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Ortho 2

Clinical Medicine: Orthopedics 2: Hip and Knee, Upper Extremity, Trauma

Pain on outside of leg vs pain in groin Bursitis vs Arthritis
Night pain when lying on affected hip, pain increases w/ long distance walking and up/down stairs or chair; Inflammation and hypertrophy of the greater trochanteric bursa. What will Dx studies show? Tx? Trochanteric bursitis. XR will show nothing. Tx: Ilio-tibial band strectching loosens it up so it doesn't rub, firstline. PT, NSAIDs, Cortico injections.
Where does trochanteric bursitis radiate? Down the outside of the thigh to knee
T/F: Trochanteric bursitis has a normal ROM of hip True, may hurt though
Loss of articular cartilage of the hip joint due to idiopathic, normal wear and tear, or secondary causes like trauma, infx, AVN etc. Bone spurs around joint. Hurts in thigh or groin. Can radiate strongly to knee. Loss of internal rotation. XR? Tx? Hip osteoarthritis; XR shows reduced joint space of hip. Tx: Activity modification, other typical ortho Tx, corticosteroid injection good for Dx purposes to see if it goes away, SURGERY (Total Hip Arthoplasty)
Death of bone due to lack of blood supply to the bone section. Progression of no pain to pain when recumbent. Most common joint affected? 4 causes? Initial Dx? Definitive Dx? Avascular Necrosis (AVN); Hip most commonly affected; Causes: 1) Steroid use 2) Alcohol 3) Trauma 4) Idiopathic; IDx: "Frog-leg" lateral of hip where loss of joint space and collapse of fem head seen; DDx: MRI (more sensitive to bone changes)
Tx of AVN Medications, Invasive, Non-invasive? Meds: NSAIDs, pain meds; Non: Rest/act mod; Inv: Joint replacement almost always occurs, bone graft, core decompression (where hopefully new blood supply will grow w/ new bone)
Generally occur in athletic population where knee gives way while cutting or pivoting. Often a pop and acute swelling (hemarthosis). Most sensitive test? Imaging? ACL Tear; Test: Lachman exam. MRI confirms.
T/F: ACL tears most common in men FALSE, more common in women
Lachman Exam Try to translate tibia forward
ACL tear Tx RICE and restore ROM initially for the first month. Surgical Tx for younger or athletes. Maybe no surgery for sedimentary, but will lead to arthritis
Loss of articular cartilage of knee joint. 55yo +, Wt bearing aggravates, Hx of injury, flexion contracture, joint line tenderness, crepitus, effusion, angular deformity, Knee Osteoarthritis
What are the standard radiographs for most Knee and hip AP, Lateral and often Merchant
Valgus or Varus: Medial bow/bowlegged? Varus alignment
Valgus or Varus: "knock-kneed" where knee bends towards the other Valgus alignment
Tx for Knee osteoarthritis: Normal ortho Tx PLUS either viscosupplementation (hyaluronic acid that mimics your own synovial fluid) or surgery (total knee replacement or osteotomy)
Osteonecrosis of the subchondral bone. Generally thought to be due to repetitive stress to the subchondral bone that disrupts the blood supply to an area of the bone. Shear forces fracture the articular cartilage. May lead to loose body. Osteochondritis dissecans
Gradual onset of knee pain and possible swelling. Best Dx? Tx? Osteochondritis dissecans; Dx: MRI often required (XR can miss); Tx: In children w/ ASx: rest and crutches 4-6 weeks; if Sx: arthoscopy removal of free fragment and fixation of loose one
What does the extensor mechanism include? (3) Quad tendon, patella tendon, tibial tubercle
patella attached to tendon attached to growth plate. Force of quad pulls it and makes it look like a walnut Osgood Schlatter (an extensor mechanism problem)
Imaging for a tendon tear? MRI
Tx for Extensor Mechanism problems? (7) 1) activity modification 2) PT 3) Oral supplements (glucosamine and chondroitin) 4) Meds (NSAIDs/Aceta) 5) Brace 6) Orthotics 7) Surgical options depending one Dx
fibrocartilaginous structure that sits between the femur and tibia. There are two in each knee (one lateral and one medial) and they assist in distributing weight bearing forces through the knee Meniscus
Twisting injury to knee, stiffness and swelling, mechanical Sx (locking/catching). Which is more common? PE test? Imaging? Tx? Meniscal injuries; Medial tear more common; PE: McMurrays; Imaging: MRI; Tx: RICE and steroids in older patients, Surgery in younger)
T/F: Although the meniscus is the most commonly injured meniscus, the lateral collateral ligament is more commonly injured FALSE, both the medial meniscus and the MCL are most commonly injured
Any injury that puts the knee into varus or valgus is going to injure the _________ collateral ligaments
