, standing, walking aggravation
More sudden onset
Days-weeks duration

102

Direct nerve root compression - spinal stenosis

Leg pain
Exercise, extension, walking, standing aggravation
Congenital or acquired onset
Acute episodes (spinal claudication) on chronic history

103

Direct nerve root compression - root compression

Leg pain
Flexion aggravation
acute leg +/- back pain onset
More constant pain (lateral disc herniation) or intermittent pain (central disc herniation

104

Back Pain - differentials

Degenerative (disc, facet, ligament)
Peripheral nerve compression (disc herniation)
Spinal stenosis (congenital, osteophyte, central disc)
Cauda equina syndrome
Others (neoplastic, infectious, metabolic, trauma, spondyloarthropathies, referred)

105

Spondylolysis

Defect in pars interarticularis with no movement of vertebral bodies, "collar" break in "Scottie dog" on oblique x-ray.
Acitivity related back pain

106

Spondylolisthesis

Defect in pars interarticularis causing forward slip of vertebrae
Congenital, degenerative, traumatic

107

Pelvic fracture classification

A: Stable avulsion fracture
Rotationally and vertically stable
A1: fracture not involving pelvic ring
A2: minimally displaced fracture of pelvic ring

B: Open book
Rotationally unstable, vertically stable
B1: open book
B2: lateral compression - ipsilateral
B3: lateral compression - contralateral

C: Unstable vertical fracture
Rotationally and vertically unstable
C1: unilateral
C2: bilateral
C3: associated acetabular fracture

108

Shenton's line

Radiographic line along upper margin of obturator foramen extending along the inferiormedial side of femoral neck. Disruption indicates subcapital fracture

109

Thomas test

Flexion of both knees and hips and eliminate lumbar lordosis, straighten out affected leg with other flexed.

Fixed flexion contracture, apparent limb shortening seen in OA

110

Knee history (CLIPS)

Clicking
Locking
Instability
Pain
Swelling

111

Anterior/posterior draw test

ACL and PCL tears

112

Lachmann test

ACL tear
Hold knee at 20 degrees flexion, sublux tibia anteriorly on femur

113

Posterior sag test

PCL tear

114

Pivot shift sign

ACL tear
Knee extended, apply valgus force and flex knee

115

Collateral ligament stress test

MCL and LCL tear

Palpate for knee joint opening

116

Meniscal tear

Joint line tenderness
Crouch compression test
McMurray test

117

McMurray test

Meniscal tear

Knee in flexion, palpate joint line.
LM - internal rotation, varus stress and extend knee
MM - external rotation, valgus stress and extend knee

118

O'Donoghue's Unhappy Triad

ACL rupture
MCL rupture
Meniscal damage

119

Patellar dislocation

Risk factors: young, female, obesity, high-riding patella, knock-knees, increased Q angle, shallow intercodylar groove, tight lateral retinaculum.

Knee catches or gives way on walking, weak knee extension, positive patellar apprehension test

120

Patellar apprehension test

Examiner laterally displaces patella

121

Patellofemoral Syndrome

Softening/eroision of articular cartilage in medial aspect of patella.
Features: deep aching anterior knee pain, exacerbated by prolonged sitting, stair climbing, sitting, sensation of instability,

122

Anterior draw foot

Lateral ligament injury

Displace foot anteriorly against fixed tibia

123

Talar tilt

Foot inverted, angle of talar rotation evaluated by x-ray

124

Ottwa ankle rules

X-ray required if:
Pain in malleolar zone AND bony tenderness over posterior aspect of medial/lateral malleolus
OR
Inability to weight bear immediately after injury or in ED

125

Danis-Weber classification

Ankle fracture

A: infrasydesmosis (pure inversion injury)
Avulsion of lateral malleolus below plafond/torn calcaneofibular ligament
B: trans-syndesmotic (external rotation and eversion)
Avulsion of medial malleolus or rupture deltoid ligament, spiral fracture of lateral malleolus starting at plafond
C: supra-syndesmotic (pure external rotation)
Avulsion of medial malleolus or torn deltoid ligament, posterior malleolus avulsion with posterior tibio-fibular ligament, fibular fracture above plafond

126

Ankle ligaments

Medial: deltoid ligament
Lateral: anterior talofibular, calcaneofibular, posterior talofibular