MCL injuries occur when the knee is forced into ________ Valgus (knock-kneed); hyper-stretches the MCL)
LCL injuries occur when the knee is forced into _________ Varus (BOWED)
Lateral knee pain, swelling, stiffness after trauma. What imaging to rule out intra-articular injury? Tx? Typical Ortho Tx unless Grade III LCL that may require surgery
Effusion, pain, fever chills, knee instability. Labs? (4); Tx? Septic Arthritis of Knee. Labs: 1) CBC 2) ESR 3) CRP, 4) Knee Aspiration (esp send for WBC count and crystals); Tx for Septic Joint is IV ABX and Surgery (total joint replacement w/in 48 hours)
Minimum of 2 preferably what 3 shoulder radiographic views? 1) AP of glenoid 2) Outlet 3) Axillary
2 main radiographical views for elbow 1) AP 2) Lateral
Gradual pain aggravated by overhead use, night pain, weakness, no limited ROM, (+) impingement maneuvers (+) Hawkins; Dx? Tx? Impingement Syndrome: Compression of the Rotator Cuff (RTC) and subacromial bursa between the humeral head (greater tuberosity) and structures that make up the coracoacromial arch (acromion and CA ligament). Dx: MRI Tx: Ortho usual and surgery
Biggest difference between Impingement Syndrome and Partial Rotator Cuff tear Their name...MOI, Sx, PE, Tx all the same
What percentage do we get worried about with partial RTC tears? >50%
Who gets rotator cuff tears and how usually? People that are 35/40 yo+ after a high energy fall
Full PROM, 90-100 degree abduction, weakness, Hx of impingement, inability to raise arm. Dx? Tx? Full Thickness RTC tear. Dx: MRI Tx: Surgery
Pain is aggravated by elevation of the arm above shoulder or lying on shoulder. Pain may awaken patient from sleep. Other complaints may be stiffness, snapping, catching, or weakness of the shoulder. Mimics impingement syndrome. Multifactorial etiology. Calcific Tendonitis: a disorder characterized by deposits of hydroxyapatite (a crystalline calcium phosphate) in any tendon of the body, but most commonly in the tendons of the rotator cuff (shoulder), causing pain and inflammation.
Calcific Tendonitis: Tx (4) 1) Activity modification 2) PT (Iontophoresis) 3) Corticosteroid injection 4) Surgical intervention
40-60 yo, smoking, previous steroid injection, often "overhead" strain, "pop" sensation, obvious deformity, ball deformity in arm. Can be due to trauma or with a history of impingement. Tx? Proximal Biceps Rupture: disruption of the long head of the proximal biceps tendon. Tx: Reassurance, eval (MRI) RTC for any tears
Fall w/ arm in ADDucted position. Decreased ADDuction, deformity. Pain/swelling w/ AC joint. Tx: AC Joint Separation: traumatic dislocation of the acromioclavicular joint in which a displacement of the clavicle occurs relative to the shoulder. Tx: Types 1-3: sling, PT, activity modification. Type 3-5: surgery
Which type(s) of AC Joint separation need surgery? Type III (severe injury)+
Etiology: DM1, women, 40-60 yo, smokers. Limited A/PROM, intact RTC, spontaneous pain, Painful-> Frozen/stiffening phase including passive ROM -> spontaneous, progressive improvement Adhesive Capsulitis: benign, self-limiting condition of unknown etiology characterized by painful and limited active and passive glenohumeral range of motion of ≥ 25% in at least two directions most notably shoulder abduction and external rotation
Imaging for Adhesive Capsulitis? Tx? XRAYs to rule out things. Tx: First line: PT, steroid injections, surgical (MUA or capsular release)
Affects people over 50 yo, most commonly w/ osteoarthritis, rotator cuff arthropathy, RA, posttraumatic arthritis, w/ Hx of diffuse deep-seated shoulder pain, worse w/ activity, progressive loss of ROM w/ ADLs being affected. Atrophy and crepitus noted Glenohumeral arthritis: destruction of articular cartilage with loss of joint space
Best Dx view for seeing loss of joint space in glenohumeral arthritis? Axillary; can see the destruction of the glenoid
Glenohumeral arthritis: Tx: Non-operative first: Education, glucosamine, NSAIDS, Ice/heat, steroid injections (6 months). Operative: TSA or hemiarthroplasty
Often a weight lifter w/ tenderness and pain at top of shoulder due to AC osteoarthritis that is normally isolated. Tx? AC Joint Arthritis: progressive loss of articular cartilage of the AC joint. Tx: Typical ortho Tx, surgical intervention (distal clavicle resection)
Shoulder highly mobile and unstable w/ dislocations and subluxations (usually anteriorly), apprehension sign, little or no mobility if dislocated. Imaging? Shoulder Instability; Dx: AP and Axillary lateral, MRI assessing labral pathology.
Defined as tearing of anterior glenoid labrum Anterior instability
Tx of Dislocations (4) 1) Reduce dislocation 2) sling for 3 weeks 3) PT program 4) Surgical Tx
Initial forceful movement of labrum attached to bicep tendon to be torn away from glenoid bone. Commonly associated with dislocation of the bone. Tx? SLAP (Superior Labrum Anterior/Posterior) lesion; Tx: Activity Modification and Surgery (<40 yo -SLAP lesion repair or >40 yo Biceps tendoesis)
FOOSH (fall on outstretched hand) leading to instability w/ frank dislocation uncommon Posterior Instability
Pain over _______ epicondyle, called "Tennis elbow" and is due to repetitive overuse of wrist extensors. Usually chronic and atraumatic presenting with weakness and pain gripping and handling objects. Full ROM. Dx? Tx? Lateral Epicondylitis; Dx: not usually necessary but will show up on AP. Tx: Normally non-operative and normal ortho Tx will work but failure after 4-6 months indicates surgery
Pain over ________ epicondyle, called "Golfer's elbow" due to repetitive overuse of wrist flexors, chronic/atraumatic. Presents w/ weakness and pain gripping and handling objects. Full ROM. Dx and Tx? Medial Epicondylitis; Dx and Tx EXACT SAME as Lateral Epicondylitis
Caused by valgus stress or force applied to elbow, seen in throwing athletes. May be a pop in acute setting but insidious onset is more common. Aggravated w/ throwing. Paresthesias. Pain along medial side of elbow. (+) Milking Maneuver. Dx? Tx? Ulnar Collateral Ligament Sprain; Dx: MRI w/ arthogram best. Tx: Typical non-operative ortho Tx with a very slow return to throwing time (4 months) or "Tommy John" surgery with complete rupture or failed non-operative.
Insidious onset common but can be acute, painless swelling over olecranon. Hx of leaning on elbow, AKA "Student's elbow". Fluctuant mass over olecranon. Any constitutional signs or warmth/redness? Dx? Tx? Olecranon Bursitis: inflammation and swelling of olecranon bursa/posterior elbow. Dx: Not usually needed but XR can pick up any calcifications. Tx: Typical ortho Tx. Possible aspiration. If septic, Iand D or complete bursectomy w/ 2-4 weeks ABX (PICC)
Usually male 50-60 yo w/ single traumatic event, w/ weakness of flexion and supination. Carefuly palpate for residual biceps tendon in AC fossa noting partial rupture may be common. Hook test abnormal. Imaging if Dx unsure? Tx? Distal Biceps Rupture: partial/full detachment of distal biceps tendon from radial tuberosity; Dx: MRI w/o contrast. Tx: non-surgical Tx pts complain of prolonged pain and remain weak. Surgery fixes.