127

Talar fracture

Mechanism: axial loading, hyperdorsiflexion

Distal to proximal blood supply, high risk of AVN with displaced fractures

128

Calcaneal fracture

Mechanism: axial loading
Loss of Bohler's angle (20-40 degrees), varus heel

129

Achilles tendon rupture

Features: palpable gap, apprehensive toe off, weak plantar flexion, Thompson test

130

Thompson test

Achilles tendon rupture

Squeezing calf muscle to elicit passive plantar flexion of foot

131

Plantar fascilitis (heel spur syndrome)

Mechanism: repetitive strain, aslo associated with obesity, DM, arthopathies
Radiological: heel spurs

132

Bunions (hallux valgus)

Valgus alignment of 1st MTP, painful bursa over medial side of 1st metatarsal head

133

Ottawa foot rules

X-ray required if:
Pain in midfoot zone AND bony tenderness over navicular or base of 5th metatarsal
OR
Inability to weight bear both immediately after injury and in ED

134

Salter-Harris classification

Epiphyseal injury

Straight: transverse through growth plate
Above: through metaphysis and along growth plate
Low: through epiphysis to plate and along growth plate
Through: through epiphysis and metaphysis
Ram: crush injury of growth plate

135

Slipped capital femoral epiphysis

Type 1 Salter-Harris at proximal hip. Common in adolescent, male, obese, hypothyroid.

Positive Trendelenburg sign, Whiteman's sign (flexion with obligate external rotation at hip), bilateral involvement in 25%.

136

Developmental dysplasia of hip

Ligament laxity, muscular underdevelopment, abnormal shallow slope of acetabulum roof.
Painless.

Tests: Barlow's, Ortolani's, Galeazzi's

137

DDH - 5 F's of predisposition

Family history
Female
Frank breach
First born
leFt hip

138

Barlow's test

DDH
Flex hips and knees at 90 degrees, grasp thighs, fully adduct thighs and push posteriorly

139

Ortolani's test

DDH
Reduce hips with fingertips from Barlow's test by abducting hips

140

Galeazzi's sign

DDH
Knee ar unequal heights when hips and knees flexed

141

Legg-Calve-Perthes Disease

Self limited AVN of femoral head, 4-10 yos
Features: child with hip pain and limp, tender over anterior thigh, flexion contracture

142

Osgood-Schlatter Disease

Repetitive stress on tibial tuberosity by patella tendon, minor avulsion
Features: tender over tibial tuberosity, pain on resisted leg extension, anterior knee pain on jumping

143

Congenital talipes equinovarus

Talipes: talus inverted and internally rotated
Equinus: ankle is plantar flexed
Varus: heel and forefoot are in varus (supinated)

144

Scoliosis

10-14 yo
Causes: idiopathic, congenital, neuromuscular, postural

145

Benign bone lesion - radiology

No periosteal reaction
Thick endosteal reaction
Well developed bone
Intraosseous and even calcification

146

Malignant bone lesion - radiology

Acute periosteal reaction: Codman's triangle, onion skin, sunburst
Broad border between lesion and normal bone
Varied bone formation
Extraosseous and irregular calcification

147

Osteoid osteoma

20-30's yo, tibia and femur common.
Features: severe intermittent pain, mostly night, relieved by NSAIDs
Radiology: small, round translucent nidus surrounded by dense sclerotic bone

148

Osteochondroma

20-30's yo, most common benign tumour, metaphysis of long bone
Feature: slow growing
Radiology: cartilage capped bony spur "mushroom"

149

Ewing's sarcoma

5-20 yo, metaphysis of long bone
Features: pain, mild fever, erythema, swelling, anaemia
Radiology: moth eaten appearence with onion-skinning
Rx: resection, chemotherapy, radiation

150

Osteosarcoma

20's, elderly with history of Paget's disease
Features: progressive pain, night pain, decreased ROM
Radiology: periosteal reaction (Codman's triangle or sunburst)
Rx: complete resection, bone scan, metastases

151

Chondrosarcoma

Primary 70% or secondary 30% (malignant degeneration of pre-existing cartilage tumour)
Features: progressive pain, mass
Radiology: medullary cavity, irregular "popcorn" calcification

152

Multiple myeloma

Most common primary malignant tumour of bone in adults
Features: bone pain, compression/pathological fractures, renal failure, infections, systemic, hypercalcaemia with pancytopenia.
Radiiological: punched out lesions
Rx: chemotherapy, radiation

153

Bone metastases

Breast
Prostate
Thyroid
Lung
Kidney