Hook test? Patient actively supinates the flexed elbow w/ abnormal hook test, there is no cord-like structure to palpate or hook
Prior fracture w/osteophytes or dislocation. Prolonged elbow flexion with a "pins and needles" sensation. (+) Tinel's over Ulnar nerve. Dx? Tx? Ulnar Neuropathy: nerve entrapment occurs when ulnar nerve in the arm becomes compressed or irritated. Dx: Xrays if prior trauma or EMG but high false negative. Tx: Mild/moderate: act mod or medrol dose pack. Surgical: if failure of non-operational
Hx of elbow trauma, loss of ROM, point tenderness over RC joint. Dx? Tx? Elbow DJD (degenerative joint disease): loss of articular cartilage in elbow. Dx: plain films. Tx: Sx: act mod, steroid injections. Surgical: arthroscopy and elbow replacement
Physical trauma (crush or electrocution) causing increased pressure in myofascial sheaths in forearm or lower leg causing death of muscles and nerves leading to permanent disability. SEVERE pain worse w/ movement, paresthesia, palor, pulselessness Compartment Syndrome
T/F: Compartments of fascia are very strong but not compliant (don't stretch well) True
Normal tissue pressure? <10 mm Hg
What labs will be elevated in compartment syndrome Serum creatinine, myoglobin, myoglobinuria
How long do patients have to get surgery before ischemia from compartment syndrome? 8 hours
End of bone forming joint Epiphyseal
Growth plate of bone (only in kids obviously) Physeal
Flared portion of bone at both ends of shaft Metaphyseal
Shaft of a long bone Diaphyseal
Orientation/Type: Perpendicular to bone Transverse
Orientation/Type: angulated fracture line Oblique
Orientation/Type: multiplanar and complex fracture line Spiral
Orientation/Type: more than two fracture fragments Comminuted
Orientation/Type: completely separated segment of bone Segmental
Orientation/Type: fracture extends into joint Intra-articular
Orientation/Type: buckle fracture of one cortex Torus (found in children)
Orientation/Type: impaction of bone Compression
Orientation/Type: incomplete fracture with angulation Greenstick (found in children)
Orientation/Type: fracture through weakened/diseased bone Pathologic
Orientation/Type: fracture fragment pulled from site by tendon/ligament Avulsion
fracture fragments are anatomically aligned Non-displaced
fracture fragments are no longer in their usual alignment Displaced
fracture fragments are malaligned Angulated
distal fragment longitudinally overlaps the proximal fragment Bayonetted
distal and proximal fragments are separated by a gap Distracted
Salter Harris I fracture through the physis only
Salter Harris II fracture through physis and metaphysis
Salter Harris III fracture through physis and epiphysis
Salter Harris IV fracture involving metaphysis, epiphysis, and physis
Salter Harris V crush fracture of the physis
What is the Salter-Harris classification? Classifies 5 types of GROWTH PLATE fractures, occuring in children
T/F: All Salter-Harris fractures can be seen on XR False, Type I cannot be seen on XR
What are the 4 Rs of fractures 1) Recognition 2) Reduction 3) Retention of reduction 4) Rehabilitation
How are most clavicle fractures treated? Indications for surgery? (3) Non-operatively in a sling; Surg: 1) angulation/tenting, 2) significant displacement and shortening, 3) open fracture
Hx: blow to top of acromion or traction on the arm. Which types require surgery? What do the other types require? Acromioclavicular separations: 1-3 ice, rest sling and a few 3 and 4-6 require surgery
Most common adult elbow fracture usually caused by a fall on out stretched hand (FOOSH), pain over lateral elbow, limited ROM. Dx? Tx? Radial Head Fractures; Dx: XRAY especially AP and radial head (would also do lateral of course). Tx: non-operatively w/ EARLY MOBILIZATION. Displaced require ORIF or Open Reduction Internal Fixation
Shaped like a “sail” – the sign describes an “occult” fracture Can usually see anterior, which is a normal finding But, a posterior __________ is abnormal. What does it indicate and what XR do you see it in? Fat Pad Sign; indicates intraarticular fracture of radial head. Only seen on Lateral XR of elbow
Usually caused by a direct fall on elbow. May have neurologic Sx (ulnar nerve). Tenderness, swelling, ecchymosis (bruise), limited ROM, (+) Tinel's sign. Dx? Tx? Olecranon Fractures; Dx: AP and Lateral (sometimes oblique). Tx: Non-displaced: long arm cast 3 weeks; Displaced: ORIF (Open Reduction Internal Fixation)
FOOSH, pain w/ ROM and grip, swelling and tenderness of dorsal wrist. (+) Watson's test. (+) Terry Thomas sign; Imaging? Tx? Scapholunate sprain/dissociation; Imaging: AP, Lat, Oblique, ulna deviation, clenched fist. Tx of Sprain: Mild- splint/brace Significant- cast. Tx of dissociation
Terry Thomas sign (widening of scapholunate joint by 2-3 mm) confirms dissociation of Scapholunate
Most common wrist and hand fracture? Distal radius fracture
What do you always check with a wrist or hand injury? (2) Snuff box and neurovascular status!
Most common carpal fracture and second most common wrist fracture. Pain in radial aspect of wrist after fall. Increased pain w/ ROM and in snuff box. Imaging? Tx? Scaphoid fracture; Imaging: XRAY initially (AP, lat, oblique, ulna dev, scaphoid), CT, bone scan or MRI. Tx: Thumb spica cast 6-12 weeks for nondisplaced. ORIF for displaced or proximal fractures
Neck fracture of 5th metacarpal after a blow Boxer's Fracture
Does the proximal or distal section of the scaphoid take longer to heal? PROXIMAL
Common in the elderly (age biggest RF), involving femoral neck in those w/ sedentary lifestyle. Often elderly white woman. Tx? Hip Fracture; Tx: almost always surgical.
Most common hip fracture? Subtrochanteric fracture
Best hip fracture surgical Tx and why? Trochanteric femoral nail (doesn't strip periosteum)
What bones are included in knee fractures? Distal femur, patella, proximal tibia, proximal figula
What is a sunrise XR view? knee bent
When does a patella fracture require surgery and what kind? If displaced and ORIF (Open Reduction Internal Fixation)
Demographic of Distal Femoral fractures? Elderly
As a general rule, what do most intra-articular fractures require? Reduction through surgery
Tx for Tibial plateau fractures? Who gets them? Elderly and many require ORIF
What is the only type of ankle fracture you DON'T have to refer to ortho? Simple avulsion
Tx for lateral ankle avulsion fracture? Same as ankle sprain: RICE followed w/ rehab
What do you check for non-displaced stable lateral ankle fractures? Tx? Ensure they are actually stable; Tx: Cast/boot then rehab (refer)
Difference between unstable and stable non-displaced lateral ankle fracture? Tx for unstable? Involve more than one side of the joint (break w/ ligament involvement of the other side). Tx: Cast/boot for 4-6 weeks then rehab
Difference between unstable non-displaced and unstable displaced? Tx for displaced and unstable? Displaced unstable fractures involve both sides of joint but also have fracture fragments that are displaced, subluxing or dislocating the ankle joint. REFER. Tx: closed reduction or ORIF, then 4-6 weeks of rehab
Rupture of deltoid ligmanet or Frx of medial malleolus in addition to tearing of syndesmosis (connects tib and fib) PE? Imaging/Dx? Tx? Maisonneuve Fracture; PE: examine/palpate proximal leg/fibula with any ankle trauma. Ankle XR, but fibular fracture will not show. Tx: Just refer that beast
Tx of metatarsal fractures? Tx: immobilization for 6 weeks in short leg cast, boot, or wooden shoe/post-op shoe
Common in runners and elderly (lots of standing/walking). Forefoot pain/swelling w/o trauma. Worse w/ activity and better w/ rest. Tx? Metatarsal Stress Fracture; Tx: Rest and immobilization -> slow return to activity
Which 5th metatarsal fractures are hardest to heal (2)? Why? Tx for the 3rd of the 3? Stress and Jones Fractures because of poor vasculature. Avulsion Tx: Boot
Fracture of the base (in the middle) of the 5th metatarsal that is very slow to heal. Tx? Jones Fracture; Short leg cast NWB for 6-8 weeks or ORIF.
Male in 3rd decade w/ indirect rotational forces and axial load. Condition characterized by disruption between the articulation of the medial cuneiform and base of the 2nd metatarsal, where the unifying factor is disruption of the TMT joint complex. Lisfranc Injuries
Usually caused by indirect rotational forces and axial load through hyperplantar flexed forefoot  hyperflexion/compression/abduction moment exerted on forefoot and transmitted to the TMT articulation metatarsals displaced in dorsal/lateral direction. Lisfranc injuries
How to ID Lisfranc on XR? Too much space between great toe and second metatarsal on AP, lateral, oblique with stress or wt bearing views
Tx of Lisfranc Nonoperative: Cast immobilization for 8 weeks if no displacement, ORIF if evidence of instability. Pt usually left w/ chronic foot pain
Created by: crward88